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

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PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
POSTOPERATIVE CARE
GENERAL
Although various methods have been employed for flap
monitoring, clinical observation is still the best available
method. After free TFL flap transfer, we prefer to monitor
the flap on an hourly basis for the first 48 h. Depending on
recipient site, we usually keep the patient in bed for 2–3
days and then ambulate.
Hospital stay of the patient depends on the defect loca­
tion, the cause, and the patient’s general condition. When
everything is normal, we discharge the patient on the 7th
postoperative day. Nevertheless, cancer patients and seri­
ously injured patients may stay longer.
RECIPIENT SITE
When the flap is applied to the ventral body surface or to
the extremities, the patient can be placed in a supine posi­
tion. The affected extremity with the flap is slightly elevated.
If the surgeon has transferred the flap to the dorsal side
(such as the ischial and sacral area), the patient is posi­
tioned in a prone or lateral decubitus position for 12–15
days. For the trochanteric region, the position may be
supine or lateral decubitus.
DONOR SITE
There is no need for special splinting for the donor site. If
donor site is grafted, standard graft care is performed. We
do not use any medication for flap viability, we only use
antibiotics, pain medication, and fluid managements. If we
re-explore the flap or if the defect is caused by heavy crush
injury, we use continuous heparin infusion in the postopera­
tive period.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
For soft tissue coverage, the TFL flap supplies a satisfactory
amount of tissue. For extremity reconstruction, the color
and texture of the flap are very good. For the head and neck,
the flap may be lighter in color, and hair growth in atypical
areas may cause problems. The TFL flap is sufficiently strong
when used for functional purposes, such as shoulder abduc­
tion, elbow flexion, knee extension, etc. This means that if
proper rehabilitation is carried out, the functional results
are highly satisfactory. Sensory restoration is also possible
with the TFL flap when the lateral cutaneous nerve of the
thigh is included, and the results are quite satisfactory for
sensory (two-point discrimination) reconstruction. However,
when a fine sensorial and thin flap is needed (i.e., for finger
reconstruction), the TFL flap is not suitable.
DONOR SITE
It is preferable to close the donor site directly. Although the
scar in the donor site can be concealed easily, it may still
be problematic with summer clothing. Another unwanted
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• The donor site is usually closed by skin grafts, and only
narrow flaps with a width of (6–8 cm) can be closed
directly. No extra effort is recommended for direct
closure, because it may cause compartment syndrome in
the leg.
• Taking an osseous portion from the iliac crest may cause
contour deformity and/or herniation of the abdominal
wall.
• Gluteal nerve branches to the gluteus medius and
minimus muscles should be preserved.
• Elevation of an extended flap without a delay procedure
may cause distal flap necrosis.
• Thinning of the flap may cause sensory nerve disruption,
so it must be kept in mind when sensory flap is planned.
• Muscle loss after harvesting a TFL muscle or musculocu­
taneous does not cause functional loss.
• Pedicle length can be extended by dissecting the lateral
femoral circumflex artery up to the profunda femoris
artery.
• In order to extend the arc of rotation for the pedicled
flap, the proximal muscle insertion is disinserted. This can
allow for the superior muscle portion to be transposed.
• When harvesting the neurosensory flap, the area of inner­
vation of the lateral femoral cutaneous nerve can be
mapped by injecting local anesthesia and mapping the
area of denervation.
FLAP USAGE
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
PEDICLED
• Groin: fascia-skin; muscle-fascia-skin
• Ischium: fascia-skin; muscle-fascia-skin
• Perineum: fascia-skin; muscle-fascia-skin
• Lower abdomen: fascia-skin; muscle-fascia-skin; muscle-
fascia
• Sacrum: fascia-skin; muscle-fascia-skin
• Trochanter: fascia-skin; muscle-fascia-skin
FREE FLAP
• Extremity
• Functional reconstruction
• Head and neck
• Abdominal wall reconstruction.
• Composite defects (including bone)
• Breast reconstruction
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
PEDICLED
• Penis reconstruction with extended flap
FREE
• Maxillofacial and extremity bony reconstruction
• Breast reconstruction with transverse skin island

CHAPTER 60 — Tensor Fascia Lata Flap
e199
• For breast reconstruction, the volume of the flap may not
be sufficient when a large breast is reconstructed. When
the transverse design is used for flap harvesting, it may
cause significant thigh asymmetry.
• In the long term, the donor site scar heals in an unsightly
manner, especially if it is closed using a skin graft.
• Very rarely, the sacrificing of the muscle can cause knee
instability and restriction in hip abduction.
• Surgical complications such as hematoma, infection,
wound dehiscence, and skin necrosis of the donor site are
rare when general basic care is applied.
• Harvesting bone from the iliac crest may cause contour
deformity of the hip.
result may be a slight contour deformity of the donor area,
although this is usually well-tolerated.
The functional loss after the TFL flap harvest is not an
important issue. This muscle assists knee stability and hip
abduction. If the muscle is used, other thigh muscles are
sufficient for these functions. The TFL can therefore be
considered as an expandable muscle.
When the donor area cannot be closed directly, it should
be skin grafted. In this case, the donor area becomes
unsightly and unattractive and cannot be concealed easily
under short clothing.
UNTOWARD OUTCOMES
• In the long term, the flap may be bulky and need a sec­
ondary debulking procedure.
A 42-year-old paraplegic patient had a large trochanteric decu-
bitus ulcer of 9 months’ duration (Fig. 60.10A). A pedicled TFL
flap was designed to close the defect (Fig. 60.10B,C). The flap
was rotated posteriorly, and the donor area was closed primarily.
Postoperative recovery was uneventful (Fig. 60.10D).
CASE 60.1  Pedicled TFL Myocutaneous Flap for Reconstruction of a Trochanteric
Decubitus Ulcer
Figure 60.10  A right trochanteric decubitus ulcer in a 42-year-old patient. (A) Preoperative view. (B) The pedicled TFL flap design.
(C) Intraoperative view of the flap after elevation. (D) Postoperative early view.
A
B
C
D

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PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A 32-year-old man had a composite defect at the anterior segment
of the mandible, caused by a close-range gunshot blast. The
defect had been reconstructed by a bone graft and a local flap
at another institution, but the result was unsatisfactory (Fig.
60.11A). We planned to reconstruct the defect with double
free flaps. We used a fibula osteoseptocutaneous flap for the
mandible and intraoral soft tissue defects. A TFL perforator flap
was used for external coverage (Fig. 60.11B,C). The flap had
two musculocutaneous perforators and the size was 18 × 8 cm.
The donor site was closed with a skin graft. The flap was deb-
ulked and shaped secondarily to achieve a better aesthetic result
(Fig. 60.11D).
CASE 60.2  TFL Perforator-Based Flap for Reconstruction of a Head and Neck External
Soft Tissue Defect
Figure 60.11  A composite tissue defect of the anterior segment of the mandible that had been reconstructed by bone graft and local
flap in another institution with unsatisfactory result. (A) Preoperative view. (B) Intraoperative view of the TFL perforator vessel-based flap.
(C) The flap after harvest. (D) Postoperative view at 24 months.
B
A
C
D
A 37-year-old man suffered a high-tension electricity injury,
which resulted in a composite tissue defect of the medial and
lateral aspects of the distal lower extremity (Fig. 60.12A). After
sufficient debridement, a TFL flap (13 × 29 cm) was harvested
(Fig. 60.12B), and used to cover the defect. The pedicle was
anastomosed to the posterior tibial vessels. The fascial layer of
the flap was used to reconstruct the defect of the Achilles tendon
as a vascularized fascial tissue. The donor area defect was closed
using a split-skin graft. Postoperative recovery was uneventful.
The flap was thinned 3 months postoperatively and the patient
had a healed wound at 12 months (Fig. 60.12C).
CASE 60.3  Achilles Tendon and Soft Tissue Reconstruction of a Lower Extremity with a
TFL Myofasciocutaneous Flap
Figure 60.12  Extensive composite soft tissue loss of the distal lower extremity. (A) Preoperative view. (B) TFL flap after harvest.
(C) Postoperative view at 12 months.
A
B
C

CHAPTER 60 — Tensor Fascia Lata Flap
e201
A 23-year-old woman presented with a tissue defect of the ante-
rior forearm caused by chemical substance extravasation. After
sufficient debridement, a TFL (10 × 24 cm) was used to cover the
defect. The pedicle was anastomosed to the ulnar artery and
its concomitant vein in end-to-side and end-to-end manners,
respectively. The donor area defect was closed primarily. Postop-
erative recovery was uneventful. The flap was thinned 6 months
postoperatively.
(Fig. 60.13)
CASE 60.4  Anterior Forearm Soft Tissue Defect Reconstructed with a Free TFL Flap
Figure 60.13  Anterior forearm soft tissue defect reconstructed with a free TFL flap. (A) Preoperative view of the patient before debride­
ment. (B) Postoperative result at postoperative 1 year after one debulking procedure.
A
B

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PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A 53-year-old paraplegic patient had a trochanteric pressure sore
(7 × 7 cm) of 6 months’ duration. A pedicled perforator vessel-
based tensor fascia lata flap was designed to close defect. The
flap was rotated posteriorly, and donor area was closed directly.
Postoperative recovery was uneventful.
(Fig. 60.14)
CASE 60.5  Trochanteric Defect Reconstructed with a Pedicled TFL Perforator Flap
Figure 60.14  Large trochanteric pressure sore. (A) Trochanteric ulcer lateral view. (B) Flap elevated and a perforator supplying the flap
is visualized. The flap healed without any vascular problem. (C) Early view of the islanded perforator-based TFL skin flap just after the
operation. (D) Postoperative result after 3 months.
A
C
B
D
A 64-year-old man was referred to us because of preauricular
basal cell carcinoma. Large excision was done including right
pinna and the defect was covered with a 15 × 7 cm TFL perfora-
tor flap. The postoperative course was uneventful. External
auditory canal was preserved so the patient could hear, with a
special device.
(Fig. 60.15)
CASE 60.6  Right Face Defect Reconstructed with a TFL Perforator Flap
Figure 60.15  Right face defect reconstructed with a TFL perforator flap. (A) The patient with a preauricular basal cell carcinoma.
(B) Defect is seen after large excision including the pinna. (C) Postoperative result after 1 year.
A
B
C

CHAPTER 60 — Tensor Fascia Lata Flap
e203
REFERENCES
1. Wangensteen OH. Repair of recurrent and difficult hernias and
other large defects of the abdominal wall employing the iliotibial
tract of fascia lata as a pedicled flap. Surg Gynecol Obstet 1934;
59:766–80.
2. Bailey BN. Excision of hip joint in bed sores. London: Edward
Arnold; 1967. p. 122.
3. Hill HL, Nahai F, Vasconez LO. The tensor fascia lata myocutaneous
free flap. Plast Reconstr Surg 1978;61:517–22.
4. Nahai F, Silverton JS, Hill HL, et al. The tensor fascia lata musculo­
cutaneous flap. Ann Plast Surg 1978;1:372–9.
5. Bostwick J 3rd, Hill HL, Nahai F. Repairs in the lower abdomen,
groin, or perineum with myocutaneous or omental flaps. Plast
Reconstr Surg 1979;63:186–94.
6. McGregor JC, Buchan AC. Our clinical experience with the tensor
fasciae latae myocutaneous flap. Br J Plast Surg 1980;33:270–6.
7. Deiler S, Pfadenhauer A, Widmann J, et al. Tensor fasciae latae
perforator flap for reconstruction of composite Achilles tendon
defects with skin and vascularized fascia. Plast Reconstr Surg 2000;
106(2):342–9.
8. Koshima I, Urushibara K, Inagawa K, et al. Free tensor fasciae latae
perforator flap for the reconstruction of defects in the extremities.
Plast Reconstr Surg 2001;107:1759–65.
9. Tuinder S, Baetens T, De Haan MW, et al. Septocutaneous tensor
fasciae latae perforator flap for breast reconstruction: radiological
considerations and clinical cases. J Plast Reconstr Aesthet Surg
2014;67(9):1248–56.
FURTHER READING
Brand PW, Beach RB, Thompson DE. Relative tension and potential
excursion of muscles in the forearm and hand. J Hand Surg 1981;
6A:209–19.
Caffee HH, Asokan R. Tensor fascia lata myocutaneous free flaps. Plast
Reconstr Surg 1981;68:195–200.
Cheng N, Shou B, Zheng M, et al. Microneurovascular transfer of the
tensor fascia lata musculocutaneous flap for reconstruction of the
tongue. Ann Plast Surg 1994;33:136–41.
Coskunfirat OK, Ozkan O. Free tensor fascia lata perforator flap as a
backup procedure for head and neck reconstruction. Ann Plast Surg
2006;57(2):159–63.
Joseph ST, Thankappan K, Mathew J, et al. Defect components and
reconstructive options in composite orbitomaxillary defects with
orbital exenteration. J Oral Maxillofac Surg 2014;72(9):1869.
Kim YH, Kim SW, Kim JT, et al. Tensor fascia lata flap versus tensor
fascia lata perforator-based island flap for the coverage of extensive
trochanteric pressure sores. Ann Plast Surg 2013;70(6):684–90.
Kimura N. A microdissected thin tensor fasciae latae perforator flap.
Plast Reconstr Surg 2002;109:69–77.
Manktelow RT, McKee NH. Free muscle transplantation to provide
active finger flexion. J Hand Surg 1978;3:416–26.
Nahai F, Hill L, Hester TR. Experiences with the tensor fascia lata flap.
Plast Reconstr Surg 1979;63:788–99.
Safak T, Klebuc MJ, Kecik A, et al. The subcutaneous pedicle tensor
fascia lata flap. Plast Reconstr Surg 1996;97:765–74.
Tan O, Kuduban SD, Algan S, et al. Total lower lip reconstruction using
free neurotendinofasciocutaneous anterolateral thigh composite
flap: a case report. J Reconstr Microsurg 2013;29(7):487–90.
Expert Commentary 
Bishara Atiyeh, MD, FACS, and Fadel M. Chahine, MD
The tensor fascia lata (TFL) pedicled transposition flap is one
of the first described musculocutaneous flaps. It gained great
popularity in the late 1970s, primarily for reconstruction of
trochanteric pressure ulcers as well as for groin, perineum,
ischium, and lower abdominal defects because of its reliable
blood supply, appropriate skin paddle size, quality, ease of
dissection and elevation, and adequate arc of rotation. Despite
high rates of successful reconstruction, a bulky dog-ear at the
flap base was an unavoidable and unwelcome outcome in many
cases. Since then, developing surgical skills and expertise have
allowed flap harvesting to evolve from traditional musculocuta-
neous, to osteomusculocutaneous or musculo-osseous flap,
or even to simple thin skin-subcutaneous tissue flaps, facilitating
reconstruction of widely diverse traumatic or ablative defects.
TFL elevated as a neurosensorial flap potentially provides
sensory restoration of critical body areas. Simultaneously, the
surgical dissection and flap elevation technique has progressed
from pedicled musculocutaneous flap to technically more
demanding perforator flap for better arc of rotation allowing
ultimately microvascular free flap transfer for soft tissue cover-
age as well as for functional reconstruction. Moreover, refine-
ments in flap design have afforded better donor site primary
closure and minimized secondary contour deformity. Recently,
a U-shaped TFL skin paddle has been described for closure
of trochanteric defects. With muscle islandization, near-
circumferential mobilization of the skin paddle, and limited
selective undermining, primary closure of trochanteric defects
without dog-ears or trifurcations may now be achieved. For
recurrent trochanteric defects, free-style recycling of a TFL flap
into a perforator-based flap is also possible.
At present, even though any composite bloc of tissues can
possibly be harvested if a supplying vessel can be identified
and dissected, and despite the fact that many other possibly
better options are available, the use of TFL for reconstruction
of various extremity and head and neck defects may still be
considered a valid alternative. It can also be successfully used
in breast reconstruction as an alternative to the deep inferior
epigastric artery perforator (DIEP) flap in certain cases where
breast reconstruction with this flap may not be possible.
Regardless, we believe that the main value of TFL resides
in the fact that it can be easily mobilized as a pedicled or
even perforator flap for reconstruction of trochanteric, groin,
perineum, ischium, and lower abdominal defects. Except for
limited and selected cases, better alternatives are available for
reconstruction of other defects.

717
INTRODUCTION
In the field of reconstructive surgery, not a day goes by
without a skin flap being used. The earliest description of
skin flaps was by Sushruta in 600bc and this was, in fact, a
local flap, of axial type. The flap described by Tagliacozzi in
1597 was a random pattern flap from the medial aspect of
the upper arm. These two flaps, being a local flap and
distant flap, respectively, were both used for reconstruction
of the nose. Despite extensive studies of the blood supply to
the skin by Manchot in 1889 and Salmon in 1936, most of
the reconstructions during the First and Second World Wars
were by tube pedicles. In 1973, McGregor and Morgan clas­
sified skin flaps into axial and random pattern flaps.1 Ponten
highlighted the value of fascia in augmenting the blood
supply to the skin.2 In 1995, Batchelor and Moss reported
that the fascia acts like a scaffold for the sub-, intra-, and
suprafascial vascular plexus.3 Taylor and Palmer in 1987,
proposed the concept of “angiosomes” (vascular territories)
and choke vessels.4 With this knowledge, the floodgates
were opened for various types of fasciocutaneous flaps.
The skin plays an important role in protecting the body
and thermoregulation. It is separated from the underlying
structures by connective tissue called fascia. The skin, in
order to regulate the temperature of the body, needs a rich
blood supply; hence there is a regular connection between
the vessels within the tissue compartment and the skin via
various perforations in the deep fascia. Taylor identified an
average of 374 cutaneous perforators in the body.4 Fujino,
in 1967, demonstrated the importance of perforators in the
circulation of skin flaps.5 He also reported that the perfora­
tors and the axial vein are important for interstitial fluid
turnover.
There are different types of perforators. Our own clinical
observations have identified two distinct vessels: the perfo­
rating vessels, which penetrate the deep fascia and have an
artery and venae comitantes, and the fascial feeder vessels,
which do not penetrate the deep fascia but terminate under
it. The latter are mainly arterial without any venae comitan­
tes. Both the perforators and the fascial feeders take part in
the formation of the subfascial, intrafascial, and suprafascial
Posterior Tibial Artery
Perforator Flap
Niri S. Niranjan
61 
Figure 61.1  Posterior tibial artery perforator flap.
Saphenous nerve
Gastrocnemius
Tibial nerve
Posterior tibial artery
Posterior tibial artery
perforator flap
Tibia
Sural nerve
PART 5  —  PERFORATOR-BASED WORKHORSE FLAPS

718
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
FLAP ANATOMY (Fig. 61.1 and see Ch. 13
and Figs 13.6, 13.7, 13.10, 13.11, 13.12, 13.13,
13.19)
The fasciocutaneous or adipofascial flaps, based on perfo­
rating vessels of the posterior tibial artery, can be proximally
or distally based. For defects over the foot, reverse posterior
tibial artery flaps can be used, incorporating all the perfora­
tors of the posterior tibial artery.
ARTERIAL SUPPLY OF THE FLAP (Fig. 61.1 and
see Figs 13.6 and 13.10)
Dominant:  perforators from posterior tibial artery
Length: 4 cm (range 2–6 cm)
Diameter: 1.5 mm (range 1–2 mm)
Perforators form three perforating vessels on the medial
side of the leg, which can be located between 9–12 cm,
17–19 cm, and 22–24 cm from the tip of the medial
malleolus.
Septocutaneous vessels, which are the direct link between
the main vascular trunk and the fascia and skin, supply this
flap. The perforators can be traced to the posterior tibial
artery, which can be included with the flap to increase the
pivot point. In that case, the vessel length could reach proxi­
mally up to the knee joint and distally to the foot.
It is not wise to sacrifice the major vessel of the leg. Only
in exceptional situations, where all the three vessels of the
leg are intact and when there are no other options available,
is the local option of using the posterior tibial artery perfo­
rator flap possible.
Minor:  random pattern supply from the plexus of the
fascia
The plexus of vessels in the fascia is fed not only by per­
forators but also by fascial feeder vessels (Ponten super­
flap).2 The fascial feeders are inconsistent and are only very
fine arterial vessels with no accompanying veins.
VENOUS DRAINAGE OF THE FLAP (see Fig. 13.19)
Primary:  venae comitantes of the perforator artery
Length: 4 cm (range 2–6 cm)
Diameter: 0.75 mm (range 0.5–1 mm)
Secondary:  cutaneous veins draining into long saphenous
or short saphenous system (Fig. 13.20)
The secondary vein is included in the flap only when
there is inadequate venous drainage (long and short saphe­
nous veins).
FLAP INNERVATION (see Fig. 61.1 and Fig. 13.19)
Sensory:  The cutaneous nerve on the anteromedial
aspect of the leg is the long saphenous nerve. Similarly,
branches of the sural nerve supply the posterior aspect of
the leg.
Motor:  This flap can contain a small segment of muscle
that would receive its blood supply in a reverse manner;
plexi. These in turn communicate and form a rich plexus
under the skin.
We now have various types of skin flaps based on perforat­
ing vessels and this has led to some confusion. To alleviate
this, Wei et al. in 2001 defined perforators as those vessels
that penetrate muscle on their path toward skin.6 But,
anatomically, the blood vessels that supply the muscles,
bone, and large tendons also penetrate the deep fascia to
supply the skin. In addition to these vessels, there are blood
vessels called “septocutaneous direct perforators” that also
perforate the deep fascia and these travel between muscles
and compartments. Linton published a detailed study of
the septocutaneous vessels of the leg and used the term
“perforator”.7 He described the communicating veins
between the superficial and deep systems and the accompa­
nying artery. In 2009, Saint-Cyr et al. introduced the term
“perforasome.”8 Each perforator holds a unique vascular
territory and by direct and indirect linking vessels they
form a network and play a critical part in perforator flap
perfusion.
Numerous anatomic cadaveric studies have established
the number, location, and type of perforators of the poste­
rior tibial artery. For practical purposes, the leg has been
divided in many ways: into an upper concealed part and a
lowed exposed part9; into five 7 cm parts10; into four zones11;
three zones12; and 10 equal parts13. Most recently, Shaverian
and Saint-Cyr found that there were three constant clusters
of perforators at 4–9 cm, 13–18 cm, and 21–26 cm from the
medial malleollus.14
There are a greater number of longer and larger-caliber,
muscle-type perforators in the upper half, while the perfora­
tors of the lower half, or lower third, of the leg are the
shorter, direct cutaneous type. My own clinical observation
is that there are three direct septocutaneous perforators in
the lower third, which correspond to Linton’s venous con­
nection between the superficial and deep vein system.7
These perforators communicate with each other as well as
with the anterior tibial and perineal artery perforators, to
form a suprafascial level network.
There is also a rich vascular network forming a circle of
anastomoses around the ankle joint. This knowledge will
help reconstructive surgeons to use various perforating
flaps based proximally or distally around the knee and ankle
joints (Table 61.1).
The posterior tibial artery perforator has septocutaneous,
musculocutaneous, and periosteocutaneous perforators as
described by Koshima et al. in 1992.10 We also noticed that,
apart from these perforators, there are vessels that supply the
Achilles tendon and also perforate to supply the skin. These
are called “tendinocutaneous.” Based on these perforating
vessels, it is possible to raise small cutaneous flaps as local
flaps to cover the exposed bone and tendon over the leg.
The perforator concept has become a method of choice
in reconstruction both as free and local pedicle flap. This
requires two basic understandings: the knowledge of blood
supply of the skin and the surface anatomy of muscles and
compartments. This will help in locating perforators and
planning a flap for reconstruction.
A Doppler is a useful tool to use prior to raising per­
forator flaps, especially pedicled perforator flaps. CT angi­
ography is a useful but not essential form of imaging, as
most perforator-based flaps do not require intramuscular
dissection.

CHAPTER 61 — Posterior Tibial Artery Perforator Flap 718.e1
Table 61.1  Anatomic Study of Posterior Tibial Artery Perforators
Anatomic Study
Zone
Number
Caliber
(mm)
Pedicle
length (cm)
Location from medial
malleolus (cm)
Clusters
Carriquiry et al.
(1985)15
3
4–5
0.5–1.5
–
9–12
17–19
22–24
–
Liu et al. (1990)9
2
–
–
–
–
–
Koshima et al.
1992)10
5 (7 cm)
3.1 ± 0.8
–
–
–
–
Wu et al. (1993)11
4
2–5
1.0–1.5
–
8–15
Zone II
Hung et al. (1996)16
–
5–8
1.5 ± 0.2
4 ± 1.3
18.6 ± 4.5
–
Whetzel et al.
(1997)13
10
3–8
0.5–1.0
–
–
95% in lower
Taylor and Pan
(1998)17
Anterior
Posterior
(SC) 6–16
(M) 1.5
(SC) 2.5
0.76
1.15
–
–
–
Ozdemir et al
(2006)12
3
–
0.4–2.1
0.5–2.0
0.3–1.5
–
Upper third
Middle third
Lower third
–
Shaverian and
Saint-Cyr (2008)14
3
4.9 ± 1.7
1.0–1.5
–
4–8
13–17+21–25
–
Tang et al. (2009)18
–
4–9
0.6–1.2
–
–
Lower-half
septocutaneous
Upper-half
muscle-cutaneous
SC, septocutaneous.

CHAPTER 61 — Posterior Tibial Artery Perforator Flap
719
should be assessed. An absolute contraindication to a
perforator flap is a degloving injury, as generally, the perfo­
rators are severed. Relative contraindications include
patients who are obese, diabetic, chronic smokers, and suf­
ferers of pyoderma gangrenosum.
The vascularity of the leg should be assessed before the
operation by the presence of peripheral pulsations of the
three major vessels of the leg. An arteriogram is helpful but
not essential. In approximately 6% of patients, the posterior
tibial artery is weak or absent.
Before the operation, the leg is shaved and cleaned with
antiseptic solution. Prophylaxis against deep vein thrombo­
sis is given perioperatively.
FLAP DESIGN
ANATOMIC LANDMARKS (Figs 61.2, 61.3)
The donor area of the posterior tibial artery perforators
extends anteriorly to the anterior border of the tibia and
posteriorly to the midline of the posterior aspect of the leg.
All the perforators of the posterior tibial artery perforate
the deep fascia in a longitudinal line from the tibial tuberos­
ity superiorly to the medial malleolus inferiorly.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Knowledge of the vascularity, distribution, and location of
the perforators helps the operating surgeon to design a
flap based on posterior tibial artery perforators. It is possi­
ble to design flaps such as large rotation, propeller, and
V-Y advancement flaps to avoid unsightly donor site skin
grafts. When a V-Y flap is used, it should be in the oblique
axis, keeping the tail of the V-Y toward the calf, as there is
usually extra skin for direct closure. If it is not possible to
close the donor site, it can be grafted with split skin
temporarily.
The reach of the flap can be extended by placing the
perforator in an eccentric position when designing the flap.
The flap should be designed based on the more distally
located perforators, since many of the proximal perforators
are musculocutaneous and require an intramuscular dissec­
tion if the flap is to be advanced significantly or used as a
free flap.
SPECIAL CONSIDERATIONS
Small defects over the distal part of the leg can be recon­
structed by a V-Y advancement flap. However, larger defects
with exposed bones will require either a propeller or a
transposition flap. When local options are not available, one
should think about free tissue transfer.
Always consider the age, sex, and general condition of the
patient first. Next, consider the vascularity of the leg and
lastly the type of wound that requires reconstruction.
DIFFERENCES IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
The pedicled flap design depends entirely on the site of the
wound. For practical purposes, the leg is divided into upper,
middle, and lower thirds (Fig. 61.2).
however, the segment of muscle would not be transferred
as a functional muscle unit.
FLAP COMPONENTS
The flaps based on perforators of the posterior tibial artery
are mostly fasciocutaneous or adipofascial type. As the per­
forators of the posterior artery anastomose with other per­
forators, it is possible to incorporate a small amount of
muscle, bone, and tendon. These structures are transported
in part with the flap and this part is vascularized by the flap
in a reverse manner.
Advantages
• The posterior tibial artery skin flap is ideal for small
defects in the leg, to reconstruct exposed bone and
tendon. As it is local tissue, it replaces like tissue.
• Harvesting the flap requires a shorter operating time and
hence, the flap is ideal for patients who are not fit for a
lengthy procedure.
• The posterior tibial artery perforator flaps have also been
used as regional flaps and as free flaps. Koshima and
Soeda have used perforator posterior tibial flaps without
sacrificing the main vessels.19
• The flap is relatively thin and can be used to resurface
defects in regions such as the hand and fingers requiring
thin tissue.
• Most of the perforators are septocutaneous, therefore
simplifying the dissection.
• The flap can include soleus muscle or a segment of tibia
bone.
Disadvantages
• The main disadvantage in a skin-grafted donor site is
when a large cutaneous flap has been either proximally
or distally based. This leaves an unsatisfactory donor site
scar. This can be avoided by using a propeller flap or V-Y
advancement flap.
• Loss of sensation distal to the flap as the cutaneous nerve
is included in the flap.
• Limited pedicle length when the flap is based on the
perforators only. This can be alleviated by including the
posterior tibial artery with the flap.
PREOPERATIVE PREPARATION
In this section the reconstructive surgeon should consider
three factors: the patient, the wound, and the leg.
Assess the patient regarding fitness for surgery, age (pos­
terior artery perforator flaps can be used with any age), and
sex (one has to bear in mind the resulting donor site mor­
bidity, especially in young female patients). Assess other
medical conditions, i.e., diabetes mellitus, arteriosclerosis,
and conditions such as pyoderma gangrenosum. Take the
necessary steps to optimize the patient’s medical condition
prior to surgery.
The wound should be assessed as to whether it is clean
with healthy granulation tissue and for the presence of
infection, while exposure of underlying structures such as
bone and tendons should also be assessed. The extent of
disease process or traumatized field surrounding the wound

720
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
The perforator in this region has an average caliber of
1.5 mm and an average length of 4 cm. Again, the disadvan­
tage is that the technique requires special skills in microsur­
gery and also the flap has a short pedicle. One could
overcome this by taking the posterior tibial artery and using
the long saphenous vein, but the trade off here is the loss
of major vessels of the leg.
FLAP DIMENSIONS
SKIN ISLAND DIMENSIONS
Length: 10–12 cm (range 3–19 cm)
Width: 2–3 cm (range 2–13 cm)
Maximum to close primarily: 3–4 cm
An ideal size of flap should be the size that does not result
in donor site morbidity. Usually a 10–12 × 3–4 cm flap is
selected so that the donor site can be closed directly or skin
grafted temporarily. The maximum amount of skin that has
been used is 19 × 13 cm.
For defects in the upper third, three types of flaps can be
designed: rotation, transposition, and advancement flaps.
The flaps in this area are normally proximally based perfora­
tor flaps. In the middle third, the above three types of flaps
can be used. In this area, it is possible to base the flaps both
proximally and distally. Our preference is distally based. The
resulting defect is more in the calf region so that the second­
ary defect can either be closed directly or skin grafted. In
lower third defects all the three types of flaps can be used
but they would be based on the distal perforators.
To design a posterior artery flap as a free flap, a large
amount of skin can be harvested, e.g., 19 × 8 cm on the
medial aspect of the leg on the long axis of the flap extend­
ing from the medial malleolus proximally. An ellipse of skin
is marked in this area in such a way that all the perforators
in the longitudinal line are included within this ellipse. The
distal perforators are usually large and are of the septocu­
taneous variety and it is possible to use them as free flaps
without sacrificing the posterior tibial artery. This obviously
requires special skills in microsurgery. Hung et al. used the
posterior tibial artery perforator flap as a free flap and
selected perforators in the middle two-quarters of a leg.16
Figure 61.2  (A,B) Showing V-Y and propeller type of flap.
B
A

CHAPTER 61 — Posterior Tibial Artery Perforator Flap
721
TECHNIQUE OF FLAP HARVEST
With perforator flap harvest (Fig. 61.4), a freestyle method
is preferred. There are 10 steps to follow in the harvesting
of perforator flaps.
1. Locate perforators around the defect using ultrasound
Doppler.
2. Apply a tourniquet but do not exsanguinate the leg, so
that the vessels are kept full, which helps dissection.
Create the defect or debride the wound and mark the
required flap, keeping the adjacent perforator as a pivot
point.
3. The exploring incision is usually one of the margins of
the flap. The flap is elevated with the deep fascia.
4. Inspect and assess the perforators.
5. Select the perforator (artery and its venae comitantes).
The site of the selected perforator is the pivot point. It
is possible that one may find two or three perforators
MUSCLE DIMENSIONS
Length: 4 cm (range 2–8 cm)
Width: 2 cm (range 2–4 cm)
Thickness: 2 cm (range 2–4 cm)
When there is dead space to be filled, muscle tissue that
is close to the skin flap could be included with the flap, as
long as it is connecting with the blood vessels.
BONE DIMENSIONS
If and when bone graft is planned, middle or upper part of
the bone is ideal for harvesting. Up to 6–8 cm of compact
bone can be harvested either on its own or in combination
with muscle or skin.
There is no indication to use bone from the tibia, as there
are other bone grafts available (fibular and/or iliac bone
graft).
FLAP MARKINGS
Flap markings (Fig. 61.3) depend on the site and type of
wound. In traumatic soft tissue loss, there will be trauma­
tized tissue surrounding the wound; hence, prior to mark­
ing the flap, perforators are located by using ultrasound
Doppler at a reasonable distance away from the trauma­
tized tissue. Once the perforators are located, flap mark­
ing should be carried out in a reverse fashion using the
perforator as a pivot point. It is important to plan an
exploring incision, which is part of one of the margins of
the flap.
Normally, when a well-established skin flap such as a fore­
head, groin, or scapular flap is used, the flap is elevated
toward the pedicle. However, in perforator flaps, the perfo­
rators are located and assessed by an exploring incision.
Once this is found to be satisfactory, the flap design can be
adjusted, based on the location of the perforator and the
defect to be covered, and the surgeon can at that point
commit to elevating the flap.
PATIENT POSITIONING
For an anteromedial flap harvest, the patient is placed in
a supine position and the operating surgeon should be
sitting opposite to the operating leg. In the same position,
the leg is slightly flexed at the knee joint and externally
rotated, and this will give access to the posteromedial aspect
of the leg.
ANESTHETIC CONSIDERATIONS
Both general and regional (spinal or epidural) anesthesia
can be used. The timing of administration of deep vein
thrombosis prophylaxis is important, as it can preclude the
use of some regional anesthetic techniques. Small flaps can
also be harvested under local anesthesia preferable with
sedation to minimize patient movement.
Figure 61.3  Flap markings.

722
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
9. If there is any vascular problem following transfer of the
flap to the defect, the flap should be returned to its origi­
nal site. Allow for the delay phenomenon to occur, which
usually takes about 1 week. The flap can then be reused.
10. If there is no vascular problem, inset the flap. The sec­
ondary defect is either directly closed or skin grafted
and a small drain is inserted because a hematoma in
the postoperative period can cause thrombosis of the
perforators.
When using the posterior artery perforator flap as a free
flap, the same freestyle method is adapted whereby with an
exploring incision, the perforators are assessed and selected.
However with a free flap, a long saphenous vein is harvested
for venous outflow.
FLAP MODIFICATION/FLAP HANDLING
The posterior tibial artery perforator flap can either be a
skin flap or an adipofascial flap. It is possible to harvest a
small amount of soleus muscle, tibia bone, and part of the
Achilles tendon. We have used part of the muscle in chronic
osteomyelitis to obliterate the bony cavity and also used part
of the Achilles tendon with the flap to bridge the gap in the
Achilles tendon (Fig. 61.5).
The posterior tibial artery perforator flap is an ideal local
option to reconstruct any skin loss. When there is soft tissue
loss resulting in dead space, the reconstruction would
involve harvesting muscle with the skin flap. The blood
supply of this part of the muscle is through the skin flap in
a reverse manner, as long as the muscle is connected with
the flap by blood vessels. Similarly, part of the Achilles
tendon along with the flap could be harvested from the
proximal part of the defect, and this is turned 180° to recon­
struct the defect in the distal part of the tendo-Achilles. The
planning of this type of flap should be in a reverse manner.
• First locate the perforators by using ultrasound Doppler.
• Cut a template of the defect and transfer it over the adja­
cent skin where the flap is elected.
• Elevate one part of the flap and identify and assess the
perforator vessels. Once this is confirmed, the elevation
of the flap is completed.
• The flap can then be transposed over the defect.
• The secondary defect is either skin grafted or closed
directly.
FLOW-THROUGH FLAP
A segment of posterior tibial artery can be included with the
flap and used to bridge an arterial defect at the recipient
site or to better match the recipient vessel when the recipi­
ent artery or vein is large. This would necessitate sacrifice
of the posterior tibial artery. If a segment of posterior tibial
artery less than 1 cm is included, the posterior tibial artery
can be mobilized and sutured primarily.
CHIMERIC FLAP
The skin, part of the muscle, part of the tendon, and part
of the bone can all be harvested, as long as the perforating
close to each other. To be safe, an extra length of flap
is harvested, keeping all the perforators either distal or
proximal to the selected perforator.
6. The perforators, other than the selected perforators,
are microclamped and then the incision is completed
all around the flap and a subcutaneous vein near the
base of the flap is preserved if present.
7. The tourniquet is released and perfusion of the flap is
confirmed. If the vascularity of the flap is satisfactory,
then all the microclamped perforators and subcutane­
ous veins are ligated. If the perfusion is not satisfactory,
one should wait for about 20–30 min and, if the vascu­
larity is still not satisfactory, adjacent microclamps over
the perforators are removed and the perfusion is reas­
sessed. If the venous outflow is a problem, the micro­
clamp of the subcutaneous vein is removed to augment
the venous outflow.
8. The flap is then moved to the defect by one of the three
methods: rotation, transposition, or advancement.
Figure 61.4  Steps of harvesting the perforator skin flap. Step 1:
wound with exploring incision. Step 2: elevation of the flap with deep
fascia, the distal perforator selected and the other two perforators
microclamped. Step 3: the fasciocutaneous flap is elevated com­
pletely, pivoting on the distal perforator. Step 4: flap inset, the donor
site grafted with a split-thickness skin graft (STSG).
1
2
3
4
STSG

CHAPTER 61 — Posterior Tibial Artery Perforator Flap
723
of the leg. The flap is elevated in the proximal part up to
the direct perforator, which is located in the middle of the
leg. This perforator is followed up to the posterior tibial
artery and is ligated at this level. The rest of the flap is
elevated with the posterior tibial artery, including all the
lower perforators. The flap is then transposed, pivoting at
medial malleolus level. This will cover the whole of the foot,
either dorsal or plantar aspect. The secondary defect is skin
grafted. This type of flap is contraindicated in high-velocity
injuries and also where there is doubtful blood supply to
the foot.
DONOR SITE CLOSURE AND
MANAGEMENT
In V-Y advancement, propeller type, and rotation flaps, the
donor sites can be closed directly. In transposition flaps, the
donor site requires a skin graft.
vessels also supply them (we have had no occasion to use
this type of flap in the leg). It is possible to use any muscle
of the leg.
FASCIAL FLAP
The fascia alone can be used as a turnover flap as the blood
supply of this part of the tissue is by the plexus of the fascia.
However, it is possible to use an adipofascial flap similar to
the fasciocutaneous flap without taking the skin.
EXTENDED FLAP
In exceptional situations, where there is a large defect over
the foot, if the patient is not fit for a free tissue transfer and
when all the three vessels of the leg are intact, a large fas­
ciocutaneous flap can be harvested extending from the
medial malleolus to 5 cm below the knee joint (Fig. 61.6).
The width is from the medial part of the tibia to the midline
Figure 61.5  Vascularized tendon graft. (A) 8 cm Achilles tendon defect. (B) Blood vessels supplying the Achilles tendon are visibile.
(C) 8 cm Achilles tendon graft, proximal vessel micro clamped and distal vessel on which the tendon graft propelled 180 degree to bridge the
gap. (D) Flap rotated and inset, tendon reconstructed. (E) Long-term result with good functional outcome. (Reprinted with permission. Chalmers
R, Tare M, Niranjan N. Vascularised Achilles tendon graft reconstruction – by the tendon for the tendon. J Plast Reconstr Aesthet Surg March
2010;63[3]:e273–6).
A
C
B
D
E
B
Figure 61.6  (A–C) Example of an extended posterior tibial artery flap.
B
C
A

724
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
• As a free flap for reconstruction in the head and neck
and other areas of the body when no other donor site is
available.
POSTOPERATIVE CARE
GENERAL
Once the flap is sutured to the defect, the leg is dressed with
a bulky dressing to keep the flap warm, preventing spasm
of the perforating artery. During the next 48 h there is a
risk of edema, which in turn causes venous outflow obstruc­
tion. It should therefore be monitored hourly during the
first 24 h and every 4 h for the next 24 h.
RECIPIENT SITE
Early mobilization of the patient is possible only if the flaps
used are propeller or V-Y advancement flaps.
If and when venous outflow problems occur, the treat­
ment is to remove the sutures where there is tightness,
which is normally around the base of the flap. Use of leeches
to relieve venous congestion is also possible and this should
be carried out for 5–7 days (this should encourage the
linking of the veins between the flap and the recipient site).
The patient should be advised to refrain from smoking and
use measures to prevent deep vein thrombosis.
DONOR SITE
If a skin graft has been used over the donor site, the graft
take is inspected after 5 days and if this is satisfactory, then
mobilization of the patient is recommended. When the flap
has been used for a defect over the foot, patients are mobi­
lized by using crutches and should not bear weight. Weight­
bearing should only be encouraged once the flap is stable,
and it should be gradual. No splinting is performed as it
may cause compression. We use bulky dressings, which
partly act as a splint without any compression.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
The best outcome is expected if the reconstruction is carried
out on the right patient for the right wound. Local tissue is
the best replacement of the tissue that has been lost.
DIFFERENT INDICATIONS
The best outcome is achieved when the perforator flaps are
used as V-Y, propeller, and rotation flaps. A good outcome
is expected when adipofascial flaps are used. A fair outcome
is expected when a transposition flap is used because the
secondary defect requires skin grafting.
DONOR SITE
The donor site can be closed directly following V-Y, propel­
ler, and rotation flaps. The donor site requires skin grafting
in transposition flaps and large defects.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• It is important to locate the perforators by using ultra­
sound Doppler, but more importantly, the perforator is
assessed via an exploring incision. Only then should one
proceed to harvest the flap.
• An advancement flap is, as is a V-Y advancement flap,
better than a rotation flap, and dissecting the perforators
through the muscle can increase the length of the pedicle.
• In a propeller type of flap, the flap is rotated almost 180°
to avoid any kinking of the vein and the perforator is
released from the rent in the deep fascia.
• It is advisable to keep a subcutaneous vein in the base of
the flap for venous outflow, as pointed out by Fujino.5 In
some situations, when venous outflow is a problem and if
the flap has a subcutaneous vein in the distal part or the
tip of the flap, it is possible to anastomose this vein to a
local vein to augment the venous outflow.
• Although the skin flap can be raised solely based on a
perforator, we would recommend keeping the fascia with
the flap. This is helpful as we have noticed that if the skin
part of the flap is lost, the fascia may still be intact and
graftable with a split skin graft.
FLAP USAGE
PEDICLED
The pedicled posterior tibial artery perforator flap is used
as a cutaneous or fasciocutaneous flap for reconstruction
of small or medium-sized defects with soft tissue loss with
exposed bone or tendon or joint, e.g., trauma and neoplas­
tic conditions. See Flap modification/flap handling, for
further indications.
FREE FLAP
Indications for free posterior tibial artery perforator flaps
are rare, since there are many skin flaps with large-diameter
vessels available.
The indications for this flap can be reconstruction of any
defect in the body requiring thin and pliable tissue for cov­
erage, given that there are suitable recipient vessels in the
vicinity of the defect.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
The posterior artery perforator flap is indicated following
soft tissue loss, mostly in low-velocity injury, neoplastic condi­
tions, and chronic ulcers of the leg due to venous stasis. Per­
forator flaps have been used to reconstruct defects over the
foot and also as a cross-leg flap. When a flap is used for recon­
struction over the foot, one can increase the length of the
flap and augment the vascularity by the delay phenomenon.
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
• Chronic ulcer with exposed bone, tendon, and joint, e.g.,
degenerative and venous stasis

CHAPTER 61 — Posterior Tibial Artery Perforator Flap
725
CONCLUSION
The posterior tibial artery gives out different types of perfo­
rating vessels in the anteromedial and posteromedial aspects
of the leg. In the upper half, the perforators are mostly of
the muscular type and in the lower half they are of the direct
septocutaneous type. All along the anterior margin of the
tibia, there are vessels that supply the periosteum and per­
forate the deep fascia to supply the skin over this region. In
addition to these, there are vessels that supply the Achilles
tendon and also perforate the deep fascia to supply the skin
directly over this area.
Soft tissue loss over the leg, especially in the lower half,
is common as a result of injury and/or excision of neoplastic
lesions that can leave defects over the bone and tendon. A
local flap based on the perforators of the posterior tibial
artery is an ideal skin cover as the replacement tissue is a
like tissue. In the upper part of the leg, especially in the
infrapatellar region, a sensate flap is required and this is
possible with a posterior tibial artery perforator flap, includ­
ing the long saphenous nerve. It is also possible to raise the
skin flap incorporating a small amount of bone, muscle, or
tendon. These structures can be used as a composite flap to
bridge the gap and obliterate dead space. A free flap can
also be used based on a single perforator but the limitations
are that it requires superb microsurgery and a very short
pedicle.
The only limitation of using the flap in the leg is that it
leaves behind a skin-grafted donor site that is not ideal in
women or children. To overcome this problem, for a smaller
defect, it is possible to use the posterior tibial artery perfora­
tor flap as a propeller or V-Y advancement flap, which will
not leave a skin-grafted donor site.
UNTOWARD OUTCOMES
GENERAL
The surgeon should be aware of the anatomic variations of
the posterior tibial artery (in 6% of the population, it is
weak).
DONOR SITE
We have already discussed the solution when the flap has a
perfusion problem. The skin-grafted donor site is far from
satisfactory. This can be avoided by planning a fasciocutane­
ous flap based on perforators as a propeller or V-Y advance­
ment flap. If this is not possible, the skin-grafted donor site
can be reconstructed by using a tissue expansion technique
at a later stage. In our experience, some patients have
expressed dissatisfaction about the outcome of the skin-
grafted donor site.
LONG-TERM OUTCOMES
GENERAL
The long-term results of perforator-based flaps are generally
excellent. Very rarely do they require either thinning of the
flap or secondary reconstruction.
DIFFERENT INDICATIONS
In a non-sensate flap, patients do acquire protective sensa­
tion. This has been noticed in clinical situations where the
flap has been used over the pretibial area. When a sensate
flap is required, a proximally based flap including a cutane­
ous nerve is selected.
DONOR SITE
A grafted donor site, if unsatisfactory, could be corrected by
serial excision or tissue expansion technique.

726
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A 2 × 3 cm wound over the right medial malleolus with exposed
tibia was referred to plastic surgery. A large V-Y fasciocutaneous
flap based on perforator of posterior tibial artery was used to
achieve the soft tissue cover (Fig. 61.7).
CASE 61.1  Medial Malleolus Defect with Exposed Tibia Reconstructed with a V-Y
Fasciocutaneous Posterior Tibial Artery Perforator Flap
A
B
C
D
E
F
G
Figure 61.7  V-Y flap in the lower part of leg. (A) A fracture of the lower tibia. (B) An exploratory incision was performed. (C) Perforators
of the posterior tibial artery are located. (D) Islanded flap. (E) Flap is advanced to the defect. (F) Postoperative results after 2 weeks.
(G) At the 2-year follow-up.

CHAPTER 61 — Posterior Tibial Artery Perforator Flap
727
A patient with thick melanoma over medial malleolus underwent
wide excision. A large V-Y flap was planned but the flap was
rotated 180° and the donor area was skin grafted. A 3-year post-
surgical photograph shows a satisfactory result (Fig. 61.8).
CASE 61.2  Large Medial Malleolus Defect Reconstructed with a Propeller-Type Posterior
Tibial Artery Perforator Flap
Figure 61.8  An example of propeller flap. A wide excision of 9 mm melanoma on the left leg. (A) V-Y flap planned but used as propeller
flap. (B,C) Flap islanded showing two perforators. (D,E) The 3-year result.
A
B
C
D
E

728
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
REFERENCES
1. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast
Surg 1973;26:202–13.
2. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of
the lower leg. Br J Plast Surg 1981;34:215–20.
3. Batchelor JS, Moss ALH. The relationship between fasciocutaneous
perforators and their fascial branches: an anatomical study in
human cadaver lower legs. Plast Reconstr Surg 1995;95:629–33.
4. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical application. Br J Plast Surg
1987;40:113–41.
5. Fujino T. Contribution of the axial and perforator vasculature to
circulation in flaps. Plast Reconstr Surg 1967;39:125–37.
6. Wei FC, Jain V, Suominen S, et al. Confusion among perforator
flaps: what is a true perforator flap? Plast Reconstr Surg 2001;
107:874–6.
7. Linton RR. The communicating veins of the lower leg and the
operative technique for their ligation. Ann Surg 1938;107:
582–93.
8. Saint-Cyr M, Wong C, Shaverian M, et al. The perforasome theory:
vascular anatomy and clinical implication. Plast Reconstr Surg
2009;124:1529–44.
9. Liu K, Li Z, Lin Y, et al. The reverse-flow posterior tibial artery
island flap: anatomical study and 72 clinical cases. Plast Reconstr
Surg 1990;86:312–15.
10. Koshima I, Moriguchi T, Ohta S, et al. The vasculature and clinical
application of the posterior tibial perforator-based flap. Plast
Reconstr Surg 1992;90:643–9.
11. Wu WC, Chang YP, So YC, et al. The anatomic basis and clinical
applications of flaps based on the posterior tibial vessels. Br J Plast
Surg 1993;46(6):470–9.
12. Ozdemir R, Kocer U, Sahin B. Examination of the skin perforators
of the posterior tibial artery on the leg and the ankle region and
their clinical use. Plast Reconstr Surg 2006;117:1619–30.
13. Whetzel TP, Barnard MA, Stokes RB. Arterial fasciocutaneous vas­
cular territories of the lower leg. Plast Reconstr Surg 1997;100(5):
1172–85.
14. Shaverian M, Saint-Cyr M. Perforators of the lower leg: analysis of
perforator locations and clinical application for pedicled perfora­
tor flaps. Plast Reconstr Surg 2008;122:161–70.
15. Carriquiry C, Costa MA, Vasconez LO. An anatomical study of the
septocutaneous vessel of the leg. Plast Reconstr Surg 1985;76:
354–61.
16. Hung LK, Lao J, Ho PC. Free posterior tibial perforator flap:
anatomy and a report of 6 cases. Microsurgery 1996;17:503–11.
17. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and
clinical implications. Plast Reconstr Surg 1998;102:599–616.
18. Tang M, Mao Y, Almutairi K, et al. Three-dimensional analysis of
perforators of the posterior leg. Plast Reconstr Surg 2009;123:
1729–38.
19. Koshima I, Soeda S. Free posterior tibial perforator-based flaps.
Ann Plast Surg 1991;26:284–8.
Access Figures 61.9 to 61.13, as well as case
examples 3, 4, 5, 6, and 7, and further reading
and table 61.1 online at
.inkling.com
Expert Commentary 
Alexandru V. Georgescu, MD, PhD
The posterior tibial artery perforator flap is one of the work-
horse flaps for covering distal lower leg skin defects. It is
mostly used as a pedicled local or regional perforator flap,
either in a V-Y advancement fashion or, especially, as a
propeller flap.
The greatest distribution of perforators is found from 5 cm
to 14 cm above the internal malleolus. A very constant sep-
tocutaneous perforator is found approximately 5 cm above
the medial malleolus.
The preoperative detection of the perforators in the distal
lower leg is not mandatory, because of the possible false
positive or negative signals from the main vessels.
First only one incision is done, corresponding to both one
edge of the flap or of a possible alternative flap. During the
dissection under magnification all the identified perforators
are preserved. All through dissection, the perforators must
be humidified with lidocaine to prevent spasm. If two or more
adjacent perforators are found, it is better to keep all of them
until the flap’s dissection is completed and the tourniquet
released. Then, after alternative clamping, only the best one
is kept. The length of the flap will be in the long axis of the
leg. To avoid any tension on the pedicle, 1–2 cm is added to
the distance between the perforator and the distal edge of
the defect and 0.5–1 cm to the width of the defect. The
perforator foramen is enlarged using a longitudinal fascial
incision, and the chosen perforator is cleared retrograde of
all muscular branches and fascial strands for at least 2 cm.
After completing the flap incision and harvesting, it is better
to wait for 15–20 min before rotation, to allow its reperfusion.
The flap can be rotated in a clockwise or counterclockwise
direction, but attention should be paid to choose the right
rotational direction to avoid kinking of the vessels. The donor
site should not be closed under big tension, which can
reduce the flap’s blood supply by compressing the source
vessel, and also can induce swelling of the distal leg. If
primary closure is not possible, the donor site can be partially
directly sutured, and the remaining defect skin grafted.

CHAPTER 61 — Posterior Tibial Artery Perforator Flap 728.e1
Figure 61.9  (A) Malignant melanoma, excision marked. (B) An exploratory incision is made and the perforator is approached. (C) The
perforator is located and dissected proximally. (D) The flap is completely isolated based on the perforator. (E) Further dissection of the
pedicle. (F) Flap is inset to reconstruct the defect.
A
B
C
D
E
F
A patient with 2 mm thick malignant melanoma over the right
calf was referred for wide excision. A wide excision with a
2 cm margin was carried out and the resulting defect was
reconstructed by a V-Y flap based on septocutaneous perforator
from the posterior tibial artery (Fig. 61.9).
CASE 61.3  Calf Wound Reconstructed with a V-Y Advancement of a Posterior Tibial Artery
Perforator Flap

728.e2 PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A
C
B
CASE 61.4  Malignant Melanoma Defect Reconstructed with V-Y Flap (Fig. 61.10)
Figure 61.10  (A) 6 cm defect of the leg following excision of malignant melanoma. (B) V-Y flap elevated based on perforators. (C) Result
4 weeks postoperatively.

CHAPTER 61 — Posterior Tibial Artery Perforator Flap 728.e3
CASE 61.5  Wide Extension of Malignant Melanoma Right Leg (Fig. 61.11)
Figure 61.11  Wide extension of malignant melanoma right leg. (A) 2 cm wide local excision. (B) Exploring incision showing perforators
of PTA. (C,D) Flap islanded on a distal direct perforator. (E) Immediate result of type III V-Y flap. (F, G) Result at 4 months.
A
B
C
E
F
G
D

728.e4 PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A 42-year-old man presented with a history of chronic osteomy-
elitis of the right lower end of the tibia with a sinus and sur-
rounding unstable scar. The X-ray showed a small bony cavity. At
operation, the bony cavity was debrided along with the unstable
scar. The defect was reconstructed with a propeller-type fascio-
cutaneous flap based on direct septocutaneous perforator of
the posterior tibial artery. Along with the flap, a small amount
of gastrocnemius muscle was taken and the blood supply of this
was maintained in a reverse manner by the flap. The flap was
rotated, the muscle was used to obliterate the cavity in the bone,
and the skin was inset to the defect. The long-term result was
good (Fig. 61.12).
CASE 61.6  Distal Third Full Soft Tissue Along with a Bony Defect Reconstructed with a
Propeller Posterior Tibial Artery Cutaneous-Muscle Perforator Flap (Including
a Cuff of Gastrocnemius Muscle)
A
B
C
D
E
F
G
H
Figure 61.12  An example of combination of perforator flap. (A) Chronic sinus and an unstable scar over the lower end of the right
leg. (B) Debridement of the wound and exploring incision. (C) Distal perforator selected. (D) Flap islanded. (E) An island of gastrocnemius
muscle included with the flap. (F) Flap inset, donor site closed. (G, H) The 6-month follow-up.

CHAPTER 61 — Posterior Tibial Artery Perforator Flap 728.e5
A patient with Gustilo IIIb underwent exploration; debride-
ment. A posterior tibial artery perforator local flap was used
to cover the medial defect but a larger defect needed an ALT
musculocutaneous flap. The result after 1 year is shown in
Figure 61.13.
CASE 61.7  Distal Third Tibia Defect Reconstructed with a Pedicled Posterior Tibial Artery
Perforator Flap and a Free Anterolateral Thigh Flap
Figure 61.13  An example of combination of a local and free perforator flaps. Gustilo fracture IIIb. (A) Defect on the medial aspect
of the leg. (B–E) An exploratory incision is made and the posterior tibial artery flap is harvested. (F) ALT flap. (G,H) Result showing a PTA
flap covering the medial aspect of the wound and an ALT covering the rest of the defect at 1 year.
A
D
B
C
E
F
H
G

728.e6 PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
FURTHER READING
Bhishagratna KL. Sushruta Samhita based on original Sanskrit text, vol.
1. [Ch. XVI]. 152 (English translation). Varanasi, India: Chowkhamba
Sanskrit Series.
Chelmers R, Tare M, Niranjan N. Vascularised Achilles tendon graft,
reconstruction by the tendon for the tendon. J Plast Reconstr Aesthet
Surg 2010;63(3):e273–6.
Cormack CG, Lambert BG. The arterial anatomy of skin flaps. 2nd ed.
London: Churchill Livingstone; 1994.
Masquelet AC, Gilbert A. An atlas of flaps in limb reconstruction.
London: Martin Kunitz; 1995.
Miller TA. The Tagliacozzi flap as a method of nasal and palatal recon­
struction. Plast Reconstr Surg 1985;76:870–5.
Mopuri N, Vasu K, Patel N, et al. Reconstruction of soft tissue defects
in the Achilles’ tendon region with perforator based fasciocutaneous
flaps. Eur J Plast Surg 2013;36(11):701–6.
Niranjan N. Invited commentary. J Plast Reconstr Aesthet Surg
2011;64(9):1214–15.
Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforator based
V-Y advancement flaps in the reconstruction of lower limb defects.
Br J Plast Surg 2000;53:679–89.
Salmon M. In: Taylor GF, Tempest M, transl. Arteries of the skin. Edin­
burgh: Churchill Livingstone; 1998.

729
Free-style Flaps
Fu-Chan Wei  |  Seng-Feng Jeng  |  Samir Mardini 62 
INTRODUCTION
Reconstructive surgery has, as its premise, the principle of
restoring form and function utilizing surrounding or
distant tissues while minimizing morbidity at the donor
site. While muscle flaps remain a viable option for recon­
structive surgery, their use has become less important in
recent years with the advent of perforator flap surgery.1–5
No longer is it necessary to take muscle as a carrier of
blood supply to the overlying structures; vessels supplying
skin flaps can be dissected in a retrograde fashion through
their intramuscular course or in the fascia between muscles
until the adequate length and caliber required are reached.
The extensive development of perforator flap surgery has
also allowed for the harvest of tissue in a free-style manner
from any part of the body where a perforator or skin vessel
is found (Fig. 62.1).6–9 This has led to an increase in the
number of flaps available, a greater versatility, and even
better outcomes in reconstructive surgery. Locating these
vessels can be performed safely and reliably with the use
of Doppler signal mapping or other imaging study
techniques.10–12 This tool allows for mapping of all skin
vessels over 0.5 mm in size in the area where the flap is
to be harvested from. The donor site for tissue transfer is
selected, based on the type of tissue desired and required
at the recipient site, the volume necessary to fill the defect,
the pliability desired, and the color that best matches the
recipient site.
Figure 62.1  The dominant cutaneous perforators emerging from the deep fascia, with different colors identifying their corresponding source
arteries in the deep layers. Note their relationship to the intermuscular and the intramuscular septa. (Redrawn with permission from Taylor GI,
Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40[2]:113–41.)
PART 5  —  PERFORATOR-BASED WORKHORSE FLAPS

730
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
the region to explore the reliability and safety of free-style
flaps. Given the large experience acquired over the years
with flaps from the thigh, it became clear that the thigh is
an ideal location to realize this concept.6 We always marked
the anatomic landmarks for the anterolateral thigh flap in
the event we encountered problems with the free-style flap.
The incisions were planned so that the back-up flap could
be used in case the skin vessels to the free-style flap were
found to be short or small, or were injured during the dis­
section. The main landmarks are the location of Dopplered
skin vessels. Because our experience and that of others has
proven that dissection and anastomosis of vessels ≥0.5 mm
is technically feasible and reliable, all 374 vessels that were
mapped by Taylor and colleagues can theoretically provide
reliable pedicles for a free-style flap.13
The area that is selected for a flap donor site is chosen
based on the defect to be reconstructed and on a donor site
that allows for a well-healed scar in an inconspicuous loca­
tion. The flap is chosen that allows for versatility in flap
design; provision of tissue volume that is adequate to recon­
struct the defect; and good match in color, texture, and
pliability at the recipient site. Additionally, if sensory rein­
nervation is desired, the flap is chosen from an area that
had sensory nerves that can be harvested with the flap.
Whenever possible, the location of the donor site should
allow for a two-team approach.
FLAP COMPONENTS
Any type of tissue can be harvested as part of a free-style
flap. Typically, free-style flaps are harvested as cutaneous
flaps. Other components such as muscle, nerve, or bone can
be harvested based on the same vessels if branches also
supply those tissues. However, predicting the course of these
vessels is difficult. If bone, muscle, or nerve is required to
reconstruct a defect, known flaps are recommended for use.
ADVANTAGES
• Free-style flaps can be harvested from any location where
a skin vessel is found.
• The type of tissue can be selected based on the require­
ment at the recipient site. The region of the body that is
most similar in color, texture, pliability, and thickness is
chosen and a flap is harvested from that region.
• This technique is particularly useful in patients with
limited flap donor sites such as in burn patients.
• The free-style approach can be applied to “recycling” a
previously used flap.22 The same flap can be reused by
finding a vessel within the flap through the use of Doppler
ultrasonography and a free-style flap is harvested. This
achieves the goal of reconstructing a defect as well as
debulking of a previously used flap (Case 62.2).
• Although free-style flaps may seem unpredictable initially,
with experience in harvesting flaps in a given region such
as the thigh or lower leg, the surgeon quickly becomes
familiar with the size and location of vessels and the
amount of tissue that can be carried reliably based on
those vessels.
• Dissection of free-style flaps is usually performed in
the suprafascial plane, which preserves more structures
such as nerve and fascia at the donor site while
Once the vessels are mapped in a given area, even if the
surgeon is unfamiliar with the region, flap harvest can begin
by surgically exploring the region for vessels of a suitable
size. The concept and approach have been termed “free-
style flap harvest” and a flap harvested in this manner is
termed a “free-style flap.”
In fact, the concept of free-style flap harvest has been
introduced in one form or another over many years. Many
surgeons have used this approach in cases where anatomic
variations were met, or when problems arose during flap
harvest such as trauma to the vessels. Taylor and Daniel in
1975 dissected the perforators of the gastrocnemius muscu­
locutaneous flap back to the sural vessels.13,14 During Wei
and colleagues’ anatomic study of the fibula osteoseptocu­
taneous flap, they performed intramuscular dissection of
perforators through the soleus muscle when they were
encountered.15 What they were performing at the time was
essentially a free-style flap harvest. Koshima introduced an
innovative concept and the surgical technique of “suprami­
crosurgery.” He harvested flaps from the paraumbilical
region and based them on the suprafascial component of
skin vessels.16 The free-style flap harvest principle has some
similarity to the previously mentioned approaches, and the
vessels supplying the flap are traced in a retrograde fashion
through whatever course they take until the appropriate size
and length are reached.17
Free-style flaps can be harvested as local or free flaps, and
can be composed of a variety of tissue types.18–20 Reconstruc­
tive surgery will continue to rely on flaps that have been
studied anatomically and have been proven clinically to be
reliable and safe. In addition to being a way of providing
tissue as a flap, free-style flap surgery has played a role where
anatomic variations are encountered or unexpected situa­
tions are met. More recently, it has been used to allow for a
flap to be “recycled” and used for the reconstruction of
a second defect following a previous reconstruction with a
flap.21 The area is explored for vessels with the use of either
Doppler mapping or immediate exploration, the flap is
designed based on a set of principles that are discussed later
in this chapter, and the flap is harvested. We believe that
having had experience with perforator flap surgery has
allowed surgeons to feel comfortable in performing free-
style flaps, and this in turn has aided in alleviating anxiety
when approaching any flap harvest, particularly when it is
less familiar to the surgeon. This allows the surgeon to begin
flap surgery knowing that many alternative plans are avail­
able if an unexpected situation is encountered.
FLAP ANATOMY
Knowledge of anatomy of the region where a free-style flap
is to be harvested is still important. In order to safely carry
out the harvest of any block of tissue from any region, it is
essential that the surgeon avoid critical structures in order
to minimize damage at the donor site. Detailed regional
anatomic landmarks, however, play a role that is less signifi­
cant when dealing with free-style flaps. Ideally, “back-up”
flaps can be available in the region where a free-style is to
be harvested. This is particularly important when the
surgeon begins to explore a new region for free-style flaps.
In the authors’ experience, the thigh was used initially as

CHAPTER 62 — Free-style Flaps
731
5. When the free-style flap is harvested from the limb, the
surgeon must realize which vessels are considered major
and are not amenable to sacrifice. We therefore mark the
skin territory based on the most distal vessel that exists
and the one that is farthest away from the vessels that
cannot be sacrificed (superficial or deep femoral arter­
ies). We also try to choose the ones that are not over fixed
areas. In those areas, the vessel course is commonly more
perpendicular. In the thigh, for example, we choose the
perforator that is farthest from the superficial femoral
artery. The skin vessel can be placed in an eccentric posi­
tion to increase the reach of the flap. Theoretically, the
shortest pedicle will be at least the straight distance
between the Dopplered vessel and the vessel that cannot
be sacrificed.
6. There is no set algorithm for deciding how much
tissue can be harvested based on a given skin vessel. The
size of the vessel and the number of vessels dictate how
much volume can be harvested. More than one skin
vessel is included whenever possible, to ensure better
circulation.
7. When beginning the process of exploring a given region
for free-style flaps, the free-style flap is marked, so that it
shares a common border with the “back-up” flap. The
procedure is begun by incising the common border.
Vessels supplying the free-style flap are located and the
rest of the harvest is performed. If no vessels are found,
the back-up flap is used. Once the surgeon is comfortable
with the procedure of harvesting free-style flaps based on
Doppler mapping of a given region, having a back-up
flap in the immediate surrounding region becomes less
important.
After performing several free-style flaps, the technique
and the entire procedure become much quicker.
SPECIAL CONSIDERATIONS
Characteristics of skin requirements at the recipient site
must be considered when designing free-style flaps. For
example, if hairless skin is required, then free-style flaps
should be harvested from areas such as the ulnar aspect of
the forearm or back, etc. The area where the flap is taken
from is based on finding tissue that matches the recipient
site skin color, pliability, and bulk. Also, the skin vessels of
the flap should match the recipient vessels’ size and should
reach the recipient vessels without vein grafts.
TECHNIQUE OF FLAP HARVEST
(Cases 62.1–62.4)
The defect to be reconstructed is evaluated for color,
texture, pliability, and thickness. A donor site in the body is
found that matches the criteria at the recipient site. The
amount of tissue required is assessed. The patient is posi­
tioned in a way that allows access to both the recipient and
donor sites at the same time, if possible. All skin vessels in
the region selected are mapped. Once 3–4 vessels with a
strong signal are found, the search may stop. We use the
Super Dopplex II model number MD2/SD2 (Huntleigh
Diagnostics, Cardiff, UK) connected to a VP10 (10 MHz).
allowing the surgeon to obtain a thinner flap. The
fascia is entered at the point where the skin vessel
pierces the fascia and followed only to the point
where adequate length and vessel caliber are achieved.
Subfascial dissection is also possible and usually easier
and quicker (Case 62.3).
DISADVANTAGES
• Pedicle size, course, and length are less predictable.
• The amount of tissue that can be harvested based on a
given skin vessel is difficult to assess. The surgeon must
acquire a feel for how much tissue can be carried based
on a given size of perforator and this depends on the size
and amount of pulsatility in a given vessel.
• Free-style flap harvest requires accurate localization of
the skin vessels utilizing Doppler mapping, which requires
familiarity through learning.
• The surgeon may have to anastomose vessels of small
caliber.
FLAP DESIGN
ANATOMIC LANDMARKS
The main landmark for a free-style flap is the location of
the Dopplered skin vessel. Other landmarks are those for
known flaps in the region from which the free-style flap is
harvested. In the thigh, the anterolateral thigh flap is
marked, in the chest the deltopectoral flap is marked, in the
back the parascapular flap is marked, and so on. The nearest
known flap is marked and an incision is made along the
border between the free-style flap and the known flap. This
is performed during the harvest of the first few cases in a
given region. When success in harvesting free-style flaps
from a given region is achieved, marking of back-up flaps
becomes less necessary.
GENERAL THOUGHTS ABOUT FLAP DESIGN
1. Each area of the body is perfused by a given perforator
based on the perforasome theory. Each perforasome is
connected to an adjacent perforasome through direct
and indirect linking vessles.23
2. Vascular axis follows the axiality of the linking vessels that
follow the long axis of the limbs. In the arm and leg the
flap is designed along the length of the limb.
3. Linking vessels in the trunk are commonly directed per­
pendicular to the midline and follow an oblique trans­
verse direction.
4. The surgeon determines the final flap design based on
the location of the skin vessel as determined by the intra­
operative findings. The markings can change to place the
located skin vessel in either a more central location or a
more eccentric location based on the location and the
distance between the recipient vessels and the defect or,
in the case of a pedicled flap, based on the arc of rotation
necessary to reach the defect. If, during the exploration,
a larger skin vessel is found, this vessel may be chosen
instead of the originally mapped one.

732
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
WHEN MUSCLE IS NEEDED AT
THE RECIPIENT SITE
Besides functional muscle transfers, there are still times
when muscle is desired at the recipient site. Muscle has the
advantage of contouring well to the defect, and some argue
that its robust blood supply provides some advantage when
reconstructing defects where bacteria are present, such
as in osteomyelitis defects. Muscle can be harvested as
described above and inserted into the defect.
WHEN FASCIA IS REQUIRED FOR
THE RECONSTRUCTION
A subfascial approach is performed and the fascia underly­
ing the skin of the free-style flap is included with the flap.
The fascia can then be used either to bridge a defect of
tendon or to reconstruct a fascial or dural defect.
WHEN BONE IS REQUIRED
Free-style flaps are not the first choice when bone is needed.
In some cases when harvesting a free-style flap, a branch
supplying surrounding bone can be used to harvest a
segment of bone; however, this is a random event and
when bone is required, well-known osseous flaps should
be chosen.
WHEN MULTIPLE SKIN ISLANDS ARE REQUIRED
Free-style free flaps are not the favored choice when more
than one skin island is required. Preoperative Doppler
mapping of the skin vessels does not guarantee that these
vessels originate from a common vessel. Therefore, unless
two separate anastomoses are planned for, the free-style free
flap is not chosen for this type of reconstruction.
“RECYCLING” A FLAP
In some patients who have previously undergone a flap,
pedicled or free, the flap is bulky and may require revision.
In those patients, tissue to be debulked can be used as
another pedicled or free flap to reconstruct another defect.
Flap harvest is performed in a free-style manner by locating
a skin vessel within the previous flap using Doppler ultraso­
nography, designing the flap over the Dopplered skin vessel.
An incision is then made through the designed incision and
the vessel is located. Proximal dissection is carried until
adequate vessel length is achieved.
FLAP USAGE
RECONSTRUCTION OF DEFECTS IN ANY PART OF
THE BODY
• Where a flap is needed and typical donor sites are not
available such as in burn patients
• When a standard flap is being harvested and anatomic
variations are encountered or the pedicle is injured
during the dissection. Vessels in the same region
are explored through Doppler ultrasonography, and/or
Higher volume sounds in relation to other sounds are
marked with larger red dots and are chosen as the vessel of
choice for a given free-style flap.
When performing the free-style flap as a free flap, if suit­
able recipient vessels are found near the defect, the flap
pedicle length can be less. The free-style flap is then marked
on top of the strongest Doppler signal. The flap is elevated,
and the vessel is located, usually in the suprafascial plane,
and traced proximally until adequate length and caliber are
achieved. The surgeon should be comfortable performing
microvascular anastomoses of vessels that are 1 mm in
diameter, otherwise more proximal dissection is needed
prior to flap harvest. It is always preferable to obtain a
longer pedicle with larger-sized vessels in order to minimize
the technical challenge of small vessel anastomosis. The
flap can be harvested in the subfascial plane. The skin
island is designed; the incision is made through the skin
and subcutaneous tissue down to the fascia layer. The fascia
is incised and dissection is performed in a subfascial plane
towards the Dopplered perforator. The vessel is then traced
proximally until adequate vessel caliber and vessel length
are achieved.
When harvesting local free-style flaps, the dissection of
the vessels is carried out to a point where the arc of rotation
allows for reach to the defect.
Several principles are useful for designing and harvesting
a free-style pedicled or free flap: initially, the incision is
taken down to the level of the muscle fascia and the flap is
dissected in the suprafascial plane toward the mapped skin
vessel. Care in maintaining meticulous hemostasis is impor­
tant as it aids in allowing the surgeon to clearly visualize all
the skin vessels and important structures. Whenever possi­
ble, cutaneous nerves are maintained in their anatomic
location and are not harvested with the flap. Once the
surgeon locates the skin vessel and determines that it is
appropriate for use, the fascia is incised in a cephalad and
caudad direction and the vessel is traced back to its mother
vessel. The dissection is discontinued once the surgeon
achieves adequate length and vessel size.
If the surgeon cannot locate the mapped skin vessel or
determines that it is not suitable for use, the back-up flap is
used. Since the first incision that is made borders the
back-up flap, the dissection is carried in the direction of the
skin vessels of the back-up flap and the procedure is carried
out as for that flap.
FLAP MODIFICATION/FLAP HANDLING
WHEN BULK IS REQUIRED
A larger than necessary skin island is harvested and part of
it is de-epithelialized and used for provision of extra volume
to fill a soft tissue deficiency.
A segment of muscle is harvested based on branches that
come off the vessel supplying the free-style flap. There is no
simple way to determine preoperatively the branching
pattern of the pedicle supplying the free-style flap and
where the muscle would be located in relation to the cuta­
neous component. Generally, there are several branches
that supply surrounding muscles as the vessel approaches
the skin.

CHAPTER 62 — Free-style Flaps
733
any perforator flap, there are risks of vessel thrombosis,
wound healing problems, inadequate tissue, and other
untoward outcomes. Similarly, the donor site is chosen to
be well hidden and in a location that allows for primary
closure. Therefore, the potential to have an inconspicuous
donor site exists and depends on the amount of tissue that
is required at the recipient site.
CONCLUSIONS
The work of Taylor and Palmer on mapping skin vessels
of the human body has provided a theoretic goal for
reconstructive surgeons to be able to harvest a flap based
on any one of these vessels.13 Whether a free-style flap is
to be harvested or the principles of free-style flap harvest
are used to salvage a situation where anatomic variations
are encountered, this has provided near-complete freedom
for the reconstructive surgeon when analyzing a defect,
selecting a donor site for tissue transfer, and attempting
surgical intervention. The ability to locate skin vessels
with Doppler ultrasound, the familiarity with perforator
flap harvest techniques, and advancement in skills in
microsurgery allow for safe harvest of flaps using free-style
principles, where the flap is harvested based on a given
skin vessel and the vessel is dissected in a retrograde
fashion.
The use of free-style flaps should not be misinterpreted
as an arrogant disregard for anatomic landmarks that have
been established through the great work of anatomists, phy­
sicians, and surgeons; however, it should be seen as another
way of approaching flaps, even established, well-known
flaps. We hope that the reconstructive surgeon will be able
to select the flap based only on the quality and type of tissue
that is required at the recipient site and which is in a loca­
tion that is acceptable and favorable for the patient.
surgical exploration. Once a vessel is found, the “free-
style” flap is designed over the vessel and harvested to
reconstruct a defect
• A flap has been previously used for reconstruction of a
given defect. A debulking procedure is required and the
patient has another defect that needs to be reconstructed.
A skin vessel is located within the old flap. A new flap is
designed within the old flap and used to reconstruct the
new defect.
POSTOPERATIVE CARE
Depending on the region where the flap is harvested and
the size of the flap, the donor site is preferably chosen in
an area that matches the recipient site and has a favorable
donor site location. When chosen carefully and appropri­
ately, the donor site is closed primarily or closed with a skin
graft, and future procedures such as serial excision or tissue
expansion allow for the skin graft to be excised.
OUTCOMES
The advantage of using a free-style flap, or free-style tech­
niques, is that the reconstruction is performed with optimal
tissue that matches the requirements at the donor site.
Therefore, if appropriate tissue is selected, the skin color,
skin tone, pliability, and bulk should match the recipient
site well, and the reconstruction allows for optimal aesthetic
and functional outcomes. Sensory reinnervation occurs in
some situations depending on the type of tissue that was
transferred and on the recipient bed. If sensory nerves are
taken with the free-style flap and connected to sensory
nerves at the recipient site, sensory reinnervation is more
likely to happen and result in an excellent outcome. As with

734
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
Patient presented to the plastic surgery service with a neck
defect. A perforator was located adjacent to the defect and a flap
was designed based on the Dopplered perforator. The flap was
elevated and rotated 180° to reconstruct the defect. The donor
site was skin grafted.
CASE 62.1  Left Neck Defect Reconstructed with a Pedicled Free-style Flap
Figure 62.2  (A) Defect in the left neck. A perforator was located near the defect. (B) A flap was designed based on the Dopplered per­
forator. (C) The Dopplered perforator was located and the flap was completely elevated and pedicled to reconstruct the defect. (D) Several
months following the surgery the flap has healed and the donor site skin graft has taken.
A
B
C
D
B

CHAPTER 62 — Free-style Flaps
735
A 61-year-old man with diabetes, undergoing reconstruction of
a through-and-through cheek defect with an anterolateral thigh
flap. Several months following the reconstruction, the patient
presented with an infected second toe, which required debride-
ment and soft tissue coverage. The patient required debulking
of the previously inset anterolateral thigh flap to reduce drool-
ing and improve contour. A perforator was located using a hand-
held Doppler and a flap was designed based on that perforator.
The flap was harvested and used to reconstruct the defect in the
area of the resected second toe.
CASE 62.2  Right Foot Defect Reconstructed with a Free-style Flap from a Previous
Transferred Anterolateral Thigh Flap
Figure 62.3  (A) Diabetic foot with infected second toe requiring debridement. (B) An ALT had been used to reconstruct a through-and-
through cheek defect. The patient had a bulky flap and oral incontinence. A perforator was located using a handheld Doppler and a flap
was designed based on that perforator. The design was made in a way to allow for excision of bulky tissue, and elevate the lower lip to
a better position to reduce drooling. (C) One side of the flap was incised and the Dopplered perforator was located. (D) The rest of the
free-style flap was elevated. (E) The free-style flap was transferred to reconstruct the foot defect. (F) The donor site of the free-style flap
was close primarily. The free-style harvest from the previous ALT resulted in debulking of the cheek and correction of drooling. (From
Feng KM, Hsieh CH, Jeng SF. Freestyle puzzle flap: the concept of recycling a perforator flap. Plast Reconstr Surg 2013;131[2]:258–63.)
A
B
C
D
E
F

736
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
A female patient with a history of a plantar foot defect recon-
structed with a free ALT flap 2 years previously, presented with
a forefoot defect and a bulky ALT flap. Following mapping of
the foot to evaluate pressure points and to avoid future ulcer-
ations, a free-style flap was planned. Intraoperative Doppler
mapping of perforators was performed using a handheld
Doppler. A free-style flap was designed based on the most distal
perforator. The flap was elevated from one side and the Dop-
plered perforator was located. The free-style flap was advanced
and rotated to reconstruct the defect. The donor site was closed
primarily.
CASE 62.3  Forefoot Defect Reconstructed with a Pedicled Free-style Flap
Figure 62.4  (A) Foot defect reconstructed with a free anterolateral thigh flap 2 years prior to presentation with a forefoot ulcer. The plan
was to debulk the ALT flap as well as harvest a free-style flap using perforators of that flap. A handheld Doppler was used to map out
two perforators. (B) An incision was made and the ALT flap was elevated from medial to lateral until the more distal Dopplered perforator
was located. (C) After debridement of the forefoot wound, the free-style flap was advanced and rotated to cover the forefoot defect. (D)
The wound was well-healed at follow-up.
A
B
C
D

CHAPTER 62 — Free-style Flaps
737
This male patient had a resection of a tumor resulting in soft
tissue defect in the upper back. Since the patient was in a prone
position for the resection, finding soft tissue from the back was
ideal for reconstruction of this defect. A Doppler signal was
found in the left back and a skin island was designed over this
perforator. The vessel was located intraoperatively and traced
back until adequate pedicle length and size were achieved. The
vessel was not traced to its “mother vessel.” The flap was trans-
ferred to the left upper back defect.
CASE 62.4  Left Upper Back Defect Reconstructed with a Free-style Flap from
the Right Back
Figure 62.5  (A) Large left upper back defect. Doppler mapping of the left back determined the location of a large perforator (in red). A
skin island was designed over the Dopplered perforator. (B) The flap was raised in the subfascial plane from lateral to medial until the
Dopplered perforator was located. The vessel was traced until adequate length and size were achieved. The rest of the flap was raised.
(C) The flap is seen on the back-table. (D) Postoperatively, the patient is well-healed at the recipient site and the donor site.
A
B
C
D

738
PART 5 — PERFORATOR-BASED WORKHORSE FLAPS
REFERENCES
1. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site
morbidity of free DIEP flaps and free TRAM flaps for breast recon­
struction. Br J Plast Surg 1997;50(5):322–30.
2. Celik N, Wei FC. Technical tips in perforator flap harvest. Clin Plast
Surg 2003;30(3):469–72.
3. Niranjan NS, Davalbhakta A. Fascial feeders. In: Blondeel PN,
Morris SF, Hallock GG, et al., editors. Perforator flaps: anatomy,
technique and clinical applications. St Louis: Quality Medical;
2006. p. 961–8.
4. Wei FC, Celik N. The perforator entity. Clin Plast Surg 2003;30(3):
325–9.
5. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue
flap? An experience with 672 anterolateral thigh flaps. Plast Recon­
str Surg 2002;109(7):2219–26.
6. Mardini S, Tsai FC, Wei FC. The thigh as a model for free-style free
flaps. Clin Plast Surg 2003;30(3):473–80.
7. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg
2004;114(4):910–16.
8. Mardini S, Wei FC, Cheng MH. Free-style free flaps. In: Blondeel
PN, Morris SF, Hallock GG, et al., editors. Perforator flaps: anatomy,
technique and clinical applications. St Louis: Quality Medical;
2006. p. 969–76.
9. Morris SF, Neligan PC, Taylor GI. Free-style local perforator flaps.
In: Blondeel PN, Morris SF, Hallock GG, et al., editors. Perforator
flaps: anatomy, technique and clinical applications. St Louis:
Quality Medical; 2006. p. 947–60.
10. Taylor GI, Doyle M, McCarten G. The Doppler probe for planning
flaps: anatomical study and clinical applications. Br J Plast Surg
1990;43:1–16.
11. Hallock GG. Doppler sonography and color duplex imaging for
planning a perforator flap. Clin Plast Surg 2003;30(3):347–57.
12. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry in
the planning of perforator flaps. Br J Plast Surg 1998;51(3):
202–9.
13. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg
1987;40(2):113–41.
14. Taylor GI, Daniel RK. The anatomy of several free-flap donor sites.
Plast Reconstr Surg 1975;56(3):243–53.
15. Wei FC, Chen HC, Chuang CC, et al. Fibular osteoseptocutaneous
flap: anatomic study and clinical application. Plast Reconstr Surg
1986;78(2):191–200.
16. Koshima I, Inagawa K, Urushibara K, et al. Paraumbilical perfora­
tor flap without deep inferior epigastric vessels. Plast Reconstr Surg
1998;102(4):1052–7.
17. Wei FC, Silverman RT, Hsu WM. Retrograde dissection of the vas­
cular pedicle in toe harvest. Plast Reconstr Surg 1995;96(5):1211–
14.
18. Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator
flaps: clinical results and vascular anatomy. Plast Reconstr Surg
2010;126(5):1589–603.
19. Song JW, Ben-Nakhi M, Hong JP. Reconstruction of lower extremity
with perforator free flaps by free-style approach in pediatric
patients. J Reconstr Microsurg 2012;28(9):589–94.
20. Sinna R, Benhaim T, Qassemyar Q, et al. Double L-shaped free-
style perforator flap for perineal and vaginal reconstruction after
cylindrical abdominoperineal resection. J Plast Reconstr Aesthet
Surg 2010;63(10):1740–3.
21. Wallace CG, Kao HK, Jeng SF, et al. Free-style flaps: a further step
forward for perforator flap surgery. Plast Reconstr Surg 2009;124(6
Suppl.):e419–26.
22. Feng KM, Hsieh CH, Jeng SF. Free-style puzzle flap: the concept of
recycling a perforator flap. Plast Reconstr Surg 2013.
23. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory:
vascular anatomy and clinical implications. Plast Reconstr Surg
2009;124(5):1529–44.
Expert Commentary 
Michel Saint-Cyr, MD, FRCS (C)
This chapter by professors Wei, Jeng, and Mardini offers a
clear and unique perspective on the applications, advan-
tages, and disadvantages of using a free-style approach to
reconstructive surgery. The authors are to be commended
for their thoughtful description of this technique of flap
harvest based on their significant clinical experience.
As mentioned by the authors and described by Taylor and
colleagues,13 there are over 347, if not more, clinically rele-
vant perforators in the body that are amenable to either a
free, or pedicle, free-style flap harvest approach. This drasti-
cally increases the options available in flap donor sites and
flap characteristics such as color, thickness, and tissue
composition.
Many of the cutaneous perforators of the body are orga-
nized and concentrated in high- and low-density areas
known as “hot and cold spots” and knowledge of these can
help in free-style flap design. For example, many perforator
high-density areas can be found near the midline, midaxial,
and periarticular areas of the body. Designing a flap over
these high-density areas or hot spots, will increase the
chances of finding one or more suitable perforators. Design-
ing a free-style flap, with the long axis centered over a known
underlying source vessel, in the area of interest (e.g., super-
ficial femoral artery, SFA), will also yield many perforator
options. Multiple perforators can be found branching sequen-
tially along the path of an underlying main source artery and
this knowledge can help in free-style flap design. Simply
drawing a line from proximal to distal (e.g., PTA, ATA, in the
lower extremity) along the path of the source artery and
having the flap long axis centered over this line will yield more
perforator options and keep intra-flap perforator density
high. This also keeps the flap axis parallel to the long axis of
the limb and maximizes the number of interperforator flow
points within the flap. Safe flap limits in free-style flap harvest
can be determined using flap imaging technology when avail-
able (e.g., ICG). If no imaging is available, careful perfusion
assessment and clinical judgment are paramount. A safe rule
of thumb is keeping the flap length roughly half the distance
between two adjacent articulations (e.g., mid-thigh for a dis-
tally based periarticular SFA pedicle perforator flap). Some
flaps based on very large perforators with numerous inter-
perforator linking vessels may be much larger.

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INTRODUCTION
The purpose of this chapter is to discuss the general
principles, challenges, and opportunities in establishing a
reconstructive transplant program. The authors bring the
experience of two centers in two different countries with
significantly differing healthcare systems: the United States
and France. The authors provide their own perspectives and
experiences. L. Lantieri is a plastic and reconstructive
surgeon who established a face transplant program in Paris,
France, and has performed one of the largest series of face
transplantations in the world.1,2 H. Amer is a transplant
nephrologist and founding medical director of the first
reconstructive transplant center in the United States to
obtain institutional approval for both hand and face trans­
plantation as an extension of clinical practice.3
Reconstructive transplantation is the bringing together of
two multidisciplinary practices, reconstructive surgery and
transplantation, to benefit a very select group of patients.
Reconstructive surgeons for many years have brought
healing and recovery to victims of significant tissue loss or
damage resulting from trauma, malignancies, or burns.
Despite significant advances in the field of reconstructive
surgery, major limitations exist, particularly in patients with
major limb loss and those with severe facial deformities.
One of the most utilized tools in reconstructive surgery
involves microvascular free tissue transfers, which is essen­
tially an autotransplant. Combining all of the conventional
techniques currently available, including prosthetics, there
remains an inability to restore a severely deformed face or
restore function and sensation to a patient with a major limb
loss. Processed biomaterial such as tendons and skin has
provided additional options but still has limitations. Trans­
plant surgery provides the patient with a procedure that is
a huge leap forward in reconstruction, where restoration of
normal anatomy is possible.
Transplant physicians and surgeons have, since the first
successful kidney transplant in 1954, offered patients with
end organ failure, the option of replacing their failed organ
with a healthy organ from another individual.4 The field of
solid organ transplantation has progressed since that first
successful kidney transplant in 1954 between identical twins,
to a point where it seems routine to have a kidney, heart,
liver, pancreas, or lung transplant. Thousands of transplants
are performed annually all over the world, some from
deceased donors and some from live donors. The under­
standing of immunology and immunosuppression manage­
ment has enabled better, more tolerated, and in some cases,
Starting a Reconstructive
Transplantation Program
Laurant Lantieri  |  Hatem Amer
63 
tailored immunosuppression for thousands of patients who
have gone on to lead productive and near normal lives.
In 1998, the collaboration between reconstructive sur­
geons and the transplant community resulted in the first
successful hand transplant and, in 2005 the first partial face
transplant.5,6
Hand and face transplantation differs from solid organ
transplantation in several ways; they require successful rein­
nervation to provide function (motor and sensory) and the
organs are visible. They differ from previously used free
flaps, grafts, and processed tissues, in that they require
immunosuppression to prevent rejection.
With over 30 face transplants and over 100 hand trans­
plants performed at the end of 2014, the concept of vascular
composite allotransplantation (VCA) has become a clinical
reality.7,8 Many of the cases, particularly in face transplants,
have been one-shot experiences. In face transplantation,
only three teams have done more than three cases. Even if
this procedure is risky, it is proven to be not only feasible
but also reproducible. Although there is a lack of long-term
results, the initial results show that in a very select group of
patients with specific indications, the benefits may outweigh
the risks.
A team that intends to set up a hand or face transplant
program must realize that not everything is written and stan­
dardized and it is through a trial and error process that a
reconstructive surgery team can establish a sustainable
program. Undoubtedly, many problems will be encountered.
Therefore, a thorough and thoughtful process must be estab­
lished, which will provide a standardized process that will be
effective and efficient. A significant amount of administra­
tive, clinical, and experimental work has to be completed
prior to embarking on a transplant. The authorization
process is generally a long process and the department needs
to become involved early in the planning process. The team
leader should propose a detailed plan. This plan consists of
team selection and approval from the independent commit­
tees. A hand or face transplantation program requires an
intricate network of physicians, nurses, technicians, and
administrators to function smoothly and effectively. The idea
itself can shock many people who are involved in the trans­
plantation process from organ procurement to the final
result. It is critical to convince all involved members of the
value of having a reconstructive transplant program. There­
fore, it is essential to organize regular meetings. The team
leaders must present to all the different groups that will be
involved in the care of these patients in order to get “buy-in.”
All levels of leadership and personnel within the institution
PART 6  —  RECONSTRUCTIVE TRANSPLANT SURGERY

CHAPTER 63 — Starting a Reconstructive Transplantation Program
e205
transplantation. This could include the departments of
surgery, medicine, laboratory medicine, physical therapy
and rehabilitation, nursing etc. Given that no transplant can
occur without a donor, rapport, education, and discussion
should be started early with the local organ procurement
organization.
FORMING THE TEAM
A reconstructive transplant team comprises many disci­
plines: reconstructive transplant surgeons; transplant physi­
cians well-versed in the evaluation and management of
transplant recipients; oculoplastic surgeons; physical and
occupational therapists; pharmacists; social workers; radi­
ologists and radiological services; tissue typing experts;
transplant infectious-disease specialists; dermatologists and
dermatopathologists; surgical pathologists, preferably famil­
iar with pathology of other organ allografts; psychiatrists and
psychologists; anesthetists; ethicists; nursing staff; intensiv­
ists; and operating room personnel. From a surgical perspec­
tive, it should be noted that contrary to most conventional
reconstructive surgery procedures, the surgical team has to
train regularly with rehearsals on cadavers with and/or
without scrub nurses and other team members. Besides the
technical knowledge gained by these rehearsals, it allows for
better cooperation between the different elements of the
team. It is essential that the adequate surgical expertise is
developed to allow simultaneous procurement and recipient
preparation at remote sites. Members of the team should be
cross-trained to allow easy substitution as the need arises.
There should also be enough redundancy to allow for sub­
stitution in the event of extreme fatigue during the lengthy
operations or unexpected absences when a donor becomes
available. The team leader must structure a schedule that
includes breaks for every team member. Surgeons in recon­
structive transplantation can be drawn from plastic and
reconstructive surgeons, oral and maxillofacial surgeons
and/or head and neck surgeons, and transplant surgeons,
as long as they are involved and believe in the project.
As the team comes together, it is important to meet regu­
larly. Allow input from all team members and have frequent
discussions and debates. This is important to build commu­
nication channels, bring everyone up to speed on the devel­
opments in the field, appreciate the various facets of the
different specialties, and ensure trust among team members.
There should be small workgroups formed to tackle particu­
lar problems. Frequent rehearsals and “walk-throughs” of
the planned protocols and procedures must be undertaken.
Collaboration with a company that provides cutting-edge
3-D technology-driven virtual surgical planning is critical
when bone is involved in the transplant. The Mayo Clinic
team has benefited from a collaboration with Medical Mod­
eling, where a team of bioengineers receive CT data for the
donor and recipient and a web meeting is undertaken with
Dr. Mardini to plan the surgical procedure.9 Models, cutting
guides, and positioning guides are provided to the surgical
team in order to optimize accuracy and efficiency during
the procedure (Fig. 63.1). For the surgical members of the
team, frequent simulated procurements and transplants
reflecting the planned transplant for each patient is impor­
tant. Team members should be encouraged, if not
must become convinced that this technique is essential for
an institution that wants to stay at the cutting edge of recon­
structive face and limb rehabilitation.
SHOULD AN INSTITUTION DEVELOP A
RECONSTRUCTIVE TRANSPLANT
PROGRAM?
The momentum to develop a reconstructive transplant
program can begin from a variety of individuals at any insti­
tution. It should be remembered; however, that reconstruc­
tive transplantation, whether hand or face, is primarily a
surgical procedure. The patients that are being helped may
benefit from transplantation, but many may best be helped
by non-transplant reconstructive procedures. As such, a
reconstructive transplant program must have a strong
reconstructive surgery program that routinely deals with
severe hand and face deformities in which a multidisci­
plinary approach is practiced. The patient must have access
to any and all necessary ancillary and complementary thera­
pies such as physical therapy, anaplastology, and prosthetics.
When a patient is evaluated, they should be considered for
all possible therapies, and transplantation would be one of
the options available to them if indicated. It should not be
the only option considered or offered.
As such, reconstructive transplant programs should
emanate from reconstructive surgery departments. Having
said that, reconstructive transplantation will require exten­
sive support and expertise not present in reconstructive
surgery departments. Once there is at least one advocate for
reconstructive transplantation in the reconstructive surgery
department, a careful assessment of the resources present
and those that are needed to bring together an expert team
and develop a program is performed. As mentioned above,
although the first successful hand transplant was performed
in 1998, since that time there have been fewer vascularized
composite transplants performed worldwide than the
number of solid organ transplants performed by some
single centers in 1 year. As such, the role of the reconstruc­
tive transplant program in the care of an institution’s
patients as well as the institution’s overall operations and
goals has to be assessed.
If the decision is made to establish a program, then the
lead reconstructive surgeon should begin to reach out to
the needed disciplines and begin making a case for the
development of such a program. Education regarding the
role of reconstructive transplantation in the care of severely
disfigured patients is of paramount importance. This educa­
tion will need to be tailored to fill anticipated gaps in knowl­
edge and understanding of various audiences. Audiences
will include fellow reconstructive transplant surgeons and
other providers who care for patients with reconstructive
surgery needs but who may not be fully aware of the state
of reconstructive transplantation. It will also include the
transplant practices with the various members and ancillary
support staff who may be very comfortable with transplanta­
tion but may not be aware of the needs of these patients, or
of the limitations of modern reconstructive surgery and
prosthetics.
Education should extend to individuals in the institution
who may not necessarily become involved in reconstructive

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PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
Figure 63.1  (A) Virtual surgical planning used to simulate the bony cuts in a face transplant on two cadaver heads. (B) Based on the planned
osteotomies, cutting guides are made that are placed on the bones. These guides allow for improved accuracy of the cuts to allow for a better
and more efficient reconstruction. This image shows the cutting guides used for the recipient and (C) cutting guides for the donor (D).
(Top) Lateral and AP views of the planned reconstruction. (Bottom) Lateral and AP views following the reconstruction demonstrating accuracy
of the reconstruction. (Courtesy of Samir Mardini, M.D.)
A
B
C
D

CHAPTER 63 — Starting a Reconstructive Transplantation Program
e207
much feedback as possible. This will also result in greater
support of the program as it develops and goes through the
expected ups and downs. At Mayo Clinic, the reconstructive
transplant program was presented to several committees
including the clinical practice committee, the hospital prac­
tice committee, IRB leadership, the ethics committee, and
the Rochester Executive Operations Team, among many
others. A parallel set of committees at the organ procure­
ment organizations were presented too, including the clini­
cal practice committee, and all of the different solid organ
committees, as face and hand programs will greatly affect
the procurement process and may affect the solid organs by
delaying cross-clamp time.
FUNDING THE PROGRAM
Funds are needed to evaluate the patients, perform the
surgery, and follow the patients thereafter. Lifelong immu­
nosuppression is mandatory and costly. Finding the funds
necessary to cover these steps will depend on the location
of the program and the healthcare system that is in place.
In France, where there is a national health service, these
steps are covered in approved centers for specified numbers
of patients at each step. Long-term follow-up and treatment
of complications come under the general principle of taking
care of a French citizen. In countries where there is no
national health service, coverage can come from several
sources that include research grants, charity care from the
institution, philanthropy, private pay or insurance coverage
for various aspects of the process such as coverage of the
immunosuppression, and/or the surgical procedure itself.
Regardless of the structure present, no program should
perform the procedure without confirming that the patient
will be able to find adequate resources to take her/his
medications and receive appropriate medical care for a
lifetime.
THE ORGAN PROCUREMENT
ORGANIZATION
Without a donor there cannot be a transplant. The organ
procurement organizations (OPOs) are an indispensable
part of any transplant endeavor. Communication with the
local OPO of the intent to establish a reconstructive trans­
plant program should be performed early in the process.
The OPO should inform the team leader of any concerns
and provide a list of the needed information and OPO com­
mittees that need to review and approve the participation
of the OPO in this endeavor. The OPO will have to develop
an education process for its personnel and develop a strat­
egy of approaching the donor families, tackling the logistics
of having the reconstructive transplant surgeons procure
these “non-life saving organs” prior to procuring the other
solid organs. Protocols have to be written and tested to
ensure that there are contingencies for possible unforesee­
able situations. What will happen if the donor becomes
unstable? What are the points of no return for the recipient
that should not be crossed until the hand or face is pro­
cured? If these points have been crossed, how do we handle
the unstable donor situation? Are there possible salvage
mandated to attend relevant society meetings such as the
American Society for Reconstructive Transplantation bien­
nial meeting or the International Hand and Composite
Tissue Allotransplantation Society.10,11 Site visits to other
reconstructive transplant programs are also beneficial.
Given the relative novelty of reconstructive transplantation
and the scarcity of patients transplanted, there are no stan­
dard universally approved data-driven guidelines of who to
transplant or how. It will be important for each new program
to gain as much knowledge and experience from other
programs prior to embarking on their first transplant.
RESEARCH OR CLINICAL PRACTICE
Many of the first reconstructive transplant programs were
developed as research programs funded by research grants
and monitored by institutional review boards (IRBs), for the
protection of the subjects engaged in research. More
recently, some institutions have considered face or hand
transplantation as an extension of already present clinical
practice and therefore monitored by the regulatory struc­
tures that govern clinical practice in the institution. As such,
the institution’s clinical practice committee (CPC) may
need to approve the program rather than an IRB. In that
situation, the reconstructive transplant procedure is gov­
erned by the CPC, while any research protocols that involve
reconstructive transplantation will also be reviewed and
monitored by the IRB. Whether a program decides to have
reconstructive transplantation as part of clinical practice or
only as a research protocol, will depend on the institution
and the team leaders. At this stage of reconstructive trans­
plantation, it is important to learn as much as possible from
all patients who receive VCA transplants, and as such we
strongly recommend that all programs develop clinical
research protocols to allow the study of these patients in
order to contribute to the understanding of the risks and
benefits of these procedures. We also recommend that all
programs participate in the International Registry on Hand
and Composite Tissue Transplantation.12
COMMITTEE APPROVALS
The committees that need to approve the development of
a reconstructive transplant program will depend on whether
a clinical practice or research-only program is planned. It
will also depend on the institution and the local and national
regulatory agencies that are involved in regulating health
care and allocation of organs. The team leaders should map
out a list of the committees that need to approve the
program and develop a timeline of presentations, submis­
sions, and follow-up of recommendations from each com­
mittee. It is imperative to understand that many members
of these committees may not be familiar with reconstructive
transplantation and enough time should be given in the
presentation for developing an understanding of the field
and the potential benefits and risks to the patients. Team
members should aim to be inclusive and extend requests of
review and endorsement to as many relevant committees as
possible. Some who may be peripheral and not necessarily
needed should be enlisted as well. The goal is to receive as

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PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
procurement organization regarding donor variables; pre­
operative, operative, and postoperative care protocols; and
order sets. These should be reviewed on multiple occasions,
critiqued, and rehearsed. Ideally, a mock patient and donor
call followed by an actual organ procurement and recipient
set-up (on cadavers) followed by the reconstruction should
be rehearsed. This will allow for a situation that mimics the
real one as much as possible. As the process of a face or
hand transplant, especially the first one, is a massive
endeavor with many steps and many potential problems,
practicing and refining every step will minimize the chances
of major problems and surprises.
MAINTAINING AN ACTIVE PROGRAM
Once established, it is important to continually review the
goals and objective of the program. Assess any problems that
have occurred and develop strategies to avoid them in the
future. Given the infrequent number of cases performed, it
will be important to continually develop strategies for engag­
ing members of the team in activities that relate to recon­
structive transplantation. Meetings for the entire team
should occur on a regular basis every 2–4 weeks. Subgroups
of the team should develop projects that keep them engaged
in the field. These projects could be clinical research pro­
tocols looking at questions that relate to the field but do not
necessarily involve an actual recipient. They could involve,
for example, attitudes of providers and injured individuals
to reconstructive transplantation, prosthesis, immunosup­
pression, etc. Members should be encouraged to present
their work to the team as a whole and to national and inter­
national meetings, and to publish.
CONCLUSIONS
Establishing a VCA program is a long and challenging
process. It requires strong will and solid leadership to
interventions that would allow the procurement to proceed
and that would be agreeable to the OPO?
Maintaining donor dignity is of paramount importance.
The defect left following face procurement, or even the
amputation of the upper extremities, can be shocking to
family members, funeral home directors, and even operating
room staff. Tackling this issue requires careful consultation
with the OPO. Policies and procedures need to be put in
place to address this important concern. Some programs
have opted to only accept organs from donors whose families
have planned cremation and do not wish to have any viewing
or visitation. Others have developed a comprehensive donor
restoration process with either upper extremity prosthetics
or utilized anaplastologists to reconstruct the facial defect
with a mask. In Lantieri’s program, a mold from the donor’s
face is formed before the procurement procedure begins
and is used to create a mask as the organ procurement
surgery takes place. In comparison with silicon, resin pre­
sents quicker, and in Lantieri’s experience, gives better
results, taking only 3 h to complete by an experienced ana­
plastologist. At the Mayo Clinic the anaplastologists will offer
the option of creating a donor mask. If so requested, they will
perform the moulage of the donor’s face at the donor’s
bedside (in the ICU) following tracheostomy placement.
After forming the moulage they mix custom-colored silicone
and paint it into the moulage, layer by layer, to re-create the
image of the donor. They use a silicone material to provide a
lifelike image of the donor (Fig. 63.2). Experience thus far is
that it can be completed within 6–8 h, a reasonable time
given the length of time needed for the procurement.
GOING LIVE
As the team forms, learns, and gears up to perform their
first transplant, it is recommended that they have written
policies and procedures that are specific to their own
program covering topics such as patient selection; evalua­
tion; listing processes; communication with the organ
Figure 63.2  (A) Cadaver head prior to lower face procurement. (B) The lower face including a LeFort III segment and mandible was procured.
A structural support is placed based on the moulage of the donor prior to procurement (C); restoration of the donor following placement of
the silicone prosthesis created by the anaplastologists. (Courtesy of Gilian Duncan and Michaela Calhou.)
A
B
C

CHAPTER 63 — Starting a Reconstructive Transplantation Program
e209
REFERENCES
1. Sedaghati-nia A, Gilton A, Liger C, et al. Anaesthesia and intensive
care management of face transplantation. Br J Anaesth 2013;111:
600–6.
2. Lantieri LA. Face transplantation: the view from Paris, France.
South Med J 2006;99:421–3.
3. Amer H, Carlsen BT, Dusso JL, et al. Hand transplantation. Minn
Med 2011;94:40–3.
4. Murray JE. Reflections on the first successful kidney transplanta­
tion. World J Surg 1982;6:372–6.
5. Dubernard JM, Owen E, Herzberg G, et al. Human hand allograft:
report on first 6 months. Lancet 1999;353:1315–20.
6. Devauchelle B, Badet L, Lengele B, et al. First human face allograft:
early report. Lancet 2006;368:203–9.
7. Khalifian S, Brazio PS, Mohan R, et al. Facial transplantation: the
first 9 years. Lancet 2014.
8. Petruzzo P, Lanzetta M, Dubernard J-M, et al. The international
registry on hand and composite tissue transplantation. Transplan­
tation 2010;90:1590–4.
9. Medical Modeling. Online. Available: <
modeling.com>.
10. American Society for Reconstructive Transplantation. Online.
Available: <>.
11. International Hand and Composite Tissue Allotransplantation
Society. Online. Available: <
=com_content&view=article&id=1187:international-hand
-and-composite-tissue-allotransplantation-society-update&catid
=105:newsletter-2012-volume-9-issue-2&Itemid=657>.
12. International Registry On Hand and Composite Tissue Transplan­
tation. Online. Available: <>.
engage the interest of the institution, to align the goals of
the program and the vision of the institution, and to achieve
a level of excellence that is sustainable. We know now that
the efforts of the few teams that have realized hand and face
transplantation have engendered a passion to push the
limits of surgery and science to restore dignity to some des­
perate disfigured humans where conventional surgery was
failing to provide them with a good quality of life. However,
only time will give us answers concerning universally
accepted standards for indications and a better understand­
ing of the risk to benefit ratio. We believe that will and
dedication, and the ability to form teams, are the pillars to
establish a reconstructive program.
Expert Commentary 
Palmina Petruzzo, MD
Vascularized composite allotransplantation (VCA) is a new field
of transplantation that gathers together several types of trans-
plantation, such as upper and lower extremity, face, larynx,
uterus, penis, and abdominal wall. The common point of all
these VCAs is that they are not life saving transplantation but
they are performed to improve the patients’ quality of life.
The most common types of VCA are upper extremity and
face allotransplantations. The potential candidates who can
benefit from these VCAs are disfigured and/or amputated
patients. The realization of these VCAs is possible combining
reconstructive surgery and transplantation. Both are indispens-
able: the first one has not only to perform the surgical operation
but also to identify VCA as the unique and/or the best option
for the patients, offering them – when it is possible – all the
other possible solutions, while the second one has to manage
the recipient during the follow-up. A right selection of the can-
didates and a careful follow-up of the patients are the basis of
a successful VCA. This goal can only be reached by creating
a multidisciplinary team, including many disciplines for the
evaluation and management of complex medical, psychiatric,
and social issues. Team communication and recognition of
each member’s contribution promote optimal outcomes. When
a team decides to start a VCA program, it is very important to
guarantee all the required resources and a leader who has to
act as a conductor. The members of the team involved in VCA
are numerous and they have to be motivated without moral
distress related to the visible nature of the allografts. It is impos-
sible to perform face or upper extremity transplantation without
“a donor,” consequently, the organ procurement organization
must be involved early on, sensitized, and educated to this new
field of transplantation. Education of the team is important, as
the reconstructive team is not familiar with transplantation
issues, including respect for the donor and donor family.
It is very useful to create detailed protocols including all the
procedures before and after transplantation as well as to
perform periodically simulated procurements and transplants.
Finally, strong collaboration and support among the different
teams involved in VCAs is indispensable to develop and
improve VCA programs.

739
Face Transplantation
Joseph A. Ricci  |  Bohdan Pomahac 64 
INTRODUCTION
The notion of drastically improving the treatment of cata­
strophic facial injuries, regardless of the cause, has moti­
vated surgeons to pursue the development of facial
transplantation in addition to other types of vascularized
composite allotransplantation (VCA) over the past few
decades. Historically, the reconstruction of such daunting
facial defects has been demanding, often requiring numer­
ous procedures and often yielding less than ideal results.
Conventional techniques have been largely inadequate to
restore facial aesthetics and function in these severe inju­
ries, while the reconstruction of anatomically and function­
ally complex facial structures such as the nose, lips, and
eyelids has been especially disappointing. Despite signifi­
cant effort and treatment, these patients are often left with
lifelong functional and aesthetic handicaps.
The first facial transplantation in the world took place
in Amiens, France in 2005.1 In the decade since, there
have been nearly 30 reported full or partial face transplants
performed in over a half dozen countries and several more
that have not yet even been reported.2,3 The first patient
was a 38-year-old woman who sustained severe injuries to
the lips, nose, and cheek from a dog bite.2 The early results
from this procedure were remarkable, in that it provided
the entire world with a medical breakthrough and gave
hope to patients with facial defects considered “unrecon­
structable” by conventional methods. Since then, several
other facial transplantations have been performed and the
encouraging outcomes of these cases have also demon­
strated the amazing potential to restore facial aesthetics and
function that was previously impossible with traditional
reconstructive techniques.1,2,4–6 However, the enthusiastic
outlook toward facial transplantation among the medical
community has recently become more guarded, given that
three of the transplant patients have died. The first patient
died of unknown causes in China, secondary to his refusal
to take immunosuppressive medications, while the second
patient was a severely burned patient, who received a simul­
taneous bilateral upper extremity and facial transplantation
and died of sepsis 1 month after his procedure. The third
confirmed death after facial transplantation occurred in
an HIV-positive patient as a result of tumor recurrence
after a prior cancer resection.3 In addition to these tragic
deaths, several minor complications have been reported,
including infections with opportunistic organisms and
steroid-induced diabetes mellitus. Despite these issues, the
fact that the long-term outcomes of facial transplantation
are unknown and the fact that this procedure is still largely
considered experimental, there remains an excitement
among reconstructive surgeons and patients alike about this
powerful new technique.
The practice of organ transplantation is associated with a
variety of ethical issues, including the limited availability of
donors, the risk of rejection, and the importance of informed
consent for both donors and recipients alike.7 On top of
these issues, there arises an additional set of new ethical
dilemmas for facial transplantation related to the potential
transfer of a person’s appearance or identity as well as the
risk–benefit ratio of the procedure.7 Concerns regarding
self-identity are based on the recognized role of facial fea­
tures in perceptions of identity and self, as well as our deal­
ings with others.2 Critics of facial transplantation might
argue that a disruption in self-recognition may lead to regret,
depression, and potentially even life crises. On the other
hand, a loss of self-recognition is likely to already be present
in candidates for facial transplantation due to their pre-
existing facial disfiguration. Additionally, facial transplanta­
tion may help candidate patients further regain their lost
sense of identity, by giving them the ability to communicate
emotions through facial expressions, which may in fact be
more important to a sense of identity than facial contours
and features.2 The early results from the first few cases of
facial transplantation performed demonstrate that trans­
plant recipients do in fact regain much of their social capac­
ity and even accept the allograft as part of their own body.
Unlike solid organ transplantation, facial transplantation
is mainly performed in patients with an otherwise normal
life expectancy. However, the required immunosuppressive
therapy is likely to shorten life expectancy because of untow­
ard side effects. Furthermore, rejection and loss of the allo­
graft would require replacement with a new allograft or
reconstruction by conventional techniques, with likely infe­
rior results. When balancing the risks and benefits of facial
transplantation, the social stigmatization experienced by
those patients with severe facial disfigurement must be con­
sidered as an acceptable facial appearance is important for
normal social interactions. As a result, patients with severe
deformities have been willing to accept the risks given the
potential of the procedure to vastly enhance their quality
of life.
Facial transplantation is an extraordinarily complex and
resource-demanding undertaking, with the potential to
change a patient’s life for the better after a disfiguring acci­
dent. A multidisciplinary team is necessary to address all
the different aspects of the preparation, procedure, and
follow-up. Potential candidates for facial transplantation
need to undergo vigorous physical and psychological testing
preoperatively. A diverse surgical team is also needed, with
expertise in head and neck reconstruction, microsurgery,
craniofacial surgery, and transplant surgery. Close follow-up
PART 6  —  RECONSTRUCTIVE TRANSPLANT SURGERY

740
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
CD4 and CD8 T-cell subtypes, as well as macrophages that
infiltrate the interstitial and vascular components of the
allograft, inflicting injury.11
CHRONIC REJECTION
Chronic rejection poses the single greatest threat to the
survival of a transplanted allograft. It is a slow, chronic dete­
rioration that compromises the function of the allograft.
Histologically, the parts of the graft affected will become
fibrotic and changes in the vasculature are seen as well. The
fibrosis is primarily the result of a low-grade inflammation,
which stimulates fibroblasts to deposit excessive amounts of
collagen as well as other components of the extracellular
matrix. The changes in the vasculature are believed to be
the result of antibody mediated rejection. Both immuno­
logic and non-immunologic events are believed to cause the
development of chronic rejection. Acute rejection episodes,
sensitization, and noncompliance with immunosuppression
are some of the main immunologic events implicated. Non-
immunologic events linked to the development of chronic
rejection include significant past medical problems such as
diabetes, hypertension, lipid abnormalities, and viral infec­
tions. Often, patients undergoing VCA tend to have a less
remarkable past medical history and this is thought to be a
factor contributing to the low frequency of chronic rejec­
tion in these patients.
GVHD
Genetic incompatibility between donor and recipient major
histocompatibility complexes (MHCs) and tissue specific
antigens can cause immunologic responses in the recipient.
with a battery of tests, as well as daily therapy sessions are
needed postoperatively. This chapter aims to shed some
light on the exciting and expanding new field of facial
transplantation.
IMMUNE SUPPRESSION
As with any type of allotransplantation, the composite tissue
allograft will be recognized as foreign tissue by the recipi­
ent’s immune system, which will lead to immunologic rejec­
tion. At the time of writing, this can only be prevented by
lifelong immunosuppressive therapy, which carries with it
significant risks and side effects. Compared with the trans­
plantation of a solid organ, such as a kidney or liver, which
could be considered lifesaving, the risks and side effects of
these medications must be weighed seriously against the
non-lifesaving nature of facial transplantation procedures.
Once the surgical feasibility was established, the immuno­
logic problem has become the main obstacle against VCA
of all types. As a result, the continuous need for the develop­
ment of new and improved immunosuppressive therapies is
of paramount importance to VCA.
Allograft rejection is the process where the transplanted
tissues are attacked by the recipient’s immune system after
it has been recognized as foreign and therefore potentially
harmful. Rejection is caused by a genetic incompatibility
between components of the recipient and donor tissues.
These incompatible components are known as antigens. It
is these antigens, along with antigen presenting cells (APCs)
and T-cells, that are the three major players in allograft
rejection. Less commonly, other tissues in the recipient’s
body may be attacked by components of the donor’s immune
system that have been harbored in the allograft. This is
known as graft-versus-host disease (GVHD).
Immunosuppressive therapy typically begins immediately
after surgery (induction therapy) to prevent the rejection
of transplanted composite tissues and must continue (main­
tenance therapy) under close monitoring, as long as the
graft remains viable. Induction therapy is essential to delay
the onset of acute rejection while allowing for maintenance
agents to reach their therapeutic levels.8 Table 64.1 outlines
the main agents used for both induction and maintenance
therapy at our institution.1,2,4,5,9 Maintenance therapy is typi­
cally a tri-agent therapy. Rescue therapy is provided to
patients during episodes of acute rejection and initially
starts with corticosteroid boluses. If this is unsuccessful, the
antibody agents used for induction therapy can be used in
addition. In contrast to solid organ transplantation, topical
forms of some agents such as corticosteroids or tacrolimus,
can be used as rescue agents in face transplantation.
ACUTE REJECTION
Acute rejection may be mediated by either antibodies or by
cells. When antibody is mediated in nature, the antibodies
are against donor tissues and may have been formed either
before or soon after the transplant has taken place. In some
cases, patients have preformed antibodies resultant from a
previous blood transfusion, solid organ transplant, or preg­
nancy. The antibodies bind to small peptides on the surface
of the graft, triggering the immune response and reducing
graft survival.10 Cell-mediated acute rejection involves both
Table 64.1  Summary of immunosuppressive
regimen for face transplantation at
our institution
Induction Therapy
ATG
1.5 mg/kg
POD 0–4
MP
1000 mg/day
dbs
400 mg/day
POD 0
200 mg/day
POD 1
160 mg/day
POD 2
120 mg/day
POD 3
Maintenance Therapy
Prednisone
60 mg/day
POD 4–5
20 mg/day
POD 6–current
MMF
1000 mg/day
dbs
2000 mg/day
POD 0–current
TAC
10–15 ng/mL
POD 0–30
8–10
POD 31–current
ATG, antithymocyte globulin; MP, methylprednisolone; MMF,
mycophenolate mofetil; TAC, tacrolimus; POD, postoperative
day; dbs, day before surgery.

CHAPTER 64 — Face Transplantation
741
INDICATIONS
In the future, face transplantation may become the treat­
ment of choice for patients with considerable functional
and social impairment, as a result of severe facial disfigure­
ment. These disfigurements often are very large, involving
more than 25% of the surface area of the face and usually
involve more than just one of the aesthetic subunits of the
face.2,19 The detailed and intricate anatomic characteristics
of the structures destroyed in these disfiguring incidents are
often impossible to completely restore with traditional
reconstructive techniques. As a result, the transplant of a
facial allograft presents surgeons with a unique opportunity
to restore not only the form but also the function of these
damaged structures to patients.
Severe facial disfigurement can be the result of a wide
array of causes. Prominent causes include, but are not
limited to trauma, burns, congenital defects, infections, and
cancer. For example, the first two face transplants ever per­
formed were to correct traumatic defects caused by the
violent attacks of a dog and a bear.1,2,4 Face transplant opera­
tions have been performed in the United States for disfig­
urements caused by high-voltage electrical burns, chemical
burns, animal attacks, as well as for a traumatic defect caused
by a shotgun blast.6,20 Additionally, face transplantation has
been performed on two patients to correct defects resultant
from neurofibromatosis.3,5 As indicated by these few cases,
there is a particular set of challenges and difficulties associ­
ated with each patient and the reconstruction of their
unique defect based on its cause.2
TRAUMA AND BURNS
Nearly one-third of all trauma cases annually in the United
States involve facial trauma, with motor vehicle collisions
When the recipient’s immune system attacks the allograft,
rejection is the result. On the other hand, when the donor’s
immune system, transplanted with the allograft, attacks the
recipient’s tissues, GVHD will result. Severe GVHD can
cause death and is more likely to occur after the transplanta­
tion of hematopoietic stem cells rather than solid organs.12
GVHD occurs in approximately 1–2% of solid organ trans­
plantations.12,13 Not enough data is available to estimate the
risk of GVHD in facial transplantation but it is presumed to
be similar or lower than that for solid organ transplantation.
Risk factors for developing GVHD include advanced age,
immunodeficiency at time of transplant, and similar human
leukocyte antigen (HLA) match.14,15
IMMUNE TOLERANCE
Immune tolerance is the ideal state of a recipient of an
allotransplantation. It is defined as the absence of immune
response by the recipient to the allograft tissue. Ideally, this
means that the recipient can tolerate the graft even in the
absence of immunosuppressive medications. The achieve­
ment of such donor-specific immune tolerance remains
elusive today. It has been reported to occur rarely, often
spontaneously, and by mechanisms not well understood.
This remains an area of intense research interest and which
could revolutionize the field of transplant medicine once
understood in greater detail.
SIDE EFFECTS OF IMMUNE SUPPRESSION
Unfortunately, despite their necessity in VCA, immunosup­
pressive medications are fraught with side effects. Chief
among them are increased incidence of infections, cancer,
and renal toxicity.12,13,16 Other reported side effects associ­
ated with immunosuppression use in patients who have
undergone VCA include metabolic derangement, diabetes,
hypertension, Cushing syndrome, and rarely, avascular
necrosis of the hip.17 Not enough data exist to precisely
identify the incidence of side effects associated with immu­
nosuppressive medications such as tacrolimus, in patients
who have undergone facial transplantation; however, these
rates have been well established in patients undergoing
renal transplantation, as seen in Table 64.2.18 Early data with
VCA seem to suggest that there is a lower incidence of renal
failure and diabetes in this patient group.17
Opportunistic infections represent perhaps the most
common side effect associated with immunosuppressive
medications in VCA patients. The current treatment
approach involves having a high index of suspicion, liberally
using laboratory tests and providing early treatment. Approx­
imately 63% of patients undergoing hand transplantation
were affected by an opportunistic infection at a median
follow-up time of 81 months.17 Rates of bacterial infection
may be comparable between hand transplant patients and
renal transplant patients with a trend toward increased
amounts of fungal, protozoal, and viral infections in patients
undergoing hand transplant.17 The infection rate after facial
transplantation is reported in approximately 1 in 4 patients.1,2
Although, the available literature on VCA seems to suggest
that the side effect rate of immunosuppressive drugs is lower
than originally perceived, there remains a need for further
research to facilitate the safe reduction of the immunosup­
pressive load.
Table 64.2  Side-effects of tacrolimus in renal
transplant patients
Side-effect
Incidence (%)
Abdominal pain
29–59
Anorexia
34
Constipation
23–35
Diarrhea
37–72
Glucose intolerance
24
Headache
37–64
Hyperlipidemia
31
Hypertension
38–89
Insomnia
32–64
Nausea
32–46
Tremors
15–56
Paresthesia
17–40
Pleural effusion
30–36
Vomiting
14–29

742
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
craniofacial clefts, among others, may continue to lack a
normal appearance. Furthermore, large vascular malforma­
tions or benign tumors of childhood, such as facial neuro­
fibromas, may grow until they become massive, causing
significant facial disfiguration. Adults with these facial dis­
figurements may derive great benefit from face transplanta­
tion.26 Of note, at the current time, facial transplantation
has not yet been performed in the pediatric population,
given concerns over the toxicities associated with immuno­
suppressive medications.
INFECTIOUS DISEASE
Numerous infectious agents can produce disfiguring facial
defects. Patients can develop necrotizing infections in the
skin and mucosa that can become highly invasive and spread
to deeper underlying structures.27 For example, noma
(cancrum oris), is a rapidly progressive, polymicrobial infec­
tion, which begins as necrotizing gingivitis that rapidly
spreads along facial tissue planes. Severe defects or even
death can result if unrecognized and untreated.28 With any
infectious etiology, the process must be halted and the
pathogen completely eradicated before considering face
transplantation.2
MALIGNANT DISEASE
Many forms of cancers that affect the head and neck are
highly invasive. These tumors can often grow to involve a
large number of structures. Resection of such tumors has
resulted in extensive defects, which have traditionally been
reconstructed with autologous tissue. Unfortunately, the
aesthetic and functional result is usually suboptimal, despite
the best surgical efforts when the tumor involves units of the
face such as the eyelids or lips. These delicate structures
were previously felt to be “unreconstructable” with conven­
tional methods.29 This group of patients stands to benefit
greatly from face transplantation. The most important issue
in this patient group is the strict adherence to oncologic
treatment protocols and a complete removal of all tumor
burden before transplantation is attempted.2 Similar to solid
organ transplants, a patient would be considered a candi­
date for facial transplantation only if they were free of
disease burden for at least 5 years.2
FUTURE INDICATIONS
At the present time, current indications for face transplant
are limited only to facial disfigurements or defects in adults,
that are large because of the risks associated with immuno­
suppressive regimens. As less toxic immunosuppressive
medications are developed, the risk–benefit ratio of per­
forming a face transplantation will dramatically decrease.
Thus, the potential exists for even smaller, complex facial
defects to be reconstructed with allograft tissue transfer,
rather than autologous tissue, thereby completely eliminat­
ing any donor site morbidity.30 Ultimately, the rate limiting
step to its widespread use will be the supply of donors.
In the future, facial transplantation might also be per­
formed in the acute setting, closely following the initial
injury. At the present time, this is a controversial issue, but
may be ideal for future patients where the indications for
representing the most common cause.21 The impact caused
by such accidents is capable of generating enough force to
produce severe facial injuries at times. Such high-speed,
high-energy crashes may result in defects of the face that are
severe enough to warrant facial transplantation.
In the civilian population, whether accidental, self-
inflicted, or the result of a violent crime, gunshot wounds
to the face represent another high-energy traumatic defect
with a wide extent. For patients who survive these traumas,
they often have severe facial disfigurement, despite under­
going several complex reconstructive procedures. Face
transplantation may be the only treatment option in these
patients with the potential to restore both a more socially
acceptable facial appearance, as well as a potentially restor­
ing facial function.
Similarly, survivors of extensive burns often have excessive
scars and contractures, which have significant functional
limitations by restricting range of motion. This issue is com­
pounded by the fact that acute burn care has made consid­
erable progress in the past decades. As the survival rates
increase, there are more and more patients with high per­
centage body surface area burns, as well as facial burns who
are seeking reconstruction. In patients with severe burns to
the face, functional limitations are magnified and recon­
structive options are often limited. The resulting deformi­
ties on these patients can significantly hinder social
interaction by impairing the patient’s facial appearance and
expression.22
Many of the aforementioned groups of patients undergo
numerous complex reconstructive procedures to improve
their quality of life and unfortunately, have less than ideal
outcomes. For these patients, face transplantation may offer
a solution to their previously unconquerable problem.
Several potential advantages of face transplantation include
not only restoring facial appearance and function, but also
potentially decreasing the number of surgical procedures
necessary to reconstruct the patient. Additionally, it may
reduce the time needed to be spent in a rehab facility and
likely would also accelerate reintegration of the patient back
into society.22
THE MILITARY
The continued improvement in the acute care of wartime
injuries, coupled with improvements in body armor have
allowed soldiers to survive wounds that were previously
fatal.23 As a result, more than half of all combat injuries and
one-fifth of all noncombat injuries are to the head, neck,
and face.24 Additionally, due to the increased usage of
improvised explosive devices, the face is among the most
frequently burned body areas on soldiers in combat, most
probably due to lack of protective coverings.25 The severe
facial defects seen in military personnel as a result of hostile
environments and lethal weaponry are ideally suitable for
reconstruction with facial transplantation.
CONGENITAL DEFECTS
Congenital and craniofacial defects are a major source of
serious facial disfigurement. Even after numerous complex
reconstructive procedures patients with congenital syn­
dromes such as Treacher–Collins syndrome and rare

CHAPTER 64 — Face Transplantation
743
studies are often performed to facilitate detailed visualiza­
tion of vascular, soft tissue, and bone anatomy to further
determine suitability as well as aid in surgical planning.
Psychosocial considerations are perhaps as important as
clinical considerations such as the aforementioned lab tests
and imaging studies. A psychiatrist must evaluate candidates
for facial transplantation as part of the screening process to
diagnose any existing psychiatric disorders; evaluate for a
history of substance abuse; evaluate the patient’s under­
standing of the procedure and its risks; as well as ensure
the candidate is able to deal with the difficulty of the pre­
operative and postoperative periods. It is also important
for psychiatrists to evaluate the patient’s motivation for
surgery. Candidates who concentrate on potential func­
tional improvements will probably be more content than
transplantation are clear. To date, only one such procedure
has been performed in Poland on a 33-year-old man, who
was injured in an industrial accident.
Furthermore, because of the risks associated with immu­
nosuppressive medications, facial transplantation is limited
to the adult population at this time. As the newer medica­
tions are developed that have a lower side effect profile, face
transplant may become a viable option in the pediatric
population.26 This might allow children with congenital cra­
niofacial deformities to grow and develop without the social
stigma of facial disfigurement.
PREOPERATIVE CONSIDERATIONS
PATIENT SELECTION
Given its current status in most centers as an experimental
procedure with uncertain long-term outcomes, the selection
of patients for facial transplantation may be just as impor­
tant as actually performing the surgical procedure. Further­
more, since the operation itself and the immunosuppressive
medications pose a significant risk to patients, the impor­
tance of strict indications and exclusion criteria cannot be
overstated. The ideal patient should have severe facial dis­
figurement not amenable to reconstruction with conven­
tional techniques, and they should be of general good
physical and mental health, with solid social support. The
recipient must not only be healthy enough to endure the
stress associated with such an operation but must also
comply with lifelong immunosuppression and be willing to
engage in aggressive rehabilitation during the first 2 years
postoperatively, to regain function of the allograft. The
ability to handle the publicity and attention generated by
such a groundbreaking operation must also be considered.
As facial transplantation in most centers is being performed
within the confines of clinical studies, all potential candi­
dates in those centers must be approved by the Institutional
Review Board. The complex nature of the screening process
requires the development of a multidisciplinary team, led
by plastic and transplant surgeons. Table 64.3 summarizes
the sequential patient screening process for facial transplan­
tation used at our institution.
A battery of laboratory tests is warranted for patients
being screened, with the aim of excluding any malignancies,
infections, or other chronic systemic diseases. These lab
studies should be supplemented with diagnostic tests or
imaging such as a chest radiograph or echocardiogram.
Further tests should be ordered as needed, depending on
the patient’s age and sex, or whether any abnormal findings
were discovered during the process. For example, checking
a prostate-specific antigen in male patients over the age of
50, or obtaining a mammogram in female patients over the
age of 40. Given the risks of postoperative immunosuppres­
sion, facial transplantation is contraindicated in patients
with an active infection, serious chronic medical conditions,
an active malignancy, or a history of cancer, with a high
likelihood of recurrence. Female patients of childbearing
age must also undergo a pregnancy test and if found to be
pregnant would not be eligible to undergo transplantation
until 6 weeks after the completion of the pregnancy. Finally,
computed tomography and magnetic resonance imaging
Table 64.3  Flow diagram of patient selection
process for face transplantation at
our institution
Initial evaluation with reconstructive plastic surgeon
Inclusion/Exclusion criteria reviewed
↓
Psychosocial evaluations by psychiatry and social work
Inclusion/Exclusion criteria
reviewed
Psychosocial support
↓
Consent
To lab tests and imaging
To screening procedure
↓
Transplant clinic screening
Information on
immunosuppression
Immunologic screening
↓
Rehabilitation consult
Information on postoperative
therapy protocol
Assess current needs of
patient
↓
Other professional visits
Infectious disease
Head and Neck
Ophthalmology
↓
Lab tests/imaging
Serum studies
CT scan/MRI
↓
Multidisciplinary meeting
Discuss patient’s eligibility
↓
Patient interested in surgery
Pre-surgical planning
Place patient on waiting list

744
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
detecting rejection episodes, especially in cases where there
is limited facial skin transplanted with the allograft. Com­
munication between these teams is of vital importance,
so they may both adjust based on the actual anatomy
encountered.
SURGICAL TECHNIQUE
Proper execution of a face transplant operation mandates
careful consideration of the blood supply to the soft tissues
and bony skeleton of the face. The facial artery and vein
supply most of the midface. The territory of these vessels
includes the anterior portion of the mandible from the
insertion of the masseter muscles, the lips, buccal tissues,
nose, the maxilla anterior to the pterygoid plates, as well as
the upper and lower eyelids, supplied by the angular artery,
which is the terminal branch of the facial artery. The most
lateral aspects of the face, as well as the scalp are primarily
supplied by the superficial temporal artery. Originally, it
was believed that both of these branches of the external
carotid artery were needed to carry the graft. However, new
research based on our institution’s experience with facial
transplantation has demonstrated that the facial artery can
supply the entire face, maxilla and mandible, and that the
superficial temporal artery is not necessary to include in the
allograft.34
Skin incisions are created in the donor patient corre­
sponding to the defect in the recipient patient’s face (Fig.
64.1). The vessels necessary for graft survival along with the
facial nerve are identified and preserved as part of the graft
along with the necessary soft and bony tissues to replace
those missing from the recipient patient. The recipient’s face
and corresponding facial structures should be simultane­
ously dissected as the graft is being harvested from the donor
(Fig. 64.2). Initially, the allograft is loosely tacked to the soft
tissue of the recipient. The vessels are then brought to the
neck without any twist or kink. Using the microscope, the
external carotid arteries, facial arteries, and corresponding
veins are prepared on both the graft and the recipient. An
end-to-end anastomosis is performed between the one set of
ipsilateral external carotid arteries. The external carotid
arteries are a convenient site of anastomosis given the large
caliber of vessels. On the contralateral side, only the facial
arteries are anastomosed typically. Performing a second end-
to-end external carotid artery anastomosis is problematic as
it could result in hypoperfusion of the hypopharynx.
Skeletal fixation of the graft to the donor tissues then
ensues. To facilitate bone apposition, it is important that the
dorsal nasal, zygomatic, and orbital floor bones be aligned
and ronguered to obtain the correct contour if needed.
Skeletal alignment is confirmed with approximation of the
maxillary bone, pterygoid plates, and infraorbital rims
coming into near-anatomic alignment. The skeletal fixation
is performed in a standard fashion using plates and screws.
To ensure maximal integration of the facial graft, neuror­
rhaphies must be performed between several nerves. Sensory
nerves, including the supraorbital nerves, the infraorbital
nerves, and the facial nerves are all coapted to maximize
the chance of return of sensation in these patients. Addi­
tionally, the facial nerves and the hypoglossal nerves, when
possible, are also coapted. Overall, the facial nerve trunk or
those who are anticipating psychological changes.31 Addi­
tionally, it is imperative that the patient be evaluated for an
ability to cope with and comply with a lifelong immunosup­
pressive regimen, since most reported failures of VCA have
been due to the patient’s noncompliance with their medica­
tion regimen. A history of noncompliance with medication,
social support, and level of education are predicting factors
for post-transplant noncompliance.32
DONOR CONSIDERATIONS
Once a patient is deemed eligible, they must wait for a suit­
able donor, which could take months. During this time,
candidate patients must be evaluated approximately every 6
months to ensure the findings of the initial screening have
not changed.2 A suitable donor is one who is the same sex,
of similar age, and whose skin color and texture are similar
in nature to the recipient. Results from computer simulation
testing suggest that the donor’s age should range between
10 years above and 20 years below the patient’s age.33 Poten­
tial donors undergo immunologic testing and if the donor
is a match for the patient, the facial transplantation team
proceeds with surgical planning and then the procedure.
SURGICAL PLANNING
The high degree of surgical complexity involved in facial
allotransplantation requires extensive preoperative evalua­
tion of facial anatomy, as well as the development of a
detailed surgical plan. Compared with other free tissue
transfers in the body, facial transplantation involves an en
bloc replacement of missing tissues with like tissues, rather
than reconstruction with shaping of tissues from other areas
of the body. The extent of facial tissue that needs to be
replaced on the recipient is of extreme importance, as each
facial allograft requires significant tailoring based on each
patient’s specific needs. In theory, transplantation is possi­
ble for nearly any size of facial defect.
The use of computed tomography allows for evaluation
of the deeper structures of the head and neck, including,
importantly, the vasculature. Vascular system evaluation is
essential to guide both the graft procurement as well as the
recipient dissection. Three-dimensional rendering provides
an important tool to assess both the donor and the recipi­
ent’s skeletal anatomy. These imaging studies are particu­
larly useful in cases where the recipient has had prior
operations or excessive scarring.
Most organ transplants today consist of two separate
teams, one for graft procurement and one for the actual
recipient surgery; however, facial transplantation does not
follow this model. These operations are very time con­
suming and surgeon fatigue must be addressed, often neces­
sitating large teams. All team members must be familiar with
the details of the procedure and many teams will spend time
together practicing on cadavers to prepare. The current
ideal clinical practice for facial transplantation is to have the
donor and the recipient in two adjacent operating rooms,
with three teams working in parallel, to minimize ischemia
time. In addition to a team each working on the donor and
recipient, a third team is often needed for procurement and
transfer of a sentinel flap. The sentinel flap is a free tissue
transfer, often a radial forearm flap, that is important in

CHAPTER 64 — Face Transplantation
745
most gratifying and fascinating procedures a plastic surgeon
can experience.
POSTOPERATIVE CONSIDERATIONS
Immediate postoperative considerations for facial transplan­
tation are similar in nature to considerations after a large
free flap, as well as those after a solid organ transplant.
Within the first hours to days after surgery, much of the
focus must be on ensuring that the patient is adequately
resuscitated. This is due to the fact that these procedures can
often be quite long, with significant ischemia times of the
graft. Reported total surgical times have varied from 14 h to
22 h with ischemia times of the graft ranging from 180 min
to 320 min.1,2,4–6,35 Another important consideration both
intraoperatively as well as postoperatively, is the need for
transfusion of blood products, given the potential for signifi­
cant blood loss during the procedure. Early reported cases
have demonstrated blood product transfusions during these
cases, ranging from 0.5 L to 12.2 L.1,2,4–6,35
As with any other free tissue transfer, survival of the
tissue is dependent on its blood supply, which has been
reestablished via a microsurgical anastomosis. The graft
must be monitored for both arterial inflow, as well as venous
outflow on a regular basis at timed intervals, similar to the
way other free tissue transfers are monitored. Often, there
are numerous microvascular anastomoses performed and
so the graft must be checked in several locations for evi­
dence of ischemia or venous congestion. Of note, no authors
have reported any microsurgical-related complications with
their facial transplantation patients and no authors have
reported either partial or complete flap loss due to vascular
compromise.2
Unlike other free tissue transfers that utilize autologous
tissues, facial transplant relies on the transfer of allogeneic
tissues. As a transplanted tissue in the immediate postopera­
tive period, this places the graft at risk for hyperacute rejec­
tion, something not seen in routine free tissue transfers.
Hyperacute rejection is initiated by a preexisting antibody-
mediated immunity against the donor tissues. It is uncom­
mon, but can manifest within minutes of transplantation.
The antibodies against the donor tissues can cause a rapid
agglutination of red blood cells. In the setting of a facial
transplantation, this would likely manifest as thrombosis
at the site of microvascular anastomosis and immediate com­
plete ischemia of the graft. The treatment would be immedi­
ate removal of the tissue and if the tissue were left in place
it could lead to a systemic inflammatory response syndrome
and eventual death. The risk of hyperacute rejection is sig­
nificantly lowered by carefully screening of both the donor
and the recipient to ensure they are an immunologic match.
To date, hyperacute rejection has not been encountered in
the known cases of facial transplantation.
Other important immediate postoperative considerations
include monitoring for commonly occurring postoperative
complications. These include issues with wound healing or
wound breakdown, early wound infections, or hematomas.
In the early facial transplantation cases, there have not been
any reports of these complications, probably due to the fact
that patients undergoing facial transplantation are usually
free of chronic conditions at the time of transplant.1,2,4–6,35
preferably branches medial to the parotid gland should be
reconnected on both sides for best results.
The last stage of the procedure is the closure of all soft
tissue. The intraoral soft tissue must be approximated by
closure of the graft palatal mucosa to the soft palate of the
recipient and then across the buccal mucosa as well. Several
drains should be left in place in the neck incisions. In our
more recent experience, we have begun to routinely inject
botulinum toxin into the donor salivary glands to minimize
the chance of salivary leaks. Although reported operative
time has varied from 15 h to 22 h, seeing the restoration of
a human face through facial transplantation is one of the
Figure 64.1  Skin incisions are created in the donor patient corre­
sponding to the defect in the recipient patient’s face.
Figure 64.2  The recipient’s face and corresponding facial structures
are simultaneously dissected as the graft is being harvested from the
donor.

746
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
reconstruction with fewer procedures and hospitalizations
than traditional techniques.
OUTCOMES
Around the world, a relatively few facial transplants have
been performed, with many other patients being evaluated
as candidates. Since the first procedure in 2005, the indica­
tions for facial transplantation have continued to evolve and
expand. Given the rapid growth of the field and interest
on the part of both surgeons and patients alike, recon­
structive surgeons have a responsibility to evaluate out­
comes, learning from prior successes and failures, to further
direct the future of this field. Unfortunately, as an emerging
field with a relatively few procedures performed, long-term
outcomes of facial transplantation are largely unknown.
However, there are some data available on the short- to
medium-term outcomes reported for some of the cases that
have been performed. Outcomes can be classified into
several categories: medical (immune-related, metabolic and
hematologic derangements, opportunistic infections, neo­
plastic growth); functional (speech, smell, airway, taste,
mastication, sensory reinnervation, facial animation, pain
relief); aesthetic (patient and physician satisfaction, contour,
scarring, identity preservation); and social (psychosocial
reintegration, cost-effectiveness).2 Each category represents
an important parameter in assessing the whole issue of facial
transplantation.
MEDICAL OUTCOMES
To date, no facial allograft has been lost due to host rejec­
tion, excluding the cases where patient noncompliance with
medications precipitated graft loss. However, nearly all
reported patients have suffered biopsy-proven episodes of
clinical (and histological) acute rejection.2 Up to three
reported episodes in a single patient have been reported
and episodes have been reported to occur between 18 days
and 17 months post-procedure (Figs 64.3, 64.4).2 All cases
of acute rejection were overcome by various treatment
modalities, including a pulse dose of corticosteroids and
other immunosuppressive medications, donor bone marrow
infusions, and photochemotherapy. A few surgical teams
have even used intraoperative graft irradiation for rejection
prophylaxis.1,2,4,5,35
Nearly all patients have suffered at least one mild or
moderate metabolic or hematologic sequel from facial
transplantation and subsequent immunosuppression. Meta­
bolic derangements have included steroid-induced confu­
sion, new onset diabetes, and acute renal failure. Hematologic
consequences have ranged from transient leukopenia to
thrombocytopenia to hemolytic anemia.2
Clinically apparent opportunistic infections have been
documented after facial transplantation, as a result of immu­
nosuppression. These have included infection with herpes
simplex 1 (HSV-1) virus, molluscum contagiosum, and cyto­
megalovirus (CMV) viremia.1,35 Often, these infections mani­
fest themselves after immunosuppression has been increased
in response to an episode of acute rejection. Although pre­
mature, given the limited amount of follow-up on these
patients, no facial transplantation patient has had evidence
of neoplastic growth in the immunocompromised state.2
COMPLICATIONS
The main complications associated with facial transplanta­
tion include graft failure, rejection, immunosuppression
toxicity, increased risk of malignancy, psychosocial issues and
excessive financial cost. None of these listed above are trivial
in nature and given that facial transplantation is a relatively
new procedure, some of the long-term outcomes are
unknown. Surgical graft failure, resulting in an unrecon­
structable defect, is often cited as a major concern, given
the complex technical nature of the procedure. It is esti­
mated that the technical failure rate for facial transplantation
is between 2% and 4%, making this a very unlikely outcome.2
Perhaps the most important complication to consider after
facial transplantation, the complication more likely than
technical failure to cause graft loss, is rejection. Early data
seem to suggest that rejection rates might be lower in VCA
when compared with solid organ transplant, but it is never­
theless still important to consider. Extrapolated data suggest
an acute rejection rate between 10% and 70%, and chronic
rejection rates of approximately 10% among VCA patients.2
Rejection can be rapidly precipitated by failure to take immu­
nosuppressive medications. The world’s first modern hand
transplant patient stopped taking his immunosuppressive
medications and his limb was ultimately amputated. Simi­
larly, the world’s second facial transplant patient stopped his
medications in favor of herbal supplements, and this ulti­
mately resulted in death, placing rejection at the top of the
list of complications after facial transplantation.2,36
Reliably taking immunosuppressive medications does not
abate the risks of having a complication after facial trans­
plantation, as infection, kidney dysfunction, lung dysfunc­
tion, and metabolic disorders are all complications associated
with over-immunosuppression.37 Regimens using tacroli­
mus, mycophenolate mofetil, and corticosteroids are associ­
ated with bacterial infection rates of 5–20%. Additionally,
they have been associated with mortality rates between 0.5%
and 4%.38 Further, the risk of developing cancer conferred
by immunosuppressive medications was previously thought
to be approximately 50% at 5 years and 71% at 10 years,
based on data with renal transplant patients.39 However,
new data from regimens using tacrolimus, mycophenolate
mofetil, and corticosteroids may be lower than with other
regimens.40
Non-immunologic complications of immunosuppression
include hypertension, diabetes, renal failure, and transient
gastrointestinal distress. The incidence of these complica­
tions may be less when compared with solid organ trans­
plantation, as facial transplant patients are typically not
systemically ill at the time of transplant. Lastly, several
authors have discussed the financial cost of facial transplan­
tation as a limit to performing the procedure. As it is such
a new field, data on the financial costs are limited; however,
recently, the Cleveland Clinic Foundation has published
costs of $170,000 for heart transplant; $95,000 for liver
transplant; $31,000 for renal transplant; and between
$100,000 and $150,000 for a facial transplantation (not
counting lifelong immunosuppressive therapy in all cases).41
When evaluating the cost of such a procedure, several points
are worth considering. First, a facial transplant allows
patients the opportunity to reintegrate into society as pro­
ductive members and second, transplantation may offer