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

530
PART 4 — CONVENTIONAL WORKHORSE FLAPS
particularly useful if the area to reconstruct is the ipsilateral
hand.
TECHNIQUE OF FLAP HARVEST
(SUBFASCIAL) (Figs 47.6 and 47.7)
After flap design and pedicle length have been meticulously
measured and rechecked, the arm is raised and, after exsan­
guination, the tourniquet inflated to 100 mmHg above sys­
tolic blood pressure. It is not necessary to leave veins dilated
as their identification is easy. Full-thickness incision through
the first layer of subcutaneous fat will expose small and large
subcutaneous veins and the major cutaneous nerves. After
appropriate ligation or preservation, the deeper fat is tra­
versed and the antebrachial fascia is exposed. A 1.0 cm to
2.0 cm cuff of fascia is raised beyond the border of the flap
and immediately sutured to the dermal layer (Fig. 47.7C).
This maneuver will prevent shearing of small septocutaneous
vessels, which are easily avulsed with retrograde or antegrade
flap elevation in both adults and children. The fascia is lifted
with the flap off the underlying muscles. The palmaris longus
tendon is usually available to be incorporated into the flap
if necessary, as the deep fascia is located directly beneath it.
With upward traction all deep branches of the radial
artery are easily visualized and carefully cauterized. The
identified and marked – these are visualized best once
manual pressure is applied in the midarm to decrease
venous outflow. It is best to consider the method of closure
prior to harvesting the flap, especially if a local flap is being
considered so that it can be incorporated into the design.
For mucosal and nasal reconstructions, the flap should be
situated in a non-hirsute area of the forearm (see Case
examples).
PATIENT POSITIONING
The patient is placed supine with the arm abducted 90° and
the hand fully supinated on a hand table. A nonsterile tour­
niquet can be placed high up in the arm to minimize blood
loss and allow good visualization during flap harvest. The
flap can be harvested with the patient in almost any posi­
tion, including lateral decubitus and prone – where careful
consideration must be given to traction on the axilla and
elbow before a long case.
ANESTHETIC CONSIDERATIONS
The flap can be harvested under regional anesthesia such
as axillary or supra- or infraclavicular nerve block. This is
Figure 47.7  Technique of flap harvesting. (A) Defect of first web space is the shape of a tetrahedron; marking of flap after careful assess­
ment of rotation arc. (B) Septocutaneous perforators supplying the flap. (C) Suturing the fascia to the dermis prevents shearing of small per­
forators. (D) A slightly longer extension of flap distally allows coverage of vessel. (E) Deep perforators of radial artery feed underlying muscle
and bone. (F) Median nerve and palmar cutaneous branch. (G) Flap transposed. (H) Donor site closed linearly and flap inset.
A
D
E
G
H
F
B
C

CHAPTER 47 — Radial Forearm Flap
531
longus and flexor carpi radialis, particularly in the distally
designed flap, keeps the connective tissue sheath around
these tendons and results in better skin graft take. The
major technical difference is that flap dissection starts supra­
fascial on the radial and ulnar sides until the vessel is
approached. Once close to the vessel, deeper dissection
underneath the fascia commences to ensure the capture of
all perforators and inclusion of the vessel in the flap. Supra­
fascial dissection does not necessarily result in a thinner
flap. Its main advantage is to improve skin graft take in the
donor site (Fig. 47.6).
TENDINOCUTANEOUS FLAP
Because the muscles supplied by the radial artery are impor­
tant for hand function, musculocutaneous flaps are not
used. Inclusion of the palmaris longus tendon, however, as
a vascularized tendinocutaneous flap has been described.
Division of the distal tendon early in the dissection facili­
tates elevation of the tendon within the flap. This modifica­
tion is helpful in facial reconstruction where a fascial sling
is required, such as mouth or lower lip cases.
OSTEOCUTANEOUS FLAP
The lateral intermuscular septum is the conduit for blood
supply from the radial artery to the radius. An area of
bone extending from the insertion of the pronator teres to
the distal radial styloid can be harvested (Figs 47.8, 47.9).
This area should not exceed 10.0–12.0 cm in the adult;
however, more bone can be harvested in special cases (see
Case 47.4).
Once the radial border of the palmaris longus has been
reached, the dissection continues deep to the fascia invest­
ing the flexor pollicis longus and the pronator quadratus.
These muscles are incised close to their attachment to the
radius but the lateral intermuscular septum is preserved
with a small cuff of flexor muscle. The forearm is supinated
and a longitudinal osteotomy is made in the incision site of
the flexor pollicis longus and pronator quadratus. The
section of bone to be removed is “boat shaped,” with the
widest area on the periosteum and the narrowest near
the central axis of the radius (deep). The forearm is then
pronated, the brachioradialis is retracted, and the lateral
osteotomy made to connect to the other osteotomy. A wedge
of rigid cortical and some cancellous bone can thus be har­
vested with a wide periosteal attachment.
Because of the increased risk of fracture, the authors
suggest using a different site for vascularized bone graft,
e.g., the medial femoral condyle (see Ch. 55) if a large
segment is needed. If this donor site must be used for a large
segment of bone, the authors suggest decreasing fracture
risk by using a bone graft buttressed with a locking plate to
repair the defect of the radius.
TISSUE EXPANSION OF THE FLAP
The flap can be increased in size by pre-harvest tissue expan­
sion. A tissue expander placed deep in between the radial
and ulnar arteries can dramatically increase the amount of
skin that can be carried by the pedicle. Tissue expansion in
the extremities, however, can have high complication rates
most proximal border of the flap is raised and the radial
artery, its venae comitantes identified between the brachio­
radialis and flexor carpi radialis muscle bellies. The lateral
antebrachial cutaneous nerve is superficial and the radial
sensory nerve nearby beneath the brachioradialis.
The next focus becomes the radial incision and distal
vascular bundle. With large flaps the venous plexus at the
wrist level and arborizations of the radial nerve must be
identified and protected from injury. The main trunk of the
superficial radial nerve is identified emerging beneath the
brachioradialis tendon. A decision is made in regard to
preservation or incorporation of the cephalic vein.
With both borders of the flap elevated on either side of
the vascular pedicle, the artery with its venae comitantes is
isolated. At this point, the tourniquet can be deflated to test
the perfusion of the flap and hand prior to ligation. This is
usually not necessary if an Allen test has confirmed a patent
palmar arch preoperatively. After ligation and division of
the distal vessels, the flap is raised. Proximal incisions made
in the forearm are dependent on the length of pedicle
desired. Always remove at least 2.0 cm extra, especially in
head and neck cases. Muscle retraction affords clear access
and identification of all vascular structures. For most
distally based vascular island flaps excess tissue around the
pedicle should be avoided. It is also wise to include an extra
tongue of overlaying skin with the pedicle for ease of flap
inset (Fig. 47.7D).
Upward traction is the key to elevation as the lateral
intermuscular septum beneath the pedicle is released from
the periosteum. For osteocutaneous flaps all connections to
periosteum at this level are preserved.
In the middle and distal thirds of the forearm, the median
nerve and its palmar cutaneous branch can be in close
proximity (Fig. 47.7F). For pedicled flaps the pivot point at
the wrist is proximal to the branching of the princeps pol­
licis artery.
Throughout this entire dissection, the highest priority
must be directed to both bleeding and moisture. Desicca­
tion from prolonged exposure and hot lights will often
result in poor skin graft take, over the distal portion of the
donor site wound, particularly the flexor carpi radialis
tendon.
FLAP MODIFICATION/FLAP HANDLING
REVERSE FOREARM FLAP
This flap is ideal for reconstruction of hand, finger, and
thumb defects. The flap is perfused from distal to proximal
and relies on an intact arch to allow blood flow from the
distal ulnar artery to the radial artery. There are fewer per­
forators in the proximal third of the forearm and even fewer
in the middle-third forearm; therefore, it is essential to take
a wide fascial attachment during flap harvest. Tension-free
flap inset is enhanced by the incorporation of a strip of skin
over the vascular pedicle (Fig. 47.7D).
SUPRAFASCIAL FLAP (Fig. 47.6)
It is possible to raise much of the radial forearm flap in a
suprafascial layer.2 Preserving the fascia over the palmaris

532
PART 4 — CONVENTIONAL WORKHORSE FLAPS
SENSATE FLAP
The lateral antebrachial cutaneous nerve provides sensation
to the lateral (radial) forearm and is the nerve of choice to
include for a sensate flap. Its small fibers are typically seen
as the flap is raised from distal to proximal and its more
proximal extension is found parallel to the cephalic vein.
The medial antebrachial cutaneous nerve may also be
included in the flap if the flap is taken more ulnarly. This
nerve runs accompanies the basilic vein.
Proximal nerve stumps should be buried within muscle
to avoid painful neuromata.
SPLIT FLAP
A big skin island can be divided into smaller, well-perfused
skin islands by keeping perforators intact to each island. To
this end, the skin islands can be separated entirely or the
space between them de-epithelialized (see Case 47.3).
FASCIAL AND ADIPOFASCIAL FLAPS
These flaps can be distally or proximally designed, reverse,
or antegrade flow flaps. A longitudinal incision is made over
the vessel and skin flaps are raised on either side. In a dis­
tally designed flap, the skin flaps must leave a thin layer of
fat under the subdermal layer to ensure good vascularity to
the flaps. The flap dissection is then completed routinely.
These flaps, especially proximally based and reverse flow,
provide good gliding surface for tendons of the hand
without significant bulk seen in a septocutaneous flap (see
Case 47.6).
A useful alternative is the perforator-based adipofascial
flap. This is a thin flap based on the distal perforators of
the radial artery. One can design a turnover flap based dis­
tally on a single perforator – usually the dorsal superficial
branch of the radial artery, which is large enough to be reli­
able. This approach has the advantage of keeping the radial
artery intact.
PERFORATOR-BASED FLAPS
The majority of the branches of the radial artery are
unnamed and too small to be dissected individually as per­
forator flaps. The proximally located inferior cubital vessel
can be raised as a perforator flap (antecubital flap) in the
proximal one-third of the forearm. The dorsal superficial
branch of the radial artery is also a reliable perforator,
which supplies an adipofacial, distally based turnover flap
for hand reconstruction.
FLOW-THROUGH FLAP
Either the artery or one of the secondary veins can be
used as a vascular conduit to provide flow-through in situa­
tions of limb revascularization or to use multiple free flaps
in series (see Case 47.4). If the artery is used as a flow-
through vessel, it is critical to do a venous anastomosis as
well to ensure good outflow. The outflow from the other
end of the artery does not relieve venous hypertension in
the flap.
Figure 47.9  Harvesting a wedge of bone.
Figure 47.8  Boat-shaped osteotomy of the radius.
Flexor pollicis longus
(origin)
Pronator teres
(insertion)
Boat-shaped bone
segment
Pronator
quadratus
Brachioradialis
and should be done meticulously and in the right patient.
Although tissue expansion can also be used to ultimately
excise a skin graft on the volar forearm after flap harvest,
the authors find that serial excision and flap advancement
are more reliable with less morbidity.

CHAPTER 47 — Radial Forearm Flap
533
FLAP APPLICATION
PEDICLED FLAPS
The long pedicle leash allows a broad area of transposition
with an arc of rotation of 360°. Distally designed pedicled
flaps can be transferred to the elbow or arm. Proximally
designed flaps can be transferred to the hand, typically for
dorsal wound reconstruction. In these cases, an adipofascial
flap is ideal to avoid bulkiness of a fasciocutaneous flap or
need for subsequent thinning.
FREE FLAPS
There are multiple applications of the free radial forearm
flap for head and neck, trunk, and extremity reconstruc­
tion. The small, thin forearm flap with a long pedicle can
be utilized for many hard to reach locations. In the head
and neck it can be transferred inside the mouth or the
oropharynx, the mandible (with bone), the esophagus
(short segment), the face (skin for burns, trauma, or tumor
and/or adipofascial for contour augmentation), the nose
(see Case 47.2) (prelamination on the forearm), or as
conduit for another free flap. It can also be used for recon­
struction of the penis (double-tubed flap for urethra and
penile shaft) (see Case 47.3), hand (first web space or
dorsum) (Fig. 47.7), ankle (Achilles tendon exposure), foot
(dorsum), and the leg (vascular reconstruction and simul­
taneous soft tissue coverage).
INDICATIONS
• Replacement of thin pliable tissue. Includes use for recon­
struction of intraoral mucosal defects, dorsal hand defects
DONOR SITE MANAGEMENT
Distally designed flaps usually require skin grafting; full
thickness or split thickness depending on the size of the
defect. Full-thickness grafts look better and are preferred
unless the defect is too big to allow primary closure of the
donor site. The authors prefer the lower abdomen for full-
thickness skin grafts. Although some surgeons advocate use
of local flaps (e.g., ulnar transposition, V-Y advancement,
bilobed) for closure of the donor site, these additional pro­
cedures introduce unnecessary scars and contour changes,
and are thus discouraged.
The graft is sewn with absorbable sutures and a non-
adherent dressing is applied with a cotton bolster. The wrist
is immobilized in a splint or a cast for 2–3 weeks. A drain is
placed under the closed portion of the wound for 24 h to
alert the surgeon in case of a hematoma. A vacuum-assisted
closure (VAC) device is an acceptable alternative and may
obviate the need for a drain. A nonexpanded mesh graft
will avoid hematoma if appearance is not a major concern.
In order to improve contour of the forearm after radial
forearm flap harvest, some surgeons offer the patient the
option of not skin grafting the donor site in the initial
setting and place a wound VAC with or without integra
placement and await for the defect to granulate. After the
wound has granulated to the level of the rest of the forearm
skin, a skin graft is placed.3
If bone is harvested, the forearm should be immobilized
to avoid a fracture. An above-elbow cast (Munster or long-
arm) should be applied to prevent pronation and supina­
tion for 3 weeks and then changed to a short-arm cast for
an additional 3 weeks. Serial radiographs are necessary to
monitor skeletal healing.
Technical Pearls
• An Allen test should ensure patency of the palmar arch prior to harvesting the flap. Patency will allow good vascular-
ity to the hand and, in case of reverse flow, the flap.
• In large flaps, consider the inclusion of additional superficial veins to ensure good drainage. The authors have used
at least one superficial and one deep venous anastomosis for most radial forearm free flaps, even small ones, and
have not encountered any untoward events.
• The deep venae comitantes communicate with the superficial veins via the common branch, going into the median
cubital vein proximally. If the vein is dissected proximal to this connection, the superficial veins of the forearm can
be used to drain the deep and superficial system.
• Occasionally, in children or small females, the venae comitantes are too small for a suitable anastomosis.
• When harvesting bone, ensure that the forearm is positioned correctly. Increased angulation can result in harvest of
too large a segment of radius. No more than 25% of the circumference of the radius should be removed.
• Consider performing the Allen test using a pulse oximeter on the thumb. The authors find this modification a more
reliable assessment of vascularity.
• If there is question about vascularity, consider clamping the radial artery and releasing the tourniquet prior to divid-
ing the vessel.
• To allay concern about vascularity, consider reconstituting the radial artery with a vein graft. This interposition pro-
cedure can be done for free and pedicled flaps.
• Take extra care to seal intraoral defects with many carefully placed everting sutures to avoid subsequent intraoral
leaks or fistulas.

534
PART 4 — CONVENTIONAL WORKHORSE FLAPS
UNFAVORABLE OUTCOMES
RECIPIENT SITE
Problems with recipient site healing are usually due to inad­
equate sealing of the wound, especially in intraoral or pha­
ryngeal reconstruction. Tracheostomy sites in close proximity
are often the source of infection or wound dehiscence;
these areas must be appropriately sealed from the recon­
struction. Meticulous attention to detail, careful analysis
and planning of the incisions, and thoughtful execution
help the surgeon avoid many of these problems. The vascu­
larity and healing of the flap is less a factor of the technical
anastomosis and more a product of planning and case
set-up.
In pedicled flap cases, sometimes the length of flap and
pedicle is suboptimally planned, thus not allowing the flap
to fully transpose into the defect. During planning, a precise
template can be used to assess whether the flap will reach
the defect. With one end held at the pivot point, the other
end can be rotated in an arc to determine the portion of
the flap most distant from the defect will reach. A template
of the defect made with an Esmarch® bandage is also useful
in these cases. Before the flap is raised, measure once and
re-measure twice!
DONOR SITE
The most concerning problem with this donor site is poten­
tial ischemia of the hand. Luckily, this is a rare complication
and can be avoided by preoperative Allen test or clamping
the artery and releasing the tourniquet to assess hand perfu­
sion during the procedure. Damage to the sensory branch
of the radial nerve can cause very painful neuromata with
complex regional pain syndrome.
Most patients dislike the appearance of a skin graft on the
forearm. This is the most common issue with the donor site.
Full-thickness skin grafts look better and are preferred. If
the tendon is denuded of overlying connective tissue, the
graft will not take well on the tendon and secondary wound
healing problems occur. Patients with darkly pigmented
skin will have more conspicuous donor sites and should be
counseled accordingly.
The harvest of bone from the radius can result in fractures
that are difficult to treat. Unless a small amount of bone is
to be taken, the authors advise against doing so – especially
where flaps such as the medial femoral condyle osseous flap
provide abundant bone with far less morbidity.
CONCLUSION
The radial forearm flap is versatile with reliable vascularity
and well-tolerated donor site morbidity. It is ideal where
thin, pliable tissue is needed in complex patterns. It can be
used as a pedicled or free flap for a variety of defects all over
the body.
(adipofascial), first web space defects, penis, nasophar­
ynx, oropharynx, palate, and face. Even though it can be
made sensate, the skin is too thin and not ideal for plantar
foot reconstruction.
• Replacement of composite tissue. Radius can be used for small
mandibular defects along with intraoral coverage using
the soft tissue component of the flap. Tendon can be
incorporated allowing flap use for reconstructing mouth
and lips. Also the forearm is an easy site for prelamina­
tion of a composite flap such as for nasal reconstruction.
Skeletal structure (rib cartilage) can be inserted along
with skin or mucosal grafts and allowed to mature and
vascularize on the forearm before transfer as a composite
free flap.
• Replacement of vascular conduit. Interposition or flow-
through arterial or venous conduit.
POSTOPERATIVE CARE
Because of myriad indications, postoperative care should be
tailored to the particular situation for which the flap is used.
After free flap surgery, the flap needs frequent skilled moni­
toring to assess for patency of the anastomoses. The authors
employ a platelet aggregation inhibitor (aspirin) for about
30 days in children and adults. Standard chemoprophylaxis
for deep venous thrombosis is used in adults only. In most
cases, no other anticoagulation is needed.
If the flap shows signs of ischemia, it is critical to diagnose
whether the ischemia is due to venous or arterial insuffi­
ciency. A free flap should be explored and the anastomoses
inspected. A pedicled flap should be explored and assessed
for kinking, twisting, compression, or excess tension on the
pedicle or the inset.
This is a very reliable flap, so any signs of trouble are
usually a result of technical surgical misadventures.
The hand is kept exposed to assess vascularity in the
immediate postoperative period. Donor site is usually kept
immobilized for about 2 weeks until the skin graft takes. A
drain under the area primarily closed is kept in place for
about 24 h to alert the surgeon about the occurrence of a
hematoma. Immobilization should continue for 6 weeks if
bone is taken.
OUTCOMES
EXPECTED OUTCOMES
The radial forearm flap is very reliable and its anatomy and
vascularity have been extensively studied. Total or near total
survival of the flap (whether free or pedicled) should be in
excess of 96%.

CHAPTER 47 — Radial Forearm Flap
535
A 15-year-old girl presented with severe scarring and ectropion
from a Buruli ulcer. After resection of the scar and reconstruc-
tion of the lower eyelid with a conchal cartilage graft, a thin,
distally designed radial forearm free flap with a very long pedicle
was harvested for reconstruction. Vascular anastomosis was per-
formed in the neck. A year after the operation, the ectropion
was improved and the color match and contour were excellent
(Fig. 47.10).
CASE 47.1  Buruli Ulcer of the Eyelid and Cheek Reconstructed with a Free Suprafascial
Radial Forearm Flap
Figure 47.10  (A) Buruli ulcer with scarring and ectropion. (B) Thin, distally based radial forearm free flap with preservation of connective
tissue over tendons. (C) Sensate flap to be inset after conchal graft reconstruction of ectropion. (D,E) The 1-year postoperative result.
A
B
C
D
E

536
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 32-year-old woman suffered a dog bite with loss of the upper
lip philtrum, philtral columns, nasal sills, and columella. A free
radial forearm flap reconstructed the philtrum, columella, and
the nasal sills, followed by a paramedian forehead flap for the
nasal tip and ala (Fig. 47.11).
CASE 47.2  Dog Bite of the Nose and Upper Lip Defect Reconstructed with a Distally
Designed Radial Forearm Flap
Figure 47.11  (A,B) Dog bite to upper lip and nose. (C) Radial forearm free flap used for (D) upper lip and nasal sill reconstruction. (E)
Forehead flap used for reconstruction of nasal tip and columella. (F,G) Result 2 years after inset and minor revision surgery.
A
B
E
F
G
C
D

CHAPTER 47 — Radial Forearm Flap
537
A 17-year-old man sustained a severe electrical burn years earlier
in life that resulted in significant scarring in the perineum and
loss of penis and both legs below the knee. Tissue expansion
and resurfacing of the scarred areas was initially completed
before a radial forearm flap for penile reconstruction. Sensory
reinnervation is critical for this type of reconstruction. The geni-
tofemoral nerve was joined to the lateral antebrachial cutaneous
nerve, and the radial vessels were anastomosed to the deep infe-
rior epigastric vessels (Fig. 47.12).
CASE 47.3  Electrical Burn Injury Requiring Reconstruction of a Neophallus with a Free
Tubed Radial Forearm Flap
Figure 47.12  (A) Severe electrical burn scars in young male patient. (B) Tissue expansion to resurface perineal and inguinal scarring.
(C) Large radial forearm flap for (D) penile and urethral reconstruction. (E) Tubed flap ready for inset. (F) The 6-month postoperative result.
A
B
C
D
E
F

538
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 47.13  (A,B) Club hand posture due to chronic osteomyelitis of radius after motor vehicle crash. (C,D) Large bony gap defect after
soft tissue distraction. (E) Osteocutaneous radial forearm flap incorporating the entire radius from the contralateral flail arm. (F) Flap inset
as a flow-through flap. (G,H) The 5-year postoperative views.
A
E
F
G
H
B
C
D
An 11-year-old boy suffered an avulsion injury and fracture of his
right radius from a motor vehicle crash, 6 years earlier. He devel-
oped chronic osteomyelitis and loss of the radius, which led to
a club-hand posture. The contralateral arm was functionless
because of a severe pan-brachial plexus injury. The bone gap was
distracted; the entire radius and overlying skin were harvested
from the contralateral arm, and transferred. A radial artery
osteocutaneous flow-through flap reconstructed the bone, the
vessel, and the skin defects (Fig. 47.13).
CASE 47.4  Osteomyelitis of the Radius with Cutaneous Defect Reconstructed with a Free
Radial Forearm Osteocutaneous Flow-Through Flap

CHAPTER 47 — Radial Forearm Flap
539
Access Figures 47.14 and 47.15, as well as
case examples 5 and 6 and further reading and
video online at
REFERENCES
1. Hsieh CH, Kuo YR, Yao SF, et al. Primary closure of radial forearm
flap donor defects with a bilobed flap based on the fasciocutaneous
perforator of the ulnar artery. Plast Reconstr Surg 2004;113(5):
1355–60.
2. Lutz BS, Wei FC, Chang SC, et al. Donor site morbidity after supra­
fascial elevation of the radial forearm flap: a prospective study in 95
consecutive cases. Plast Reconstr Surg 1999;103(1):132–7.
3. Murray RC, Gordin EA, Saigal K, et al. Reconstruction of the radial
forearm free flap donor site using integra artificial dermis. Micro­
surgery 2011;31(2):104–8.
4. Soutar DS. Radial forearm flap. In: Wei F-C, Mardini S, editors. Flaps
and reconstructive surgery. Elsevier; 2009.
Expert Commentary
Hani Sbitany, MD, FACS
When harvested from the distal third of the forearm as a
microvascular fasciocutaneous flap, the radial forearm flap
remains one of the ideal choices for skin and soft tissue
resurfacing. This is due to the thin, pliable nature of the flap,
and the long vascular pedicle that can be obtained. The
primary drawback of this flap is the donor site defect, and
the need for a thin skin graft over the gliding flexor carpi
radialis (FCR) and palmaris longus (PL) tendons. However,
this can be improved with immediate placement of a dermal
tissue matrix (Integra monolayer) underneath the donor site
skin graft.
Flap design centers over the radial artery, between the
FCR and brachioradialis (BR) tendons. The distal margin of
the flap should be designed at the proximal wrist crease. The
tissue has the distinct ability to be taken with the superficial
cephalic vein or the deep venae comitantes (VC). When the
cephalic vein is to be harvested, the flap must be designed
well onto the dorsum of the forearm, in some cases over the
area of Lister’s tubercle. With contraction during healing, the
wound margin routinely ends up back on the volar margin,
and is well-tolerated. During elevation of the dorsal/radial
aspect of the flap, great care must be taken to identify and
preserve sensory branches of the superficial radial nerve.
Injury of these nerves can lead to postoperative paresthesias.
These nerve branches run parallel to the cephalic vein in the
suprafascial plane. To prevent both nerve and tendon injury,
we advocate a suprafascial elevation plane for the majority
of the flap, with the only subfascial dissection occurring in
the pedicle interspace between the FCR and BR tendons.
For reconstruction areas where venous congestion is at
high risk, such as lower extremity and head and neck areas
to be radiated, it is advisable to harvest both the cephalic
vein and the VC, and anastomose both as free flap outflow
veins. This dual (superficial and deep) venous drainage allows
for improved flap outcomes. When only one vein can be
used, both offer equivalent flap drainage clinically.

CHAPTER 47 — Radial Forearm Flap 539.e1
A palatal defect from multiple failed attempts at cleft palate
repair can be a challenging problem. This 7-year-old patient
had a large defect that had failed all conservative options. A
template was made of the defect and transposed onto a non–
hair-bearing area of the volar forearm. The nasal closure was
done first with turnover flaps, and the forearm flap then
carefully inset to complete a two-layer closure of the defect. The
pedicle was tunneled posterior to the last molar and anterior to
the coronoid process of the mandible, where it emerged in a
subcutaneous plane anterior to the ear. A separate preauricular
incision exposed the superficial temporal artery and vein, which
were the recipient vessels for the pedicle (Fig. 47.14).
CASE 47.5  Palatal Defect Reconstructed with a Free Radial Forearm Flap
A
B
C
D
E
F
A
D
Figure 47.14  (A) Defect from multiple failed attempts at cleft palate repair. (B) Esmarch bandage template on stone model. (C,D) Radial
forearm free flap markings and after harvest. (E) Nasal floor lining closure with turnover flaps. (F) Flap inset.
A 48-year-old man sustained a wood-shaper injury to the thumb,
which claimed dorsal skin, the extensor pollicis longus tendon,
and the dorsal support of the interphalangeal joint. After
debridement and reconstruction of the tendon defect with a
palmaris longus free graft, the wound was covered with a
distally based reverse-flow adipofascial flap and a split-thickness
skin graft (Fig. 47.15).
CASE 47.6  Industrial Wood-Shaper Injury of the Thumb Reconstructed with a Pedicled
Distally Based Reverse-Flow Radial Forearm Adipofascial Flap
Figure 47.15  (A) Dorsal thumb wound injury with missing extensor tendon and exposed joint. (B) After debridement and reconstruction
of extensor with tendon graft. (C) Reverse-flow radial forearm adipofascial flap. (D) Wound covered with flap and split-thickness skin graft.
(E) Final result after 9 months.
A
B
C
D
E

539.e2 PART 3 — RECONSTRUCTION
FURTHER READING
Badran D, Soutar DS, Robertson AG, et al. Behavior of radial forearm
skin flaps transplanted into the oral cavity. Clin Anat 1998;11:
379–89.
Bardsley AF, Soutar DS, Elliot D, et al. Reducing morbidity in the radial
forearm flap donor site. Plast Reconstr Surg 1990;86:287–92.
Boutros S, Yuksel E, Weinfeld AB, et al. Neural anatomy of the radial
forearm flap. Ann Plast Surg 2000;44:375–80.
Carty MJ, Ferraro N, Upton J. Reconstruction of pediatric cranial base
defects: a review of a single microsurgeon’s 30-year experience.
J Craniofac Surg 2009;20(Suppl. 1):639–45.
Eberlin KR, Chang J, Curtin CM, et al. Soft-tissue coverage of the hand:
a case-based approach. Plast Reconstr Surg 2014;133:91–101.
Elliot D, Bardsley AF, Batchelor AG, et al. Direct closure of the radial
forearm flap donor defect. Br J Plast Surg 1988;41:358–60.
Hwang K, Hwang JH, Jung CY, et al. Cutaneous perforators of the
forearm: anatomic study for clinical application. Ann Plast Surg
2006;56:284–8.
Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and
clinical implications. Plast Reconstr Surg 1996;98:195–210.
Koshima I, Moriguchi T, Etoh H, et al. The radial artery perforator-
based adipofascial flap for dorsal hand coverage. Ann Plast Surg
1995;35:474–9.
Labow BI, Rosen H, Pap SA, et al. Microsurgical reconstruction: a more
conservative method of managing large scalp defects? J Reconstr
Microsurg 2009;25:465–74.
Lu KH. The forearm radial arterial turnover flap and its clinical applica­
tions. Zhonghua Wai Ke Za Zhi 1982;20:695–7.
Lutz BS, Wei FC, Chang SC, et al. Donor site morbidity after suprafas­
cial elevation of the radial forearm flap: a prospective study in 95
consecutive cases. Plast Reconstr Surg 1999;103:132–7.
Ma S, Cheng K, Liu Y. Sensibility following innervated free radial
forearm flap for penile reconstruction. Plast Reconstr Surg 2011;
127:235–41.
Mahmoud M, El Shafie S, Coppola EE, et al. Perforator-based radial
forearm fascial flap for management of recurrent carpal tunnel syn­
drome. J Hand Surg [Am] 2013;38:2151–8.
Mühlbauer W, Herndl E, Stock W. The forearm flap. Plast Reconstr
Surg 1982;70:336–44.
Parrett BM, Pomahac B, Orgill DP, et al. The role of free-tissue transfer
for head and neck burn reconstruction. Plast Reconstr Surg
2007;120:1871–8.
Pickford MA, Soutar DS. Intraoral reconstruction using a second free
flap for recurrent or metachronous carcinoma. Br J Plast Surg
1995;48:559–63.
Pribaz JJ, Weiss DD, Mulliken JB, et al. Prelaminated free flap recon­
struction of complex central facial defects. Plast Reconstr Surg
1999;104:357–65.
Sinclair CF, Gleysteen JP, Zimmermann TM, et al. Assessment of donor
site morbidity for free radial forearm osteocutaneous flaps. Micro­
surgery 2012;32:255–60.
Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg
1982;9:21–6.
Soutar DS, McGregor IA. The radial forearm flap in intraoral recon­
struction: the experience of 60 consecutive cases. Plast Reconstr Surg
1986;78:1–8.
Soutar DS, Scheker LR, Tanner NS, et al. The radial forearm flap:
a versatile method for intra-oral reconstruction. Br J Plast Surg
1983;36:1–8.
Stock W, Muhlhauer W, Biemer E. The neurovascular forearm island
flap. Z Plast Chir 1981;5:158–65.
Strauch B, Yu H-L. Atlas of microvascular surgery: anatomy and opera­
tive approaches. 2nd ed. New York: Thieme; 2006.
Taghinia AH, Carty M, Upton J. Fascial flaps for hand reconstruction.
J Hand Surg [Am] 2010;35:1351–5.
Taylor IG. The angiosome concept in tissue transfer. Boca Raton, FL:
CRC Press; 2013.
Timmons MJ. The vascular basis of the radial forearm flap. Plast Recon­
str Surg 1986;77:80–92.
Upton J, Havlik RJ, Coombs CJ. Use of forearm flaps for the severely
contracted first web space in children with congenital malformations.
J Hand Surg [Am] 1996;21:470–7.
Vriens JP, Acosta R, Soutar DS, et al. Recovery of sensation in the radial
forearm free flap in oral reconstruction. Plast Reconstr Surg 1996;
98:649–56.
Yang G, Chen B, Gao Y, et al. Forearm free skin flap transplantation.
Natl Med J China 1981;61:139–42.

540
Local Flaps in the Foot
Kevin D. Han  |  Karen Kim Evans  |  Christopher E. Attinger
48 
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION G  —  LOCAL AND FREE FLAPS IN THE LOWER EXTREMITY
INTRODUCTION
“It is not uncommon to find split skin grafts applied to an
ulcer bed as the sole method of treatment. This can be suc­
cessful, but failure is a common end result … because of a
failure to treat the primary disease and an unreceptive bed
of fibro-granulation tissue and/or underlying bone to
support the thin split skin.” Ger1,2 first documented the
usage of lower extremity muscle flaps to treat advanced
stasis ulcers of the lower leg in cases where split-thickness
skin graft had previously failed. He introduced vascularized
muscle to prepare the wound beds for eventual skin graft­
ing. He recognized that flexor digitorum longus, though
deficient in its distal bulk, can be easily mobilized without
disturbing its vascular supply to cover a variety of defects in
the lower tibia.
Functional restoration of the complex and highly effi­
cient biomechanics of the foot and ankle is a challenge for
the reconstructive surgeon. Trauma, tumor ablation, neu­
ropathy, motor dysfunction, skeletal instability, blood supply
abnormalities, and immunocompromise can render the
foot and ankle susceptible to breakdown. Inability to salvage
the injured foot traditionally has led to major amputation,
carrying with it morbid sequelae and an expensive lifetime
dependence on prosthetic devices. Successful foot and
ankle reconstruction demands a multidisciplinary team
approach consisting ideally of a vascular surgeon skilled in
endovascular and bypass techniques; a foot and ankle
surgeon skilled in internal and external (Ilizarov) bone sta­
bilization techniques; a soft tissue surgeon for soft tissue
reconstructive techniques; an infectious disease specialist;
and an endocrinologist. Surgical goals include ensuring a
good local blood supply; debriding the wound to a clean
base; correcting any biomechanical abnormality; preparing
the wound for closure; closing the wound; and providing
adequate off-loading to allow for healing. Reconstruction
can then usually be accomplished by simple techniques 90%
of the time and by complex flap reconstruction in 10% of
cases. This chapter will focus on intrinsic pedicled flaps of
the foot and ankle that are commonly used. Microsurgical
free flaps can accomplish the same task for small defects and
can fill larger defects. They do require an intact recipient
vessel and a longer procedure with greater anesthetic risk.
The success rates of both intrinsic muscle flaps and free
flaps in the lower extremity are the same, although the
complications associated with the former is twice that of the
latter.
VASCULAR ANATOMY (Fig. 48.1 and Figs 13.7,
13.9, 13.10, 13.11, 13.15, 13.16 and 13.19)
The foot and ankle consist of six angiosomes. The following
arteries feed the angiosomes of the foot and ankle: (a) the
distal anterior tibial artery feeds the anterior ankle while
its continuation, the dorsalis pedis artery, supplies the
dorsum of the foot; (b) the calcaneal branch of the poste­
rior tibial artery feeds the medial and plantar heel; (c) the
calcaneal branch of the peroneal artery feeds the lateral and
plantar heel; (d) the anterior perforating branch of the
peroneal artery feeds the anterolateral ankle; (e) the medial
plantar artery feeds the plantar instep; and (f) the lateral
plantar artery feeds the lateral plantar midfoot and forefoot
(Fig. 48.2). Note that the plantar heel receives dual blood
supply from the calcaneal branches of the posterior tibial
and peroneal arteries. When the heel develops gangrene,
this usually implies severe vascular disease involving both
the peroneal and posterior tibial artery.
Because the foot is an end organ, there are many arterial–
arterial anastomoses that provide a duplication of inflow.
These arterial–arterial anastomoses provide a margin of
safety if one of the main arteries becomes occluded. At the
ankle, the anterior perforating branch of the peroneal
artery is connected to the anterior tibial artery through the
lateral malleolar artery. At the Lisfranc joint, the dorsalis
pedis artery dives into the first interspace to connect directly
with the lateral plantar artery. This vascular loop is critical
in determining the direction of flow within the anterior
or posterior tibial arteries, which can be antegrade or retro­
grade, or both. In addition, the plantar and dorsal metatar­
sal arteries are linked to one another at the Lisfranc joint
by proximal perforators and at the web space by distal per­
forators. Finally, the posterior tibial artery and peroneal
artery are directly connected deep to the distal Achilles
tendon by 1–3 connecting arteries. Using a Doppler ultra­
sound probe and selective occlusion, one can determine
the patency of these connections as well as the direction
of flow. This is critical in designing local flaps and pedicled
flap.
THE SURAL FLAP
The sural flap is contained in the area of the posterior calf
between the popliteal fossa and midportion of the leg. It is
centered over the mid raphe between the medial and lateral
heads of the gastrocnemius muscle.

CHAPTER 48 — Local Flaps in the Foot
541
Figure 48.1  Sural flap.
Lateral sural
cutaneous nerve
Sural flap
Peroneal artery
Medial head of
gastrocnemius
Lateral head
of gastrocnemius
Tibial nerve
Popliteal artery
and vein
Medial sural
cutaneous nerve
Superficial
sural artery
Posterior tibial
artery
Lesser saphenous
vein
Perforators from
peroneal artery
Common peroneal
nerve
FLAP ANATOMY (Figs 48.1 and 13.9 and 13.19)
Arterial and Venous Supply of the Flap
Dominant:  superficial sural artery
Length: 3 cm
Diameter: 1.4 mm
In a study by Leclère and colleagues,3 a total of 26 flaps
were dissected. Of these, 50% had the takeoff of the super­
ficial sural artery from the medial sural artery; 46% from
the popliteal artery; and the remainder from the lateral
sural artery. They found several perforators coming off the
superficial sural artery along its course down the leg.
Minor:  perforators from the peroneal artery (retrograde
flow)
Length: 1 cm
Diameter: 1 mm
Minor:  perforators from the posterior tibial artery
Length: 1 cm
Diameter: 1 mm
Minor:  neurocutaneous perforators from vasa nervorum
of the sural nerve

542
PART 4 — CONVENTIONAL WORKHORSE FLAPS
PREOPERATIVE PREPARATION
See above for general preoperative evaluation and pre­
paration. A handheld Doppler should be used to investigate
the sural artery perforators and the distal perforators
from the peroneal artery in order to guide the skin paddle
design.
FLAP DESIGN
Anatomic Landmarks
The skin paddle design runs from the popliteal fossa to the
mid-point of the leg. Its width should be at least 3 cm but it
depends on the defect.
General Thoughts About Flap Design
The most common usage for this flap is reverse sural flap
to cover defects for the distal third of the leg. This
distally based reverse sural artery is based on the peroneal
perforators in the distal third of the flap (5–7 cm proximal
to the lateral malleolus). When designing this flap, one
must first determine the pivot point distally (Fig. 48.3).
Special Considerations
In the current setting of perforator flaps, one can harvest
and rotate the flap based on the peroneal perforator. This
avoids placing a defect over the gastrocnemius muscles and
risking less than an ideal donor site should the patient
unfortunately go on to a below knee amputation.
Difference in Design, if Any, When Performing the
Flap as Pedicled or Free
Reverse sural artery flap is used a local flap for reconstruc­
tion of distal third of the leg.
Length: 1 cm
Diameter: 1 mm
In most cases, the arterial component is a plexus of vessels
that travel along the sural nerve and receive retrograde flow
from the peroneal artery perforators (3–6 perforators) 5 cm
above the lateral malleolus.
Venous Drainage of the Flap (Fig. 13.19)
Primary:  venae comitantes of the perforating vessels
named above
Length: 1 cm
Secondary:  subdermal plexus if skin is harvested
Flap Innervation (Fig. 13.19)
Sensory:  medial sural cutaneous nerve
FLAP COMPONENTS
The flap can be harvested as fasciocutaneous, fasciocutane­
ous with muscle, or fascia only.
Advantages
• A good substitute for free flap coverage of lateral, medial,
and posterior ankle defects
Disadvantages
• Venous congestion (common)
• Distal necrosis of the flap
• Bulky (can require secondary debulking procedures)
• Risking a posterior myocutaneous flap for a future below
knee amputation
• In certain patients, a delay procedure should be done
prior to inset.
Figure 48.2  The angiosomes of the foot and ankle. These include (A) the anterior ankle fed by the anterior tibial artery and the dorsum of
the foot fed by the dorsalis pedis artery; (B) the plantar heel fed by the calcaneal branch of the posterior tibial artery, the plantar instep fed
by the medial plantar artery, the lateral plantar midfoot and forefoot fed by the lateral plantar artery; and (C) the anterolateral ankle fed by both
the calcaneal branch and the anterior perforating branch of the peroneal artery.
A
B
C

CHAPTER 48 — Local Flaps in the Foot
543
DONOR SITE CLOSURE AND MANAGEMENT
A split-thickness skin graft is often used to close the donor
site if skin is included in the flap. The donor site may be
closed primarily if it is small or if only fascia was taken.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
• The venous congestion often seen with this flap can be
minimized if the pedicle is harvested with 3 cm of tissue
on either side of the pedicle and with the overlying skin
intact.
• Problems with the venous drainage can be further allevi­
ated by delaying the flap for 7–10 days after ligating the
proximal lesser saphenous vein and sural artery.
• Supercharging of the reversal sural flap can be performed
via anastomosis of the proximal end of the small saphe­
nous vein to any vein in the receipt site.
• The inset of the flap is critical to avoid kinking of the
pedicle. Offloading the flap and heel during the healing
phase is simplified by using an Ilizarov-type frame.
FLAP USAGE
Pedicled
It can be rotated proximally to cover the defects of the
popliteal fossa and upper third of the leg. The reverse flap
reaches the ankle, heel, and foot.
Typical Indications for the Use of This Flap
• Ankle
• Posterior heel
Atypical Indications for the Use of This Flap
• Popliteal fossa
• Knee defects.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES
General
See the Abductor digiti minimi (ADM) section.
Recipient Site
The operated side should be elevated and rested in a plaster
splint.
Donor Site
The donor site is closed primarily if a fascia only flap was
harvested. Standard postoperative occlusive dressings
can be applied. If a skin graft was required, a negative-
pressured vacuum dressing can be used as described
previously.
OUTCOMES
Expected Outcomes
Temporary venous congestion or distal flap loss is often
encountered. The major donor deficit of the flap is the loss
of sensibility along the lateral aspect of the foot and a skin-
grafted depression at the posterior calf donor site that may
pose a problem if the patient later undergoes a below knee
amputation. In a well-vascularized extremity, the pedicle
FLAP DIMENSIONS
Skin Island Dimensions
Length: average 12 cm
Width: average 6 cm
FLAP MARKINGS
The flap is outlined over the raphe between the two heads
of the gastrocnemius muscle. The pedicle can be Dopplered
out by tracing the lesser saphenous vein from the lateral
ankle up to central raphe between the two heads of the
gastrocnemius muscle (Fig. 48.3).
PATIENT POSITIONING
Although the flap can be harvested in the lateral decubitus
position, prone position is preferred.
ANESTHETIC CONSIDERATIONS
The harvesting of this flap should be done under general
anesthesia.
Technique of Flap Harvest
The flap is outlined over the raphe between the two heads
of the gastrocnemius muscle. The pedicle can be found by
Dopplering the lesser saphenous vein from the lateral ankle
up to central raphe between the two heads of the gastroc­
nemius muscle. Flap elevation begins along its proximal
edge. Through this incision, the lesser saphenous vein
superficial to the deep fascia and the sural nerve superficial
(distal) or deep (proximal) to the fascia, is identified and
ligated. The proximal sural nerve stump should be buried
in the proximal gastrocnemius muscle to minimize the
chances of developing a neuroma. The deep fascia, together
with the above structures, is elevated with the flap. The flap
pedicle edges lie 2–3 cm on either side of the lesser saphe­
nous vein. The pedicle can be elevated with or without the
overlying skin. By taking the overlying skin, one avoids
placing excessive twist on the vein as it rotates 180°. The arc
of rotation will provide coverage of the lateral ankle, medial
ankle, and posterior heel.
FLAP MODIFICATION/FLAP HANDLING
When skin is not required, the sural flap can be harvested
with fascia, only leaving the skin in place by undermining
in the subcutaneous plane. If additional bulk is needed to
close dead space in the defect, a part of gastrocnemius
muscle can be harvested with one or two intact myocutane­
ous perforators that would otherwise be divided. One
common complication of the reverse sural flap is venous
congestion and one potential solution is to delay the
flap. The flap is dissected and undermined, as described
previously, but a skin bridge proximally is left intact to
allow venous egress. After 7–10 days, the area of connec­
tion can be divided and the flap can be rotated into the
defect.
Special Instruments
A handheld Doppler should be readily available. A thigh
tourniquet can be used to achieve a bloodless field. A der­
matome can be used for the harvesting of the skin graft.

544
PART 4 — CONVENTIONAL WORKHORSE FLAPS
ADM is a type II muscle with one dominant vascular
pedicle and minor pedicles for its blood supply. The lateral
plantar artery is responsible for both the dominant and
minor pedicles to the flap. The major pedicle arises from
the lateral plantar artery close to the origin of the muscle
(Fig. 48.3).
Venous Drainage of the Flap
Primary:  venae comitantes of the lateral plantar artery
Length: 1 cm (range 1–1.5 cm)
Secondary:  secondary venous systems are not significant.
Flap Innervation (see Figs 13.11 and 13.19)
Sensory:  branches of the sural nerve and lateral plantar
nerves
A small skin paddle receives sensory innervations from
the lateral plantar nerve, and the sural nerve can be included
(not commonly used).
Motor:  branches of lateral plantar nerve
The ADM flap is not used as a motorized flap.
FLAP COMPONENTS
It is commonly taken as a muscle-only flap. Very rarely it is
used as a musculocutaneus pedicled flap.
Advantages
• Ease with dissection
• Low donor site morbidities
Disadvantages
• Small size
• Small amount of distal tissue
• Short arc of rotation
can be removed after 3–4 weeks to improve the contour of
the leg.
Untoward Outcomes
We have seen a near 40% complication rate, mostly due to
venous congestion from a reverse sural flap. Risk factors for
increased complications are older age; history of smoking;
obesity; diabetes; and peripheral vascular disease.
ABDUCTOR DIGITI MINIMI (ADM) FLAP
The ADM (see Figs 13.11 and 13.16) is a triangular muscle
with a wide posterior origin extending from the medial to
the lateral process of the calcaneus, along with the adjacent
intermuscular septum. The bulk of the muscle is found at
the proximal portion of the 5th metatarsal. It ultimately
inserts on the lateral side of the proximal phalanx of the
small toe with the flexor digiti minimi brevis muscles. Ana­
tomic variations can exist, with separate muscle bellies that
stop and start at the opposite base of the 5th metatarsal. The
muscle functions to abduct the small toe.
FLAP ANATOMY (Figs 13.11, 13.16 and 13.19)
Arterial and Venous Supply of the Flap
Dominant:  one dominant pedicle from lateral plantar
artery
Length: 2 cm
Diameter: 0.6 mm
Minor:  minor pedicle(s) from the lateral plantar artery
(1–2)
Length: 1 cm
Diameter: 0.5 mm
Figure 48.3  Abductor digiti minimi. This muscle has a type 2 vascular pattern, with the dominant pedicle at the level of the distal calcaneus.
It is harvested on its dominant proximal pedicle. The distal muscle bulk is often disappointingly small. However, this muscle is useful to fill
small midfoot, rear foot, and distal ankle defects. (From Clemens, M, Colen, L, Attinger, C. Foot reconstruction. In: Neligan P, editor. Plastic surgery,
vol. 4, 3rd ed. Philadelphia: Elsevier; 2012.)4
Medial
plantar
artery
Lateral
plantar
artery
Abductor
digiti minimus
muscle artery
Posterior
tibial artery
Lateral incision site

CHAPTER 48 — Local Flaps in the Foot
545
FLAP DIMENSIONS
Muscle Dimensions
Length: average 10 cm
Width: average 3 cm
FLAP MARKINGS
A line is drawn from the 5th metatarsal-phalangeal joint to
the lateral heel along the glabrous junction between the
dorsum and sole of the foot (Fig. 48.4).
PATIENT POSITIONING
The patient is placed supine with a pillow for adequate
exposure of lateral plantar surface of the foot. Careful
attention to padding for any potential pressure points is
essential.
ANESTHETIC CONSIDERATIONS
The ADM flap can be raised with regional block, especially
in the setting of insensate neuropathic population. If an
PREOPERATIVE PREPARATION
As described previously, a complete understanding of the
wound, a thorough history, and physical exam pertinent to
wound healing should be undertaken. If the wound is
infected, adequate surgical debridement needs to be done.
All patients that undergo local muscle flap surgery require
a thorough Doppler exam, with a complete understanding
of the antegrade and retrograde components of the patient’s
foot blood supply. If there is an abnormality, we recommend
an angiogram or angiography prior to surgery. The lateral
plantar artery coming off the posterior tibial artery must be
patent. If the posterior tibial artery is not palpable over the
tarsal tunnel, handheld Doppler or noninvasive vascular
flow studies or angiography can be used for determining
patency.
FLAP DESIGN
Anatomic Landmarks
Origin: lateral and medial processes of the calcaneus tuber­
osity and the intermuscular septum
Insertion: the lateral base of the 5th proximal phalanx
General Thoughts About Flap Design
A line is drawn from the 5th metatarsal-phalangeal joint to
the lateral heel along the glabrous junction between the
dorsum and sole of the foot (Figs 48.4, 48.5A). A Doppler
probe is used to locate the major as well as the minor ped­
icles. Dissection should proceed from distal to proximal
with loupe magnification, taking care to avoid injury to the
muscle belly.
Special Considerations
Defects of the distal foot and 5th metatarsal joints can be
covered by distally based ADM muscle. Dissection proceeds
from proximal to distal, tying off the major pedicle as it
enters the muscle medially. In our experience, basing this
flap on the minor pedicles is unreliable.
Difference in Design, if Any, When Performing the
Flap as Pedicled or Free
The ADM muscle flap is used as a local flap for reconstruc­
tion of the foot.
Figure 48.4  Abductor digiti minimi. Flap markings.
Figure 48.5  Abductor digiti mini technique (cadaver dissection).
(A) Flap marking. (B) Flap elevated from distal to proximal. (C) The
muscle is pedicled to cover a proximal defect.
A
B
C

546
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Typical Indications for the Use of This Flap.  The ADM
muscle is very useful in repairing small lateral calcaneal soft
tissue defects.
Atypical Indications for the Use of This Flap.  It can also be
used for larger plantar heel defects, when used in conjunc­
tion with either or both the flexor digiti brevis and the AHB
muscle. Further modifications have expanded the indica­
tions to toe reconstruction when it is raised distally.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES
General
A standard postoperative care includes pain control and
management of medical commodities, such as an aggressive
glucose management for diabetics. Perioperative antibiot­
ics, culture-directed when possible, should be used follow­
ing the procedure.
Recipient Site
A bolster dressing or a vacuum-assisted negative-pressure
wound therapy can be used for the first 3–5 postoperative
days to assist in the skin graft taken. The ankle joint should
be immobilized in a neutral position to avoid tension at
the suture line. The patient will need protection of the
flap with a splint, a Cam walker boot, or a cast at discharge
until the first postoperative visit. Patients are typically non-
weightbearing for 4 weeks postoperatively.
Donor Site
The donor site is often closely primarily. Standard postop­
erative occlusive dressings can be used for the first 2 days
after the procedure.
OUTCOMES
Expected Outcomes
With adequate flap protection, we expect the flap to survive.
Based on our experience, the flap has at least a 96% success
rate in the diabetic and non-diabetic population, which is
comparable with microsurgical reconstruction in a similar
population.
Untoward Outcomes
Without adequate blood glucose control and management of
comorbidities, and avoidance of vasoconstrictive substances
(tobacco), patients can develop total or partial flap loss.
ABDUCTOR HALLUCIS (AH) FLAP
The abductor hallucis (AH) muscle is located in the medial
plantar region between the great toe and the base of the
heel. The muscle arises from the calcaneus medially with a
wide muscle belly, and then tapers into a long tendinous
insertion to the great toe. The muscle is expendable and
functions to abduct the great toe.
FLAP ANATOMY (see Fig. 48.6 and Figs 13.11 and 13.19)
Arterial and Venous Supply of the Flap
Dominant:  proximal branch of medial plantar artery
Length: 2 cm
Diameter: 0.6 mm
ankle block is to be used, 5 mL of 0.5% bupivacaine injected
at the tarsal tunnel is required, with a wheel extending
anteriorly around the ankle covering medial and lateral
cutaneus branches of the superficial peroneal nerve and
sural nerve.
TECHNIQUE OF FLAP HARVEST
A line is drawn from the 5th metatarsal-phalangeal joint
to the lateral heel along the glabrous junction between
the dorsum and sole of the foot. The incision is then made
following the line drawn and taken down to the level of
the muscle. The muscle is detached from the lateral
5th metatarsal-phalangeal joint by dividing the tendinous
insertion. It is then elevated off of the flexor digiti minimi
until one reaches the proximal portion of the 5th meta­
tarsal. Once it has been divided from the insertion, a
suture is placed in the distal tendon to allow manipulation
and dissection with minimal trauma. The minor pedicles
enter the muscle medially. The dominant pedicle is at
the medial posterior corner of the cavity that houses the
main bulk of the muscle belly and is derived from the
lateral plantar neurovascular bundle (Fig. 48.3). A Doppler
probe is used throughout the case to mark the major as
well as the minor pedicles. The origin of the muscle can
be detached off of the lateral calcaneus for improved
mobilization of the muscle. The muscle is inset using
either PDS or Prolene suture. A split-thickness skin graft is
subsequently harvested and secured on top of the muscle
flap if necessary. The donor site can be closed primarily
(Fig. 48.5).
FLAP MODIFICATION/FLAP HANDLING
The ADM muscle flap can be used in conjunction with other
intrinsic muscle flaps of the foot for coverage of larger
defects. ADM can be used with abductor hallucis brevis to
cover a larger plantar heel defect. ADM can be used with
extensor digitorum brevis for the coverage of lateral malleo­
lar soft tissue defects.
Special Instruments
A handheld Doppler should be readily available. A derma­
tome can be used for the harvesting of the skin graft.
DONOR SITE CLOSURE AND MANAGEMENT
Donor site can be closed primarily when a muscle-only
flap is harvested. With a musculocutaneous flap, a split-
thickness skin graft will likely be needed to close the donor
defect.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
• Avoid tension near the posterior aspect of flexor digito­
rum brevis (FDB), where the pedicle will rotate.
• Distal elevation of adherent attachment to the base of the
5th metatarsal bone requires care.
FLAP USAGE
Pedicled
The muscle has a small arc of rotation. It will cover small
defects on the distal lateral ankle, distal Achilles tendon,
and distal fibula.

CHAPTER 48 — Local Flaps in the Foot
547
Advantages
• Easy dissection
• Medial glabrous junction incision
• Bulky proximal muscle
Disadvantages
• Small arch of rotation
• Thin muscle belly distally
PREOPERATIVE PREPARATION
See the Abductor digiti minimi (ADM) section. Similarly to
ADM, the medial plantar artery comes off the posterior
tibial (PT) artery. The PT artery must have a palpable pulse.
If PT is not palpable, handheld Doppler exams, along with
noninvasive vascular studies or angiography must be per­
formed prior to harvesting the muscle flap.
FLAP DESIGN
Anatomic Landmarks
Origin: calcaneus and adjacent plantar fascia and intermus­
cular septum
Insertion: medial aspect of the proximal phalanx of the
great toe.
General Thoughts About Flap Design
The approach to the muscle is through a medial foot inci­
sion (Figs 48.7, 48.8A). The muscle is identified distally at
the level of medial first metatarsal bone. A Doppler is used
to identify the proximal dominant pedicle and distally based
minor pedicles. As with ADM harvesting, dissection should
proceed from distal to proximal with loupe magnification.
Minor:  minor branches of medial plantar artery (2–3
branches)
Length: 1.5 cm
Diameter: 0.5 mm
The medial plantar artery courses between the AH muscle
and flexor digitorum brevis and flexor hallucis brevis
muscles. AH is a type II muscle with one proximal dominant
pedicle and 2–3 minor pedicles (Fig. 48.6).
Venous Drainage of the Flap
Primary:  venae comitantes of the lateral plantar artery
Length: 1 cm (Range 1–1.5 cm)
Secondary:  secondary venous systems are not significant.
Flap Innervation (see Figs 13.11 and 13.19)
Sensory:  medial plantar nerve
It may be included with a skin island over the AH muscle
but often is not. A sensate skin flap is more often designed
as the medial plantar artery fasciocutaneous flap without
elevating the AH muscle.
Motor:  branch of medial plantar nerve
The AH muscle is not used as a motorized flap for recon­
struction of the foot.
FLAP COMPONENTS
It is commonly taken as a muscle-only flap for reconstruc­
tion of the foot. But it can used as a musculocutaneus ped­
icled flap (3 × 10 cm V-Y advancement flap).
Figure 48.6  Abductor hallucis. This muscle has a type 2 vascular pattern, with the dominant pedicle at the level of the distal calcaneus.
It is harvested on its dominant proximal pedicle. The distal muscle bulk is often disappointingly small. However, this muscle is useful to fill
small midfoot, rear foot, and distal ankle defects. (From Clemens, M, Colen, L, Attinger, C. Foot reconstruction. In: Neligan P, editor. Plastic surgery,
vol. 4, 3rd ed. Philadelphia: Elsevier; 2012.)4
Abductor
hallucis
brevis
Medial
plantar
artery
Posterior
tibial artery
Medial incision site

548
PART 4 — CONVENTIONAL WORKHORSE FLAPS
FLAP DIMENSIONS
Muscle Dimensions
Length: average 10 cm
Width: average 3 cm
FLAP MARKINGS
A linear medial foot incision is marked along the medial
glabrous junction to expose the muscle (Figs 48.7, 48.8A).
PATIENT POSITIONING
The patient can be placed supine with a frog-leg position to
expose the medial aspect of the foot. The muscle can also
be harvested prone or in a lateral decubitus position.
ANESTHETIC CONSIDERATIONS
The AH muscle can also be raised with regional blocks,
especially in the setting of an insensate neuropathic
population.
TECHNIQUE OF FLAP HARVEST
The flap (Fig. 48.8) is elevated through a medial foot inci­
sion along the medial glabrous junction. The tendon is
divided distally and the muscle is separated from the medial
head of the flexor hallucis brevis that has a distinct blood
supply. Since both muscles are intertwined distally, it is
easier to separate both by starting to tease them apart at the
proximal first metatarsal. Because the blood supply enters
the muscle proximally at the distal tarsal tunnel as dominant
pedicle(s) from the medial plantar artery, the more distal
pedicles can be safely ligated. If an increase in the arc of
rotation is needed, the medial plantar artery may be ligated
distal to the proximal muscle and the origin is detached off
of the medial calcaneus.
Special Considerations
Based on its proximal dominant vascular pedicles, the
muscle can rotate from distal to proximal to cover defects
of medial malleolus and medial ankle. Less frequently, the
muscle can be rotated distally to cover metatarsal base
defects by dividing the origin at the calcaneus. A V-Y skin
island is designed with its base distal, centered over the long
axis of the muscle. Muscle dissection is done as described
previously, while preserving the minor pedicles distally. This
will allow a V-Y translocation of the myocutaneous flap to
cover metatarsal base defects.
Difference in Design, if Any, When Performing
the Flap as Pedicled or Free
The AH muscle flap is used as local flap for reconstruction
of the foot.
Figure 48.7  Abductor hallucis. Flap markings.
Figure 48.8  Technique of flap harvest. Abductor hallucis (cadaver dissection). (A) Flap marking. (B) Flap elevated from distal to proximal.
(C) Muscle completed isolated on its vascular pedicle.
A
B
C

CHAPTER 48 — Local Flaps in the Foot
549
Untoward Outcomes
Without adequate blood glucose control and management
of comorbidities, patients can develop total or partial flap
loss. The flap is less reliable if it is distally based to cover
distal metatarsal defects. As with all local flaps, we advise
patients to avoid any vasoconstrictive products, such as
tobacco.
FLEXOR DIGITORUM BREVIS (FDB) FLAP
The flexor digitorum brevis (FDB) (see Fig. 13.11) muscle
lies deep to the plantar fascia and is bordered by the abduc­
tor hallucis medially and abductor digiti minimi laterally. It
originates from the medial process of calcaneus and plantar
fascia and inserts onto middle phalanges of the 2nd to 5th
toes. It is responsible for toe flexion and it is expandable
with an intact flexor digitorum longus.
FLAP ANATOMY (see Figs 13.11 and 13.19)
Arterial and Venous Supply of the Flap
Dominant:  proximal branch of the medial plantar artery
Length: 1–2 cm
Diameter: 0.6 mm
The pedicle enters the medial deep surface of the muscle
proximally.
Dominant:  proximal branch of the lateral plantar artery
Length: 1–2 cm
Diameter: 0.6 mm
The pedicle enters the lateral deep surface of the muscle
proximally.
Minor:  minor pedicle(s) from the medial plantar artery
(2–3)
Length: 1 cm
Diameter: 0.5 mm
Minor:  minor pedicle(s) from the lateral plantar artery
(2–3)
Length: 1 cm
Diameter: 0.5 mm
Venous Drainage of the Flap
Primary:  venae comitantes of the lateral plantar artery
and medial plantar artery into posterior tibial veins
Length: 1 cm
Secondary:  secondary venous systems are not significant.
Flap Innervation (see Figs 13.11 and 13.19)
Sensory:  branches of calcaneal nerves and medial plantar
nerves innervate the skin overlying the medial and proximal
portions of the muscle.
The lateral plantar nerves provide sensation of the distal
lateral aspect of the skin.
Motor:  branches of medial plantar nerve
FLAP MODIFICATION/FLAP HANDLING
The abductor hallucis muscle flap may be elevated in com­
bination with medial plantar artery fasciocutaneous flap
when skin and bulk are desired. Though these authors do
not use the reverse flap, the AH muscle can be harvested
with a small skin island to cover distal metatarsal defects.
Special Instruments
A handheld Doppler should be readily available. A thigh or
ankle tourniquet can be used to achieve a bloodless field. A
dermatome can be used for the harvesting of the skin graft.
DONOR SITE CLOSURE AND MANAGEMENT
The donor site can be closed primarily.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
• Meticulous distal dissection to preserve the medial plantar
artery branches
• Tenodesis of remaining proximal AH tendon into the
medial proximal metatarsal using an anchor stitch to
avoid the hallux drifting into hallux valgus
FLAP USAGE
Pedicled
A small arc of superior rotation that will reach medial mal­
leolus and medial ankle.
Typical Indications for the Use of This Flap
• Medial malleolus
• Medial plantar heel
• Tarsal tunnel
Atypical Indications for the Use of This Flap.  As described
in the previous section, AH muscle can be harvested with
medial plantar artery fasciocutaneous flap to increase the
bulk of the flap. At the same time, a distal arc rotation is
possible to cover small defects at the metatarsals.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES
General
See the Abductor digiti minimi (ADM) section.
Recipient Site
See the Abductor digiti minimi (ADM) section.
Donor Site
See the Abductor digiti minimi (ADM) section.
OUTCOMES
Expected Outcomes
With adequate flap protection, we expect the flap to survive.
However, partial skin graft loss over the muscle is not uncom­
mon. It is generally treated with local wound care. Skin graft
loss can sometimes be avoided by trimming as much tendon
as possible to avoid grafting directly over the tendinous part
of the muscle. Other options include using a neodermis,
such as Integra (Integra LifeSciences Corp., Plainsboro, NJ)
over the tendinous portion and skin grafting in a secondary
setting.

550
PART 4 — CONVENTIONAL WORKHORSE FLAPS
PATIENT POSITIONING
The patient is placed in the supine position. The prone
or lateral decubitus position can also be used. Careful
attention to padding for any potential pressure points is
essential.
ANESTHETIC CONSIDERATIONS
The FDB flap can be raised with a regional block, especially
in the insensate neuropathic population. However, general
anesthesia is preferred if any osteotomy is planned at the
recipient site.
TECHNIQUE OF FLAP HARVEST
A midline plantar foot incision is used to expose the muscle
for elevation through the skin and plantar fascia. The skin
and plantar fascia are elevated medially and laterally off
the underlying muscle. The four small flexor tendons are
divided distally and sewn together to avoid damaging the
muscle during harvest. The muscle is then dissected off
the quadratus plantaris muscle. Further mobilization is pos­
sible by continuing the pedicle dissection as proximal as
the origin of the lateral plantar artery in the tarsal tunnel.
The muscle is then turned over 180° to fill the defect
(Fig. 48.10).
FLAP MODIFICATION/FLAP HANDLING
We typically use this flap as a muscle-only flap. However, if
a myocutaneous flap is planned, a skin island is based over
the non-weightbearing aspect bordered by the 2nd and 4th
metatarsals. The lateral plantar artery and associated venae
comitantes are divided in the midfoot and are included with
the flap. The nerve is not included in the flap unless a neu­
rosensory flap is planned. The flap can then be divided at
its origin to allow complete mobilization.
The FDB flap is not used as a motorized flap for recon­
struction of the foot.
FLAP COMPONENTS
It is commonly taken as a muscle-only flap.
Advantages
• Easy dissection
• A local option for small defects of the plantar heel.
Disadvantages
• Very limited bulk
• Limited reach
• Not durable if needs skin graft
PREOPERATIVE PREPARATION
See the Abductor digiti minimi (ADM) section.
The lateral plantar artery and medial plantar artery
coming off the posterior tibial artery must be patent. If
posterior tibial artery is not palpable over the tarsal tunnel,
non-invasive vascular flow studies or angiography can be
used for determining patency.
FLAP DESIGN
Anatomic Landmarks
Origin: medial process of the calcaneus, plantar aponeuro­
sis, and intermuscular septum
Insertion: middle phalanges of the 2nd to 5th toes
General Thoughts About Flap Design
When muscle-only flap is to be used, a linear incision along
the length of the 3rd metatarsal is used for exposure. A
Doppler probe is used to locate the major pedicles and
minor pedicles. This is a small muscle that is typically used
to fill smaller, deep defects of the plantar heel when local
plantar skin can close primarily over the rotated muscle
(Figs 48.9, 48.10A).
Special Considerations
A reverse flap can be accomplished with an intact distal
plantar arch to cover distal foot defects. A muscle-only
reverse flap can be harvested in the standard fashion. A V-Y
myocutaneous advancement flap is also an option that
allows a maximal advancement of 2–3 cm.
Difference in Design, if Any, When Performing the
Flap as Pedicled or Free
The FDB muscle or myocutaneous flap is used as a local flap
for reconstruction of the foot.
FLAP DIMENSIONS
Muscle Dimensions
Length: Average 10 cm
Width: Average 4 cm
Skin Dimensions
Length: Average 12 cm
Width: Average 5 cm
FLAP MARKINGS
A midline plantar foot incision is marked to expose the
muscle for elevation through the skin and plantar fascia
(Fig. 48.9).
Figure 48.9  Flexor digitorum brevis muscle. Flap markings. A
midline plantar foot incision is used to expose the muscle for eleva­
tion through the skin and plantar fascia.

CHAPTER 48 — Local Flaps in the Foot 550.e1
Figure 48.10  Technique of flap harvest. Flexor digitorum brevis.
(A) Flap marking. (B) Flap isolated on its pedicle.
A
B

CHAPTER 48 — Local Flaps in the Foot
551
graft due to lack of durability of the skin graft on this weight­
bearing surface.
EXTENSOR DIGITORUM BREVIS (EDB) FLAP
The extensor digitorum brevis (EDB) is a thin muscle
located on the dorsum of the foot, located deep to the
tendons of extensor digitorum longus muscle. The muscle
is expandable as long as extensor digitorum longus and
extensor hallucis longus are intact.
FLAP ANATOMY (see Fig. 48.11 and Figs 13.15
and 13.19)
Arterial and Venous Supply of the Flap
Dominant:  one dominant pedicle from lateral tarsal
artery
Length: 1 cm
Diameter: 0.6 mm
Minor:  minor pedicle from dorsalis pedis artery
Length: 1 cm
Diameter: 0.5 mm
EDB is a type II muscle and has a dominant pedicle from
the lateral tarsal artery derived from dorsalis pedis artery
located at the distal edge of the extensor retinaculum. The
minor pedicle is located about 1–3 cm distal to the main
artery (Fig. 48.11).
Special Instruments
A handheld Doppler should be readily available.
DONOR SITE CLOSURE AND MANAGEMENT
The donor site can be closed primarily. Care should be
taken to reapproximate the plantar fascia.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
• The 4-flexor tendons are divided distally and sewn
together to avoid damaging the muscle during harvest.
• When covering soft tissue defects of the heel with this
flap, the outcome is better if the EDB is covered with
glabrous skin.
• The flap is best based on the lateral rather than medial
plantar circulation.
FLAP USAGE
Pedicled
This muscle-only flap has a 180° arc of rotation to cover
defects of plantar heel.
Typical Indications for the Use of This Flap.  The muscle-
only flap is very useful to cover defects of plantar heel.
Atypical Indications for the Use of This Flap.  With ade­
quate pedicle dissection, the flap can potentially reach the
ankle and posterior heel and Achilles areas.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES
General
See the Abductor digiti minimi (ADM) section.
Recipient Site
The patient will need protection of the flap with a splint
immobilization. Compliant patients may be permitted to
ambulate with crutches with strict non-weightbearing of the
operated limb. Limb elevation is key to avoid postoperative
swelling. One can use an Ilizarov frame to offload the heel
in the non-compliant patients until the wound heals in
about 3–4 weeks after surgery.
Donor Site
The donor site is often closely primarily with a small suction
train, which can be removed in the first postoperative
day. If a myocutaneous flap was harvested with a non-
weightbearing area of the foot, a split thickness or full thick­
ness skin needs to be used to cover the donor site.
OUTCOMES
Expected Outcomes
With adequate flap protection, we expect the flap to survive.
Untoward Outcomes
Without adequate blood glucose control and management
of comorbidities, patients can develop total or partial flap
loss. In particular, weightbearing on the flap will cause flap
loss. If a skin graft was needed to replace glabrous skin, one
should expect poor outcome with eventual loss of the skin
Figure 48.11  The extensor digitorum brevis muscle flap. This
type 2 muscle has a blood supply derived from the lateral tarsal
artery, which is a branch of the dorsalis pedis artery. (From Clemens,
M, Colen, L, Attinger, C. Foot reconstruction. In: Neligan P, editor.
Plastic surgery, vol. 4, 3rd ed. Philadelphia: Elsevier; 2012.)4
Extensor retinaculum
Lateral tarsal
artery
Dorsalis pedis
artery
Extensor hallucis
brevis muscle
Extensor digitorum
brevis muscle
Skin incision

552
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Difference in Design, if Any, When Performing the
Flap as Pedicled or Free
The EDB muscle is used as a local flap for reconstruction
of the foot.
FLAP DIMENSIONS
Muscle Dimensions
Length: average 6 cm
Width: average 4.5 cm
FLAP MARKINGS
Exposure is obtained through a curvilinear incision marked
on the foot dorsum that communicates with the wound to
be closed (Fig. 48.12).
PATIENT POSITIONING
The patient is placed in a supine position.
ANESTHETIC CONSIDERATIONS
The EDB muscle flap is best harvested under general
anesthesia.
TECHNIQUE OF FLAP HARVEST
Exposure is obtained through a curvilinear incision on the
foot dorsum that communicates with the wound to be
closed. Division of the dorsalis pedis proximally or distal to
the lateral tarsal artery increases the reach of the flap but
can only be done in the setting of an intact arch and it
increases the proximal reach (distal division) or distal reach
(proximal division). We do not recommend this in diabetic
patients with peripheral vascular disease. The long exten­
sors are then retracted off of the underlying short extensor
muscle slips to the 1st, 2nd, 3rd, and 4th toes. The distal
Venous Drainage of the Flap
Primary:  venae comitantes of lateral tarsal artery
Length: 1 cm
Secondary:  secondary venous systems are not significant.
Flap Innervation
Sensory:  branches of superficial and deep peroneal nerves
Only if the dorsum skin is also harvested as a dorsalis
pedis artery fasciocutaneous flap.
Motor:  lateral branch of the peroneal nerve
The EDB flap is not used as a motorized flap for recon­
struction of the foot.
FLAP COMPONENTS
It is commonly taken as a muscle-only flap.
Advantages
• Very useful for anterior ankle defects or coverage of vas­
cular grafts in the anterior leg
• Easy dissection.
Disadvantages
• Small slips of muscle
• Limited mobility
• Can only divide dorsalis pedis to increase distal or proxi­
mal reach with an intact arch
PREOPERATIVE PREPARATION
As above. The patency of dorsalis pedis artery is essential for
perfusion of the EDB flap. Harvesting the EDB muscle with
proximal dorsalis pedis artery is contraindicated if there is
no retrograde flow to the feed the distal dorsalis pedis,
therefore causing necrosis to dorsal skin of the foot after
the flap harvesting.
FLAP DESIGN
Anatomic Landmarks
Origin: distal and lateral portions of the calcaneus, lateral
talocalcaneal ligament
Insertion: dorsal surfaces of first four toes
General Thoughts About Flap Design
The dorsalis pedis artery and lateral tarsal arteries are iden­
tified by a handheld Doppler. The quality of antegrade flow
via dorsalis pedis artery is verified by manual occlusion of
the posterior tibial artery. Retrograde flow can be checked
by occluding the dorsalis pedis artery proximal to the take-
off of the lateral tarsal artery. Exposure of the muscle is
obtained through a curvilinear incision on the dorsum of
the foot (Fig. 48.12).
Special Considerations
The EDB muscle may also be raised as a distally based
reverse-flow muscle flap. It is supplied by the distal branch
of the dorsalis pedis artery, by receiving retrograde flow
from the lateral plantar artery. However, this muscle flap has
a small arc of rotation.
Figure 48.12  Extensor digitorum brevis. Flap markings. The length
of the curvilinear incision depends on the location of the wound.

CHAPTER 48 — Local Flaps in the Foot
553
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
To extend its reach, the dominant pedicle has to be har­
vested with the proximal or distal dorsalis pedis. If that is
the case, there has to be an intact antegrade or retrograde
flow along the dorsalis pedis.
FLAP USAGE
Pedicled
Typical Indications for the Use of This Flap.  As an ante­
grade muscle flap, the EDB will cover anterior ankle defects
and proximal dorsum of the foot in the setting of trauma
and oncological resections.
Atypical Indications for the Use of This Flap.  With ade­
quate dissection, an antegrade-based EDB muscle flap can
also cover lateral malleolar defects and lateral calcaneus
defects. Infrequently, EDB muscle can be designed as a
distally based reverse-flow flap to cover the distal forefoot.
Free Flap
EDB muscle has been described as a free flap to recon­
struct small defects of the hand. It also has been described
to act as a free flap for contralateral foot and ankle
defects. If there is a good antegrade and retrograde flow
along the dorsalis pedis artery, the tarsal artery can be
harvested with a segment of the dorsalis pedis artery to
increase pedicle length for free tissue transfer. It has also
been used as functional muscle free flap for facial
reanimation.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES
General
See the Abductor digiti minimi (ADM) section.
Recipient Site
Skin graft care is done as described above. After 1 week
of strict limb elevation and immobilization, partial weight­
bearing can begin and full weightbearing can be started at
4–6 weeks.
Donor Site
The donor site is often closely primarily. Standard postop­
erative occlusive dressings can be used for the first 2 days
after the procedure.
OUTCOMES
Expected Outcomes
With adequate flap protection, we expect the flap to
survive.
Untoward Outcomes
Without adequate blood glucose control and management
of comorbidities, patients can develop total or partial flap
loss. This is especially true in the setting of vasoconstrictive
substances, such as tobacco. Delayed wound healing and
donor site partial necrosis can occur if aggressive skin
undermining occurred during the muscle harvesting.
Figure 48.13  Harvest of the extensor digitorum brevis muscle.
The dorsalis pedis artery can be divided distal to the origin of the
lateral tarsal vessels to provide for increased arc of the rotation for
muscle transposition. The four slips of the muscle are broad and thin,
measuring 4.5 × 6 cm in the adult, making the flap useful for relatively
small wounds. (From Clemens, M, Colen, L, Attinger, C. Foot recon­
struction. In: Neligan P, editor. Plastic surgery, vol. 4, 3rd ed. Philadel­
phia: Elsevier; 2012.)4
Dorsalis pedis
artery
Extensor hallucis
brevis muscle
Extensor digitorum
brevis muscle
tendons 1–4 of the EDB are divided and sewn together
during the harvest, so that the slips of muscle do not sepa­
rate during the dissection. The lateral minor tarsal branches
are ligated as the dissection proceeds proximally. Elevate the
lateral tarsal vessel with the muscle while dividing the origin
of the muscle off the calcaneus. The muscle flap can then
be skin grafted (Fig. 48.13).
FLAP MODIFICATION/FLAP HANDLING
The dorsalis pedis artery also provides blood flow to the
second metatarsal osteocutaneous flap. EDB can be har­
vested in conjunction with this flap.
Special Instruments
A handheld Doppler should be readily available. A derma­
tome can be used for the harvesting of the skin graft. A
tourniquet and a bipolar electrocautery can be useful to
maintain a bloodless flap dissection.
DONOR SITE CLOSURE AND MANAGEMENT
The donor site can be closed primarily when a muscle-only
flap was harvested. If dorsum skin is not sufficient for
primary closure, a split-thickness skin graft or in conjunc­
tion with a neodermis, such as Integra (Integra LifeSciences
Corp., Plainsboro, NJ), can be used.

554
PART 4 — CONVENTIONAL WORKHORSE FLAPS
FLAP DESIGN
Anatomic Landmarks
After the perforating branch of the peroneal artery has
been located with the handheld Doppler, the base of the
flap should be centered at this point. Flap width includes
the tissue between the fibula and tibia. The length should
be adequate to reach the malleolus or more distally, as dic­
tated by wound location (Figs 48.14, 48.15A).
General Thoughts About Flap Design
If the flap is designed as a rotation flap, the arc of rotation
is small but the flap maintains continuity of the perforating
branch and no vascular dissection is required.
Special Considerations
A proximally based pedicled flap is based on anterior lateral
malleolar artery. A more commonly used distally based ped­
icled flap is based on the perforating branch, which is
ligated just proximal to the cutaneous branch and released
as far as the sinus tarsi, where it constitutes the pivot point
of the pedicle.
Difference in Design, if Any, When Performing the
Flap as Pedicled or Free
Lateral supramalleolar flap is used as a local rotational or
pedicled flap for reconstruction of the foot.
FLAP DIMENSIONS
Skin Island Dimensions
Length: average 20 cm
Width: average 8 cm
LATERAL SUPRAMALLEOLAR FLAP
A lateral supramalleolar flap is supplied by the cutaneous
branches of the anterior perforating branch from the pero­
neal artery. It can be used as a rotational flap and a reversed
pedicled flap. It has been most useful in coverage of bony
defects that accompany loss of soft tissue over the lateral
malleolus and anterior ankle.
FLAP ANATOMY (see Figs 13.7, 13.8, 13.16 and 13.19)
Arterial and Venous Supply of the Flap
Dominant:  anterior perforating branch of the peroneal
artery
Length: 8 cm
Diameter: 0.6 mm
Skin perforators off the anterior perforating branch of
the peroneal artery as it pierces the interosseous membrane
5 cm proximal to the tip of the lateral malleolus. Cutaneous
vessels then course upward, from the medial to the fibula,
and anastomose with the vascular network that accompanies
the superficial peroneal nerve.
Venous Drainage of the Flap
Primary:  venae comitantes of the anterior perforating
branch
Length: 8 cm
Flap Innervation (see Figs 13.7 and 13.8)
Sensory:  branches of superficial peroneal nerve
This fasciocutaneous or fascia-only flap is raised and
often does not include sensory nerves. Since the superficial
peroneal nerve must be divided in order to elevate and
rotate the flap, a sensate flap can only be achieved by coapta­
tion of the superficial peroneal nerve to a nerve at the
recipient site.
FLAP COMPONENTS
The flap can be harvested as a fasciocutaneous flap but can
also be harvested as a fascia-only flap with a skin graft for
coverage.
Advantages
• Combined cutaneous and bony defects over the lateral
malleolus and anterior ankle
• Thin and pliable
• No donor site defect for fascial only flap
Disadvantages
• Limited size for proximally based flap
• Tedious dissection
• Donor site morbidities for fasciocutaneous flap
PREOPERATIVE PREPARATION
See above for general preoperative evaluation and prepara­
tion. A handheld Doppler can be used to investigate ante­
rior perforating branch of the peroneal artery.
Figure 48.14  Lateral supramalleolar flap. Flap markings. The per­
forating branch of the peroneal artery has been marked by a cross;
the base of the flap is centered on this point. Flap width includes the
tissue between the fibula and tibia. The length should be adequate
to reach the wound location.

CHAPTER 48 — Local Flaps in the Foot 554.e1
Figure 48.15  Technique of flap harvest. (A) Marking of the flap. (B,C) Perforator is located and flap is elevated. (D) Flap rotated to cover
the defect.
A
B
C
D

CHAPTER 48 — Local Flaps in the Foot
555
DONOR SITE CLOSURE AND MANAGEMENT
The donor site can be problematic but should heal with
neodermis, skin graft, and ankle immobilization.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
• Meticulous dissection to avoid venous congestion
• The flap is not suitable for resurfacing the weightbearing
area of the heel
• Postoperative elevation of extremity is critical
FLAP USAGE
Typical Indications for the Use of This Flap
• Soft tissue and bony defects over the lateral malleolus and
anterior ankle
• Proximal dorsal foot defects
Atypical Indications for the Use of This Flap
• Posterior aspect of the heel
• Soft tissue resurfacing from a transmetatarsal ampu­tation.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES
General
See the Abductor digiti minimi (ADM) section.
Recipient Site
Skin graft care has been described in the previous section
if a fascia-only flap is used. Otherwise, the patient will need
protection of the flap with a splint. Strict elevation of the
affected limb is strongly recommend to avoid venous
congestion.
Donor Site
If a fasciocutaneous flap is used, the donor site will need to
be closed with a skin graft.
OUTCOMES
Expected Outcomes
With adequate flap protection, we expect the flap to
survive.
Untoward Outcomes
Without adequate blood glucose control and management
of comorbidities, patients can develop total or partial flap
loss. We advise patients to avoid any vasoconstrictive prod­
ucts, such as tobacco, because venous congestion can occur.
OVERVIEW OF POSTOPERATIVE CARE
All patients who have undergone reconstructive foot sur­
gery require a structured, well-planned, multidisciplinary
recovery program to ensure success. All patients are main­
tained on a non-weightbearing regimen for at least 4 weeks
following procedures that place suture lines on the plantar
surface of the foot (i.e., the FDB flap). This is of paramount
importance to ensure uneventful healing. The use of strict
bed rest and/or crutches, wheelchairs or roll-abouts,
fol­lowing reconstruction varies with the nature of the
FLAP MARKINGS
The anterior perforating branch of the peroneal artery may
be located with the handheld Doppler. The base of the flap
is centered and marked around this point (Figs 48.14,
48.15A).
PATIENT POSITIONING
The patient is placed supine.
ANESTHETIC CONSIDERATIONS
This flap is best harvested with general anesthesia.
TECHNIQUE OF FLAP HARVEST
The anterior perforating branch of the peroneal artery is
identified with the handheld Doppler. The base of the flap
should be centered at this point. If the flap is to cover a
small defect over the lateral ankle, it can be proximally based
but its size is limited. If it is to cover larger defects over the
lateral ankle, the anterior ankle, or proximal dorsal foot,
the flap should be distally based, relying on retrograde flow
to the anterior perforating branch of the peroneal from the
lateral malleolar artery. The flap width includes the fascio­
cutaneous tissue between the fibula and tibia. The length
should be adequate to reach the malleolus (6–8 cm) or
more distally, as dictated by wound location. This flap is
frequently developed as a fascial flap and its surface is skin-
grafted. When performed in this manner, the donor site may
be closed directly. For the distally based fasciocutaneous
flap, the anterior perforating branch of the peroneal artery
is tied off proximally and the blood flow comes from the
arterial–arterial anastomosis with the lateral malleolar artery.
With the flap more distally based and a longer vascular
reach, it has more mobility medially, laterally, and distally
(Fig. 48.15). The donor site healing can be problematic, and
we suggest using a neodermis over the donor site and skin-
grafting it after it revascularizes. A monoframe fixator can
be used to immobilize the ankle until the donor site heals.
FLAP MODIFICATION/FLAP HANDLING
The flap is often harvested as a fasciocutaneous flap but it
can be harvested as a fascia-only flap.
For the fascia flap, the skin incision is made centrally over
the space between the fibula and the tibia, so that skin flaps
may be elevated off the underlying deep fascia. The fascia
is then incised along its medial margin, and progressively
reflected until the anterior perforating peroneal branch is
seen, as well as the perforators from it to the overlying fascia.
Branches of the superficial peroneal nerve course within the
fascia and must be divided to permit safe elevation and rota­
tion. Final release of the flap will require incision through
the lateral margin and release of its attachments to the
septum that separates the anterior and lateral muscular
compartments. This flap, as a pedicled fascia flap with a skin
graft, is an elegant way to reconstruct a lateral malleolus
defect. When harvested with ligation of the proximal ante­
rior perforating branch of the peroneal artery, the reach of
the flap is much longer. One has to be sure that the anterior
tibial artery and lateral malleolar artery are open.
Special Instruments
A handheld Doppler should be readily available. A derma­
tome can be used for the harvesting of the skin graft.

556
PART 4 — CONVENTIONAL WORKHORSE FLAPS
be performed when the debrided wound shows signs of
healing. Most wounds can be closed with simple surgical
techniques (delayed primary closure or skin graft) and only
a few would benefit from utilizing flaps. Pedicled flaps in
the foot and ankle require exact anatomic knowledge for
safe dissection. They require less anesthesia time and
provide great coverage. They should be part of the arma­
mentarium that every reconstructive surgeon has to solve
the complex foot and ankle wounds.
procedure performed and the physical ability and coordina­
tion of the patient. Local flaps generally require a day of
elevation, and skin grafts 3–5 days. Control of pedal edema
is important and may be accomplished with bed rest and
elevation, followed by the careful use of elastic wraps
once the patient is permitted to place the limb in a depen­
dent position. During the bed rest phase, the use of low-
molecular-weight heparin significantly reduces the risk of
deep venous thrombosis.
Postoperative antibiotic use should be dictated by the
surgical findings. Patients who present without acute infec­
tion and where the bone biopsy is negative, usually require
only 5 days of broad-spectrum antimicrobials (parenteral
while in hospital, enteral once discharged). Patients who
present with acute infection will require a 2-week course of
culture-specific antibiotics. These are usually started intra­
venously and continued orally after discharge from the hos­
pital. Management of patients who have biopsy-proven
osteomyelitis are more complex. If the debridement proce­
dure completely removes the offending bone, a 1-week
course of culture-specific antibiotics should be prescribed;
otherwise, a 6-week course is standard therapy.
The L’Nard splint has been a very useful tool in keeping
the posterior heel off of the surface of the bed while provid­
ing the necessary immobilization of the foot and ankle. It is
lightweight and therefore quite useful when the patient
begins non-weightbearing ambulation with crutches or a
walker. The Cam walker boot is often used to protect foot
repairs and tendon transfers/lengthenings when the patient
becomes weightbearing. Because of frequent lack of compli­
ance (diabetics comply only 29% of the time with offloading
regimens), wrapping cast material around the Cam walker
to ensure compliance is very useful. A heavy device (similar
to a cast), the Cam walker comfortably and effectively immo­
bilizes the foot and ankle while allowing for adjustment of
the degree of equinus required at the ankle.
Sutures are generally removed just before the patient is
permitted to begin weightbearing ambulation. Sutures will
often incite callous formation on the plantar surface of the
foot, and trimming of the callous is extremely important.
Local wound care may be necessary for 7–10 days after
suture removal before weightbearing is allowed.
Follow-up should be frequent and performed in a multi­
disciplinary manner. Plastic surgery, vascular surgery, ortho­
pedic surgery, podiatry, and prosthetist/orthetist, should all
be available to participate in the patient’s care. Experienced
nursing personnel adept at all aspects of wound assessment
and care should also contribute.
CONCLUSION
The use of pedicled flaps in foot and ankle wounds requires,
at a minimum, the presence of adequate blood flow, absence
of infection, and a biomechanically stable skeletal frame­
work. This requires a team approach to limb salvage. One
first has to ensure that the extremity has adequate blood
flow. Adequate debridement has to be aggressive and
repeated as many times as necessary until the wound is ready
for reconstruction. Biomechanics should be addressed with
every reconstruction, so that recurrent breakdown can be
averted. Reconstruction of chronic wounds should only
Access Figures 48.10 and 48.15, as well as case
examples 1, 4, 5, and 6 and further reading
online at
Expert Commentary
Randy Sherman, MD, FACS
Wound healing in and around the foot is one of the more chal-
lenging enterprises, cutting across the disciplines of orthopedic,
vascular, plastic, and podiatric surgery. Unfavorable biome-
chanical loads, prolonged dependent positioning, and forced
confinement in footwear all favor chronicity. Peripheral vascular
disease, diabetes mellitus, neuropathies, and underlying ortho-
pedic malformations, either alone or together, further compli-
cate wound care and successful closure. Local flaps for foot
coverage should be brought to bear only when all underlying
pathological conditions are corrected or minimized. Extremity
revascularization, tight control of diabetes, tendon release for
biomechanical rebalancing, and personalized orthotic care
should always precede tissue rearrangement if indicated and
appropriate. The nearly lost art of total contact casting should
be understood by anyone who chooses to devote his or her
expertise to reconstructive surgery of the foot. Many small
wounds, once having developed a reasonable granulating bed,
may do surprisingly well with skin grafting alone. Local or
regional flap choices are relatively scarce and are meant to
cover small wounds with underlying bone defects or hardware
exposures. Understanding the role of toe or partial foot amputa-
tions is critical.
As mentioned in the chapter, the sural flap has gained popu-
larity over the years for ankle and high hindfoot soft tissue
coverage. It can, at times, provide an elegant solution for
resurfacing in these areas. Unfortunately, it may suffer partial
failures (just at the site of most need) often enough as to cat-
egorize it as risky, in the best of hands.
V-Y advancement flaps with release of the plantar fascia and
generous undermining will often work as effectively as most of
the small turnover muscle flaps. Once one is thoroughly familiar
with the intrinsic musculature of the foot through dissections in
the cadaver lab, the flexor digitorum brevis, abductor digiti
minimi, abductor halluces, and lateral supramalleolar artery
flaps may help solve very specific problems if applied correctly.
Paramount to these flaps being useful is the surgeon’s appre-
ciation of their very limited size and reach. Appropriate wounds
should be small, deep, with minimal undermining and sur-
rounding soft tissue injury or callus formation.

CHAPTER 48 — Local Flaps in the Foot 556.e1
This patient presented with a heel ulcer with osteomyelitis of the
calcaneus (Fig. 48.16A). A sural artery flap was dissected out and
inset over the defect (Fig. 48.16B). After 2 weeks, the pedicle was
cut and the defect was skin grafted (Fig. 48.16C). The flap went
on to heal without complications (Fig. 48.16D).
CASE 48.1  Calcaneus Defect Reconstructed with a Pedicled Retrograde Sural Flap
A
B
C
D
Figure 48.16  Case 48.1: Retrograde sural artery flap. (A) Heel defect. (B) Flap elevated and rotated to cover the defect. (C) Flap
divided 3 weeks postoperatively. (D) The patient several months postoperatively.
Plantar heel ulcer reconstructed with an FDB muscle rotation
flap and a glabrous skin advancement flap.
This patient developed a plantar heel ulcer secondary to a
calcaneal gait. The flexor digitorum brevis (FDB) muscle is dis-
sected out after a midline incision is made to expose the muscle.
The muscle is harvested all the way back to the pedicle off the
lateral plantar artery. On Figure D, the origin of abductor digit
minimi is retracted to the left. The muscle was harvested to fill
in the heel defect and glabrous skin was closed over the patient.
In this case, the heel was offloaded with completely non-
weightbearing. However, one can use an Ilizarov frame to offload
the heel in the non-concordant patient until the wound heals.
CASE 48.4  Plantar Heel Defect Reconstructed with a Flexor Digitorum Brevis (FDB)
Muscle Flap
A
B
C
D
Figure 48.19  Case 48.4: Flexor digitorum brevis (FDB) muscle flap. (A) The midline incision as well as the muscle is marked.
(B) FDB muscle pedicled to cover the defect. (C,D) Postoperative result.

556.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
Dorsal lateral foot defect reconstructed with an EDB muscle
rotation flap.
This patient developed infected sinus tarsi after treatment of
an ankle fracture. The extensor digitorum brevis muscle flap, a
type II muscle, has a blood supply derived from the lateral tarsal
artery. The four slips of the muscle are broad and thin, measur-
ing 4.5 × 6 cm in the adult, making the flap useful for this small
wound. The patient went on to heal after the muscle flap and
primary closure with the surrounding skin.
CASE 48.5  Dorsal Foot Defect Reconstructed with an Extensor Digitorum Brevis (EDB)
Muscle Flap
Figure 48.20  Case 48.5: Extensor digitorum flap. Flap isolated and rotated to cover the defect. Postoperative result is seen.

CHAPTER 48 — Local Flaps in the Foot 556.e3
Anterior lateral ankle defect reconstructed with a supramalleolar
rotation flap.
This patient presented with anterior lateral ankle defect after
squalors cell resection. The figure is an injected anatomic dis-
section of the supramalleolar flap based on the anterior perfo-
rating branch of the peroneal artery. Note the connection
between the anterior perforating branch of the peroneal artery
and the lateral malleolar artery. The anterior perforating branch
can be ligated proximally, so that the flap is sufficiently mobi-
lized for distal coverage. The patient went on to heal his cancer
defect and his donor site was covered with a split-thickness skin
graft.
CASE 48.6  Lower Leg Anterior Defect Reconstructed with a Lateral Supramalleolar Flap
Figure 48.21  Lateral supramalleolar flap. (A) Flap marking. (B,C) Flap is elevated and rotated to cover the defect. (D) Postoperative
result.
A
B
C
D

CHAPTER 48 — Local Flaps in the Foot
557
A diabetic and neuropathic patient presented with a defect over
the posterior heel to the calcaneus. The abductor digiti minimi
(ADM) muscle flap is harvested from the lateral compartment
and is bulky enough that it covers the large defect easily. The
muscle was then skin grafted and the wound went on to heal.
CASE 48.2  Posterior Heel Defect Reconstructed with an Abductor Digiti Minimi (ADM)
Muscle Flap Covered with a Skin Graft
Figure 48.17  Case 48.2: Abductor digiti minimi (ADM) muscle flap. (A) Heel defect. (B) ADM located and pedicle is Doppler.
(C,D) Muscle is rotated to cover the heel defect. (E) Postoperative result.
A
B
C
D
E

558
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Posterior medial ankle soft tissue defect reconstructed with an
AH muscle rotation flap and skin graft.
This patient presented with a large posterior-medial ankle with
soft tissue loss and partially exposed Achilles tendon. The abduc-
tor hallucis (AH) muscle was harvested via an incision along the
glabrous junction. Note the dominant pedicle off the medial
plantar artery. Note the range of the muscle flap when the origin
is detached. The muscle is harvested to cover a large medial
ankle defect with exposed Achilles tendon. The muscle was then
skin grafted.
CASE 48.3  Medial Malleolar Defect Reconstructed with an Abductor Hallucis (AH)
Muscle Flap
Figure 48.18  Case 48.3: Abductor hallucis (AH) muscle flap. (A) Flap marking. (B,C) AH muscle pedicled and inset into the defect.
(D) Postoperative result.
A
C
D
B
REFERENCES
1. Ger R. The operative treatment of the advanced stasis ulcer. A pre­
liminary communication. Am J Surg 1966;111(5):659–63.
2. Ger R. Operative treatment of the advanced stasis ulcer using muscle
transposition. A follow-up study. Am J Surg 1970;120(3):376–80.
3. Leclère FM, Eggli S, Mathys L, et al. Anatomic study of the superfi­
cial sural artery and its implication in the neurocutaneous vascular­
ized sural nerve free flap. Clin Anat 2013;26(7):903–10.
4. Clemens M, Colen L, Attinger C. Foot reconstruction. In: Neligan
P, editor. Plastic surgery, vol. 4. 3rd ed. Philadelphia: Elsevier;
2012.

CHAPTER 48 — Local Flaps in the Foot 558.e1
FURTHER READING
Attinger C, Cooper P, Blume P, et al. The safest surgical incisions and
amputations applying the angiosome principles and using the
Doppler to assess the arterial-arterial connections of the foot and
ankle. Foot Ankle Clin 2001;6(4):745–99.
Attinger CE, Ducic I, Cooper P, et al. The role of intrinsic muscle flaps
of the foot for bone coverage in foot and ankle defects in diabetic
and nondiabetic patients. Plast Reconstr Surg 2002;110(4):1047–57.
Clemens MW, Attinger CE. Angiosomes and wound care in the diabetic
foot. Foot Ankle Clin 2010;15(3):439–64.
Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle
flaps versus free flaps and the role of diabetes. Plast Reconstr Surg
2011;128(1):173–80.
Han KD, Colen L, Attinger CE. Local flaps for the foot and ankle.
Techn Foot Ankle Surg 2013;12(2):63–73.
Mojallal A, Wong C, Shipkov C, et al. Vascular supply of the distally
based superficial sural artery flap: surgical safe zones based on com­
ponent analysis using three-dimensional computed tomographic
angiography. Plast Reconstr Surg 2010;126(4):1240–52.
Strauch B, Vasconez L, Hall-Findlay EJ, et al., editors. Grabb’s encyclo­
pedia of flaps, vol. 3. 3rd ed. Chs 525–530. Philadelphia: Lippincott
Williams & Wilkins; 2009. p. 1501–13.

559
INTRODUCTION
The gracilis flap was described in 1972 by Orticochea, as a
pedicled myocutaneous flap, and the first cases included a
penile reconstruction and one of calcaneal soft tissue cover­
age.1 It was one of the first myocutaneous flaps described in
humans, and in 1976, Harii published a series of gracilis free
flaps for soft tissue cover2 and, in a separate paper, a func­
tional free gracilis for facial reanimation.3 Since then the
flap has become one of the most widely used of all flaps due
to its versatile nature, reliable pedicle, and good donor site.
It is commonly utilized for soft tissue coverage, as a func­
tional flap, and for contour deformities such as in breast
reconstruction. It may be transferred as a pedicled flap, a
free flap, or a perforator flap. The flap may include all of
the muscle, a longitudinal segment, or a vertical segment.
It may be muscle only or combined with skin (myocutane­
ous) and can be innervated to act as a functioning muscle.
It has become one of the essential tools of the reconstructive
surgeon.
FLAP ANATOMY (see Fig. 49.1 and Figs 13.1,
13.2, 13.19)
The muscle takes origin from the symphysis pubis and pubic
arch and inserts distally into the medial surface of the proxi­
mal tibia. It is a large strap-shaped muscle and is the most
superficially located of the adductors. The muscle belly is
relatively broad at its origin and tapers toward the insertion.
The muscle belly length is approximately 30 cm.4 The distal
tendon of the gracilis is round in shape but becomes a flat­
tened sheet as it inserts into the tibia. At its distal end the
muscle lies between sartorius anteriorly and semitendinosus
posteriorly. The function of the muscle is to adduct, flex,
and medially rotate the hip and to flex the knee.
ARTERIAL ANATOMY (see Figs 49.1, 13.1, 13.2)
The gracilis muscle has a type 2 vascular supply, as described
by Mathes and Nahai,5 with one dominant and several minor
vascular pedicles. The muscle is most commonly raised on
the dominant pedicle only, and the entire muscle may be
harvested this way. Although its pedicle is relatively consis­
tent, some variations have been described in anatomic
studies, including split and duplicate dominant pedicles.6
Gracilis Flap
Ronald M. Zuker  |  Robert D. Bains 49 
Figure 49.1  Gracilis flap.
Anterior branch
of obturator nerve
Cutaneous
branch of
obturator nerve
Medial tibial
condyle
Tensor fascia lata
Rectus femoris
Vastus lateralis
Vastus medialis
Sartorius
Adductor longus
Pubic tubercle
Pectineus
Iliopsoas
Inguinal ligament
Anterior superior iliac spine
Ascending branch
of LFCA
Transverse branch
of LFCA
Descending branch
of LFCA
Branch of
medial
circumflex
femoral artery
Common femoral artery
Femoral nerve
Lateral femoral
cutaneous nerve
Lateral femoral
circumflex artery
(LFCA)
Deep femoral
artery
Deep femoral artery
Gracilis flap
Gracilis
Gracilis tendon
Superficial
femoral
artery
Adductor
magnus
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION G  —  LOCAL AND FREE FLAPS IN THE LOWER EXTREMITY

560
PART 4 — CONVENTIONAL WORKHORSE FLAPS
DOMINANT PEDICLE
Dominant:  branch of the medial femoral circumflex
artery or direct branch from the profunda femoral artery
Length: 7 cm (range 6–8 cm)
Diameter: 2 mm (range 1.5–3 mm)
The main vascular supply enters the gracilis approxi­
mately 10 cm inferior to the pubic tubercle in the adult. The
course of the pedicle runs deep between adductor magnus
and longus and arises from either the descending branch
of the medial circumflex femoral or directly from the pro­
funda femoris artery (Fig. 49.2).4 A large branch arises from
the pedicle on the deep surface of the adductor longus and
goes on to supply that muscle. Harvest of both gracilis and
adductor longus on the common vascular pedicle has been
described.7
MINOR PEDICLES
Minor pedicles enter the muscle distal to the main pedicle
and normally arise from the superficial femoral artery. Sec­
ondary pedicles may also arise from the descending genicu­
lar artery in less than 10% of cases. There are commonly
two minor pedicles but there may be up to six. It is not
common to base a flap on these minor pedicles although
this technique has been described.8
PERFORATOR VESSELS
Perforators are most common in the proximal third of the
muscle in association with the dominant pedicle. Fasciocu­
taneous vessels arising from the fascia between gracilis and
adductor longus may be present, but musculocutaneous
perforators arising from the anterior part of the muscle are
more common. Perforators from the minor pedicles may
also be present but are not as reliable as those associated
with the dominant vessel. Perforator diameters of 0.5–1 mm
may be found arising from the proximal aspect of the
muscle at the level of the major pedicle, making a gracilis
perforator flap feasible.9
Figure 49.2  Intraoperative photograph of the gracilis flap. Vessel
loops placed around the nerve and vascular pedicle (arrow). The
nerve can be seen to travel obliquely entering the flap near the domi­
nant pedicle.
Figure 49.3  Intraoperative photograph of a segmental gracilis
flap demonstrating motor nerve (divided). Muscle at rest.
VENOUS ANATOMY
Primary:  venae comitantes (two) of the dominant gracilis
branch
Length: 7 cm (range 5–8 cm)
Diameter: 2 mm (range 1.5–2.5 mm)
Usually two venae comitantes are found accompanying
the artery. They drain into the profunda femoris vein and
may converge to form a common vein a short distance
before entering the profunda. The long saphenous does not
make a significant contribution to drainage but may be used
as a landmark as the gracilis muscle is commonly the first
muscle to be found posterior to the vein.
NERVE SUPPLY (see Fig. 49.1 and Figs 13.1, 13.2
and 13.19)
Motor:  The motor supply is from the anterior branch of
the obturator nerve. This nerve arises from the obturator
foramen and branches into anterior and posterior divisions
beneath pectineus. The anterior division then travels
between adductor longus and brevis (which it supplies)
before entering the gracilis close to the location of the
dominant pedicle. The nerve has a more oblique course
proximally than the vascular pedicle, which lies perpendicu­
lar to the muscle and enters on its deep surface (Figs 49.3,
49.4). The nerve is at least 7–8 cm in length but up to 13 cm
may be obtained by dissection back as far as the obturator
foramen.10
Sensory:  Sensory nerve supply to the skin of the proximal
medial thigh is also from the anterior division of the obtura­
tor nerve, which runs along the deep surface of the adduc­
tor longus muscle (Figs 13.1, 13.2 and 13.19).
FLAP COMPONENTS
• Muscle-only flap
• Functional muscle flap (with motor nerve)

CHAPTER 49 — Gracilis Flap
561
Disadvantages
• Shape of muscle may not be as good as latissimus dorsi
for coverage of large wounds.
• Skin paddle may not be reliable distally, due to paucity
of perforators. Including the fascia between the gracilis
and the adductor longus helps ensure better perfusion to
the skin
PREOPERATIVE PREPARATION
The patient is usually positioned supine and a sandbag
may be placed under the contralateral hip. The hips are
abducted and knees flexed into a frog leg position. The flap
is harvested without the use of a tourniquet due to the
proximal extent of the dissection. Hair removal is some­
times required prior to marking, and perforating vessels
may be located using Doppler or CT angiogram if a perfora­
tor flap is planned.
FLAP DESIGN AND MARKINGS
Bony landmarks of importance are the pubic tubercle and
the medial condyle of the femur and/or tibia. A line can be
drawn connecting these structures, and the incision line for
a muscle-only flap lies parallel and 2–3 cm posterior to this
line (Fig. 49.5). The length of the incision for muscle-only
harvest depends on the quantity of muscle required but
clearly, the critical area of access overlies the dominant
pedicle (around 10 cm) distal to the pubis. The entire
muscle may be harvested through a relatively short proximal
incision for pedicle dissection and a separate distal incision
to divide the tendinous insertion. Care should be taken to
avoid the groin crease in the incision, as this may become
a painful scar.
If a skin paddle is required, it is designed over the proxi­
mal third of the muscle for greatest reliability. The skin
paddle may be transverse, longitudinal, or fleur-de-lis in
shape, and dimensions of up to 35 × 19 cm are theoretically
possible.11
• Segmental functional muscle flap (proximal segment
including motor nerve)
• Segmental muscle based on minor pedicle (non-
functional)
• Myocutaneous flap (various skin paddles have been
described)
• Perforator fasciocutaneous flap
• Combined gracilis and adductor longus muscle flaps
(may be used as functional transfer)
Advantages
• Consistent anatomy of dominant pedicle.
• Relatively easy dissection.
• Large muscle belly useful for coverage of large wounds.
• Skin paddle may be designed over proximal muscle and
can be useful for flap monitoring or for contour deficits
such as in breast reconstruction.
• Single motor nerve consistent and located near main
pedicle makes flap ideal for functional transfer. Whole
muscle or small segmental transfers possible.
• Location makes two-team approach possible when the
recipient site is in the head and neck, upper extremity,
or even the contralateral lower extremity.
• Donor site well hidden on inner thigh.
• Expendable muscle with no functional loss when utilized.
Figure 49.4  Intraoperative photograph of a segmental gracilis
flap demonstrating motor nerve (divided). Nerve stimulator causing
muscle contraction.
G, gracilis
AM, adductor magnus
S, sartorius
ST, semitendinosus
Adductor longus
Adductor longus
Medial condyle
of the femur
Pubic tubercle
Figure 49.5  Preoperative markings showing one possible design of skin paddle for a gracilis flap.

562
PART 4 — CONVENTIONAL WORKHORSE FLAPS
muscle should not be confused with the gracilis proximally
as it is located distant to the site of dissection.
With the muscle belly isolated, careful dissection around
the muscle reveals the dominant and secondary pedicles.
The dominant pedicle is easily identified as it is the largest,
most proximal and is associated with the entry point of the
motor nerve. Once all pedicles are identified the secondary
pedicles may be ligated and divided.
Dissection of the main pedicle commences in a distal to
proximal direction. Retraction to elevate the adductor
longus is required as the pedicle passes between this muscle
and the adductor magnus. Branches of the main pedicle
passing upward to the adductor longus should be ligated
and divided (Fig. 49.6). The pedicle is then dissected to its
origin from the profunda femoris. At this point the artery
and its accompanying venae comitans should be separated
in preparation for division if the flap is to be used as a free
flap.
If the flap is intended to be for functional reconstruction,
the motor nerve should be identified at the time of identi­
fication of the dominant pedicle. This is then preserved and
dissected proximally following its oblique course as far as is
required.
Finally, the muscle itself is divided to isolate the flap on
its pedicle. The proximal origin of the muscle is easily
accessed through the same incision as the pedicle dissec­
tion. If the distal tendon is required for a functional transfer
a separate incision can be made at the knee to isolate the
tendon. The gracilis tendon lies between the insertion of
sartorius anteriorly and semitendinosus posteriorly and the
tendon is round in cross-section. The flattened distal portion
of the insertion may be taken and can include some perios­
teum over the tibia if extra length is required.15
SEGMENTAL FUNCTIONAL GRACILIS FLAP FOR
FACIAL REANIMATION
In cases of facial reanimation, the entire muscle belly of the
gracilis is too large and its use results in an unacceptably
bulky appearance of the cheek. In these cases we perform
a segmental gracilis transfer, and flaps as small as 8 g in
weight can be safely harvested in children (Fig. 49.7). The
dissection proceeds as described above through a limited
FLAP DIMENSIONS
MUSCLE DIMENSIONS
Length of muscle belly: 30 cm (range 27–34 cm) in adults.
Approximately two-thirds of medial thigh length in
children
Width: max 5–8 cm proximally (3–4 cm in children)
Thickness: 3 cm (range 2–4 cm). Distal tendon length
15 cm in adults
SKIN ISLAND DIMENSIONS
Longitudinally orientated skin paddles may be up to 30 cm
in length and 8–10 cm wide.12 It has been recommended to
ensure harvest of all fascia surrounding the gracilis in order
to maximize the viability of the skin paddle, which can be
precarious, particularly distally. Transverse skin paddles of
25 × 10 cm may be harvested and a combination of longitu­
dinal and transverse paddles is possible,13 although atten­
tion should be paid to feasibility of donor site closure when
planning such large flaps (Fig. 49.5).
ANESTHETIC CONSIDERATIONS
A general anesthetic is usually required for harvest of the
gracilis flap, but if the recipient site is also in the lower
limbs, the procedure may be performed under regional
anesthesia.14 This may be of particular advantage if the
patient is not fit for general anesthesia. Free flap reconstruc­
tion for the elderly has become increasingly accepted. The
shorter procedure time associated with a two-team approach
may be beneficial in this situation.
TECHNIQUE OF FLAP HARVEST
MUSCLE-ONLY FLAP
With the patient supine and under general anesthetic, the
lower limb is prepared and draped from the anterior supe­
rior iliac spine to below the knee. The hip is abducted and
flexed and the knee flexed and a sandbag placed under the
contralateral hip. With the hip abducted, the adductor
longus becomes taught, and this may be easily palpated at
its origin from the pubis with the gracilis origin lying just
posterior. The medial femoral condyle is then palpated and
a line drawn between the two. A second line, marking the
incision is then drawn 2–3 cm parallel and posterior to the
first line. The incision is started in the proximal third of
the thigh and extended distally beyond the region of entry
of the dominant pedicle (located approximately 10 cm infe­
rior to the pubic tubercle).
The gracilis muscle is then identified as the most super­
ficially located adductor. It lies posterior to the long saphe­
nous vein. Care should be taken at this point to correctly
identify the muscle and avoid inadvertent dissection of any
of its neighbors. It may be readily distinguished from the
adductor longus (lying anterior) and magnus (posterior) by
flexing and extending the knee as the gracilis is the only
muscle of the three to cross the knee joint. The sartorius
Figure 49.6  Intraoperative view of gracilis muscle and pedicle with
branches to adductor longus (arrow).

CHAPTER 49 — Gracilis Flap
563
reconstruction (Case 49.7). Criticisms of the flap for breast
reconstruction include the small volume obtained,16 and
some surgeons routinely use two flaps for a single breast
reconstruction in order to overcome this problem.17
Longitudinally oriented skin paddles and fleur-de-lis pat­
terns have been described, which rely on the integrity of
perforators from the secondary pedicles.18 The functional
free gracilis for brachial plexus reconstruction as described
by Doi routinely includes a longitudinally oriented skin
paddle for monitoring, and the authors stress the impor­
tance of inclusion of harvesting all surrounding fascia with
the muscle to maximize reliability of the skin paddle.15
GRACILIS PERFORATOR FLAPS
Hallock first described the gracilis perforator flap in 200319
and since then, other authors have studied the vascular
anatomy of the flap allowing further extension of the skin
paddle. In the original description perforators were identi­
fied by Doppler ultrasound at the start of the case and a skin
paddle of 12 × 16 cm was designed around these vessels. The
territory was located posterior to the site of the femoral
vessels and distal to the groin crease. Peek et al. later defined
the skin paddle in cadaveric studies as 18 × 15 cm but showed
that by inclusion of intramuscular anastomosis between the
dominant and secondary pedicles this territory may be
extended, theoretically up to 27 cm distally.9
There is minimal functional deficit following gracilis
harvest and some authors argue that use of a perforator flap
sparing the whole muscle is unnecessary.20
SPECIAL INSTRUMENTS
No special instruments are required for standard flap eleva­
tion, but some authors have performed endoscopic harvest
of the flap in an attempt to minimize donor site morbidity.21
DONOR SITE CLOSURE
AND MANAGEMENT
After careful hemostasis if there was no significant amount
of fascia harvested, the fascia is closed loosely to avoid
muscle herniation and the skin closed in two layers with
subcuticular absorbable sutures. If desired a compression
bandage may then also be applied. There is no restriction
in terms of postoperative mobilization. A drain may be used
if required although it is often not necessary in children.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• In designing the incision, care should be taken to make
it as short as possible and to place the incision far enough
posteriorly that the resultant scar cannot be seen with the
patient standing.
• In the case of bilateral harvest care should be taken to
make the incisions symmetrical.
• In cases of facial reanimation the flap should be segmen­
tal and made small enough that it does not produce a
significant bulge when transplanted to the face.
Figure 49.7  Segmental gracilis flap for facial reanimation prior to
insetting. The muscle bulk has been reduced significantly prior to
harvest as described.
proximal thigh incision. After identification and dissection
of the neurovascular pedicle, the portion of muscle to be
harvested is marked. We measure the length of muscle
required at the recipient site and then add 1 cm of length
on either side to allow for anchoring sutures. This required
length is then marked on the gracilis, while it lies in situ in
the thigh and before division of any of the muscle belly. The
neurovascular pedicle is placed in the middle of the marked
muscle segment. The desired portion of muscle is then dis­
sected from the main portion of the muscle belly to include
the neurovascular pedicle. The posterior third of the muscle
segment is most often discarded to reduce bulk as the
pedicle enters at the junction of anterior and middle thirds
on the deep surface. The bulk may be reduced further by
excision of an additional strip of muscle from the anterior
border.
Cavadas et al. in 2004 showed that it may be possible to
harvest small portions of the gracilis based on secondary
pedicles only.8
THE GRACILIS SKIN PADDLE VARIATIONS AND
THE TUG FLAP
The transverse upper gracilis (TUG) musculocutaneous
flap was first described by Yousif et al. in 1992.13 The skin
paddle is orientated transversely over the proximal third of
the muscle and extends from the site of the femoral vessels
anteriorly to the midline of the thigh posteriorly. Its proxi­
mal location is designed to include the most consistent
perforators that are associated with the dominant pedicle.
Skin paddles of 25 × 10 cm have been used, with the main
limiting factor being donor site closure. The flap has gained
popularity although is still seen as a secondary choice to
lower abdominal free flaps for breast reconstruction. It is a
reasonable choice in the patient for whom a DIEP/TRAM
flap is not possible and who requires a small volume

564
PART 4 — CONVENTIONAL WORKHORSE FLAPS
7. Free flap, functional reconstructions as double muscle transfer.
The gracilis may be transferred with the adductor longus
using the common dominant pedicle for functional
reconstruction. Terzis et al. described its use with the
gracilis providing elbow flexion and adductor longus for
shoulder abduction in brachial plexus patients.7
POSTOPERATIVE CARE
There are no specific restrictions in terms of mobility with
regards to the gracilis donor site except that we ask the
patients to refrain from heavy exercising and running for
4–6 weeks. Suctions drains, if used, are removed after a 1–2
days when quantity of drainage is minimal.
If a skin paddle is used this can make flap monitoring
easier, which is particularly useful when transferred as a free
flap. The skin paddle may then be excised later, if desired.
For free flaps to the lower limb, some initial elevation and
• For closure of the donor site in a muscle-only flap it can
be useful to close the fascia to avoid muscle herniation.
FLAP USAGE
INDICATIONS
1. Pedicled flap, nonfunctional. The proximal location of the
pedicle allows for proximal rotation of the distal portion
of the muscle and this allows easy coverage of the peri­
neal area and proximal femoral triangle. The flap has
been described for coverage of exposed femoral vessels22
and scrotal23 and vulval24 reconstruction and to promote
healing of urethral repairs25 and rectovaginal fistulas26 as
well as obliteration of dead space in pelvic sepsis.27
2. Pedicled flap, functional. From the earliest descriptions of
the gracilis flap attempts have been made to utilize its
functional properties to reconstruct anal sphincter func­
tion. Many authors have demonstrated success with this
technique and particularly with the recent advent of con­
tinuous electrical stimulation of the muscle to provide
sphincter tone.28 The gracilis has also been used for ure­
thral sphincter reconstruction in urinary incontinence.29
3. Free flap, soft tissue coverage. The gracilis has become one
of the most popular flaps for coverage of lower limb
trauma wounds.30 It may be used for moderate-sized
wounds, and the location of the donor site can be desir­
able in this group of patients. In particular, avoidance of
harvest of the latissimus dorsi may be desirable in a group
of patients who rely on crutches for mobility in the period
after a lower limb injury and reconstruction. Muscle flaps
are also the first choice in reconstructing osteomyelitic
lesions of bone, and the free gracilis flap is used exten­
sively in this role.31
4. Free flap, breast reconstruction. The TUG flap is a popular
second-line choice for many breast reconstructive sur­
geons due to its relatively inconspicuous donor site and
ease of harvest. Size and volume of the flap limit its
popularity.
5. Free flap, functional reconstruction. Due to its size and shape
the gracilis free flap has gained widespread popularity
for restoration of elbow flexion in brachial plexus
patients. The motor nerve may be coapted to a variety of
donors in this situation including intercostals, intraplexal
transfers, and ulnar nerve fascicular transfer.32 The flap
may also be used in the forearm for finger flexion or
extension in the brachial plexus patient33 or a single
muscle may be utilized for more than one function as in
the Doi transfer.34 A similar approach may be taken to
patients after tumor resection or Volkmann’s ischemic
contracture, where functional muscle replacement is
required.35
6. The gracilis may be transferred as a segmental functional trans­
fer. In this technique the bulk of the muscle is reduced
dramatically, which is desirable in facial reanimation
surgery (Fig. 49.8). Transfer of the entire muscle would
produce excessive facial fullness compromising the aes­
thetic outcome.36 The muscle is frequently neurotized to
a cross face nerve graft coapted to a functioning contra­
lateral facial nerve branch at a prior procedure (Fig.
49.9). Alternatively, it can be neurotized with the ipsilat­
eral nerve to masseter.
Figure 49.9  Cross face nerve graft. A sural nerve graft is shown
on the unaffected side of the face, coapted to a buccal branch of
facial nerve (arrow). This procedure is performed as a first stage with
the functional muscle transfer 9–12 months later.
Figure 49.8  Functional segmental gracilis muscle free flap in situ
for facial reanimation. Anastomosis of flap vessels to facial artery and
vein can be seen (arrow).

CHAPTER 49 — Gracilis Flap
565
breakdown. Late donor site complaints are related to the
scar, occasional hypoesthesia, and contour irregularities.
These problems are rare, and overall, the gracilis donor site
is not usually problematic in a functional or aesthetic regard.
CONCLUSION
The gracilis is one of the most commonly utilized flaps in
reconstructive surgery. Its popularity comes from its ability
to address a variety of reconstructive challenges with minimal
donor site morbidity.
bed rest is desirable. The limb is gradually allowed to
become more dependent after a few days and then mobiliza­
tion is commenced. If the flap is being used as a functional
transfer a splint is usually applied in the first instance to
protect the gracilis tendon repairs.
OUTCOMES
In the initial postoperative phase the risks are of pain, bleed­
ing, and infection as for other flap donor sites.37,38 If a large
skin paddle is harvested, the closure may be at risk of wound
A 5-year-old child was referred to us with an untreated talipes
equinovarus. Splinting was impossible at this stage, and surgical
release was planned. A very extensive soft tissue release was
carried out, and a full repositioning of the deformity required a
mid-foot osteotomy. This resulted in a large soft tissue defect with
exposed joint, bone, and Achilles tendon. In order to cover this,
a gracilis muscle flap was used. The flap was positioned so that
the pedicle was behind the medial malleolus. The distal part of
the gracilis flap would constitute the more distal medial part of
the foot resurfacing. An end-to-side arterial anastomosis was
carried out to the posterior tibial artery. An end-to-end venous
repair was carried out to the vena comitans of the posterior tibial
artery. The muscle was carefully inset beneath the adjacent skin
with mattress sutures. After the muscle had been carefully posi-
tioned in an almost fully extended position, the surface was
closed with a split-thickness skin graft. After bony union, the child
began ambulation and achieved an excellent result from a func-
tional standpoint and from a contour standpoint (Fig. 49.10).
CASE 49.1  Free Gracilis Flap for Coverage of Soft Tissue Defect
A
B
Figure 49.10  (A) Untreated talipes equinovarus preoperatively, showing tight soft tissue of the medial left ankle resulting in inversion
contracture. (B) Intraoperative view following release of soft tissues. The deformity has been corrected but a large soft tissue defect can
be seen with exposed articular surface, tendon, and bone in the base. (C) Prior to insetting of free gracilis muscle flap for soft tissue
coverage. (D) Postoperatively showing corrected deformity and stable soft tissue coverage. The free muscle flap was covered with a
split-thickness skin graft.
C
D

566
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 12-year-old girl presented with weakness of wrist and finger
extension. After investigation, she was found to have a tumor of
the posterior interosseous nerve. We did not feel we could
remove the nerve tumor without the proximal part of the exten-
sor musculature in a safe manner. Thus, the nerve tumor, as well
as the extensor muscle mass involved, was excised on block. As
there was a normal proximal posterior interosseous nerve, we
felt that reconstruction could be carried out with a functional
gracilis muscle. This free functioning gracilis was procured and
transplanted to the external aspect of the forearm after excision
of the nerve tumor with its muscle mass. The muscle was appro-
priately positioned and revascularized through microvascular
anastomoses. The posterior interosseous vessels were utilized in
an end-to-end fashion to revascularize the muscle. A direct nerve
coaptation between the motor nerve to gracilis and the healthy
proximal stump of the posterior interosseous nerve was carried
out. The muscle was then stretched out to its normal extended
position. This was done by markings, which had been placed in
the thigh when the hip was abducted and the knee extended.
Markings at 5 cm intervals indicated full extension of the muscle.
After revascularization and reinnervation, the muscle was
stretched out to its normal extended position as indicated by our
5 cm marks. This fully extended position should be present
when the wrist is flexed and the fingers are flexed, in order to
obtain maximum strength for extension and minimize any tight-
ness that may occur because of contracture of the muscle. The
tendon repairs were carried out at the site where the tendon of
the gracilis met the tendon of the wrist extensors and finger
extensors of the wrist in flexion and the fingers in flexion. A
secure tendon repair was carried out. Fortunately, we were able
to obtain skin closure directly.
The patient was then placed in a protective splint, maintaining
the wrist in the neutral position and the fingers in slight exten-
sion. We did this to minimize the tension on the site of tendon
repair. After 3 weeks, we began mobilizing the digits and after 6
weeks, we began fully mobilizing the wrist and finger joints into
full flexion. After 6 months, the muscle became reinnervated
and began active contraction. Exercise to strengthen the muscle
function was then undertaken and a full range of movement was
attained (Fig. 49.11).
CASE 49.2  Free Functioning Gracilis to Restore Finger and Wrist Extension
Figure 49.11  (A) The patient presented with weakness of the wrist and long finger extensors. Imaging revealed a tumor of the posterior
interosseus nerve accounting for the deficit. (B) Intraoperative image of extensor compartment of forearm showing posterior interosseus
nerve tumor. (C) Following resection of the tumor and extensor muscle mass. A free functional gracilis muscle flap has been raised and
is seen prior to inset. (D) Following reconstruction showing adequate return of finger and wrist extension from the functional flap.
A
C
B
D

CHAPTER 49 — Gracilis Flap
567
A 5-year-old girl presented with a synovial cell sarcoma of the
distal volar forearm. Resection of the tumor required excision
of the flexor muscle mass as well as the median nerve. Fortu-
nately, we were able to identify and preserve the anterior interos-
seous nerve. This would serve as the recipient motor to power a
free functioning gracilis muscle transplant to reconstruct finger
and thumb flexion.
Our plan was to provide an immediate reconstruction. After
the tumor excision, the surgical sites were re-prepped and
draped. The median nerve was reconstructed with sural nerve
grafts in the standard manner. The gracilis muscle was procured
from the thigh. It would be revascularized through the anterior
interosseous artery and vein in an end-to-end fashion. As we were
able to preserve the stump of the anterior interosseous nerve,
this would serve as the recipient nerve to power our transplant.
An end-to-end microneural coaptation was carried out.
We had identified and saved the profundus tendons in the
distal forearm. They were sutured together in a cascade fashion,
so that with proximal traction, they came down to the palm in a
synchronous fashion. The superficialis tendons were resected.
We then positioned the thumb flexor, so that it came into the
palm slightly behind the cascading fingers. This was done pur-
posely in order to avoid the thumb being trapped inside the
palm and thus diminishing function. The flexor pollicis longus
tendon was sutured to the cascading profundus tendon mass and
secured. Then, this mass of five tendons was sutured to the
tendon of the gracilis in a tendon weave fashion. It was critical
to have the tension of the gracilis muscle appropriate, so as to
maximize finger and thumb flexion. Markings were made on the
gracilis muscle in the thigh, with the hip abducted and the knee
extended at 5 cm intervals. This would be maximal gracilis
extension. The muscle was anchored proximally in the forearm
and distal arm to the medial epicondyle. It had been revascular-
ized and reinnervated and then the tendon was stretched down-
ward in order to find the appropriate location for suturing to
our flexor pollicis longus and flexor digitorum profundus mass.
Maximum stretch of the muscle as indicated by our previously
placed sutures was achieved with traction on the gracilis tendon.
We wanted this maximum extension to be present when the wrist
was extended and the fingers were extended. This would facili-
tate maximal contraction when the hand was in this position and
avoid any tightness of extension of the finger and wrist because
of malpositioning of the muscle. Thus, the site of tendon repair
was marked with the wrist in extension and the fingers in exten-
sion, and the tendon of the gracilis pulled out to its maximum
stretch. These points were marked on both the gracilis tendon
and the conjoined profundus flexor pollicis longus tendon. An
intertendinous weave suture was carried out. Wound closure was
completed by repositioning our skin flaps. On occasion, a split-
thickness skin graft is necessary to cover the muscle if a skin
deficiency occurs.
The arm and forearm are then placed in a resting splint main-
taining the wrist at neutral and the fingers in the neutral posi-
tion. After 3 weeks, we begin passive exercises for elbow and wrist
joint mobility and finger extension. This is carried out gradually
over a 3-week period. Then, as the muscle becomes reinner-
vated, we begin to see active flexion of the fingers and thumb.
It is at this point that we can begin active exercises and an inten-
sive rehab program undertaken. After 6 months, the patient will
have achieved a maximal range of motion of the fingers and
thumb. In most instances, this is sufficient, but occasionally a
tenolysis is required in order to improve mobility of the tendons
and increase finger and thumb flexion (Fig. 49.12).
CASE 49.3  Free Functioning Gracilis for Finger and Thumb Flexion
A
B
D
C
Figure 49.12  (A) Sagittal magnetic resonance image of tumor in the distal volar forearm. Biopsy showed the lesion to be a synovial
sarcoma. (B) Intraoperative image following resection of the contents of the volar aspect of the forearm for sarcoma. Flexor carpi ulnaris
and brachioradialis can be seen to be intact either side of the resection. (C) Following reconstruction with sural nerve grafts for median
nerve, vein graft for radial artery and free functional gracilis flap for finger and thumb flexion. (D) Functional result demonstrating powerful
finger and thumb flexion from the functional transfer.

568
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Expert Commentary 
Yuan-Kun Tu, MD, PhD, FICS
The applications of gracilis flap transfers have gained popu-
larity in the past 3 decades. Numerous papers have been
published to demonstrate using gracilis flap in soft tissue
coverage for trauma and tumor resection, for overcoming
osteomyelitis, and for serving as functioning muscle transfer
for extremities and facial reconstructions. Recent advance-
ment of this technique was to harvest the combined gracilis
and adductor longus muscle flap for the functional recon-
struction of Volkmann’s ischemia (contracture) and brachial
plexus injury. The technique tip to harvest a reliable skin flap
of this combined gracilis-adductor longus flap is to preserve
the fasciocutaneous perforator vessels from the fascia inter-
val between gracilis and adductor longus. Therefore, if we
harvested the skin flap near the upper third of gracilis, espe-
cially including the fascia between the gracilis and adductor
longus, this skin flap is more likely to survive without marginal
necrosis. The adductor longus muscle, similar to the vascu-
larity of gracilis, has one dominant vascular pedicle and
several minor pedicles. We commonly harvested the com-
bined gracilis-adductor longus flap based on their major
pedicles, and ligated those minor pedicles. The easiest
method to find the common pedicle to gracilis-adductor
longus muscle is to explore the fascia plane between the
adductor longus muscle and the profunda femoral artery.
The length of muscle belly of gracilis is around 30 cm, while
the adductor longus is around 22 cm. The working capacity
index of gracilis compared with adductor longus is 2 : 3, while
the functional tendon excursion ratio of gracilis compared
with adductor longus is 3 : 2. The applications of this com-
bined gracilis-adductor longus flap are versatile. We may
apply this flap for double or triple functioning muscle recon-
struction for total arm type brachial plexus palsy, in which
the combined gracilis-adductor longus can be transferred for
elbow flexion and finger extension in the same surgery. The
other application is to split the obturator nerve into two parts.
We can suture the separated obturator nerve with different
recipient nerve (such as median nerve and radial nerve sepa-
rately), in which the double functioning muscle transfer for
Volkmann’s ischemia (contracture) is performed with gracilis
for finger flexor and adductor longus for finger extensor. The
choice of different recipient nerve makes this gracilis-
adductor longus flap possible for either synergic or antago-
nist muscle function reconstruction.
6. Natoli NB, Wu LC. Vascular variations of the transverse upper
gracilis flap in consideration for breast reconstruction. Ann Plast
Surg 2015;74(5):528–31.
7. Terzis JK, Kostopoulos VK. Free muscle transfer in posttraumatic
plexopathies: part 1: the shoulder. Ann Plast Surg 2010;65(3):
312–17.
8. Cavadas PC, Sanz-Giménez-Rico JR, Landín L, et al. Segmental
gracilis free flap based on secondary pedicles: anatomical study and
clinical series. Plast Reconstr Surg 2004;114(3):684–91.
9. Peek A, Müller M, Ackermann G, et al. The free gracilis perforator
flap: anatomical study and clinical refinements of a new perforator
flap. Plast Reconstr Surg 2009;123(2):578–88.
10. Rodríguez Lorenzo A, Morley S, Payne AP, et al. Anatomy of the
motor nerve to the gracilis muscle and its implications in a one-
stage microneurovascular gracilis transfer for facial reanimation.
J Plast Reconstr Aesthet Surg 2010;63(1):54–8.
11. Whitaker IS, Karavias M, Shayan R, et al. The gracilis myocutane­
ous free flap: a quantitative analysis of the fasciocutaneous blood
supply and implications for autologous breast reconstruction. PLoS
ONE 2012;7(5):e36367.
12. Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap:
vascular anatomy and clinical application. Plast Reconstr Surg
1997;99(6):1642–55.
13. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis
musculocutaneous flap. Ann Plast Surg 1992;29(6):482–90.
14. Alam NH, Haeney JA, Platt AJ. Three episodes of gracilis free
muscle transfer under epidural anaesthesia. J Plast Reconstr
Aesthet Surg 2006;59(12):1463–6.
15. Addosooki AI, Doi K, Hattori Y. Technique of harvesting the gracilis
for free functioning muscle transplantation. Tech Hand Up Extrem
Surg 2006;10(4):245–51.
16. Locke MB, Zhong T, Mureau MA, et al. Tug ‘O’ war: challenges of
transverse upper gracilis (TUG) myocutaneous free flap breast
reconstruction. J Plast Reconstr Aesthet Surg 2012;65(8):1041–50.
17. Healy C, Allen RJ Sr. The evolution of perforator flap breast recon­
struction: twenty years after the first DIEP flap. J Reconstr Micro­
surg 2014;30(2):121–5.
18. Saint-Cyr M, Wong C, Oni G, et al. Modifications to extend the
transverse upper gracilis flap in breast reconstruction: clinical
series and results. Plast Reconstr Surg 2012;129(1):24e–36e.
19. Hallock GG. The gracilis (medial circumflex femoral) perforator
flap: a medial groin free flap? Ann Plast Surg 2003;51(6):623–6.
20. Momeni A, Bannasch H, Lee GK. The free gracilis perforator flap:
is a perforator flap really indicated in the case of the gracilis flap?
Plast Reconstr Surg 2009;124(3):1008–9, author reply 1009–10.
21. Ramakrishnan V, Southern S, Hart NB, et al. Endoscopically
assisted gracilis harvest for use as a free and pedicled flap. Br J Plast
Surg 1998;51(8):580–3.
22. Morasch MD, Sam AD 2nd, Kibbe MR, et al. Early results with use
of gracilis muscle flap coverage of infected groin wounds after
vascular surgery. J Vasc Surg 2004;39(6):1277–83.
23. Hsu H, Lin CM, Sun TB, et al. Unilateral gracilis myofasciocutane­
ous advancement flap for single stage reconstruction of scrotal
and perineal defects. J Plast Reconstr Aesthet Surg 2007;60(9):
1055–9.
24. Chen SH, Hentz VR, Wei FC, et al. Short gracilis myocutaneous
flaps for vulvoperineal and inguinal reconstruction. Plast Reconstr
Surg 1995;95(2):372–7.
25. Kua EH, Leo KW, Ong YS, et al. Vascularisation of urethral repairs
with the gracilis muscle flap. Arch Plast Surg 2013;40(5):584–8.
26. Troja A, Käse P, El-Sourani N, et al. Treatment of recurrent
rectovaginal/pouch-vaginal fistulas by gracilis muscle transposition
– a single center experience. J Visc Surg 2013;150(6):379–82.
27. Gultekin FA, Bakkal BH, Tayfun S, et al. Chronic pelvic absceda­
tion after completion proctectomy in a rectal stump insufficiency;
treatment with gracilis muscle flap following vacuum assisted
closure therapy. Ann Coloproctol 2013;29(4):172–6.
28. Mander BJ, Wexner SD, Williams NS, et al. Preliminary results of
a multicentre trial of the electrically stimulated gracilis neoanal
sphincter. Br J Surg 1999;86(12):1543–8.
29. Janknegt RA, Baeten CG, Weil EH, et al. Electrically stimulated
gracilis sphincter for treatment of bladder sphincter incontinence.
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Reconstr Surg 2000;106(7):1507–13.
Access Figures 49.13, 49.14, 49.15, 49.16, and
49.17, as well as case examples 4, 5, 6, 7, and
8 online at
REFERENCES
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Plast Reconstr Surg 1976;57(3):294–303.
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with microneurovascular anastomoses for the treatment of facial
paralysis. A preliminary report. Plast Reconstr Surg 1976;57(2):
133–43.
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radiological study. Clin Anat 2008;21(7):696–704.
5. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous
flaps. St Louis: Mosby; 1979.

CHAPTER 49 — Gracilis Flap 568.e1
A 4-year-old boy sustained a supracondylar fracture, which was
ineffectively treated, resulting in a Volkmann’s ischemic contrac-
ture. He had absent finger and thumb flexion and our goal was
to reconstruct this with a single free functioning gracilis muscle
flap, but with a degree of independent thumb and finger flexion.
Similar to Case 49.3, the forearm was appropriately prepared
and we were able to identify the anterior interosseous nerve as
a healthy stump. Further to this, we were able to identify the
branch that normally went to the flexor pollicis longus on the
radial side of the anterior interosseous nerve. The other segment,
running on the ulnar side of the anterior interosseous nerve,
would be the section going to the finger flexors. Thus, the recipi-
ent anterior interosseous nerve had two separate donor compo-
nents that could be utilized for independent function. The
anterior interosseous artery and vein were available also to revas-
cularize our muscle transplant. Distally in the forearm, we were
able to isolate the flexor pollicis longus tendon in the distal
forearm, as well as the profundus tendons. The profundus
tendons were sutured in a fashion that, with proximal traction,
led to finger flexion in unison. The superficialis tendons were
resected. Thus, the forearm had been prepared such that the
gracilis could be split and provide independent finger and
thumb flexion, at least to a certain degree.
The gracilis muscle in the thigh was prepared in the usual
fashion. However, we then split the distal tendon into two sepa-
rate sections so that we could suture one for thumb flexion and
the other for finger flexion. We then evaluated the motor nerve
to gracilis and stimulated its fascicles in a separate fashion. We
had done this in several previous gracilis muscle procurements
and found that in most cases one could distinguish contraction
of a certain part of the muscle with stimulation of a certain fas-
cicle. In this case, we found this to be true and we identified the
fascicle that would stimulate one section of the muscle that we
had separated. The other fascicle would go to the other segment.
The gracilis was thus procured with appropriate markings, as
to which fascicle stimulated which segment of muscle and also
having the muscle stretched out and marked at 5 cm intervals.
The muscle was transplanted to the forearm. It was revascular-
ized in an end-to-end fashion to the anterior interosseous artery
and vein. Then the segment of the anterior interosseous nerve
that originally went to the flexor pollicis longus was sutured to
one fascicle of the gracilis. This was the fascicle that stimulated
one section of the gracilis muscle, and this was tagged to be
sutured to the residual tendon of the flexor pollicis longus. In a
similar fashion, the segment of the anterior interosseous nerve
on the ulnar aspect was coapted to the motor nerve to gracilis
that would innervate the remaining segment of that muscle.
That remaining segment would be sutured to the tendons that
provided finger flexion, that is to say the flexor profundus
tendons. The tendon repairs were done after the muscle had
been secured to the medial epicondyle and stretched out to its
normal length. It was placed under sufficient tension to allow
for full wrist extension and finger extension with the muscle
being stretched to its normal fully stretched position, as indi-
cated by our 5 cm marks. The tendon repairs were carried out
at this level after the nerve coaptations had been carried out and
after the muscle had been secured to the medial epicondyle.
Skin closure was incomplete requiring a small split-thickness skin
graft. The patient was placed in a protective splint in the neutral
position, again for approximately 3 weeks, then passive exten-
sion of the elbow, wrist, and fingers was begun. When active
contraction of the muscle was seen, we then initiated active
exercises. Good recovery of function of the gracilis was seen with
flexion of the fingers and thumb. These could be activated to a
certain extent in an independent fashion. This overall separa-
tion of function between the fingers and thumb helps to improve
the functional capability of the hand (Fig. 49.13).
CASE 49.4  Free Functioning Split Gracilis Muscle Flap for Independent Thumb and Finger
Flexion
Figure 49.13  (A) Patient with Volkmann’s ischemic contracture of the forearm following a supracondylar fracture. Nonfunctional muscle
has been excised. (B) A functional gracilis muscle has been harvested. Its insertion has been split as has the motor nerve to isolate two
separate functional muscle units. (C) The functional muscle was used to power flexor digitorum profundus and flexor pollicis longus as
separate units. (D) Functional outcome showing flexion of the digits due to action of the gracilis flap.
A
B
C
D

568.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
During cholesteatoma surgery at 11 months of age, the facial
nerve was injured. A greater auricular nerve graft was carried out
to bridge the gap. There was considerable recovery in terms of
tone and eye protection, but the child remained with an asym-
metrical smile. When evaluated by our team some 7 years later,
the involved right side had a facial droop of 4 mm and a midline
shift of 3 mm to the normal left side. Actively, she had no brow
elevation, almost complete eye closure, but oral commissure
movement of only 2 mm, which was largely transverse. There was
virtually no commissure elevation (Fig. 49.14A,B). She wanted
to smile, and at age 10, underwent stage I cross face nerve graft-
ing. The normal left side was explored, a facial nerve map was
created, and a section of the facial nerve was identified as to be
the appropriate branch going to the zygomaticus major and
minor muscles. This would be used as our donor for the cross
face nerve graft. We carefully confirmed that there were other
branches to innervate the musculature on the normal side as
well prior to sacrificing the selected branch of facial nerve. A
tunnel was created to the paralyzed side. The sural nerve was
procured and placed across the face through this tunnel. Micro-
neural coaptation was then carried out between the sural nerve
graft and the segment of facial nerve that had been selected.
One year later, she underwent stage II, segmental gracilis
muscle transplantation. Appropriate markings were made featur-
ing the site for muscle insertion, the proposed vector of move-
ment, the incision line, and palpated facial artery. The paralyzed
side was prepared for segmental gracilis muscle transplantation.
The length of the muscle required was the distance between the
oral commissure and the root of the helix, plus 1 cm on each
side for suturing. Approximately one-third of the circumference
of the gracilis muscle was to be taken with the neurovascular
pedicle in the center of the section selected. The face was pre-
pared along with exploration of the cross face nerve graft, which
had been banked in the upper buccal sulcus. The muscle was
appropriately positioned, revascularized through microvascular
anastomoses to the facial artery and vein. The muscle was rein-
nervated with coaptation of the motor nerve to gracilis, to the
banked end of the sural nerve graft in the upper buccal sulcus.
After about 4 months, the muscle became reinnervated, showing
signs of contraction. Our patient was instructed to exercise the
muscle in front of a mirror to provide biofeedback. As the inner-
vation was from the 7th nerve on the normal side, no relearning
was necessary. She regained a symmetrical and synchronous
smile (Fig. 49.14C through G).
CASE 49.5  Free Functioning Segmental Gracilis Muscle Transplantation for Unilateral
Facial Paralysis
A
B
C
D
E
F
G
Figure 49.14  (A) The patient has a congenital left facial palsy and can be seen at rest in this image. (B) Pre-operatively showing asym­
metrical smile. (C) Case following cross face nerve graft and free functional segmental gracilis flap as a two-stage procedure. (D) Reani­
mation of the smile can be seen on the left side of the face though the tension of the reconstruction was felt to be high and required
release by Dr Joe Upton, in Boston at a later date. (E,F,G) Long-term result.