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

CHAPTER 2 — Classification of Flaps
e3
Mathes and Nahai (see below)34 are very similar, as each uses
subtle differences in circulation patterns to distinguish their
flap subtypes. This is also a pragmatic approach, as the vas­
cular supply, if nothing else, must be correctly identified
and protected to ensure flap viability. Yet even further con­
solidation of cutaneous flap types is possible.
TAYLOR’S “ANGIOSOME” CONCEPT-BASED
CLASSIFICATION
Angiosomes refer to specific 3-dimensional blocks of tissue,
including skin and deeper tissues layers that are supplied by
specific source arteries.27 In 1893, Spalteholz36 performed
injection studies using pigment mixed in gelatin to demon­
strate a pure (intermuscular) or impure (i.e., primarily sup­
plied deeper tissues, mostly muscle) course of cutaneous
perforators. All arteries to the skin could most simply be
considered to be either “direct” or “indirect” branches from
Figure 2.2  The subtypes of fasciocutaneous flaps in Cormack and Lamberty’s classification schema differ according to the means of vascu­
larization of the “fascial plexus.”
Type A: multiple feeders
Type B: solitary
Type C: segmental
Type D: osteomyofascial
Figure 2.3  Mathes and Nahai’s tripartite system of fasciocutaneous flaps is based on the three major types of deep fascial perforators.
Type A: direct cutaneous
Type B: septocutaneous
Type C: musculocutaneous
Figure 2.4  The six distinct deep fascia perforators according to
Nakajima et al.14 A different type of fasciocutaneous flap can be
sustained by each discrete type of perforator. S, source or “mother”
vessel; F, deep fascia.
Musculocutaneous
perforator (VI)
Muscle
Direct
septocutaneous (II)
Skin
F
F
S
Direct cutaneous (I)
Septocutaneous
perforator (V)
Perforating cutaneous branch of
muscular vessel (III)
Direct
cutaneous branch of
muscular vessel (IV)

e4
PART 1 — PRINCIPLES
decades, the use of muscle flaps has evolved so that muscle
function is rarely sacrificed simply to supply skin blood
supply but rather, muscle flaps are used when a large volume
of flap is required to fill dead space or muscle function is
required, as, for example, with facial reanimation. It remains
important that the pattern of vascularity of muscles will
determine muscle flap survival and must be respected.
MATHES AND NAHAI MUSCLE
FLAP CLASSIFICATION
Mathes and Nahai45 (1981) categorized muscles into Types
I–V, based on their vascular supply (Fig. 2.6). On the other
hand, it is not just a coincidence that the majority of mus­
culocutaneous perforators arise near where the dominant
pedicle enters the hilum of that muscle. The astute student
of muscle perforator flaps must be fully aware of the most
reliable muscle types, which pedicle is dominant, and where
they are typically located to better predict the presence of
musculocutaneous perforators. This is essential for skilful
elevation of these flaps, even though the muscle itself is not
to be included.
TAYLOR CLASSIFICATION
Taylor et al.46 have also divided muscles into four groups
(Types I–IV) that differ by their mode of motor innervation
(Fig. 2.7). This classification becomes important when a
dynamic muscle transfer is considered, to ensure capture of
an appropriately functioning muscle unit.
OTHER FLAPS
Vascularized bone flaps are used less frequently than soft
tissue flaps. Again, as for all other flaps, a good system would
categorize these primarily on the basis of their circulatory
patterns.
SERAFIN CLASSIFICATION
Serafin has divided osseous flaps according to whether the
flap has a direct (endosteal) or indirect (periosteal) circula­
tion (Fig. 2.8).47 Vascularized joint transfers could similarly
be subclassified according to the source of vascularization
of their bony constituents.
COMBINED FLAPS
In extraordinary circumstances, the creative combination of
flaps from a single donor site is used to repair challenging
defects where multiple tissue islands are required. The spo­
radic introduction of variations of combined flaps has
created much confusion in terminology, since minor modi­
fications of technique often have been called different
names or given eponyms, but the basic flap composition
has remained unaltered. There are two major subtypes
of combined flaps that are distinctly different in regards
to the physical relationship of their component parts, yet
both are similar in that each anatomic territory that is part
of that combination always retains an independent blood
supply.
an underlying source vessel. Taylor has repeatedly argued
that the direct vessels are the primary cutaneous supply, and
it is irrelevant if they have first traversed intermuscular or
intramuscular septa, as their main destination always is to
the skin.27,28,37,38 The indirect vessels emerge above the deep
fascia as terminal, spent branches whose main purpose was
to supply the deeper tissues, so they are in reality only a sec­
ondary means of cutaneous blood supply.39 It can be further
argued that all deep fascia perforators would be “direct” if
they coursed from the source vessel to perforate the fascia
without first passing through some other tissue intermediary,
or otherwise they would be “indirect” perforators (Fig. 2.5).28,40
All corresponding cutaneous flaps would then be either
direct perforator flaps or indirect perforator flaps.
Because the perforator supplying a muscle perforator
flap, by definition,35 must have first traveled through the
substance of that muscle, in this classification system, these
would be indirect perforator flaps. Neurocutaneous flaps
would be an excellent example of indirect non-muscle per­
forator flaps. These flaps rely on an intrinsic and extrinsic
neurocutaneous or venocutaneous vascular supply that
accompanies a peripheral cutaneous nerve.41–44 The extrin­
sic vascular supply can often be a true artery, and, depend­
ing on the nerve, both structures can simultaneously pierce
the deep fascia before proceeding within the subcutaneous
tissues.41–44 The major purpose of this accompanying vascu­
lar system is to provide circulation to the nerve, and only
secondarily (or indirectly) are cutaneous branches given off
that will support an overlying cutaneous flap. Niranjan
et al.33 pointed out that perforators similar to those accom­
panying the cutaneous nerves can also arise independently
from fascioperiosteal or tenosynovial branches, which in
turn also can supply indirect non-muscle perforator flaps.
Thus, indirect perforator flaps, more than any other cutane­
ous flap, deserve a separate categorization to ensure the
appropriate dissection of whatever are the intermediary
structures, while protecting the requisite vascular supply.
MUSCLE FLAPS
In the 1980s, muscle flaps became very popular, since it was
a reliable method to transfer large skin flaps. Over the
Figure 2.5  The deep fascia perforators of Nakajima et al.14 (see Fig.
2.4) can be more simply considered to be either “direct” or “indirect”
perforators. All perforators arise from the same source vessel (S) but
only “indirect” perforators (dotted lines) first pass through another
tissue intermediary (here depicted as muscle) before piercing the
deep fascia.
Direct perforators
Indirect perforators
S

CHAPTER 2 — Classification of Flaps
e5
Any direct or indirect perforator flap40 that has more
than a single perforator could also be considered to be
a “conjoined” flap, as each perforator retains its specific
vascular territory that, for example, Tsai et al.50 have
used to advantage as the basis for “splitting” the flap. These
would be called “perforator-based conjoined flaps” in con­
tradistinction to Harii et al.’s25,48 flap that retained indepen­
dent branches of the source vessel to each territory, hence
being an example of a “branch-based (independent) con­
joined flap.” If the independent branches had a common
“mother” vessel, as in a conjoined parascapular and latissi­
mus dorsi muscle flap as theorized by Nassif et al.,51 this
would be an example of a “branch-based (common) con­
joined flap.”
CONJOINED FLAPS
Harii et al.25,48 first introduced the concept of combined
flaps when they described a “combined myocutaneous flap
and microvascular free flap.” This captured the skin territo­
ries of the latissimus dorsi musculocutaneous flap and groin
flap, where both remained connected together to essentially
form a bipedicled flap with the thoracodorsal and superfi­
cial circumflex iliac vessels remaining as pedicles at opposite
ends, respectively.25 Such a conjoined flap or Siamese flap
(named after the conjoined Siamese twins, Chang and Eng,
1811–1874)49 will have multiple flap territories that remain
dependent due to some common physical junction, yet each
territory retains its intrinsic and independent vascular
supply (Fig. 2.9).
Figure 2.6  The classic classification schema for muscle flaps by Mathes and Nahai45 is divided into five types, according to the predominant
vascular pattern for that type muscle. D, dominant pedicle; M, minor; SS, secondary segmental; S, segmental.
D
D
M
SS
SS
SS
M
D1
D
D2
M
M
Serratus anterior
Internal oblique
Gastrocnemius
Trapezius
Type III
Type V
Type I
Type II
Type IV
S
S
S
S
S
Tibialis anterior
Figure 2.7  Taylor’s46 alternative schema classified muscles according to the increasing complexity of their innervation, and concomitant
diminished suitability for use as a dynamic muscle transfer. (A) Type I: single unbranched nerve entering muscle. (B) Type II: single nerve that
branches just before entering muscle. (C) Type III: multiple branches from same nerve trunk. (D) Type IV: multiple branches from different nerve
trunks.
Sartorius
Rectus abdominis
Latissimus dorsi
A
B
C
D
Vastus lateralis

e6
PART 1 — PRINCIPLES
specific blood supply (Fig. 2.10). The more traditional chi­
meric flap or branch-based type will have multiple and rela­
tively large subfascial branches emanating from a common
“mother” vessel. The subscapular system epitomizes this
subtype, where fascial (dorsal thoracic), muscle (serratus
anterior, latissimus dorsi), and osseous (rib, scapula) flaps,
based on either the thoracodorsal or circumflex scapular
branches, can allow over 60 known different flap combina­
tions, which still permit independent insetting of each
part.53
If the common boundary of a “perforator-based con­
joined flap” is split apart, yet each part based on an indi­
vidual perforator still remains attached to the same source
vessel, these would become perforator-based chimeric
flaps.50 The anterolateral thigh flap is the prototypical donor
site for this variation, where it has been split into smaller
flaps to allow, for example, simultaneous intraoral and
cheek reconstruction without the need for flap infolding or
de-epithelialization.54
Koshima et al.,55 in their introduction to the chimeric flap
principle, prefabricated combinations by attaching other­
wise independent flaps to either side branches of the main
source vessel or to its distal continuation.48 This type of
fabricated chimeric flap always requires a microanastomo­
sis. If the added flap is connected to the terminus of the
source vessel, this would be a fabricated (sequential) chime­
ric flap as the circulation must proceed as a “flow-through”
across the first flap and then to that attached in sequence.
If a side branch of the first flap is used for this microanas­
tomosis, this would be a fabricated (internal) chimeric flap,
CHIMERIC FLAPS
The chimeric flap, originally conceived as a combination of
local flaps from the same anterolateral thigh angiosome,26
has become entrenched in our vocabulary, despite the
obvious problem that a chimera generally refers to an
organism with a mixture of genetically different tissues. The
chimeric flap has two or more subunits, each with an inde­
pendent vascular supply, that are independent of any physi­
cal interconnection except where linked by a common
source or “mother” vessel. Huang et al.52 have further sub­
divided chimeric flaps into three subtypes, based on their
Figure 2.9  Conjoined flaps have two subclasses distinguished by
the distinctly different caliber of their source of vascularization. The
larger caliber and often subfascial or axial branches of the branch-
based form may have completely unrelated origins from different
angiosomes (independent type), or these branches may arise from a
common source vessel (common type). The perforator-based form
usually has multiple deep fascia perforators arising from a common
source vessel.
Branch-based
CONJOINED
Perforator-based
Independent
Common
Figure 2.10  Chimeric flaps can be stratified into three subclasses
on the basis of either their intrinsic vasculature or whether prefabri­
cated via a microanastomosis. Perforator-based chimeric flaps are
nourished by perforators arising from a common source vessel.
Larger caliber and usually subfascial vessels to the branch-based
chimeric flap also ultimately are connected to a common “mother”
vessel. In the fabricated chimeric flap, the added component can be
attached to the terminus of the source vessel to create a “flow-
through” (sequential type) or to a branch indigenous within the flap
(internal type).
Perforator-based
Sequential
Branch-based
Internal
CHIMERIC
Intrinsic
Fabricated
Figure 2.8  Osseous flaps according to Serafin47 can be classified
as either endosteal, where the blood supply directly enters the bone,
usually via a nutrient foramen (left), or periosteal, which circumscribes
the bone within the periosteum to eventually reach the bone
indirectly.
Endosteal
Periosteal

CHAPTER 2 — Classification of Flaps
e7
Therefore, a nomenclature system for describing perforator
flaps was reported, which identifies all skin flaps according
to the source vessel (e.g., lateral circumflex femoral, LCF);
artery perforator (AP, or septocutaneous S), and the muscle
penetrated by the perforator if required (e.g., tensor fascia
lata, tfl). Therefore, an upper anterolateral thigh flap would
be LCFAP-tfl.23,24
VASCULARIZED COMPOSITE
ALLOTRANSPLANTATION
CLASSIFICATION
In the continued quest for perfection, sources other than
autogenous tissues have shown promise for better results
with less donor site morbidity. Although tissue engineering
or regeneration may ultimately be the final answer, at the
present time, vascularized composite allotransplantation is
more pragmatic with stunning results, especially in face and
upper extremity reconstruction (see Chs 64 and 65). Other
body parts and organ systems such as the penis, abdominal
wall, and uterus have been transferred, but in comparably
smaller numbers (see Ch. 66). Successful transfer of flaps
such as muscle VCA has been reported,60 as has a DIEAP
(deep inferior epigastric artery perforator) free flap for
breast reconstruction61 and a temporoparietal scalp flap for
alopecia,62 with the latter two unique, in that they were
between identical twins, so no immunosuppression was
required. Since in all cases, VCA differs from autogenous
tissue transfers only in that the donor and recipient are not
the same individual, it would seem reasonable not to have
as there would be flow only internally within the combina­
tion and no “flow-through.”
SECONDARY CHARACTERISTICS
There is no system that can perfectly categorize all types of
flaps,56 and most likely one never would be universally
accepted anyway. This is a Herculean task, just considering
the primary attributes of all flap types. To be absolutely
complete, other secondary characteristics must also be
accounted for. Tolhurst57,58 listed all possible distinguishing
characteristics that should be enumerated in his “atomic
system” but flap composition, rather than circulation was
his primary focus (Fig. 2.11). Cormack and Lamberty30,59
used a similar format with their anatomic system for com­
plete flap classification, but advocated using the source of
circulation as the nucleus or most critical factor in flap
selection. They also proposed a mnemonic of the “6 Cs” for
complete flap identification that, in addition to the circula­
tion, included constituents (composition), conformation
(form/shape), contiguity (destination), construction (type
of pedicle), and conditioning (preparation) (Table 2.1).32
PERFORATOR FLAPS
A perforator flap may be defined as a vascularized tissue
transfer based on a cutaneous perforator (direct, septocu­
taneous, or musculocutaneous). The individual perforators
are quite variable but the underlying source vessels and
regional vascular supply (angiosome) are quite consistent.
Figure 2.11  The “atomic system” that enumerates all known characteristics that are essential to fully describe any flap. (Reprinted with per­
mission from Tolhurst DE. A comprehensive classification of flaps: the atomic system. Plast Reconstr Surg 1987; 80:608–609).
Bipedicle
Unipedicle
Free
Pedicled
Distant
Rhomboid, etc.
Bilobed
Special
Random
Non-skin:
blood vessels
subcutaneous tissue
fascia
muscle
Skin
Skin
Fat
Fascia
Muscle
Cartilage
Bone
and
Composite:
fasciocutaneous
musculocutaneous
Pedicle
Local
Destination
Axial
Blood supply
Transposition
Delay
Tissue expansion
Special preparation
Rotation
Form

e8
PART 1 — PRINCIPLES
a special classification nomenclature just for VCA tissues
as the tissues themselves are no different from one person
to another. Composite tissues would be named according to
the region transferred, with VCA written as a suffix just to
clarify the source, e.g., “face composite VCA” or “face VCA”
for short. Individual flaps or combinations would follow the
same schema as outlined earlier in this chapter. Thus, a
DIEAP flap transferred from one individual to another
would simply be a DIEAP VCA free flap, again to differenti­
ate appropriately the tissue source.
CONCLUSION
Although there are a bewildering array of classification
schemes, some, such as the muscle flap classification of
Mathes and Nahai,45 have become well established. It would
be just as convenient to categorize all cutaneous flaps as
either direct or indirect perforator flaps,40 which also alerts
the surgeon to anticipate differences in the requisite dissec­
tion techniques to preserve the blood supply to the flap.
However, the terms axial, fasciocutaneous, and musculocutane­
ous are so entrenched that this will be unlikely. Some other
uncommonly used types of flaps have not even been dis­
cussed in this context but venous flaps, for example, could
be considered to be indirect perforator flaps, since all super­
ficial veins at some point pierce the deep fascia with their
intrinsic and/or extrinsic arterial supply.41 Visceral flaps
could be distinguished by the anatomic origin of the flap,
e.g., colon, jejunum, appendix, etc. To compound this
dilemma, so many other potential permutations or combi­
nations exist that it is just not possible to clearly stratify all
possibilities. A complete classification of flaps will always be
an elusive goal,56 but it is important to use surgical princi­
ples and a keen awareness of vascular anatomy to try to
simplify classifications rather than make them unusable due
to complexity. Muscle perforator flaps are the prototypical
example of this controversy, in which several classifications
have been proposed.23,63–65 The overall goal of classifications
should be to aid in communication between surgeons in the
quest to continually improve our results and try to use the
best flap for each reconstructive challenge.
Table 2.1  The complete classification of a flap
Primary
characteristics
Pedicled flap
Free flap
Secondary
characteristics
Pedicled flap
Free flap
Circulation
(blood supply)
Direct vessels
Direct vessels
Contiguity
(destination)
Local
Free flap
Axial
Axial
Regional
Septocutaneous
Septocutaneous
Distant
Endosteal
Endosteal
Construction
(flow)
Unipedicled
Orthograde flow
Indirect vessels
Indirect vessels
Bipedicled
Retrograde flow
Myocutaneous
Myocutaneous
Orthograde flow
Turbocharged
Periosteal
Periosteal
Retrograde flow
Supercharged
Constituents
(composition)
Fasciocutaneous
Fasciocutaneous
Turbocharged
Muscle/
myocutaneous
Muscle/
myocutaneous
Supercharged
Visceral
Visceral
Conditioning
(preparation)
Delay
Delay
Nerve
Nerve
Tissue expansion
Tissue expansion
Bone
Bone
Prefabrication
Prefabrication
Cartilage
Cartilage
Conformation
(geometry)
Special configurations
Tubed
Other
Other
Tubed
Combined flaps
Combined flaps
(Adapted from Cormack GC, Lamberty BGH. Alternative flap nomenclature and classification, the arterial anatomy of skin flaps, 2nd ed.
Edinburgh: Churchill Livingstone; 1994. p. 514–22.)

CHAPTER 2 — Classification of Flaps
e9
10. Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z
J Surg 1968;38:61–3.
11. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of
the lower leg. Br J Plast Surg 1981;34:215–20.
12. Esser JF, Schwerer S. Verschluss einer Brustwand perforation.
Berliner Klin Wochenschr 1918;55:1197.
13. Gillies HD. The tubed pedicle in plastic surgery. New York Med J
1920;3:1–12.
14. Nakajima H, Fujino T, Adachi SA. New concept of vascular supply
to the skin and classification of skin flaps according to their vascu­
larization. Ann Plast Surg 1986;16:1–19.
15. Batchelor JS, Moss AL. The relationship between fasciocutaneous
perforators and their fascial branches: an anatomical study in
human cadaver lower legs. Plast Reconstr Surg 1995;95:629–33.
16. Nakajima H, Minabe T, Imanishi N. Three-dimensional analysis
and classification of arteries in the skin and subcutaneous adipo­
fascial tissue by computer graphics imaging. Plast Reconstr Surg
1998;102:748–60.
17. Manchot C. The cutaneous arteries of the human body. New York:
Springer-Verlag; 1983. p. 136–7.
18. Ger R. The technique of muscle transposition in the operative
treatment of traumatic and ulcerative lesions of the leg. J Trauma
1971;11:502–10.
19. Taylor GI, Townsend P, Corlett R. Superiority of the deep circum­
flex iliac vessels as the supply for free groin flaps. Clinical work.
Plast Reconstr Surg 1979;64:745–59.
20. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A
clinical extension of microvascular techniques. Plast Reconstr Surg
1975;55:533–44.
21. Taylor GI. Free vascularized nerve transfer in the upper extremity.
Hand Clin 1999;15:673–95.
22. Robinson DW, MacLeod A. Microvascular free jejunum transfer. Br
J Plast Surg 1982;35:258–67.
23. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution,
classification, and applications. Ann Plast Surg 2003;50:90–9.
24. Blondeel PN, Hallock GG, Morris SF, et al. Perforator flaps:
anatomy, technique & clinical applications. St Louis: Quality
Medical Publishing; 2006.
25. Harii K. Microvascular free flaps for skin coverage. Indications and
selections of donor sites. Clin Plast Surg 1983;10:37–54.
26. Hallock GG. Simultaneous transposition of anterior thigh muscle
and fascia flaps: an introduction to the chimera flap principle. Ann
Plast Surg 1991;27:126–31.
27. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg
1987;40:113–41.
28. Taylor GI. The “Gent” consensus on perforator flap terminology:
preliminary definitions. Plast Reconstr Surg 2003;112:1384–7.
29. Cormack GC, Lamberty BG. A classification of fascio-cutaneous
flaps according to their patterns of vascularisation. Br J Plast Surg
1984;37:80–7.
30. Cormack GC, Lamberty BG. The anatomical basis for fasciocu­
taneous flaps. In: Hallock GG, editor. Fasciocutaneous flaps.
Cambridge, MA: Blackwell Scientific Publications; 1992. p. 13–24.
31. Hallock GG. Principles of fascia and fasciocutaneous flaps. In:
Weinzweig J, editor. Plastic surgery secrets. Philadelphia: Hanley
and Belfus; 1999. p. 419–26.
32. Cormack GC, Lamberty BG. The arterial anatomy of skin flaps.
Edinburgh: Churchill Livingstone; 1994. p. 514–22.
33. Niranjan NS, Price RD. Govilkar P. Fascial feeder and perforator-
based V-Y advancement flaps in the reconstruction of lower limb
defects. Br J Plast Surg 2000;53:679–89.
34. Mathes SJ, Nahai F. Flap selection: analysis of features, modifica­
tions, and applications. Reconstructive surgery: principles, anatomy,
and technique. New York: Churchill Livingstone; 1997. p. 37–160.
35. Wei FC, Jain V, Suominen S, et al. Confusion among perforator
flaps: what is a true perforator flap? Plast Reconstr Surg 2001;
107:874–6.
36. Spalteholz W. Die Vertheilung der Blutgefasse in der Haut. Archive
für Anatomie und Physiologie (Anat Abtheil) 1893;1:54.
37. Taylor GI, Palmer JH. McManamny D. The vascular territories of
the body (angiosomes) and their clinical applications. In: McCar­
thy JG, editor. Plastic surgery, vol. 1. Philadelphia: WB Saunders;
1990. p. 329–78.
38. Taylor GI. Foreword. In: Manchot C, editor. The cutaneous arteries
of the human body. New York: Springer-Verlag; 1983. p. i–ixiv.
REFERENCES
1. Mathes SJ, Nahai F. The reconstructive triangle: a paradigm for
surgical decision making. In: Reconstructive surgery: principles,
anatomy, and technique. New York: Churchill Livingstone; 1997.
p. 9–36.
2. Pearl RM, Johnson D. The vascular supply to the skin: an anatomi­
cal and physiological reappraisal – Part II. Ann Plast Surg 1983;
11:196–205.
3. Daniel RK, Kerrigan CL. Principles and physiology of skin flap
surgery. In: McCarthy JG, editor. Plastic surgery, vol. 1. Philadel­
phia: WB Saunders; 1990. p. 275–328.
4. Milton SH. Pedicled skin-flaps: the fallacy of the length: width ratio.
Br J Surg 1970;57:502–8.
5. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast
Surg 1973;26:202–13.
6. Orticochea M. The musculo-cutaneous flap method: an immediate
and heroic substitute for the method of delay. Br J Plast Surg
1972;25:106–10.
7. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of inde­
pendent myocutaneous vascular territories. Plast Reconstr Surg
1977;60:341–52.
8. Tanzini I. Sopra il mio nuovo processo di amputazione della mam­
mella. Gaz Med Ital 1906;57:141.
9. Owens NA. Compound neck pedicle designed for the repair of
massive facial defects: formation, development and application.
Plast Reconstr Surg (1946) 1955;15:369–89.
Expert Commentary
Michel Saint-Cyr, MD, FRCS (C)
Regardless of origin and distribution, any single perforator holds
a unique vascular territory (Perforasome) and if large enough,
can be used as either a pedicle, or free, perforator flap. With
over 350 clinically relevant perforators in the body, this allows
for a tremendous number of options in flap choices and design.
Knowledge of the location of the most dominant perforators is
critical and will help facilitate flap design and harvest. Most
perforators in the body are distributed within “cold spots” and
“hot spots,” with hot spots being high perforator–concentrated
locations and cold spots being relative poor areas of perforator
distribution. Most hot spots can be found adjacent to articula-
tions and mid-point between two articulations in the extremi-
ties, whereas in the trunk, perforators are clustered parallel to
the posterior and anterior midline as well as midaxillary regions.
Designing the skin paddle over the hot spots will ensure that
as many perforators are incorporated within the flap, and
this will help maximize interperforator flow via linking vessels
between each perforator. Interperforator flow is ensured by a
series of direct and indirect linking vessels as well as multiple
communicating branches between the former two. The flap’s
long axis should be parallel to the direction of these linking
vessels in order to maximize interperforator flow, and hence,
increase flap perfusion. Linking vessels are usually oriented
parallel to the extremities and perpendicular to the midline in
the trunk. A perforator flap based on a perforator that originates
from a source artery with multiple sequential perforators, will
have more of an axial pattern of vascularity, compared with a
single dominant perforator. Perforators from the same source
artery will fill preferentially first before adjacent source artery
perforators (e.g., perforators of the descending branch of the
LCFA, lateral circumflex femoral artery). Mass vascularity of a
perforator found close to an articulation will also be directed,
in general, away from that same articulation, whereas mid-point
perforators (perforators found between two articulations) will
have a multidirectional distribution. With a significant number
of clinically relevant perforators available in the body, custom-
ized ad-hoc, or freestyle, perforator flaps can be designed to
reconstruct a panoply of defects.

e10
PART 1 — PRINCIPLES
52. Huang WC, Chen HC, Wei FC, et al. Chimeric flap in clinical use.
Clin Plast Surg 2003;30:457–67.
53. Hallock GG. Permutations of combined free flaps using the sub­
scapular system. J Reconstr Microsurg 1997;13:47–54.
54. Huang WC, Chen HC, Jain V, et al. Reconstruction of through-and-
through cheek defects involving the oral commissure, using chime­
ric flaps from the thigh lateral femoral circumflex system. Plast
Reconstr Surg 2002;109:433–43.
55. Koshima I, Yamamoto H, Hosoda M, et al. Free combined compos­
ite flaps using the lateral circumflex femoral system for repair of
massive defects of the head and neck regions: an introduction to
the chimeric flap principle. Plast Reconstr Surg 1993;92:411–20.
56. Hallock GG. The complete classification of flaps. Microsurgery
2004;24:157–61.
57. Tolhurst DE. Fasciocutaneous flaps and their use in reconstructive
surgery. Perspec Plast Surg 1990;4:129–45.
58. Tolhurst DE. A comprehensive classification of flaps: the atomic
system. Plast Reconstr Surg 1987;80:608–9.
59. Lamberty BG, Healy C. Flaps: physiology, principles of design, and
pitfalls. In: Cohen M, editor. Mastery of plastic and reconstructive
surgery. Boston: Little Brown; 1994. p. 56–70.
60. Jones TR, Humphrey PA, Brennan DC. Transplantation of vascular­
ized allogeneic skeletal muscle for scalp reconstruction in a renal
transplant patient. Transplantation 1998;65:1605–10.
61. Allen RJ Jr, LoTempio MM, Craigie JE, et al. Transplantation in
identical twins: another option for breast reconstruction. Plast
Reconstr Surg 2008;122:1019–23.
62. Valauri FA, Buncke HJ, Alpert BS, et al. Microvascular transplanta­
tion of expanded free scalp flaps between identical twins. Plast
Reconstr Surg 1990;85:432–6.
63. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The “Gent”
consensus on perforator flap terminology: preliminary definitions.
Plast Reconstr Surg 2003;112:1378–84.
64. Kim JT. New nomenclature concept of perforator flap. Br J Plast
Surg 2005;58:431–40.
65. Hallock GG. Muscle perforator flaps: the name game. Ann Plast
Surg 2003;51:630–2.
39. Taylor GI. The blood supply of the skin. In: Aston SJ, Beasley RW,
Thorne CHM, editors. Grabb and Smith’s plastic surgery. Philadel­
phia: Lippincott-Raven; 1997. p. 47–59.
40. Hallock GG. Direct and indirect perforator flaps: the history and
the controversy. Plast Reconstr Surg 2003;111:855–66.
41. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries
of the cutaneous veins and cutaneous nerves in the extremities:
anatomical study and a concept of the venoadipofascial and/or
neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr
Surg 1998;102:779–91.
42. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by
the vascular axis of the sensitive superficial nerves: anatomic study
and clinical experience in the leg. Plast Reconstr Surg 1992;89:
1115–21.
43. Hallock GG. Microleaps in the progression of flaps and grafts. Clin
Plast Surg 1996;23:117–38.
44. Bertelli JA, Catarina S. Neurocutaneous island flaps in upper limb
coverage: experience with 44 clinical cases. J Hand Surg [Am]
1997;22:515–26.
45. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg
1981;67:177–87.
46. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories
of the skin and muscles: anatomic study and clinical implications.
Plast Reconstr Surg 1994;94:1–36.
47. Serafin D. Atlas of microsurgical composite tissue transplantation.
Philadelphia: WB Saunders; 1996. p. 513–691.
48. Harii K, Iwaya T, Kawaguchi N. Combination myocutaneous flap
and microvascular free flap. Plast Reconstr Surg 1981;68:700–11.
49. Webster’s New World dictionary of the American language. New
York: World Publishing; 1960. p. 1353.
50. Tsai FC, Yang JY, Mardini S, et al. Free split-cutaneous perforator
flaps procured using a three-dimensional harvest technique for the
reconstruction of postburn contracture defects. Plast Reconstr
Surg 2004;113:185–94.
51. Nassif TM, Vidal L, Bovet JL, et al. The parascapular flap: a new
cutaneous microsurgical free flap. Plast Reconstr Surg 1982;69:
591–600.

6
need to be re-established? Can this be accomplished with a
single flap, or are multiple flaps each with different compo­
nents required? The answers to these basic questions will
immediately narrow the search for the proper flap donor
site. This is most obvious if specialized tissues such as joints,
cartilage, nail, nerve, tendon, bone, or viscera are needed,
as the available resources are extremely limited (Table 3.6).
On the contrary, soft tissue coverage problems, which are
more commonplace, have a plethora of potential options.
Herein lies the major dilemma where proper flap selection
deserves the most emphasis.
If a local or so-called “pedicled flap” is available,3–6 and
best satisfies all the criteria to provide what is needed, that
will always be preferable to the vagaries and inherent risks
of a microsurgical tissue transfer. Indeed, the hierarchy for
flap selection in the upper7 and lower extremities8 has tra­
ditionally emphasized the value of local flaps. Although
these schema typically have also suggested the use of free
flaps for more acral defects,9 a revolution has recently
emerged in the consideration of distal-based regional
flaps10–12 or perforator propeller flaps13–16 that can capture
more proximal extremity skin territories for distal transfer
as an acceptable alternative. These newer possibilities can
be especially valuable if the patient has multiple comorbidi­
ties that would preclude any lengthy surgical procedure, if
the allocation of resources including time is limited, or if
the requisite technical expertise is absent.
Soft tissue coverage can basically always be achieved using
either a cutaneous or muscle flap. Each has distinct attri­
butes that must be considered (Tables 3.1–3.5), and the
preference for either will differ from patient to patient. One
must remember that the use of any muscle as a flap, even if
function preservation techniques were observed,17 will
always result in some loss of function. This risk is minimized
if a cutaneous flap or especially if a perforator flap is used.
The availability and quality of the recipient site vascula­
ture if a free flap is indicated for either type of flap, will
further limit the alternatives. The length of the potential flap
pedicle must be long enough to reach them, and preferably
do so without the need for vein grafts. The caliber of the free
flap vessels should be similar to and definitely not exceed a
3 : 1 ratio to those at the recipient site. This will simplify any
microanastomosis, increase the patency rate and reliability,
and thereby minimize the risk of complications.
Not only must the initial coverage result be satisfactory,
but long-term durability and stability,18 coupled with a rea­
sonable cosmetic appearance must always be a concern
Considerations in
Flap Selection
Geoffrey G. Hallock
3 
INTRODUCTION
A meticulous preoperative problem analysis leading to the
selection of the proper strategy for solving the given wound,
defect, or deformity1 can be a difficult task, yet certainly as
critical as the actual surgical procedure that may be required.
If a vascularized tissue transfer is indicated, there can then
be little question that the selection of the correct flap is
imperative as, if chosen improperly, the entire reconstruc­
tive endeavor may be doomed to failure – no matter how
careful the subsequent surgical execution. This initial phase
of planning should be appreciated as the most intellectually
stimulating and challenging stage, as sometimes the hours
spent in the operating room afterwards may seem actually
too much like “work.” Unfortunately, if simplicity were the
only goal, unlike the early days of plastic surgery, when the
only option was to use some variation of the random flap,
now an almost overwhelming cornucopia of flap alternatives
is available. A “laundry list” of all the available flaps and
their indications would be an impossible job, even if limited
to the “workhorse” flaps outlined in the other chapters in
this book (Fig. 3.1); but a brief dissertation on basic prin­
ciples to follow in completing this selection process may
prove invaluable. An appreciation of the attributes and limi­
tations of the many available flaps (Tables 3.1–3.6) and their
specific indications for use (Tables 3.7–3.9) is critical before
a decision can be made as to which is most appropriate for
the task at hand.
THE RECIPIENT SITE
The primary objective in the reconstruction of any wound,
defect, or deformity, is to restore as closely as possible the
“normal”2 appearance and function; but in that process also
to minimize any residual abnormality or accrue any addi­
tional disability, including that at the donor site. Many
concerns must thus be addressed in an orderly fashion,
beginning with an assessment as to whether a vascularized
flap is even needed in the first place. Yet if not, would a
flap nevertheless still be the preferable solution to provide
the most optimal outcome not just for today, but also in the
long term?
Specific requirements at the recipient site must be met as
closely as possible, beginning with the use of flaps with
similar tissue characteristics (Tables 3.1–3.6). In addition,
will the structural integrity within the region or function
Text continued on p. 11
PART 1  —  PRINCIPLES

CHAPTER 3 — Considerations in Flap Selection
6.e1
Table 3.1  Comparison of attributes of the basic flap subtypes
Bone
Cutaneous
non-perforator
based
Cutaneous
perforator
Intestine
Muscle
Toe
Ease of dissection
Somewhat
difficult
Easy
Difficult
Requires
laparotomy
Easy
Moderately
difficult
Anatomic anomalies
Occasional
Rarely important
Expected
Rare
Rare
Common
Availability
Always
Always
Usually
Always
Always
Possible
Potential for harvest as
compound flap
Sometimes
Sometimes
Always
Never
Usually
Sometimes
Contour (thin → bulky)
N/A
Variable
Variable
Moderate
thickness
Relatively
thin
N/A
Potential for thinning
No
Secondarily
Immediate
No
Yes
No
Donor site morbidity
Potential
If skin graft
necessary
If skin graft
necessary
Requires
laparotomy
Loss of
function
Potential,
especially
great toe
Dynamic transfer
No
No
No
No
Yes
No
Expendability
Maybe
Yes
Yes
Yes
Maybe
Maybe
Reliability (blood supply)
Usually
good
Can be
precarious
Usually good
Always
Best
Sometimes
Sensibility
No
Yes
Yes
No
No
Yes
Surface area
N/A
Small
Very large
Moderate
Large
N/A
Vascular pedicle caliber
Large
Variable
Can be large
Very large
Large
Large
Vascular pedicle length
Short
Variable
Exceedingly long
Very long
Medium
Medium
When used as pedicled flap
Arc of rotation
Short
Limited
Wide
N/A
Wide
N/A
Reliability
Usually
good
Can be
precarious
Usually good
N/A
Best
N/A
Need for supercharge
Sometimes
Usually not
possible
Sometimes
N/A
Not
possible
N/A
N/A, not applicable.

6.e2
PART 1 — PRINCIPLES
Table 3.2  Comparison of attributes of “workhorse” muscle-free and pedicled flaps
Gracilis
Gastrocnemius
Gluteus
Latissimus
dorsi
Pectoralis
major
Rectus
abdominis
Soleus
Trapezius
Ease of dissection
Easy
Minimal difficulty
Moderate
difficulty
Easy
Easy
Easy
Minimal
difficulty
Moderate
difficulty
Anatomic anomalies
Not
important
Not important
No
No
Not important
No
Not
important
Sometimes
Potential for harvest as
compound flap/component
tissues that can be included
Yes/skin
Yes/skin, tendon
Yes/skin,
bone unusual
Most versatile/
skin, rib,
scapula bone
Yes/skin, rib
Yes/skin
Not usually
Yes/skin,
scapula bone
Contour (thin → bulky)
Moderately
thin
Moderately thick
Thick
Moderately
thick
Moderately
thick
Thin
Moderately
thick
Thin
Potential for thinning
Yes
Yes
Yes
No
No
Difficult due to
inscriptions
Yes
No
Dynamic transfer
Best
Pedicle transfer
No
Minimal value
Minimal value
Segmental
innervation
Pedicle
transfer
Yes, for
shoulder
Donor site morbidity
None
Some, if athletic
Significant, if
ambulatory
Minimal
Limited
Can be
significant
Some, if
athletic
Possible,
shoulder drop
Surface area
Narrow
Moderate
Small
Largest
Moderate
Small
Moderate
Moderate
Vascular pedicle caliber
Moderate
Moderate
Large
Large
Moderate
Large
Small
Moderate
Vascular pedicle length
Medium
Medium
Short
Long
Short
Long
Variable
Medium
When used as pedicled flap
Arc of rotation
Moderate
Limited
Limited
Great
Great
Wide
Limited
Great
Reliability
Very good
Always
Usually
Always
Very
Usually
Usually
adequate
Usually
Need for supercharge
No
No
No
No
No
Possible
No
Possible
Potential for harvest as
distally based
No
Unusual
No
Yes, on
secondary
pedicles
Yes, on
secondary
pedicles
Yes, has two
dominant
pedicles
Only if distal
perforator
present
No
Need for delay procedure
No
No
No
No
Sometimes, if
composite flap
Sometimes, if
composite flap
No
No
Splitting into subportions
Maybe
No
Yes
Yes
Yes
No
Yes
Maybe

CHAPTER 3 — Considerations in Flap Selection
6.e3
Table 3.3  Comparison of attributes of “workhorse” fasciocutaneous pedicled and free flaps
Deltopectoral
Groin
Lateral arm
Parascapular
Radial forearm
Scapular
Temporoparietal
Ease of dissection
Unusual
Difficult
Moderately
difficult
Easy
Easy
Easy
Moderately
difficult
Anatomic anomalies
Sometimes
Major concern
Minimal
No
No
No
Rarely
Potential for harvest as
compound flap/component
tissues that can be included
Usually not
Usually not
Minimal/bone,
tendon
Excellent/
bone, muscle
Minimal/bone, tendon
Excellent/
bone, muscle
Yes/bone, hair
Contour (thin → bulky)
Medium
thickness
Usually bulky
Medium
thickness
Usually thick
Moderately thin
Usually thick
Very thin
Potential for thinning
Not immediate
Not immediate
Not immediate
Not immediate
No
Not immediate
No
Donor site morbidity
Disfiguring
Most easily hidden
Minimal
Minimal
Maximal
Minimal
Little
Surface area
Medium
Maximum
Small
Long
Medium
Medium
Small
Vascular pedicle caliber
Large
Variable
Medium
Large
Large
Large
Small
Vascular pedicle length
Variable
Variable
Medium
Long
Long
Long
Short
When used as pedicled flap
Arc of rotation
Medium
Long
Marginal
Medium
Moderate
Medium
Limited
Reliability
Moderate
Unpredictable
Good
Good
Good
Good
Moderate
Need for supercharge
No
No
No
No
Sometimes, especially
if distally based
No
No
Potential for harvest as
distally based
No
Not usually
Yes
No
Yes
No
Unusual
Need for delay procedure
Sometimes to
extend length
No
No
No
No
No
No

6.e4
PART 1 — PRINCIPLES
Table 3.4  Comparison of attributes of “workhorse” perforator flaps
ALT
AMT
DIEAP
Freestyle
IGAP
PTAP
SIEA
SGAP
TFL
TDAP
Ease of dissection
Moderate
Depends
on anatomy
Easy
Depends
on anatomy
Difficult
Easy
Depends
on anatomy
Moderate
Difficult
Easy
Anatomic anomalies
Can be
compensated
for
Major
concern
Sometimes
Depends
on location
Variable
Minimal
Major
concern
Not a
problem
Not
usually
Can be
compensated
for
Potential for harvest
as compound flap/
component tissues
that can be
included
Yes/muscle,
fascia
Yes/muscle
Yes/
muscle
Depends
on chosen
perforator
Yes/
muscle
No
No
Yes/
muscle
Yes/
muscle,
fascia
Yes/muscle,
bone
Contour (thin →
bulky)
Moderate
Moderate
Very bulky
Variable
Extremely
bulky
Thin
Very bulky
Extremely
bulky
Moderate
Moderate
Potential for
thinning
Yes
Yes
Yes
Variable
Difficult
No
Possible
Difficult
Yes
Possible
Donor site
morbidity
Moderate
Moderate
Least
Variable
Limited
Minor
Least
Somewhat
Moderate
Limited
Surface area
Large
Moderate
Huge
Variable
Limited
Small
Large
Limited
Moderate
Large
Vascular pedicle
caliber
Large
Small
Large
Variable
Moderate
Small
Variable
Large
Moderate
Large
Vascular pedicle
length
Long
Short
Long
Short
Short
Short
Variable
Short
Moderate
Long
When used as
pedicled flap
Arc of rotation
Wide
Limited
Large
Limited
Limited
Limited
Limited
Limited
Wide
Wide
Reliability
Good
Variable
Great
Good
Moderate
Good
Unreliable
Good
Moderate
Good
Need for
supercharge
Sometimes, if
distal-based
No
Possible
No
No
No
No
No
No
No
Need for delay
procedure
No
No
No
No
No
No
No
No
No
No
DIEAP, deep inferior epigastric artery perforator; SIEA, superficial inferior epigastric artery; SGAP, superior gluteal artery perforator; IGAP, inferior gluteal artery perforator; ALT, anterolateral
thigh; AMT, anteromedial thigh; TFL, tensor fascia lata; TDAP, thoracodorsal artery perforator; PTAP, posterior tibial artery perforator.

CHAPTER 3 — Considerations in Flap Selection
6.e5
Table 3.5  Comparison of attributes of “workhorse” bone pedicled and free flaps
Fibula bone
with peroneal
perforator flap
Humerus bone
with lateral arm
flap
Iliac bone
with iliac
flap
Rib bone with
pectoralis major
flap
Radius bone
with radial
forearm flap
Scapula bone
with scapular/
parascapular flap
Scapula bone
with trapezius
flap
Ease of dissection
Easy
Moderate
Difficult
Easy
Moderate
Moderate
Moderate
Anatomic anomalies
No
No
Minimal
No
No
Sometimes
Sometimes
Potential for harvest as
compound flap/component
tissues that can be included
Yes/muscle, skin
Yes/fascia, tendon
Yes/muscle
Yes/skin
Yes/fascia,
tendon
Yes/muscle
Yes/skin
Contour (thin → bulky)
Thin
Moderate thickness
Bulky
Moderate thinness
Thin
Moderate thickness
Thin
Implant osseointegration
Yes
No
Yes
No
Unlikely
Maybe
Maybe
Donor site morbidity
Limited
Minor
Sometimes
significant
Minimal
Major
Minimal
Minimal
Bone length
Long
Very short
Moderate
Minimal
Short
Short
Short
Vascular pedicle caliber
Large
Moderate
Moderate
Moderate
Large
Large
Moderate
Vascular pedicle length
Moderate
Moderate
Moderate
Minimal
Long
Long
Minimal
When used as pedicled flap
Arc of rotation
Moderate
Limited
Very limited
Large
Moderate
Large
Moderate
Reliability
Best
Somewhat
Good
Somewhat
Moderate
Very
Somewhat
Need for supercharge
No
No
No
No
Possible, if
distally based
No
No
Potential for harvest as
distally based
Possible
Possible
No
No
Yes
No
No
Need for delay procedure
No
No
No
No
No
No
No

CHAPTER 3 — Considerations in Flap Selection
7
TPF (F, FS)
Trapezius (M, MS, BMS, BM)
Scapular/parascapular (FS, S, BFS)
Latissimus (M, MS, BM, BMS)
Serratus (M, BM)
TDAP (FS, S)
SGAP and IGAP (FS, S)
TFL (M, MF, MFS)
Gastrocnemius (M, MS)
Fibula (B, BS, BMS)
Soleus (M, MS)
Lateral arm (FS, MFS, BMFS)
Radial forearm (FS, S, B, BFS)
Gracilis (M, MFS)
ALT (M, MF, MFS, FS, S)
AMT (M, MFS, FS, S)
PTAP (S)
Toe (B, BS)
B
Posterior interosseous (S)
Ulnar artery perforator (S)
Dorsal metacarpal (S)
Sural (F, FS, FSM, S)
Median forehead (S)
Cervicofacial (S)
Submental (S)
Supraclavicular (S)
FAMM (Mu)
FDB (S)
MFC (B)
Supramalleolar (S)
EDB (S)
Abductor hallucis (M)
ADM (M, SM)
Descending genicular (S, SB)
TPF (F, FS)
Trapezius (M, MS, BMS, BM)
Groin (FS, S, BFS)
Iliac (B, BFS)
TFL (MF, MFS)
Gastrocnemius (M, MS)
Fibula (B, BS, BMS)
Soleus (M, MS)
Deltopectoral (FS, S)
Pectoralis major
(M, MFS, BMFS, BM)
Lateral arm (FS, MFS, BMFS)
Rectus abdominis (M, MFS)
DIEAP (FS, S)
SIEA (FS, S)
Jejunum (M, Mu)
Radial forearm (FS, S, B, BFS)
Gracilis (M, MFS)
ALT (M, MF, MFS, FS, S)
AMT (M, MF, MFS, FS, S)
PTAP (FS, S)
(medial plantar,
medialis pedis)
Toe (B, BS)
Pulp (S)
A
Figure 3.1  (A,B) Conventional and perforator-based workhorse flaps available in several regions of the body. Tissue types and some potential
combinations that can be carried with the flaps are mentioned: B, bone; M, muscle; S, skin; F, fascia; Mu, mucosa.

8
PART 1 — PRINCIPLES
(C,D) Workhorse flaps commonly used for reconstruction of specific body regions. These are flaps customarily used for
each body part, and include both free flap and pedicled flap alternatives. Although it may not be specifically listed, many workhorse flaps often
have additional potential roles as a choice for other body regions. ADM, abductor digiti minimi; ALT, anterolateral thigh; AMT, anteromedial
thigh; DIE(A)P, deep inferior epigastric (artery) perforator; DP, deltopectoral; EDB, extensor digiti brevis; FAMM, facial artery musculomucosal;
FDB, flexor digitorum brevis; IGAP, inferior gluteal artery perforator; MFC, medial femoral condyle; PM, pectoralis major; PTAP, posterior tibial
artery perforator; SEAP, superior epigastric artery perforator; SGAP, superior gluteal artery perforator; SIEA, superficial inferior epigastric artery;
TDAP, thoracodorsal artery perforator; TPF, temporoparietal fascia; TFL, tensor fascia lata; TRAM, transverse rectus abdominis myocutaneous;
VRAM, vertical rectus abdominis myocutaneous.
Midface/nose Median forehead, Nasolabial, Radial forearm, Fibula, Iliac,
Rectus abdominis, submental, cervicofacial
Tongue/floor of mouth Radial forearm, ALT, AMT, DP, PM, FAMM
Esophagus Jejunum, ALT, Radial forearm, Colon
Neck Deltopectoral, Pectoralis major, ALT, Parascapular, supraclavicular
Forehead Temporoparietal, Radial forearm, median forehead
Wrist flexion/extension Gracilis
Sternum/mediastinum Pectoralis major, Rectus abdominis,
Omentum, ALT, TFL
Vagina (in female) Jejunum, Colon, Gracilis, VRAM, DIEP
Thigh TFL, ALT, Gracilis, SCIA
Knee Latissimus dorsi, Reverse ALT,
Reverse vastus lateralis, Gastrocnemius, Sural
Chest wall Pectoralis major, Rectus abdominis,
Omentum, External oblique, ALT, TFL
Foot Glabrous skin flaps (FDB, medialis pedis, medial plantar),
Radial forearm, Temporoparietal, Rectus abdominis, EDB,
abductor hallucis
Empyema/bronchopleural fistula Latissimus dorsi,
Serratus anterior, Pectoralis major
Abdominal wall Rectus abdominis, ALT, TFL, DIEAP, SEAP
Groin DIEP, TRAM, Gracilis, ALT, TFL, SCIA
Penis ALT, Fibula, Rectus abdominis, Groin
Ear Temporoparietal, ALT fascia flap, Lateral arm fascia flap
Orbit Temporoparietal, Radial forearm, ALT
Breast Latissimus dorsi, DIEP, TRAM,
Transverse gracilis myocutaneous flap, SGAP, IGAP
Elbow flexion Latissimus dorsi, Gracilis
Finger amputation
Replantation of amputee,
Toe, Glabrous skin
Finger pulp Glabrous skin flaps
(Medialis pedis, Toe pulp flap, Medial plantar)
Cross-finger, Moberg, homodigital
Palm Glabrous skin flaps, Homodigital, ADM
(Medial plantar, Medialis pedis),
Radial forearm, Posterior interosseous
Upper Gastrocnemius, ALT, Sural
Middle Soleus, ALT
Lower Soleus, Reverse sural, ALT
Tibia
Scalp Temporoparietal, Latissimus, ALT, Trapezius
Shoulder Latissimus dorsi,
supraclavicular, Scapular, Trapezius, Pectoralis major
Buccal FAMM Radial forearm, ALT, DP, PM
Adynamic shoulder Trapezius, Gracilis
Arm Scapular, Latissimus dorsi,
Radial forearm, ALT, Lateral arm
C
supramalleolar
Achilles Distal sural, Radial forearm,
ALT, TFL, Lateral arm, Distal soleus, EDB
Skull base
Rectus abdominis, ALT, Vastus lateralis
Mandible
Fibula, Iliac, Metatarsal, Radial forearm
Arm Latissimus dorsi, Radial forearm,
ALT, Lateral arm, Scapular
Sacrum SGAP, IGAP, Gluteus
Posterior thigh Gracilis, ALT, IGAP
Finger
Posterior interosseous, Toe, Dorsal metacarpal,
Cross finger, Homodigital
Ischium
IGAP, Gracilis, Posterior thigh, Inferior gluteal, TFL
Scalp Temporoparietal, Latissimus dorsi, ALT
Neck Trapezius, Latissimus dorsi, ALT
Midline back Latissimus dorsi, Trapezius, Parascapular
Elbow Radial forearm, Lateral forearm, Latissimus dorsi
Lower back SGAP, Lumbar perforator, Latissimus dorsi
Dorsal hand
Posterior interosseous, Radial forearm, Temporoparietal, ALT
Dorsal metacarpal, Ulnar artery perforator
Dorsal forearm Radial forearm, Lateral arm, Latissimus dorsi
Greater trochanter TFL, ALT, Vastus lateralis
Popliteal Gastrocnemius, ALT, Latissimus dorsi, Sural
D
Figure 3.1, cont’d

CHAPTER 3 — Considerations in Flap Selection
9
Table 3.6  Comparison of attributes for “workhorse specialized” tissue flaps
Colon
Glabrous
skin
Jejunum
Joints
Nail beds
Toe
Ease of dissection
Simple
Not easy
Easy
Moderate
Difficult
Moderate
Anatomic anomalies
No
Usually
No
Common
No
Common
Potential for harvest as
compound flap/component
tissues that can be included
No
No
No
Yes/bone,
skin
Yes/any
part of toe
Yes/any part of foot
Contour (thin → bulky)
Bulky
Thin
Moderate
thickness
N/A
N/A
N/A
Implant osseointegration
N/A
N/A
N/A
No
N/A
Yes
Donor site morbidity
Laparotomy
needed
Minimal
Laparotomy
needed
Can be
minimal
Loss of
nail
First toe, yes;
Second toe, minimal
Bone length
N/A
N/A
N/A
Shorter
Variable
Short
Vascular pedicle caliber
Large
Small
Very large
Large
Small
Large
Vascular pedicle length
Long
Short
Very long
Medium
Short
Medium
When used as pedicled flap
Arc of rotation
Wide
Limited
Moderate
N/A
N/A
N/A
Reliability
Good
Moderate
Good
N/A
N/A
N/A
Potential for harvest as
distally based
N/A
Yes
N/A
N/A
N/A
N/A
N/A, not applicable.
Table 3.7  Typical and atypical indications for the free and pedicled version of “workhorse” flaps harvested
from the head and neck, chest, abdomen, and back regions
Flap
Free microvascular transfer
Pedicled
Typical indication
Atypical indications
Typical indication
Atypical indications
Temporoparietal
fascia
Thin, gliding surface
to cover tendons,
especially hand
Hair transplant
Ear salvage
Beard or eyebrow
reconstruction
Pectoralis major
None
None
Closure of chest or
facial wounds
Repair of esophagus or
trachea
Deltopectoral
None
None
Oropharynx
Chest wounds
Rectus abdominis
Breast reconstruction
Lower extremity
Breast reconstruction
Groin
Jejunum
Cervical esophagus
Oropharynx lining
N/A
N/A
Trapezius
None
None
Midline posterior neck
coverage
Lateral face
Scapular and
parascapular
Large defects
Bone flap
Axillary contractures
Head and neck coverage
Latissimus flap
Large defects
Quadriceps function
restoration
Breast, chest wounds,
thoracic spine
Axillary contractures, head and
neck, dynamic upper extremity
N/A, not applicable.

10
PART 1 — PRINCIPLES
Table 3.8  Typical and atypical indications for the free and pedicled version of “workhorse” flaps harvested
from the upper extremities, pelvis, groin, buttock, and lower extremities
Flap
Free microvascular transfer
Pedicled
Typical indication
Atypical indications
Typical indication
Atypical indications
Lateral arm
Small defect of arm or leg
Short segment bone or
tendon defect
Elbow coverage
Axilla
Radial forearm
Oral lining
Foot or distal third leg
Hand coverage
Elbow coverage
Iliac
Mandible
Long bone segmental defects
Pubis
Sacrum
Groin
Large defect if cosmetic
donor site imperative
Extremities
Thigh or abdomen
Staged upper extremity
pedicle flaps
Gluteus
Breast reconstruction
None
Sacral or ischial
pressure sores
Lumbar pressure sores
Tensor fascia
lata
Vascularized fascia,
Achilles repair
Abdominal wall
Abdominal wall
Groin
Gracilis
Small extremity wound,
facial reanimation
Breast reconstruction
Groin, perineum
or vagina
Scrotum, penis
Gastrocnemius
None
Pressure sore
Knee wound
Cross-leg flap
Soleus
None
None
Proximal leg
Distal leg
Fibula
Mandible or large bone
segmental gap
Pelvis
Knee arthrodesis
Ipsilateral tibia
segmental gap
Glabrous skin
Hand
Foot
Foot
None
Toe
Hand
Nail transfer
N/A
N/A
N/A, not applicable.
Table 3.9  Typical and atypical indications for the free and pedicled version of “workhorse” perforator flaps
Flap
Free microvascular transfer
Pedicled
Typical indication
Atypical indications
Typical indication
Atypical indications
Deep inferior epigastric
artery perforator flap
Breast reconstruction
Large soft tissue
defect
Groin coverage
Abdomen
Superficial inferior epigastric
artery perforator flap
Breast reconstruction
Extremity defect
Groin
Staged upper
extremity coverage
Superior gluteal artery
perforator flap
Breast reconstruction
None
Sacral pressure
sores
Lumbar pressure
sores
Inferior gluteal artery
perforator flap
Breast reconstruction
None
Ischial pressure
sores
Perineum
Anterolateral thigh (ALT) flap
Large soft tissue defect
Achilles tendon
Thigh wounds
Abdomen
Anteromedial thigh flap
Large soft tissue defect
if ALT flap unavailable
None
Thigh wounds
Groin
Thoracodorsal artery
perforator flap
Large soft tissue
defects
Breast
reconstruction
Breast
reconstruction
Axilla
Posterior tibial artery
perforator flap
Thin contour required
None
Distal lower
extremity
None

CHAPTER 3 — Considerations in Flap Selection
11
Wei and colleagues20 in their voluminous experience with
the anterolateral thigh flap, consider it to be the “ideal”
soft tissue flap for “all seasons” (Table 3.4 and Chapter 59),
since it can be prefabricated,21 thinned to the desired
contour,22 used as a megaflap or split into multiple flaps,23
has a long and reliable vascular pedicle, and can be used in
combination with multiple other tissue components such as
fascia lata or muscle if desired.24
Few would disagree that muscle perforator flaps, at least
in the Western Hemisphere, where obesity is more preva­
lent, require a more difficult dissection that potentially
makes them less reliable.25–27 Logically then, the muscle flap
will still have a role particularly in obese patients; and, of
course, if a dynamic muscle transfer is required.28 If used
for coverage only, a skin graft will be needed on the muscle,
so that the cosmetic result will virtually always be inferior to
that possible with any cutaneous flap (Fig. 3.2).
THE DONOR SITE
Solving the given problem element that the reconstructive
surgeon is confronted with by incorporating the proper
restorative surgical strategy,1 is of paramount importance.
Yet an equally important objective must be to minimize any
iatrogenic morbidity, especially when inflicted at the donor
site of the selected flap. Currently, the total absence of
donor site morbidity is possible only if the patient with the
defect to be reconstructed has an identical twin willing to
donate the missing part.29,30 As previously mentioned, and
again here reiterated for emphasis, all muscles used as a flap
will result in some function loss even with function preserva­
tion techniques.17 The reality is that the same is true with
muscle perforator flaps, even though all muscle is totally
excluded from these cutaneous flaps. The unavoidable
(Fig. 3.2). Secondary touch-ups may be inevitable, but
should be avoided whenever possible by the proper flap
selection to begin with (Fig. 3.3). Whether or not muscle
flaps atrophy with time is a controversial point,19 but cutane­
ous flaps after resolution of edema will maintain the char­
acteristics of the initial donor site, even over time as regards
their size and contour.
Figure 3.2  (A) Although the bulk and contour of this latissimus dorsi muscle free flap used to cover the degloved plantar and posterior hindfoot
was acceptable, the final appearance after the necessary skin graft was not ideal. (B) This can be compared with metachronous bilateral
anterolateral thigh free flaps used to cover complications of an open distal tibial fracture, where both blend almost imperceptibly into each
other and the surrounding lower limb to give a superior appearance.
A
B
Figure 3.3  This scapular free flap was obviously too bulky for cover­
age of the dorsal foot subunit. A thin flap would have been a prefer­
able choice to allow more immediate use of shoewear.

12
PART 1 — PRINCIPLES
Figure 3.4  (A) A linear scar typical when primary closure of the anterolateral thigh free flap donor site is possible; (B) and the poor aesthetic
result if a skin graft were necessary.
B
A
intramuscular dissection of the requisite musculocutaneous
perforator will cause some minor injury,31 albeit usually
undetectable.
Mathes and Nahai32 clearly showed that the extent of
viability of muscle flaps depends on the pattern of the intrin­
sic circulation to that muscle. Since this anatomy is fairly
constant, the surgical approach to harvest a given muscle or
portion thereof can be predictably reliable. The same has
not been the case for cutaneous flaps, so most donor sites
have been restricted to specific angiosomes fed by relatively
large and relatively consistent source vessels. This opinion
has changed dramatically with our realization that now any
part of the body can be used as a “free-style” local33,34 or
“free-style” free flap35,36 chosen on the basis of its special
characteristics, as long as an identifiable and adequate cuta­
neous perforator exists. Even this has become a less haphaz­
ard experience and perhaps no longer even “free-style”, as
preoperative imaging studies such as computed tomography
(CT)37 or magnetic resonance angiography (MRA)38 can
pinpoint not only the location and size of the requisite
perforator, but its course as it spreads out into the periphery
on its way to the subdermal plexus.
Of course, the preferred perforator flap donor site can
now also be selected on the basis of the potential donor site
deformity. This must be comparable with that possible with
muscle flaps, where direct closure leaving a linear scar is the
routine that will always be preferable from an aesthetic
standpoint. Endoscopic techniques for the harvest of muscle
flaps have minimized even the extent of this residual scar­
ring to little more than that required for access ports,
although this does increase the complexity of flap harvest.39
Yet this preceding goal will never be obtainable for all
perforator flaps. For example, a large cutaneous flap usually
will need a donor site skin graft to avoid the risk of a com­
partment syndrome;40 and the result may be unacceptable
even if the skin graft could be readily hidden by clothing
(Fig. 3.4). Preoperative tissue expansion techniques can
ultimately eliminate the need for a skin graft,21 but often as
in traumatic wounds this may not be an option. Similarly,
postoperative tissue expansion can reduce the non-cosmetic
appearance of the skin grafted donor site, but either way
this is a lengthy process requiring great patience.41 Some­
times a second local flap can instead be used to avoid a skin
graft at the donor site, but that may require comparatively
more complex surgery while still causing additional local
scarring at the least.42
ROLE OF COMBINED FLAPS
Compound flaps can be composite flaps such as any muscu­
locutaneous flap, or a combination of flaps, e.g., the con­
joined or chimeric flap.43,44 The latter flap combinations
can provide multiple tissue components in a single yet com­
prehensive unit of virtually unlimited size to simultaneously
fill any volume deficit, re-establish any underlying frame­
work, and provide immediate coverage.43 The final shape
and contour of this unit can be independently customized
ex vivo and then inset with impunity, as is particularly true
of the chimeric type of combined flap (Fig. 3.5).45 The ideal
scenario would allow all the necessary components of a flap
to be obtained from a single donor site that can be closed
primarily so as to minimize both the recipient site and
donor site morbidity. Wei and colleagues24 have shown this
to be another “ideal” attribute of the anterolateral (medial)
thigh region, which is also true of the subscapular axis,
where the latissimus dorsi and serratus anterior muscles,
parascapular or scapular fasciocutaneous flaps, and even
scapular bone or rib can be assorted together into numer­
ous combinations and permutations.46

CHAPTER 3 — Considerations in Flap Selection
13
If a combined flap has a single source vessel that supplies
all its independent portions, then only a single recipient site
may be required for revascularization if used as a free flap.
This is most advantageous if there is a paucity of recipient
vessels, such as after bilateral radical neck dissections or in
a single-vessel lower extremity. Other advantages include
the capability of retaining a small independent cutaneous
flap as part of a chimeric free flap that could relieve tension
on insetting or provide coverage at a tenuous recipient
site,46 or perhaps serve as a monitoring flap for a muscle or
buried free flap.47
FUTURE CONSIDERATIONS
Fear of iatrogenic morbidity at the donor site if a vascular­
ized flap is the selected surgical strategy, must always be
tempered by ensuring that the needs of the recipient site
will be solved. Compromise usually is inevitable, even if an
identical twin exists.29,30 Until the day arrives when bioengi­
neering technology can be used for the fabrication in the
laboratory or via autogenous regeneration of parts, the
Figure 3.5  (A) Open left mid-tibia fracture with a large cavity surrounding the exposed bone (arrow); (B) undersurface of chimeric anterolateral
(ALT) thigh free flap with two perforators (p), and a portion of vastus lateralis (VL) muscle that is separately supplied by the distal continuation
(arrow) of the lateral circumflex femoral descending branch source vessel (proximal pedicle in microclamps). (C) The ALT flap was used to
cover the bone and medial leg open wound, whereas the VL muscle (arrow) was independently inset into the cavity between the exposed ends
of the tibia to eliminate all dead space. (D) Once coverage had healed satisfactorily, conversion to internal fixation of the tibia was possible
with minimal risks of infection.
A
B
C
D
only presently foreseeable recourse to avoid any donor site
morbidity altogether, while still maximizing the desired
outcome at the recipient site, may be via vascularized com­
posite allotransplantation (VCA). Long-term successful VCA
has already included the hand,48 abdominal wall,49 and skel­
etal muscle.50 VCA of the face and its parts is in its infancy,51
but the results so far have been spectacular, especially con­
sidering the relatively mediocre outcomes achieved using
our currently limited flap capabilities. Of course, lifelong
immunosuppression currently remains the obstacle for uni­
versal acceptance of this concept. Someday soon, however,
it is conceivable that the flap of choice that has just the right
size, color, vascular pedicle length and caliber, and exact
secondary characteristics to perfectly restore a missing part
such as an ear, nose, or eyebrow, could be taken “off the
shelf” from where it is stockpiled in the storeroom of every
hospital! Then, there would be absolutely no donor site
morbidity, and the appearance of the final result truly pre­
dictable. We must remember that these will still be “free
flaps” awaiting their replantation, and that the services of a
skilled, dedicated, and interested microsurgeon will con­
tinue to be in demand.

14
PART 1 — PRINCIPLES
neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr
Surg 1998;102:779–91.
12. Baumeister SP, Spierer R, Erdmann D, et al. A realistic complica­
tion analysis of 70 sural artery flaps in a multimorbid patient group.
Plast Reconstr Surg 2003;112:129–40.
13. Jiga LP, Barac S, Taranu G, et al. The versatility of propeller flaps
for lower limb reconstruction in patients with peripheral arterial
obstructive disease: initial experience. Ann Plast Surg 2010;64:
193–7.
14. Teo TC. The propeller flap concept. Clin Plast Surg 2010;37:
615–26.
15. Oh TS, Hallock GG, Hong JP. Freestyle propeller flaps to recon­
struct defects of the posterior trunk: a simple approach to a diffi­
cult problem. Ann Plast Surg 2012;68:79–82.
16. Pignatti M, Ogawa R, Hallock GG, et al. The “Tokyo” consensus on
propeller flaps. Plast Reconstr Surg 2011;127:716–22.
17. Mathes SJ, Nahai F. Muscle flap transposition with function preser­
vation: technical and clinical considerations. Plast Reconstr Surg
1980;68:242–9.
18. Hallock GG. Long-term superiority of composite versus muscle-
only free flaps for skull coverage. Ann Plast Surg 2004;52:507–11.
19. Salmi A, Tukiainen E, Härmä M, et al. Prospective study of changes
in muscle dimensions following free-muscle transfer measured by
ultrasound and CT scanning. Plast Reconstr Surg 1996;97:1443–50.
20. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue
flap? An experience with 672 anterolateral thigh flaps. Plast Recon­
str Surg 2002;109:2219–26.
21. Hallock GG. The pre-expanded anterolateral thigh free flap. Ann
Plast Surg 2004;53:170–3.
22. Kimura N, Satoh K, Hasumi T, et al. Clinical application of the free
thin anterolateral thigh flap in 31 consecutive patients. Plast
Reconstr Surg 2001;108:1197–208.
23. Tsai FC, Yang JY, Mardini S, et al. Free split-cutaneous perforator
flaps procured using a three-dimensional harvest technique for the
reconstruction of postburn contracture defects. Plast Reconstr
Surg 2004;113:185–93.
Access Tables 3.1 to 3.5 online at

REFERENCES
1. Lineweaver WC. Problem analysis in reconstructive surgery: up and
beyond the reconstructive ladders. In: Wei FC, Mardini S, editors.
Flaps and reconstructive surgery. Philadelphia, PA: Elsevier; 2009.
p. 3–6.
2. Millard DR Jr. Tissue losses should be replaced in kind. Principaliza­
tion of Plastic Surgery. Boston, MA: Little, Brown; 1986. p. 191–228.
3. Hallock GG. Evidence-based medicine: lower extremity acute
trauma. Plast Reconstr Surg 2013;132:1733–41.
4. Lu TC, Lin CH, Lin CH, et al. Versatility of the pedicled peroneal
artery perforator flaps for soft-tissue coverage of the lower leg and
foot defects. J Plast Reconstr Aesthet Surg 2011;64:386–93.
5. Lee BT, Lin SJ, Bar-Meir ED, et al. Pedicled perforator flaps: a new
principle in reconstructive surgery. Plast Reconstr Surg 2010;125:
201–8.
6. Maciel-Miranda A, Morris SF, Hallock GG. Local flaps, including
pedicled perforator flaps: anatomy, technique, and applications.
Plast Reconstr Surg 2013;131:896e–911e.
7. Hallock GG. The utility of both muscle and fascia flaps in severe
upper extremity trauma. J Trauma 2002;53:61–5.
8. Hallock GG. Utility of both muscle and fascia flaps in severe lower
extremity trauma. J Trauma 2000;48:913–17.
9. Hollenbeck ST, Woo S, Komatsu I, et al. Longitudinal outcomes
and application of the subunit principle to 165 foot and ankle free
tissue transfers. Plast Reconstr Surg 2010;125:924–34.
10. Hallock GG. A paradigm shift in flap selection protocols for zones
of the lower extremity using perforator flaps. J Reconstr Microsurg
2013;29:233–40.
11. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries
of the cutaneous veins and cutaneous nerves in the extremities:
anatomical study and a concept of the venoadipofascial and/or
Expert Commentary
Milomir Ninković, MD, PHD
Reconstructive microsurgery has progressed from its initial
ability to achieve a wound coverage using free tissue transfer
to new levels of sophistication in regard to restoration of func-
tion and aesthetics when dealing with acquired or congenital
problems in all body regions. The ability to select optimal
reconstructive procedure, concerning suitable donor tissue and
to transfer them directly to the sites of the tissue or/and func-
tional defects has permanently altered many reconstructive
methods and has expanded the indications for microsurgery.
Advances in anatomy, concerning vascular and nerve supply,
established the unique role of free tissue transfer in reconstruc-
tive surgery. However, in my experience in order to select the
optimal reconstructive procedure, the following guidelines have
to be taken into consideration:
1. Definition of reconstructive requirements according to
assessment of damaged or missing structures based on:
a. Anatomical requirements (localization, extent of soft/bone
loss-size and depth, extent of nerve injury, quality of
vascular supply, presenting infection …)
b. Functional requirements (restoration of sensibility, mobil-
ity …)
c. Aesthetic requirements (skin color/texture, volume …)
2. Etiology of the defect
a. Trauma (complexity, full spectrum of severity …)
b. Tumour resection/radiation
c. Infection
d. Congenital anomalies
e. Vascular disease
3. Flap features (characteristics)
a. Size, color, bulk, pliability, durability
b. Composite flap possibilities (tendon, nerve, bone …)
c. Sensibility
d. Functional motor units
4. Donor site morbidity
5. Time of reconstruction
a. Primary/immediate
b. Primary delayed
c. Secondary
6. Needs for secondary procedure
a. Tendon, nerve, bone repair
b. Implant use …
7. Age and general condition of the patient
8. Capability of the surgical team
9. Equipment available in the hospital.
The goal in reconstructive microsurgery today is to obtain the
best possible result regarding function and aesthetics, with
minimal donor site morbidity. It is known that the major role of
free flaps remains the coverage of difficult wounds. However,
after the first successful functioning neurovascular muscle, the
work in this area has led to exciting concepts on the capability
of functioning muscle to restore facial expression, to improve
extremity flexion or extension, or to replace paralyzed urinary
bladder detrusor. Functional reconstruction is a most fascinat-
ing challenge.

CHAPTER 3 — Considerations in Flap Selection
15
24. Wei FC, Celik N, Jeng SF. Application of “simplified nomenclature
for compound flaps” to the anterolateral thigh flap. Plast Reconstr
Surg 2005;115:1051–5.
25. Hallock GG. Have we found an ideal soft-tissue flap? An experience
with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:
2227–30.
26. Alkureishi LWT, Shaw-Dunn J, Ross GH. Effects of thinning the
anterolateral thigh flap on the blood supply to the skin. Br J Plast
Surg 2003;56:401–8.
27. Hallock GG. Is there a “learning curve” for muscle perforator flaps?
Ann Plast Surg 2008;60:146–9.
28. Hallock GG. In an era of perforator flaps, are muscle flaps passé?
Plast Reconstr Surg 2009;123:1357–63.
29. Kaplan JI, Allen RJ. Transplantation in breast reconstruction.
Semin Plast Surg 2002;16:101–7.
30. Valauri FA, Buncke HJ, Alpert BS, et al. Microvascular transplanta­
tion of expanded free scalp flaps between identical twins. Plast
Reconstr Surg 1990;85:432–6.
31. Kimata Y, Uchiyama K, Ebiharra S, et al. Anterolateral thigh flap
donor-site complications and morbidity. Plast Reconstr Surg 2000;
106:584–9.
32. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg
1981;67:177–87.
33. Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforator-
based v-y advancement flaps in the reconstruction of lower limb
defects. Br J Plast Surg 2000;53:679–89.
34. D’Arpa S, Cordova A, Pignatti M, et al. Freestyle pedicled perfora­
tor flaps: safety, prevention of complications, and management
based on 85 consecutive cases. Plast Reconstr Surg 2011;128:
892–906.
35. Mardini S, Tsai FC, Wei FC. The thigh as a model for free style free
flaps. Clin Plast Surg 2003;30:473–80.
36. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg
2004;114:910–16.
37. Rozen WM, Ribuffo D, Atzeni M, et al. Current state of the art in
perforator flap imaging with computed tomographic angiography.
Surg Radiol Anat 2009;31:631–9.
38. Masia J, Kosutic D, Cervelli D, et al. In search of the ideal method
in perforator mapping: noncontrast magnetic resonance imaging.
J Reconstr Microsurg 2010;26:29–35.
39. Miller MJ, Robb GL. Endoscopic technique for free flap harvesting.
Clin Plast Surg 1995;22:755–73.
40. Addison PD, Lannon D, Neligan PC. Compartment syndrome after
closure of the anterolateral thigh flap donor site: a report of two
cases. Ann Plast Surg 2008;60:635–8.
41. Hallock GG. Tissue expansion techniques to minimize morbidity
of the anterolateral thigh perforator flap donor site. J Reconstr
Microsurg 2013;29:565–70.
42. Marsh DJ, Chana JS. Reconstruction of very large defects: a novel
application of the double skin paddle anterolateral thigh flap
design provides for primary donor-site closure. J Plast Reconstr
Aesthet Surg 2010;63:120–5.
43. Hallock GG. Simplified nomenclature for compound flaps. Plast
Reconstr Surg 2000;105:1465–70.
44. Hallock GG. The complete nomenclature for combined perforator
flaps. Plast Reconstr Surg 2011;127:1720–9.
45. Kohsima I, Yamamoto H, Hosoda M, et al. Free combined com­
posite flaps using the lateral circumflex femoral system for repair
of massive defects of head and neck regions: an introduction
to the “chimeric” flap principle. Plast Reconstr Surg 1993;92:
411–27.
46. Hallock GG. Permutations of combined free flaps using the sub­
scapular system. J Reconstr Microsurg 1997;13:47–54.
47. Hallock GG. Free-flap monitoring using a chimeric sentinel muscle
perforator flap. J Reconstr Microsurg 2005;21:351–4.
48. Francois CG, Breidenbach WC, Maldonado C, et al. Hand trans­
plantation: comparisons and observations of the first four clinical
cases. Microsurgery 2000;20:360–71.
49. Levi DM, Tzakis AG, Kato T, et al. Transplantation of the abdomi­
nal wall. Lancet 2003;361:2173–6.
50. Piza-Katzer H. Free allogeneic muscle transfer for cranial recon­
struction. Br J Plast Surg 2002;55:436–8.
51. Pomahac B, Bueno EM, Sisk GC, et al. Current principles of facial
allotransplantation: the Brigham and Women’s Hospital Experi­
ence. Plast Reconstr Surg 2013;131:1069–76.

e11
INTRODUCTION
In recent years, surgeons have taken advantage of various
technologies to aid in microvascular free flap reconstruc­
tions. In this chapter, we discuss the use of virtual surgical
planning and rapid prototype modeling for use in craniofa­
cial reconstructions with vascularized bone flaps, which
helps the surgeon to plan an idealized reconstruction with
respect to restoring the facial skeleton and streamlines the
creation of osteotomies. Indocyanine green (ICG) angiog­
raphy and computed tomography angiography (CTA) allow
visualization of flap pedicle and perforator blood vessels,
which can aid in flap design, among other useful applica­
tions in reconstructive surgery. Finally, surface 3-dimensional
photography is useful not only for analyzing postoperative
results in terms of quantifying volumetric changes, but it
holds promise as a way of more accurately planning soft
tissue surgery.
VIRTUAL SURGICAL PLANNING AND
RAPID PROTOTYPE MODELING
Advances in computer-assisted design (CAD) software have
enabled surgeons to utilize 2-dimensional data, such as
from a computed tomography (CT) scan, to generate a
3-dimensional virtual representation of a given body part.
Such virtual body parts can be further manipulated, so that
not only can surgical resections be rehearsed preoperatively,
but various reconstructions with flaps, grafts, and implants
can also be carried out on the computer to restore the
missing parts in an idealized fashion (Fig. 4.1). While the
applications for computer simulation of reconstructive sur­
geries is limitless, such technologies have become most
widely applied to bony reconstruction of mandibular, maxil­
lary, and other craniofacial defects.
Concurrent with advances in software, the development
of 3-dimensional printing allows the creation of physical
models from CAD computer data that are not only helpful
in allowing the surgeon to visualize the patient’s actual
anatomy but, more practically, can serve as a template for
bending and shaping the hardware used for bone flap, graft,
and implant fixation (Fig. 4.2).1–3 Additionally, computer-
generated slotted cutting guides can also be manufactured
using the same 3-dimensional printing process to assist with
making osteotomies at the precise angles and lengths needed
to replicate the planned reconstruction. Three-dimensional
printing typically involves laying down successive thin layers
of material that are bound or hardened by glue, light, or
heat until the desired object has been manufactured. Three-
dimensional printing processes are available for polymers,
ceramics, glass, and metals. Because the process does not
involve molds or dyes, 3-dimensional printing is substantially
faster and less expensive than conventional manufacturing
processes. Three-dimensional printing is also known as addi­
tive manufacturing, to distinguish it from subtractive pro­
cesses, such as milling items from a block of material.
The term “stereolithography” specifically refers to the
manufacture of 3-dimensional models using UV-light cured
acrylic polymer resins. Stereolithography was the first addi­
tive manufacturing technique developed (in the 1980s) and
has since spawned a multi-billion dollar industry for
3-dimensional printing. The process utilizes an ultraviolet
laser to cure a photosensitive resin in sequential, thin,
horizontally-oriented layers. The laser traces an area on the
surface of a vat of liquid resin, curing only where it traces.
The single layer, ranging of about 0.05–0.2 mm in thickness,
is then hardened and “dipped” into the liquid vat to coat it
with a new liquid layer. Subsequent scanning of the laser on
the new layer both solidifies the new layer and adheres it to
the layer below. Over the course of several hours, a
3-dimensional model is created. Post-processing is per­
formed to remove excess liquid resin and fully cure the
resultant parts. Stereolithographic models can be gas steril­
ized for use during surgery.
MANDIBULAR AND MAXILLARY
RECONSTRUCTION
In a typical scenario, a fine cut (1–1.25 mm) axial head and
neck CT scan with 0° of gantry tilt is obtained. The data is
saved to a computer disk in a generic format (Digital
Imaging and Communications in Medicine, DICOM),
which can be utilized by CAD software to create a virtual
3-dimensional model of the facial skeleton that can be
rotated in any direction. A CT scan of the bony free flap
donor site is obtained, so that it can be manipulated using
the software to create an idealized reconstruction. The
fibula is usually used for bony free flap reconstruction in
most practices, but virtually any site (e.g., scapula or iliac
crest) can be imaged and imported into the CAD platform.
If a donor site CT scan is not obtained, outcomes from using
generic donor site data are usually acceptable.
The author, as well as others, have had success collaborat­
ing with computer engineers in third-party manufacturers
Emerging Technology in
Reconstructive Surgery
Matthew M. Hanasono
4 
PART 1  —  PRINCIPLES

e12
PART 1 — PRINCIPLES
width on its lateral border in males) and the anterior man­
dible (mean of 33.5 mm in height at the symphysis in
males).4
Once the virtual plan is finalized, a model of the
reconstructed mandible or maxilla is constructed using
3-dimensional printing technology. Slotted cutting guides
are made for the maxilla or mandible that fit along the
existing bony contours, as well as for the fibula or other free
flap donor site (Fig. 4.3). During surgery, the cutting guides
are temporarily fixated to the mandible or maxilla and to
the fibula with monocortical screws, and a reciprocating saw
blade is inserted into the slots. Newer generation cutting
guides feature metal inserts that snap into the slots, to mini­
mize saw blade play and increase the accuracy of osteoto­
mies. The models are sterilized and made available for use
rather than designing and printing our own models as
we initially did.1–3 Virtual resection osteotomies of the man­
dible or maxilla in consultation with the resecting surgeon,
if different from the reconstructive surgeon, are then
planned. Next, the desired fibula, left or right, is selected
and virtual osteotomies are performed as needed to recon­
struct the missing mandible or maxilla. The original man­
dible or maxilla can be visualized as a partial transparency
or “ghost” to help guide the shaping of the fibula recon­
struction. When the existing mandible is misaligned due
to displaced fracture or prior resection, the mandibular
remnants can be repositioned. Occlusion is checked in
multiple planes prior to finalizing the plan. If desired, a
“double-barrel” fibula can be configured to correct for the
height discrepancy between the fibula (mean of 17.9 mm in
Figure 4.1  Computer-assisted design virtual reconstruction of the mandible with a fibula free flap in (A) anterior-posterior and (B) submental
views. The head can be rotated in any direction to confirm that the planned reconstruction is ideal in terms of restoring the patient’s mandibular
shape and occlusion.
A
B

CHAPTER 4 — Emerging Technology in
Reconstructive Surgery
e13
methods of template bending along the native contours of
the maxilla or mandible, and “eyeballing” the reconstruc­
tion when necessary, as well as a close correlation between
the final reconstruction and the computer-assisted virtual
plan.2 It has also been suggested that virtual planning and
medical modeling makes bony head and neck reconstruc­
tion more accessible to less experienced and occasional
osteocutaneous free flap surgeons.5 Even in experienced
hands, however, computer planning and 3-dimensional
models are beneficial for those cases in which the original
architecture of the mandible or maxilla is not easily identifi­
able, including patients with exophytic tumors, displaced or
comminuted pathologic fractures, and prior resections with
and without prior reconstructions. In these patients, creat­
ing a template for shaping the reconstruction along the
native contours of the mandible or maxilla is often difficult
or impossible.
A negative of utilizing these technologies includes costs
for engineering and manufacturing the models, which are
arguably offset by operative time savings and increased accu­
racy. Virtual planning requires anywhere from 30 to 60 min,
usually performed between the surgeon and a software engi­
neer via web conference. Time is also needed to print and
ship the models. While this usually only takes 1–2 days with
express shipping, it makes the technique unfeasible when
the initial consultation is performed just prior to surgery.
Perhaps the greatest limitation is that the benefits of virtual
planning and medical modeling are reduced when the
operative plan changes, for example, due to tumor growth.
To limit the potential for change in the resection and
needed reconstruction, recent imaging is recommended, as
is close communication between the resecting and recon­
structive surgeons.
Rapid prototyping and computer-assisted design software
continues to evolve. Such technologies are already com­
monly used by oral surgeons to guide endosteal implant
placement in the native mandible and maxilla.6 Some have
during surgery. Utilizing models to prebend titanium hard­
ware prior to surgery can save operative time.
In our experience, use of virtual computer planning and
3-dimensional medical models with cutting guides saves
operative time and increases reconstructive accuracy.2 Pre­
bending hardware, as well as using the cutting guides to
simplify osteotomies, saves operative time, particularly when
multiple osteotomies are needed. The preoperative plan­
ning that occurs may also increase operative efficiency by
improving surgical decision-making and reducing trial and
error during fibular harvest and shaping, since the surgeon
is forced to mentally rehearse the surgery ahead of time. We
have shown increased accuracy compared with traditional
Figure 4.2  A 3-dimensional rapid prototype model made of acrylic
polymer that can be used to guide surgery as well as act as a tem­
plate for bending titanium hardware, which can be done preopera­
tively to save time, then sterilized in preparation for surgery.
Figure 4.3  Computer-generated cutting guides can also be manufactured to simple osteotomies, making it easier to cut the fibula at the
precise lengths and angles needed to duplicate the virtual plan. (A) Virtual representation and (B) actual intraoperative photograph, demonstrat­
ing the use of the cutting guide.
A
B

e14
PART 1 — PRINCIPLES
a virtual template for reconstructing the bony contours of
the orbit can be created by mirroring the unaffected side
onto the affected side. Another more costly alternative is to
create a patient-specific implant or plate that is produced
by a third company that either mirrors the normal side or
is created based on an orbit of an age matched control.
INTRAOPERATIVE STEREOTACTIC NAVIGATION
While use of bony free flap models combined with computer-
generated cutting guides increases the accuracy of osteoto­
mies and fixation of the flap segments to each other,
accurate fixation to the remaining craniofacial skeleton is
also necessary to restore facial shape and symmetry. Flap or
graft insetting is particularly challenging in the midface and
orbit when limited access incisions are used and surgical
exposure is compromised. Inaccurate insetting, even by
several millimeters, can result in malocclusion and inap­
propriate mid-facial projection or height in maxillary recon­
struction, even when bony free flap osteotomies are perfectly
executed. In orbital reconstruction, the tolerance for inac­
curacy is even lower, with errors in fixation having not only
aesthetic consequences but also potentially impaired vision
or even blindness. In such cases, we, as well as others, have
utilized intraoperative stereotactic navigation to confirm
positioning of flaps and grafts in three dimensions.8,9
Intraoperative navigation systems were initially developed
for neurosurgical applications and were then adopted for
use also in endoscopic sinus surgery. When utilizing naviga­
tion for virtually planned reconstructions, the virtual recon­
struction images are back-converted to DICOM files and
loaded into the central processing unit (CPU) of the naviga­
tion system along with the original CT data, so that both
sets of images can be referenced during surgery. The most
common computer navigation systems include InstaTrak
(General Electric Healthcare, Buckinghamshire, UK);
StealthStation (Medtronic-Xomed, Jacksonville, FL); Stryker
Navigation System (Stryker-Leibinger, Kalamazoo, MI), and
explored performing immediate implant placement at the
time of free flap reconstruction, utilizing computer plan­
ning and custom drill guides to precisely place implants
between hardware screws.7 Immediate implant placement
takes advantage of the increased accuracy of bony recon­
struction, since implants are rendered unusable if placed
inaccurately at the wrong angulation. Another step that may
substantially contribute to increased accuracy is the creation
of patient-specific titanium hardware, which is not prebent,
but rather milled from a solid block of titanium for maximal
strength. Such patient-specific hardware allows the surgeon
to select individual screw hole placement in the number,
location, and angulation that is most optimal for a specific
defect (Fig. 4.4).
ORBITAL RECONSTRUCTION
In addition to mandibular and maxillary reconstruction,
virtual surgical planning and medical models has also been
useful for orbital reconstruction.8,9 Very precise restoration
of the orbital cavity is necessary to avoid enophthalmos,
exophthalmos, or vertical dystopia (eyes at different
heights). Bony free flaps can be designed for orbital recon­
struction virtually, just as for the mandible and maxilla.
More commonly in our practice, titanium mesh or bone
grafts are used for orbital reconstruction and supported by
soft tissue flaps. In these cases, we find that using a
3-dimensional model as a template for shaping bone grafts
and mesh implants is easier than using the patient’s actual
orbit because surgical exposure is often limited, and retrac­
tion of the eye can result in injury to the globe, traction on
the optic nerve, or bradycardia due to the oculocardiac
reflex. Hardware or mesh is bent along the contours of a
rapid prototype model (Fig. 4.5), so that accurate restora­
tion of the orbit is achieved. In cases where the original
anatomy is distorted or absent, such as by tumor or trauma,
Figure 4.4  A custom-made titanium plate based on the preopera­
tive virtual plan next to a 3-dimensional mandible model. The plate is
created using a computer-guided milling process rather than by print­
ing for increased strength. The screw hole placement and angulation
is defined by the surgeon during computer planning. (Photograph
courtesy of Patrick Garvey, MD.)
Figure 4.5  A 3-dimensional model used to guide orbital reconstruc­
tion with titanium mesh and bone graft for accurate restoration of the
orbital floor, which is critical to prevent enophthalmos, exophthalmos,
and/or orbital dystopia.

CHAPTER 4 — Emerging Technology in
Reconstructive Surgery
e15
reflectors on it for localization with infrared light-emitting
diodes, is used to confirm positioning by acting as a hand­
held pointer whose tip location is mirrored on the screen
of the computer unit (Fig. 4.6). Prior to use, a registration
procedure in which the virtual patient on the computer
workstation and the actual patient are overlapped by local­
ization of at least three reference points with the probe. If
the inset is not accurate, then it can be readjusted and posi­
tioning again checked against the virtual ideal.
ASSESSMENT OF TISSUE PERFUSION
WITH INDOCYANINE GREEN
ANGIOGRAPHY
Indocyanine green (ICG) is a non-toxic contrast agent that
is bound to protein in plasma. Laser-assisted ICG angiogra­
phy (Spy Elite System, LifeCell Corp., Branchburg, NJ) is an
VectorVision (BrainLab, Westchester, IL). All of the systems
utilize some type of sensor, either optical or electromag­
netic, that is carried on a probe as well as fixed on the
patient. Optical systems are utilized for reconstructive
surgery, since electromagnetic systems require special
instrumentation. Standard metallic instruments disrupt the
electromagnetic field and result in tracking inaccuracies.
The main disadvantage of optical systems is that a direct line
of site must be maintained between the infrared-emitting
diodes on the patient and probe, and the infrared sensors
connected to the CPU.
Intraoperative navigation for reconstructive surgery is
best performed using a rigidly fixed mobile array rather
than a headset or frame, since the head must be able to turn
freely during surgery. The infrared cameras are used to
detect the patient’s position based on reflectors connected
to the mobile array, which is rigidly fixed to the calvarium
at the start of surgery. The probe, essentially a wand with
Figure 4.6  (A) Midfacial reconstruction with a fibula free flap using a rapid prototype model to guide shaping. (B) Inset of the flap is performed
transorally, without facial incisions. Correct flap positioning prior to rigid fixation is confirmed using stereotactic navigation, which requires a
fixed array so that the system can locate the facial skeleton in 3-dimensional space. (C) A handheld probe is used to confirm that the flap is
in the planned position. (D) The tip of the probe can be located on the patient’s computed tomography (CT) scan in multiple planes. Note the
virtual fibula flap has been superimposed on the CT scan images.
A
B
C
D

e16
PART 1 — PRINCIPLES
FREE FLAP PERFUSION
Early reports described using ICG angiography to assess first
cardiac bypass, then later free flap anastomoses. ICG angi­
ography can be very accurate when used to verify the patency
of an anastomosis that is questionable. The dye, injected via
a peripheral IV, can be seen crossing first the arterial anas­
tomosis, then the venous anastomosis shortly afterwards.
Imperfections or blockages along the anastomotic suture
line can be readily visualized. For practical purposes, most
of the time this is not necessary, since signs of anastomotic
failure are usually readily apparent clinically. However, in
cases of partial obstruction due to an accumulating throm­
bus at the anastomosis or around an intimal tear, ICG angi­
ography may theoretically be of benefit when other clinical
findings are equivocal.
More commonly, ICG angiography is used to assess blood
flow to the skin paddle of pedicled and free flaps to ensure
its adequacy (Fig. 4.8). If ICG dye does not accumulate in
a portion of the flap skin paddle, generally within 2 min or
less following intravenous injection, it suggests that that this
portion of the skin will ultimately be non-viable. Generally
about 5 mL of ICG is injected, then the skin is observed on
the imaging system monitor, while the camera is focused
on the skin flap. Tissue that demonstrates subjectively ques­
tionable perfusion on black and white imaging is examined
clinically for signs of hypoperfusion. In this way, partial flap
loss is decreased.
Another related technique is to use ICG angiography to
determine which or how many perforators are necessary to
avoid partial skin flap loss or fat necrosis. In this case, mul­
tiple perforators are dissected then individually temporarily
occluded with microvascular clamps, except for the perfora­
tor or perforators that the surgeon plans to use. Blood flow
to the skin flap is then analyzed by ICG imaging. If the skin
flap appears well perfused, then the temporarily occluded
perforators can be divided. If the skin flap appears hypoper­
fused after about 2 min following injection, then additional
clamp(s) are then released until the entire flap appears
adequately nourished. This second technique has mostly
been utilized to analyze deep inferior epigastric artery per­
forator (DIEP) flap perforator flow, but has also been
reported for various flaps used in head and neck reconstruc­
tion, such as the anterolateral thigh and fibula free flaps.11
In addition to the black and white video image captured
by the charge-coupled camera, the Spy Elite system comes
bundled with analysis software (SPY-Q). The software fea­
tures two options for quantitative measurement of the fluo­
rescence recorded on the video images. The first option is
a relative percentage technique, which reports the fluores­
cence of selected areas of the image relative to a user-defined
reference point that is designated as 100% perfusion. This
reference point is subjective and can lead to values that are
above 100% if the brightest portion of the image is not
selected as the reference point. The second method is an
absolute measurement that uses a 255-level grayscale and
assigns a point value to selected areas of the image that cor­
respond to the signal intensity. In this scale, a value of 6.0
is considered the lower limit of acceptable perfusion.12
Wu et al.13 reported a 14% false-negative (specific area of
the flap looked viable by ICG angiography, but resulted in
necrosis) rate and a 9% false-positive (specific area of the
imaging modality that provides real-time imaging of tissue
perfusion, in which an 806 nm laser light source is used to
induce fluorescence with a peak at 830 nm of the ICG dye
that is captured on a charge-coupled camera with filters that
block out ambient and laser light (Fig. 4.7). Common uses
of ICG angiography include assessing viability of random,
pedicled, and free flap tissues, assessing perforator location
to aid in the design of perforator flaps, and predicting mas­
tectomy skin necrosis in implant and autologous tissue
breast reconstruction. Additionally, ICG plays a role in the
diagnosis and microsurgical treatment of lymphedema by
allowing the surgeon to visualize subcutaneous lymphatics
when injected subcutaneously and picked up by the lym­
phatic system. Most of the published data involving ICG
“lymphography” has involved the use of another system,
which utilizes an infrared light emitting diode light source
coupled with a handheld (rather than arm-mounted)
camera (Photodynamic Eye; Hamamatsu Photonics K.K.,
Hamamatsu, Japan). There have been no studies comparing
the two systems, however, both systems allow visualization of
dye in real-time as well as a review of video capture.
ICG has an excellent safety profile, having been used to
measure cardiac output, assess hepatic function, and for
ophthalmic angiography for over 40 years. There is a small
risk (0.17%) of adverse drug reaction, including anaphy­
laxis in subjects allergic to iodides, which are present in
the injectable product.10 ICG is excreted by the liver with a
half-life of 3–5 min. Because of the short plasma half-life,
multiple evaluations can be performed during the same
operative procedure. ICG is widely available (IC-Green,
Akorn, Inc., Lake Forest, IL) and of low cost when used
with the handheld near-infrared camera. However, the
Photodynamic Eye is not available at this time in the USA.
The Spy Elite System is available in the USA and is pack­
aged with sterile drapes that allow handling of the imaging
system during surgery. Other than cost, another disadvan­
tage of ICG imaging is the time needed to perform it intra­
operatively, which typically requires 15–20 min in most
situations.
Figure 4.7  Indocyanine green (ICG) intraoperative angiography
system (Spy Elite System, LifeCell Corp., Branchburg, NJ). A sterile
drape allows the surgeon to position the laser light source.

CHAPTER 4 — Emerging Technology in
Reconstructive Surgery
e17
difficult in these patients. A caveat of utilizing ICG to assess
flap viability includes the fact that superficial perfusion at
the time of dye injection can be affected by many variables
including blood pressure, volume status, patient tempera­
ture, use of vasopressors, and other factors that influence
resistance in the microcirculation. Also, it has not been
definitively determined at what timepoint following flap dis­
section a stable state of perfusion has been achieved in
which ICG angiography results will be most accurate. They
also pointed out that computer algorithms for quantitative
assessment of flap perfusion continue to be refined.
Venous congestion is also difficult to define using ICG
angiography. Delayed clearing of fluorescent dye is expected
when venous compromise to a flap exists, but there are no
set timepoints as to what should be considered delayed as
of yet. Again, venous outflow is a dynamic process and may
change with time such that the information obtained at the
time of ICG angiography may not be an accurate reflection
of the ultimate fate of the flap. Expert opinion has sug­
gested re-imaging 5–20 min after administration of ICG to
look for dye clearance if venous congestion is a concern
following flap dissection, transfer, or inset.14
Further experience with ICG angiography will no doubt
better define its accuracy and utility. At the present time,
the author utilizes ICG angiography when clinical findings
are equivocal as a confirmatory study. In addition to utiliz­
ing it to determine whether the entire skin paddle is per­
fused in perforator flap reconstruction, it also seems useful
following microvascular anastomosis and flap inset in some
cases, such as in head and neck reconstruction following
flap folding and placement into spaces where the flap and
its vasculature may be compressed or under modest tension.
Additionally, it may be useful in cases involving anastomotic
revision following a thrombotic event, both to visualize the
patency of the pedicle as well as to confirm the viability of
the flap, which may be difficult following ischemia and
reperfusion or resolution of venous congestion, when the
flap may be hyperemic or ecchymotic, respectively.
FREE FLAP DESIGN
A diagnostic test that identifies the correct position of a
cutaneous perforating blood vessel prior to skin incision is
desirable because it permits the surgeon to design the skin
paddle of a flap such that the blood supply is reliable by
centering the perforator in the middle of the skin paddle.
Such a test can eliminate the occasionally unnecessary skin
incision when no viable perforator exists, allowing a differ­
ent donor site to be chosen, and is requisite in the design
of free-style perforator flaps, by definition. An accurate
method of pre-incision perforator localization may also help
to minimize the size of the incision needed by eliminating
the need for a large exploratory incision to look for the
perforator.
The accuracy of ICG in assessing perforator is higher in
thin flaps, since the depth of visualization is only about
1 cm. In thicker flaps, the ICG “blush” becomes very diffuse
as it travels farther away from the perforator, where it is
carried by smaller and smaller branching blood vessels to
the skin. Thus, ICG angiography has been utilized by some
to help design thin cutaneous perforator flaps, such as the
anterolateral thigh flap in non-obese patients. As the amount
flap looked non-viable by ICG angiography but did survive)
rate. Although they concluded that ICG angiography was
not superior to clinical judgment in assessing flap perfusion
for most patients, they hypothesized that a good indication
for ICG angiography was in assessing flap vascularity in
dark skinned individuals, since clinical assessment is more
Figure 4.8  (A, upper) Image captured using ICG angiography of a
right abdomen muscle-sparing transverse rectus abdominis free flap
following dissection. (A, lower) The user assigns a value of “100%”
to an area that appears to have optimal perfusion, and the software
included with the system analyzes the intensity of signal of the rest
of the image, assigning relative perfusion values. (B) Photographic
appearance of the same flap. Perforator locations were marked with
an “x” using a skin marker.
A
B

e18
PART 1 — PRINCIPLES
and 83% specificity when the value was ≤7 absolute perfu­
sion units calculated by the included SPY-Q quantitative
software, based on a fixed grayscale. False-positive cases were
more likely in patients with a smoking history and/or in
which epinephrine-containing tumescent solution was used
during mastectomy. By excluding these patients, the speci­
ficity increased to 97%. They concluded that ICG angiogra­
phy was a useful as an adjunctive way of assessing skin flap
viability but did not replace clinical judgment. Duggal
et al.19 found that patients who underwent ICG angiography
had a lower skin flap necrosis rate compared with historical
controls, prior to the introduction of ICG angiography in
their practice (13% vs 23.4%, p = 0.01).
LYMPHATIC SURGERY
Lymphedema is a chronic, progressive, and, ultimately,
debilitating condition. Until recently, treatment was mostly
centered on decongestive physiotherapy, including manual
drainage techniques and compression garment usage.
Microsurgical techniques, such as lymphovenous bypass, in
which subcutaneous lymphatics are anastomosed to adjacent
small veins, have ushered in new hope for patients with
lymphedema. Such techniques owe their success not only in
increased microsurgical skill, finer instrumentation, and
high quality optical magnification, but also to ICG-based
imaging that allows visualization of subcutaneous lymphat­
ics, both for diagnostic purposes and surgical intervention.
Lymphoscintigraphy was previously considered the main
imaging modality for the evaluation of lymphatic function.
Lymphoscintigraphy can detect abnormalities of lymphatic
flow and provides quantitative assessment of lymphatic func­
tion. However, the technique is expensive, time-consuming,
requires the use of radioactive pharmaceuticals, and is not
of high enough resolution to localize individual lymphatic
channels for microsurgical treatment. In contrast, ICG can
be injected subcutaneously and used to follow lymphatics in
real-time during surgery. The appearance of lymphatics as
visualized by ICG lymphography appear to correlate with
the stage of lymphedema.20–23 Linear visualized lymphatics
are associated with normal lymphatic flow. Dermal backflow
patterns represent pathologic blockage of the lymphatic
channel.
Intraoperatively, approximately 0.2 mL of ICG is injected
subcutaneously into the first and fourth web spaces of the
hand or foot of the affected limb as well as into the lateral
border of the Achilles tendon or at the wrist flexion crease.22
After injection, circumferential fluorescent images of lym­
phatic drainage channels are visualized using the near-
infrared camera system. The near-infrared spectral range
includes the fluorescence maximum of ICG (about 800 nm)
and human tissue is relatively transparent to near-infrared
light. The lymphatic channels are simultaneously traced
with a skin-marking pen. ICG lymphography can be used
diagnostically or in planning treatment with microsurgical
lymphovenous bypass. Linear patterns represent targets for
lymphovenous bypass (Fig. 4.9). Backflow patterns do not
lend themselves to localization of a lymphatic vessel that can
be used for microsurgical anastomosis. Skin incisions are
then made and the lymphatic channels are dissected in the
subcutaneous tissues using high-power magnification. Visu­
alization of the lymphatics within the subcutaneous fat can
of subcutaneous fat increases, the accuracy of ICG angiog­
raphy in locating the position of deep perforators decreases.
Onoda et al.15 compared ICG angiography with the Pho­
todynamic Eye to CTA. They found ICG angiography had
an 84% positive predictive value and CTA 100% positive
predictive value in a series of 50 patients undergoing a
variety of free and pedicled flaps with a skin paddle compo­
nent. Perforators were difficult to detect by ICG angiogra­
phy when the flap thickness was >20 mm, with perforators
being correctly identified in only 12 of 50 flaps (24% sensi­
tivity). In contrast, CTA was not very useful in detecting
perforators when the flap thickness was <8 mm, showing
only 30% sensitivity in these patients. Perforators with a long
course through subcutaneous fat are most easily visualized
by CTA. They recommended utilizing ICG angiography in
combination with handheld Doppler ultrasound when the
flap thickness was ≤8 mm, and CTA in combination with
handheld Doppler ultrasound to localize perforators when
the flap thickness was ≥20 mm, in order to minimize time
and expense while still maintaining reasonable accuracy.
For flaps with intermediate thickness, they recommended
using a combination of all three modalities.
MASTECTOMY SKIN FLAP NECROSIS
In breast reconstruction, whether with autologous tissues or
implants, ICG angiography is employed to predict mastec­
tomy skin flap necrosis. An estimated 20% of implant-based
breast reconstructions experience necrosis of the native
breast skin.16 An even higher rate of necrosis is reported in
patients undergoing skin-sparing and nipple-sparing mas­
tectomies. Necrosis can lead to infection, delayed tissue
expander expansion, implant exposure, and implant loss.
Several investigators have examined ICG angiography as a
tool to help decrease necrosis rates by indicating to the
surgeon what parts, if any, of the mastectomy skin flaps will
go on to full-thickness loss and should be excised prior to
breast reconstruction.
Using the SPY 2001 Imaging System (Novadaq, Bonita
Springs, FL), an earlier version ICG imaging system, Phillips
et al.17 prospectively compared ICG angiography with clini­
cal assessment and fluorescein dye angiography as methods
for assessing mastectomy skin viability in 51 patients under­
going implant-based reconstruction. Fluorescein was admin­
istered in a dose of 10 mg/kg intravenously, then the breast
skin was inspected after waiting 15 min. Under a Wood’s
lamp, they observed yellow fluorescence indicating ade­
quate perfusion and blue fluorescence indicating inade­
quate perfusion. Yellow-blue mottling was also observed and
indicated intermediate or indeterminate perfusion, and
these areas were counted as predictive of necrosis. ICG
and fluorescein angiography both predicted the occurrence
of partial or full thickness skin necrosis in 19 of 21 cases
where clinical judgment had failed (sensitivity, 90%). ICG
correctly predicted no necrosis in 15 of 30 cases (specificity,
50%) and fluorescein correctly predicted no necrosis in 9
of 30 cases (specificity, 30%), thus leading the authors to
conclude that ICG angiography is a better predictor of mas­
tectomy skin flap necrosis than fluorescein dye angiography
and clinical judgment.
Munabi et al.18 found that the Spy Elite System predicted
mastectomy flap necrosis in 62 breasts with 88% sensitivity

CHAPTER 4 — Emerging Technology in
Reconstructive Surgery
e19
BREAST RECONSTRUCTION
The DIEP flap is often preferred to the free transverse
rectus abdominis myocutaneous (TRAM) flap because of
potentially lower donor site morbidity and equal reliability.
However, these theoretic advantages are actually dependent
on locating adequate perforators that do not require
extensive interruption of the rectus abdominis muscle and
its innervation to dissect. Visual evaluation of perforator
anatomy can require substantial time-consuming dissection
to determine which perforator or perforators are best suited
to base the flap on.
CTA has been used as a method of localizing cutaneous
perforators preoperatively for DIEP flap harvest by several
investigators.23–27 By doing so, the theoretic advantage is that
the surgeon saves time by focusing only on the dominant
perforator or perforators while ligating minor unessential
perforators. It also allows the surgeon to pick the side of the
abdomen with better perforators in unilateral breast recon­
struction (Fig. 4.10). In some cases, the location of a favor­
able perforator preoperatively might cause the surgeon to
reposition the planned skin incisions for the flap. CTA also
has utility in preoperatively visualizing the branching pattern
and course of the vascular pedicle to determine whether it
be aided by injection with methylene blue into the same
subcutaneous sites as the ICG injection.
PREOPERATIVE PLANNING WITH
COMPUTED TOMOGRAPHY
ANGIOGRAPHY
Computed tomography angiography (CTA), using multide­
tector row CT scanners, is another imaging modality that is
used evaluate recipient, pedicle, and perforator blood
vessels. Because of its less invasive nature, CTA has become
more popular than digital subtraction angiography, which
involves additional risks of arterial puncture, pseudoaneu­
rysm, and bleeding. CTA not only provides high-resolution
images of both the arterial and venous systems, but also
allows for simultaneous visualization of the surrounding
bony and soft tissue architecture. In addition to verifying
the patency of major blood vessels in settings such as vascu­
lar disease, prior surgery, trauma, and congenital anomalies,
CTA has been used in reconstructive surgery to map perfo­
rators in abdominally-based free flaps used for breast recon­
struction, as well as in anterolateral thigh and fibula free
flaps used for reconstruction in other parts of the body.
Figure 4.9  (A) ICG lymphography of the right upper extremity. (B) A linear pattern is seen distally to the left, indicating a patent lymphatic
channel, but eventually becoming non-patent proximally, toward the right. The course of the lymphatics are traced with a skin marker.
(C) During surgery, an incision is made over the skin marking and a lymphatic (filled with methylene blue dye) is readily visualized next to
an adjacent vein, which are usually easily found subcutaneously. Veins can occasionally be seen causing voids along lymphatics visualized
by ICG lymphography as they cross superficial to the lymphatic vessel (not shown).
A
B
“Linear” Pattern
“Diffuse” Pattern
C
Lymphatic Vessel
Vein

e20
PART 1 — PRINCIPLES
muscle-sparing TRAM, rather than a DIEP flap for breast
reconstruction.
USE IN DESIGNING OTHER FREE FLAPS
Garvey et al.28 examined the accuracy of CTA in the detec­
tion of perforators for ALT free flaps. Among 16 flaps, CTA
identified 40 out of 54 perforators identified intraopera­
tively, suggesting a sensitivity of 74%. The perforator loca­
tion averaged 0.35 cm from the CTA-predicted position.
The ability of CTA to predict perforator size was 67.5%. CTA
was able to differentiate between septocutaneous and intra­
muscular perforators 77.5% of the time. As mentioned
above, CTA is probably most useful in cases where the sub­
cutaneous fat is ample, since the perforators can be visual­
ized easily in the background of low-density fatty tissues. In
individuals with thin thighs, ICG angiography or handheld
Doppler may be more accurate and useful, at least in iden­
tifying perforator location.
In a separate study, Garvey et al.29 examined the utility of
CTA for examining cutaneous perforators in the fibula
osteocutaneous free flap (Fig. 4.11). CTA identified 94.9%
of cutaneous perforators found intraoperatively in a series
of 40 patients. The perforators were located an average of
8.7 mm from their predicted locations. The slightly lower
accuracy in predicting the spatial location of perforators
may be because they are best seen between the lower leg
muscles and not in the scant subcutaneous fat where they
may take an oblique course toward the skin. The course of
the perforators (intramuscular or septocutaneous) was dis­
cernable 93% of the time by CTA, however, the size could
only be accurately predicted 66.7% of the time. In addition
to being used for flap design, CTA may be of great benefit
in verifying three-vessel flow to the lower extremity, particu­
larly in patients with equivocal findings by history or physi­
cal exam, such as when the dorsalis pedis and posterior
tibial arteries are not easily palpable (Fig. 4.12).
Ogata et al.30 compared ICG angiography with the Pho­
todynamic Eye to CTA. They found ICG angiography had
an 84% positive predictive value and CTA 100% positive
predictive value in a series of 50 patients undergoing a
is amenable to straightforward dissection without substan­
tial destruction of the rectus abdominis muscle. In cases
where the branching pattern requires the surgeon to sacri­
fice a large amount of muscle to capture the desired
perforator(s), plans for a DIEP flap are abandoned and a
muscle-sparing TRAM flap is harvested instead. The disad­
vantages of CTA include modest radiation exposure, cost,
and risk for allergic reactions to intravenous contrast.
Patients undergo multidetector helical CT scans with
100–150 mL of contrast injected at a rate of 4–6 mL/s via a
peripheral intravenous line. Axial CT data is used to create
sagittal and coronal images, as well as a 3-dimensional image
of the abdominal wall vasculature that can be rotated hori­
zontally and vertically. The branching pattern of the deep
inferior epigastric artery (DIEA) is determined as is its
intramuscular course. Perforators are then examined as
they arise from the DIEA and their position relative to the
umbilicus is noted. Perforators as small as 0.3 mm can be
visualized by CTA. The presence of the superficial inferior
epigastric artery (SIEA) and associated veins are also noted
to determine an SIEA flap is possible.
Rozen et al.24 performed a study of 42 patients undergo­
ing DIEP flap surgery in which they mapped all perforators
>1 mm. CTA identified 280 major perforators in 42 patients
with one false-positive and one false-negative, resulting in a
sensitivity of 99.6% and positive predictive value of 99.6%.
Casey et al.25 performed a retrospective review of DIEP
and SIEA breast reconstruction comparing operative times
in 186 flaps performed with the assistance of handheld
Doppler to 100 flaps performed subsequently with CTA.
They found a statistically significant decrease in operative
times in both unilateral and bilateral cases (370 vs 459 min,
and 515 vs 657 min, respectively; both p < 0.01). Smit et al.26
performed a similar study and also found a shorter opera­
tive time associated with CTA compared to Doppler (264 vs
354 min, p < 0.001). Tong et al.27 reported a lower sensitivity
of 79%, but also reported significantly shorter operative
times and found that CTA changed the preoperative plan
in 50% of cases by identifying the best perforator in unilat­
eral cases or perforators with a long intramuscular course,
causing them to select the contralateral side or utilize a
Figure 4.10  A computed tomography (CT) angiogram of the abdomen used for preoperative planning prior to deep inferior epigastric perfora­
tor flap harvest. (A) Arrows demonstrate subcutaneous perforators arising from the deep inferior epigastric arteries in the axial view. (B) Arrows
point to the deep inferior epigastric arteries, which are seen branching in this section, in the anterior-posterior view.
A
B

CHAPTER 4 — Emerging Technology in
Reconstructive Surgery
e21
localize perforators when the flap thickness was ≥20 mm in
order to minimize time and expense, while still maintaining
reasonable accuracy. For flaps with intermediate thickness,
they recommended using a combination of all three modali­
ties. Combining these findings with our own experience,28,29
it would seem that CTA is most useful in breast reconstruc­
tion with flaps of ample thickness, as well as in fibula flap
harvest, where it can be utilized to confirm three-vessel
patency to avoid donor site morbidity, and the relatively
direct course of perforators within the intermuscular septum
seems to result in accurate perforator location, despite the
generally scant amount of subcutaneous fat in most patients’
lower legs.
THREE-DIMENSIONAL IMAGING SYSTEMS
Planning for soft tissue reconstructive surgery, such as breast
reconstruction, largely relies on the surgeon’s clinical assess­
ment and review of 2-dimensional photographic images.
Three-dimensional imaging technology has evolved in
recent years and is now available in platforms specifically
adapted to medical applications, primarily for face and
trunk imaging. Most systems are based on either laser scan­
ning or stereophotogrammetry. Stereophotogrammetry is
probably more widely used in clinical practice and relies on
depth perception achieved by taking photographs from
slightly different views. Paired cameras rely on the trian­
gulation of disparate images, which are matched by com­
puter software to create a 3-dimensional image that can be
examined from various angles on the computer monitor
(Figs 4.13, 4.14). Laser systems also utilize the principle of
triangulation, but rely on a laser light source to scan the
desired body part(s), which are processed by computer soft­
ware into a surface model. Software can be used to analyze
the images and provide accurate quantitative data, such
as surface area, distance measurements, and volume.31,32
Currently available imaging systems in the USA include
Vectra (Canfield Imaging Systems, Fairfield, NJ), and 3dMD
(3dMD, Atlanta, GA), both available in various models
variety of free and pedicled flaps with a skin paddle compo­
nent. Perforators were difficult to detect by ICG angiogra­
phy when the flap thickness was >20 mm with perforators
being identified only on 12 of 50 flaps (24% sensitivity). In
contrast, CTA was not very useful in detecting perforators
when the flap thickness was <8 mm, showing only 30% sen­
sitivity in these patients. Perforators with a long course
through subcutaneous fat are most easily visualized by CTA.
Based on their data, Ogata et al.30 recommended utilizing
ICG angiography in combination with handheld Doppler
ultrasound when the flap thickness as ≤8 mm and, MDCTA
in combination with handheld Doppler ultrasound to
Figure 4.11  An axial CT angiogram showing a perforator arising
from the peroneal artery on the patient’s left side (arrows). Note that
this is the same patient as seen in Figure 4.12 and the anterior tibial
arteries are not visualized.
Figure 4.12  A 3-dimensional CT angiogram reconstruction of a
patient’s lower extremities demonstrating bilateral occlusion of the
anterior tibial arteries (arrow).
Figure 4.13  A 3-dimensional stereophotogrammetry system (3dMD,
Atlanta, GA) with two sets of multiple cameras attached to a central
processing unit.

e22
PART 1 — PRINCIPLES
breast that they utilized in 12 patients to shape an abdomi­
nal free flap (TRAM or DIEP), cutting away excess tissue
until the cast was precisely filled. Utilizing this reverse engi­
neering method, none of the 12 patients required second­
ary procedures to correct symmetry and all patients were
satisfied with their result. As the cost of imaging systems
decreases, software platforms evolve, and other investigators
demonstrate favorable clinical outcomes, reconstructive sur­
geons may more widely adopt 3-dimensional imaging for
free flap planning.
CONCLUSIONS
In recent years, surgeons have harnessed technology to
further refine microvascular free flap reconstruction. While
not a replacement for good judgment and technique, these
technologies have been embraced by many surgeons as
ways of increasing the reliability, accuracy, and efficiency of
reconstruction. Undoubtedly, other technologies will be
developed and applied to assist in the planning of recon­
struction, as well as in the evaluation of flap vascularity.
depending on user needs. Costs remain high for these
systems, in the range of US$20 000–US$60 000 at time of
writing.31,32
Clinically, 3-dimensional imaging has mostly been used
for subjective planning and as communication tool between
surgeon and patient. Additionally, several studies have
employed 3-dimensional imaging as a research tool to assess
for shape and volumetric changes before and after surgical
intervention, such as in orthognathic surgery or autologous
fat grafting.33,34 However, 3-dimensional imaging has poten­
tial useful applications in planning reconstructive surgery.
In breast reconstruction, 3-dimensional surface imaging can
be used to assist in selecting implant size prior to mastec­
tomy; to determine whether sufficient abdominal tissue is
present to reconstruct the breast or breasts when consider­
ing autologous abdominal flap(s); and to detect asymmetry
in volume such as when reduction or reconstruction has
occurred and a secondary symmetrizing procedure is
planned.35 Most recently, Ahcan et al.36 utilized laser scan­
ning to produce a plastic breast replica cast to assist in
autologous breast reconstruction planning. The cast is a
mirror-image model of the contralateral non-cancerous
Figure 4.14  (A) Representative preoperative and (B) postoperative 3-dimensional images in a patient who underwent left mastectomy and
autologous tissue breast reconstruction.
A
B

CHAPTER 4 — Emerging Technology in
Reconstructive Surgery
e23
7. Levine JP, Bae JS, Soares M, et al. Jaw in a day: Total maxillofacial
reconstruction using digital technology. Plast Reconstr Surg 2013;
131:1386–91.
8. Pham AM, Rafii AA, Metzger MC, et al. Computer modeling and
intraoperative navigation in maxillofacial surgery. Otolaryngol
Head Neck Surg 2007;137:624–31.
9. Hanasono MM, Jacob RF, Bidaut L, et al. Midfacial reconstruction
using virtual planning, rapid prototype modeling, and stereotactic
navigation. Plast Reconstr Surg 2010;126:2002–6.
10. Takahashi M, Ishikawa T, Higashidani K, et al. Spy™: an innovative
intra-operative imaging system to evaluate graft patency during
off-pump coronary artery bypass grafting. Interact Cardio Vasc
Thorac Surg 2004;3:479–83.
11. Benya R, Quintanna J, Brundage B. Adverse reactions to indocya­
nine green: a case report and review of the literature. Catheter
Cardiovasc Diagn 1989;17:231–3.
12. Green JM, Thomas S, Sabino J, et al. Use of intraoperative fluores­
cent angiography to assess and optimize free tissue transfer in head
and neck reconstruction. J Oral Maxillofac Surg 2013;71:1439–49.
13. Wu C, Kim S, Halvorson EG. Laser-assisted indocyanine green angi­
ography: a critical appraisal. Ann Plast Surg 2013;70:613–19.
14. Gurtner GC, Jones GE, Neligan PC, et al. Intraoperative laser angi­
ography using the SPY system: review of the literature and recom­
mendations for use. Ann Surg Innov Res 2013;7:1–14.
15. Onoda S, Azumi S, Hasegawa K, et al. Preoperative identification
of perforator vessels by combined MDCT, Doppler flowmetry, and
ICG fluorescent angiography. Microsurgery 2013;33:265–9.
16. Newman MI, Samson MC, Tamburrino JF, et al. Intraoperative
laser-assisted indocyanine green angiography for the evaluation of
mastectomy flaps in immediate breast reconstruction. J Reconstr
Microsurg 2010;26:487–92.
17. Phillips BT, Lanier ST, Conkling N, et al. Intraoperative perfusion
techniques can accurate predict mastectomy skin flap necrosis in
breast reconstruction: Results of a prospective trial. Plast Reconstr
Surg 2012;129:778e–788e.
18. Munabi NCO, Olorunnipa OB, Goltsman D, et al. The ability of
intra-operative perfusion mapping with laser-assisted indocyanine
green angiography to predict mastectomy flap necrosis in breast
reconstruction: A prospective trial. J Plast Reconstr Aesthet Surg
2014;67:449–55.
19. Duggal CS, Madni T, Losken A. An outcome analysis of intraopera­
tive angiography for postmastectomy breast reconstruction. Aesthet
Surg J 2014;34:61–5.
20. Furukawa H, Osawa M, Sito A. Microsurgical lymphaticovenous
implantation targeting dermal lymphatic backflow using indocya­
nine green fluorescence lymphography in the treatment of post­
mastectomy lymphedema. Plast Reconstr Surg 2011;127:1804–11.
21. Yamamoto T, Matsuda N, Doe K. The earliest finding of indocya­
nine green lymphography in asymptomatic limbs of lower extrem­
ity lymphedema patients secondary to cancer treatment: the
modified dermal backflow stage and concept of subclinical lymph­
edema. Plast Reconstr Surg 2011;128:314e–321e.
22. Chang DW, Suami H, Skoracki R. A prospective analysis of 100
consecutive lymphovenous bypass cases for treatment of extremity
lymphedema. Plast Reconstr Surg 2013;132:1305–14.
23. Masia J, Clavero J, Larrañaga J, et al. Multidetector-row computed
tomography in the planning of abdominal perforator flaps. J Plast
Reconstr Surg 2006;59:594–9.
24. Rozen WM, Ashton MW, Stella DL, et al. The accuracy of computed
tomographic angiography for mapping the perforators of the deep
inferior epigastric artery: a blinded prospective cohort study. Plast
Reconstr Surg 2008;122:1002–9.
25. Casey WJ III, Chew RT, Rebecca AM, et al. Advantages of preopera­
tive computed tomography in deep inferior epigastric artery per­
forator flap breast reconstruction. Plast Reconstr Surg 2009;123:
1148–55.
26. Smit JM, Dimopoulou A, Liss AG, et al. Preoperative CT angiogra­
phy reduces surgery time in perforator flap reconstruction.
J Plast Reconstr Aesthet Surg 2009;62:1112–17.
27. Tong WMY, Dixon R, Ekis H, et al. The impact of preoperative CT
angiography on breast reconstruction with abdominal perforator
flaps. Ann Plast Surg 2012;68:525–30.
28. Garvey PB, Selber JC, Madewell JE, et al. A prospective study of
preoperative computed tomographic angiography for head and
neck reconstruction with anterolateral thigh flaps. Plast Reconstr
Surg 2011;127:1505–14.
REFERENCES
1. Levine JP, Patel A, Saadeh PB, et al. Computer-aided design and
manufacturing in craniomaxillofacial surgery: the new state of the
art. J Craniofac Surg 2012;23:288–93.
2. Hanasono MM, Skoracki RJ. Computer-assisted design and rapid
prototype modeling in microvascular mandible reconstruction.
Laryngoscope 2013;123:597–604.
3. Kokemueller H, Tavassol F, Ruecker M, et al. Complex midfacial
reconstruction: a combined technique of computer-assisted surgery
and microvascular tissue transfer. J Oral Maxillofac Surg 2008;66:
2398–406.
4. Chang EI, Clemens MW, Garvey PB, et al. Cephalometric analysis
for microvascular head and neck reconstruction. Head Neck
2012;34:1607–14.
5. Antony AK, Chen WF, Kolokythas A, et al. Use of virtual surgery
and stereolithography-guided osteotomy for mandibular recon­
struction with the free fibula. Plast Reconstr Surg 2011;128:
1080–4.
6. Okay DJ, Buchbinder D, Urken M, et al. Computer-assisted implant
rehabilitation of maxillomandibular defects reconstructed with
vascularized bone free flaps. JAMA Otololaryngol Head Neck Surg
2013;139:371–81.
Expert Commentary 
Uros Ahcan, MD, PhD
Re-creating an aesthetically pleasing breast in reconstructive
surgery demands a combination of good measurements, some
artistic insight, and a significant level of surgeon expertise. In
pursuit of perfection, the use of modern technology has helped
surgeons to make considerable progress in better planning of
surgical procedures, advanced intraoperative techniques, and
much better aesthetic outcomes. Computed tomography angi-
ography in autologous breast reconstruction has led to a faster,
more accurate, and less invasive course of operations. Assess-
ing tissue perfusion during flap preparation with laser-assisted
indocyanine green angiography (Spy Elite System) is especially
useful for assessing perforator location and its corresponding
perfusion areas. With the help of this system, surgeons could
make a proper intraoperative decision regarding the dominant
perforator and pedicle.
Newly emerging laser technology enables us to scan different
body parts and render a 3-dimensional (3-D) model with the
help of special computer-assisted design software. Our group
has implemented reverse engineering techniques in autologous
breast reconstruction. A few days before the procedure, a laser
scans the contralateral healthy breast and computer software
subsequently creates a 3-D model from which a mirrored 3-D
new breast replica cast is designed. Immediately before the
procedure, the cast is used to draw crucial landmarks for skin
incisions on a standing patient’s chest wall, with special atten-
tion to the new desired breast topography, which facilitates
faster and more accurate positioning of the flap (new breast)
during the procedure. After the replica cast is sterilized it is used
for reshaping the free flap (DIEP or MS-TRAM). Perforators of
the flap are oriented centrally and are therefore constantly under
direct visual surveillance when excessive tissue is removed.
With the aid of such a cast, surgeons can shape a new breast
quickly, easily, accurately, and reliably, culminating in a very
high degree of breast symmetry being achieved, as the recon-
structed breast is an exact replica of the healthy breast. This
method is especially useful in delayed reconstructions, where
the weight of the removed breast is unknown and when the
anatomical properties of the chest have been altered due to
scars, poor skin quality, or changed breast anatomy, and for
young plastic surgeons with less experience.

e24
PART 1 — PRINCIPLES
29. Garvey PB, Chang EI, Selber JC, et al. A prospective study of pre­
operative computed tomographic angiographic mapping of free
fibula osteocutaneous flaps for head and neck reconstruction. Plast
Reconstr Surg 2012;130:541e–548e.
30. Ogata F, Narushima M, Mihara M, et al. Intraoperative lymphogra­
phy using indocyanine green dye for near-infrared fluorescence
labeling in lymphedema. Ann Plast Surg 2007;59:180–4.
31. Tepper OM, Small K, Rudolph L, et al. Virtual 3-dimensional mod­
eling as a valuable adjunct to aesthetic and reconstructive breast
surgery. Am J Surg 2006;192:548–51.
32. Tepper OM, Unger JG, Small KH, et al. Mammometrics: the stan­
dardization of aesthetic and reconstructive breast surgery. Plast
Reconstr Surg 2010;125:393–400.
33. de Menezes M, Rosati R, Ferrario VF, et al. Accuracy and reproduc­
ibility of a 3-dimensional stereophotogrammetric imaging system.
J Oral Maxillofac Surg 2010;68:2129–35.
34. Choi M, Small K, Levovitz C, et al. The volumetric analysis of fat
graft survival in breast reconstruction. Plast Reconstr Surg 2013;
131:185–91.
35. Galdino GM, Nahabedian M, Chiaramonte M, et al. Clinical appli­
cations of three-dimensional photography in breast surgery. Plast
Reconstr Surg 2002;110:58–70.
36. Ahcan U, Bracun D, Zivec K, et al. The use of 3D laser imaging
and a new breast replica cast as a method to optimize autologous
breast reconstruction after mastectomy. Breast 2012;21:183–9.

16
Prefabrication and
Prelamination
Indranil Sinha  |  Lifei Guo  |  Julian J. Pribaz
5 
INTRODUCTION
Flap prefabrication and prelamination are distinct tech­
niques designed to address complex reconstructive needs.
While these techniques are generally not primary recon­
structive options, their usage has increased in response to
demands for more sophisticated reconstructive efforts. In
reconstructive surgery, a delicate balance exists between the
availability of matching donor tissue and the complexity of
the recipient defect. Prefabrication and prelamination tech­
niques have been applied to areas where a special surface,
contour, or structure is desired and reconstructive goals
cannot be met by conventional means. Areas of the body
where prefabrication (Fig. 5.1) and prelamination have
played a role in reconstruction include facial subunits, facial
cartilage, facial skeleton, oropharynx/esophagus, and the
penis (Tables 5.1–5.5).1–26 This chapter focuses on problems
of the head and neck region, where aesthetic, structural,
and functional needs are complex and demanding, with
scarce reconstructive options.
They terms flap “prefabrication” and “prelamination” are
two distinctive entities in reconstructive surgery. Flap prefab­
rication, first introduced by Shen in 1982,27 describes a two-
stage process: the introduction of a vascular pedicle into a
body of tissue that bears desired characteristics of the area to
be reconstructed, followed by a transfer of this neovascular­
ized tissue into the defect based on its implanted vascular
pedicle. Flap prelamination, a term coined by Pribaz and Fine
in 1994,28 also refers to a two-stage process, whereby one or
more tissues are engrafted into a reliable vascular bed to
create a composite flap. This flap is subsequently transferred
on its original vascular supply, en bloc, for reconstruction. A
clear understanding of these two techniques is helpful in
choosing the appropriate method to deal with a specific clini­
cal problem and also for scientific communication.
PART 1  —  PRINCIPLES
Figure 5.1  Flap prefabrication technique.
Desired skin flap
Muscle
Deep vascular pedicle
Pedicle with fascia
or small cuff of
muscle dissected out
Vascular pedicle
placed subcutaneously
on top of tissue expander
TE
TE
TE
Gore-Tex tubing around
proximal pedicle to
facilitate later
flap harvest
Gore-Tex
Gore-Tex
Gore-Tex
Expansion started at
1 week and continued
for 8 weeks
• Tissue expanded
fully at 8 weeks
• Neovascularization
of skin and capsule
around tissue
expander
• Prefabricated flap is
raised off of the tissue
expander. The capsule
layer is included with
the flap
• Gore-Tex around
proximal pedicle
facilitates flap
dissection
A
B
C
D

CHAPTER 5 — Prefabrication a nd Prelamination
17
Table 5.2  Clinical applications of prefabrication and prelamination: Facial soft tissue with cartilage
Defect
Technique
Flap location
Technique description
References
Nose
(a) Partial or
full-thickness
loss
(b) Total
Existing
laminated flap
Prelamination
Prelamination
Ear
Forehead
Forearm
Ascending helical free flap based on
superficial temporal artery
Skin graft for lining and cartilage for support
in paramedian forehead flap
Skin graft for lining and cartilage for support
in radial forearm flap
Pribaz and Falco14
Gilles15
Pribaz et al.11
Costa et al.4
Baudet5
Ear
Absent ear
Prelamination
Forearm
Carved costal cartilage graft or silicone
framework covered with radial forearm
fascia and skin graft with secondary
transfer to ear
Costa et al.4
Baudet5
Hirase et al.16
Trachea/Larynx
(a) Tracheal defect/
stenosis
(b) Hemilarynx
defect
Prelamination
Prefabrication
Radial forearm
Radial forearm
fascia
Mucosa or ear cartilage prelaminated onto
antebrachial fascia for tracheal defects
Free radial forearm fascial flap wrapped
around upper trachea, which is
subsequently moved for hemilarynx
reconstruction
Vranckx et al.17
Delaere et al.18
Table 5.1  Clinical applications of prefabrication and prelamination: Facial soft tissue subunits
Defect
Technique
Flap location
Technique description
References
Lips
(a) Superficial (hair-
bearing) lip loss
(b) Full-thickness upper
lip loss
(c) Upper and lower lip
(mouth) loss
Direct axial
flap
Prefabrication
Prelamination
Prelamination
Scalp/submental
scalp
Submental
forearm
Staged transfer of hair-bearing flap from
scalp/submental
Vascular pedicle implant + secondary
transfer
Tissue expander + skin graft on
underside of submental platysma flap
Subfascial skin grafts in radial forearm
flap
Hyakusoku et al.1
Pribaz and Guo2
Pribaz and Fine3
Costa et al.4
Baudet5
Cheek
(a) Partial thickness
(e.g., burn)
(b) Full thickness
Direct axial
flap
Prefabrication
Prelamination
Submental neck/
upper chest or
distant forearm
Submental island flap to cheek
Implant vascular pedicle beneath skin
and over a tissue expander with
secondary transfer
Subfascial skin graft over a tissue
expander in radial forearm territory, or
subfascial mucosal graft and silicone
sheeting in radial forearm territory  
(± nerve)
Martin et al.6
Faltaous et al.7
Kim8
Khouri et al.9
Pribaz et al.10
Pribaz et al.3,11
Rath et al.12
Rath et al.13
Neck
Burn contracture
Prefabrication
Thigh forearm
upper chest
Implantation of pedicle subcutaneously
placed over a tissue expander and
subsequently transferred to neck
Khouri et al.9
Pribaz et al.10

18
PART 1 — PRINCIPLES
Table 5.3  Clinical applications of prefabrication and prelamination: Facial skeleton
Defect
Technique
Flap location
Technique description
References
Maxilla
(a) Partial
– premaxilla
(b) Extensive
defect
Existing
laminated
flap
Prelamination
Second toe
proximal
phalanx
Scapular or fibula
Osteointegrated implants placed into proximal
phalanx with composite flap based on dorsalis
pedis artery and transferred to premaxilla
Prelaminate scapular bone or fibula dermal graft +
wrap with silicone sheeting ± osteointegrated
implants
Pribaz and Guo2
Holle et al.19
Rohner et al.20
Mandible
Segmental or
total loss
Prelamination
Scapular
Cancellous bone in carrier tray placed in scapular
flap territory + secondary transfer to mandible
Orringer et al.21
Table 5.4  Clinical applications of prefabrication and prelamination: Oropharynx and esophagus
Defect
Technique
Flap location
Technique description
References
Intraoral
Mucosa-lined
soft tissue loss
Prelamination
Forearm
Mucosal grafts placed over radial forearm and later
transferred for intraoral reconstruction
Rath et al.12
Carls et al.22
Chiarini et al.23
Esophagus
(a) Cervical
esophagus
(b) Entire
esophagus
Prelamination
Prelamination
Radial forearm
Tensor fascia
lata (TFL)
Skin surface of the radial forearm flap is rolled into a
lumen during first stage to allow healing of suture
line; during second stage 2 weeks later,
microvascular transfer is completed
Longer defect requires TFL flap with skin lumen
prelaminated the same way
Chen et al.24
Table 5.5  Clinical applications of prefabrication and prelamination: Penis
Defect
Technique
Flap location
Technique description
References
Penis
Absence secondary
to tumor or trauma
Prelamination
Lateral arm radial
forearm fibula
Prelamination with skin tube for neo-urethra
reconstruction with subsequent transfer of
osteocutaneous flap when using fibula
Young et al.25
Capelouto et al.26
FLAP PREFABRICATION
CONCEPT
The first step in planning a reconstruction is to delineate
the specific needs. It is desirable to use flaps that provide
a good color match and restore surface and contour.
Regarding head and neck reconstruction, in particular,
the recipient site may require further specialized flaps,
such as hair-bearing or mucus-producing flaps, for optimal
reconstruction.29 Although there may be local flap options
with the desired characteristics, these may not have a reli­
able axial blood supply on which they can be transferred.
The technique of flap prefabrication provides this by
implanting an axial blood supply into the donor tissue,
rendering that tissue transferable once neovascularization
has occurred.
TECHNIQUE
A vascular pedicle includes at least an artery and its venae
comitantes, surrounded by an adventitial cuff. It may be
available locally or, if not, imported as a small free flap and
implanted beneath the intended donor tissue. The distal
end of the pedicle is ligated. To prevent scarring around the
base of the pedicle and to facilitate secondary harvest of the
prefabricated flap, a short segment of Gore-Tex (polytetra­
fluoroethylene) tubing or thin silicone sheeting can be
placed around the pedicle up to the undersurface of the
tissue that the new pedicle is expected to support (Fig. 5.1).
A nonadhesive sheeting may be placed under the implanted
pedicle, away from the proposed flap, not only to facilitate
secondary elevation of the flap but also to shunt the direc­
tion of neovascularization from the pedicle toward the flap
to be prefabricated. A tissue expander is frequently used
in this capacity. In experimental animal models, a neural

CHAPTER 5 — Prefabrication a nd Prelamination
19
using a native subcutaneous vein in the prefabricated flap
can all help to minimize flap venous congestion. Finally,
there was a recent report of a further surgical delay per­
formed at 6–7 weeks after pedicle implantation and 2 weeks
before flap transfer that was shown to minimize venous
congestion in that series.38
CLINICAL EXAMPLES
As illustrated in Figure 5.2, flap prefabrication can be
designed in any of the four basic forms. With proper plan­
ning, it is possible to avoid performing microvascular anas­
tomoses in two separate settings by choosing pedicles in
nearby sites to fabricate a new flap with desirable character­
istics. Choice of a design hinges on two questions: What is
needed? What is available? With the patient presented in
Figure 5.3, it is important to reconstruct the central defect
in her face with similarly matched skin. Local reconstructive
options were not available, as she previously underwent
right external carotid artery embolization for an arteriove­
nous malformation and suffered full-thickness skin necrosis.
In such cases, a flap may be prefabricated in the submental
area by utilizing the descending branch of the lateral cir­
cumflex femoral vessels with microvascular transfer. The
newly axialized submental flap may be transferred 8 weeks
following the original procedure as a pedicled flap.
The patient illustrated in Figure 5.4 requires a significant
contracture release and resurfacing of her neck after a dis­
figuring burn injury suffered many years before. There are
no local options for reconstruction, as the surrounding skin
has also undergone traumatic injury. For this type of defect,
distantly prefabricated skin flaps have been used previously.
In this patient, the deep inferior epigastric vessels were
utilized to prefabricate a sizable and robust abdominal skin
flap. Transfer of such distantly prefabricated flaps then takes
place via microvascular anastomosis (Fig. 5.4).
Sometimes, one encounters the need to reconstruct a
specialized surface, for instance, a hair-bearing area of the
face. While local options for a good surface match may exist,
it may not possess a reliable blood supply. Prefabrication can
be used to bring in this blood supply. The patient illustrated
in Figure 5.5 needs to have his cheek skin and lip mustache
reconstructed after a disfiguring burn suffered several years
prior to presentation. While he still has enough scalp hair
to serve as a donor, the extent of his burn injury with sub­
sequent scarring would prevent a reliable transfer, all the
way to the midline, of any hair-bearing surface. The tempo­
ral parietal fascia (TPF) is not available in this patient due
island flap can also be prefabricated. In this model, a periph­
eral nerve can be placed under subcutaneous tissue and the
intrinsic vasculature of the nerve can supply the flap follow­
ing a delay period.30
FLAP MATURATION
Neovascularization between the implanted pedicle and the
donor tissue matures by 8 weeks in humans.3 However,
experimentally, maturation may possibly be hastened. Angio­
genic factors, such as basic fibroblast growth factor (bFGF)31
and vascular endothelial growth factor (VEGF),32 have been
shown in animal models not to improve flap survival by
increasing its vascularity.33 Flap delay has also been success­
fully employed, experimentally, to accelerate neovascular­
ization.34 By virtue of the need to prefabricate the donor
tissue (which lacks a good axial blood supply), the delay is
accomplished by progressively raising the flap tissue off
its non-axial blood supply, thus rendering it dependent
on the implanted pedicle. Although the contact area of
the vascular pedicle did not seem to be significant in our
initial experiments, others have found that there is a
proportional relationship of pedicle size and the rate of
neovascularization.35
Another helpful adjunct is the use of tissue expansion.36
Tissue expansion and flap prefabrication both are two-stage
procedures and thus complement each other nicely. The
implanted pedicle is placed directly underneath the donor
tissue and above the expander. Expansion can start as early
as 1 week and may be monitored by Doppler ultrasonogra­
phy. Expansion can be as aggressive, as allowed by the con­
tinued presence of the Doppler signal of a patent pedicle
and clinical observation of flap color. Tissue expansion
accomplishes four things: (1) it provides an abundance of
tissue that facilitates donor site closure following final trans­
fer; (2) it thins out the donor tissue flap, which is helpful
in head and neck reconstruction; (3) it provides mechanical
stretch that stimulates endothelial cells to proliferate,
thereby enhancing the rate of neovascularization; and (4)
it focuses the direction of the neovascularization from the
implanted pedicle toward just the side of the prefabricated
flap. Assessment of flap vascularity and viability by modali­
ties designed to evaluate perfusion may be useful in preop­
erative planning and optimizing flap harvest.37
FLAP TRANSFER
During the second stage of flap prefabrication, the prefab­
ricated flap is transferred to its final location, based on its
newly acquired axial blood supply. This can be done locally
as a pedicled flap if close to the defect or via microvascular
anastomosis if prefabrication is at a remote site (Fig. 5.2). A
commonly observed problem seen after flap transfer is tran­
sient venous congestion. This may be caused by unequal
neovascularization of the lower-pressured venous system
compared with the higher-pressured arterial system of the
same pedicle. This problem can be ameliorated in several
ways. All maneuvers that enhance neovascularization,
including flap delay, lengthening maturation time, or
increasing the contact area between the pedicle (usually in
the form of a fascial flap) and the donor tissue, would help.
Also, other strategies such as delayed insetting, temporary
leeching (chemical or medicinal), avoiding flap folding or,
if possible, performing an additional venous anastomosis
Figure 5.2  Various algorithms in flap prefabrication.
Regional transfer of prefabrication flap
Distant transfer of prefabrication flap
Implant vascular pedicle into proposed flap (8 weeks)
Micro
Micro
Implant distant AV pedicle
Implant regional AV pedicle

20
PART 1 — PRINCIPLES
different layers into an axial vascular territory, allowing time
for the tissues to mature before being transferred. During
stage 2 the laminated layers are transferred to the defect as
a composite structure based on the original axial blood
supply. As with any composite graft, these added layers have
to be sufficiently thin or small for them to take. The ratio­
nale for prelaminating those layers at a different site prior
to transfer rests on the belief that this offers the best chance
for the prelaminating layers to heal, stabilize, and assume
their expected structures and positions if the construction
is done in a reliable vascular bed at a less conspicuous
site versus in situ, where local complicating factors can
be numerous. This is particularly important for reconstruc­
tion of functional units that need to be transferred
to complex local environments, where loss of structural
integrity may precipitate grave complications, for example,
neo-urethra in the perineum and neo-esophagus in the
mediastinum.
TECHNIQUE
Aside from skin, the added graft materials may be as diverse
as cartilage, bone, mucus-producing membrane,40 nerve
to the burn injury. For cheek and mustache reconstruction,
a distant radial forearm fascial flap along with its pedicle is
anastomosed into the external carotid and jugular systems
and inserted over a tissue expander beneath a hairy postau­
ricular region of the scalp. This newly axialized hair-bearing
flap is transposed 8 weeks later to reconstruct the patient’s
mustache and beard area.
Possibilities with flap prefabrication are endless and many
combinations of transplanted vascular pedicles, donor
tissues, and geographic locations have been described for
various clinical needs. This technique is especially powerful
in reconstructing specialized tissues, such as hair-bearing
areas and nerves (in cases of vascularized nerve grafts),39
where conventional approaches are often inadequate.
FLAP PRELAMINATION
CONCEPT
The word “lamination” means bonding together of thin
sheets. In reconstructive surgery, the term flap prelamination
describes a two-stage process. The first stage involves adding
Figure 5.3  (A) Frontal view of a young patient with a history of a right facial arteriovenous malformation, presenting with facial contour defor­
mity following an embolization of her lesion and reconstruction subsequent facial tissue necrosis. Furthermore, there was thrombosis of multiple
external carotid branches. (A) The patient continued to have significant facial contour deformity and tethering of right oral commissure following
debridement and radial forearm free flap reconstruction. (B,C) Design of flap to be prefabricated in the submental region, with descending
branch of the lateral femoral circumflex vascular pedicle transferred into the area and anastomosed with the external carotid; Gore-Tex tubing
was applied to the proximal pedicle (visible in C). The transferred pedicle was placed over a tissue expander. (D) Early postoperative result
following prefabricated flap transfer. A left facial artery musculomucosal (FAMM) flap was utilized for upper lip reconstruction. (E) Result 6
months later, after two thinning and refinement procedures.
A
B
D
E
C

CHAPTER 5 — Prefabrication a nd Prelamination
21
A
B
C
E
F
G
D
Figure 5.4  (A) A young woman with extensive burn scars in the neck, neck resurfacing
and contracture release. (B,C) Given the lack of donor sites, as well as the need for relatively
large amounts of skin, a template was designed in the patient’s lower abdomen. Bilateral
deep inferior epigastric vessels were harvested and placed subcutaneously, overlying a
tissue expander. Gore-Tex tubing was again applied to the base of the pedicle. (D) Appear­
ance of prefabricated lower abdominal flaps following expansion. (E) A large, pliable cuta­
neous flap was harvested and maintained complete vascularity on a single pedicle. (F)
Following neck contracture release, there was a significant portion of the neck that required
resurfacing. (G) The 6-month postoperative outcome following prefabricated flap inset.

22
PART 1 — PRINCIPLES
Figure 5.5  (A) A 59-year-old man with extensive burn scars in the forehead, right orbit, upper and lower lips, reconstructed with a split-
thickness skin graft at the time of injury, wanted to have facial resurfacing and reconstruction of the mustache and beard to match the opposite
side. (B) A template illustrated the area to be reconstructed, hatched area designating mustache and beard skin with required hair. (C) Scapular
flap design and orientation for reconstruction of the forehead and right orbit. (D) Radial forearm fascial flap for flap prefabrication for the lips
and cheek. (E) Scapular free flap inset for the forehead and orbit defect, vascularized radial forearm fascia flap tunneled beneath the scalp and
laid over a tissue expander. (F) At 8 weeks later, the prefabricated flap was ready for transfer and additional scar revision on the right cheek
planned. (G) Intraoperative dissection of the prefabricated flap raised based on its implanted pedicles. (H) Early postoperative and (I,J) 9 months
later, the prefabricated flap has good hair growth.
A
B
C
D
E
F
H
I
J
G

CHAPTER 5 — Prefabrication a nd Prelamination
23
graft,13 cultured keratinocyte sheet,41 or bioengineered
tissues.42 Tissue expansion again can play an important role
in many cases of flap prelamination, especially when a large
surface is desired, for example, during reconstruction of
mucosal intraoral linings.
FLAP MATURATION
Because the blood supply is not manipulated, the time
required for a prelaminated flap to mature is shorter than
for a prefabricated flap3 – usually 3–4 weeks.
FLAP TRANSFER
Since the layering of structures takes place in an established
vascular territory, venous congestion is usually not the
problem in a prelaminated flap that it can be in a prefabri­
cated flap. However, all flaps, including prelaminated flaps,
become edematous after transfer and exhibit increased scar­
ring at each healing interface. In attempting to reconstruct
complex 3-dimensional structures, the multiple layers with
scarring and contractile forces at each interface can result
in distortion and loss of contour of the flap. Because of this,
the initial result is often suboptimal and, in general, revision
operations are necessary.
CLINICAL EXAMPLES
The forearm remains a preferred site for non-bony flap
prelamination because of easy accessibility, patient conve­
nience, and the availability of a reliable but dispensable
vascular pedicle (usually radial or occasionally the ulnar
system, which has the benefit of being less hairy). Other sites
include the subscapular and fibular regions, where local
bony structures can be readily incorporated into the pre­
laminated flap for mandibular, maxillary, or even penile
reconstruction.
Distant prelamination, while it necessitates microvascular
transfer and generally lacks good color match, does have
the appeal of being inconspicuous and being able to utilize
local resource as needed (bone, cartilage, and other special­
ized tissues). Furthermore, there is more freedom in flap
reach with a flexible pedicle. While the decision to choose
a site for flap prelamination takes into account all these
factors, the foremost questions are always: What is needed?
What is available? Figure 5.6 shows a patient who needs a
total nasal reconstruction after an arteriovenous malforma­
tion resection. A flap is prelaminated in his forearm in the
ulnar artery distribution with a skin graft as for lining before
being transferred en bloc to the nasal and cheek defect. By
maintaining local options, further refinement of the nasal
reconstruction can be performed by utilizing cartilage grafts
for reconstruction of the defect and a forehead flap for
resurfacing.
In Figure 5.7, a patient presents with a large segment
of anterior maxilla missing. Reconstruction is planned with
a scapular free flap. The flap is prelaminated by the addi­
tion of a bone graft to mimic bony contour or the anterior
maxilla and a dermal graft. The construct is then covered
in a silicone membrane and allowed to heal. Approximately
4 weeks later, the flap is ready for transfer and inset. Once
the flap is healed, the patient may have dental implants
placed in the transferred bone.
If a flap is prelaminated within the head and neck
region, it takes only a pedicled transfer to inset the com­
posite flap. Local prelamination may involve the forehead
skin flap based on the supratrochlear or supraorbital
vessels, the TPF based on the superficial temporal vessels,
or the submental skin flap based on branches of the facial
artery. Advantages of prelaminating in the head and neck
include no need for microanastomosis during the second
stage of the procedure and a good match of skin color
and contour. A significant disadvantage is that the prepara­
tion stage may be socially awkward with obvious deformi­
ties present. However, if a suitable donor site is available
locally, it is clearly the best option. An example of local
tissue prelamination without the need for microanastomo­
sis is illustrated in Figure 5.8, where a forehead flap is
raised for nasal reconstruction, bilateral submental flaps
are prelaminated with full-thickness skin grafts for intra­
oral lining, and an Abbé flap is used to reconstruct the
upper lip.
Traditionally, prelaminated flaps are used to reconstruct
central facial defects11 and other anatomies that have a sig­
nificant degree of 3-dimensional structure, such as the penis
and esophagus. Extensive defects that are not amenable to
local flaps often require multiple layers reconstructed to
provide framework, lining, and tissue bulk for future refine­
ments. The goal of flap prelamination is not to provide a
one-step solution; it simply delivers the tissue support and
bulk to the area to render further reconstructive revisions
possible.
CONCLUSION
Flap prefabrication and prelamination offer sophisticated
approaches to difficult reconstructive needs that conven­
tional methods cannot meet. Tables 5.1–5.5 provide a com­
prehensive overview of the clinical applications of these two
techniques. The two techniques are distinctively different
and yet can be perfectly complementary. Prelamination can
add virtually anything to where there is a good axial blood
supply and prefabrication can bring an axial blood supply
to almost anywhere in the body. The two techniques can
even be combined when certain complex reconstructive
needs exist.
Prefabrication and prelamination can also serve as a
conduit through which products of tissue engineering and
embryonic stem cell technologies can be applied to the
reconstruction of head and neck defects. Tissues synthe­
sized in vitro with better structural, color, texture, and
functional match can be prelaminated to a site that
has already been prefabricated. Prefabrication of a bio­
absorbable matrix system can create a well-perfused scaffold
to which more and larger subunits can be pre­laminated. As
our understanding of the techniques evolves, the breadth
of their usage will also expand. Difficult problems that used
to baffle the very best reconstructive surgeons may no
longer seem so impossible and patients’ expectations may
also rise to a new level. This represents the beginning of a
new era in reconstructive surgery.

24
PART 1 — PRINCIPLES
Figure 5.6  (A,B) A young woman with extensive defects of her nose, secondary following resection of an arteriovenous malformation. (C,D)
Reconstruction of the resultant defect was planned with a tailored radial forearm free flap that had been prelaminated with a skin graft of its
undersurface for mucosal lining. (E) Immediate postoperative outcome, as well as (F) postoperative outcome following cartilage grafting and
forehead flap for resurfacing.
A
B
D
C
F
E

CHAPTER 5 — Prefabrication a nd Prelamination
25
Figure 5.7  (A) A patient presented with a hypoplastic anterior maxilla and absence of anterior maxillary teeth. A scapular free flap was designed
for reconstruction (B). (C,D) A template was created and a bone graft fashioned and fixated to reconstruct the anterior maxillary contour. (E)
Next, a dermal graft was attached to the surface to provided soft tissue covering. (F) The prelaminated flap was covered in a silicone wrap,
whereas the pedicle was isolated by covering with a Gore-Tex graft. (G,H). Approximately 4 weeks later, the prelaminated flap was harvested
and transferred to the donor site. (I) Postoperative appearance approximately 4 months following the procedure. The prelaminated flap provides
a stable bony base for subsequent dental implant reconstruction.
A
B
D
E
G
H
I
F
C

26
PART 1 — PRINCIPLES
Figure 5.8  (A) An 18-year-old man with extensive defects of the upper lip, cheek, and nose, secondary to noma infection. (B,C) Tissue
expander with full-thickness skin graft to be placed in the submental area deep to the platysma and anterior belly of the digastric muscle. (D)
Lateral view at 4 weeks showing expansion of the submental and forehead areas. (E) Intraoperative view showing the design of right and left
prelaminated, submental composite flaps, each based on the submental branch of the facial artery and also containing innervated platysma
muscle. (F) The tissue expander was removed and the left submental flap raised, showing healed skin graft on the inner aspect of the prelami­
nated flap. (G) Nasal reconstruction with local turndown flap for lining and cartilage grafts for support; forehead flap raised and ready to provide
external coverage of the nose; also, the two prelaminated submental flaps are in place and the Abbé flap is planned for reconstruction of the
central part of the upper lip. (H,I) Frontal and lateral views 6 weeks later.
A
D
G
H
I
E
F
B
C

CHAPTER 5 — Prefabrication a nd Prelamination
27
23. Chiarini L, De Santis G, Bedogni A, et al. Lining the mouth floor
with prelaminated fascio-mucosal free flaps: clinical experience.
Microsurgery 2002;22(5):177–86.
24. Chen HC, Kuo YR, Hwang TL, et al. Microvascular prefabricated
free skin flaps for esophageal reconstruction in difficult patients.
Ann Thorac Surg 1999;67(4):911–16.
25. Young VL, Khouri RK, Lee GW, et al. Advances in total phalloplasty
and urethroplasty with microvascular free flaps. Clin Plast Surg
1992;19(4):927–38.
26. Capelouto CC, Orgill DP, Loughlin KR. Complete phalloplasty with
a prelaminated osteocutaneous fibula flap. J Urol 1997;158(6):
2238–9.
27. Shen TY. Microvascular transplantation of prefabricated free thigh
flap [letter]. Plast Reconstr Surg 1982;69:568.
28. Pribaz JJ, Fine NA. Prelamination: defining the prefabricated flap:
a case report and review. Microsurgery 1994;15:618–23.
29. Mathy JA, Pribaz JJ. Prefabrication and prelamination applications
in current aesthetic facial reconstruction. Clin Plast Surg
2009;36:493–505.
30. Sonmez E, Cengiz Bayram F, Safak T. A new flap prefabrication
model: prefabricated neural-island flap. Ann Plast Surg 2011;66:
364–9.
31. Haws MJ, Erdman D, Bayati S, et al. Basic fibroblast growth factor
induced angiogenesis and prefabricated flap survival. J Reconstr
Microsurg 2001;17:39–42.
32. Li QF, Reis ED, Zhang WX, et al. Accelerated flap prefabrication
with vascular endothelial growth factor. J Reconstr Microsurg
2000;16:45–9.
33. Ko CY, Shaw WW. Durability of prefabricated versus normal random
flaps against a bacterial challenge. Plast Reconstr Surg 1997;99:
372–7.
34. Maitz PKM, Pribaz JJ, Duffy FJ, et al. The value of the delay phe­
nomenon in flap prefabrication: an experimental study in rabbits.
Br J Plast Surg 1994;47:149–54.
35. Tark KC, Shaw WW. The revascularization interface in flap prefab­
rication: a quantitative and morphologic study of the relationship
between carrier size and surviving area. J Reconstr Microsurg
1996;12:325–30.
36. Maitz PKM, Pribaz JJ, Hergrueter CA. Impact of tissue expansion
on flap prefabrication: an experimental study in rabbits. Microsur­
gery 1996;17:35–40.
37. Green JM, Thomas S, Sabino J, et al. Use of intraoperative fluores­
cent angiography to assess and optimize free tissue transfer in
head and neck reconstruction. J Oral Maxillofac Surg 2013;71:
1439–49.
38. Margulis A, Licekson M, Tzur T, et al. Prefabricated and pedicled
expanded flaps for reconstruction of complex pediatric soft tissue
defects. Paper presented at the Plastic Surgery International Sym­
posium, Eilat, Israel, March 2005.
39. Saray A, Teoman Tellioglu A, Altinok G. Prefabrication of a free
peripheral nerve graft following implantation on an arteriovenous
pedicle. J Reconstr Microsurg 2002;18:281–8.
40. Miyawaki T, Degner D, Jackson IT, et al. Easy tissue expansion of
prelaminated mucosa-lined flaps for cheek reconstruction in a
canine model. Plast Reconstr Surg 2002;109:1978–85.
41. Lauer G, Schimming R, Gellrich NC, et al. Prelaminating the
fascial radial forearm flap by using tissue-engineered mucosa:
improvement of donor and recipient sites. Plast Reconstr Surg
2001;108:1564–72.
42. Ting V, Sims CD, Brecht LE, et al. In vitro prefabrication of human
cartilage shapes using fibrin glue and human chondrocytes. Ann
Plast Surg 1998;40:413–20.
REFERENCES
1. Hyakusoku H, Okubo M, Umeda T, et al. A prefabricated hair-
bearing island flap for lip reconstruction. Br J Plast Surg
1987;40(1):37–9.
2. Pribaz JJ, Guo L. Flap prefabrication and prelamination in head
and neck reconstruction. Semin Plast Surg 2003;17:351–62.
3. Pribaz JJ, Fine NA. Prefabricated and prelaminated flaps for head
and neck reconstruction. Clin Plast Surg 2001;28:261–71.
4. Costa H, Cunha C, Guimaraes I, et al. Prefabricated flaps for the
head and neck: a preliminary report. Br J Plast Surg 1993;46(3):
223–7.
5. Baudet J Reconstruction of the face. Paper presented at the 4th
European Course in Plastic Surgery, Glasgow, 1990.
6. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a
new donor site. Anatomy and clinical applications as a free or
pedicled flap. Plast Reconstr Surg 1993;92(5):867–73.
7. Faltaous AA, Yetman RJ. The submental artery flap: an anatomic
study. Plast Reconstr Surg 1996;97(1):56–60.
8. Kim JJ. Submental artery perforator flap. In: Blondeel PN, Morris
SF, Hallock GG, editors. Perforator flaps – anatomy, technique, and
clinical application, vol. 1. St Louis: Quality Medical Publishing;
2006. p. 161–80.
9. Khouri RK, Ozbek MR, Hruza GJ, et al. Facial reconstruction with
prefabricated induced expanded (PIE) supraclavicular skin flaps.
Plast Reconstr Surg 1995;95(6):1007–15.
10. Pribaz JJ, Fine N, Orgill DP. Flap prefabrication in the head
and neck: a 10-year experience. Plast Reconstr Surg 1999;103(3):
808–20.
11. Pribaz JJ, Weiss DD, Mulliken JB, et al. Prelaminated free flap
reconstruction of complex central facial defects. Plast Reconstr
Surg 1999;104:357–65.
12. Rath T, Millesi W, Millesi-Schobel G, et al. Mucosal prelamination
of a radial forearm flap for intraoral reconstruction. J Reconstr
Microsurg 1997;13(7):507–13.
13. Rath T, Tairych GV, Frey M, et al. Neuromucosal prelaminated
flaps for reconstruction of intraoral lining defects after radical
tumor resection. Plast Reconstr Surg 1999;103:821–8.
14. Pribaz JJ, Falco N. Nasal reconstruction with auricular microvascu­
lar transplant. Ann Plast Surg 1993;31(4):289–97.
15. Gilles H. A new free graft applied to the reconstruction of nostril.
Br J Surg 1942;30:305.
16. Hirase Y, Valauri FA, Buncke HJ. An experimental model for ear
reconstruction with moulded perichondrial flaps: a preliminary
report. Br J Plast Surg 1989;42(2):223–7.
17. Vranckx JJ, Den Hondt M, Delaere P. Prefabrication and prelami­
nation strategies for the reconstruction of complex defects of
trachea and larynx. J Reconstr Microsurg 2014;30:145–52.
18. Delaere PR, Hardillo J, Hermans R, et al. Prefabrication of com­
posite tissue for improved tracheal reconstruction. Ann Otol
Rhinol Laryngol 2001;110(9):849–60.
19. Holle J, Vinzenz K, Wuringer E, et al. The prefabricated combined
scapula flap for bony and soft-tissue reconstruction in maxillofacial
defects – a new method. Plast Reconstr Surg 1996;98(3):542–52.
20. Rohner D, Bucher P, Kunz C, et al. Treatment of severe atrophy of
the maxilla with the prefabricated free vascularized fibula flap. Clin
Oral Implants Res 2002;13(1):44–52.
21. Orringer JS, Shaw WW, Borud LJ, et al. Total mandibular and lower
lip reconstruction with a prefabricated osteocutaneous free flap.
Plast Reconstr Surg 1999;104(3):793–7.
22. Carls FR, Jackson IT, Behl AK, et al. Prefabrication of mucosa-lined
flaps: a preliminary study in the pig model. Plast Reconstr Surg
1998;101(4):1022–8.