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

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 55.3  Flap harvest is performed through a 12–20 cm incision placed over the medial aspect of the thigh in-line with the medial femoral
condyle. (A) The incision originates over the medial femoral condyle and then extends proximal as far as is required to obtain adequate pedicle
length. If an articular graft is to be harvested, a more anterior incision is made half the distance between the medial edge of the patella and
medial femoral condyle. (B) The descending genicular artery is most easily exposed by initially incising the fascia of the vastus medialis.
(C) The use of a Chandler retractor allows for retraction of the vastus medialis and exposure of the descending geniculate system. (D) Both
the transverse vascular branch (white arrowhead) and corticoperiosteal vascular branch (black arrow), which may be used for bone harvest.
(E) For harvest of an articular graft the superior medial margin of the joint capsule can be opened (arrow). (F) A corticocancellous graft is tem­
plated over the corticoperiosteal branch going to the condyle. A ruler is used to template the graft to fit the defect size and then a saw is used
to aid in graft elevation. (G) An example of a pure corticocancellous graft and its respective pedicle, which will be used for treatment of a
scaphoid non-union Flap after harvest (see Case 55.3).
A
B
C
D
E
F
G
H
not required, as in cases of Kienböck disease and some
cases of scaphoid non-union. In addition, the SGA has a
good diameter vessel match when performing end-to-end
anastomosis to side branches of the radial artery.
• An average of 30 arterial perforators to the medial
femoral condyle has been reported. The perforating
vessels run perpendicular to the cortex over an average
area of 19 cm2, extending to an average depth of 13 mm.
The majority of perforators lie in the posterior medial
quadrant of the condyle.7 Care should be taken to iden­
tify these perforators and include them within the bone
flap
• If a skin paddle is to be taken with the flap, it is necessary
to separate the saphenous nerve from the saphenous
branch of the DGA. Injury to this nerve will result in
paresthesia or dysesthesias over the anterior medial aspect
of the parapatellar/pretibial region of the leg.
corticoperiosteal (MFC) flap can provide a versatile source
of vascularized bone with limited donor site morbidity and
requires minimal time for flap harvest.
Although a periosteal flap can be elevated alone (without
the underlying bone), disrupting the strongly adherent
Sharpey fibers between the periosteum and cortex risks
injury to the cambium layer; injury to this layer decreases
the osteogenic potential of the graft. As such, studies have
recommended including a layer of cortex when harvesting
the flap, thus minimizing this risk of injury to the cambium
layer.12–16
SPECIAL CONSIDERATIONS
• The SGA, while smaller in diameter than the DGA, is still
a very reasonable option when longer pedicle length is

CHAPTER 55 — Medial Femoral Condyle and De scending Ge nicular Artery Perforator Flaps
641
ANESTHETIC CONSIDERATIONS
Although regional blocks are possible for harvest of the flap
and for reconstruction of a hand defect, general anesthesia
is suggested, as the surgery can be lengthy and uncomfort­
able for the patient. Also, any movement during microvas­
cular anastomosis can be detrimental to the success of the
operation.
TECHNIQUE OF FLAP HARVEST
SURGICAL TECHNIQUE (Fig. 55.3)
• A sterile tourniquet is used to facilitate dissection.
The leg is elevated but not exsanguinated prior to
tourniquet inflation to improve visualization of the
vessels.
• A mid-axial incision is made from the lower one third of
the thigh over the adductor hiatus to the medial collateral
ligament over the patella (Fig. 55.3A).
• If a skin flap is required, a handheld Doppler is used to
identify the saphenous branch of the DGA, supplying the
overlying skin. This is often located posterior to the mid­
lateral line in the distal third of the thigh, in the proxim­
ity of the condyle (Fig. 55.4).
• The fascia of the vastus medialis is incised and the muscle
is retracted anteriorly with the use of a Chandler retractor
to expose the descending genicular vessels and osteoar­
ticular perforators (Fig. 55.3B).
• The branches of the artery are identified and isolated as
they enter the periosteum of the femur. Retrograde dis­
section then begins over the DGA back to its origin at the
adductor canal.
• If the DGA is small (<1 mm) or absent (10% of cases),
the superomedial genicular artery is identified and dis­
sected back to its origin at the popliteal artery.
• Once the artery is isolated, the condyle is cleared of all
superficial soft tissue of the required size of the graft is
drawn on the condyle of the femur. The graft is centered
over 2–3 major bony perforators.
• Care is taken to protect the articular surface and the
medial collateral ligament during harvest of the vascular­
ized bone graft.
• The periosteum is cut with cautery and the cortex is ele­
vated with a chisel or electric saw (Fig. 55.3G).
• The bone graft is carefully elevated as to not damage
the fine connection between the periosteum and the
cortex.
• Using a rongeur or high-speed burr the vascularized peri­
osteal bone graft is contoured to fit the bony defect.
• If additional cancellous autograft is need for the defect it
can be harvested from the cortical defect created in the
medial condyle.
• A microvascular anastomosis is performed (usually by an
end-to-side connection with the radial artery and the
venous repair with an end-to-end anastomosis with the
venae comitantes) and the flap is inset at the recipient
site.
• K-wires, screws, or suture anchors are used to hold the
grafts in place.
• The convex articular surface of the medial femoral troch­
lea has a similar radius of curvature to carpus, specifically
the proximal scaphoid and lunate.
Relative contraindications may include radiation to the
region of flap harvest, or significant peripheral vascular
disease involving the adductor canal or popliteal area, as
these may compromise the arterial pedicle to the flap. Previ­
ous knee surgery, which has injured or ligated the genicu­
late arterial system, which feeds the MFC flap, will prevent
the successful use of the flap.
Other patient-specific contraindications in cases of scaph­
oid non-union, Preiser disease, and Kienböck disease, would
be the existence of wrist arthritis. In such cases, once wrist
arthritis is established, bony revascularization or bony union
will not alleviate the patient’s pain. In such cases, some form
of intercarpal fusion is usually indicated.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
The design is similar in either case, although there are rare
indications for pedicled flaps from this region.
FLAP DIMENSIONS
Skin Island Dimensions
Length: average 3 cm (range 2–8 cm)
Width: average 3 cm (range 2–8 cm), maximum to close
primarily 2–4 cm
In most cases, a small skin island is taken for flap monitor­
ing. This skin island is excised at a later date.
Bone Dimensions
Length: average 5 cm
Width: average 3 cm
Thickness: average 3 cm
The MFC flap should not be the first choice in cases
where the bony defect is >3 × 5 cm. LaPierre et al. has
described using MCF grafts with dimensions as large as 13
× 8 cm.17 These findings have been further validated by
Iorio, who in a cadaveric study found that the geniculate
system may be capable of perfusing flaps of up to 13 cm in
length 8. Despite these findings, we would recommend
using a graft with more structural integrity if the bony defect
extends beyond 3 × 3 cm.
FLAP MARKINGS (Fig. 55.3A, 55.7B)
Doppler ultrasonography is used to map the perforators in
the region. A small skin island is designed over the Dop­
plered perforator.
PATIENT POSITIONING
The patient is placed in the supine position with the leg
flexed at both the knee and the hip in external rotation.
This provides access to the medial knee and distal thigh.

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 55.4  (A) The location of the angiosome supplied by the branch of the DGA to the skin (red) and the angiosome of the saphenous
cutaneous artery branch (green). (B–D) Examples of a clinical case utilizing the cutaneous perforating branch of descending genicular artery
to the skin. The skin island is dissected prior to bone harvest to minimize any trauma to small skin perforators. (D) Perfusion to skin paddle
and bone (arrowhead) when the tourniquet is released.
B
D
C
A
Descending genicular artery
Articular branch
Saphenous cutaneous
branch
DONOR SITE CLOSURE AND
MANAGEMENT
• The donor site is closed in layers with absorbable suture
and a drain is placed in the thigh.
• Postoperatively, the flaps are monitored for 48 h by exam­
ining the skin paddle or by using implanted Doppler
probes.
• The patient is encouraged to ambulate the following day.
A knee immobilizer may be worn for the first 2 weeks
postoperatively, as it can provide comfort to the patient.
• Postoperative X-rays are obtained at 2 weeks and a CT
scan is obtained at 7–9 weeks, to verify healing.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• For DGA vessel identification, it is easiest to mobilize the
vastus medialis just proximal to the condyle and then to
place a retractor over the femur allowing one to see
the osteoarticular branches of the artery (Fig. 55.3).
Dissection can then be carried out in a retrograde fashion
to the origin of the DGA from the femoral artery.
FLAP MODIFICATION/FLAP HANDLING
CHIMERIC FLAP WITH SKIN, BONE, AND MUSCLE
A Doppler ultrasound is used to map perforators in the
region. A skin island is marked over the Dopplered perfora­
tor. The anterior incision is made and a suprafascial dis­
section is performed from anterior to posterior until the
perforator is located. The perforator is then traced proxi­
mally until its takeoff from the descending genicular artery.
The DGA is exposed. The branches supplying muscle and
bone are located. Bone is included as described above.
CUTANEOUS TENDON GRAFT
The DGA is dissected proximally to the level of the adductor
magnus tendon. The tendon and peritenon are harvested
with the DGA and skin paddle (Case 55.2, Fig. 55.7).
SPECIAL INSTRUMENTS
Standard microsurgery instruments are required. A bone
saw is required if bone is to be harvested.

CHAPTER 55 — Medial Femoral Condyle and De scending Ge nicular Artery Perforator Flaps
643
2. Osteoarticular graft for management of articular defects
in the scaphoid, radius, or lunate. This graft is taken from
the superior medial aspect of the articular surface of the
medial femoral condyle (Fig. 55.5B).
3. Thin corticocancellous sheet of bone with periosteum,
which can be wrapped around tubular bones, such as the
clavicle, humerus or ulna, for cases of recalcitrant non-
union (Fig. 55.5C).
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
General indications for this procedure include small non-
unions that have failed traditional therapy or patients at
high risk for contemporary non-vascularized graft failure
(such as proximal pole scaphoid non-union). Other indica­
tions include:
• Recalcitrant bony non-unions due to infection, radiation-
induced osteonecrosis, or avascular necrosis
• A bone defect (3 × 3 cm) with composite soft tissue loss.
A skin paddle of ≥3 × 3 cm may be taken with the flap as
well as a portion of the vastus medialis if muscle coverage
is required for coverage of composite bony defects
• Small bony defects (up to 3 × 3 cm), where harvest of a
fibular or iliac crest would be excessive. The small size
MFC flap reduces risk of donor site morbidity and serves
as an ideal flap for defects that necessitate coverage with
a thin and pliable flap with minimal bulk.
UPPER EXTREMITY
The MFC has been successfully used for non-unions of the
clavicle, humerus, elbow, forearm, wrist-scaphoid, lunate,
phalanges, and metacarpals.11,18–20 More recent reports have
described the versatility of the flap being harvested with
both skin and muscle, allowing it to be used for a variety of
composite defects.20 Similarly, the MFC can be combined
with a portion of the medial femoral trochlea, providing an
osteoarticular flap for reconstruction of articular surfaces of
the scaphoid, capitate, and lunate.21,22
One of the original publications by Doi and colleagues
described the use of this flap in 46 patients with avascular
necrosis at the body of the lunate, scaphoid, and talus bone.
In Doi’s report 31/33 (93.9%) of patients achieved bony
union.23
Jones and colleagues examined the use of the vascular­
ized bone graft in treatment of scaphoid non-unions in 12
• Anatomic variation exists within the arterial pedicle and
the DGA may be absent in up to 10% of patients. If the
DGA is absent, one can still elevate the flap on the SGA,
though its pedicle will be shorter.
• Fixation of the graft can be achieved with screws, K-wires,
small plates, or suture anchors. A compression screw is
preferred in cases of scaphoid non-union. Suture anchors
and small plates work best for corticoperiosteal graft fixa­
tion in the radius and humerus.
• Firm fixation has been associated with improved out­
comes
POSTOPERATIVE CARE
• A vascularized skin paddle should be taken with the
graft to facilitate wound closure, thus allowing minimal
tension to be placed over the pedicle. If the wound can
be closed primarily without undue tension, the small
skin paddle can always be excised at the time of closure
(Fig. 55.4).
• Postoperative immobilization should be achieved with a
splint that does not apply compression over the site of the
anastomoses.
• Flap monitoring is performed with the use of an implant­
able Doppler probe or with the use of a skin paddle.
FLAP USAGE AND OUTCOMES
FREE FLAP
The MFC corticoperiosteal bone graft has been shown to be
a reliable flap for coverage of bony defects of the upper
extremity including the clavicle, humerus, radius, ulnar,
scaphoid, lunate, metacarpal, and phalanx bones.11,18–20
More recent reports have described the versatility of the flap
being harvested, with both skin and muscle allowing it to be
used for a variety of composite defects.20
The bone in the MFC flap is usually elevated in one of
three major patterns:
1. Corticocancellous block of bone of up to 3 × 3 cm for
use as a structural wedge graft in cases of collapsed
scaphoid non-unions, metacarpal and phalangeal
defects, and in some cases of distal radius non-unions
(Fig. 55.5A).
Figure 55.5  Bone for the medial geniculate arterial system may be harvested as (A) a corticocancellous block; (B) cortical-periosteal sheet;
or (C) an articular wedge.
A
B
C
A
B

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
upper and lower extremity. They found that nine non-union
sites (75%) healed primarily without complication at an
average of 3.8 months (range 2–7 months). Two of the non-
unions failed to heal primarily, one from hardware failure
and recurrent infection, and the other from inadequate
bony fixation and ongoing chemotherapy. There was one
case of flap failure secondary to arterial thrombosis, which
resulted in a lower limb amputation. Three donor site com­
plications occurred due to seroma formation. Limb salvage
was 91%. All patients with grafts to their upper extremities
returned to regular activities with minimal pain.11
Cavadas and Landín reported their outcomes of the use
of the MFC flap for the treatment of recalcitrant non-unions
of the distal tibia.24 A total of 21 patients, all of whom had
failed previous surgeries to achieve union of a distal tibia
fracture, were treated successfully using an MFC. In seven
of these patients, the corticoperiosteal flap was a composite
flap, associated with fat or muscle. All of the fractures had
healed at an average 3.1 months (range 2–7 months), with
minimal complications.24
Rahmanian-Schwarz and colleagues described the use of
the MFC as a composite osteomusculocutaneous free flap
for coverage of complex defects.27 In this report, two
patients, the DGA and its main branches (saphenous, articu­
lar, and muscular) were harvested on a single pedicle and
used for reconstruction of calcaneal defects. In this small
report, the flap was successful in providing wound coverage
for complex foot and ankle defects, with wound healing and
flap survival in both cases.27 Similarly, a recent report by
Haddock and colleagues further described the use of the
MFC for the treatment of AVN in the foot and ankle.26 In
this study of five patients with AVN of the talus (n = 3) and
navicular (n = 1), as well a talar neck non-union (n = 1), all
patients had healed and were fully weightbearing on the
extremity at an average 23.8 weeks (range 10–52 weeks).26
HEAD AND NECK
Since the corticoperiosteal MFC is a small, thin, flexible
flap, it can be used in areas where other, larger free tissue
flaps are simply too large and bulky, specifically the orbit
and mandible.28,29 The flexible MFC allows for contouring
around the curved bony structure of the head and neck,
making it suitable for reconstruction in these areas.
Kobayashi and colleagues described the use of a cortico­
periosteal flap to reconstruct orbital defects following
trauma, tumor resection and Crouzon disease.28 The flap
was combined with a skin paddle and five patients showed
complete healing and minimal resorption at an average
follow-up of 48.6 months (range 36–60 months).28 Similarly,
Martin and colleagues used a composite MFC for recon­
struction of mandibular defects in two patients. The authors
showed healing of the graft at 7.5 weeks, and considered
reconstruction of mandibular defects one of the “best indi­
cations” for the use of the flap.30
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
Although it does not include the medial femoral condyle,
Acland and colleagues have shown that if the saphenous
nerve is taken in its entirety, it can be used to provide sensa­
tion to composite flaps based of the saphenous vessels.31 In
patients over a 3-year period.19 Four measures were used to
evaluate postoperative success and included mean lateral
intrascaphoid angle, scaphoid height : length ratio, scaph­
olunate angle, and radiolunate angle. In 8/12 of the
patients, the DGA vessel was used and in the other four
patients, the SGA was utilized. The graft was harvested and
the artery repair was performed between the donor vessel
to the radial artery in an end-to-side fashion and the venous
anastomosis was performed end-to-end with the venae comi­
tantes. Fixation was obtained with a compression screws in
eight of the fractures, Kirschner (K)-wires in three, and a
compression screw and a K-wire in one patient. Postopera­
tive care consisted of mobilization with a long-arm thumb
spica, which was changed at 3 weeks for a long-arm thumb
spica cast. A short-arm cast was then used until radiographic
evidence of union was obtained. Full weightbearing was
allowed on the donor site lower extremity immediately. All
12 patients obtained union at a mean of 13 weeks. Postop­
erative range of motion averaged 35° of flexion and 45° of
extension. Mean grip strength improved from 70% to 86%.
Patient satisfaction reported that 7/12 were very satisfied
and 5/12 reported moderate satisfaction, with limited range
of motion or stiffness being the chief complaint.19
Kakar and colleagues reported their outcomes of the use
of the MFC flap for the treatment of recalcitrant non-unions
of the humerus. Six patients were treated over a 4-year
period.18 The size of the non-union defects ranged 8–22 mm.
The non-unions were present from 6 to 68 months (mean
25.6 months), and all patients had undergone an average
of three previous attempts at bone grafting. All patients
healed within 6.8 months following surgery. One case of
seroma was again noted at the donor site. The follow-up
period averaged 35 months. All patients had improvement
in their DASH scores, Mayo elbow performance scores, and
Constant-Murley outcome scores.
Burger and colleagues recently reported on the use of an
osteoarticular MFC graft for the reconstruction of articular
defects of the carpus.22 In a series of 16 patients with non-
unions of the proximal pole of the scaphoid, the authors
were able to show a reduction in wrist pain in all patients,
with 15 of 16 patients achieving union of the graft at last
follow-up.5,21,22 The one patient who failed to progress to
union was a smoker. Wrist motion and carpal alignment
were unchanged following the procedure. Similar to the
reports of the scaphoid non-unions, Burger and colleagues
examined the use of the osteoarticular MFC to reconstruct
16 patients with AVN of the lunate (Kienböck disease). In
this review, the authors noted similar results, with 15 of 16
patients, between 12 and 16 weeks postoperatively, report­
ing a reduction in wrist pain.21
LOWER EXTREMITY
Although not as popular as its use in the upper extremity,
the MFC has also been successfully used in the lower extrem­
ity. The MFC has corticoperiosteal bone graft has been
shown to successfully treat non-unions of the tibia, calca­
neus, femur, talus, as well as avascular necrosis (AVN) of the
tarsal bones.11,24–26
Choudry and colleagues reported their experience with
the MFC flap in 11 patients.11 Nine MFC flaps were per­
formed as free flaps, while three flaps were used in a pedi­
cled fashion to treat recalcitrant non-unions in both the

CHAPTER 55 — Medial Femoral Condyle and De scending Ge nicular Artery Perforator Flaps
645
this study of 23 patients, a composite saphenous artery flap
was transferred with the saphenous nerve, providing sensa­
tion to the flap. In two presented cases, the authors noted
a 2-point discrimination of 9 and 14 mm over the flap in
one patient, and early signs of reinnervation in another
patient at last follow-up.31
UNTOWARD OUTCOMES
• If harvested without the cortical components, the bone
graft may not be viable. Care must be taken to preserve
the cambium layer when harvesting the graft. In addition,
the surgeon must verify that a perforator enters the bone
at the site of bone harvest.16
• Ectopic bone production at the recipient site has been
noted, and may account for decreased motion following
surgery.
• Donor site morbidity includes seroma formation and tem­
porary knee stiffness.
• Injury to the saphenous nerve during flap harvest will
produce pain and paresthesia in the medial portion of
the lower leg overlying the medial tibia.
• Expertise and training in microvascular surgery are
needed for this operation.
• Although theoretical, biomechanical testing has shown
the stress of ambulation is not sufficient to cause a femur
fracture, even in the setting of a large graft harvest.
Bony defects in uncomplicated non-unions should be
managed initially with conventional grafting or pedicled
vascularized bone grafts, prior to moving to a MFC flap. In
addition, the MFC flap should not be the first choice in
cases where the bony defect is >3–5 cm.
CONCLUSIONS
The MFC flap offers another option in the selection of vas­
cularized bone. Its smaller size makes it ideal for defects
within the hand, wrist, and foot. When harvested as a thin
corticoperiosteal flap it may be wrapped to cover tubular
bones, making it an ideal flap for clavicular, humeral, and
radial non-unions. Finally, this flap produces minimal donor
site morbidity, allowing most patients to quickly return to
ambulation.
A 52-year-old man who has undergone three previous surgeries, presented with ulnar non-union. He was reconstructed with an MFC
corticoperiosteal sheet graft.
CASE 55.1  Ulnar Non-Union Reconstructed with an MFC Corticoperiosteal Sheet Graft
Figure 55.6  (A) AP radiographs of the forearm showing persistent non-union of ulnar shaft following iliac crest bone grafting. A cortical-
periosteal sheet graft is harvested from the medial femoral condyle and wrapped around the non-union site (B–E). Sutures are used to
secure the graft over the top of the bone graft and hardware. (F) Initial postoperative radiographs showing the corticoperiosteal graft
abutting the non-union site. (G) Solid bony union is seen on CT at 9 months.
A
B
C
D
E
F
G

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 74-year-old man presented with an Achilles tendon infection following open Achilles tendon repair. The defect was treated with a
cutaneous tendon graft based on the geniculate arterial system.
CASE 55.2  Achilles Tendon and Soft Tissue Defect Reconstructed with a Cutaneous
Tendon Graft Based on the Genicular Arterial System
Figure 55.7  (A) Infected wound prior to debridement. (B) The skin markings for a cutaneous flap designed over the course of the descend­
ing genicular artery. The DGA is dissected proximally to the level of the adductor magnus tendon. Here the tendon (arrow) and peritenon
are harvested with the DGA and skin paddle (C,D). The Achilles tendon is debrided (E) and then the tendon graft is placed within the
defect as an intercalated graft (F). The flap was vascularized through an anastomosis to the posterior tibial system (G). (H) The appearance
of the graft at the completion of the insetting. (I) The long-term results with return of Achilles function.
A
B
C
D
E
F
G
H
I

CHAPTER 55 — Medial Femoral Condyle and De scending Ge nicular Artery Perforator Flaps
647
Access Figure 55.8 as well as case example
55.3 online at
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femoral condyle bone transfer in the treatment of scaphoid non-
unions. Plast Reconstr Surg 2010;125:1176.
20. Malizos KN, Dailiana ZH, Innocenti M, et al. Vascularized bone
grafts for upper limb reconstruction: defects at the distal radius,
wrist and hand. J Hand Surg [Am] 2010;35:1710–18.
21. Bürger HK, Windhofer C, Gaggl AJ, et al. Vascularized medial
femoral trochlea osteochondral flap reconstruction of advanced
Kienböck disease. J Hand Surg [Am] 2014;39(7):1313–22.
22. Bürger HK, Windhofer C, Gaggl AJ, et al. Vascularized medial
femoral trochlea osteocartilaginous flap reconstruction of proxi­
mal pole scaphoid non-unions. J Hand Surg [Am] 2013;38(4):
690–700.
23. Doi K, Oda T, Soo-Heong T, et al. Free vascularized bone graft for
non-union of the scaphoid. J Hand Surg [Am] 2000;25(3):507–
19.
24. Cavadas PC, Landín L. Treatment of recalcitrant distal tibial non-
union using the descending genicular corticoperiosteal free flap.
J Trauma 2008;64(1):144–50.
25. Pelzer M, Reichenberger M, Germann G. Osteo-periosteal-cutane­
ous flaps of the medial femoral condyle: a valuable modification
for selected clinical situations. J Reconstr Microsurg 2010;26(5):
291–4.
26. Haddock NT, Wapner K, Levin LS. Vascular bone transfer options
in the foot and ankle: a retrospective review and update on strate­
gies. Plast Reconstr Surg 2013;132(3):685–93.
27. Rahmanian-Schwarz A, Spetzler V, Amr A, et al. A composite osteo­
musculocutaneous free flap from the medial femoral condyle for
reconstruction of complex defects. J Reconstr Microsurg 2011;
27(4):251–60.
28. Kobayashi S, Kakibuchi M, Masuda T, et al. Use of vascularized
corticoperiosteal flap from the femur for reconstruction of the
orbit. Ann Plast Surg 1994;33(4):351–7, discussion 357–8.
29. Kademani D, Salinas T, Moran SL. Medial femoral periosteal micro­
vascular free flap: a new method for maxillary reconstruction.
J Oral Maxillofac Surg 2009;67(3):661–5.
30. Martin D, Bitonti-Grillo C, De Biscop J, et al. Mandibular recon­
struction using a free vascularised osteocutaneous flap from the
internal condyle of the femur. Br J Plast Surg 1991;44(6):397–
402.
31. Acland RD, Schusterman M, Godina M, et al. The saphenous neu­
rovascular free flap. Plast Reconstr Surg 1981;67(6):763–74.
Expert Commentary 
Tarek Abdalla El-Gammal, MD
The medial condyle of the femur has become a versatile and
increasingly used surgical donor site. The junction of the
descending genicular artery into three branches allows trans­
plantation of several tissue types with one pedicle and allows
the possibility of including cortical and cancellous bone, peri­
osteum, articular cartilage, muscle, tendon, and skin.
This chapter is very informative on all aspects of this flap.
A few points we feel are critical for the reader should be
stressed. Several studies have detailed the branching pattern
of the vessels about the distal femur. Because of the ana­
tomic variation of the main vascular supply (descending
genicular artery vs superior medial genicular artery), pedicle
dissection should always start distally at the terminal bifurca­
tion point into the transverse and longitudinal branches to
the medial femoral condyle, then work your way proximally.
This way, the surgeon will be confident of dissecting the
correct pedicle from the beginning.
Although the MFC corticoperiosteal flap is very successful
for the treatment of non-unions, it is not suitable for all bone
defects. For defects >5 cm the first choice should not be the
MFC flap. Application of the MFC flap to larger defects has
been limited by the proximal extent of periosteal blood
supply of the medial column of the femur provided by the
DGA system, and the unknown effects of such a harvest on
the osseous stability of the femur.
When using the MFC flap for carpal non-unions or AVN
reconstruction, it is important to plan the flap size and shape
to harvest only the amount of cartilage needed for reconstruc­
tion and to achieve congruent insetting of the flap. A preop­
erative 3-D CT of the recipient site is a must. It is also advisable
to do a CT for the contralateral hand and wrist to use as a
template. When using the osteochondral MFC flap for replace­
ment of scaphoid or lunate articular surface, it is crucial to
explore the recipient site first, and examine the joint surfaces
before harvesting your flap, since a healthy non-arthritic joint
surface is a prerequisite for success of this procedure.

CHAPTER 55 — Medial Femoral Condyle and De scending Ge nicular Artery Perforator Flaps 647.e1
A 23-year-old man, with 6-month history of an untreated scaph­
oid proximal pole fracture, presented with a non-union. He was
treated with a vascularized corticocancellous graft harvested on
the descending genicular artery
CASE 55.3  Scaphoid Proximal Pole Fracture Non-Union Treated with an MFC
Corticocancellous Graft
Figure 55.8  (A) CT image of the non-union showing bone resorption at fracture site in addition to proximal pole sclerosis suggestive of
avascular necrosis. (B,C) Surgical exposure of the geniculate system. (D) An 8 mm vascularized corticocancellous graft is harvested on
the descending genicular artery. (E) The scaphoid non-union is approached palmarly. K-wires are placed palmarly to hold the graft, while
an additional wire is placed in the distal segment of the scaphoid to allow the surgeon to manipulate the position of the distal scaphoid
during graft positioning. (F) Intraoperative fluoroscopic imaging of the compression screw being placed through the graft and the use of
an antirotational wire to prevent graft displacement during screw application. (G–I) Lateral and AP radiographs, respectively, showing
healing of the bone at 3 months. (I) A CT scan verifying bony union.
A
B
E
F
G
H
D
C
I

648
Perforator Flaps in the
Lateral Thoracic Region
Jeong-Tae Kim
56 
INTRODUCTION
The conventional latissimus dorsi muscle or myocutaneous
flap has undoubtedly served an important role as one of
the most common flaps in reconstructive microsurgery.
However, its bulkiness and the sacrifice of donor structures
often preclude its use. In this respect, the reduction in
volume and complete preservation of the muscle and its
motor nerve that can be achieved using the perforator
concept are indeed worthwhile.
Cutaneous branches from the thoracodorsal and lateral
thoracic artery were first mentioned by de Coninck et al.1
and the flaps based on these arteries have been known as
thoracodorsal skin flaps, thoracodorsal axillary flaps, and
lateral thoracic flaps. Since the introduction of the perfora­
tor concept by Koshima2, the perforator flap from the lateral
thoracic region was attempted by Angrigiani et al.3 under
the name of the latissimus dorsi musculocutaneous flap
without muscle. It has since been developed as a thin pattern
for a resurfacing tool by Kim et al.4; another septocutaneous
perforator has also proven to be a useful pedicle of the per­
forator flap. Three distinct rows of perforator patterns are
present and interconnected with each other in the lateral
thoracic region. According to the author’s nomenclature
system, they may be given different names, such as the
Figure 56.1  Perforator flaps in the lateral thoracic region.
Lateral
thoracic artery
Pectoralis
major
Direct
cutaneous
perforator
Subscapular
artery
Anterior
serratus
Septocutaneous
perforator
Latissimus
Musculocutaneous
perforator
Anterior
cutaneous
branches of
intercostal nerve
Lateral cutaneous
branches of
intercostal nerve
Circumflex
scapular
artery
Thoraco-
dorsal
artery
PART 5  —  PERFORATOR-BASED WORKHORSE FLAPS

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
649
perforators arising from the lateral thoracic vessels, and is
located on the serratus anterior muscle along the lateral
border of the pectoralis major muscles. The middle row,
about 2 cm anterior to the latissimus dorsi muscle border,
is composed of septocutaneous (or direct cutaneous) per­
forators from the cutaneous branches of thoracodorsal
vascular systems. The most posterior row is composed of
musculocutaneous perforators through the latissimus dorsi
muscle, and its anterior group is located within 2 cm of the
anterior border of the latissimus dorsi muscle.
There are horizontal communications among these per­
forators; therefore, the criss-cross network is formed by the
connection of a musculocutaneous perforator via a septo­
cutaneous perforator going to a direct cutaneous perforator
in each row (Fig. 56.2). Intercostal vessels are also con­
nected in each horizontal row, and intercostal nerve
branches are collateral with this network. The perforator
from the intercostal vessels is very tiny, but it can be available
for the pedicle of an island pattern for regional coverage.
To discriminate between these perforator flaps that have
the same donor skin territory, a different nomenclature is
required to better understand the pedicle base or the course
dissected. According to the author’s new version of the
nomenclature system, the perforator flap based on a muscu­
locutaneous perforator is named the latissimus dorsi perfo­
rator flap, and the flap based on a septocutaneous perforator,
is named the “thoracodorsal perforator flap.” An additional
perforator flap is available in this area based on a direct
cutaneous perforator from the lateral thoracic artery, and it
is named the lateral thoracic perforator flap (Fig. 56.3).
LATISSIMUS DORSI PERFORATOR FLAP
Dominant:  musculocutaneous perforators from the thora­
codorsal artery through the latissimus dorsi muscle
Length: 12 cm (range 8–14 cm from the origin of the tho­
racodorsal artery)
Diameter: 1 mm (range 0.8–2 mm at the level of the proxi­
mal thoracodorsal artery)
Thoracodorsal vessels are divided into a muscle branch
to serratus anterior and latissimus dorsi muscles (Fig. 56.3B)
and the latter is divided into a horizontal and a vertical
branch inside the muscle (see Ch. 11 and Ch. 41).
The pedicle can be lengthened an additional 6–8 cm, by
including the proximal source vessel of the subscapular
artery or shortened to the level where the thoracodorsal
artery enters the latissimus dorsi muscle, according to the
condition and diameter of recipient vessels. Sometimes, its
length can be controlled by the perforator chosen (proxi­
mal or distal) and the location of the perforator on the flap
(central or peripheral).
Minor:  there are several minor perforators distributed
several centimeters apart from the reliable perforator.
One of these can be included and thus pedicle length
and diameter may be changed according to the perforator
selected.
THORACODORSAL PERFORATOR FLAP (Fig. 56.3C)
Dominant:  septocutaneous perforators from the thora­
codorsal artery
“latissimus dorsi perforator flap” based on a musculocutane­
ous perforator, the “thoracodorsal perforator flap” based on
a septocutaneous perforator, and the “lateral thoracic per­
forator flap” based on a direct cutaneous perforator.
These perforator flaps from the lateral thoracic region
region can provide many options for reconstruction, such
as resurfacing a wound with a thin cutaneous flap, recon­
structing a head and neck defect including intraoral resur­
facing, and reconstructing defects requiring different tissue
components by harvesting the flap as a chimeric flap.
FLAP ANATOMY (Figs 56.1, 56.2 and
11.1, 11.2, 11.3, 11.5, 11.8, and 11.9)
The subscapular artery arises from the axillary artery and
divides into the thoracodorsal and the circumflex scapular
arteries The thoracodorsal artery penetrates the latissimus
dorsi muscle about 8–14 cm from the bifurcation of the
subscapular artery into the circumflex scapular and thora­
codorsal. Shortly before it enters the muscle, the vascular
bundles send a branch to the serratus anterior muscle.
The latissimus dorsi muscle is nourished by two main mus­
cular branches from the thoracodorsal artery: a lateral
branch running parallel to the anterior border and a hori­
zontal branch passing obliquely to the dorsal and medial
part of the muscle. They give multiple terminals to the
skin as perforators through the muscle along the course
of branches, and these musculocutaneous perforators are
located at intervals in the back area. Septocutaneous perfo­
rators arise from the branch to the serratus anterior or other
cutaneous branches, and they reach the skin between the
latissimus dorsi and serratus anterior muscles. Cutaneous
branches originate from the main thoracodorsal artery
or from the branch to the serratus anterior. They also
supply septocutaneous perforators or direct cutaneous
perforators.
Additional cutaneous branches are supplied from the
lateral thoracic artery, which arises as a third branch from
the axillary artery at the lateral border of the pectoralis
major muscle. It supplies the pectoralis major, the pectoralis
minor and upper digitations of the serratus anterior muscle,
while running distally along the lateral border of the pecto­
ralis major and superficially on the serratus muscle fascia,
anterior to the long thoracic nerve, and terminating in the
skin as direct cutaneous perforators. In females, this branch
is prominently developed to supply the lateral portions of
the breast. The additional accessory lateral thoracic artery
is present as a direct branch in 70% from the axillary artery
between the origin of the lateral thoracic artery and the
subscapular artery. It runs along the midaxillary line, termi­
nating with several direct cutaneous perforators.
ARTERIAL SUPPLY OF THE FLAP (see Figs 56.1,
56.2 and 11.1, 11.2, 11.3, 11.5)
Three distinct rows of perforator groups are well detected
in the lateral thoracic region, at intervals parallel to the
anterior border of the latissimus dorsi muscle. The most
frontal line is a longitudinal series of direct cutaneous

650
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
perforator arising from the branch. Moreover, the perfora­
tor flap can be harvested as a thin pattern based on the
single, reliable perforator, excluding the underlying deep
fascia. Its dimension may extend over its angiosome, com­
pared with the conventional flap. In our clinical experience,
all three perforators are always present, but the location of
the reliable perforator in each row varies according to the
patient.
Minor:  there are several minor perforators several centi­
meters apart from the reliable perforator.
One of these can be included and its pedicle length and
diameter are similar to that of the dominant perforator.
LATERAL THORACIC PERFORATOR FLAP (Fig. 56.3D)
Dominant:  direct cutaneous perforators from the lateral
thoracic artery
Length: 8 cm (range 5–10 cm from the subclavian artery)
Diameter: 1 mm (range 0.5–2 mm at the origin of the
lateral thoracic artery)
In the latissimus dorsi perforator flap, the pedicle is
usually reliable in its diameter and comitant veins. Con­
versely, the pedicles of the septocutaneous and direct
cutaneous perforators may be smaller in diameter, and they
have several tiny branches to the surrounding adipose
tissues. Sometimes, they have the constant diameter of an
artery in spite of the proximal dissection of the pedicle, and
end-to-side arterial anastomosis may be required. The
Length: 10 cm (range 7–12 cm from the origin of the tho­
racodorsal artery)
Diameter: 1 mm (range 0.8–2 mm at the level of the thora­
codorsal artery)
Septocutaneous perforators arise from the branch to the
serratus anterior, cutaneous branches, or thoracodorsal
vessels. The origin of cutaneous branches is also variable
from the main thoracodorsal artery or from the branch to
the serratus anterior. Several direct cutaneous perforators
may originate from the cutaneous branch. In 100 cadaver
dissections by Rowsell et al.5, direct cutaneous branches were
identified in the subscapular–thoracodorsal arterial system
in 81% of dissections. A total of 7% originated from the axil­
lary artery, 28% from the subscapular artery, and 47% from
the thoracodorsal artery, with an average diameter of
1.0 mm. This study was published before the advent of the
perforator concept and some branches might be confused
with perforators. The branch was introduced in another
study as a direct cutaneous branch from the extramuscular
course of the thoracodorsal artery, reported in 55% of dis­
sections. The anatomic basis of the subscapular arterial
system has been ascribed by Cabanie et al.6 to a consistent,
direct cutaneous branch of the thoracodorsal artery.
To review the evolution of using the pedicle in flaps (Fig.
56.4), conventional flaps were based on the arterial concept
and later were developed on the branch-based concept.
Recently, it was clinically confirmed that the same dimen­
sion of the flap can be reliably based on only one available
Figure 56.2  The network of perforators in the left lateral thoracic region. (A,B) Musculocutaneous perforators run through the latissimus
dorsi muscle, and each perforator is connected horizontally to the septocutaneous perforator arising from the branch to the serratus anterior
muscle, between the latissimus dorsi and serratus anterior muscles. An additional cutaneous branch may originate from the thoracodorsal
artery, which supplies septocutaneous or direct cutaneous perforators. Anterior to these, several direct cutaneous perforators originate from
the lateral thoracic artery, supplying the pectoralis major muscle, and the lateral branches of intercostal nerves run parallel to the horizontal
interconnections of those perforators.
Pectoralis major
muscle
Serratus anterior
muscle
Latissimus dorsi
muscle
Subscapular artery
Circumflex scapular
artery
Intercostal nerves
Lateral thoracic
artery
Direct cutaneous
perforators
Branch to serratus
anterior muscle
Septocutaneous perforator
Musculocutaneous perforators
Thoracodorsal artery
Cutaneous branch
B
A

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
651
Length: same length as the artery it accompanies
Diameter: 1 mm (range 0.8–5 mm)
The venous drainage of the latissimus dorsi perforator
flap through the comitant veins is quite reliable, with a reli­
able proximal diameter. However, in the perforator-based
flap preserving the proximal thoracodorsal vessels, the
distal comitant vein beneath the latissimus dorsi muscle is
often too small to be used for vascular anastomosis, and
further proximal dissection of the vein might be required
to insure safer venous anastomosis. Conversely, the venous
drainage of the thoracodorsal or lateral thoracic perforator
pedicles of the lateral thoracic and the thoracodorsal per­
forator flap are shorter than that of the latissimus dorsi
perforator flap.
Minor:  there are several minor perforators several centi­
meters apart from the reliable perforator.
One of these can be included and its pedicle length and
diameter are similar to that of the dominant perforator.
VENOUS DRAINAGE OF THE FLAP (see Fig. 11.8)
Primary:  comitant veins of the thoracodorsal, subscapu­
lar or lateral thoracic artery
Figure 56.3  Three perforator rows. (A) Perforator flaps in the lateral thoracic region. The latissimus dorsi perforator flap (B) is based on a
musculocutaneous perforator of the latissimus dorsi muscle, and the thoracodorsal perforator flap (C) is based on the septocutaneous perfora­
tor of the cutaneous branch of the thoracodorsal vessel. The lateral thoracic perforator flap (D) is based on the direct cutaneous perforator of
the lateral thoracic vessel.
B
C
A
D
Circumflex
scapular
artery
Pectoralis
major
muscle
Direct
cutaneous
perforator
Lateral thoracic
artery
Thoracodorsal
artery
Septocutaneous
perforator
Musculocutaneous
perforator
Latissimus
dorsi muscle

652
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
Advantages
• Reduced donor site morbidity.
• Perforator dissection allows for preservation of muscle and
motor nerves and minimizes donor site morbidity.
• Controlled resurfacing with a thin flap (see Flap modification/
flap handling).
• Various patterns and compositions can be harvested and used
to reconstruct defects requiring different tissue arrange­
ments and tissue types. Composite flaps based on the
perforator concept are easier to handle and the compo­
nents of the flap can be arranged in the recipient site
without restriction. More delicate, controlled contouring
is possible in three-dimensional reconstruction (see Flap
modification/flap handling).
• Sensate flap (see Flap modification/flap handling).
• Long pedicle and proximal branching system. An additional
length of 5–6 cm (>15 cm in total) can be obtained
through transmuscular perforator pedicle dissection
(“transmuscular” is the term we prefer over the more
commonly used term “intramuscular” since the dissection
is made through the muscle to the proximal source
vessel). Further lengthening is possible by designing the
flap with the perforator in an eccentric position.
• Minimal morbidity of the donor scar. The donor site can be
closed primarily up to 10 cm (12 cm in older patients),
resulting in an acceptable linear scar and no functional
deficits.
• Availability of secondary options. Other perforator patterns
or conventional flaps, such as the scapular, parascapular,
and muscle flaps, can be considered as secondary options
in the worst cases.
• Short and simple intramuscular dissection due to the thinness
of the latissimus dorsi muscle.
• The operation can be performed in the supine position
when a large flap is not required.
Disadvantages
• Inconsistent anatomy. The learning curve for identifying a
reliable perforator with ease may be steep. Preoperative
ultrasound studies prove helpful in alleviating intraopera­
tive difficulties. It is possible to convert the flap into the
muscle-sparing technique involving a minimal segment of
the muscle.
flap may be variable, ranging from tiny comitant veins to a
large, parallel vein.
Secondary:  lateral thoracic vein or other superficial veins
Length: 8 cm (range 6–10 cm)
Diameter: 1.2 mm (range 1–1.5 mm)
In the thoracodorsal and lateral thoracic perforator flaps,
the comitant veins may be too narrow to use for anastomo­
sis, and a separate large cutaneous vein may be included in
the pedicle. The separate vein, draining into the proximal
axillary vein, has a variable course and multiple branches.
The lateral thoracic vein runs parallel and anterior to the
muscle border of the latissimus dorsi with a reliable diam­
eter. Other superficial cutaneous veins are also optional;
they mainly drain directly into the axillary vein.
FLAP INNERVATION (see Figs 11.2, 11.9)
Sensory:  A lateral branch of the intercostal nerve is recom­
mended for the flap sensation because these branches can
be easily detected during dissection of a reliable perforator.
The sensation is quite useful in resurfacing reconstruc­
tions, especially in the neck, hand, foot, and oral cavity,
including the tongue.
Motor:  The perforator flaps are harvested without muscle,
and motor nerve preservation is attempted during intramus­
cular dissection.
Minor tributaries are sometimes inevitably sacrificed at
some points along the perforator pedicle; however, func­
tional deficit is not apparent. The thoracodorsal and lateral
thoracic perforator flaps do not require an intramuscular
dissection and no injury occurs.
FLAP COMPONENTS
Perforator flaps in the lateral thoracic region are elevated
as cutaneous flaps but can be composed of the latissimus
dorsi muscle, the serratus anterior muscle, the rib or scapu­
lar bone and regional fat tissues based on a separate branch
of the pedicle (see Flap modification/flap handling).
Figure 56.4  The concept of the flap based on its pedicle started from the arterial-based concept (red dashed line), advanced to the branch-
based concept (yellow line), and finally to the perforator-based concept (blue dashed line) with which the tissues can be taken very selectively.
P, perforator.
P

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
653
perforator identification, this equipment may no longer be
required preoperatively because the reliable perforator can
be found in the expected area and other perforator rows
can be found in this region.
There are no age limitations, but obese patients can be
moderately contraindicated for harvesting a thin flap, espe­
cially in the thoracodorsal or lateral thoracic perforator
flap. The reason for this is the fact that the purpose of har­
vesting flaps from this region is the ease of handling and
the thinness of the flaps as compared to other parts of the
body, and this is not the case in obese patients. However,
thinning can be performed safely if necessary. In children
or in elderly patients with atrophied adipose tissue, flap
harvest is easier than usual. Diseases such as diabetes, heart
disease, and paralysis are not major obstacles in the harvest
of perforator flaps.
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 56.5)
The anterior border of the latissimus dorsi muscle and the
center of the axillary fossa are marked. The anterior border
of the muscle is made prominent by upward traction of the
arm in the lateral decubitus position. Locating a musculo­
cutaneous perforator near the proximal thoracodorsal
vessels is of practical use because of its shorter transmuscu­
lar dissection. The expected area is 8–10 cm (6–8 cm in
children) from the center of the axillary fossa and within
2 cm posterior to the anterior border of the muscle; the
next is seen 2–5 cm inferior to the first. According to a study
by Ishida,7 the distance from the axilla is variable, from 8 cm
to 17 cm, and the distance from the muscle border is
reported to be 1–4 cm. At the same level, anterior to the
muscle border, the septocutaneous or direct cutaneous per­
forator can be found.
GENERAL THOUGHTS ABOUT FLAP DESIGN
All perforators can be used confidently as a pedicle for the
perforator flap; however, their reliability is still questionable
for the perfusion of a large flap extending over its original
angiosome territory. Even though each perforator domi­
nates a measure of skin territory, a reliable perforator has
the great ability of being able to expand its perfusion over
its own angiosome. Such a perforator is called a “reliable
perforator” and is defined as a perforator arising from the
carrier muscle with a “visible pulsation.” It has a larger than
normal diameter (0.5–1.5 mm) and is often combined with
the collateral sensory nerve, a useful indicator by which to
find it. Despite the evident lack of hemodynamic studies,
such a reliable perforator with a “visible pulsation” has a
clinically peculiar ability to overcome the angiosome barrier
through the subdermal vascular network. As the identifica­
tion of this reliable perforator is critical, the flap design may
be modified intraoperatively based on its size and location
(Fig. 56.6A). The design can be oriented in various direc­
tions but horizontal or longitudinal elliptical design is
mostly acceptable based on a single reliable perforator.
However, the design is made according to the most relaxed
or redundant skin tension by pinch test (Fig. 56.6B) because
• Long operation time. Searching for a reliable perforator
and, in some cases, changing position of the patient can
increase operation times.
• Pedicle injury during dissection and potential for compres­
sion and kinking during the inset. Extreme care is
required during the dissection and later positioning of
the pedicle during the inset. Postoperatively, controlling
the position of the patient and movements is critical.
• Initial temporary vascular insufficiency. Initial temporary
flow disturbance, including flap ischemia and flap con­
gestion, has been observed. This is considered to be an
adaptive phenomenon to overcome the flow overload
through a narrow perforator pedicle in the new flow
redistribution. Its clinical course is variable. If a sluggish
venous return or indistinct bleeding at the flap margin is
observed after anastomosis, arterial insufficiency is sus­
pected in spite of a positive milking test. As the distal
perforator pedicle is very narrow in diameter and the
dissection time of the pedicle may be long, the arterial
component of the pedicle can easily undergo spasm. Loss
of visible pulsation in the reliable perforator can be seen
during dissection; the color of the flap can turn slowly
from the pedicle side to the distal end of the flap after
anastomosis. Initial temporary venous congestion is some­
times observed because of the centralization of venous
drainage into tiny comitant veins of the perforator
pedicle, such as in a traffic jam. Before final clipping of
the pedicle for flap harvesting, a gradual color change
should be observed in the flap, from slight congestion to
the acceptable hue, in the process of adapting to the new
flow distribution. These phenomena are particularly pro­
nounced in large flaps, 25 cm or more in length, or in
very long flaps (compared with their narrow widths), and
they are more prevalent in the thoracodorsal and lateral
thoracic perforator flaps (14.3%) than in the latissimus
dorsi perforator flap (11.9%). Because the reliable per­
forator in the lateral thoracic region has a smaller diam­
eter than that in the lateral thigh or abdomen, the initial
temporary congestion or insufficiency can be more
observed here. The return of the color takes from several
hours to several days after anastomosis. Initial temporary
ischemia may progress to mild congestion and this may
last for several days or more.
• Deviation of the breast. In female patients, primary closure
of the donor site may result in deformity of the breast
with the thoracodorsal or lateral thoracic perforator flap;
however, this can be released over time.
PREOPERATIVE PREPARATION
The reliable perforator is located alongside the muscle
border using an audible Doppler and is marked. No evident
pulsating sound is detected around a perforator, in contrast
to the source vessel which has a longitudinal pulsating
course. This method is not specific. Color Duplex or power
Doppler imaging can aid in locating the perforators. The
arterial or venous component of the pedicle can be con­
firmed in the spectral Doppler mode. According to these
studies, the musculocutaneous perforator runs through the
muscle obliquely, and the septocutaneous perforator has
a more tortuous course. If one is well acquainted with

654
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
Figure 56.5  Anatomic landmarks. The anterior border of latissimus dorsi and the lateral border of pectoralis major are good landmarks. The
anterior border of latissimus dorsi becomes prominent with lateral traction of the arm. The center of the armpit is detected and a point 10 cm
from it along the anterior border of latissimus dorsi is marked. Reliable perforators are located around this point. Reliable musculocutaneous
perforator (MCp) is located on the muscle and reliable septocutaneous perforator (SCp) is found anterior to the muscle border within a 2 cm
boundary, though it is sometimes variable. Near to the muscle border of pectoralis major, reliable direct cutaneous perforator (DCp) is detected.
Sometimes, SCp and DCp are not distinguished exactly and venous drainage may have a different course from arterial supply. (Reprinted from
Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Trapezius muscle
Spine of scapula
Deltoid muscle
Triceps brachii muscle
Long head
Lateral head
Tendon
Infraspinatus muscle
Teres major muscle
Latissimus dorsi muscle
Erector spinae muscle
Iliac crest
Posterior superior iliac spine
Intergluteal (natal) cleft
Gluteal fold
Greater trochanter of femur
Gluteus maximus muscle
Sacrum
Gluteus medius muscle
Spinous process of T12 vertebra
Anterior border of the latissimus
Inferior angle of scapula
Medial border of scapula
Spine of scapula
Center of axillary fold
Deltoid muscle
Spinous process of C7 vertebra
Ligamentum nuchae
External occipital protuberance
Lumbar (triangle of Petit)
Triangle of auscultation
Sternocleidomastoid muscle
Jugular notch
Deltoid muscle
Body of sternum
Nipple
Cephalic vein
Serratus anterior muscle
External oblique muscle
Tendinous intersection
Rectus abdominis muscle
Linea alba
Xiphoid process of sternum
Serratus anterior muscle
Latissimus dorsi muscle
Anterior border of the latissimus
muscle
Sternal head
Clavicular head
Pectoralis major muscle
Anterior axillary fold
Posterior axillary fold
Axilla
Triceps brachii muscle
Biceps brachii muscle
Clavicle
Sternal head
Clavicular head
B
A

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
655
primary closure, a sizable flap dimension, such as 16 × 23 cm
or 15 × 25 cm, could be safely elevated. Considering that the
pedicle is routinely located in a peripheral area of the flap,
a dimension exceeding 30 cm in length can be used if the
pedicle is designed in the center of the flap. Additional
perforators, such as two septocutaneous or one musculocu­
taneous and one septocutaneous, can be included in a
larger or longer flap. Moreover, the dimension can be
expanded if a small portion of muscle is included, such as
in the muscle-sparing technique of the TRAM flap.
MUSCLE DIMENSIONS
Muscle can be included if needed to complete the recon­
struction and the size depends on the size and condition of
the defect and the size and branching pattern of the perfo­
rators found. Other regional muscles such as serratus ante­
rior can also be included in a chimeric flap.
BONE DIMENSIONS
Rib bone or scapular bone can be included in a chimeric
flap. Dimensions vary based on the location and size of the
vessels.
FLAP MARKINGS
The skin territory available for these perforator flaps extends
to the deltoid groove above, the midvertebral line medially,
the posterior iliac crest below, and the ipsilateral nipple
anteriorly. A flap based on the direct cutaneous perforator
dominates the more anterior portion of the territory, and a
flap based on the musculocutaneous perforator covers the
more posterior portion (Fig. 56.7). The axis of the flap
design can be horizontal, but an oblique design is better
to insure effective primary closure of the donor site. The
marking should include a portion anterior to the latissimus
muscle border as some of the reliable musculocutaneous
perforators are located more anterior than anticipated.
PATIENT POSITIONING
The patient is usually placed in a lateral decubitus position
with the ipsilateral upper extremity positioned freely and
primary closure is better than skin graft in terms of postop­
erative scarring. The design may be modified with fish­
mouth ends to decrease the size of skin graft when a large
flap is required. After harvest, a local flap is designed for
the primary closure of a large donor site (Fig. 56.6C).
In female patients, the flap is designed according to the
brassiere line.
SPECIAL CONSIDERATIONS
More anterior design is recommended because the reliable
musculocutaneous perforator is located more anterior than
expected. With the anterior incision, another septocutane­
ous or direct cutaneous perforator can be present as another
option. The perforator pedicle is spontaneously located
peripherally in the flap because of the routine procedure
of identifying the reliable perforator in advance. However,
the reliable perforator has a tremendous ability to perfuse
its flow to the distal end of the flap, even in large flaps.
DIFFERENCES IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
With a pedicled flap, the perforator pedicle should be
located in an eccentric location to insure a wider arc of
rotation and to make the pedicle longer.
A pedicled flap can reach the entire shoulder, upper arm,
upper back, breast, and lower half of the neck. In this indica­
tion, the design is made according to the rotation arc of the
flap to reach the defect.
FLAP DIMENSIONS
SKIN ISLAND DIMENSIONS
Length: 5–25 cm
Width: 10 cm (range 5–25 cm). Maximum to close primar­
ily: 12 cm
Thickness: 6 mm (range 4–10 mm or more in obese
patients)
Flap perfusion is quite reliable up to 20 cm from the
perforator pedicle, and 20–25 cm can be a marginal limit,
depending on the perforator selected and the patient. Even
though the skin island dimension depends on the need for
Figure 56.6  (A) The flap design can be modified during the operation according to the perforator selected. (B) The usual oblique elliptical
design according to the relaxed skin tension by pinch grasp. (Note that this is a different patient.) (C) The donor defect is closed primarily with
a local transposition flap.
A
B
C

656
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
exposing the axilla by using adequate supports and padding,
taking great care to avoid compression of the axillary neu­
rovascular structures. Generally, the flap design is located
anterior to the conventional latissimus dorsi flap. There­
fore, the supine or semi-lateral position, which frees the
upper extremity, and padding of the small of the back are
used to alleviate the need for changing positions during the
operation. This supine position is used if a small to moder­
ate size (up to 10 cm) flap is required, such as for intraoral
reconstruction. It is important to place the operative field
of perforator pedicle dissection close to the border of the
table to insure a comfortable dissection.
ANESTHETIC CONSIDERATIONS
General anesthesia is required for this procedure. Muscle
paralysis is necessary during perforator pedicle dissection to
prevent any accidental injury of the pedicle by muscle
twitching during electrocauterization.
TECHNIQUE OF FLAP HARVEST
An incision is made along the anterior border of the
designed flap (Fig. 56.8A) and the subcutaneous layer is
split gently to the level of the fascia overlying the muscle.
Vertical dissection is carried to the plane of deep fascia
using a sharp instrument until a pulsating perforator is
detected. Great care is required near the expected area of
Figure 56.7  The design of the three perforator flaps can vary, according to the perforator selected. The entire lateral thoracic area is held in
common among the three designs, but the lateral thoracic perforator flap is located anterior to the latissimus dorsi perforator flap. (A) Latis­
simus dorsi perforator flap (MCp). (B) Thoracodorsal perforator flap (SCp). (C) Lateral thoracic perforator flap (DCp). MCp, musculocutaneous
perforator; SCp, septocutaneous perforator; DCp, direct cutaneous perforator.
Latissimus dorsi
perforator flap
(MCp)
A
Thoracodorsal
perforator flap
(SCp)
B
Lateral thoracic
perforator flap
(DCp)
C
the perforator. The dissection continues in the same plane
with vertical traction of the skin until a reliable perforator
is found (Fig. 56.8B). Tiny vascular tributaries and the col­
lateral nerve branch can be good indicators for reaching
the reliable perforator, and the nerve can be preserved for
a sensate flap. After the identification of the reliable mus­
culocutaneous perforator, it is traced distally to isolate the
point of entry into the fat and skin (Fig. 56.8C). Some of
these perforators follow a horizontal course above the fascia
for a few centimeters before piercing the overlying fat. The
dissection of the pedicle proceeds through the muscle (Fig.
56.8D). Muscle fascicles are spread gently following the
course of the dissection and tiny muscular branches are
carefully tied or cauterized with a bipolar instrument at a
safe distance. Initial transmuscular dissection requires great
care until the diameter of the perforator increases under­
neath several muscular fascicles. The thoracodorsal nerve is
separated from the vascular pedicle and dissection proceeds
proximally by retracting the muscle and adipose tissue in
the axilla until the length and the diameter match those of
the recipient vessels (Fig. 56.8E). For the septocutaneous or
direct cutaneous perforator, dissection proceeds through
the subcutaneous layer to the source artery. These perfora­
tors can be found more easily than the musculocutaneous
perforator; however, their pedicles are shorter and the dis­
section course of the pedicle is more variable in the proxi­
mal connection to the source vessels.
The entire dimension of the flap is outlined after com­
plete visualization of the perforator pedicle, after which the
preoperative design can be modified. If an additional length

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
657
itself without sacrifice of the source vessel (Fig. 56.10). Since
the flap vessels are small in this situation, they are matched
well to other small vessels at the recipient site without
needing to sacrifice major donor and recipient vessels. More
proximal dissection of the vein is sometimes required to
match the vein to the recipient bed.
FLOW-THROUGH FLAP
Proximal branches of the subscapular artery, such as the
circumflex scapular artery or branch to the serratus ante­
rior, can be used for T-anastomosis (see Technical tips to
optimize outcomes and avoid complication) or the chimeric
pattern.
of the pedicle is required, the perforator pedicle is posi­
tioned near the margin of the flap. Flap thickness is con­
trolled in accordance with the recipient condition when the
flap is elevated. Finally, the isolated pedicle is divided and
the donor site is closed or grafted.
FLAP MODIFICATION/FLAP HANDLING
THINNED FLAPS
Flap thickness can be controlled by dissection between two
adipose layers. The final thickness can be in the range of
4–10 mm. The subcutaneous layer is composed of superfi­
cial and deep adipose tissue. After identification of the reli­
able perforator, the flap can be thinned between these
layers. With the flap stretched by two skin hooks (Fig. 56.9),
the thickness can be controlled by electrocautery in cutting
mode (4–10 mm thickness, so-called “controlled resurfac­
ing”). A 2–3 cm cuff of subcutaneous tissue is left intact
surrounding the perforator pedicle to induce the cushion
effect and to insure a more reliable venous return. Preop­
erative color Doppler sonography might be useful for
mapping the locations of perforators, recognizing the ana­
tomical variations, and detecting the suprafascial courses of
perforators. However, it is not absolute.
PERFORATOR-BASED FLAP
As the perforator pedicle is generally longer than that of
the conventional flap, the proximal source artery of the
subscapular artery can be preserved, depending on the
recipient status. Therefore, the circumflex scapular artery
and even circulation to the serratus anterior muscle are
often preserved by stopping pedicle dissection in or just
underneath the muscle. The flap is based on the perforator
Figure 56.9  Flap thinning can be achieved by separating the super­
ficial and deep adipose layers with electrocautery in cutting mode
and traction by skin hooks.
Figure 56.8  The process of flap harvest. (A) Intraoperative design. (B) A reliable perforator (arrow) is found with its visible pulsation. (C) The
perforator pedicle is dissected out through the transmuscular dissection. (D) The motor nerve is completely separated from the pedicle during
pedicle dissection through the muscle. (E) The flap is elevated.
A
B
C
D
E

658
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
SENSATE FLAP
The sensate flap is available using a lateral branch of the
intercostal nerve (Figs 56.11 and 11.9). While searching for
the reliable perforator, several intercostal nerves are easily
detected and dissected out. They are preserved for the
sensate flap, especially in intraoral, hand, or foot recon­
struction. Embryologically, the nerve and vascular bud
develop together and the sensory nerve can be a good indi­
cator to find the reliable perforator.
COMPOSITE OR CHIMERIC PATTERN FLAP
INCLUDING MUSCLE AND/OR BONE
The subscapular vascular system has several reliable branches
such as the circumflex scapular artery, branch to serratus
anterior, angular artery to scapula, cutaneous branch to
skin, and so on. A detailed understanding of the perforator
distribution allows various combinations of the conven­
tional flaps of muscle or bone. The perforator flap can be
combined with various tissue components according to the
recipient defect, such as a large thin cutaneous flap, a der­
moadiposal flap, an adiposal flap, and a rib or scapular bone
flap in chimeric pattern (Fig. 56.12). Compared with other
conventional flaps, the composite flap based on the perfora­
tor is more comfortable to handle and each component of
the flap can be arranged in the recipient site with less
restriction. Therefore, more delicate, controlled contouring
is possible with the perforator flap in 3-dimensional recon­
struction (Fig. 56.13).
Figure 56.10  Latissimus dorsi perforator-based free flap. (A,B) Two different examples. The proximal dissection of the pedicle up to the
thoracodorsal vessels was not necessary as the recipient vessels were superficial and a long pedicle was not required.
A
B
Figure 56.11  (A) The branch of the intercostal nerve (pulled by a rubber loop) is collateral to the reliable perforator (arrow). (B) A sensate
perforator flap with a sensory nerve (arrow).
A
B
Figure 56.12  A composite flap with a single pedicle (yellow back­
ground) that is composed of a perforator-based adiposal flap, a
latissimus dorsi perforator flap, and a serratus anterior-rib bone
osteomuscular flap for 3-dimensional reconstruction.
VARIOUS COMPOSITION FLAP OR SPLIT
CUTANEOUS FLAP
Tissues are appropriately selected according to the recipient
status, therefore, dermoadiposal, dermoadipofascial, myoa­
dipofascial or adiposal perforator flap can be combined
based on the perforator (Fig. 56.14) and the two or more
flaps can be split (Fig. 56.15).

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
659
Figure 56.13  (A,C) A complex cutaneous and oromaxillary fistula after maxillectomy was repaired by a 3-dimensional maxillary reconstruction
with a composite tissue flap based on the perforator concept. (B,D,E) After reconstruction, the outer skin, oral and nasal lining (asterisk) were
well contoured.
*
A
C
B
D
E
Figure 56.14  (A,B) A 22-year-old woman having forehead depression after traffic accident, showed frontal sinusitis in open wound. (C,D) A
thoracodorsal perforator flap based on a septocutaneous perforator was taken in adipomyofascial component, which included deep fascia and
attaching muscle tissue for better shaping. (E,F) At 2 years after the reconstruction.
A
B
D
C
F
E

660
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
EXTENDED ARC OF ROTATION PEDICLED FLAP
A pedicled flap can reach whole shoulder, upper arm, upper
back, breast, and lower half of neck. In this indication, the
design is made according to the rotation arc necessary to
reach the defect. During flap inset, the small flap can be
passed between muscle fascicles to reach the recipient site or
the anterior part of the muscle can be divided for better arc
of rotation in a large flap if the motor nerve is not damaged.
SPECIAL INSTRUMENTS
A magnified loupe with an attachable light source is useful
during the intramuscular dissection. A fine, curved haemo­
stat (so-called “mosquito”) is used for perforator pedicle
dissection. A bipolar coagulator is commonly used for
pedicle isolation instead of hemoclips.
TUBED FLAP
As these perforator flaps can be harvested as a thin pattern
even in large dimension, the flap can be tubed for a esopha­
geal reconstruction (Fig. 56.16), and therefore, these flaps
have replaced the classical jejunal flap which required
laparotomy.
MUSCLE-SPARING PATTERN
A large skin paddle (34 × 10 cm is a long shape; 28 × 15 cm
is an elliptical shape in this series) can be created by the
inclusion of small segments of the muscle. The thoracodor­
sal nerve and muscle function can be maintained even with
this pattern. Avoiding this muscle-sparing procedure is sug­
gested in most cases, but the pattern is quite useful in some
indications.
Figure 56.15  (A) A 76-year-old patient presented with left maxillary cancer. (B,C) A chimeric flap, composed of three pieces of skin flaps
based on septocutaneous perforators and one muscle flap based on a branch of the thoracodorsal vessel, was harvested from the lateral
thoracic area. (D) The postoperative appearance showed satisfactory results with the proper filling of orbital defect for the later artificial eye;
good oral and nasal lining.
A
C
D
B

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
661
for quilting sutures. The operative wound is painted with
Dermabond paste and exposed with no dressing.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATION
A sufficient space for pedicle dissection can be secured with
a self-retaining retractor until the required length and diam­
eter are reached. Rubber vessel loops are helpful for ensur­
ing gentle traction of the pedicle and motor nerve during
the dissection procedure (Fig. 56.8D).
It is helpful if the surgeon can distinguish an intercostal
from a reliable or usable perforator early on to avoid wasting
time. Intercostal perforators are less in number and not
as distinct as reliable perforators from the thoracodorsal
vascular system. The intercostal perforator exit is located
DONOR SITE CLOSURE AND
MANAGEMENT
Whenever possible, the donor site is closed primarily in two
layers. If primary closure is not possible, a regional local flap
is designed for tension-free closure (Fig. 56.6C). If primary
closure is possible under high tension, several towel clips
are applied for skin expansion as for intraoperative tissue
expansion. If direct closure is impossible, the skin from the
dog-ear deformity in the marginal closure may be trimmed
for grafting after approximation of the defect, instead of
harvesting new skin from another donor site. A drain is
inserted in the primary closure wound and removed within
several days. The risk of seroma is quite low because of
primary closure of the donor site and less muscle dissection
than conventional muscle flap. Therefore, there is no need
Figure 56.16  (A) Preoperative view of a pharyngeal cancer in 61-year-old man. (B,C) A chimeric flap composed of two skin flaps based on
two reliable perforators was taken from the lateral thoracic area. One big latissimus dorsi perforator flap was tubed for the cervical esophageal
reconstruction and a 4 × 2 cm small lateral thoracic perforator was used for monitoring. (D) Postoperative esophagogram showing good passage.
A
B
C
D
A

662
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
is required to distinguish it from real flap failure. Return of
the color takes from several hours to several days even after
successful anastomosis (Fig. 56.17A–D). To prevent the phe­
nomenon of transient venous congestion, several methods
are suggested:
• T-anastomosis (Fig. 56.17E,F). The proximal branch of
the source artery is included in the pedicle of the perfora­
tor flap for a T-shaped interposition into the recipient.
The flow and pressure into the perforator flap can be
anterior to the septocutaneous perforator row. Even though
it looks definite, in most cases it is not an intercostal perfora­
tor but a septocutaneous perforator.
As the pulsation of the reliable perforator can easily dis­
appear with a spasm, the perforator pedicle should be fre­
quently irrigated with a vasodilator solution. In spite of this,
the pedicle is quite sensitive to spasm or congestion. Initial
temporary ischemia may turn to a mild congestion and may
remain for several days or more. Initial temporary venous
congestion looks more serious and more clinical experience
Figure 56.17  Serial changes in initial temporary congestion: (A) 1 h; (B) 3 h; (C) 24 h; and (D) 2 weeks after anastomosis. (E,F) To prevent
temporary congestion, several options may be considered, such as a T-anastomosis (white arrows). N, sensory nerve. (G,H) Other options are
a proximal pedicle with a branch, two musculocutaneous or septocutaneous perforators (white arrows); (I) a supercharged vein (white arrow);
and (J) a pattern with small segments of the muscle included.
F
Intercostal nerve
Thoracodorsal vein
Comitant vein 1
Comitant vein 2
Posterior tibial artery
Thoracodorsal artery
Sensory nerve
in the
recipient bed
A
B
C
D
E
G
H
I
J

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
663
• Nose reconstruction
• Skin and soft tissue resurfacing after radical resection of
skin cancer or radiation ulcer
• Correction of depression deformity or soft tissue asym­
metry with de-epithelialized flap
• Three-dimensional reconstruction after trauma, tumor
ablation or congenital deformity, chimeric or compound
pattern
• Scalp and forehead resurfacing
• Tongue, oral cavity, pharynx, and esophageal wall lining,
tubed esophageal reconstruction
• Hemilaryngeal reconstruction.
TRUNK
• Resurfacing defects after release of post-burn or post-
traumatic contracture deformity
• Skin and soft tissue resurfacing after radical resection of
skin cancer or radiation ulcer
• Correction of depression deformity or soft tissue asym­
metry with de-epithelialized flap
• Partial breast reconstruction
• Total autologous breast reconstruction in small to
medium breasted patients when abdominal tissues are
not available.
UPPER EXTREMITY
• Resurfacing defects after release of post-burn or post-
traumatic contracture deformity
• Skin and soft tissue resurfacing after radical resection of
skin cancer
• Elbow, wrist, and other joint resurfacing
• Hand and finger resurfacing, wrap-around resurfacing of
degloving injury
• Bone exposure or chronic fistula wound
• Hand resurfacing (wrist, dorsum, finger, and thumb) –
sensate flap.
LOWER EXTREMITY
• Resurfacing defects after release of post-burn or post-
traumatic contracture deformity
• Skin and soft tissue resurfacing after radical resection of
skin cancer
• Foot resurfacing in diabetic foot, crushing foot injury or
degloved foot
• Plantar resurfacing, great toe resurfacing
dispersed with T-anastomosis, and flow balance can be
achieved over time. Furthermore, the dominant recipient
flow can also be preserved.
• An additional perforator (Fig. 56.17G,H). Another per­
forator can be included in the pedicle, especially in a very
long perforator flap.
• Supercharged vein (Fig. 56.17I). Another satellite vein
can be prepared, away from the main pedicle, for the
venous supercharge.
• Inclusion of small segments of the muscle (Fig. 56.17J).
This is an option when a large or long flap is required.
• Others. The irrigation or infusion of vasodilators, the
appropriate position of the reconstructed site in the neck
and extremity, and the application of a heat lamp.
The elevated flap is secured in situ until final harvest to
prevent accidental detachment of the perforator pedicle by
the flap weight. During flap inset, special attention is given
to pedicle positioning to avoid compression or kinking.
In elderly patients, the perforator is more prominent and
easier to detect. Sometimes, a musculocutaneous perforator
is as easy to dissect as a septocutaneous perforator, passing
just underneath several muscular fascicles. Because of ease
of dissection and its becoming visible soon after making the
incision, we call this the “good morning” perforator pedicle
(Fig. 56.18). This well-exposed pattern of the perforator is
caused by age-induced atrophy of the latissimus dorsi muscle
and fatty tissue.
FLAP USAGE
PEDICLED
• Shoulder, lower half of neck, upper arm, upper back,
ipsilateral chest wall, and breast resurfacing (burn con­
tracture, radiation ulcer, large skin cancer, etc.)
• Correction of Poland syndrome or other deep defect of
chest wall, with or without muscle
FREE FLAP
HEAD AND NECK
• Resurfacing defects after release of post-burn or post-
traumatic contracture deformity (neck, forehead, scalp,
etc.)
Figure 56.18  (A–C) “Good morning” perforator pedicle (white arrows). Sometimes, in elderly patients, the musculocutaneous perforator runs
just beneath several fascicles of the muscle, as does the course of the septocutaneous perforator, and the pedicle is easily dissected from the
muscle.
A
C
B

664
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
HEAD AND NECK RECONSTRUCTION
Instead of the radial forearm flap, this thin perforator flap
can be considered as a good option for head and neck
reconstruction without a noticeable donor scar, especially
for intraoral or tongue resurfacing and 3-dimensional
reconstruction (Fig. 56.19). Moreover, the perforator flap
provides fundamental requirements for head and neck
reconstruction, such as thinness with a long pedicle and
well-developed proximal branching system. Finally, the pre­
viously accepted use of a forearm flap as the choice in head
and neck reconstruction has recently changed, and flap
selection in head and neck reconstruction is now based
more on the perforator concept.
COMPOSITE OR CHIMERIC PATTERN
A composite flap containing nerve, bone, muscle, and skin
can be used (Fig. 56.12), and a chimeric pattern is possible
due to the well-developed, proximal branching systems of
the subscapular artery (Fig. 56.19). In addition, the flap can
be designed with a flow-through pattern. If an extremely
large defect needs to cover with flaps, several perforator skin
flaps conjoined with neighboring muscles, scapula bone
and adiposal component maybe be a good option from the
lateral thoracic area because of an economical use of tissue,
minimal donor site morbidity, and possible primary closure
of the donor site.
PERFORATOR–BASED FLAP
See Flap modification/flap handling, above.
• Skin and soft tissue resurfacing after radical resection
of large vascular malformation (with or without muscle
component)
• Fistula or skin and soft tissue defect by chronic
osteomyelitis
• Disrupted wound of knee joint operation
• Resurfacing of bone exposure wound (pretibial, malleo­
lar, foot dorsum, etc.).
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
SKIN RESURFACING
This flap is useful for resurfacing when a thin, hairless large
skin flap with a lengthy pedicle of a large external diameter
is required. It can be used for defects caused by the release
of a burn scar contracture, the resection of a malignant skin
lesion with Mohs micrographic operation, a degloved injury
of the extremity, a radiation ulcer, etc. This flap can also be
considered for the reconstruction of areas composed of thin
skin and subcutaneous tissue, such as the hand, including
the thumb and fingers, pretibial area, foot and ankle, joint
area, shoulder, scalp, etc. This flap is applicable to female
and child patients who wish to avoid an exposed donor scar.
In the reconstruction of a large burn scar contracture, par­
ticularly, the linear donor scar well hidden in the lateral
thoracic region is typically more acceptable than the donor
scar of a skin graft.
SENSATE FLAP
See Flap modification/flap handling, above.
Figure 56.19  A chimeric pattern composed of a jejunal flap and a latissimus dorsi perforator flap for the reconstruction of recurrent laryngeal
cancer after resection. (A) Appearance of recurred cancer. (B) Diagram of chimeric composition. (C) Appearance after the reconstruction.
Superior
thyroid
artery
Thoracodorsal
artery
Anastomosis
Anastomosis
Jejunal
flap
Latissimus dorsi
perforator flap
Perforator
Jejunal artery
B
A
C

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
665
Figure 56.20  A dermoadiposal pattern was used for the reconstruction of a depression deformity caused by radical resection of a vascular
malformation in the right cheek. (A) Appearance before the operation. (B) A dermoadiposal thoracodorsal perforator flap harvested. (C) Appear­
ance after the operation.
A
B
C
This pattern can be used as an island flap of the skin or
as a fasciocutaneous pattern for covering a regional defect,
such as the whole shoulder, lower neck, anterior chest wall,
ipsilateral breast or upper arm.
DERMOADIPOSAL PATTERN
More adipose tissue can be harvested in the thoracodorsal
and lateral thoracic perforator flap, and the dermoadiposal
pattern based on the perforator is available to use as filling
tissue (Fig. 56.20).
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
The flap can be indicated in breast reconstruction, either
in partial breast reconstruction after ablative surgery or
autologous augmentation for hypoplasia or dysplasia. A skin
flap including the axillary hair can be used for the recon­
struction of pubic alopecia.
Nose reconstruction can be challenging in the patient
with a whole or half defect of the nose after a facial burn or
radical resection of skin cancer of the nose (Fig. 56.21).
POSTOPERATIVE CARE
GENERAL
Early postoperative monitoring is important because the
flap is often very sensitive to the position of the recipient
site and initial temporary ischemia or congestion can be
caused after the operation. Therefore, a more accurate
monitoring technique, such as laser Doppler flowmetry or
tissue oximetry, may be helpful for comparing the perfusion
value with baseline data taken immediately after the opera­
tion. Generally, the patient is admitted to hospital for 1 week
or more, depending on the site. No specific medications are
necessary; however, mild flap congestion requires low-dose
intravenous heparin. Early ambulation is strongly recom­
mended except after lower extremity reconstruction.
RECIPIENT SITE
The perforator flap is generally very sensitive to congestion
and it is recommended that the reconstructive site is ele­
vated for good venous return, especially after extremity
reconstruction. The resurfacing area is open, with the
wound margin pasted with Dermabond glue. After intraoral
reconstruction, the wound requires frequent irrigation for
oral hygiene.
DONOR SITE
Because the donor site is located in the trunk and closed
primarily in most cases, the hospitalization period is short­
ened considerably. No specific splinting, dressing or medi­
cations are required (see Donor site closure and management,
above).
OUTCOMES
EXPECTED OUTCOMES
GENERAL
These perforator flaps are often more difficult for inexpe­
rienced surgeons; however, the advantages and clinical
modifications of the flap are expanding. With accumulation
of experience in identifying the reliable perforator and
skilled training in perforator pedicle dissection, the recon­
structive results are acceptable cosmetically as well as
functionally.

666
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
In our series using the latissimus dorsi perforator flap,
the maximal dimension was 25 × 15 cm (12 × 4 cm in chil­
dren). The thoracodorsal perforator flap was utilized with
maximal dimensions of 18 × 15 cm without any serious com­
plications, including marginal necrosis. A perforator flap
with a small segment of muscle was utilized in an unduly
Figure 56.21  Nose reconstruction with a latissimus dorsi perforator flap in a facial burn contracture deformity. (A) A perforator flap harvested.
(B) Frontal view before operation. (C) Left lateral view before operation. (D) Frontal view 6 months after reconstruction. (E) Left oblique view
before operation. (F) Left lateral view 6 months after reconstruction. (G) Left oblique view 6 months after reconstruction.
B
C
A
D
E
F
G
Figure 56.22  Because the unreliable perforator has a decreased
ability to overcome its own angiosome, a flap margin at the same
distance apart from the perforator (white arrow) is not sufficiently
perfused, resulting in necrosis.
FOR DIFFERENT INDICATIONS
After resurfacing, there is no need for a secondary touch-up
procedure. For head and neck, extremity, and shoulder
reconstruction, the color and texture of the flap are well
matched to the recipient sites. Non-hair-bearing skin is
useful for intraoral and tongue reconstruction compared to
fasciocutaneous or perforator flaps from the extremities.
DONOR SITE
The risk of seroma is almost nil because the donor site is
closed primarily with some tension, and muscle is not dis­
sected except for transmuscular pedicle dissection. Muscle
and motor function of the latissimus dorsi are completely
preserved.
UNTOWARD OUTCOMES
GENERAL
The selection of a reliable perforator is very important.
When a less reliable perforator (tiny diameter with no
visible pulsation) is selected instead of the reliable one,
marginal flap necrosis is caused beyond its angiosome ter­
ritory, which is located exactly the same distance away from
the perforator (Fig. 56.22).

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region
667
Access Figures 56.23, 56.24 and 56.25, as well
as case examples 1, 2 and 3 and further reading
online at
REFERENCES
1. de Coninck A, Vanderlinden E, Boeckx W. The thoracodorsal skin
flap: a possible donor site in distant transfer of island flaps by
microvascular anastomosis. Chir Plastica 1976;3:283–91.
2. Koshima I, Saisho H, Kawada S, et al. Flow-through thin latissimus
dorsi perforator flap for repair of soft-tissue defects in the legs.
Plast Reconstr Surg 1999;103:1483–90.
large or long pattern and its maximal size was 34 × 10 cm or
28 × 15 cm. The lateral thoracic perforator flap was used
with maximal dimensions of 15 × 10 cm.
DONOR SITE
Postoperative seroma has been reported in the conventional
latissimus dorsi myocutaneous flap; however, it is rare in the
perforator flap because the muscle is completely preserved
without any perimuscular wide dissection and it has tight
closure of the donor site under moderate tension. Even
hematoma is rare due to the tight closure of the donor site.
LONG-TERM OUTCOMES
After the flap is used for resurfacing, there is no need for a
subsequent debulking or contouring procedure. Its thick­
ness can be controlled according to the defect status, and it
is thin enough to cover the hand and neck effectively. Good
contour and proper resurfacing have been achieved in
tongue and mouth floor reconstruction. Even a skin graft
with large dimensions can be replaced with a thin perfora­
tor flap in severe burn contractures.
A perforator-based island flap has been used effectively
with a long pedicle for shoulder resurfacing, and the sensate
pattern showed recovery of sensation at 3 months after
reconstruction in the oral cavity and hand. Compared with
conventional flaps, such as the radial forearm flap, the
results were satisfactory in the aspects of contour, sensation,
and donor scar.
CONCLUSION
The perforator concept applied to the lateral thoracic
region area provides cutaneous and fasciocutaneous flaps,
with or without the inclusion of other components such as
muscle or bone to provide flaps that range from very thin
to extra bulky that can be used to reconstruct complex
defects in an elegant fashion with minimal donor site
morbidity.
Expert Commentary
Stephanie A. Caterson, MD and Edward J. Caterson,
MD, PhD
Plastic surgeons have long been enamored with the thoracic
region as a donor site for complex reconstructive needs, both
in the pedicled and free formulations. The latissimus dorsi
muscle is the largest muscle in the body. Its wide, thin, pliable
nature in combination with the relative ease of harvest has
made it a reliable workhorse for many reconstructive sur-
geons. Despite the attractive qualities this muscle possesses,
there are described shortcomings in its use. These include
the loss of donor site latissimus function, change in overlying
thoracic contour in area of harvest, and unfavorable harvest
site scars. This chapter eloquently describes the modern-day
application of using the lateral thoracic region for reconstruc-
tion, far exceeding the historic capacity of the latissimus
muscle alone. Our knowledge of perforator anatomy, as well
as advancing skill in perforator flap surgical techniques,
allows us to fine tune and individualize the reconstructive
needs of the patient with simultaneous attempts to decrease
donor site complications. The lateral thoracic area has mul-
tiple options for sensate flaps or composite/chimeric flaps,
allowing the surgeon to “take only what one needs”.
Temperamental perfusion following the delicate perforator
dissection is a major limitation of the techniques described
here. As the author suggests, optimal perforator selection is
crucial for success. In our practice, preoperative imaging is
essential to allow for better flap design. Anticipating specific
perforator angiosomes as well as venosomes, will help to
avoid the pitfalls of vascular compromise. New techniques
with 3D printing and CT/MR angiograms/venograms may
hold the key to optimizing perforator flap planning and exe-
cution in the lateral thoracic region. If preoperative imaging
is not available, preservation of all perforators with intraop-
erative clamp trials for perfusion assessment is helpful.
Laser-assisted indocyanine green dye angiography may be
used as in intraoperative adjunct. Conversion to a non-
perforator flap to ensure proper perfusion should not be
looked on as a failure, but rather a wise decision, based on
anatomic limitations.
The thoracodorsal and associated pedicles can be invalu-
able options to develop custom solutions to difficult prob-
lems. Overall, perforator versatility coupled with the benefits
of minimal donor site morbidity support the author’s descrip-
tion of elegant and utilitarian reconstructions using the lateral
thoracic region.
3. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutane­
ous flap without muscle. Plast Reconstr Surg 1995;96:1608–14.
4. Kim JT, Koo BS, Kim SK. The thin latissimus dorsi perforator-based
free flap for resurfacing. Plast Reconstr Surg 2001;107:374–82.
5. Rowsell AR, Davies DM, Eisenberg N, et al. The anatomy of the
subscapular-thoracodorsal arterial system: study of 100 cadaver dis­
sections. Br J Plast Surg 1984;37:574–6.
6. Cabanie H, Garbe JF, Guimberteau JC. Anatomical basis of the
thoracodorsal axillary flap with respect to its transfer by means of
microvascular surgery. Anat Clin 1980;2:65–73.
7. Ishida LH. The anatomic study of the perforator flap. Paper pre­
sented at the 36th meeting of the Asociacion Mexicana de Cirugia
Plastica Estetica y Reconstructiva, May 18–21, Veracruz, Mexico.

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region 667.e1
CASE 56.1  Thumb Skin Defect Resurfaced with a Latissimus Dorsi Perforator Flap
(Fig. 56.23)
Figure 56.23  (A) The replanted thumb was necrotic and the patient refused a toe-to-thumb transfer. (B) A 9 × 9 cm latissimus dorsi
perforator flap was designed for whole resurfacing of the exposed digital bone after debridement of necrotic tissues. (C,D) The flap was
elevated as a thin pattern and was used for resurfacing the thumb. (E,F) After the reconstruction, the natural shape of the thumb and its
pinching function were successfully achieved.
A
B
C
D
E
F
CASE 56.2  Tongue Defect Reconstructed with a Thoracodorsal Perforator Flap
(Fig. 56.24)
Figure 56.24  A patient with a squamous cell carcinoma of the left lateral tongue (A) was admitted, and a thoracodorsal perforator flap
was designed after hemi-glossectomy (B). An 11 × 8 cm perforator flap was elevated as a controlled shape, with a thin distal pattern for
tongue resurfacing and a proximal volume for the tongue base (C). The reconstruction of a well-contoured and symmetric shape of the
tongue was achieved after the operation (D).
A
B
C
D

667.e2 PART 5 — PERFORATOR-BASED WORKHORSE FL APS
CASE 56.3  Neck Defect Resurfaced with a Lateral Thoracic Perforator Flap (Fig. 56.25)
Figure 56.25  (A,B) A male patient was transferred with a recurrent squamous cell carcinoma in the left neck. (C) The lesion was radically
removed with an additional neck dissection, and the defect was covered with a thin lateral thoracic perforator flap (15 × 10 cm). (D,E) After
the reconstruction, the neck was well contoured and adjuvant therapy was available. (F) The donor site was closed primarily.
A
B
C
D
E
F

CHAPTER 56 — Perforator Flaps in the Latera l Thoracic Region 667.e3
FURTHER READING
Baudet J, Guimberteau J, Nascimento E. Successful clinical transfer of
the free thoracodorsal axillary flaps. Plast Reconstr Surg 1976;58:
680–8.
Colohan S, Wong C, Lakhiani C, et al. The free descending branch
muscle-sparing latissimus dorsi flap: vascular anatomy and clinical
applications. Plast Reconstr Surg 2012;130:776e–87e.
Guerra AB, Metzinger SE, Lund KM, et al. The thoracodorsal artery
perforator flap: clinical experience and anatomic study with empha­
sis on harvest techniques. Plast Reconstr Surg 2004;114:32–41.
Hallock GG. The combined parascapular fasciocutaneous and latissi­
mus dorsi muscle conjoined free flap. Plast Reconstr Surg 2008;121:
101–7.
Harii K, Torii S, Sekiguchi J. The free lateral thoracic flap. Plast Recon­
str Surg 1978;62:212–22.
Heitmann C, Guerra A, Metzinger SW, et al. The thoracodorsal artery
perforator flap: anatomic basis and clinical application. Ann Plast
Surg 2003;51:23–9.
Kim JT. Latissimus dorsi perforator flap. Clin Plast Surg 2003;30:
403–31.
Kim JT. New nomenclature concept of perforator flap. Br J Plast Surg
2004;58:431–40.
Kim JT. Two options for perforator flaps in the flank donor site: latis­
simus dorsi and thoracodorsal perforator flaps. Plast Reconstr Surg
2005;115:755–63.
Kim JT, Kim SK. Hand resurfacing with the superthin latissimus dorsi
perforator-based free flap. Plast Reconstr Surg 2003;111:366–70.
Kim JT, Kim YH. Initial temporary vascular insufficiency in latissimus
dorsi and thoracodorsal perforator flaps. Plast Reconstr Surg 2009;
124:408e–18e.
Kim JT, Ng SW, Naidu S, et al. Lateral thoracic perforator flap: addi­
tional perforator flap option from the lateral thoracic region. J Plast
Reconstr Aesthet Surg 2011;64:1596–602.
Kim SW, Youn SK, Kim JD, et al. Reconstruction of extensive lower limb
defects with thoracodorsal axis chimeric flaps. Plast Reconstr Surg
2013;132:470–9.
Lin CT, Huang JS, Hsu KC, et al. Different types of suprafascial courses
in thoracodorsal artery skin perforators. Plast Reconstr Surg 2008;
121:840–8.
Lin CT, Yang KC, Hsu KC, et al. Sensate thoracodorsal artery perforator
flap: a focus on its preoperative design and harvesting technique.
Plast Reconstr Surg 2009;123:163–74.
Santanelli F, Longo B, Germano S, et al. Total breast reconstruction
using the thoracodorsal artery perforator flap without implant. Plast
Reconstr Surg 2014;133:251–4.
Schwabegger AH, Harpf C, Rainer C. Muscle-sparing latissimus dorsi
myocutaneous flap with maintenance of muscle innervation, func­
tion, and aesthetic appearance of the donor site. Plast Reconstr Surg
2003;111:1407–11.
Van Landuyt K, Hamdi M, Blondeel P, et al. Autologous breast augmen­
tation by pedicled perforator flaps. Ann Plast Surg 2004;53:322–7.
Van Landuyt K, Hamdi M. Thoracodorsal artery perforator flap. In:
Blondeel P, Morris S, Hallock GC, et al., editors. Perforator flaps:
anatomy, technique, and clinical applications. St Louis, MO: Quality
Medical Publishing; 2006. p. 442–59.

668
Deep and Superficial
Inferior Epigastric Artery
Perforator Flaps
Alain R. Gagnon  |  Phillip N. Blondeel
57 
Figure 57.1  Deep and superficial inferior epigastric artery perforator
flap.
Lateral and
medial
branches
of deep
inferior
epigastric
arteries
Perforator
from deep
inferior
epigastric
artery
Superficial
inferior
epigastric
artery
Superficial
inferior
epigastric
artery
Rectus
abdominis
muscle
(split)
Fascia
(split)
Superficial
circumflex
iliac artery
Deep inferior
epigastric
artery
Lateral
cutaneous
branches of
intercostal
nerves
Sensory
branch of
intercostal
nerve
PART 5  —  PERFORATOR-BASED WORKHORSE FLAPS
INTRODUCTION
Since the dawn of plastic surgery, the lower abdominal region
has always been a loyal provider of abundant well-perfused
tissue. First used in pedicled and tubed flaps for distant
transfers, the lower abdomen skin and fat was discovered to
be an ideal material for breast reconstruction. That specific
use of the rectus abdominis musculocutaneous flap was pio­
neered by Drever1 in 1977 and, a few years later, Hartrampf
et al.2 showed that the skin island could be harvested trans­
versally across the lower abdomen. The transverse rectus
abdominis muscle (TRAM) flap was born and it eventually
became the gold standard in autogenous breast reconstruc­
tion. Interestingly, the free TRAM was performed first in
1979 by Holmström but was not recognized for several years.3
The free TRAM eventually demonstrated better vascularity
over its pedicled counterpart due to the vigorous blood
supply brought in by the deep inferior epigastric system.
In the mid-1980s, following Taylor’s landmark work on
the vascular territory of the deep inferior epigastric artery,
it became apparent that the lower abdominal flap could
probably be perfused solely by a large periumbilical perfo­
rating vessel. That assumption was confirmed in 1989 when
Koshima and Soeda published two cases of “inferior epigas­
tric skin flaps without rectus abdominis muscle”.4 Allen and
Treece5 and Blondeel et al.6 expanded the use of the deep
inferior epigastric artery perforator (DIEAP) flap to breast
reconstruction and raised the operation to a high level of
technical refinement. The DIEAP flap quickly gained popu­
larity, as it allowed the same advantageous reconstructive
results as a TRAM flap but without the added morbidity of
sacrificing an important muscle.
In the meantime, other surgeons transferred the same
lower abdomen anatomic unit but instead used the superfi­
cial inferior epigastric vessels to vascularize the flap. Back in
1971, this was the basis for the first free flap ever reported
in the literature. In 1976, Boeckx7 published his experience
with six superficial inferior epigastric artery (SIEA) free flaps,
most of them for facial reconstruction. Hester et al.8 demon­
strated successful polyvalent use of the flap in 1984 and
Grotting was the first to use the free abdominoplasty flap for
breast reconstruction in 1991.9 The SIEA flap can provide
ample skin and subcutaneous fat with minimal donor site
morbidity as the abdominal musculature is not breached.
In this time of rapidly evolving science, perforator flaps
constitute the latest milestones in the never-ending quest
for the best possible result with the least cost to the patient.
The DIEAP and SIEA flaps can provide excellent-quality
autogenous reconstruction with minimum morbidity and
should be considered as the golden standard by the contem­
porary surgeon.

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps
669
minor supply to the skin, and, conversely, perforators that
are mainly directed at the skin. Obviously, the latter consti­
tute the target vessels to vascularize a DIEAP flap. Occasion­
ally, one can see perforators going around the edge of the
rectus abdominis and not through the muscle itself. These
pararectal fasciocutaneous perforators pass either medially
just next to the linea alba or laterally from the lateral seg­
mental vessels through the external oblique aponeurosis.
After piercing the anterior rectus sheath, the different
perforators take on a variable course through the subcuta­
neous fat. Some ascend vertically to the overlying skin,
whereas others will have a more horizontal trajectory. Per­
forators usually arborize in a fractal manner until they join
the subdermal plexus to supply it. The subdermal plexus
effectively constitutes an intricate network of microvessels
spanning the entire abdominal skin and allowing innumer­
able redundant connections. Through the subdermal
plexus, we find the second level of anastomotic channels
between the source arteries. This is where perforators from
the DIEA will meet cutaneous branches of the SEA, lower
intercostal arteries, deep and superficial circumflex iliac
arteries, superficial inferior epigastric artery, superficial
external pudendal artery, and contralateral DIEA perfora­
tors. The subdermal plexus is the supporting vascular frame­
work of lower abdominal skin flaps and the reason why the
same skin/fat island can be perfused by either the deep
or the superficial inferior epigastric system. In fact, the sub­
dermal plexus can be conceptualized as an interface between
the relatively scarce vessels originating from the deep fascia
and the dense network of terminal dermal microvessels. It
may act as a random equilibrating system that distributes
blood evenly across surrounding cutaneous areas. If all
vessels feeding into the subdermal plexus are ligated except
for one perforator, the area of irrigated skin would be deter­
mined by the capacity of the perforator to provide pressure
into the subdermal system. Therefore, the diameter and
branching pattern of the perforator become key elements
in defining the clinical territory of perforator flaps. Of
course, further anatomic and physiologic studies are war­
ranted to compare this theory to the angiosome and choke
vessel concept in order to help elucidate the intricacies of
skin perfusion.
The superficial inferior epigastric artery (SIEA) is the
second important blood supply provider to the lower
FLAP ANATOMY (Figure 57.1; see Figs 11.2, 11.3,
11.6, 11.8, 11.9, 11.10)
ARTERIAL SUPPLY OF THE FLAP (Figures 57.1;
see 11.2, 11.3 and 11.6)
The lower abdominal flap can be vascularized by either
the deep or the superficial inferior epigastric artery. The
superficial circumflex iliac artery only vascularizes the
lateral part of the lower abdomen. By definition, the DIEAP
flap is perfused only via one or more perforators of the
DIEA.
The blood supply of the anterior trunk is founded on the
presence of two epigastric arcades, each linking the external
iliac artery and the subclavian artery through the rectus
abdominis muscle. Caudally, the deep inferior epigastric
artery (DIEA) originates from the external iliac artery just
proximal to the inguinal ligament. After running superome­
dially for a short distance, it approaches the posterior aspect
of the rectus abdominis muscle and divides into two main
branches. These branches enter the rectus muscle and
follow a cranial intramuscular course to feed the muscle and
overlying skin. The cephalad portion of the epigastric
arcade is made of the internal mammary artery, which arises
from the subclavian artery. The internal mammary artery
continues in the abdomen as the superior epigastric artery
(SEA) to finally coalesce in a watershed area midway between
the xiphoid process and the umbilicus. In this region, mul­
tiple anastomotic channels exist between the superior and
inferior epigastric systems. Laterally, the epigastric arcade
anastomoses with the terminal branches of the lower six
intercostal arteries as well as with the ascending branch of
the deep circumflex iliac artery.
It is evident that the DIEA is relatively more important
than the SEA. First, the DIEA is larger, with an external
diameter of 3.4 mm at its point of origin as compared with
1.6 mm for the SEA. Second and more importantly, the vast
majority of cutaneous perforators are located in the peri­
umbilical region, inferior to the watershed anastomotic
zone, and therefore in the DIEA territory. The branching
pattern of the DIEA is summarized in Figure 57.2. There
are muscular branches to the rectus abdominis, myocutane­
ous perforators with major contribution to the muscle and
Figure 57.2  Axial cut through the rectus abdominis showing the different branching patterns of the DIEA. 1, Branch directed to muscle only;
2, branch directed mostly to muscle; 3, branch directed mostly to skin; 4, fasciocutaneous perforator. EO, external oblique; IO, internal oblique.
1
4
2
3
Scarpa’s fascia
Fat
Subdermal plexus
Skin
EO
IO

670
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
Dominant:  superficial inferior epigastric artery
Length: 5 cm (range 4–7 cm)
Diameter: 1.6 mm (range 0.75–3.5 mm)
After piercing the deep fascia, the SIEA passes superiorly
and laterally in the femoral triangle, crossing the inguinal
ligament at its midpoint and lying deep to Scarpa’s fascia.
The vessel continues on superomedially towards the umbili­
cus, penetrating Scarpa’s fascia, well above the inguinal liga­
ment to lie in the superficial subcutaneous tissue (Fig. 57.3).
A recent anatomic study showed that the SIEA was identi­
fied in 72% of specimens, with an average diameter of
1.6 mm (0.75–3.5 mm) at the level of the inguinal ligament.
In 58% of cases, the artery was present bilaterally. The
length of the pedicle ranged from 4 cm to 7 cm.
Minor:  superior epigastric artery
Length: 6 cm (range 4–8 cm)
Diameter: 2 mm (range 0.5–2.5 mm)
Secondary arterial inputs to the lower abdominal flap
come from the SEA, lower intercostal arteries, superficial
and deep circumflex iliac arteries, and superficial external
pudendal artery. Since the DIEAP and SIEA flaps are ele­
vated as skin islands isolated on their respective dominant
pedicle, the minor contributors are ligated during harvest­
ing of the flap. If indicated, however, a minor pedicle can
be dissected and anastomosed in addition to the dominant
pedicle to extend the territory of the flap.
VENOUS DRAINAGE OF THE FLAP (see
Figs 11.6 and 11.8)
The venous anatomy of the lower abdominal area is similar
to the arterial anatomy in that the different venae comitan­
tes closely follow their paired arteries to the proximal vessels.
Indeed, the small veins perforating the anterior rectus
sheath drain into the deep inferior epigastric veins (DIEV)
and then on to the external iliac vein. Similarly, the SIEA
possesses two venae comitantes closely related to it, which
drain into the common femoral vein or occasionally into
the saphenous bulb. However, these veins are often small
and can even be absent. On the other hand, there is a con­
stant and often large superficial inferior epigastric vein
(SIEV) located medial to the SIEA and more superficial
(Fig. 57.3). The SIEV is not accompanied by an artery and
is a tributary of the greater saphenous vein close to the fossa
ovale. It actually drains an extensive polygonal network of
subcutaneous veins in the anterior abdominal wall. There
exist anastomotic connections between this superficial
system and perforating veins from the DIEV. The SIEV is
considered by certain authors to be the preferential drain­
age path of the abdominal panniculus in the normal, non-
surgical condition.
Primary:  deep inferior epigastric veins
Length: 16 cm (range 14–18 cm)
Diameter: 4 mm (range 3.5–4.5 mm)
abdominal skin. The SIEA is a direct cutaneous vessel, origi­
nating from the common femoral artery 2–3 cm below the
inguinal ligament in 17% of cases or from a common trunk
with the superficial circumflex iliac artery in 48% of patients.
The artery is absent or hypoplastic in 35% of specimens, in
which case it is often substituted by a large ascending branch
from the superficial circumflex iliac artery. The SIEA courses
in the subcutaneous fat towards the umbilicus where it often
anastomoses with large periumbilical perforating arteries.
Dominant:  deep inferior epigastric artery
Length: 16 cm (range 14–18 cm)
Diameter: 3.5 mm (range 2–4 mm)
After taking off from the external iliac artery, the DIEA
travels superomedially in between the peritoneum and a
very thin fibrous layer that is an extension of transverse
fascia. In its lower portion, it gives off its first branches
directed to the pubic bone, the lower rectus abdominis, and
the pyramidalis muscle. A variable amount of peritoneal
branches can emerge, the most cranial one providing vas­
cularization to the umbilical stalk. The DIEA then enters
the rectus muscle by passing anterior to the arcuate line. As
it penetrates the muscle, the DIEA generally divides into two
major branches. The lateral branch is dominant in 50% of
cases and the medial branch in 7%. There is equal caliber
of both branches in 15% and one central axis with multiple
side branches in 28%. During their cranial course, the
medial and lateral divisions of the DIEA give off several
muscular and myocutaneous side branches. Overall,
although small-caliber cutaneous perforators are numerous,
there is an average of five perforators with a diameter of
0.5 mm originating from each DIEA. Sometimes, perfora­
tors as large as 1.5 mm can be encountered. Box 57.1 pre­
sents key points on the typical location of perforators.
When the pedicle is dissected down to the lower lateral
rectus border, a typical pedicle length of 10–14 cm is
obtained, depending on the position of the perforator.
Although this length is generally sufficient for the purpose
of free tissue transfer, it can be increased by up to 4 cm if
the pedicle is dissected to its origin. At this point, the diam­
eter of the artery is 3–3.5 mm.
Box 57.1  Topographic Distribution of
Musculocutaneous Perforators
from the DIEA
• More than 90% of the major perforators are located within
a 6 cm radius lateral and inferior to the umbilicus.
• There is a higher concentration of perforators in the middle
and medial thirds of the muscle.
• The largest periumbilical perforators take origin from the
terminal branches of the DIEA and are often located within
the lowest tendinous intersection of the rectus abdominis.
• The lowest fifth of the muscle contains only sparse perfora-
tors and the veins are rarely of adequate size.
• Medial and lateral pararectal fasciocutaneous perforators are
often of small caliber.
• The distribution of perforators on both sides of the abdomen
is rarely symmetrical.

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps
671
primary venous drainage system. In 18% of the cases, a large
venous connection exists between the left and right SIEV
over the midline and below the umbilicus.
Secondary:  the secondary venous drainage of the flap is
composed of the venae comitantes of the SIEA, SEA, cir­
cumflex iliac arteries, and lower intercostals.
If the venae comitantes of the SIEA are large, they can be
used to drain the flap. However, they are almost always
<1 mm in diameter or even non-existent.
FLAP INNERVATION (see Figs 11.2, 11.9 and 11.10)
The motor and sensory innervation to the abdominal wall
is provided mainly by the intercostal nerves 7–12 with some
contribution from the iliohypogastric and ilio-inguinal
nerves. As shown in Table 57.1, the lateral muscles are sup­
plied by all eight nerves, whereas the more medial rectus
abdominis and pyramidalis are innervated solely by the
intercostals. The sensory innervation to the abdominal
skin is derived from the lateral and anterior cutaneous
branches of the intercostal nerves giving rise to segmental
Primary:  superficial inferior epigastric veins
Length: 5 cm (range 4–7 cm)
Diameter: 4 mm (range 3–5 mm)
The lower abdominal skin has two primary outflow path­
ways: the deep and the superficial inferior epigastric veins.
In most cases, the DIEAP flap is primarily drained via the
DIEV. These paired veins have multiple ladder-like connec­
tions (H-bridges) and often unite just prior to their junction
with the external iliac vein. However, there exists an inverse
size relationship between veins from the deep system and
the superficial veins. The SIEV network might actually be
dominant over the deep system in some cases. When the
SIEV is important in diameter, it should be preserved
because the selected perforating vein(s) from the DIEV
could be insufficient to drain the flap. Conversely, if the
superficial veins have been interrupted by a previous Pfan­
nenstiel incision, a delay-type phenomenon can occur,
resulting in enlargement of the deep system veins. Of
course, in the case of an SIEA flap, the SIEV constitutes the
Figure 57.3  Paramedian sagittal view of the abdominal wall. At the level of the inguinal ligament, the superficial inferior epigastric artery
(SIEA) is located deep to Scarpa’s fascia while the superficial inferior epigastric vein (SIEV) is within the superficial subcutaneous tissue. As it
progresses cranially, the SIEA becomes more superficial and provides flow into the subdermal plexus. It eventually connects with periumbilical
perforators of the deep inferior epigastric artery (DIEA). Therefore, the deep and superficial inferior epigastric systems share common vascular
channels and can be used interchangeably to vascularize the lower abdominal skin.
Scarpa’s fascia
Deep inferior epigastric
artery and veins
Rectus abdominis
Subdermal
plexus
Umbilicus
Superficial inferior
epigastric vein
Superficial inferior
epigastric artery and
venae comitantes

672
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
Advantages
• The DIEAP/SIEA flap essentially has all the advantages
of the TRAM flap with few of its disadvantages. It provides
generous amounts of well-perfused soft tissue and its com­
plication rate is similar to other free tissue transfers.
• The first and foremost advantage of the DIEAP/SIEA over
the TRAM is its markedly decreased donor site morbidity.
Since no muscle or fascia is sacrificed, the incidence of
late hernias and abdominal bulges is minimized.
• The problem of abdominal and umbilical asymmetry seen
with the TRAM flap is also eliminated.
• Postoperative pain is minimal and the hospitalization
time is reduced, resulting in lower healthcare costs. Fur­
thermore, patients can return more quickly to work and
physical activities.
• Because of the intramuscular dissection, the pedicle
length obtained with a DIEAP flap is longer by several
centimeters, translating into superior flexibility in the way
the flap can be positioned at the recipient site, resulting
in easier and better flap shaping.
• Patients undergoing a DIEAP/SIEA flap reconstruction
also benefit from an abdominal contour-improving pro­
cedure with a well-concealed scar.
• The DIEAP/SIEA flap can be harvested with an additional
contralateral SIEA pedicle and lymph nodes enabling a
simultaneous lymph node transfer to the axilla.
Disadvantages
• As with other perforator flaps, the operation involves a
certain learning curve and demands delicate dissection.
dermatomes. A small skin area immediately superior to the
pubis is supplied by the anterior cutaneous branch of the
iliohypogastric nerve.
Sensory:  The DIEAP flap can be innervated using one of
the sensory intercostal branches entering the panniculus on
its way to the skin, usually in company with a perforator
from the DIEA (see Figs 11.2, 11.9 and 11.10).
After traveling in the plane between the internal oblique
and the transversus abdominis muscles along with their
respective intercostal arteries and veins, the mixed intercos­
tal nerves T7–T12 pierce the lateral edge of the rectus
sheath and then run on the posterior surface of the muscle
for a short distance. Less frequent the mixed nerves enter
the muscle at the lateral border or its anterior surface. Pos­
teriorly, they enter the rectus abdominis usually at the junc­
tion of the middle and lateral thirds (Fig. 57.4). At that
point, they arborize into muscular motor branches to the
medial and lateral muscle and a pure sensory branch that
perforates the anterior rectus sheath together with the per­
forator vessels to supply the overlying skin. The SIEA flap is
not used as an innervated flap because harvesting a sensory
nerve entails an intramuscular dissection.
Motor:  No muscle is included with these flaps.
FLAP COMPONENTS
The DIEAP and SIEA flaps consist solely of skin and fat from
the lower abdomen. No muscle or fascia is harvested.
Table 57.1  Innervation of the Abdominal Wall
Rectus Abdominis
Pyramidalis
EO/IO/TA
Cutaneous Innervation
Intercostal nerves (T7–T11)
+
+
+
Subcostal nerve (T12)
+
+
+
+
Iliohypogastric nerve (L1)
+
+
Ilio-inguinal nerve (L1)
+
EO, external oblique; IO, internal oblique; TA, transversus abdominis.
Figure 57.4  Axial view through right rectus abdominis showing the typical course of a segmental intercostal nerve. The mixed nerve
runs with the intercostal vessels to penetrate the muscle posteriorly. It gives off a recurrent motor branch to the lateral third and another motor
branch that crosses anterior to the DIEA to supply the medial muscle. A pure sensory branch accompanies a perforator on its way to the skin.
Linea alba
Intercostal nerve
and vessels
Motor
Sensory
Mixed

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps
673
the creation of a 3-dimensional map of the perforating
vessels with coordinates centered on the umbilicus. An alter­
native to angio-CT, duplex-Doppler ultrasound allows the
location and diameter of the vessels to be evaluated plus
the blood flow and arborization patterns. This provides the
surgeon with invaluable information to help with the safe
planning of a DIEAP flap in different individuals.
The status of the internal mammary vessels is also assessed
at the same time, as this is our preferred recipient vessel in
breast reconstruction. Alternatively, the perforator mapping
can be done using a handheld Doppler; however, one
should be aware that, although more accessible and less
costly, this device generates more false-positive and false-
negative signals and provides less detailed anatomic and
functional vessel information.
The use of high-resolution multidetector spiral CT scan
has replaced color duplex imaging in our practice. Contrast-
enhanced CT scanning appears to be the modality of choice
in preoperative investigation of perforating vessels. Although
no flow information is obtained, it allows excellent three-
dimensional understanding of the arterial and venous per­
forator morphology and the intramuscular course of the
DIEA, DIEV and SEIV (Fig. 57.5). A preoperative angio-CT
can gain 60–90 min of operating time. More recently, the
use of magnetic resonance angiography has been described
for preoperative work-up of perforator vessels. Although
great imaging can be obtained with this modality, routine
use can be restricted because of accessibility reasons, cost
and length of the procedure.
FLAP DESIGN
ANATOMIC LANDMARKS
The major anatomic landmarks are the umbilicus, both
anterior superior iliac spines (ASIS), and the pubic symphy­
sis (Fig. 57.6).
GENERAL THOUGHTS ABOUT FLAP DESIGN
As studies of skin perfusion showed, perforating vessels can
safely irrigate skin islands of their own angiosome as well as
skin from immediately adjacent angiosomes. This is related
to the presence of interconnections in the subdermal plexus
between angiosomes. Therefore, DIEAP flaps can have
custom-designed skin paddles located over any reasonably
sized perforator. First, the desired perforator is localized on
the abdomen and then the flap design is centered as much
as possible over it. The extension of the flap can confidently
encompass skin from adjacent angiosomes (intercostal
vessels and contralateral DIEV). We routinely harvest DIEAP
flaps using a conventional abdominoplasty design. This
affords an aesthetic closure and the benefits of abdominal
recontouring. Additionally, the extra tissue harvested pro­
vides us with more flexibility in how the flap is inset and
shaped at the recipient site. The upper incision is typically
located just cranial to the umbilicus, whereas the inferior
incision, 12–15 cm below the upper incision, follows a
gentle curve from the pubic symphysis along both ASIS.
However, if the most interesting perforator is located more
cranially, the surgeon should not hesitate to move the skin
The operation duration can be marginally longer than a
comparable free TRAM flap, especially if the surgeon is
not familiar with the technique.
• On rare occasions, a state of venous congestion can occur
after flap harvest as a result of the limited diameter of the
veins. However, this situation is successfully treated with
an extra venous anastomosis of the SIEV.
• With a SIEA flap, the volume of tissue safely perfused can
be significantly less than that of a DIEAP or TRAM flap.
• The SIEA pedicle is rather short, making the insetting
and shaping of the flap more difficult.
• The SIEA is anatomically inconstant and can be absent in
up to a third of cases.
• The SIEA is particularly prone to vessel spasm.
• Due to the pedicle dissection in the area of inguinal
nodes, the SIEA flap has a higher rate of donor site
seroma than DIEAP or TRAM flaps.
PREOPERATIVE PREPARATION
When contemplating elective microsurgical reconstruction
with perforator flaps, appropriate patient selection is man­
datory in order to insure a satisfactory outcome. During the
patient’s first visit, a complete history is taken and physical
examination performed. Comorbid conditions and abdomi­
nal scars are noted. A previous full abdominoplasty or
abdominal lipectomy is an absolute contraindication for
a DIEAP or SIEA flap. If the peri-umbilical perforators
are still intact after a mini-abdominoplasty, a DIEAP flap
can still be considered. A past history of abdominal lipo­
suction is a relative contraindication but if a DIEAP/SIEA
flap is considered nonetheless, a preoperative duplex or
angio-CT scan investigation of the cutaneous vessels will be
required. So as to withstand the prolonged anesthesia asso­
ciated with free tissue transfer, the patient should be in a
good general state of health. Age is usually not an important
factor but we prefer to offer autogenous microsurgical
reconstruction to patients under the age of 80. Although
perforator flap surgery is not contraindicated in obese
patients, they are advised to lose weight before the opera­
tion, to limit the incidence of peri- and postoperative com­
plications. Smokers are asked to refrain from smoking for
at least 3 months before surgery. Use of aspirin, non-steroidal
anti-inflammatory drugs, and herbal medications should be
avoided for 3 weeks before surgery. Tamoxifen and any
other drugs increasing thrombosis risk is stopped at 1 pre­
operative week.
During the initial consultation, selected patients also
receive thorough explanations on the procedure, including
possible complications, at both the donor and recipient
sites. The usual course of reconstruction is discussed and
typical expected outcomes are presented with the use of
photographs. All questions are answered and the patient’s
motivation is carefully assessed.
The preoperative investigation should include a study of
the abdominal wall vascular anatomy. Although it is possible
to harvest a DIEAP flap without prior knowledge of the
exact position and size of the perforators, we believe it is
much safer and faster to do so with a map of the perforators
on hand. Therefore, angio-CT imaging is used routinely in
our department in the planning of DIEAP flaps. This allows

674
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
Figure 57.5  Preoperative investigation of abdominal wall vessels using multidetector CT scan. A perforator of interest is marked with a
yellow arrow.
Figure 57.6  Anatomic landmarks used in the design of a DIEAP or SIEA flap.
Anterior
superior
iliac spine
Umbilicus
Anterior
superior
iliac spine
Pubic
symphysis
island design in order to obtain optimal flap perfusion, even
at the expense of a slightly higher scar.
SPECIAL CONSIDERATIONS
Particular attention needs to be directed towards abdominal
scars. Although it can constitute a contraindication for an
SIEA flap, the presence of a low transverse scar (i.e. Pfan­
nenstiel) is usually not an issue in DIEAP flaps because the
lower incision can be placed in the same location. However,
large-caliber musculocutaneous perforators from the recti
muscles may or may not still be present, depending on the
extent of upper flap undermining performed at the initial
operation. Therefore, a preoperative duplex or angio-CT
scan study is mandatory in this case. Small abdominal scars
(e.g., appendectomy scars) can also be ignored because
their presence does not significantly affect the vasculariza­
tion of the flap. Midline scars are more problematic because
they will result in insufficient blood flow to the contralateral
side of the flap. If the whole flap is necessary for the recon­
struction, then dissection of a bipedicled flap, with an extra
pair of microanastomoses will result in excellent vasculariza­
tion to both halves.
DIFFERENCES IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
The DIEAP/SIEA free flap is most often used in breast
reconstruction and is harvested routinely using the abdomi­
noplasty pattern. On the other hand, pedicled flaps are used

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps
675
symmetry. To facilitate donor site closure, it is also usually
necessary to elevate the lower extremities. The resultant hip
flexion decreases tension on the lower abdominal skin.
ANESTHETIC CONSIDERATIONS
The flap is harvested under general anesthesia. It is crucial
that the patient be fully paralyzed during the intramuscular
dissection of the perforators to facilitate surgical manipula­
tion and to avoid undue damage to the flap pedicle by
muscular contraction. Because the operation can take place
over a prolonged period, IV fluid replacement should be
controlled meticulously throughout surgery in order to
avoid hyper- or hypovolemia. Fluid overload can result in
deleterious flap edema, whereas hypoperfusion will lead to
sluggish microvascular flow and increased risk of thrombo­
sis. Appropriate measures of thromboprophylaxis should
also be taken in the peri- and postoperative periods. We use
antiembolic stockings, leg pumps during surgery and post­
operative low-molecular-weight heparin (LMWH) until dis­
charge from the hospital.
TECHNIQUE OF FLAP HARVEST
(Figs 57.8–57.12)
After induction of general anesthesia, the patient is prepped
and draped in a sterile fashion. The incision lines are infil­
trated with an epinephrine-containing local anesthetic
except for the region of the superficial inferior epigastric
vessels. The lower abdominal incision is made first. A blood­
less dissection of the subcutaneous fat is performed with the
electrocautery needle. The SIEV is identified on both sides
in the superficial subcutaneous tissue at a point about
for local defects and should be tailored to adequately fill
them while allowing primary closure of the donor site if
possible. It is important to note that some motor nerves will
likely be severed during mobilization of a pedicled DIEAP
flap. Those intramuscular nerves should be repaired follow­
ing transposition of the flap to minimize functional sequelae
to the rectus muscle.
FLAP DIMENSIONS
SKIN ISLAND DIMENSIONS
Flap height: average 13 cm, maximum 18 cm
Flap width: average 34 cm, maximum 60 cm
Thickness: 4 cm (range 2–8 mm)
The maximal size of a DIEAP flap is influenced by the
patient’s body habitus and determined by the ability to
obtain primary closure of the donor site. Most often, the
contralateral, least vascularized part is not needed for the
reconstruction and is discarded. In the case of a SIEA flap,
the same elliptic design is used in order to facilitate donor
site closure. However, the perfusion can be unreliable past
the midline and, usually, only the ipsilateral half of the SIEA
flap is used in the reconstruction.
FLAP MARKINGS (Figs 57.6 and 57.7)
The patient is in the supine position. First, the position of
the major perforators is marked on the skin according
to the findings of the preoperative duplex or angio-CT scan
study. A system of coordinates centered on the umbilicus is
used to accurately localize the perforators. A handheld
Doppler can be used to locate and mark the position of the
superficial inferior epigastric arteries and veins. Next, the
flap is designed over the main perforator (Fig. 57.7). Total
skin resection is typically elliptic and extends from one ASIS
to the other. The lateral corners of the flap should be posi­
tioned relatively low to avoid high-riding scars. If necessary,
the flap design can be expanded laterally in the flanks along
the iliac crest. It is important to note that the position or
shape of the skin paddle should be adapted to guarantee
the safe capture of the most interesting perforator. The
lower incision is positioned in the suprapubic crease,
whereas the superior incision runs just above the umbilicus.
The tissue laxity is then examined using the “pinch test” to
insure that wound closure will be possible without excessive
tension. Alternatively, the abdominal flap can be harvested
using an infraumbilical upper incision. In that case, however,
the large-caliber periumbilical perforators would be
excluded from the flap. Further, basing the flap on a more
caudal perforator will result in a shorter pedicle.
PATIENT POSITIONING
The patient should be in the supine position with the upper
extremities adducted and immobilized next to the trunk.
For breast reconstruction, the installation should be planned
in a way to allow the patient to be in the sitting position, as
this position is useful to adequately inset the flap and verify
Figure 57.7  Depending on the tissue requirements, a smaller or
larger skin paddle can be harvested. A vertical design is also possible
for the DIEAP flap. The key point is to center the skin island as much
as possible over the selected perforator.

676
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
incisions are made according to preoperative markings. The
superior aspect of the flap is dissected through fat with
minimal cephalic beveling until the deep fascia is visualized.
This allows inclusion of more volume in the flap and avoids
damage to marginal perforators. The flap is then detached
from the deep fascia in a lateral to medial direction. Dissec­
tion proceeds rapidly up to the semilunar line, at which
point a meticulous exploration for musculocutaneous per­
forators starts. Using the preoperative duplex or CT scan
markings, the largest perforating vessels are isolated sequen­
tially, taking care not to sacrifice a perforator before a more
suitable one is found. Probably the most crucial part of the
operation is choosing which perforator(s) to use. To help
with this decision, refer to Box 57.2, in which we have com­
piled general guidelines derived from our experience.
Once the best perforator is selected, it is freed circumfer­
entially above the level of the fascia (Fig. 57.9). The anterior
sheath of the rectus muscle is then opened longitudinally
cranially and caudally in the direction of the pubis, starting
at the point of emergence of the vessel. There is often an
open slit in the fascia around the perforating vessels, which
facilitates the insertion of the tips of the fine specific dissec­
tion scissors. Caution should, however, be exercised because
the pedicle sometimes follows a subfascial course (Fig.
57.10A) and can easily be damaged by a careless move. The
fascia should also be opened for 2–3 cm on the cephalic
side of the perforator to ease exposure. Following the fasci­
otomy, the most delicate phase of the flap harvest begins.
The intramuscular dissection demands constant attention
and meticulous handling of tissues by both the surgeon and
the assistants. It is also mandatory to have the patient in a
completely paralyzed state so as to avoid muscle jerking
movements and ensuing avulsion damage to the pedicle.
The dissection proceeds by sagittal splitting of the muscle
between its fibers, thereby minimizing muscular damage.
Undue transection of muscle fibers should be avoided.
Using blunt dissection, the pedicle is gently teased off the
surrounding perimysial areolar tissue. Side branches are
carefully ligated and cut. Although there is great variability
in the intrarectal course of the vessels, it is usually easier to
dissect them in the most inferior portion because, at this
point, the vessels have emerged on the posterior side of the
rectus and lie in a fatty plane. During dissection of the
lateral pedicle, one or more segmental intercostal nerves
will normally be encountered (Fig. 57.10B). Motor nerves
are less associated with medial perforators. The mixed
nerves enter the rectus sheath laterally, penetrate the muscle
posteriorly, and then split into a motor and a sensory branch
(Fig. 57.10C). The sensory nerves usually accompany perfo­
rating vessels on their course towards the skin. They can be
sacrificed or used to obtain a sensate flap. The motor
branches travel oblique-horizontally across the muscle and
usually are located anterior to the intramuscular vascular
pedicle. These nerve branches should be preserved to avoid
denervation of the muscle. When two or more perforators
are used in the same vertical row, sometimes an intervening
motor nerve has to be cut during harvest. In these cases, the
nerve is reanastomosed before closure. In other cases, a
small strip of muscle may be located between both perfora­
tors (Fig. 57.10D). If no nerves are running within this strip,
the muscle can be cut at the level of the closest tendinous
intersection and later re-sutured.
4–5 cm lateral to the midline. The diameter of these vessels
is noted, as it gives an important clue to the relative impor­
tance of the superficial drainage system versus the deep
inferior epigastric pathway. Unless it is very small and insig­
nificant, the SIEV is always dissected for a few centimeters
by careful ligation of all side branches. Of course, in the
case of a SIEA flap, the SIEV constitutes the flap’s main
drainage path and should be dissected down to its origin. A
large SIEV should be preserved during a DIEAP flap dissec­
tion, as it can potentially be used to supercharge the flap in
the event of venous outflow insufficiency of the deep system.
The dissection then proceeds laterally to identify the SIEA.
It is usually located at the midpoint of the inguinal ligament,
2–3 cm lateral to the SIEV and deep to Scarpa’s fascia (Fig.
57.8). If the diameter of the SIEA is larger than 1 mm, the
abdominal flap can be safely harvested based on the super­
ficial vessels. If not, the contralateral SIEA should be
explored or the flap converted to a DIEAP.
If the decision is taken to base the flap on the SIEA, the
artery and its two venae comitantes are dissected down to
their points of origin. The periumbilical and superior
abdominal incisions are made and deepened down to the
muscular fascia. The flap is harvested by dissection in the
plane immediately superficial to the deep fascia, in the same
way as a classic abdominoplasty resection. The SIEA can
reliably irrigate the flap up to the midline, sometimes with
some extension over the medial half of the contralateral
rectus muscle. Therefore, the rest of the flap usually needs
to be discarded.
In the case of a DIEAP flap harvest, following dissection
of the superficial inferior epigastric veins, the operation
proceeds with the identification and skeletonization of one
or more suitable musculocutaneous perforators from either
rectus abdominis muscle. The dissection is first done on one
side of the abdomen while leaving the other side intact and
keeping it as a lifeboat. The periumbilical and superior
Figure 57.8  The lower incision has been made and the superficial
vessels are visible. Note the presence of the superficial circumflex
iliac artery (SCIA) laterally. SIEA, superficial inferior epigastric artery;
SIEV, superficial inferior epigastric vein.
Contralateral
SIEV
Midline
SIEV SIEA
SCIA

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps
677
muscle. At this level, exposure of the vessels is obtained
easily either by a lower lateral extension of the fascial inci­
sion or by a separate short fascial incision in the lower
semilunar line. After an adequate dissection of the pedicle,
the contralateral side of the flap can then be detached from
the deep fascia (Fig. 57.12). We usually save the biggest
perforator on the contralateral side and clamp it. Flap per­
fusion can then be assessed based on the dissected perfora­
tor. If inadequate, the clamped perforator can be dissected
and used to vascularize the flap. Otherwise it is ligated
and cut. Intraoperatively, flap perfusion is always evaluated
clinically with color and capillary refill. In questionable
cases, indocyanine green laser angiography can be used to
help delineate non-viable zones. Similarly to a free TRAM
flap, zone IV will often suffer from vascular insufficiency
and will be resected. If the whole flap is required for the
reconstruction and the contralateral, least vascularized part
is either hypoperfused or congested, the flap should be
supercharged by anastomosing an additional contralateral
perforator and/or the contralateral SIEV, thereby facilitat­
ing vascular augmentation of the contralateral, least vascu­
larized part.
FLAP MODIFICATION/FLAP HANDLING
SIAMESE FLAP: DOUBLE PEDICLE LOWER
ABDOMINAL FLAP
The lower abdominal skin flap can be harvested as a Siamese
flap by dissecting a vascular pedicle on each side. Because
the two sides are independent, any combination of pedicle
is possible: DIEAP/DIEAP, DIEAP/SIEA, or SIEA/SIEA.
This way, excellent vascularization of the whole flap can be
obtained in patients with a median scar. The Siamese flap
can also be converted into two separate flaps by dividing it
in halves. This constitutes an ideal choice for bilateral simul­
taneous breast reconstruction. Lastly, another application of
the double pedicle concept would be to extend the viable
territory of the DIEAP flap. Indeed, a larger flap can be
transferred when the contralateral superficial circumflex
iliac vessels are used to supercharge it.
Without doubt, the easiest and fastest dissection can be
executed with the presence of pararectal perforators,
running around the medial border of the rectus muscle,
which occur in about 10% of cases. By pulling the rectus
muscle laterally after making a long paramedian incision of
the deep fascia, wide exposure can be obtained and all kinds
of intramuscular dissection can be avoided (Fig. 57.11).
The deep inferior epigastric vessels are usually dissected
until they reach the lower lateral border of the rectus
Figure 57.9  Suprafascial view of a perforator from the DIEA.
Box 57.2  Guidelines on Choosing the
Right Perforator
• Preoperative investigation with a color duplex scan or with
a multidetector spiral CT is a key element in surgical plan-
ning. Information, such as vessel position, diameter, and
branching patterns can be obtained. This is used as a road
map to aid dissection and decision-making.
• The largest perforating vessels from the DIEA are virtually all
located within a 6 cm radius lateral and inferior to the umbi-
licus. The dominant perforator is the one with the largest
diameter and with subcutaneous branching in all directions,
specifically towards the midline.
• Usually only one perforator of adequate diameter (0.1 mm)
is sufficient to vascularize the entire lower abdominal skin.
Inflow is rarely a problem when the perforator shows good
pulsatility.
• One of the most important factors in selecting a perforator
is the size of the accompanying vein. In order to minimize
the chances of outflow insufficiency, the largest-diameter
vein should be selected if the paired perforating artery is
suitable.
• When only small- to moderate-caliber vessels are present,
the flap can be harvested based on two or three perforators
in the same vertical row. In this case, intervening motor
nerves between perforators must be cut and re-sutured after
flap harvest.
• If possible, the perforator should be located close to the
center of the flap. A marginal perforator can also be satisfac-
tory if the branching pattern seen perioperatively or in the
preoperative study appears to be directed mainly into the flap.
• Perforators from the lateral row have a shorter intramuscular
course and are easier to dissect. Further, the lateral branch
of the DIEA is dominant in the majority of cases.
• Perforators in the medial row are more centrally located in
the flap. Use of a medial row perforator may result in better
perfusion of the contralateral, least vascularized part because
it is anatomically closer to the distal contralateral side. This
can be an important factor in cases where as much volume
as possible is required. However, the intramuscular course
of a medial row perforator can be longer.
• A large medial pararectal perforator constitutes an ideal
choice because of its central location in the flap and
because the dissection is much less tedious, being com-
pletely extramuscular.
• The lowest tendinous inscription of the rectus is situated at
the level of the umbilicus or slightly below. It constitutes a
common point of emergence for fairly large lateral perfora-
tors. Although the dissection can be somewhat tedious
because of fibrous attachments, the intramuscular course is
usually quite short. The vessels typically traverse the muscle
directly and then run on top of the posterior fascia. This can
result in a decreased harvest time.

678
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
THIN PARAUMBILICAL PERFORATOR-BASED FLAP
Koshima et al. have described the use of thin paraumbilical
perforator-based flaps.10 They effectively showed that it
is possible to obtain a thin version of the DIEAP flap
by resecting most of the pannicular fat. Only 5 mm of
adipose tissue is left under the skin to protect the subdermal
plexus. However, it is crucial that a 3 cm cuff of tissue
be preserved around the perforator during the thinning
process to avoid endangering the blood supply of the flap.
In the absence of precise knowledge of the perforator mor­
phology, this thinning procedure remains nonetheless risky
and should probably be undertaken only by experienced
surgeons using careful microsurgical dissection around
the perforator. We believe it is more advisable to proceed
SENSATE DIEAP FLAP
It is also possible to harvest the DIEAP flap as a sensate flap.
The selected perforator will usually be accompanied on its
way to the skin by a pure sensory nerve, which is the anterior
cutaneous branch of one of the mixed segmental nerves
supplying the rectus muscle (Fig. 57.10C). This sensory
branch can be harvested by epineural splitting of the mixed
nerve up to the lateral edge of the rectus sheath. This pro­
vides a length of 3–9 cm, thus making it feasible to reanas­
tomose the nerve at the recipient site. In breast reconstruction,
the anterior ramus of the lateral cutaneous branch of the
fourth intercostal nerve is preferentially used as a recipient
nerve, resulting in good sensory restoration and even the
return of erogenous sensation.
Figure 57.10  (A) Typical example of the dissection of a medial perforator. The perforator runs close to the undersurface of the deep fascia
once it has pierced it in a caudal direction. There is mostly a long and superficial course of the perforator through the rectus muscle before it
descends and finally traverses through to the posterior surface of the muscle. Multiple branches can be visualized providing blood circulation
to the middle part of the rectus muscle. Large motor and sensory nerves are rarely observed in this part of the muscle. (B) Typical image of
the dissection of a lateral perforator. The perforator runs straight through the muscle down to the main lateral branch of the DIEA. The dissec­
tion is often short and easy. Several mixed and/or pure motor nerves cross over this branch and the perforator. A lateral recurrent motor branch
can be seen coming off a mixed nerve near the perforator. It turns around to innervate the lateral portion of the muscle. (C) Schematic drawing
of the most common anatomic presentation of a dissection of a lateral perforator. A sensory nerve is branching off a mixed segmental nerve
and is running with the perforating vessels to the overlying skin. A sensate DIEAP flap can be harvested based on these structures. Motor
nerves cross over the deep vessels. (D) A few fibers or a small strip of muscle can be transected without functional loss. If necessary it can
be re-sutured.
Intersection
tendinea
Segmental artery,
comitant veins, and
mixed segmental nerve
Rectus
abdominis
muscle
Anterior rectus
fascia
Motor branch
of segmental nerve
Posterior
rectus fascia
Perforating artery, vein,
and sensate branch of
the segmental nerve
Cranial
Lateral
Caudal
Lateral branch of the deep inferior
epigastric artery and comitant veins
Panniculus adiposus
C
A
Medial
B
Lateral
D

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps
679
suture. Since no fascia has been resected, there is no tension
on the repair and a mesh is never required. The epigastric
skin is undermined up to the xiphoid process, the umbilicus
is exteriorized at its new position, suction drains are inserted,
and the abdomen is closed in layers. Dermabond (Ethicon
Inc., Somerville, NJ) is applied on all skin incisions. Careful
attention is paid to immediately deal with the resulting dog
ears. Liposuction of the anterior part of the love handles is
also performed immediately to improve the final aesthetic
appearance of the abdomen.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
In spite of the fact that, at first sight, perforator flaps
may look more challenging and more technically demand­
ing than other flaps, their dissection rapidly becomes
routine with growing surgical experience. Several recom­
mendations can help make the DIEAP flap a safe and reli­
able operation with complication rates no higher than other
free flaps:
• It is crucial to obtain good exposure during the intramus­
cular dissection of the perforator. Before even starting to
ligate side branches, the muscle should be widely split
along the length of its fibers to unveil the 3-dimensional
neurovascular structures.
• The operator should take time to clearly understand
the anatomy and its variants before progressing any
further.
• Perfect hemostasis should constantly be sought. Even a
small amount of blood will stain the areolar planes of
dissection, thereby obscuring the path. Further, extralu­
minal hemoglobin acts as a vasoconstrictor, so blood
should be quickly washed away with an irrigation syringe.
Use of bipolar electrocautery allows efficient bloodless
dissection.
• Delicate tissue manipulation is mandatory and the flap
harvest should be performed using loupe magnification.
• Tissues should be periodically irrigated with normal
saline to avoid desiccation of the small vessels.
• As the pedicle becomes exposed and vulnerable to shear­
ing and traction damage, the flap should always be stabi­
lized on the patient either by an attentive assistant or with
the use of staples. Excessive tension on the pedicle my
cause intima tears that are invisible for the surgeon but
are responsible for inexplicable arterial thrombosis in a
later postoperative phase.
• If more than one perforator seems suitable to vascularize
the flap, thus making the choice not straightforward,
the surgeon can use microvascular clamps to selectively
occlude perforating vessels and check for flap perfusion.
• After completion of the microanastomoses at the recipi­
ent site, ensure that the long and redundant flap pedicle
is in an appropriate position without any twist or kink.
• Following flap reperfusion, the surgeon should exercise
low-threshold tolerance for venous congestion and
perform an additional venous anastomosis at the slightest
doubt. We either use the SIEV or a second perforating
vein. This will add a little time to the whole procedure
to flap debulking and sculpturing using liposuction at a
later procedure.
DIEAP FLAP WITH VASCULARIZED BONE
It is possible to design a DIEAP flap containing a piece of
vascularized bone. Such a compound flap can be obtained
by harvesting part of the superior pubic ramus, which is
supplied by pubic branches of the deep inferior epigastric
vessels. It has been used in maxillofacial reconstruction with
a thinned cutaneous paddle.
DONOR SITE CLOSURE AND
MANAGEMENT
After flap transfer to the recipient site, the anterior sheath
of the rectus is repaired with a braided non-resorbable
Figure 57.11  Pararectal perforators can easily be dissected by
retracting the rectus muscle medially via a long paramedian incision
of the deep fascia. With wide exposure a swift dissection can be
performed.
Figure 57.12  Following complete dissection, the DIEAP flap is an
island of skin and fat only. Flap harvest results in minimal donor site
morbidity and the rectus sheath can be closed without tension.

680
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
struction can be either immediate (primary) or delayed
(secondary). Immediate reconstruction is preferred in
patients who are not expected to undergo postoperative
radiation therapy because it generally results in the best
aesthetic outcome. The ability to spare native breast skin
minimizes the likelihood of patchwork appearance and
color mismatch in the reconstructed breast. However,
patients often present for reconstruction months or years
after the mastectomy and radiation therapy. In those patients,
we resect the mastectomy scar and de-epithelialize the area
of skin between the incision and the inframammary fold.
After the flap is put in place, this provides a better result by
hiding the most inferior scar within the inframammary fold
and respecting the principles of aesthetic subunits.
The internal mammary vessels constitute our preferred
recipient vessels for microsurgical breast reconstruction.
They are exposed by removal of the third or fourth rib
cartilage. An intercostal exposure is also possible. Mean­
while, the lower abdominal flap is harvested on the side
contralateral to the reconstructed breast and allows the
simultaneous unhindered presence of two surgical teams,
one elevating the flap and the other preparing the recipient
site. If the dominant perforator is located on the ipsilateral
side, an ipsilateral flap will be dissected. Next, the insetting
of the flap is performed with a 180° rotation movement,
thereby bringing the SIEV cephalad and closer to the inter­
nal mammary vessels. Thus the SIEV can easily be mobilized
and microanastomosed as the primary outflow vessel in a
SIEA flap or as a secondary drainage pathway in the advent
of venous congestion in a DIEAP flap.
After the microsurgical anastomoses are completed, the
position of the pedicle is checked for kinks and torsion.
The flap can then be shaped and inset (Fig. 57.13). The
desired volume is obtained by resection primarily of the
contralateral, least vascularized part. The area of skin
needed for the reconstruction is determined and the rest is
de-epithelialized. In the case of an immediate reconstruc­
tion following skin-sparing mastectomy, the flap is allowed
to fill the cutaneous envelope and no fixation is necessary.
In a delayed reconstruction, three features are important to
recreate:
1. The inframammary fold should be placed at the lower
border of the breast footprint. This is usually fairly well
estimated as 2 cm cranial to the contralateral normal side
because it will be lowered with closure of the abdominal
donor site.
2. The second landmark to reconstruct is the lateral border
of the breast. Two key sutures are put between the flap
and the deep tissues on a vertical line along the anterior
axillary fold. One stitch is put in the superolateral quad­
rant and another in the inferolateral quadrant. This will
help define the lateral border of the breast and prevent
the flap from migrating into the axilla.
3. Finally, breast projection is determined by the amount of
tissue gathering performed during closure of the lower
horizontal incision.
Enough tissue is added superomedially to prevent even­
tual hollowing secondary to gravitational flap movement.
Symmetry and adequacy of the reconstruction are always
checked by sitting the patient up. Two suction drains are left
but will ensure proper flap healing and will minimize the
risk of flap loss and steatonecrosis.
FLAP USAGE
PEDICLED
Although more commonly used as a free tissue transfer,
the DIEAP flap can be harvested as a pedicled island adipo­
cutaneous flap and used to reconstruct locoregional defects.
By dissecting the deep inferior epigastric vessels to their
origin, a pedicled DIEAP flap will cover the groin, the
perineum, the sacrum, part of the gluteal region, and the
greater trochanter, as well as the proximal and middle third
of the thigh. If further reach is needed, the contralateral,
least vascularized part can be extended and supercharged
by anastomosing the contralateral superficial or deep infe­
rior epigastric pedicle or even the superficial circumflex
iliac system to the genicular vessels. The pedicled DIEAP
flap has also been used for vaginal reconstruction. Because
of its shorter pedicle, the SIEA flap is less poly-valent as a
pedicled flap but can be used for defects that are adjacent
to the donor site.
FREE FLAP
• Head and neck: tongue reconstruction following total or
subtotal glossectomy, reconstruction of large ablative
compound defects of the head and neck, correction of
facial contour deformities such as Romberg’s disease.
• Trunk: post-mastectomy breast reconstruction, correction
of congenital breast hypoplasia or amastia, autogenous
breast augmentation, chest wall reconstruction.
• Upper/lower extremities: reconstruction of large area com­
pound defects necessitating soft tissue bulk.
In our practice, DIEAP and SIEA flaps have completely
replaced TRAM flaps and constitute our first choice for
autologous breast reconstruction. Although sharing the
same adipocutaneous component as the TRAM, DIEAP and
SIEA flaps have the additional benefit of significantly lower
donor site morbidity. This makes these flaps more desirable
considering the current medical trend towards less invasive
procedures. The DIEAP/SIEA flap is also used when there
is a need for microsurgical transfer of a moderate to large
amount of soft tissue. The lower abdomen is effectively the
single largest donor site of vascularized skin and fat in the
human body. A typical DIEAP flap will yield anywhere from
400 g to 2 kg or more of soft fatty tissue. A considerable area
of skin is also provided by the flap, as demonstrated by
typical skin paddle dimensions of 34 × 13 cm. We feel the
DIEAP/SIEA flap is very useful as a volume filler, especially
when a soft and natural texture is required. It can also be
used for coverage of large area defects, specifically in cases
when additional soft tissue bulk is necessary.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
The DIEAP/SIEA flap is most commonly used for breast
reconstruction because it provides an ideal tissue match.
Following oncologic breast ablation, the timing of recon­

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps
681
Although sharing the same indications as the DIEAP flap,
the SIEA flap is more suited to clinical situations requiring
only a moderate amount of tissue for unilateral or bilateral
breast reconstruction. This is because the perfusion to the
contralateral side of the flap is less reliable than in a DIEAP
flap. Obese patients often have a well-developed superficial
system and can be good candidates for a SIEA flap. Further­
more, in overweight patients, half of a large abdominal
panniculus may be more than enough for unilateral breast
reconstruction. Bilateral breast reconstruction seems to be
an ideal indication for the SIEA flap because it avoids any
intramuscular dissection. Another good indication is for
partial breast reconstruction when a limited volume of
tissue is required to correct a secondary breast deformity
following breast-conserving surgery.
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
The DIEAP flap can be useful in head and neck reconstruc­
tion, especially in cases requiring bulk, such as in total glos­
sectomy. Its long pedicle easily reaches the cervical vessels
in place, making sure they are not in direct contact with the
pedicle.
In the case of a bilateral breast reconstruction, the
abdominal flap is harvested as a bipedicled flap. The flap is
split in two and each half is microanastomosed to the con­
tralateral chest. It is interesting to note that the lower
abdominal flap virtually always provides sufficient soft tissue
for a simultaneous bilateral breast reconstruction, even in
thin women. Still within the realm of breast reconstructive
surgery, other indications for a DIEAP/SIEA flap include
salvage of a failed implant reconstruction and correction of
congenital asymmetry such as in Poland syndrome. For
severe breast hypoplasia or aplasia, flap transfer is preceded
by tissue expansion and careful surgical planning is neces­
sary. We usually approach these cases using an inframam­
mary incision. The DIEAP and SIEA flaps have also been
used with excellent results for aesthetic autogenous breast
augmentation. The long pedicle of the DIEAP flap allows
the use of a single axillary incision to inset the flap behind
the gland and perform microanastomoses to the thora­
codorsal vessels. A highly natural and lasting result can thus
be achieved with a minimal scar.
Figure 57.13  Major steps in shaping the DIEAP/SIEA flap in secondary breast reconstruction. (A) Following microvascular anastomosis;
(B) the old site of the umbilicus is excised and sutures are put in place to define the lateral border of the breast. (C) Zone IV is resected and
projection is created by skin gathering along the inframammary closure line. (D) The upper portion of the flap is de-epithelialized and buried
under the thoracic skin flap to provide bulk superiorly and medially.
A
C
D
Vascular anastomosis
De-epithelialized skin
with new inframammary
fold in correct position
Sutures
Triangular excision of
periumbilical skin
B
Skin gathering
creates projection
Excision of zone IV
Bulk added medially
with de-epithelialized
portion of flap
Final skin paddle

682
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
OUTCOMES
EXPECTED OUTCOMES
Our experience with over 2000 DIEAP and SIEA free flaps
in the last decade supports the claim that these flaps are
safe and successful in achieving superior aesthetic results.
When adequately planned and performed, these operations
actually have a complication rate equal or inferior to com­
parable free TRAM flaps, while still maintaining the high
standard of autogenous reconstruction. Additionally, since
donor site morbidity is minimal, a swifter rehabilitation is
expected.
UNTOWARD OUTCOMES
GENERAL
As free flaps, the DIEAP and SIEA are subject to known
microvascular complications. Currently, we experience a
re-exploration rate of 3% and a total flap loss rate of <0.7%.
Partial flap necrosis was observed in 7% of our earlier cases
but since we started using angio-CT strategical flap design
planning and discarding the contralateral, least vascularized
part systematically, partial flap necrosis rates have decreased
to 3%. Also fat necrosis rates are down to 2% but that
figure can be higher in smokers and patients with post-
reconstruction radiotherapy.
BREAST RECONSTRUCTION
In case of partial flap failure, we like to debride necrotic
tissue and reclose the wound primarily before the patient
leaves the hospital in order to minimize subsequent breast
deformity. If minor superficial sloughing occurs, treat­
ment is expectative. Persistent nodules of fat necrosis are
resected 6 months postoperatively at the time of nipple
reconstruction.
REGIONAL RECONSTRUCTION WITH PEDICLED FLAPS
Unfortunately, pedicled flaps sometimes fail where they
are needed the most. When a long reach is needed, DIEAP
and SIEA flaps should be supercharged on their contra­
lateral side to provide adequate perfusion to the distal
flap.
DONOR SITE
Wound-healing problems occur in up to 10% of cases
and this complication is often associated with smokers
and obesity. Seroma formation develops in about 2% of
DIEAP flaps but it is much more common following SIEA
flaps because of the more extensive dissection in the ingui­
nal region. Clips should be used to ligate large lymphatic
channels whenever they can be observed. A compression
garment can also be used postoperatively. Lastly, lower
abdominal bulging after DIEAP flap harvest is seen in fewer
than 1% of cases. True incisional hernias have not been a
problem in our practice. This constitutes a major improve­
ment over the TRAM flap and is an eloquent demonstration
of how donor site morbidity is minimized with perforator
flaps.
and the flap can be harvested while the extirpative surgery
is being performed, thereby reducing total operative time.
Also, since no muscle is included with the DIEAP flap, virtu­
ally no flap atrophy will occur and the volume persistence
will be more predictable than with a rectus abdominis myo­
cutaneous flap. This is especially important for tongue
reconstruction because an adequate volume is necessary for
swallowing function. Use of the DIEAP and SIEA flaps has
also been described for correction of facial contour defor­
mities such as Romberg’s disease.
Large thoracic defects are good indications for the use of
a free DIEAP flap when local options are insufficient. The
flap can be combined with skeletal stabilization using bone
grafts or a prosthetic mesh. Similarly, defects of the upper
and lower extremities can be good indications for a DIEAP
flap, specifically when bulk and extensive skin coverage
need to be provided. In cases of lower limb trauma, the long
pedicle makes it easier to carry out the microsurgical anas­
tomoses out of the zone of injury.
A more uncommon use of the lower abdominal flap is as
a pedicled flap for reconstruction of locoregional defects.
As mentioned previously, one or more segmental motor
nerves will likely have to be severed during elevation of the
pedicled flap. Those should be repaired to optimize the
return of muscle function. The reach of a pedicled DIEAP
flap is maximized by passing the skin island through the
rectus muscle to move the pivot point close to the origin of
the pedicle from the external iliac vessels. Moreover, the
design of an extended skin paddle along with supercharging
of zone IV will allow the flap to reach an even more distant
location.
POSTOPERATIVE CARE
GENERAL
The patient is sent to the surgical ward where flap monitor­
ing is performed clinically. Factors, such as flap color,
temperature, and capillary refill are assessed regularly. Intra­
venous hydration is continued for 2 days to support ade­
quate intravascular volume and optimize flap perfusion. On
postoperative day 1, parenteral narcotics are replaced by
oral analgesics and, unless used for lower extremity or
pelvis/peroneal reconstruction, the patient is allowed to
ambulate. All patients receive LMWH during hospital stay
and 2 weeks after discharge. Patients are usually discharged
on postoperative day 4–7.
RECIPIENT SITE
In breast reconstruction, drains are usually taken out on
postoperative day 2 or 3 when drainage decreases. The
patient is allowed to wear a loose sport bra upon discharge
from the hospital.
DONOR SITE
Drains are removed after the patient has begun to ambulate
and when drainage is <50 cc per day. A compressive garment
is not used routinely unless a seroma is developing.

CHAPTER 57 — Deep and Superficial I nferior Epigastric Artery Perforator Flaps
683
flap, the outcome of sensory recovery is in general quite
satisfactory, especially in reconstructions with a larger skin
island. About 30% of patients even recover erogenous sensa­
tion. Of course, factors such as age of the patient, smoking,
and radiotherapy will greatly influence the final level of
sensory return.
CONCLUSION
The lower abdomen definitely constitutes an ideal donor
site of abundant soft tissue and has become the first choice
for autogenous breast reconstruction. The development of
perforator flaps can be seen as the ultimate refinement of
myocutaneous flaps, as they allow harvesting of the ideal
tissue with the most minimal donor site sequelae. Nowadays,
the DIEAP flap has become the gold standard in breast
reconstruction and is paving the way to an exciting new
chapter in the evolution of plastic surgery.
LONG-TERM OUTCOMES
BREAST RECONSTRUCTION
The use of the DIEAP or SIEA flap in breast reconstruction
is expected to produce high-quality and durable results.
However, the final outcome is usually achieved after at least
three steps:
1. 0 months: initial flap transfer
2. 6 months: volume and symmetry adjustments, surgery
to contralateral breast, nipple reconstruction, scar
revision
3. 9 months: tattooing of areola.
As opposed to prosthetic reconstruction, the results of a
DIEAP/SIEA tissue transfer are expected to improve with
time, as the flap settles and matures. It is interesting to note
that the flap volume can fluctuate in time as the patient
gains or loses weight. Following transfer of a sensate DIEAP

684
PART 5 — PERFORATOR-BASED WORKHORSE FL APS
This patient was diagnosed with right-sided breast carcinoma at
the age of 37. Following a modified radical mastectomy, she
received radiotherapy and chemotherapy. At 1 year later, she
underwent breast reconstruction with a contralateral DIEAP
flap. At 10 months after the free tissue transfer, a breast reduc-
tion was done on the left side and a modified skate flap nipple
reconstruction was performed on the right. The areola was tat-
tooed 3 months later (Fig. 57.14).
CASE 57.1  Post-mastectomy and Radiation Breast Defect Underwent Delayed
Reconstruction with a Free DIEAP Flap
Figure 57.14  DIEAP flap for delayed breast reconstruction. (A,B) Post-mastectomy defect. (C,D) At 8 months after flap transfer.
(E,F) Following nipple and areola reconstruction.
A
B
C
D
E
F