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

CHAPTER 68 — Peripheral Nerve Allotransplantation
785
allografts were used to reconstruct large segmental defects
in the extremities. Between 72 cm and 248 cm of nerve
allograft pretreated with cold preservation were used in
each case and in conjunction with the available nerve auto­
graft in 9 of the 11 patients.
• Most cases were in younger patients (age range: 3–54
years).
• Patient 6 lost the graft due to acute rejection from non-
compliance with immunosuppression.
• Most patients recovered protective sensation with varying
degrees of motor reinnervation.
• Motor reinnervation was most robust in proximal muscle
groups.
• The average length of time patients remained on FK-506
was 20.1 months. This was dictated by clinical evidence of
nerve growth beyond the distal end of the allograft.
In contrast to the first 11 cases of allotransplantation, the
most recent patient underwent nerve allotransplantation
for significant pain after a thoracotomy. This 54-year-old
man had recalcitrant right intercostal neuralgia following
two thoracic operations 8 years prior to presentation to our
clinic. Following his second thoracic procedure (a pleural
leak repair after a right upper lobe resection), he developed
severe pain localized to the dermatomes of T5-T8. His dys­
esthetic pain was unresponsive to conservative therapy (Fig.
68.3). In a novel use of allograft transplantation, two 48 cm
nerve allografts were looped between the T5-T6 and T7-T8
intercostal nerves following exposure and transection of the
proximal nerve roots.70 Each was looped to connect two
consecutive levels and allowed the regenerating intercostal
nerves to taper off, preventing neuroma formation and
pain. His neuralgia pain subsided by 7 months after his
reconstruction. Autografts were avoided in this patient to
avoid a second site of neuropathic pain. At 30 months post­
operatively, the patient reported his pain was entirely
resolved in the thoracic distribution and only limited to the
spinal incision site. On a visual analog scale, he rated his
pain a 3 out of 10. He controls his pain with topical anes­
thetic patches and activity modifications. He reported the
procedure was “life-changing.”
Our current clinical protocol involves exhausting all
available autografts followed by the use of ABO-blood typed
nerve allograft matched donors harvested within 24 h of
death. More recently, living, related donors have also been
used, as this can eliminate the waiting period for a matched
donor and can decrease immunogenicity. To further
reduce allogenicity, our protocol utilizes the University of
Wisconsin Cold Storage Solution at 4°C for 7 days prior to
implantation.71,72 We also use multiple small-diameter
allograft cables as these revascularized more consistently
than larger-diameter grafts. Our immunosuppression
regimen incorporates the initiation of FK-506, 3 days pre­
operatively to maximize the regenerative potential. Our
current protocol is detailed in Table 68.4.
NERVE REGENERATION IN VASCULARIZED
COMPOSITE ALLOTRANSPLANTATION
The long-term functional outcome in vascularized compos­
ite allotransplantation (VCA) is dependent on the quality
of nerve regeneration and muscle reinnervation of trans­
planted parts. With successful results from the multiple
hand and face transplants performed to date, VCA is a
viable option to treat devastating upper extremity and facial
injuries. Understanding the nuances of nerve regeneration
in these transplanted parts is necessary and critical to main­
tain the functional benefit of these procedures.
A number of differences between nerve regeneration in
a nerve allograft versus that in VCA exist. Unlike isolated
nerve allografting, which only requires temporary immuno­
suppression, VCA requires lifelong immunosuppression to
prevent the rejection of the more immunogenic tissues such
as skin, muscle, and bone.5,24 As mentioned earlier, nerve
allografts depend on the migration of SCs from both the
distal and proximal host nerve stumps into the graft to
ensure axonal regeneration and ultimately function of the
nerve.31,32,73 In VCA, there are no distal host SCs, as the
entire distal neuromuscular unit is composed of donor
tissue. Therefore, repopulation of the transplanted nerve
with host SCs is dependent on the proximal stump only (Fig.
68.4). Currently, it is unknown if there is a limit to how far
host SCs are able to migrate to functionally repopulate a
nerve in a transplanted part.14,73 Further, in nerve allografts,
SC migration in the graft was stimulated by episodes of
subclinical rejection in an effort to replace depleted donor
SCs.32 In the presence of continuous immunosuppressive
regimens, as required in VCA, it is unknown to what extent
host SC migration will be stimulated and how this will affect
long-term function.
Long-term characterization of host and donor SCs in VCA
is not yet fully understood. It is believed that donor SCs are
no different from host SCs in their ability to support nerve
regeneration.14 However, lapses in therapeutic immunosup­
pression causing acute rejection and early loss of donor SCs
may have a more pronounced clinical effect in VCA, leading
to demyelination and resulting in conduction blocks or a
devastating permanent functional failure. Until immuno­
suppressive strategies are developed to induce tolerance to
all donor tissue, the late loss of donor SCs from unexpected
episodes of rejection is a significant concern.
Currently, VCA has a very specific application involving
severely injured or disfigured patients who have adequate
motivation to undergo a major surgical procedure, lifelong
immunosuppression, and a lengthy rehabilitation process.
Despite this, patients who undergo the procedure remain
very satisfied and are recovering neurologic function.4,74,75
Length-dependent functional motor and sensory axonal
regeneration has been observed in both facial and upper
extremity transplants.4 Compared with more proximal trans­
plants, distal hand transplants have demonstrated both a
superior sensory and motor recovery, with reported return
of intrinsic motor function, and discriminative sensation.76–78
Forearm and upper arm transplant patients have demon­
strated return of sensation over longer time periods, but
inconsistent and commonly protective sensation at best.75
The motor recovery of these more proximal transplants
appears to continually improve over the first 5 years, but is
commonly limited to elbow and forearm animation.78,79
Future strategies to enhance nerve regeneration in VCA
should consider the delicate balance between donor and
host SCs. Strategies to optimize donor SC migration into
regenerating transplanted nerves within a therapeutic
immunosuppression environment should be developed.

786
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
(N) T5 intercostal, proximal end
Nerve allograft,
T5 and T6
Nerve allograft,
T7 and T8
(N) T6 intercostal,
proximal end
(N) T8 intercostal, proximal end
(N) T7 intercostal,
proximal end
(N) T5 intercostal,
proximal end
A
B
D
C
E
(N) T6 intercostal,
proximal end
(N) T7 intercostal,
proximal end
(N) T8 intercostal,
proximal end
C
Figure 68.3  Case study: Patient 12 (see Table 68.3). This 54-year-old man developed severe right intercostal neuralgia following a thora­
cotomy. X-ray images: (A) demonstrate the location of the thoracotomy and site of the intercostal nerve injury. Clinical examination demonstrated
injury to T5–T8 intercostal nerves. (B) Exposure, decompression, and transection of the injured right T5–8 intercostal nerves (N) in preparation
for grafting. (C) Two 48 cm cadaveric nerve allografts were harvested from the donor to be used as looped grafts between the intercostal
nerves. (D) Looped cadaveric nerve graft in situ. The two proximal ends of T5–6 were looped together, as were the proximal ends of T7–8.
(E) Cadaveric nerve (N) graft loops were mobilized into the exposure site.

CHAPTER 68 — Peripheral Nerve Allotransplantation
787
Preoperative pain evaluation
Postoperative pain evaluation
F
(F) The pre- (left) and postoperative (right) pain evaluation demonstrates significant reduction in right intercostal neuro­
pathic pain 7 months following the procedure.
Figure 68.3, cont’d 
Table 68.4  Current immunosuppressive protocol for nerve allotransplantation
Preoperative preparation
Intraoperative details
Postoperative care
Assess patient suitability
Resect patient’s injured nerve
to healthy proximal and distal
stumps
Induction immunotherapy (dose 2)
  Medical comorbidities
  Basiliximab 20 mg intravenously
(postoperative day 4)
  Infection/Malignancy
  Psychosocial fitness
Laboratory tests
Use patient’s autografts in
addition to cadaveric allografts,
donor-related or
donor-unrelated allografts
Standard immunotherapy
  ABO blood type
  Continue FK-506 (goal level 5–8 ng/mL)
  CBC, CMP
  Azathioprine 1–1.5 mg/kg per day
  HIV/Hepatitis
Nerve allografts
Insert extra allograft
subcutaneously for rejection
monitoring
Antibiotics
  Consider related donors
  Sulfamethoxazole-trimethoprim
  Harvest small-diameter grafts
  Three times a week
  Cold preservation (4°C University of Wisconsin
Solution, 7 days)
Immunotherapy
Stop immunotherapy
  FK-506 (tacrolimus) 1–2 mg PO BID (start 3 days
preoperatively)
  6 months after Tinel’s crosses distal
repair site
  Induction immunotherapy (dose 1) – basiliximab
20 mg intravenously (immediately preoperatively)

788
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
donor nerve function, increased operative time, additional
incisions and scarring, as well as potential neuroma forma­
tion.1,80 Thus, a considerable amount of research has been
invested in “off-the-shelf” alternatives, such as synthetic
nerve conduits and processed nerve allografts,81–88 with
current trends focusing on the local delivery of neuro­
trophic factors and the cultivation of donor SCs.89–96 Con­
duits and processed nerve allografts both have the advantage
of being readily available, with no donor site morbidity. But
they currently lack both viable SCs and neurotrophic factors
relying on host SC migration to functionally bridge nerve
gaps.97 For this reason, their clinical utility and effectiveness
to date is limited to short nerve gaps and small-diameter
nerves.98,99
NERVE CONDUITS
Reports of using tubular structures to repair nerve injuries
date back to as early as 1891, when Büngner reported suc­
cessful nerve regeneration through an arterial graft.100 Clini­
cal interest in both synthetic and nonsynthetic conduits;
however, began in the mid-1980s. Today, at least seven syn­
thetic nerve conduits and four synthetic nerve wraps have
been approved for use by the US Food and Drug Adminis­
tration (FDA) (Table 68.5).1,101
Nerve conduits are appealing because they (a) provide a
means for supporting regeneration across the nerve gap;
(b) remove tension from the repair; (c) prevent scar tissue
infiltration; (d) are readily available in a variety of lengths
and diameters; and (e) can be taken “off-the-shelf” as
needed.3,102,103 A significant amount of research has
Keeping donor SCs alive to support axonal regeneration
during this time period is important, and may help prevent
rejection or functional failure over the lifetime of the
patient.
SUMMARY
Nerve allotransplantation provides an alternative strategy
to manage severe, long gap, or segmental nerve injuries.
However, the potential morbidity associated with systemic
immunosuppression has limited widespread utilization. We
reserve this procedure for patients with devastating injuries
not amenable to other surgical options. Research directed
toward inducing tolerance to donor tissue without the need
for chronic immunosuppression is currently underway. If
successful, the indications for nerve, as well as vascularized
composite allotransplantation, will expand our ability to
treat devastating injuries.
NERVE AUTOGRAFT SUBSTITUTES
CONDUITS AND PROCESSED
NERVE ALLOGRAFTS
Autologous nerve grafts remain the gold standard for nerve
grafting due to the presence of SCs and extracellular scaf­
fold of endoneurial tubes. However, nerve autografts are not
without their own associated morbidity including loss of
Figure 68.4  Rejection of nerves in composite tissue allografts. (A) Composite tissue allografts include nerve and associated Schwann
cells from the donor (muscle and gray portion of nerve) transplanted into the host (yellow). (B) If early acute rejection can be abated, nerve
regeneration toward the target will continue. (C) Maintenance immunosuppression prevents rejection, allowing axonal regeneration (aided by
host Schwann cells migrating from the proximal nerve stump and donor Schwann cells), leading to innervation of the target end organ. (D) In
the event of a significant rejection episode prior to repopulation of the donor nerve with host Schwann cells, a loss of donor Schwann cells
can occur. (E) The loss of Schwann cells results in a conduction block and permanent functional deficit.
Cell body
Composite
tissue autograft
Early acute
rejection
No rejection
Late rejection
Muscle
Timing of rejection
Conduction block
A
B
C
D
E

CHAPTER 68 — Peripheral Nerve Allotransplantation
789
Table 68.5  FDA-approved guidance conduits and wraps for peripheral nerve surgery
FDA approval
Company
Product
Material
Diameter (mm)
Length (cm)
Absorbable nerve conduits
1995, 1999
Synovis Micro Companies
Alliance Inc.
Neurotube
Polyglycolic acid
2.3–8
2–4
2001
Integra Life Sciences Corp.
NeuraGen
Type I collagen
1.5–7
2–3
2001
Collagen Matrix Inc.
Neuroflex
Type I collagen
2–6
2.5
2001
Collagen Matrix Inc.
NeuroMatrix
Type I collagen
2–6
2.5
2003
Cook Biotech Products
AxoGuard Nerve
Connector
Porcine small
intestinal submucosa
1.5–7
10
2003, 2005
Polyganics B.V.
Neurolac
Poly(DL-lactide-ε-
caprolactone)
1.5–10
3
2010
Salumedica L.C.C.
SaluTunnel
Nerve Protector
Polyvinyl alcohol
2–10
6.35
Absorbable nerve cuffs/wraps
2000, 2001
Salumedica L.C.C.
Salubridge
Polyvinyl alcohol
2–10
6.35
2003
Cook Biotech Products
AxoGuard Nerve
Protector
Porcine small
intestinal submucosa
2–10
2–4
2004
Integra Life Sciences Corp.
NeuraWrap
Type I collagen
3–10
2–4
2006
Collagen Matrix Inc.
NeuroMend
Type I collagen
4–12
2.5–5
Acellular nerve allografts
2007
AxoGen Inc.
Avance
Human acellularized
nerve
1–5
1.5–5*
*Available in lengths up to 7 cm by special order.
contributed to our understanding of the indications and
limitations of the use of conduits. Multiple clinical studies
have shown their efficacy in short nerve gaps (<3 cm) and
in small-diameter nerves such as digital nerves (Table 68.6).
Although successful regeneration via conduits has been
reported, clinicians are beginning to push the limits of
conduit use. Larger-diameter nerves such as the median and
ulnar nerve are being reconstructed with conduits with
larger nerve gaps. Unfortunately, clinical failures are now
arising. In 2009, Moore et al. published a clinical series of
patients with failures of large-caliber nerve conduit recon­
struction (Fig. 68.5).104 At our institution, since this publica­
tion, we have continued to see more patients with conduit
and nerve wrap failures. Most of these failures have involved
reconstruction of the ulnar and median nerves and all have
required further surgical interventions for poor outcomes.
Not surprisingly, these cases have led to reevaluating the
clinical indications for the use of conduits.
The conduit failures could be attributed to technical
factors, such as the failure to properly secure the conduits
and/or lack of adequate resection of the damaged nerve.
Another possibility of the failure relates to the concept of
volume.104 The use of conduits in large-diameter nerves over
excessively long distances likely exceeded the critical volume
of regeneration capable for a nerve conduit. The basic equa­
tion for volume of a cylinder is:
V
r L where V
volume r
radius and L
length
=
=
=
=
π 2 ,
,
.
,
If the radius is doubled (i.e., increased diameter of the
nerve), the overall volume is quadrupled (Fig. 68.6).
When considering neurotropism, volume becomes impor­
tant. Neurotropism is the concept that the proximal sprout­
ing axons regenerate along the concentration gradient of
neurotrophic factors released into the gap by the distal
stump. As the volume of the conduit increases, there may
be associated decrease or dilution of the concentration of
neurotrophic factors, leading to less tropic and trophic
support of nerve regeneration.
Although the concept of volume-limiting nerve regenera­
tion is not novel, it is not widely recognized. Lundborg et al.,
in 1982, first described conduit volume and length as influ­
ential factors in nerve regeneration when deterring the criti­
cal gap length of regeneration across a silicone conduit in a
rat.105 They found that the distal stump contribution to
regeneration was limited by the length, i.e., the volume of
the chamber. It was later established that the fluid secreted
by the nerve stumps into the conduit promoted neurite out­
growth.106,107 Because critical gap lengths exist in rat models,
it makes sense that limitations of volumes of conduits in
human use also exist. Further studies are needed to deter­
mine the exact parameters and critical volumes for humans,
but until then, caution is needed when using conduits to
repair large-diameter nerve defects with long gap lengths.
Case reports of successful regeneration across conduits
used to reconstruct large diameter nerves exist (Table 68.7).
Further, creative strategies have been employed to achieve

790
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
Table 68.6  Clinical data on FDA-approved absorbable nerve conduit use for small-caliber nerve repair
Material
First author
(year)
Study
type
No. conduit
repairs
(total no.
patients)
Age
Nerve
Gap size
(cm)
Conduit
diameter
(mm)
Conduit
length
(cm)
Follow-up
Outcome
PGA
Mackinnon (1990)
Series
16 (15)
30.5 ± 7.6
Digital
1.7 ± 0.6
(r. 0.5–3)
~2
Gap + 0.5
overlap/
end
22.4
months
(r. 11–32
months)
Sensory –
33% excellent;
53% good; 7%
poor; 7% none
PGA
Crawley (1992)
Report
1 (1)
51
Inferior
alveolar
2.5
2
Gap + 0.5
overlap/
end
2 years
Sensory
– excellent
PGA
Weber (2000)
RCMT
62, 74
controls (98)
36 ± 14
Digital
0.7 ± 0.56
Not given
Gap + 0.5
overlap/
end
9.4 ± 4.4
months (r.
up to 12
months)
Sensory –
44% excellent,
30% good, 26%
poor
PGA
Kim (2001)
Report
1 (1)
11
Medial
plantar
2
Not given
Gap + 0.5
overlap/
end
10 months
Sensory
– excellent
PGA
Battiston (2005)
Series
19, 13
muscle-vein
(30)
40
(r. 15–67)
Digital
2 (r. 1–4)
Not given
Not given
30 months
(r. 6–74
months)
Sensory –
10% excellent,
58% good, 16%
poor, 16% none
PGA
Ducic (2005)
Report
1 (1)
63
Spinal
accessory
2.5
Not given
2.5
4 months
Motor –
full (M5) shoulder
abduction
PGA
Dellon (2006)
Report
3 (1)
40
Radial
sensory,
digital in
toe-to-thumb
Radial 2.5,
Digital 3.0
2.3
Radial
3.5,
digital 4.0
30 months
Sensory
– excellent

CHAPTER 68 — Peripheral Nerve Allotransplantation
791
Material
First author
(year)
Study
type
No. conduit
repairs
(total no.
patients)
Age
Nerve
Gap size
(cm)
Conduit
diameter
(mm)
Conduit
length
(cm)
Follow-up
Outcome
Collagen
Lohmeyer (2007)*
Series
12 (11)
r. 12–66
Digital
r. 0.6–1.8
2
Not given
12 months
Sensory –
66% excellent,
17% poor, 17%
none
Collagen
Bushnell (2008)
Series
12 (12)
33
(r. 18–50)
Digital
≤2
2–4
≤2
15 months
(12–22
months)
Sensory – 44%
excellent, 44%
good, 12% fair
Collagen
Taras (2008)
Technique
2 (2)
22, 23
Digital, radial
sensory
2, 1.5
Not given
Not given
8 months,
6 months
Sensory
– excellent and
not given
Collagen
Lohmeyer (2009)*
Series
15 (14)
38
(r. 12–66)
Digital
1.27 ± 0.37
(r. 0.6–1.8)
2
Gap + 0.2
overlap/
end
12 months
Sensory – 33%
excellent, 42%
good, 8% poor,
17% none
Collagen
Thomsen (2010)
Series
11 (10)
30
Digital
1.13
(r. 0.5–2)
2–4
2–3
11.8
months
(6–17
months)
Sensory – 36%
excellent, 9%
good, 46% fair,
9% poor
PLC
Bertleff (2005)
RCMT
21, 13
controls (30)
43
Digital
0.6-0.8
(r. ≤2)
Not given
Gap +
0.4–0.5
overlap/
end
12 months
Sensory – good,
no difference
from controls
PLC
Meek (2006)
Report
1 (1)
20
Plantar
digital
2
Not given
Gap + 0.5
overlap/
end
14 months
Sensory – poor
PLC
Hernandez-Cortes
(2010)
Letter
1 (1)
17
Digital
Not given
Not given
Not given
7 months
Sensory – poor
PGA, polyglycolic acid; PLC, Poly(DL-Lactide-ε-Caprolactone); r., range; RCMT, randomized controlled multicenter trial. *Publications represent data from same cohort at different time
points.

792
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
minced or a whole piece, has been shown previously and
conclusively to enhance regeneration over greater distances
in rodent models.102,110–112 We recommend this technique
whenever a nerve conduit is used. The proximal nerve will
contain healthy viable Schwann cells. After the nerve ends
have been “freshened up,” a small sliver of the proximal
nerve end can be harvested, minced, and placed into the
conduit to enhance regeneration.
PROCESSED NERVE ALLOGRAFTS
Processed nerve allografts, also known as “acellular nerve
allografts” (ANAs) were developed out of the desire to take
advantage of the regenerative successes of allogenic nerve
tissue (allografts), while preventing the negative effects of
the grafts’ inherent immunogenicity. Comparison of ANAs
with nerve conduits has demonstrated a number of advan­
tages of the ANAs.113 Unlike nerve conduits, ANAs preserve
the 3-dimensional scaffolding and endoneurial architecture
present within native nerve tissue, which promote cell
migration and nerve fiber elongation.114–116 In addition,
ANAs maintain collagen and laminin (components of the
neural basal lamina) within their extracellular matrix that
have an important role in axonal outgrowth.117
ANAs are immunologically tolerated within the recipient
due to decellularization techniques. These methods main­
tain the beneficial extracellular matrix, while removing
Figure 68.6  Demonstration of the relationship between nerve diam­
eter, gap distance, and overall volume of a conduit. Conduits A and
B are of equal volume. To achieve a similar volume after the radius
in conduit (A) is doubled, and conduit (B) has to decrease the length
by a factor of 4. The volume of a conduit is determined by the formula
V = πr2L where V is the volume, r is the radius, π is pi (~3.14), and L
is the length.
L
r
1/4 L
2r
A
B
Volume = p r2L
Figure 68.5  This patient presented 4 years following a failed collagen conduit repair of a right median nerve injury. Histological examination
of the surgical specimen demonstrates dense fibrous scar tissue and an absence of nerve structures in the distal conduit (left). The middle
portion of the conduit (middle) is consistent with neuroma, showing significant amounts of disorganized architecture and no axonal organiza­
tion. The nerve proximal to the conduit maintained its normal architecture.
10.00 µm
Distal nerve
Proximal nerve
Middle conduit
10.00 µm
10.00 µm
successful results in larger-diameter nerves and/or longer
nerve gap lengths. The successful reconstruction of 4 cm
median and ulnar nerve defects has been reported by inter­
posing a slice of autogenous nerve between two 2 cm con­
duits.83,108,109 The addition of nerve tissue to conduits, either

CHAPTER 68 — Peripheral Nerve Allotransplantation
793
Table 68.7  Clinical data on FDA-approved absorbable nerve conduits use for large-caliber nerve repair
Material
First author
(year)
Study
type
No.
conduit
repairs
(total no.
patients)
Age
Nerve
Gap
size
(cm)
Conduit
diameter
(mm)
Conduit
length (cm)
Follow-up
Outcome
PGA
Navissano
(2005)
Series
7 (7)
m 26
Facial
r. 1–3
Not given
Not given
r. 7–12
months
Motor – 14% very
good, 57% good,
29% fair
PGA
Donoghoe
(2007)
Series
2 (2)
40, 61
Median
(forearm)
3
2.3 (4
conduits/
repair)
4
5 years
Motor – APB function;
Sensory – good to
excellent
PGA
Rosson
(2008)*
Series
4 (3)
A: 9;
B: 53;
C: 51
A: Ulnar
(forearm);
B: Median,
ulnar
(mid-
brachium);
C: Ulnar
(mid-
brachium)
A: 2.7;
B: 3.0,
1.5;
C: 4.0
A: not given;
B: not given
(4 conduits/
median, 3
conduits/
ulnar);
C: 8 mm
A: not given;
B: not given;
C: 4 (two 2 cm
end-to-end with
sliced nerve
interposed)
A: 2.5
years;
B: 5.5
years;
C: 14
months
A: Motor – excellent;
B: Motor – reinnervation
of forearm median/ulnar
muscles; no intrinsic
reinnervation;
C: reinnervation of
forearm ulnar muscles
and FDI
PGA
Hung (2008)
Report
1 (1)
53
Median
(carpal
tunnel)
4
4
5 (two
stretched 2 cm
end-to-end with
sliced nerve
interposed)
2 years
Motor – APB function;
Sensory – good
PGA
Dellon (2008)
Letter
1 (1)
50
Ulnar
(proximal
arm)
4.2
8
5 (two
stretched 2 cm
end-to-end with
sliced nerve
interposed)
18 months
Sensory – progression
of Tinel to mid-forearm;
Motor – EMG evidence
of reinnervation to RF/
SF FDP
Collagen
Ashley (2006)
Series
11 (5)
8 months
(r. 2.8–17.3
months)
Brachial
plexus
≤2
5–7
≤2
23.3 ± 4
months
Motor – 60% excellent,
20% good, 20% poor
Collagen
Wangensteen
(2010)
Series
126 (96)
33 (r. 7–79
years)
Varied: 82
digital, 23
other small
caliber, 21
large
caliber
1.3 (r.
0.25–2)
2 (r. 2–7)
Not given
m 256
days
Sensory – 45%
qualitative
improvement, 24% 2PD
improvement; not
stratified for nerve type/
size
2PD, two-point discrimination; APB, abductor pollicis brevis; EMG, electromyography; FDI, first dorsal interosseous; FDP, flexor digitorum profundus; PGA, polyglycolic acid; r., range;
RF, ring finger; SF, small finger. *Publication includes data presented in two previous papers; duplicate data are excluded from the table.

794
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
CONCLUSION
Given the prevalence of nerve injuries and the limited
supply of nerve autografts, nerve allotransplantation, pro­
cessed nerve allografts, and conduits remain viable options
for treatment of the nerve gap. When considering vascular­
ized composite tissue transplantation, regeneration of the
nerves is critical for function. In both scenarios, high quality
of regeneration and rapidity of regeneration are essential,
as there is a critical window of time for regeneration prior
to detrimental changes at the nerve and target muscle. Opti­
mizing surgical technique, enhancing nerve regeneration
with adequate SC support, and accelerating axonal regen­
eration with the administration of FK-506 are important to
consider in the effort to return neurologic function to our
patients who have devastating injuries.
immunogenic cellular components, such as Schwann cells.
The only currently clinically available, FDA-approved pro­
cessed nerve allograft is the Avance® nerve graft by Axogen,
Inc. (Alachua, FL). They use a proprietary protocol for
processing cadaveric nerve involving a combination of
detergent decellularization and gamma-irradiation steriliza­
tion. They also employ a chondroitinase to remove chon­
droitin sulfate proteoglycans (SCPGs), a protein shown to
inhibit axonal growth that is upregulated following periph­
eral nerve injury.118–120 These nerve grafts have been avail­
able for clinical use since 2007. In animal models, ANAs
have demonstrated both more consistent regeneration and
a significantly larger number of fibers in the nerve distal to
the graft site when compared with conduits. This result was
even more pronounced when comparing the 28 mm with
the 14 mm nerve gap repairs.121 Although ANAs appear to
be superior to nerve conduits, this same research demon­
strated they did not have equivalent regeneration when
compared with autografts.30
At the current time, Avance grafts are available in diam­
eters between 1 mm and 5 mm, at lengths between 15 mm
and 50 mm, or longer by special order. Interestingly, it has
been observed in animal studies that as longer ANA grafts
are used, axonal regeneration decreases.121 ANAs depend
on the replication and migration of host Schwann cells to
repopulate the graft tissue. One reason for this decreased
axonal regeneration may be that longer grafts exceed the
Schwann cell regenerative potential of the host.122 This is
currently a focus of research in our laboratory.
Clinically, there are few published reports and case series
demonstrating the efficacy and safety of the use of Avance
grafts.125–128 In 2009, Karabekmez et al. evaluated the early
clinical outcomes in 10 sensory nerves treated with Avance
grafts with a mean graft length of 2.23 cm (range 0.5–3 cm).
At the end of the study (9 months average follow-up), the
average static and moving two-point discrimination was
5.5 mm and 4.4 mm, respectively.125 More recently, multi­
center studies have been published reporting the efficacy of
the Avance grafts in sensory, mixed, and motor nerves.127,128
In these studies the authors evaluated and defined “meaning
recovery” as S3-S4 or M3-M4 on the Medical Research Council
Classification (MRCC) for sensory and motor function,
respectively. Brooks et al. reported on 76 injuries (49 sensory,
18 mixed and 9 motor nerves) with a mean graft length of
22 ± 11 mm. They report meaningful recovery in 87% of the
repairs with no differences between the groups. A 5% revi­
sion rate was reported. They concluded that the processed
nerve allografts were safe and effective and that their results
compared favorably to the published literature for nerve
autograft and higher than those for conduits.127 Cho et al.
evaluated upper extremity use of Avance nerve grafts. They
reported on 51 subjects (35 sensory, 13 mixed, and 3 motor
nerves), with a mean gap length of 23 ± 12 mm. They found
meaningful recovery in 86% of the procedures and gave the
same conclusions as reported by Brooks et al.127,128
When considering the laboratory and clinical studies,
further comparative human trials are needed to delineate
the appropriate indications and limitations for the use of
ANAs. Given the current data, we recommend processed
nerve allograft use in small-diameter nerve injuries with
<3 cm nerve gap defects.
Expert Commentary
Yur-Ren Kuo, MD, PhD, FACS
Peripheral nerve injury is a relatively common sequela of
trauma. This process is dependent on the degree of nerve
injury. When a nerve is transected, the goal is to perform a
tensionless, primary neurorrhaphy. If a segmental nerve gap
precludes such repair, the current gold standard is to bridge
the nerve defect with a sensory nerve autograft. Autologous
nerve grafts remain the standard for nerve grafting due to the
presence of Schwann cells (SCs) and extracellular scaffold of
endoneurial tubes. However, nerve autografts are not without
their own associated morbidity, including loss of donor nerve
function, additional incisions and scarring, as well as potential
neuroma formation. For these reasons, clinicians and scientists
have developed nerve allograft, and biologic and artificial con-
duits to serve as axonal guidance channels. Nerve allotrans-
plantation provides an alternative strategy to manage severe,
long gap, or segmental nerve injuries. However, the potential
morbidity associated with systemic immunosuppression has
limited widespread utilization. The nerve allografts act as a
biological and temporary conduit through which host motor
and sensory axons traverse to reach the host end-organ target.
Thus, nerve allografts require only temporary systemic immu-
nosuppression, which can be withdrawn once the axons have
crossed the allograft. Clinical trials demonstrated the tacrolimus
(FK-506) ability to speed regeneration and increase reinnerva-
tion of distal nerve allotransplantation patients. Current strate-
gies to augment nerve regeneration include, e.g., cold
preservation, which has shown to reduce allogenicity of nerve
allografts. Acellular nerve allografts (ANAs), mesenchymal stem
cells (MSCs), and use of neurotrophic factors, were developed
to take advantage of the regenerative successes of allografts.
The effects are dependent on length of exposure. For vascular-
ized composite allotransplantation (VCA), reinnervation of allo-
transplant ultimately dictates functional recovery but provides
a significant regenerative challenge. However, long-term char-
acterization of host and donor SCs in VCA is not yet fully
understood. Length-dependent functional motor and sensory
axonal regeneration has been observed in both facial and
upper extremity transplants. Compared with more proximal
transplants, distal hand transplants have demonstrated both a
superior sensory and motor recovery, with reported return of
intrinsic motor function and discriminative sensation.

CHAPTER 68 — Peripheral Nerve Allotransplantation
795
27. Romine JS, Aguayo AJ, Bray GM. Absence of Schwann cell migra­
tion along regenerating unmyelinated nerves. Brain Res 1975;
98(3):601–6.
28. Aguayo AJ, David S, Bray GM. Influences of the glial environment
on the elongation of axons after injury: transplantation studies in
adult rodents. J Exp Biol 1981;95:231–40.
29. Aguayo AJ, Kasarjian J, Skamene E, et al. Myelination of mouse
axons by Schwann cells transplanted from normal and abnormal
human nerves. Nature 1977;268(5622):753–5.
30. Whitlock EL, Myckatyn TM, Tong AY, et al. Dynamic quantifica­
tion of host Schwann cell migration into peripheral nerve
allografts. Exp Neurol 2010;225(2):310–19.
31. Jensen JN, Brenner MJ, Tung TH. Effect of FK506 on peripheral
nerve regeneration through long grafts in inbred swine. Ann Plast
Surg 2005;54(4):420–7.
32. Whitlock EL, Myckatyn TM, Tong AY, et al. Dynamic quantifica­
tion of host Schwann cell migration into peripheral nerve
allografts. Exp Neurol 2010;225(2):310–19.
33. Gulati AK. Immune response and neurotrophic factor interac­
tions in peripheral nerve transplants. Acta Haematol 1998;99(3):
171–4.
34. Pollard JD, Gye RS, McLeod JG. An assessment of immunosup­
pressive agents in experimental peripheral nerve transplantation.
Surg Gynecol Obstet 1971;132(5):839–45.
35. Trumble TE, Shon FG. The physiology of nerve transplantation.
Hand Clin 2000;16(1):105–22.
36. Lassner F, Schaller E, Steinhoff G, et al. Cellular mechanisms of
rejection and regeneration in peripheral nerve allografts. Trans­
plantation 1989;48(3):386–92.
37. Mackinnon S, Hudson A, Falk R, et al. Nerve allograft response:
a quantitative immunological study. Neurosurgery 1982;10(1):
61–9.
38. Yu LT, Rostami A, Silvers WK, et al. Expression of major histocom­
patibility complex antigens on inflammatory peripheral nerve
lesions. J Neuroimmunol 1990;30(2–3):121–8.
39. Gulati AK, Cole GP. Nerve graft immunogenicity as a factor deter­
mining axonal regeneration in the rat. J Neurosurg 1990;72(1):
114–22.
40. Marmor L. The repair of peripheral nerves by irradiated homo­
grafts. Clin Orthop Relat Res 1964;34:161–9.
41. Campbell JB, Bassett AL, Boehler J. Frozen-irradiated homografts
shielded with microfilter sheaths in peripheral nerve surgery.
J Trauma 1963;3:303–11.
42. Hiles RW. Freeze dried irradiated nerve homograft: a preliminary
report. Hand 1972;4(1):79–84.
43. Anderson PN, Turmaine M. Peripheral nerve regeneration
through grafts of living and freeze-dried CNS tissue. Neuropathol
Appl Neurobiol 1986;12(4):389–99.
44. Wilhelm K, Ross A. Homeoplastic nerve transplantation with
lyophilized nerve. Arch Orthop Unfallchir 1972;72(2):156–67.
45. Wilhelm K. Briding of nerve defects using lyophilized homolo­
gous grafts. Handchirurgie 1972;4(1):25–30.
46. Singh R, Lange SA. Experience with homologous lyophilised
nerve grafts in the treatment of peripheral nerve injuries. Acta
Neurochir (Wien) 1975;32(1–2):125–30.
47. Martini AK. The lyophilized homologous nerve graft for the pre­
vention of neuroma formation (animal experiment study). Hand­
chir Mikrochir Plast Chir 1985;17(5):266–9.
48. Evans PJ, Mackinnon SE, Midha R, et al. Regeneration across cold
preserved peripheral nerve allografts. Microsurgery 1999;19(3):
115–27.
49. Lawson GM, Glasby MA. A comparison of immediate and delayed
nerve repair using autologous freeze-thawed muscle grafts in a
large animal model. The simple injury. J Hand Surg [Br] 1995;
20(5):663–700.
50. Ray WZ, Kale SS, Kasukurthi R, et al. Effect of cold nerve allograft
preservation on antigen presentation and rejection. J Neurosurg
2011;114(1):256–62.
51. Brenner MJ, Lowe JB, Fox IK, et al. Effects of Schwann cells and
donor antigen on long-nerve allograft regeneration. Microsurgery
2005;25(1):61–70.
52. Hess JR, Brenner MJ, Fox IK, et al. Use of cold-preserved allografts
seeded with autologous Schwann cells in the treatment of a long-
gap peripheral nerve injury. Plast Reconstr Surg 2007;119(1):
246–59.
REFERENCES
1. Millesi H. Bridging defects: autologous nerve grafts. Acta Neuro­
chir Suppl 2007;100:37–8.
2. Abrams M, Widenfalk J. Emerging strategies to promote improved
functional outcome after peripheral nerve injury. Restor Neurol
Neurosci 2005;23(5–6):367–82.
3. Meek MF, Coert JH. Clinical use of nerve conduits in peripheral-
nerve repair: review of the literature. J Reconstr Microsurg 2002;
18(2):97–109.
4. Pomahac B, Gobble RM, Schneeberger S. Facial and hand allo­
transplantation. Cold Spring Harb Perspect Med 2014;4(3):
a015651.
5. Siemionow M, Sonmez E. Nerve allograft transplantation: a
review. J Reconstr Microsurg 2007;23(8):511–20.
6. Burnett MG, Zager EL. Pathophysiology of peripheral nerve
injury: a brief review. Neurosurg Focus 2004;16(5):E1.
7. Fu SY, Gordon T. The cellular and molecular basis of peripheral
nerve regeneration. Mol Neurobiol 1997;14(1–2):67–116.
8. Stoll G, Jander S. The role of microglia and macrophages in
the pathophysiology of the CNS. Prog Neurobiol 1999;58(3):
233–47.
9. Bigbee JW, Yoshino JE, DeVries GH. Morphological and prolifera­
tive responses of cultured Schwann cells following rapid phagocy­
tosis of a myelin-enriched fraction. J Neurocytol 1987;16(4):
487–96.
10. Funakoshi H, Frisén J, Barbany G, et al. Differential expression of
mRNAs for neurotrophins and their receptors after axotomy of
the sciatic nerve. J Cell Biol 1993;123(2):455–65.
11. Rogister B, Delree P, Leprince P, et al. Transforming growth factor
β as a neuronoglial signal during peripheral nervous system
response to injury. J Neurosci Res 1993;34(1):32–43.
12. Brushart TM. Preferential reinnervation of motor nerves by
regenerating motor axons. J Neurosci 1988;8(3):1026–31.
13. Lundborg G, Dahlin L, Danielsen N, et al. Trophism, tropism, and
specificity in nerve regeneration. J Reconstr Microsurg 1994;
10(5):345–54.
14. Glaus SW, Johnson PJ, Mackinnon SE. Clinical strategies to
enhance nerve regeneration in composite tissue allotransplanta­
tion. Hand Clin 2011;27(4):495–509.
15. Matsuyama T, Mackay M, Midha R. Peripheral nerve repair and
grafting techniques: a review. Neurol Med Chir (Tokyo) 2000;
40(4):187–99.
16. Slutsky D. A practical approach to nerve grafting in the upper
extremity. Atlas Hand Clin 2005;10(1):73–92.
17. Schlosshauer B, Dreesmann L, Schaller HE. Synthetic nerve guide
implants in humans: a comprehensive survey. Neurosurgery 2006;
59(4):740–8.
18. Mackinnon SE, Doolabh VB, Novak CB. Clinical outcome follow­
ing nerve allograft transplantation. Plast Reconstr Surg 2001;
107(6):1419–29.
19. Midha R, Mackinnon SE, Evans PJ, et al. Comparison of regenera­
tion across nerve allografts with temporary or continuous cyclo­
sporin A immunosuppression. J Neurosurg 1993;78(1):90–100.
20. Steiner JP, Connolly MA, Valentine HL, et al. Neurotrophic
actions of nonimmunosuppressive analogues of immunosuppres­
sive drugs FK506, rapamycin and cyclosporin A. Nat Med 1997;
3(4):421–8.
21. Gold BG. FK506 and the role of immunophilins in nerve regen­
eration. Mol Neurobiol 1997;15(3):285–306.
22. Naesens M, Kuypers DRJ, Sarwal M. Calcineurin inhibitor neph­
rotoxicity. Clin J Am Soc Nephrol 2009;4(2):481–508.
23. Taylor AL, Watson CJE, Bradley JA. Immunosuppressive agents in
solid organ transplantation: mechanisms of action and therapeu­
tic efficacy. Crit Rev Oncol Hematol 2005;56(1):23–46.
24. Mackinnon SE, Doolabh VB, Novak CB, et al. Clinical outcome
following nerve allograft transplantation. Plast Reconstr Surg
2001;107(6):1419–29.
25. Atchabahian A, Doolabh VB, Mackinnon SE, et al. Indefinite sur­
vival of peripheral nerve allografts after temporary Cyclosporine
A immunosuppression. Restor Neurol Neurosci 1998;13(3–4):
129–39.
26. Mews M, Meyer M. Modulation of Schwann cell phenotype by
TGF-β1: inhibition of P0 mRNA expression and downregulation
of the low affinity NGF receptor. Glia 1993;8(3):208–17.

796
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
76. Petruzzo P, Lanzetta M, Dubernard JM, et al. The international
registry on hand and composite tissue transplantation. Transplan­
tation 2010;90(12):1590–4.
77. Hautz T, Engelhardt TO, Weissenbacher A, et al. World experi­
ence after more than a decade of clinical hand transplantation:
update on the Innsbruck program. Hand Clin 2011;27(4):
423–31.
78. Landin L, Bonastre J, Casado Sanchez C, et al. Outcomes with
respect to disabilities of the upper limb after hand allograft trans­
plantation: a systematic review. Transpl Int 2012;25(4):424–32.
79. Brandacher G, Ninkovic M, Piza-Katzer H. The Innsbruck hand
transplant program: update at 8 years after the first transplant.
Transplant Proc 2009;41(2):491–4.
80. IJpma FFA, Nicolai J-PA, Meek MF. Sural nerve donor-site morbid­
ity: thirty-four years of follow-up. Ann Plast Surg 2006;57(4):
391–5.
81. Xie F, Li QF, Gu B, et al. In vitro and in vivo evaluation of a bio­
degradable chitosan–PLA composite peripheral nerve guide
conduit material. Microsurgery 2008;28(6):471–9.
82. Liu BS. Fabrication and evaluation of a biodegradable
proanthocyanidin-crosslinked gelatin conduit in peripheral nerve
repair. J Biomed Mater Res A 2008;87(4):1092–102.
83. Hung V, Dellon AL. Reconstruction of a 4-cm human median
nerve gap by including an autogenous nerve slice in a bioabsorb­
able nerve conduit: case report. J Hand Surg [Am] 2008;33(3):
313–15.
84. Oh SH, Kim JH, Song KS, et al. Peripheral nerve regeneration
within an asymmetrically porous PLGA/Pluronic F127 nerve
guide conduit. Biomaterials 2008;29(11):1601–9.
85. Chang JY, Lin JH, Yao CH, et al. In vivo evaluation of a biodegrad­
able EDC/NHS-cross-linked gelatin peripheral nerve guide
conduit material. Macromol Biosci 2007;7(4):500–7.
86. Chiu D, Strauch B. A prospective clinical evaluation of autoge­
nous vein grafts used as a nerve conduit for distal sensory nerve
defects of 3 cm or less. Plast Reconstr Surg 1990;86(5):928–34.
87. Chen YS, Chang JY, Cheng CY, et al. An in vivo evaluation of a
biodegradable genipin-cross-linked gelatin peripheral nerve
guide conduit material. Biomaterials 2005;26(18):3911–18.
88. Merrell JC, Russell RC, Zook EG. Polyglycolic acid tubing as a
conduit for nerve regeneration. Ann Plast Surg 1986;17(1):49–58.
89. Hedayatpour A, Sobhani A, Bayati V. A method for isolation and
cultivation of adult Schwann cells for nerve conduit. Arch Iran
Med 2007;10(4):474–80.
90. Kim SM, Lee SK, Lee JH. Peripheral nerve regeneration using a
three dimensionally cultured Schwann cell conduit. J Craniofac
Surg 2007;18(3):475–88.
91. Li Q, Ping P, Jiang H, et al. Nerve conduit filled with GDNF gene-
modified Schwann cells enhances regeneration of the peripheral
nerve. Microsurgery 2006;26(2):116–21.
92. Hadlock T, Sundback C, Koka R, et al. A novel, biodegradable
polymer conduit delivers neurotrophins and promotes nerve
regeneration. Laryngoscope 1999;109(9):1412–16.
93. Fansa H, Keilhoff G, Förster G, et al. Acellular muscle with
Schwann-cell implantation: an alternative biologic nerve conduit.
J Reconstr Microsurg 1999;15(7):531–7.
94. Mohammad JA, Warnke PH, Pan YC. Increased axonal regenera­
tion through a biodegradable amnionic tube nerve conduit: effect
of local delivery and incorporation of nerve growth factor/
hyaluronic acid media. Ann Plast Surg 2000;44(1):59–64.
95. Jesuraj NJ, Santosa KB, Newton P, et al. A systematic evaluation of
Schwann cell injection into acellular cold-preserved nerve grafts.
J Neurosci Methods 2011;197(2):209–15.
96. Moore AM, Wood MD, Chenard K, et al. Controlled delivery of
glial cell line–derived neurotrophic factor enhances motor nerve
regeneration. J Hand Surg [Am] 2010;35(12):2008–17.
97. Ray WZ, Mackinnon SE. Management of nerve gaps: autografts,
allografts, nerve transfers, and end-to-side neurorrhaphy. Exp
Neurol 2010;223(1):77–85.
98. Sjöberg J, Kanje M, Edström A. Influence of non-neuronal cells
on regeneration of the rat sciatic nerve. Brain Res 1988;453(1–2):
221–6.
99. Anderson PN, Turmaine M. The role of Schwann cells and basal
lamina tubes in the regeneration of axons through long lengths
of freeze-killed nerve grafts. Neuropathol Appl Neurobiol 1990;
16(5):411–21.
53. Fox IK, Schwetye KE, Keune JD, et al. Schwann-cell injection
of cold-preserved nerve allografts. Microsurgery 2005;25(6):
502–7.
54. Evans PJ, Mackinnon SE, Levi AD, et al. Cold preserved nerve
allografts: changes in basement membrane, viability, immunoge­
nicity, and regeneration. Muscle Nerve 1998;21(11):1507–22.
55. Atchabahian A, Mackinnon SE. Cold preservation of nerve grafts
decreases expression of ICAM-1 and class II MHC antigens.
J Reconstr Microsurg 1999;15(4):307–11.
56. Pollard JD, Fitzpatrick L. A comparison of the effects of irradia­
tion and immunosuppressive agents on regeneration through
peripheral nerve allografts: an ultrastructural study. Acta Neuro­
pathol 1973;23(2):166–80.
57. Pollard JD, McLeod JG, Gye RS. Regeneration through peripheral
nerve allografts. An electrophysiological and histological study
following the use of immunosuppressive therapy. Arch Neurol
1973;28(1):31–7.
58. Gye RS, Hargrave JC, Loewenthal J, et al. Use of immunosuppres­
sive agents in human nerve grafting. Lancet 1972;1(7752):
647–50.
59. Bain JR, Mackinnon SE, Hudson AR, et al. Preliminary report of
peripheral nerve allografting in primates immunosuppressed with
cyclosporin A. Transplant Proc 1989;21(1 Pt 3):3176–7.
60. Wang MS, Zeleny-Pooley M, Gold BG. Comparative dose-
dependence study of FK506 and cyclosporin A on the rate of
axonal regeneration in the rat sciatic nerve. J Pharmacol Exp Ther
1997;282(2):1084–93.
61. Jost SC, Doolabh VB, Mackinnon SE, et al. Acceleration of periph­
eral nerve regeneration following FK506 administration. Restor
Neurol Neurosci 2000;17(1):39–44.
62. Lee M, Doolabh VB, Mackinnon SE, et al. FK506 promotes func­
tional recovery in crushed rat sciatic nerve. Muscle Nerve 2000;
23(4):633–40.
63. Gold BG, Zeleny-Pooley M, Wang MS, et al. A nonimmunosup­
pressant FKBP-12 ligand increases nerve regeneration. Exp
Neurol 1997;147(2):269–78.
64. Klettner A, Baumgrass R, Zhang Y, et al. The neuroprotective
actions of FK506 binding protein ligands: neuronal survival is
triggered by de novo RNA synthesis, but is independent of inhibi­
tion of JNK and calcineurin. Brain Res Mol Brain Res 2001;
97(1):21–31.
65. Gold BG, Yew JY, Zeleny-Pooley M. The immunosuppressant
FK506 increases GAP-43 mRNA levels in axotomized sensory
neurons. Neurosci Lett 1998;241(1):25–8.
66. Tanaka K-I, Fujita N, Higashi Y, et al. Neuroprotective and anti­
oxidant properties of FKBP-binding immunophilin ligands are
independent on the FKBP12 pathway in human cells. Neurosci
Lett 2002;330(2):147–50.
67. Brenner MJ, Mackinnon SE, Rickman SR, et al. FK506 and anti-
CD40 ligand in peripheral nerve allotransplantation. Restor
Neurol Neurosci 2005;23(3–4):237–49.
68. Sobol JB, Lowe III JL, Yang RK, et al. Effects of delaying FK506
administration on neuroregeneration in a rodent model. J Recon­
str Microsurg 2003;19(2):113–18.
69. Snyder AK, Fox IK, Nichols CM, et al. Neuroregenerative effects
of preinjury FK-506 administration. Plast Reconstr Surg 2006;
118(2):360–7.
70. Guelinckx PJ, Sinsel NK, Lerut T. Intercostal nerve loop as an
original treatment for long-term post-thoracotomy pain. Eur J
Plast Surg 1998;21(3):139–45.
71. Evans PJ, Mackinnon SE, Midha R, et al. Regeneration across cold
preserved peripheral nerve allografts. Microsurgery 1999;19(3):
115–27.
72. Strasberg SR, Hertl MC, Mackinnon SE, et al. Peripheral nerve
allograft preservation improves regeneration and decreases sys­
temic cyclosporin A requirements. Exp Neurol 1996;139(2):
306–16.
73. Moore AM, Ray WZ, Chenard KE, et al. Nerve allotransplantation
as it pertains to composite tissue transplantation. Hand (N Y)
2009;4(3):239–44.
74. Schneeberger S, Ninkovic M, Gabl M. First forearm transplanta­
tion: outcome at 3 years. Am J Transplant 2007;7(7):1753–62.
75. Schneeberger S, Landin L, Jableki J, et al. Achievements and
challenges in composite tissue allotransplantation. Transpl Int
2011;24(8):760–9.

CHAPTER 68 — Peripheral Nerve Allotransplantation
797
100. Büngner OV. Uber die degenerations- und regenerations vor­
gange am nerven nach verletzungen. Beitr Pathol Anat 1891;10:
321–87.
101. Rosen JM, Hentz VR, Kaplan EN. Fascicular tubulization: a cel­
lular approach to peripheral nerve repair. Ann Plast Surg 1983;
11(5):397–411.
102. Battiston B, Geuna S, Ferrero M, et al. Nerve repair by means of
tubulization: literature review and personal clinical experience
comparing biological and synthetic conduits for sensory nerve
repair. Microsurgery 2005;25(4):258–67.
103. Taras JS, Nanavati V, Steelman P. Nerve conduits. J Hand Ther
2005;18(2):191–7.
104. Moore AM, Kasukurthi R, Magill CK, et al. Limitations of conduits
in peripheral nerve repairs. Hand (N Y) 2009;4(2):180–6.
105. Lundborg G, Dahlin LB, Danielsen N, et al. Nerve regeneration
in silicone chambers: influence of gap length and of distal stump
components. Exp Neurol 1982;76(2):361–75.
106. Williams LR, Longo FM, Powell HC, et al. Spatial-temporal prog­
ress of peripheral nerve regeneration within a silicone chamber:
parameters for a bioassay. J Comp Neurol 1983;218(4):460–70.
107. Longo FM, Skaper SD, Manthorpe M, et al. Temporal changes of
neuronotrophic activities accumulating in vivo within nerve
regeneration chambers. Exp Neurol 1983;81(3):756–69.
108. Rosson GD, Williams EH, Dellon AL. Motor nerve regeneration
across a conduit. Microsurgery 2009;29(2):107–14.
109. Dellon AL. Author reply. J Hand Surg [Am] 2008;33(8):1442–3.
110. Francel PC, Francel TJ, Mackinnon SE, et al. Enhancing nerve
regeneration across a silicone tube conduit by using interposed
short-segment nerve grafts. J Neurosurg 1997;87(6):887–92.
111. Lloyd BM, Luginbuhl RD, Brenner MJ. Use of motor nerve
material in peripheral nerve repair with conduits. Microsurgery
2007;27(2):138–45.
112. Maeda T, Mackinnon SE, Best TJ, et al. Regeneration across
“stepping-stone” nerve grafts. Brain Res 1993;618(2):196–202.
113. Karabekmez FE, Duymaz A, Moran SL. Early clinical outcomes
with the use of decellularized nerve allograft for repair of sensory
defects within the hand. Hand (N Y) 2009;4(3):245–9.
114. Hudson TW, Zawko S, Deister C, et al. Optimized acellular nerve
graft is immunologically tolerated and supports regeneration.
Tissue Eng 2004;10(11–12):1641–51.
115. Hudson TW, Evans G, Schmidt CE. Engineering strategies for
peripheral nerve repair. Orthop Clin North Am 2000;31(3):
485–98.
116. Hudson TW, Liu SY, Schmidt CE. Engineering an improved acel­
lular nerve graft via optimized chemical processing. Tissue Eng
2004;10(9–10):1346–58.
117. Hall SM. Regeneration in cellular and acellular autografts in the
peripheral nervous system. Neuropathol Appl Neurobiol 1986;
12(1):27–46.
118. Krekoski CA, Neubauer D, Zuo J, et al. Axonal regeneration into
acellular nerve grafts is enhanced by degradation of chondroitin
sulfate proteoglycan. J Neurosci 2001;21(16):6206–13.
119. Neubauer D, Graham JB, Muir D. Chondroitinase treatment
increases the effective length of acellular nerve grafts. Exp Neurol
2007;207(1):163–70.
120. Zuo J, Hernandez YJ, Muir D. Chondroitin sulfate proteoglycan
with neurite-inhibiting activity is up-regulated following periph­
eral nerve injury. J Neurobiol 1998;34(1):41–54.
121. Whitlock EL, Tuffaha SH, Luciano JP, et al. Processed allografts
and type I collagen conduits for repair of peripheral nerve gaps.
Muscle Nerve 2009;39(6):787–99.
122. Saheb-Al-Zamani M, Yan Y, Farber SJ, et al. Limited regeneration
in long acellular nerve allografts is associated with increased
Schwann cell senescence. Exp Neurol 2013;247:165–77.
123. Seddon HJ. Three types of nerve injury. Brain 1943;66(4):238–88.
124. Sunderland S, Walshe F. Nerves and nerve injuries. Baltimore:
Williams & Wilkins; 1968.
125. Karabekmez FE, Duymaz A, Moran SL. Early clinical outcomes
with the use of decellularized nerve allograft for repair of sensory
defects within the hand. Hand 2009;4(3):245–9.
126. Shanti RM, Ziccardi VB. Use of decellularized nerve allograft for
inferior alveolar nerve reconstruction: a case report. J Oral Maxil­
lofac Surg 2011;69(2):550–3.
127. Brooks DN, Weber RV, Chao JD, et al. Processed nerve allografts
for peripheral nerve reconstruction: a multicenter study of utiliza­
tion and outcomes in sensory, mixed, and motor nerve recon­
structions. Microsurgery 2012;32(1):1–14.
128. Cho MS, Rinker BD, Weber RV, et al. Functional outcome follow­
ing nerve repair in the upper extremity using processed nerve
allograft. J Hand Surg Am 2012;37(11):2340–9.

This page intentionally left blank

799
Index
Page numbers followed by “f ” indicate figures, “t” indicate tables, “b” indicate boxes, and “e” indicate online content.
soft tissue reconstruction of lower
extremity and, with TFL
myofasciocutaneous flap, e200b, e200f
Active errors, 358
Acute humoral rejection, e213
Acute post-traumatic facial paralysis,
microsurgical management for,
168–169
Acute rejection, e213
immune suppression and, 740
Acute setting, surgical objectives in, 257–260
Adductor hiatus, superficial femoral artery
and, 119
Adenoid cystic carcinoma, of right maxilla,
476b, 476f
Adipocutaneous island flap, 505
Adipofascial flap
in anterolateral thigh flap, 706
for lateral arm flap, 516
radial forearm, 532, 539.e1b, 539.e1f
Adipofibrous tissue, debulking of, 628
Adipose tissue, SCIP flap with, 484
Adipose-derived stem cells, 4
Adipose-derived stromal cells (ASCs), 33
Adjunctive treatments, for second free flap,
362
ADM. see Abductor digiti minimi (ADM)
muscle
Adult brachial plexus injury (A-BPI)
case, 250b–253b, 251f–253f
clinical presentation and examination for,
244–246
complex problems in, 242, 242b
expert commentary in, 254b
exploration of, timing of, consensus in,
244
levels of, consensus in, 242–244, 243f
management of, 242–244, 244t
patient examination in, 244–246
patient history in, 244
postoperative management for, 249,
250f
reconstruction of, 242–254
in elbow, 250
in hand, 250
results and outcomes of, 250
in shoulder, 250
rehabilitation for, 249, 250f
sequelae deformities in, palliative
reconstruction for, 249–250
surgical treatment for, 246–247
level I of, 247–249
level II of, 249
level III of, 249
level IV of, 249
strategies in, 247–249
Advancement flap, pectoralis major,
reconstruction of, 204, 204f
Adventitia, gross trimming of,
310–311
Adventitia scissors, 312–313, 312f
A
Abdomen
clinical anatomy and recipient vessel
selection in, 75–88
femoral artery in, 82
inferior epigastric artery in, 82
intercostal artery in, 82
muscular anatomy of, 75
nerve anatomy of, 86
recipient arteries for reconstruction of, 82
superficial inferior epigastric and
circumflex iliac arteries in, 82
veins of posterior abdominal wall venous
drainage of, 83f
Abdominal bulge, in chest and back
reconstruction, 211
Abdominal CT scan, in abdominal wall
reconstruction, 220
Abdominal flaps, in breast reconstruction,
187–194
complications of, 198–199, 198f
DIEP flap, 187–190, 188f–190f
free TRAM flap, 190–191, 190f–193f, 191t
pedicle TRAM flap, 193–194, 193f–194f
preoperative considerations in, 184–185
SIEA flap, 191–193
Abdominal muscles, in iliac flap, 469–470
Abdominal wall
allotransplantation, 772–773
anterior
nerves of, 87f
veins of, 85f
composite allograft, 773f
posterior, nerves of, 88f
Abdominal wall defect, full-thickness, 283b,
283f
right-sided, 284b, 284f–285f
Abdominal wall reconstruction, 218–226,
282–285
in anterolateral thigh flap, 703
in anteromedial thigh flap, 710
cases of, 224b–225b, 224f–225f
complications of, 223–224
expert commentary in, 226b
free flap options in, 222
indications to, 218–219
local flap options in, 221–222
outcomes of, 224
patient evaluation in, 220
postoperative considerations for, 223
preoperative considerations to, 219–223
recipient vessels in, 222–223
by region, 220–221, 220t–221t
regional flap options in, 222
Abductor digiti minimi (ADM) muscle,
544–546, 544f
anesthetic considerations for, 545–546
arterial and venous supply of, 544
atypical indications for the use of, 546
donor site closure and management of,
546
flap anatomy of, 544
flap components of, 544
flap design of, 545
flap dimensions of, 545
flap handling of, 546
flap innervation of, 544
flap markings of, 545, 545f
flap modification of, 546
flap usage of, 546
outcomes of, 546
patient positioning for, 545
for posterior heel defect, 557b, 557f
postoperative care for, 546
preoperative preparation for, 545
special instruments for, 546
technical tips to optimize outcomes and
avoid complications for, 546
technique of flap harvest in, 546
typical indications for the use of, 546
venous drainage of, 544
Abductor hallucis (AH) muscle, 546–549,
547f
anesthetic considerations for, 548
arterial and venous supply of, 546–547
atypical indications for the use of, 549
donor site closure and management of,
549
flap anatomy of, 546–547
flap components of, 547
flap design of, 547–548
flap dimensions of, 548
flap handling of, 549
flap innervation of, 547
flap markings of, 548, 548f
flap modification of, 549
flap usage of, 549
for medial malleolar defect, 558b,
558f
outcomes of, 549
patient positioning for, 548
postoperative care for, 549
preoperative preparation for, 547
special instruments for, 549
technical tips to optimize outcomes and
avoid complications for, 549
technique of flap harvest in, 548, 548f
typical indications for the use of, 549
venous drainage of, 547
ABO blood group antigens, e211
A-BPI. see Adult brachial plexus injury
(A-BPI)
Accelerated rejection, e213
Accessory nerve transfer, for facial paralysis,
174
“Acellular nerve allografts” (ANAs),
792
Achilles tendon
leg and, 119
posterior tibial artery and, 121–122
soft tissue defect and, free groin flap for,
487, 490.e1b, 490.e1f

800
Index
Aesthetic subunit, appearance of,
craniofacial microvascular
reconstruction and, 138–139
Age, of patients, in avoiding complications,
324
AH. see Abductor hallucis (AH) muscle
“Airborne” technique, 321
Allograft rejection, immune suppression
and, 740
Allografts
composite tissue, rejection of nerves in,
788f
nerve, 781
processed nerve, 792–794
Allorecognition pathways, e211–e214
Allotransplantation
abdominal wall, 772–773
composite tissue, 770
intestinal, 772
laryngeal, 770–772
peripheral nerve, 779–797
ALT. see Anterolateral thigh (ALT) flap
Amer, H., e204
Amputations
distal, finger, homodigital island flap for,
503b, 503f
thumb tip, Moberg flap for, 498b, 498f
AMT. see Anteromedial thigh (AMT) flap
ANAs. see “Acellular nerve allografts” (ANAs)
Anastomosis
around elbow, 94, 94t
choosing the site of, 310
end-to-end, 315–316, 315f–316f
end-to-side, 316–317, 318f–319f
flow-through, 316–317, 320
pharyngogastric, pharyngocutaneous
fistula after, pectoralis major flap
for, 408–409
vertically oriented, suturing of, 319–320
Anastomotic technique, avoiding
complication and, 328
Anatomic landmarks
of deltopectoral flaps and internal
mammary artery perforator flap,
e88–e89, e89f
of external oblique flap, e103
of iliac flap, 466, 467f
of internal oblique flap, e106
of jejunum flap, e118, e118f
of latissimus dorsi flap, 450, 450f
of omentum flap, e99, e99f
of pectoralis major flap, 400, 400f
of rectus abdominis flap, 419, 419f
of superior epigastric flap, e101
of supraclavicular artery flap, 389
of temporoparietal fascia flap, e77, e77f
Anergy, e214–e215
Anesthesia
in hand and upper extremity
transplantation, 759
recipient vessel selection in lower
extremity, 137
in upper extremity procedures, 113
Anesthetic complications, 327
Anesthetic considerations
for gluteus flap, e162
for great toe pulp flap and second toe
pulp flap, e179–e180
for iliac flap, 468
for medial femoral condyle, 641
for medial plantar flap, e183
for pectoralis major flap, 403
for rectus abdominis flap, 421
for scapular flaps, 439
for supraclavicular artery flap, 389
for temporoparietal fascia flap, e79
Angiosome, e3–e4
concept, of deltopectoral flaps and
internal mammary artery perforator
flap, e89
of foot and ankle, 540, 542f
Angulated vessel dilator forceps, 312–313
Animal attack reconstructed, with full face
allograft, severe facial deformity
resulting from, 751b, 751f
Ankle soft tissue defect
extended scapular flap for, 445.e2b,
445.e2f
latissimus dorsi flap for, 463.e1b, 463.e1f
SCIP flap for, 487
medial, 489b, 489f
Antebrachial cutaneous nerve, lateral, in
antecubital fossa, 94–95
Antecubital fossa, 94–96
exposure of distal brachial artery and its
bifurcation in, 113.e2b, 113.e2f
Anterior abdominal wall, arteries of, 187,
188f
Anterior branch, in CLA, 638
Anterior descending branch, in UTA, 638
Anterior division of radial collateral artery
(ARCA), in arm, 94
Anterior forearm soft tissue defect, free TFL
flap for, e201b, e201f
Anterior interosseous artery, as branch of
ulnar artery, 99–100
Anterior interosseous nerve, 780t–781t
Anterior palate defect, 374b, 374f
Anterior tibial artery
inflow vessel and, 134
in leg, 124–127
exposure of, 133
surgical exposure of, 133f
Anterior ulnar recurrent artery, as branch of
ulnar artery, 99
Anterolateral chest, reconstruction in,
204–208
advancement/island flap, 204, 204f
external oblique, 207, 207f
intercostal perforator flap, 207, 208f
latissimus dorsi, 206, 206f
omentum, 206, 206f
pectoralis major, 204
rectus abdominis, 205–206, 205f
scapular/parascapular perforator flap,
207–208
serratus anterior, 207
trapezius, 208
turnover flap, 204–205, 205f
Anterolateral thigh (ALT) flap, 4, 11,
700–716
anatomic landmarks of, 702, 702f
anatomy, 700f, 701–708
anesthetic considerations, 704
arterial supply of, 701
bulk is required in, 705f, 706, 707f
components, 701–702
craniofacial microvascular reconstruction
and, 141, 148–149, 149f–150f
design, 702–703
differences in design of, 703
dimensions, 703–704
free
orbital reconstruction using, 159b
scalp reconstruction using, 159b
general thoughts about design of,
702–703
harvest, 704–706
subfascial dissection in, 705f, 706
suprafascial dissection in, 704f, 706
innervation, 701
markings, 702f, 704, 704f
modification/handling of, 706–708
patient positioning, 704
in pelvic and urogenital reconstruction,
e51, e51b
pedicled, e54
preoperative preparation, 702
previous transferred, right foot defect
reconstructed with free-style flap
from, 735b, 735f
special considerations in design of, 703
venous drainage of, 701
Anterolateral thigh perforator (ALTP) flap,
e67
Anteromedial thigh (AMT) flap, 700–716,
700f
arterial supply of, 708
atypical indications for, 710
donor site closure and management of,
708–709
expected outcomes, 711
harvest, 708
long-term outcomes, 711–712
outcomes, 711–712
overview, 708
palate defect reconstructed with, 715b,
715f
postoperative care for, 710–711
tips to optimize outcomes and avoid
complications, 709
typical indications for, 709–710
untoward outcomes, 711
usage, 709–710
venous drainage of, 708
Antithrombotic therapy, for management of
surgical complications, 353
Antithymocyte globulin, 776
Anxiolytics, for second free flap, 363
Aortic graft, exposed, reconstructed with
pedicled omentum flap, e108b, e108f
Appendix, for voice reconstruction, 145
Areflexic bladder, 285–287
Arm
anastomoses around elbow in, 94
anatomy of, 89, 89f–90f
anterior compartment of, 89
brachial artery in, 89–92, 93f
branches of brachial artery in, 93–94
medial, exposure of brachial artery in, 94,
113.e1b, 113.e1f
median nerve in, 106
musculocutaneous nerve in, 106–107
posterior compartment of, 89, 92f
radial nerve in, 107–109
superficial veins and cutaneous nerves of,
112f
ulnar nerve in, 106
venous anatomy of, 111–113
Arterial anatomy
of region, 583f
of trapezius muscle, e135–e136, e138f
Arterial spasm, in flap compromise,
340–341
Arterial supply
of deltopectoral flaps and internal
mammary artery perforator flap,
e87–e88
of gluteus flap, e157–e158
of groin and SCIP flap, 478–480, 479f
of latissimus dorsi flap, 447–448, 447f
of pectoralis major flap, 397–398
of rectus abdominis flap, 417
of scapular and parascapular flaps,
433–435, 433f
of supraclavicular artery flap, 387
of temporoparietal fascia flap, e74, e75f
for trapezius flap, e135f, e137–e139

Index
801
Arterial vasospasm, 631
Arteriovenous loop, inflow vessel and, 134
Arteriovenous malformation, in foot, SCIP
flap for, 487
Arteriovenous vascular loops, 321
Articular branch, of DGA, 638
ASCs. see Adipose-derived stromal cells
(ASCs)
Aspirin, for flap re-exploration, 334
AT9 guidelines, 349t
Atherosclerosis vessels, suturing of, 321
Atraumatic transfer valve (AT-Valve), 33
Auricular nerve, great, in head and neck,
71–73
Auriculotemporal nerve (ATN), in
temporoparietal fascia flap, e75
Autogenous nerve grafts, 300–301
Autograft
interposed, 780
nerve, substitutes of, 788–794
Autologous breast reconstruction, 183
complications of, 198–199
in abdomen, 198–199, 198f
in gluteal flaps, 199
in posterior thigh, 199
in posterior thorax, 199
computerized tomography angiography
in, 185, 185f
duplex ultrasound in, 186
expert commentaries in, 200b
fluorescent angiography in, 186–187, 186f
indications for, 185
intraoperative assessment and monitoring
tools for, 186–187, 186f
magnetic resonance angiography, 185–186
near infrared spectroscopy in, 198
outcome analysis in, 199
postoperative considerations for, 198
postoperative recovery for, 198
preoperative considerations for, 183–185
preoperative imaging in, 185–186, 185t
surgical procedures for, 187–198, 187t
in abdomen, 187–194
medial thigh flaps, 196–197
posterior thigh flaps, 198
in posterior thorax, 194–195
Autologous rib cartilage, microtia
reconstructed with, e83b, e83f
Avance® nerve graft, 792–794
Avulsion, of volar tissue of thumb, Moberg
flap for, 499b, 499f
Axial flaps, e1
Axillary artery
in arm, 93f
in chest, 80f
Axillary fat, in chest, 80
Axillary flap, for lymph node transfer, 50
Axonal disruption, 779
“Axonometric injuries”, 296
Axonotmesis, 779t
Axons, 295, 295f
B
Babysitter procedure, for facial paralysis,
169–170, 170f, 173–174
Back
arterial anatomy of, 84
clinical anatomy and recipient vessel
selection in, 75–88
muscular anatomy of, 78–79, 79f
nerve anatomy of, 84f, 86
Back reconstruction, 203–217
cases, 212b, 212f–215f, 214b–215b
complications of, 211
expert commentary in, 216b
indications to, 203–204
outcomes of, 211–216
posterior torso, 208–210
postoperative considerations for, 210–211
preoperative considerations for, 203
by region, 204–210
“Bands of Büngner”, 297, 779–780
Barium latex injection studies, of larynx,
770
Basic fibroblast growth factor (bFGF), 19
Basilic vein
in arm, forearm, and hand, 113
in exposure of brachial artery, 94
B-cell activation, e212
Behavioral evaluation, for facial paralysis,
167, 167t–168t
Beta-lactam antibiotic, for postoperative
care, 351
Beveling, for vessel size discrepancy, 317,
319f
bFGF. see Basic fibroblast growth factor
(bFGF)
Biceps function, pedicled latissimus muscle
transfer for restoration of, 463.e3b,
463.e3f
Biceps tendon, antecubital fossa and, 95
Bilateral breast reconstruction, DIEAP/SIEA
flap in, 681
Bilateral cheek, reconstruction of, using
bilateral SCIA-based free groin flaps,
152f, 159b
Bilateral combined SGAP/DIEP flaps, breast
reconstruction with, 699.e3b, 699.e3f
Bilateral free fibula osseus flaps, pelvic ring
reconstruction with, 612.e1b, 612.e1f
Bilateral functional segmental gracilis flap,
568.e3b, 568.e3f
Bilateral gracilis, in vulvar and vaginal
reconstruction, e54, e54b
Bilateral limb loss, upper
due to hands caught in a farm machine,
766b, 766f–767f
lower and, due to an explosion injury,
768.e1b, 768.e1f–768.e2f
Bilateral mastectomies, extended transverse
upper gracilis free flap for, 568.e5b,
568.e5f
Bilateral pedicled pectoralis major flaps,
sternal and neck defect reconstructed
with, 411b, 411f
Bilateral SCIA-based free groin flaps,
bilateral cheek reconstruction using,
159b
Bilateral sliding
GM musculocutaneous flaps, e169f
V-Y fasciocutaneous flaps, for gluteus flap,
e167, e169f
Bilateral transverse upper gracilis flap,
568.e4b, 568.e4f
Bilobed flap, of temporoparietal fascia flap,
e80
Bilobed split latissimus dorsi flap, 455
Biological dressings, e28
Bipedicled flap, in midline defects, 221
Biphasic suturing method, 316
Bladder, tissue engineering-based clinical
applications for, e30
Bladder acontractility, 288
Blood-outgrowth endothelial cells (BOECs),
e27
BOECs. see Blood-outgrowth endothelial
cells (BOECs)
Bone
defect, lower extremity with, latissimus
dorsi flap for, 450–451
fibula, 598–599
flap, 598
in free-style flap, 732
length, of fibula flap, 599
support of, craniofacial microvascular
reconstruction and, 140
tissue engineering-based clinical
applications for, e30
Bone dimensions, 655
of external oblique flap, e104
of iliac flap, 468
of internal oblique flap, e107
of lateral arm flap, 514
of latissimus dorsi flap, 451
of medial femoral condyle, 641
of posterior tibial artery perforator flap,
721
of radial forearm flap, 529
of rectus abdominis flap, 420
of tensor fascia lata flap, e194, e194f
Bone grafts, 641
non-vascularized, craniofacial
microvascular reconstruction and,
140
radius vascularized, anterior interosseous
artery and, 99–100
Bony restoration, for lower extremity, 258,
258.e2f–258.e4f
“Borrow from Peter to pay Paul” rule, 28
Brachial artery
in arm, 89–92, 91f, 93f
branches of, in arm, 93–94
distal, exposure of, 95–96, 113.e2b, 113.e2f
in medial arm, exposure of, 94, 113.e1b,
113.e1f
Brachial plexus, anatomy of, 243f
Brachytherapy, pectoralis major flap for, 409
Brain death, e213–e214
Branch-based conjoined flaps, e5
Brava, 32
breast augmentation with, 35.e2b, 35.e2f
breast reconstruction with, 37b–38b,
37f–38f
fat transfer and, 35.e1b, 35.e1f
Breast
anatomy of, 183, 184f
deviation of, in lateral thoracic region,
653
Breast reconstruction, 183–202, 682–683
in anterolateral thigh flap, 703
in anteromedial thigh flap, 710
bilateral
DIEAP/SIEA flap in, 681
with IGAP flaps, 699.e3b, 699.e3f
with bilateral combined SGAP/DIEP flaps,
699.e3b, 699.e3f
computed tomography angiography
(CTA) and, e19–e20, e20f
gluteus flap for, e161, e170
with ITC-IGAP flap, 699.e1b, 699.e1f
latissimus dorsi flap for, 450, 452f, 456
pedicled extended latissimus
dorsimyocutaneous flap for, 463.e2b,
463.e2f
in rectus abdominis flap, 419, 427
secondary, DIEAP/SIEA flap in, 680, 681f
with tensor fascia lata flap, e193
with thigh inferior gluteal artery
perforator (TGAP) flap, 698b, 698f
three-dimensional surface imaging and,
e22
Breast shape preserving, in pectoralis major
flap, 407
“Bridle procedure”, 289–291
Brorson’s guidelines, 44–45
Buccal fat pad, in head and neck, 63
Bulk, in free-style flap, 732

802
Index
Burns
as indication for face transplantation,
741–742
severe facial deformity resulting from,
reconstructed with full face allograft,
749b–750b, 749f–750f
Buruli ulcer, of eyelid, free suprafascial
radial forearm flap for, 535b, 535f
Buttocks, 687f
C
C7 nerve root transfer, for facial paralysis,
174
Calcaneus defect, sural flap for, 556.e1b,
556.e1f
Calf wound reconstructed with V-Y
advancement, of posterior tibial
artery perforator flap, 728.e1b, 728.e1f
Calvarium, function in, 61
Cam walker boot, for local flaps, in foot, 556
Caprini risk stratification, 349t
Cardiovascular system, tissue-engineering
based clinical applications for, e32
Carotid artery, external, 68f
Carrel, Alexis, 310
Cauda equine syndrome, associated
acontractile bladder and, 286b,
286f–287f
C-curved incision, 246–247
Cell cultivation, in tissue engineering, e27
Cell therapy, for myocardium, e32
Cell-based therapies, in VCA, e216–e217
Cell-containing skin substitutes, e28
Cell-free biodegradable scaffolds, e28
Cells, in tissue engineering, e27
Cell-sheet engineering, e26–e27
Central longitudinal artery (CLA), 638
Cephalic vein
in arm, forearm, and hand, 112–113
in chest, 85–86
Cervical esophagus, reconstruction of, using
free jejunum, e126, e130b, e130f
Cervical fascia, superficial, in head and
neck, 63
Cervicodeltopectoral flap, supraclavicular
extension of, e92–e93
Cervicofacial flap, 382–386
anatomic landmarks of, 384–385, 384b,
384f
anatomy of, 382–383
arterial supply of, 383
design of, 384–385
dimensions of, 385
donor site closure and management for,
385–386
expected outcomes, 386
facial artery in, 383
innervation of, 383–384
postoperative care for, 386
technique of flap harvest for, 385–386
usage of, 386
venous supply of, 383
Cervicofacial nerve transfer, minihypoglossal
to, for depressor restoration, 178
Cervicopectoral flaps, supraclavicular
extension of, e92–e93
CFNG. see Cross-facial nerve grafting
(CFNG)
Cheek, periorbital and, reconstruction of,
using SCIA-based free groin flap,
151f, 159b
Chest
cephalic vein in, 85–86
clinical anatomy and recipient vessel
selection in, 75–88
internal mammary artery in, 80–81
jugular vein in, 86
lateral thoracic artery in, 81
muscular anatomy of, 75, 76f–77f
nerve anatomy of, 86
recipient arteries for reconstruction of, 81
subscapular system in, 80
thoracoacromial artery in, 81
Chest reconstruction, 203–217
anterolateral, 204–208
cases, 212b, 212f–215f, 214b–215b
complications of, 211
expert commentary in, 216b
indications to, 203–204
intrathoracic, 208, 208f
outcomes of, 211–216
postoperative considerations for,
210–211
preoperative considerations for, 203
by region, 204–210
Chest wall
defects
musculocutaneous flap design for, of
external oblique flap, e104
pectoralis major flap for, 409
reconstruction
pedicled transfer of, latissimus muscle
for, 453–454
in rectus abdominis flap, 419
Chimeric flap, 658, 659f, 664f, e6–e7, e6f
in gastrocnemius flap, 576, 576f–577f,
579b, 579f
latissimus dorsi flap and, 454
pattern, 664
perforator-based, e6
in posterior tibial artery perforator flap,
722–723
in scapular flap, 441
for mandibular reconstruction, 445b,
445f
of tensor fascia lata flap, e196–e197
Chimerism, donor bone marrow
transplantation and, e215–e216
Chinese flap, 525
Chitosan, e28
Chondroitin sulfate proteoglycans (SCPGs),
792–794
Chorda tympani, facial paralysis in, 166
Chronic allograft destruction, e213
Chronic allograft vasculopathy, e213–e214
Chronic rejection. see also Chronic allograft
vasculopathy
immune suppression and, 740
Chronic wound, with desiccated bone
exposure, 271.e1b, 271.e1f
Chuang’s triangle, 246–247
CIC. see Clean intermittent catheterization
(CIC)
Circumferential pharyngeal defects,
pectoralis major flap for, 409
Circumferential skin incision, 624–625
Circumflex iliac artery, superficial, in
abdomen, 82
Circumflex scapular artery, 433–434, 444
in chest, 80–81
in latissimus dorsi flap, 447f, 448
Circumflex scapular vessels, in chest, 80
Cisterna chyli, 40–42
CLA. see Central longitudinal artery (CLA)
Clamps, for microsurgery, 314
Clavicular artery, in pectoralis major flap,
397
Clavicular head, of pectoralis major
muscle
flap harvest in, 404
as functional muscle transfer, 406
Clavicular head osteomusculocutaneous
flap, 407
Claw deformity, prevention of, 628
Clean intermittent catheterization (CIC),
287
“Clever muscles”, 771
Clinical practice committee (CPC),
reconstructive transplantation
program and, e207
Clinical status, of patient, for patient-
centered decision-making, 357–358
Closing pressure, 314
of clamp, in microsurgery, 314
CMV. see Cytomegalovirus
Coaptation devices, for vessels, 313–314
Cold preservation, in peripheral nerve
allotransplantation, 782–783
Collagen nanofibrous scaffolds, e29–e30
Combined flaps, e4–e7
chimeric, e6–e7, e6f
perforator-based, e6
conjoined, e5, e6f
branch-based, e5
perforator-based, e5
role of, 12–13, 13f
Combined SCIP flap-iliac bone
osteocutaneous flap, 485f
Combined SCIP-anterolateral thigh (ALT)
flap, 484–485, 484f
Complex facial nerve, in head and neck, 61
Complications, avoiding, 323–332
in defects, 324–325
in donor flaps, 325–326
failure of
execution and, 326–329
planning and, 323–326
postoperative care and, 329–331
in patients, 323–324
size mismatch and, 328
vascular grafting and, 328–329
Composite, full-thickness, in abdominal wall
reconstruction, 218–219
Composite flap, 658, 658f–659f
in elbow and proximal forearm soft tissue
defect reconstruction, 237–238
pattern, 664
Composite iliac and internal oblique flap,
for mandibular defect, 474b, 474f
Composite tissue allograft, rejection of
nerves in, 788f
Composite tissue allotransplantation,
770
Composition, of donor flap, avoiding
complications in, 325
Compound flaps, 12
Compromised flap, 335–345
Computed tomography angiography (CTA),
e11
in breast reconstruction, 185, 185f,
e19–e20, e20f
preoperative planning with, e19–e21
Computer-assisted design (CAD) software,
e11, e12f–e13f
Conduit
jejunum as, e118, e119f, e131b, e131f
diversionary, for swallowing, e123–e124,
e124f
nerve, 788–792, 789t–791t, 792f, 793t
Congenital defects, as indication for face
transplantation, 742
Congenital myo rhabdosarcoma, free
musculocutaneous latissimus dorsi
transfer for, 462b, 462f
Conjoined flaps, e5, e6f
branch-based, e5
perforator-based, e5

Index
803
Continuous suturing, for vessel, 316, 317f
Contracture
of hand, neurosensory fasciocutaneous
ELAF for, 524.e3b, 524.e3f
release, in traumatic reconstruction, 265
Contralateral foot, e182
Conventional latissimus dorsi muscle, 648
Conventional thin flap, e63–e64, e64f
Corticocancellous block, 643
Costomyocutaneous flap, 404–405, 405f
pedicled, 400
Coupler device, for vessel, 313
Coupler technique, for vessels, 313
CPC. see Clinical practice committee
Cranial reconstruction, scapular flap for,
443
Craniofacial defects, as indication for face
transplantation, 742
Craniofacial microvascular reconstruction,
138–142
aesthetic subunit appearance and,
138–139
bone and soft tissue support for, 140
defect boundaries and, 139–140
secondary revisions and, 141–142
soft tissue volume for, 140–141
timing for, 141
tissue requirements for, 140
ulnar forearm flap, 145–147
Cross finger flap, 494–497
anesthetic considerations for, 496
for DIP joint flexion crease ring finger
defect, 496b, 496f
flap anatomy of, 494–495
flap components of, 495
flap design of, 495
flap dimensions of, 495
flap innervation of, 495
flap markings of, 495–496
flap modification of, 497
handling of, 496
outcomes of, 497
preoperative preparation of, 495
technique of harvest in, 496
venous drainage of, 495
volar and dorsal digit reconstruction, 229,
230f
Cross-facial nerve grafting (CFNG), for
facial paralysis, 162, 169–173,
169f–170f
CT angiography, in abdominal wall
reconstruction, 220
CTA. see Computed tomography
angiography (CTA)
Cutaneous defects, pectoralis major flap for,
409
Cutaneous flap, and soft tissue coverage, 6
Cutaneous nerves
of arm, 112f
in leg, 119–120
Cutaneous perforators
from deep fascia, 729f
for pectoralis major flap, 398
Cutaneous tendon graft
Achilles tendon and soft tissue defect
reconstructed with, 646b
of medial femoral condyle, 642
Cutaneous veins, of forearm, 110f
Cystoplasty, e30
Cytomegalovirus, in hand and upper
extremity transplantation, 754
D
DCIA. see Deep circumflex iliac artery
(DCIA)
DCIA-based iliac crest flap, and internal
oblique flap, maxillary reconstruction
using, 160b
DCIV. see Deep circumflex iliac vein (DCIV)
Debridement, in lower extremity
reconstruction, 257–258
Debulking, of previously used flap, 730,
735b, 735f
Decellularization, in tissue engineering, e27
Deep circumflex iliac artery (DCIA), 465,
e103, e105
flap
for craniofacial reconstruction,
151–152, 153f–156f
for reconstruction, 143–144
Deep circumflex iliac vein (DCIV),
465–466
Deep femoral artery
branching pattern of, 120f
collateral pathways between superficial
femoral artery and, 118f
thigh and, 116–119
Deep inferior epigastric artery (DIEA), e20
flap, 4
Deep inferior epigastric artery perforator
(DIEAP) flap, 668–686, 668f
anatomic landmarks, 673, 674f
anatomy of, 669–672
anesthetic considerations, 675
arterial supply of, 669–670
branching pattern of, 669, 669f
in breast reconstruction, 187–190,
188f–190f
components of, 672–673
design of, 673–675
differences in design of, 674–675
dimensions of, 675
donor site closure and management of,
679
expected outcomes, 682
general thoughts in design of, 673–674
harvest, 675–677, 677b, 677f–679f
innervation of, 671–672, 672t
long-term outcomes, 683
lower limb post-traumatic contour defect
reconstructed with, 686.e1b, 686.e1f
markings, 675, 675f
modification/handling, 677–679
musculocutaneous perforators from, 670,
670b
outcomes, 682–683
patient positioning, 675
post-mastectomy and radiation breast
defect underwent delayed
reconstruction with, 684b, 684f
postoperative care, 682
preoperative preparation in, 673, 674f
sensory innervation of, 672, 672f
special considerations in design of, 674
tips to optimize outcomes and avoid
complications of, 679–680
untoward outcomes, 682
usage, 680–682
atypical indications for, 681–682
free flap, 680
pedicled, 680
typical indications for, 680–681
venous drainage of, 670–671
Deep inferior epigastric vein (DIEV), 670
Deep palmar arch, in hand, 111
Deep peroneal nerve
anterior tibial artery and, 124
in foot, 127–128
in leg, 119–120
Deep plantar artery, dorsalis pedis artery
and, 130
Deep temporal fascia, e72–e74
in head and neck, 63
temporoparietal fascia flap with, e80
Deep vein thrombosis, postoperative care
for, 348–350
Deep venous system, outflow vessel and, 136
Defect
avoiding complications in, 324–325
boundaries of, craniofacial microvascular
reconstruction and, 139–140, 139f
Delayed flap, 440
of tensor fascia lata flap, e196
Deltoid branch, in arm, 93–94
Deltopectoral flaps, 1, e87–e97
advantages of, e88
anatomic landmarks of, e88–e89, e89f
anesthetic considerations for, e90
angiosome concept in, e89
arterial supply of, e87–e88
atypical indications for, e93–e94
disadvantages of, e88
donor site of
closure and management of, e93
expected outcomes of, e94
long-term outcomes of, e95
postoperative care for, e94
untoward/unfavorable outcomes of, e95
expanded, e92
flap anatomy in, e87–e97
flap design for, e88–e90
flap dimensions of, e90
flap innervation of, e88
flap markings for, e90, e90f
flap modification/flap handling of,
e91–e93
flap usage in, e93–e94
free microvascular transfer of, e91
island, e91
L-shaped, e91
outcomes of, e94–e95
patient positioning for, e90
pedicled or free, difference in design,
e90
postoperative care for, e94
preoperative preparation for, e88
skin island dimensions of, e90
special considerations in, e89–e90
split, e91
supraclavicular extension of, e92–e93
technical tips to optimize outcomes and
avoid complications in, e93
technique of flap harvest in, e90–e91
two-layered, e91
typical indications for, e93
untoward/unfavorable outcomes of,
e94–e95
venous drainage of, e88
Dendritic cells, e216
Denervated muscle, sensory protection of,
298
Depressor complex, facial paralysis in, 166
Dermatomes, of upper extremity, 101f
Dermoadiposal pattern, flap, 665, 665f
Descending branch, of LCFA, 701
Descending genicular artery (DGA),
636–637, 637f
Desensitization protocols, e211
Detrusor myoplasty, latissimus dorsi muscle
flap and, 285–289
introduction to, 285–288
operative technique for, 288–289, 289b
outcomes of, 289
postoperative considerations in, 289
preoperative considerations in, 288
Devascularized grafts, 3
Dextran, for flap re-exploration, 335

804
Index
DGA. see Descending genicular artery
(DGA)
Diabetic foot, in lower extremity
reconstruction, 256
complications in, 267
indications of, 260–261
outcomes in, 268
Diagonal upper gracilis (DUG) flap, in
breast reconstruction, 197
DIEA. see Deep inferior epigastric artery
(DIEA)
DIEAP. see Deep inferior epigastric artery
perforator (DIEAP) flap
DIEV. see Deep inferior epigastric vein
(DIEV)
Digastric muscle, transfer of, for depressor
restoration, 178–179, 179f
Digital arteries, in hand, 111
Digital nerve reconstruction, posterior
interosseous nerve for, 109–110
DIP joint flexion crease ring finger defect,
cross finger flap for, 496b, 496f
Direct muscle neurotization, for facial
paralysis, 173
Direct pathway, in allorecognition, e211
Discharge care, 353–354
Dissecting scissors, for microsurgery,
312–313
Dissection, of free-style flaps, 730–731, 736b,
736f
Distal femur fracture, 270b, 270f
Distal finger pulp defect, homodigital island
flap for, 504b, 504f
Distal fingertip reconstruction, 227–229,
228f, 230f
transverse and oblique defect, 228–229,
228f
Distal forearm, transplant, technique for,
762, 763f–764f
Distal nerve transfer, for level I injury, of
adult brachial plexus, 247, 248t
Distal revascularization, flow-through flap
for, 517
Distal third full soft tissue with bony defect,
reconstructed with propeller
posterior tibial artery cutaneous-
muscle perforator flap, 728.e4b,
728.e4f
Distal third tibia defect, reconstructed with
pedicled posterior tibial artery
perforator flap and free anterolateral
thigh flap, 728.e5b, 728.e5f
Distal thumb reconstruction, 229, 229f
Distal ulnar artery perforator flap,
505.e1–505.e2
atypical indications for, 505.e2
donor site closure in, 505.e2
for dorso-ulnar hand wound, 505.e2b,
505.e2f
flap anatomy of, 505.e1
flap design of, 505.e1
flap dimensions of, 505.e1
outcomes of, 505.e2
preoperative preparation for, 505.e1
technique of harvest in, 505.e1–505.e2
for thumb distal phalanx defect, 496b,
496f
Distal-based regional flaps, 6
Distally-based hemi-soleus, 584
Distally-based medial soleus muscle flap,
588, 589f
typical indication of, 591
Diversionary conduit, for swallowing,
jejunum flap as, e123–e124, e124f
Donor bone marrow transplantation,
chimerism and, e215–e216
Donor considerations, in face
transplantation, 744
Donor dignity, maintenance of, in
reconstructive transplantation
program, e208
Donor flap, avoiding complications in,
325–326
Donor morbidity, of donor flap, avoiding
complications in, 325
Donor restoration process, in reconstructive
transplantation program, e208, e208f
Donor site
in anteromedial thigh flap
closure and management, 708–709
expected outcomes, 711
long-term outcomes, 712
postoperative care, 711
untoward outcomes, 711
closure and management, 679
for iliac flap, 469f, 471–472
complications, in chest and back
reconstruction, 211
of deltopectoral flaps and internal
mammary artery perforator flap
closure and management of, e93
expected outcomes of, e94
long-term outcomes of, e95
postoperative care for, e94
untoward/unfavorable outcomes of,
e95
of expected outcomes
in fibula flap, 605
of glabrous skin flaps, e184
of external oblique flap
closure and management of, e105
postoperative care for, e105
fibula flap of, 605
geometry of, e62, e63f
of internal oblique flap
closure and management of, e107
postoperative care for, e108
of jejunum flap
closure and management in, e125
outcomes of, e128–e129
long-term outcomes of, 593
of omentum flap
closure and management of, e100
postoperative care for, e100
of pectoralis major flap
expected outcomes of, 410
long-term outcomes of, 410
postoperative care for, 410
untoward outcomes of, 410
of posterior tibial artery perforator flap,
724–725
postoperative care in, 682
of rectus abdominis flap
expected outcomes, 427
long-term outcomes in, 428, 428f
postoperative care for, 427
untoward/unfavorable outcomes in, 427
in selection of flaps, 11–12, 12f
of superior epigastric flap
closure and management of, e102
postoperative care for, e102
of supraclavicular artery flap
closure and management of, 390
long-term outcomes of, 391
postoperative care of, 390
untoward outcomes of, 391
of tensor fascia lata flap, e198–e199
untoward outcomes of, 592–593, 631, 682
in fibula flap, 605
in glabrous skin flaps, e184
“Don’t cut what you don’t see!” rule, 28
Doppler flowmeter, e62
Doppler probe, 692–693
Doppler ultrasonography, in muscle flap
vascularization, 289
Dorsal branch, of anterior interosseous
artery in forearm, 99–100
Dorsal carpal arch, in hand, 111
Dorsal dissection, in flap harvest, 618, 619f
Dorsal foot defect
reconstructed with free TPF flap and skin
graft, e85b, e85f
thin suprafascial anterolateral thigh flap
for, 716.e1b, 716.e1f
Dorsal hand defect reconstruction, 231–235,
233b, 233f–234f, 235b
with free TPF flap and skin graft, e84b,
e84f
Dorsal hand injury, reconstructed with free
TPF flap and skin graft, e82b, e82f
Dorsal hand soft tissue defect, posterior
interosseous artery flap for, 508b, 508f
Dorsal metacarpal artery flap, in volar and
dorsal finger reconstruction, 231,
232f
Dorsal rami cutaneous nerves, in back, 86
Dorsal scapular artery, trapezius flap based
on
advantages of, e141
anatomic landmarks of, e142, e142f
arterial supply of, e137
components of, e141–e142
disadvantages of, e142
donor site closure and management for,
e147
flap anatomy of, e136, e140f
flap design of, e143
flap dimensions of, e144–e145, e144f
flap harvest of, e146
flap usage of, e148–e149
patient positioning in, e145
variation of arterial origin of, e138–e139,
e139f, e141t
venous drainage of, e139–e141
Dorsal venous arch, in lower extremity, 136
Dorsalis pedis artery, 130
anatomy of, 131f
exposure of, 133
flap and, 134
posterior tibialis/medial plantar arteries
and, arterial branches between, 132f
surgical exposure of, 134f
Dorso-ulnar hand wound, distal ulnar
artery perforator flap for, 505.e2b,
505.e2f
Double muscle transfer, free flap, functional
reconstructions, in gracilis flap, 564
Double pedicle lower abdominal flap, 677
Double-barreled fibula osseous, femur
defect reconstructed with, 612.e2b,
612.e2f
Dressings, for flap compromise, 339–340
Drop foot, neuromusculotendinous transfer
for, 289–292
Drop foot sign, 290b, 290f–291f
Drop foot syndrome, 289–291
DUG flap. see Diagonal upper gracilis
(DUG) flap
Duplex ultrasound, in breast reconstruction,
186
E
Ear flap, for nasal reconstruction, 143
EDB. see Extensor digitorum brevis (EDB)
muscle
Education, about reconstructive
transplantation program, e205

Index
805
ELAF. see Extended lateral arm flap (ELAF)
Elbow
adult brachial plexus injury reconstruction
in, 248, 250
anastomoses around, 94, 94t
soft tissue defects of, 518
Elbow defect reconstruction, 235–238, 235b,
237b, 237f–240f
Electrodiagnosis, in adult brachial plexus
injury, 245–246
Electrophysiological studies, in facial
paralysis, 166–167
Electrostimulation, for
neuromusculotendinous transfer,
291b
Endoscopic-assisted harvest, of
temporoparietal fascia flap, e79–e80
End-to-end anastomosis, 315–316, 315f
End-to-side anastomosis, 316–317, 318f
End-to-side nerve transfers, 304–305, 305f
Enlarged flap, for latissimus dorsi flap,
454–455
Enneking Outcome Measurement Scale,
268
Epigastric artery, inferior, in abdomen, 82
Epigastric defects, abdominal wall
reconstruction for, 220t
Epineurial suture, 299, 299f
Epiperineurial suture, 299f–300f, 300
Equipment, for flap re-exploration, 334
Esophageal reconstruction
in anteromedial thigh flap, 710
patients
pectoralis major flap and, 410
supraclavicular artery flap and, 390
pedicled jejunum flap for, e122, e125–
e127, e129, e131b, e131f
Esophagus, reconstruction of, 144–145
Execution, failure of, 326–329
of anastomotic technique, 328
of intraoperative thrombosis, 329
of ischemia reperfusion injury and the
no-reflow phenomenon, 329
of pedicle tension and torsion, 327–328,
328f
size mismatch and, 328, 328f
of surgeon, 326–327, 326b
of vascular grafting, 328–329
of vessel preparation, 327
Expanded deltopectoral flap, e92
Expanded skin island, of tensor fascia lata
flap, e196
Expected outcomes, in toe flaps, 630–631
Extended arc flap, of rotation pedicled,
660
Extended arc of rotation, in deltopectoral
flaps, e92
Extended flap
in deltopectoral flaps, e92
for latissimus dorsi flap, 455
in posterior tibial artery perforator flap,
723, 723f
Extended free parascapular flap, for large
leg soft tissue defect, 445.e1b, 445.e1f
Extended lateral arm flap (ELAF), 511. See
also Lateral arm flap
fasciocutaneous, 524.e2b, 524.e2f
free, 518–519, 522b, 522f
neurosensory, 524.e3b, 524.e3f
pedicled, 518
technique of flap harvest in, 515, 516f
Extended latissimus dorsi flap
for reconstruction, 459b, 459f
without additional implant, 461b, 461f
Extended pedicle flap, of pectoralis major
flap, 406–407
Extended scapular flap
for ankle soft tissue defect, 445.e2b,
445.e2f
for neck contracture release, 445.e3b,
445.e3f
Extended skin island, in pectoralis major
flap, 407
Extended transverse upper gracilis flap,
568.e5b, 568.e5f
Extended trapezius myocutaneous flap,
e146–e147
Extensor digitorum brevis (EDB) muscle,
551–553
anesthetic considerations for, 552
arterial and venous supply of, 551
donor site closure and management of,
553
for dorsal foot defect, 556.e2b, 556.e2f
flap anatomy of, 551–552, 551f
flap components of, 552
flap design of, 552
flap dimensions of, 552
flap handling of, 553
flap innervation of, 552
flap markings of, 552, 552f
flap modification of, 553
flap usage of, 553
free flap, 553
pedicled, 553
outcomes of, 553
patient positioning for, 552
postoperative care for, 553
preoperative preparation for, 552
special instruments for, 553
technical tips to optimize outcomes and
avoid complications for, 553
technique of flap harvest in, 552–553,
553f
venous drainage of, 552
Extensor tendons, in hand, 109–110
External compression, for flap compromise,
339–340, 340f
External Doppler, 351–352
External fixator, comminuted compound
fracture of leg, immobilized with,
595.e2b, 595.e2f
“External laryngeal nerve”, 771
External oblique fascia, for Achilles tendon
and soft tissue defect, 487
External oblique flap, e103
advantages for, e103
anatomic landmarks of, e103
arterial and venous supply of, e103
atypical indications for, e105
bone dimensions of, e104
disadvantages for, e103
flap anatomy in, e103
flap components in, e103
flap design in, e103–e104, e104f
flap innervation in, e103
flap markings for, e104
flap modification/flap handling in,
e105
flap usage of, e105
muscle dimensions of, e104
outcomes of, e105
patient positioning in, e104
pedicled or free, difference in design,
e104
postoperative care for, e105
preoperative preparation for, e103–e105
skin island dimensions of, e104
special considerations in, e104
technique of flap harvest in, e104–e105
typical indications for, e105
venous drainage of, e103
External oblique reconstruction
in anterolateral chest, 207, 207f
in posterior torso, 210
Extraluminal factors, of flap failure, 359
Extraplexus nerve transfer, for level I injury,
of adult brachial plexus, 247
Extratemporal portion, of facial paralysis,
163–165, 164t
Extrinsic factor, of flap compromise,
337–340
dressing, bandages, and external
compression in, 339–340, 340f
hypovascularization in, 339
implanted materials in, 337–338, 337f
skin closure and tunneling in, 338–339,
338f–339f
wound bed anatomy in, 337
Eye, facial paralysis in
orbicularis oculi muscle (OOM)
substitution for, 175–176
reanimation for, 170–171, 171f
temporalis for, 176
static procedures for, 174–175
Eye sphincter, facial paralysis in, 165
substitution of, frontalis for, 175, 176f
F
Face
frontalis muscles in, 63–64
procurement, e208f
skin of, 61
soft tissue defects on, trapezius flap for,
e143
Face transplantation, 739–753, e204
complications of, 746
first, 739
future indications of, 742–743
immune suppression of, 740–741
indications of, 741–743
in military, 742
outcomes of, 746–748
aesthetic, 747–748
discussion, 748
functional, 747
medical, 746, 747f
social, 748
postoperative considerations of, 745
preoperative considerations of,
743–744
summary of immunosuppressive regimen
for, 740t
surgical technique of, 744–745
Facial artery
in cervicofacial flap, 383
in head and neck, 64–69, 65f, 68f
Facial artery musculomucosal (FAMM) flap,
64–68, 373–375
anatomic landmarks of, 373, 374b,
374f
anatomy of, 373
arterial and venous supply of, 373
design of, 373
dimensions of, 375
donor site closure and management of,
375
expected outcomes of, 375
facial artery in, 373
flap designs for particular types of
reconstructions, 374–375
for gracilis muscle, 280
innervation of, 373
postoperative care for, 375
technique of flap harvest of, 375
usage of, 375
venous drainage of, 373

806
Index
Facial defect
large composite, reconstructed with free
VRAM flap, 429b, 429f
lateral composite, skull base and,
reconstructed with free VRAM flap,
430b, 430f
Facial deformity, severe
resulting from animal attack
reconstructed with full face allograft,
751b, 751f
resulting from burn injury reconstructed
with full face allograft, 749b–750b,
749f–750f
Facial expression, muscles of, 63–64, 64f
Facial muscles, reinnervation of, 747
Facial musculature, anatomy of, 63–64
Facial nerve, in head and neck, 72f–73f,
73–74
Facial paralysis (FP), 162, 162f
additional tests for, 168
behavioral evaluation for, 167, 167t–168t
clinical presentation of, 165–166
discussion, 180–181, 181f
electrophysiological studies in, 166–167
etiology of, 163–165
lesion location and, 163–165, 164t
extratemporal portion of, 163–165
imaging studies in, 166
injury and impairment in, mechanism of,
165
intracranial portion of, 163
intratemporal portion of, 163
in lower face, 166
microsurgical management strategies of,
168–173
acute post-traumatic, 168–169
late, 169–173
in middle face, 165–166
patient examination for, 166–168
physical examination in, 166
postoperative rehabilitation for, 180
revisions for, 179–180
speech evaluation for, 168, 168t
surgical techniques for, 173–179
cross-facial nerve grafting in, 173
direct muscle neurotization in, 173
in eye, 174–176
in smile, 176–179
in tongue movement and bulk, 179
unilateral, free functioning segmental
gracilis muscle transplantation for,
568.e2b, 568.e2f
in upper face, 165
Facial reanimation, 162–182
lower, 172–173, 172f–173f
middle, 171–172, 172f
segmental functional gracilis flap for,
562–563, 564f, 568.e3b, 568.e3f
upper, 170–171, 171f
Facial reconstruction, reconstruction
elevator and, 2
Facial skeleton, anatomy of, 61–63
Facial venous system, in head and neck, 71
Failed free flap, 357
with repeat microvascular procedure,
365.e1b, 365.e1f
without repeat microvascular procedure,
365.e1b, 365.e1f
FAMM. see Facial artery musculomucosal
(FAMM) flap
Fascia, 717
dimensions, of tensor fascia lata flap,
e194
for reconstruction, of free-style flap, 732
Fascial component, use of, in anterolateral
thigh flap, 707
Fascial feeders, 718
Fascial flap
in lateral arm flap, 516
in posterior tibial artery perforator flap,
723
in scapular flap, 441
in tensor fascia lata flap, e197
Fascial plexus, in survival of fasciocutaneous
flaps, e2
Fascial radial forearm flap, 532
Fascicles, 295, 295f
Fasciocutaneous flaps, e1–2
in elbow and proximal forearm soft tissue
defect reconstruction, 238
in gluteus flap, e169f
in lateral arm flap, 516–517
Fat
in obese patients, in anteromedial thigh
flap, 709
pad, in head and neck, 63
Fat grafting
breast reconstruction with, 37b–38b,
37f–38f
in percutaneous aponeurotomy and
lipofilling, 32–33
interstitial fluid pressure in, 32–33, 33f
recipient site vascularity in, 33
surface area-to-volume ratio in, 32
techniques for, 33–35
fat delivery in, 34–35, 34f, 37f
fat harvest in, 33, 34f
fat processing in, 33–34, 34f
FDB. see Flexor digitorum brevis (FDB)
FDMA. see First dorsal metatarsal artery
(FDMA)
Femoral artery
in abdomen, 82
thigh and
deep, 116–119
superficial, 119
Femoral nerve, in thigh, 115
Femur defect reconstructed, with double-
barreled fibula osseous, 612.e2b,
612.e2f
Fenestrated flap, e91
Fibrillations, 297
Fibula, 598–599
for mandible, 607b, 607f–609f
Fibula flap, 596–612, 596f
anesthetic considerations of, 600
donor site closure and management of,
604
flap anatomy of, 596–597
flap design of, 598–599
flap usage of, 604–605
free
for craniofacial reconstruction,
152–153, 158f–159f
mandible reconstruction using,
160b
orbital reconstruction using, 160b
tibia reconstruction with, 611b, 611f
mandible for, 607b, 607f–609f
outcomes of, 605–606
patient positioning of, 599–600
postoperative care of, 605
preoperative preparation of, 597–598
technical tips to optimize outcomes and
avoid complications of, 604
technique of flap harvest, 600–604
Fibula harvest, step by step, 601f
Fibula osteocutaneous flap, 258
Fibula osteoseptocutaneous flap, 597, 603f
Fine trimming, of adventitia, 310–311
Finger, adult brachial plexus injury
reconstruction in, 248–249, 248t
Finger soft tissue reconstruction, 227–231,
227b
distal fingertip, 227–229, 228f, 230f
transverse and oblique defect, 228–229,
228f
distal thumb, 229, 229f
fingertip and distal finger, 229–231,
230f–232f
volar and dorsal digit, 229, 230f
volar and dorsal finger, 231, 232f
Fingertip and distal finger reconstruction,
229–231
free toe pulp flap, 230–231, 232f
homodigital and heterodigital flaps in,
229–230, 230f–231f
thoraco-epigastric flap, 230, 231f
First dorsal metacarpal artery flap, 492–494
for defect over IP joint, 493b, 493f
donor site closure in, 494
flap anatomy of, 492
flap components of, 492
flap design of, 492–493
flap dimensions of, 493
flap innervation of, 492
outcomes in, 494
postoperative care for, 494
technique of harvest in, 493–494
for thumb distal phalanx defect, 494b,
494f
venous drainage in, 492
First dorsal metatarsal artery (FDMA), 614
dorsalis pedis artery and, 130
in foot, 132–133
First plantar metatarsal artery (FPMA), 614
in foot, 131
in leg, 131–132
First web flap, 628f
First web space soft tissue defect
reconstruction, 235, 236f
Fitness, for anesthesia, 324
FK-506 (Tacrolimus), 783
Flap anatomy
in lateral thoracic region, 649–652
of medial femoral condyle, 636–639
Flap components
of fibula flap, 597
of great toe pulp flap and second toe
pulp flap, e178
of medial plantar flap, e182
of soleus flap, 583–584
Flap compromise, 335–345
extrinsic factor of, 337–340
dressing, bandages, and external
compression in, 339–340, 340f
hypovascularization in, 339
implanted materials in, 337–338, 337f
skin closure and tunneling in, 338–339,
338f–339f
wound bed anatomy in, 337
intrinsic factors of, 340–343
arterial spasm in, 340–341
kinking and twisting in, 341, 342f
vascular thrombosis in, 341–343
Flap delay, 19, 440
Flap design
of combined toe transfer, 625–626
of fibula flap, 598–599
of great toe pulp flap and second toe
pulp flap, e178–e179, e179f
of great toe transfer, 616–617
of lateral thoracic region, 653–655,
654f–655f
of medial femoral condyle, 639–641,
640f
of medial plantar flap, e182
of phalloplasty, e47, e48f–e49f

Index
807
of second toe transfer, 623, 623f
of soleus flap, 584–586, 586f
of supraclavicular artery flap, 389, 389f
of temporoparietal fascia flap, e77–e78,
e77f
of trimmed great toe transfer, 619–620
Flap dimensions
of combined toe transfer, 627
of deltopectoral flaps and internal
mammary artery perforator flap, e90
of fibula flap, 599
of great toe pulp flap and second toe
pulp flap, e179
of great toe transfer, 617
of lateral thoracic region, 655
of medial femoral condyle, 641
of medial plantar flap, e182
of second toe transfer, 623–624
of soleus flap, 586
of trimmed great toe transfer, 620
Flap failure
causes of, 359b
extraluminal factors, 359
reconstructive options for, 357–366
root cause analysis of, 358–359
systemic factors, 358
Flap harvest
great toe, 619f
process of, 657f
technique
for cervicofacial flap, 385–386
for combined toe transfer, 627
for FAMM flap, 375
for fibula flap, 600–604
for forehead flap, 371–372
for gluteus flap, e162–e166, e163f–e168f
for great toe pulp flap and second toe
pulp flap, e180
for great toe transfer, 618–619
for groin and SCIP flap, 479f, 482–483,
482f–484f
for iliac flap, 468–471, 469f
for lateral thoracic region, 656–657
for latissimus dorsi flap, 452–454, 453f
for medial femoral condyle, 641
for medial plantar flap, e183
for nasolabial flap, 381–382
for scapular and parascapular flaps,
439–440, 439f
for second toe transfer, 624
for second toe wrap-around, 624–625
for soleus flap, 588–589
for third toe transfer, 625
for trapezius flap, e145–e146, e146f
for trimmed great toe transfer, 620
for vascularized joint transfer, 627, 633b,
633f
for wrap-around technique, 621
Flap innervation
of fibula flap, 597
of glabrous skin flaps, e178
of groin flap, 480
of iliac flap, 466
of latissimus dorsi flap, 447f, 449
of medial femoral condyle, 639
of scapular and parascapular flaps, 435
of soleus flap, 583, 584f–585f
of trapezius flap, e141
Flap markings
of combined toe transfer, 627
of fibula flap, 598f, 599
of great toe pulp flap and second toe
pulp flap, e178
of great toe transfer, 617–618, 618f
of groin and SCIP flap, 481, 482f
of lateral thoracic region, 655
of medial femoral condyle, 641
of medial plantar flap, e182, e183f
of second toe transfer, 623–624
of soleus flap, 586–588
of supraclavicular artery flap, 389
of trimmed great toe transfer, 620
Flap modifications, in glabrous skin flaps,
e180
Flap monitoring, 351–353
cellular and wireless devices for, 353
clinical assessment for, 351
external Doppler for, 351–352
internal Doppler for, 352
laser Doppler for, 352
near infrared angiography for, 352
photography for, 352
pulse oximetry for, 352
surface temperature for, 352–353
Flap reconstruction, in abdominal wall, 218
Flap re-exploration, 333–347
approach to a compromised flap and,
335–345
aspirin for, 334
compressing the flap in, 344
dextran for, 335
Fogarty catheters in, use of, 344
heparin for, 334–335
new recipient vessels in, 344–345
opening the anastomosis in, 344
preparing for, 334
problem, recognition of, 333–334
specific steps in, 343–345
stripping the pedicle in, 343–344
thrombolytics for, 335
vascular grafts in, use of, 344
vasodilators for, 335
vessel dilation in, 344
Flap salvage, 333–347
Flap selection, considerations for, 184–185
Flap thinning, 706
Flap usage
of fibula flap, 604–605
of great toe pulp flap and second toe
pulp flap, e181
of lateral thoracic region, 663–665
of medial plantar flap, e183
of soleus flap, 591–592
Flap vessels, management of, 311–312
Flaps
anterior tibial artery for, 134
anterolateral thigh, 11
arterial anatomy of, 636–638
arterial supply of, 581–583, 582f, 596–597
in thoracic region, 649–651
atypical indications for, 591–592, 605,
644–645, 665, 666f
axial, e1
basic types, comparison of attributes for,
6.e1t
brief history of, e1–e2, e1f
chimeric, e6–e7, e6f
with skin, bone, and muscle, 642
classification of, e1–10, e9b
complete, e8t
Cormack and Lamberty, e2, e3f
Mathes and Nahai, e2, e3f
Nakajima, e2–e3, e3f
Serafin, e4, e6f
Taylor’s “angiosome” concept-based,
e3–e4, e4f
combined, e4–e7
role of, 13f
components, in thoracic region,
652–653
composite/chimeric pattern, 658,
658f–659f, 664f
compound, 12
concept of, 652f
conjoined, e5, e6f
craniofacial microvascular reconstruction
and
denervated muscle, 140–141
homogeneity of, 139
latissimus dorsi, 140–141
cutaneous, 6
DCIA, for mandible reconstruction,
143–144
deep inferior epigastric artery perforator
(DIEAP), 668–686, 668f
distal-based regional, 6
dorsalis pedis artery for, 134
ear, for nasal reconstruction, 143
expansion of width of, 589
extended arc of rotation pedicled, 660
extension of length of, 589
facial artery musculomucosal, 64–68
fasciocutaneous, e1–2
flexor carpi ulnaris as, 98–99
flow-through, 657
folding of, e67–e68
free, 591, 643–644, 643f, 663–664
future considerations for, 13–14
geometry of, e62
gluteus, e157–e175
groin, 478–490, 478f
ileocolon, for voice reconstruction, 145,
146f
ileo-ileocecal, for voice reconstruction,
145, 146f
iliac, 464–477, 464f
inclusion of muscle in, e1
innervation of, 652
jejunum
for esophageal reconstruction, 145
for voice reconstruction, 145, 145f
latissimus dorsi, 446–463, 446f
microdissection of, e65–e67, e65f–e66f
modification/handling, 589, 603–604,
603f, 642, 657–660
molding of, e62–e63
muscle, 6, e4
Mathes and Nahai classification of, e4,
e5f
Taylor classification of, e4, e5f
muscle perforator, 11, 11f
muscle-sparing pattern, 660
neurocutaneous, e4
pedicled, 6
perforator, e7
perforator propeller, 6
perforator-based, 657
perfusion, 655
peroneal artery and, 134
planning of, e64f
prefabrication of, 18–20
prelamination of, 20–23
random skin, e1
salvaging of, 345, 345f
scapular and parascapular, 432–445,
432f
secondary characteristics of, e7, e7f
selection of, considerations in, 6–15, 14b
donor site as, 11–12, 12f
recipient site as, 6–11, 11f
role of combined flaps as, 12–13
sensate, 658, 658f
shaping of, e62–e63
special instruments, 660
splitting of, e67–e68
submental, 69
superficial circumflex iliac artery
perforator, 478–490, 478f

808
Index
superficial inferior epigastric artery
perforator, 668–686, 668f
superficial temporal artery as, 69–70
superior thyroid artery as, 69
supratrochlear artery as, 71
tailoring of, e62–71
thinning of, e62–71
three-dimensional description of, e63f
trapezius, e134–e156, e134f
tubed, 660, 661f
typical indications for use of, 591,
604–605, 643, 664–665
usage and outcomes of, 643–645
use of, 604–605
various composition/split cutaneous, 658,
659f–660f
vascularized bone, e4
vascularized composite allotransplant
classification and, e7–e8
venous drainage of, 583, 597, 639
in thoracic region, 651–652
workhorse, 6, 7f–8f
Fleur-de-lis incision, for latissimus dorsi flap,
454
Flexor carpi ulnaris, in forearm, 98–99
Flexor carpi ulnaris flap (FCU), in elbow
and proximal forearm soft tissue
defect reconstruction, 235
Flexor digitorum brevis (FDB), 549–551
anesthetic considerations for, 550
arterial and venous supply of, 549
donor site closure and management of,
551
flap anatomy of, 549–550
flap components of, 550
flap design of, 550
flap dimensions of, 550
flap handling of, 550–551
flap innervation of, 549–550
flap markings of, 550, 550f
flap modification in, 550–551
flap usage of, 551
outcomes of, 551
patient positioning for, 550
for plantar heel defect, 556.e1b, 556.e1f
postoperative care for, 551
preoperative preparation for, 550
special instruments for, 551
technical tips to optimize outcomes and
avoid complications for, 551
technique of flap harvest in, 550, 550.e1f
venous drainage of, 549
Flow-through anastomosis, 320
Flow-through flap, 657
in anterolateral thigh flap, 707
for distal revascularization, 517
in posterior tibial artery perforator flap,
722
Flow-through radial forearm flap, 532, 538b,
538f
Fluorescent angiography, in breast
reconstruction, 186–187, 186f
Fogarty catheters, use of, in flap
re-exploration, 344
Foot
cutaneous nerves and superficial veins of,
e177f
dorsalis pedis artery in, 130
nerves of, 127–128
plantar vascular system in, 130–132
soft tissue coverage of, latissimus dorsi
flap for, 463.e1b, 463.e1f
Foot reconstruction, 263–264, 264f
Force-extension relation, of skeletal muscle,
276f
Forearm, 96–98
branches of ulnar artery in, 99–100
cross-sectional anatomy of, 95f
cutaneous nerves of, 109
distal
exposure of radial artery in, 104–106
exposure of ulnar artery in, 100–101
dorsal compartment of, 97
median, ulnar, and radial nerves in,
100f
median nerve in, 106
mobile wad of, 98
musculocutaneous nerve in, 106–107
radial artery in, 101–104
radial nerve in, 107–109
superficial veins and cutaneous nerves of,
110f
ulnar artery in, 98–99
ulnar nerve in, 106
venous anatomy of, 111–113
volar compartment of, 96–97, 96f–98f
Forefoot defect, reconstructed with pedicled
free-style flap, 736b, 736f
Forehead, reconstruction of, 142
using ulnar free flap, 139f, 158b
Forehead flap, 1, 367f, 368–373
anatomic landmarks for, 369–371, 370b,
370f
anatomy of, 368
arterial supply of, 368
design of, 369–371
dimensions of, 371
donor site closure and management for,
372
expected outcomes for, 372–373
innervation of, 369, 369f
postoperative care for, 372–373
supratrochlear artery in, 368
technique of flap harvest for, 371–372
usage of, 372
venous drainage for, 368
“Four flapper”, 696–697
FP. see Facial paralysis (FP)
FPMA. see First plantar metatarsal artery
(FPMA)
Free anterolateral thigh flap
buccal mucosa defect and soft tissue
augmentation of neck with, 716.e3b,
716.e3f
distal third tibia defect reconstructed
with, 728.e5b, 728.e5f
orbital, nasal, and maxillary defect
reconstructed with, 714b, 714f
right lower extremity tibia-fibula fracture
with exposed hardware reconstructed
with, 713b, 713f
Free fibula osseus flaps
bilateral, pelvic ring reconstruction with,
612.e1b, 612.e1f
tibia reconstruction with, 609b, 610f
Free fibular phalloplasty, e51–e52, e51b, e51f
Free flaps
in abdominal wall reconstruction, 222,
224f–225f
in anteromedial thigh flap, 709
buccal mucosa defect reconstructed
with, 716.e2b, 716.e2f
breast reconstruction, in gracilis flap, 564
for craniofacial reconstruction, 145–153
anterolateral thigh flap, 148–149,
149f–150f
deep circumflex iliac artery flap,
151–152, 153f–156f
fibula flap, 152–153, 158f–159f
groin flap, 149–151, 151f–152f
ulnar forearm flap, 145–147, 146f, 148f
for defects of the left mandibular and oral
floor, e69b, e69f–e70f
design of
computed tomography angiography
and, e20–e21, e21f
indocyanine green angiography and,
e17–e18
functional reconstruction, in gracilis flap,
564
for gluteus flap, e162–e163, e168, e170
for groin and SCIP flap, 486
for iliac flap, 472
jejunum flap as
harvest of, e120–e122, e120f–e122f
indications for, e125
jejunum-mesenteric, e123
for latissimus dorsi flap, 451
usage of, 456–457
for lower lip reconstruction, 279–280
pectoralis major flap as, 409
perfusion, and indocyanine green
angiography, e16–e17, e17f
reconstruction, considerations for, 204
in rectus abdominis flap, 424
atypical indications of, 427
indications of, 426
typical indications of, 426
in scapular and parascapular flaps, 442
soft tissue coverage, in gracilis flap, 564
surgery, precautions for, e68–e69
in temporoparietal fascia flap, e80
dorsal foot defect reconstructed with,
e85b, e85f
dorsal hand defect reconstructed with,
e84b, e84f
dorsal hand injury reconstructed with,
e82b, e82f
in tensor fascia lata flap, e198
anterior forearm soft tissue defect
reconstructed with, e201b, e201f
for trapezius flap
based on the DSA, e153b, e153f
myocutaneous, e149
usage, of posterior tibial artery perforator,
724
Free functioning gracilis flap, 566b–567b,
566f–567f
Free functioning segmental gracilis flap,
568.e2b, 568.e2f
Free functioning split gracilis muscle flap,
568.e1b, 568.e1f
Free gastrocnemius flap, 578b, 578f
Free groin flaps, 1, 4
flap harvest of, 483, 483f
for soft tissue deficit, 487, 490.e2b,
490.e2f
Free lateral arm flap, 518–519, 523b, 523f
Free microvascular transfer
of deltopectoral flaps, e91
of iliac flap, 472
of latissimus dorsi flap, for distant
reconstruction, 454, 457
of rectus abdominis flap, 425–426
of TFL muscle flap, e195
Free muscle flaps, robotic harvest of,
e37–e38
Free musculocutaneous latissimus dorsi
transfer, 462b, 462f
Free pectoralis major muscle, 405
Free radial forearm flap, 533, 536b, 536f,
538b, 538f, 539.e1b, 539.e1f
tubed, 537b, 537f
Free soleus muscle flap, 589
Free tissue flaps, in phalloplasty, e47
Free toe pulp flap, in fingertip and distal
finger reconstruction, 230–231, 232f
Flaps (Continued)

Index
809
Free TRAM flap, in breast reconstruction,
190–191, 190f–192f, 191t
Free-style flaps, 4, 729–738
anatomic landmarks of, 731
anatomy of, 730
bone in, 732
bulk in, 732
components of, 730–731
design, 731
fascia, for reconstruction of, 732
general thoughts about design of, 731
harvest, 730–732
left upper back defect reconstructed with,
from right back, 737b, 737f
from limb, 731
modification/handling, 732
multiple skin islands in, 732
muscle, at recipient site in, 732
outcomes, 733
pedicled
forefoot defect reconstructed with,
736b, 736f
left neck defect reconstructed with,
734b, 734f
postoperative care, 733
reconstruction, of defects in, 732–733
“recycling” in, 732
right foot defect reconstructed with, from
previous transferred anterolateral
thigh flap, 735b, 735f
special considerations in design of, 731
usage, 732–733
Frontalis muscle
for eye sphincter substitution, 175, 176f
of face, 63–64
facial paralysis in, 165
Frostbite, severe, of foot, neurosensory
fasciocutaneous ELAF for, 524.e3b,
524.e3f
Full chimerism, e215
Full face allograft
animal attack reconstructed with, 751b,
751f
burn injury reconstructed with, 749b–
750b, 749f–750f
Full-thickness composite, in abdominal wall
reconstruction, 218–219
Functional lower lip reconstruction,
innervated gracilis muscle flap and,
276–282
complications of, 281
indications of, 280
outcomes of, 281
preoperative considerations of, 276–280
techniques for, 280–281
Functional muscle, of tensor fascia lata flap,
e196
Functional muscle transfers, 275–294
abdominal wall reconstruction in,
282–285
clavicular head, of pectoralis major
muscle as, 406
detrusor myoplasty, 285–289
in gastrocnemius flap, 576
introduction to, 275–276, 276f
lower lip reconstruction in, 276–282
neuromusculotendinous transfer,
289–292
in pectoralis major flap, 409
patients of, postoperative care in,
410
in rectus abdominis flap, 424
trapezius flap and, e147
Functional reconstruction, e62
Functional restoration, in traumatic
reconstruction, 265
Functioning free muscle transplantation
(FFMT), in adult brachial plexus
injury reconstruction, 249
G
Galea aponeurotica, e72–e74
in head and neck, 62–63
Gamma probe, in vascularized groin lymph
node transfer with reverse lymphatic
mapping, 51
GAP. see Gluteal artery perforator (GAP)
flaps
Gastrocnemius flap, 570–580, 570f
anatomic landmarks in, 572, 572f
arterial supply of, 571
chimeric, 576, 576f–577f, 579b, 579f
differences in design of, 572–573
distally based, 575
extension of effective flap length of, 576
flap anatomy of, 571
flap components of, 571–572
flap design of, 572–573
flap dimensions of, 573
flap handling of, 575–576
flap innervation of, 571
flap markings of, 572–573
flap modification of, 575–576
free, 578b, 578f
functional muscle transfer in, 576
general thoughts about flap design of,
572
lateral, 574–575, 575f, 580.e2b, 580.e2f
lateral sural artery perforator, 575
medial, 573–574, 574f, 580.e2b, 580.e2f
medial sural artery perforator, 575
muscle dimensions of, 573
musculocutaneous, 575
myocutaneous, 579b, 579f, 580.e1b, 580.e1f
outcomes of, 578
patient positioning for, 573
postoperative care for, 578
preoperative preparation for, 573
skin island dimensions of, 573
special considerations in, 572
technical tips to optimize outcomes and
avoid complications for, 576–577
technique of flap harvest in, 573–575
use of, 577–578
in lateral head, 578
in medial head, 577
venous drainage of, 571
Gastrocnemius muscle
lateral, 571
in leg, 119
medial, 571
for neuromusculotendinous transfer, 291
Gastrocnemius musculoadipofascial flap, 576
Gastrocnemius musculocutaneous flap, 575
Gastrocnemius myocutaneous flap, 580.e1b,
580.e1f
Gastrocnemius-propeller myocutaneous flap,
579b, 579f, 580.e1b, 580.e1f
Gelpi retractor, e65, e66f
Gender identity disorder, penile
reconstruction for, 487
General complications, of prolonged
surgery, 330b
Genicular arterial system, Achilles tendon
and soft tissue defect reconstructed
with, 646b
Genicular artery perforator flaps,
descending, medial femoral condyle
and, 636–647, 636f
donor site closure and management of,
642
flap anatomy of, 636–639
flap components of, 639
flap design of, 639–641, 640f
flap usage and outcomes of, 643–645
patient positioning of, 641
postoperative care, 643
preoperative preparation of, 639
technical tips to optimize outcomes and
avoid complications, 642–643
untoward outcomes of, 645
Geniculate artery distal cutaneous branch,
descending, 638
Gigli saw, 589
Glabrous, defined, e176
Glabrous skin flaps, e176–e189, e187b–e188b,
e187f
donor site closure and management of,
e180
great toe pulp flap and second toe pulp
flap, e177–e181
medial plantar flap of, e181–e183
outcomes of, e184
patient positioning of, e179–e180
postoperative care of, e183–e184
regional anatomy of, e176–e177
special instruments of, e180
technical tips to optimize outcomes and
avoid complications of, e181
Glansplasty, e49, e50f
Gluteal artery perforator (GAP) flaps,
687–699, 687f
anatomy of, 688–689
arterial and venous supply of, 688
design, 690–691
dimensions, 691–694
donor site closure and management,
696
expected outcomes, 697
general thoughts about design of,
690–691
long-term outcomes, 697
modification/handling, 696
outcomes, 697
postoperative care for, 697
special considerations in design of,
691
technical tips to optimize outcomes and
avoid complications, 696–697
thigh inferior, breast reconstruction with,
698b, 698f
untoward outcomes, 697, 697t
venous drainage of, 688–689
Gluteal flaps, in breast reconstruction,
195–196, 196f
complications of, 199
Gluteal perforator flaps, advantages of,
e158–e159, e159f
Gluteal thigh flap, e167
Gluteus flap, e157–e175
anatomy of, e157–e158
anesthetic considerations for, e162
components of, e158–e159
design of, e159–e162, e159f–e161f
dimensions of, e161
donor site closure and management of,
e167–e168
flap modification/flap handling of,
e166–e167
outcomes of, e171
patient positioning for, e162
postoperative care for, e170
preoperative preparation for, e159
technical tips for, e168–e170
technique of flap harvest for,
e162–e166
usage of, e170

810
Index
Gluteus maximus muscle
advancement flaps, for sacral defects,
e172b, e172f
anatomy of, e157–e158
muscle flap, e167, e169f
muscle free flap, superior, e162, e164f
musculocutaneous flap
bilateral sliding, e169f
pedicle length of, e159f
musculocutaneous free flap, inferior, e163,
e166f
perforator flaps, advantages, e158–e159
Gold weight, 174, 174f
Gracilis flap, 559–569, 559f, 568b
anatomy of, 559
anesthetic considerations for, 562
arterial anatomy of, 559–560
bilateral functional segmental, 568.e3b,
568.e3f
bilateral transverse upper, 568.e4b, 568.e4f
dominant pedicle in, 560, 560f
donor site closure and management of,
563
extended transverse upper, 568.e5b,
568.e5f
flap components of, 560–561
flap design of, 561
flap dimensions of, 562
flap usage for, 564, 564f
free, 565b, 565f
free functioning gracilis, 566b–567b,
566f–567f
free functioning segmental, 568.e2b,
568.e2f
free functioning split, 568.e1b, 568.e1f
indications of, 564
for lower lip reconstruction, 276–282,
278f
markings of, 561, 561f
minor pedicles in, 560
muscle dimensions of, 562
muscle only, 562, 563f
nerve supply of, 560, 560f–561f
outcomes of, 565
perforator, 563
perforator vessels in, 560
postoperative care for, 564–565
preoperative preparation for, 561
segmental functional, 562–563, 564f
skin island dimensions of, 562, 562f
skin paddle variations, 563
special instruments for, 563
technical tips to optimize outcomes and
avoid complications for, 563–564
technique of flap harvest in, 562–563
transverse gracilis musculocutaneous
(TUG), 563
venous anatomy of, 560
Gracilis muscle, transfer of, for smile
restoration, 176–177, 177f
Gracilis perforator flap, 563
Grafts
bone, 641
craniofacial microvascular
reconstruction and, 140
non-vascularized, craniofacial
microvascular reconstruction and,
140
radius vascularized, anterior
interosseous artery and, 99–100
devascularized, 3
nerve, 300–304
interfascicular, 302–303, 303f
lateral antebrachial cutaneous nerve as,
94–95
nerve transfer and, comparison of, 304t
options, characteristics of suitable
interpositional, 780t–781t
sural, 301, 301f–302f
vascularized, 301, 303–304, 303f
vascular, e32
vein, 320–321, 320f
Graft-versus-host disease (GVHD), 740
immune suppression of, 740–741
Great saphenous vein
anatomy of, 135f
in lower extremity, 135
Great toe pulp flap, e177–e181
anatomy of, e177–e178
arterial supply of, e177
free, e181
preoperative preparation of, e178
typical indications for use of, e181
venous drainage of, e177–e178
Great toe transfer, 616–619, 617f
thumb reconstruction with, 635.e1b,
635.e1f
trimmed, 619–620, 620f
Groin
clinical anatomy and recipient vessel
selection in, 75–88
defect, reconstructed with inferiorly-based
pedicled VRAM flap, 431b, 431f
as donor site, for lymph node transfer, 50
nerve anatomy of, 86
recipient arteries for reconstruction of, 82
surgical exposure of femoral vessels in,
117f
Groin flap, 478–490, 478f, e186b, e186f
anatomy of, 478–480
components of, 480
for craniofacial reconstruction, 149–151,
151f–152f
design of, 481
dimensions of, 481
donor site closure and management of,
485
with external oblique fascia, for Achilles
tendon and soft tissue defect, 487
flap modification/flap handling of,
484–485
outcomes of, 486–487
patient positioning for, 481–482
postoperative care for, 486
preoperative preparation for, 480–481
for soft tissue deficit, 487
technical tips for, 485–486
technique of flap harvest for, 482–483,
482f–483f
usage of, 486
Gross trimming, of adventitia, 310–311
Gustilo IIIB tibia-fibula fracture, 269b,
269f
Guyon’s canal
exposure of ulnar artery in, 100–101,
113.e3b, 113.e3f
hand and, 109
GVHD. see Graft-versus-host disease (GVHD)
H
Hand, 109–110
adult brachial plexus injury reconstruction
in, 250
arterial anatomy of, 108f
deep dissection of dorsum of, 107f
deep palmar arch and princeps pollicis in,
111
pedicled flaps of, 491–510, 491f
radial side of, 105f
superficial dissection of dorsum of,
104f
superficial palmar arch and digital arteries
in, 111
venous anatomy of, 111–113
vessel lumens in, 113t
Hand and upper extremity transplantation
complications in, 764, 765t
definition of, 754
future directions of, 766–768
immunotherapy and, 754–755
indications for, 755
outcomes of, 765–766
postoperative considerations for, 764
preoperative considerations for
cadaver rehearsal in, 756, 758f
ischemia time in, 757
patient screening, 755, 756f
planning, 755–757
rotating surgeons in, 757
team assignments in, 756–757
use or replace existing motors in, 757
surgical technique for
anesthesia considerations in, 759
dissections, 759–760, 760f
donor operation, 757–759, 757f–759f
dressing for, 762
muscle/tendon reconstruction in, 760,
760f
nerve reconstruction in, 760–761
operating room set-up for, 759, 759f
osteosynthesis, 760
revascularization in, 761, 761f
skin closure in, 761–762, 761f
transplant level, specific techniques for
distal forearm, 762, 763f–764f
middle forearm, 762
proximal forearm, 762
transhumeral, 762–764, 765f
Hand defect, medial plantar free flap for
reconstruction of, e183
Hand therapy, 764
Hand transplantation, e204
Hand trauma surgery, and reconstructive
microsurgery, 3
Head and neck, 61–74
arteries and veins of, 66f–67f
defects on, trapezius flap for, e147–e148
external soft tissue defect, reconstruction
of, TFL perforator-based flap for,
e200b, e200f
facial artery in, 64–69
facial nerve in, 73–74
fascia of, 62–63, 63f
flap usage of, 663
free flap usage in, 680
local flaps of, 367–386
of medial femoral condyle, 644
reconstruction of, 138–161. see also
Craniofacial microvascular
reconstruction
in anterolateral thigh flap, 703
in anteromedial thigh flap, 709–710
complications of, 154–155
expert commentary for, 160b–161b
of flap, 664
indications for, 142
outcomes of, 156
postoperative considerations for,
153–154
preoperative considerations for,
138
regions of, for reconstruction, 142–145
esophagus, 144–145
mandible, 143–144
midface, 143
nose, 143
periorbit, 142–143

Index
811
scalp and forehead, 142
tongue, 144
voice, 145
scapular and parascapular flaps for, 442
of soleus flap, 591
submental artery in, 69
superficial temporal artery in, 69–70
superior thyroid artery in, 69
supratrochlear artery in, 71
transverse cervical artery in, 70–71
veins in, 71
Heart valves, e32
Hematomas, in flap compromise, 340
Hemi-tongue defects, in anteromedial thigh
flap, 710
Heparin, for flap re-exploration, 334–335
Hernias, 282, 283f
in chest and back reconstruction, 211
Heterodigital flap, in fingertip and distal
finger reconstruction, 229–231,
230f–231f
Hip reconstruction, pedicled bone flaps for,
472
HLA. see Human leukocyte antigens (HLA)
Homodigital flap, in fingertip and distal
finger reconstruction, 229–231,
230f–231f
Homodigital island flap, 500–505
anesthetic considerations for, 501
for distal finger pulp defect, 504b, 504f
donor site closure of, 504
flap anatomy of, 500–501
flap dimensions of, 501
flap innervation of, 501
flap markings of, 501, 501f
flap modification of, 502
flap usage of, 504
handling of, 502
for index and middle finger distal
amputations, 503b, 503f
indications for the use of, 504
outcomes of, 504–505
patient positioning for, 501
postoperative care for, 504–505
special instruments for, 502
technical tips to optimize outcomes and
avoid complications for, 502–504
technique of flap harvest in, 501–502
venous drainage in, 500–501
Hook-nail deformity, in Moberg flap, 500
Human leukocyte antigens (HLA), e210
Hunter’s canal, superficial femoral artery
and, 119
Hyaluronic acid, e28
Hyperacute rejection, e213
risk of, 745
Hyperbaric oxygen, for second free flap,
363–364
Hyperglycemic control, 350
Hypogastric defects, abdominal wall
reconstruction for, 221t
Hypopharynx, using free jejunum, e126,
e130b, e130f
Hypopharynx defect, carcinoma of,
fasciocutaneous ELAF, 524.e2b, 524.e2f
Hypovascularization, due to systemic factor,
in flap compromise, 339
I
IGAP. see Inferior gluteal artery perforator
(IGAP) flaps
IGL. see Indocyanine green
lymphangiography (IGL)
Ileocolon flap, for voice reconstruction, 145,
146f
Ileo-ileocecal valve flap, for voice
reconstruction, 145, 146f
Iliac bone
flap, for mandibular defect, 475b, 475f
graft based on the DCIA, 485, 485f
multiple segment osteotomies of, 469f,
471
Iliac crest, 464, 466
bone flap, 469f
flap, for mandible reconstruction,
143–144
split, 471
Iliac flap, 464–477, 464f
anatomy of, 465–466
components of, 466
design of, 466–468
dimensions of, 468
donor site closure and management for,
469f, 471–472
flap modification/flap handling of, 471
innervation of, 466
outcomes of, 473
patient positioning for, 468
postoperative care for, 472–473
preoperative preparation for, 466
technical tips for, 472
technique of flap harvest for, 468–471,
469f
without internal oblique, 470
usage of, 472
vascularized, for central mandibular
defect, 474b, 474f
Iliohypogastric nerve, in abdomen and
groin, 86
Ilio-inguinal nerve, in abdomen and groin,
86
Immediate implant placement, e13–e14
Immediate postoperative considerations, for
facial transplantation, 745
Immune tolerance, immune suppression of,
741
Immunologic factors, of chronic rejection,
e213, e214f
Immunologic self-tolerance, e214
Immunology, of nerve allotransplantation,
781–782, 783f
Immunosuppression
facial transplantation of, 740–741
in hand and upper extremity
transplantation, 766
side effects of, 741
systemic, 781
Immunosuppressive agents, in hand and
upper extremity transplantation,
adverse effects of, 754
Immunosuppressive protocol
of French face transplant, e216
in laryngeal allotransplantation, 772
for nerve allotransplantation, 787t
in uterus transplantation, 776–777
Immunosuppressive regimen, summary of,
for face transplantation, 740t
Immunosuppressive therapy, 740
Immunotherapy, and hand and upper
extremity transplantation, 754–755
Implantable penile prosthesis (IPP), e49
Implanted materials, in flap compromise,
337–338, 337f
Inconsistent anatomy, in lateral thoracic
region, 652–653
Indian flap, 368
Indirect pathway, in allorecognition,
e211
Indocyanine green (ICG) angiography, e11
assessment of tissue perfusion with,
e15–e19
free flap design in, e17–e18
free flap perfusion and, e16–e17, e17f
laser-assisted, e15–e16, e16f
lymphatic surgery and, e18–e19, e19f
mastectomy skin flap necrosis and, e18
Indocyanine green lymphangiography
(IGL), for lymphedema, 42, 47–48,
47f
Induced pluripotent stem cells, e27
Induction exercise, in adult brachial plexus
injury reconstruction, 249, 250f
Infections
mesh, in abdominal wall reconstruction,
223–224
opportunistic, 741
Infectious disease, as indication for face
transplantation, 742
Infectious post-debridement, in lower
extremity reconstruction, 256
Inferior epigastric artery, in abdomen, 82
Inferior gluteal artery (IGA), 688
of gluteus flap, e157–e158
Inferior gluteal artery perforator (IGAP)
flaps, 196, 197f, 687–699, 687f
anatomic landmarks, 690, 691f
anesthetic considerations in, 694
arterial and venous supply of, 688, 689f
bilateral breast reconstruction with,
699.e3b, 699.e3f
components, 689–690, 690t
dimensions, 692–694, 693f
expected outcomes, 697
free, e162–e163, e165f
general thoughts about design of,
690–691, 692f
harvest, 694–696, 695f
innervation, 689
long-term outcomes, 697
outcomes, 697
patient positioning, 694
postoperative care for, 697
preoperative preparation in, 690
typical indications for use of, 697
untoward outcomes, 697, 697t
usage, 697
venous drainage of, 689
Inferior gluteus maximus musculocutaneous
free flap, e163, e166f
Inferior ulnar collateral artery, in arm, 94
Infraclavicular brachial plexus, exploration
of, 246–247, 246f
Infraorbital nerve, in facial skeleton, 61–62
Initial induction period, in
immunosuppressive protocol, for
uterus transplantation, 777
Initial inspection, for flap compromise,
336
Initial temporary vascular insufficiency, in
lateral thoracic region, 653
Innervated flap, in anterolateral thigh flap,
707
“Innominate” branch, 708
Innominate fascia, e72–e74
Insetting, flap/graft, e14
Institutional review boards (IRB),
reconstructive transplantation
program and, e207
Intercostal artery, in abdomen, 82
Intercostal muscles, in chest, 75, 81
Intercostal nerve, 780t–781t
Intercostal perforator flap, reconstruction of
in anterolateral chest, 207, 208f
in posterior torso, 209
Intercostobrachial nerve, in chest, 86
Interfascicular nerve grafting, 302–303, 303f
Intermuscular septum, in leg, 119

812
Index
Internal mammary artery perforator flap,
e92. see also Deltopectoral flaps
Internal oblique flap, e105–e106
advantages of, e106
anatomic landmarks of, e106
arterial and venous supply of, e105–e106
atypical indications for, e108
bone dimensions of, e107
DCIA-based iliac crest and, maxillary
reconstruction using, 160b
disadvantages of, e106
flap components for, e106
flap design of, e106–e107, e107f
flap innervation for, e106
flap modification/flap handling in, e107
flap usage of, e108
for mandibular defect, 474b, 474f
muscle dimensions of, e107
outcomes of, e108
patient positioning for, e107
pedicled or free, difference in design,
e107
postoperative care for, e108
preoperative preparation for, e106–e108
skin island dimensions of, e107
special considerations in, e106–e107
technical tips to optimize outcomes and
avoid complications in, e108
technique of flap harvest in, e107
typical indications for, e108
venous drainage of, e106
Internal oblique muscle
flap harvest without, 470
free iliac crest flap with, for maxillectomy
defect, 476b, 476f
iliac crest with, for iliac flap, 471
Interosseous artery, as branch of ulnar
artery, 99
Interosseous recurrent artery, in forearm,
100
Interpolated flap, 494–495
Interposed autograft, 780
Interposition nerve grafts, for acute
post-traumatic facial paralysis, 169
Interstitial fluid pressure, in fat grafting,
32–33, 33f
Intestinal allotransplantation, 772
Intestinal vaginoplasty, e55, e55f
Intra oral defects, pectoralis major flap for,
409
Intra-adipose vessel, anatomy of, e66–e67,
e67f
Intracranial portion, of facial paralysis, 163,
164t
Intrafascicular dissection, 628
Intraluminal factors, of flap failure, 359
Intraoperative stereotactic navigation,
e14–e15, e15f
for reconstructive surgery, e15
systems for, e14–e15
Intraoral reconstruction patients,
supraclavicular artery flap and,
390
Intraplexus nerve transfer, for level I injury,
of adult brachial plexus, 247
Intratemporal portion, of facial paralysis,
163, 164t
Intrathoracic defects, pedicled sternocostal
portion for, 409
Intrathoracic pectoralis major,
reconstruction in, 208, 208f
Intrinsic factors, of flap compromise,
340–343
arterial spasm in, 340–341
kinking and twisting in, 341, 342f
vascular thrombosis in, 341–343
IPP. see Implantable penile prosthesis (IPP)
Ipsilateral foot, e182
Ipsilateral hemi-mandible reconstruction,
iliac flap for, 467f
IRB. see Institutional review boards
Irradiated tissue, in head and neck region,
pectoralis major flap for, 409
Ischemia reperfusion injury, 329
Ischemia time, in hand and upper extremity
transplantation, 757
Ischemia-reperfusion injury, e214
Ischial defects, gluteus flap for, e170
Island deltopectoral flap, e91
for lower neck cutaneous defect, e95b, e95f
for pharyngocutaneous fistula, e96b, e96f
Island flap
pectoralis major, reconstruction of, 204,
204f
in scapular and parascapular flap, 442
in trapezius flap, e143
ITC-IGAP flap, breast reconstruction with,
699.e1b, 699.e1f
J
“Jackhammer grafting”, 32
Jackson Pratt drain, 281
Jejunal artery, e116–e117, e117f
Jejunum, e112–e114
blood supply of, e114, e115f
as conduit, e118, e119f, e131b, e131f
diversionary, for swallowing, e123–e124,
e124f
nerve supply of, e115–e116
as patch, e118, e120f
free or pedicled, e123, e124f
repair of esophageal stricture using,
e126
for voice reconstruction, e124, e124f
Jejunum flap, e112–e133
advantages of, e117
anatomic landmarks for, e118, e118f
arterial anatomy of, e114, e114f
arterial supply of, e116–e117
atypical indications for, e127–e128
disadvantages of, e117–e118
donor site of
closure and management in, e125
outcomes of, e128–e129
for esophageal reconstruction, 145
flap anatomy of, e116–e117
flap components of, e117–e118
flap design for, e118–e119
flap dimensions for, e119–e120
flap innervation of, e117
flap markings for, e120
flap modifications/ flap handling,
e123–e124
flap usage in, e125–e128
as free flap
harvest of, e120–e122, e120f–e122f
indications for, e125
jejunum-mesenteric, e123
indications by region in, e125
long-term outcomes of, e129
outcomes of, e128–e129
patient positioning for, e120
as pedicled flap
harvest of, e122, e123f
indications for, e125
lengthening, e126, e126f
reconstruction after total
esophagectomy using, e127
reconstruction of thoracic esophagus
with, e127
supercharging, e123
pedicled or free, difference in design,
e119
postoperative care for, e128
preoperative preparation for, e118
recipient site of, e128
regional anatomy for, e112–e116
special considerations for, e118
special instruments for, e124
technical tips to optimize outcomes and
avoid complications in, e125
technique of flap harvest in, e120–e123
untoward outcomes of, e129
venous anatomy of, e115, e116f
venous drainage of, e117
for voice reconstruction, 145, 145f
Jugular vein
in chest, 86
in head and neck, 71
K
Karapandzic flap, for lower lip
reconstruction, 279
Keloid scar, in donor site, of pectoralis
major flap, 410
Keystone flaps, in abdominal wall
reconstruction, 221–222
Knee
arterial anatomy of, 121f
bone reconstruction in, 261
defect reconstruction in, 261–262
reconstruction of, 133
soft tissue reconstruction in, 261–262,
261f
surgical exposure to popliteal vessels at,
123f
L
Lacertus fibrosus, in exposure of distal
brachial artery, 95
Langer, Robert, e25
Lantieri, L., e204
Lantieri’s program, in reconstructive
transplantation, e208
Large composite facial defect, reconstructed
with free VRAM flap, 429b, 429f
Large flank defect, reconstructed with
pedicled external oblique
myocutaneous flap, e110b, e110f
Large leg defect, gastrocnemius flap for,
580.e2b, 580.e2f
Large medial malleolus defect,
reconstructed with propeller type
posterior tibial artery perforator flap,
727b, 727f
Laryngeal allotransplantation
arterial anatomy, 770–771
composite tissue component, 771,
771f
flap for
design, 771–772
modifications, 772
future landmarks in, 772
immunosuppressive protocol in, 772
indications for, 771
neural anatomy, 771
postoperative care for, 772
venous anatomy, 771
Laryngeal composite allograft, 771f
Laryngectomy, total, pharyngocutaneous
fistula after, pectoralis major flap for,
408–409
Laser Doppler, 352
Late facial paralysis, microsurgical
management for, 169–173

Index
813
Latent errors, 358
Lateral antebrachial cutaneous nerve
in antecubital fossa, 94–95
in forearm, 109
musculocutaneous nerve and, 106–107
Lateral antebrachial cutaneous nerve graft,
780t–781t
Lateral approach, of soleus flap, 588
flap harvest and, 588–589, 590f
Lateral arm flap, 511–524, 511f
adipofascia, 516
anesthetic considerations for, 514
arterial and venous supply of, 511–512
atypical indications for the use of, 519
donor site closure and management of,
517, 517f
extremity reconstruction in, 513–514
fascia, 516
fasciocutaneous, 516–517, 524.e1b, 524.e1f
flap anatomy of, 511–512
flap components of, 512
flap design of, 513–514
anatomic landmarks in, 513, 513f
general thoughts about, 513
special considerations in, 513–514
flap dimensions in, 514
flap handling of, 515–517
flap innervation of, 512
flap markings of, 514, 515f
flap modification of, 515–517
flap usage of, 518–519
free, 518–519, 523b, 523f
head and neck reconstruction in, 513
musculotendinous, 516–517
neurosensory, 517, 524.e3b, 524.e3f
osseofasciocutaneous, 516
outcomes of, 519–520
patient positioning for, 514
pedicled, 518, 521b, 521f
postoperative care for, 519
preoperative preparation for, 512–513
reverse, 515–516, 518
special instruments for, 517
split cutaneous, 517
technical tips to optimize outcomes and
avoid complications for, 517–518
technique of flap harvest in, 515, 516f
typical indications for the use of, 518
venous drainage of, 512
Lateral cutaneous nerve, of the thigh,
780t–781t
Lateral femoral circumflex artery, thigh and,
116–117
Lateral femoral cutaneous nerve, in thigh,
115
Lateral gastrocnemius flap, 574–575, 575f,
580.e2b, 580.e2f
Lateral head, gastrocnemius flap in, 578
Lateral intermuscular septum, in arm, 89
Lateral perforator, dissection of, 678f
Lateral plantar artery, in leg, 130–131
Lateral soleus, 581–583, 585f
Lateral supramalleolar flap, 554–555
anesthetic considerations for, 555
arterial and venous supply of, 554
donor site closure and management of,
555
flap anatomy of, 554
flap components of, 554
flap design of, 554
flap dimensions of, 554
flap handling of, 555
flap innervation of, 554
flap markings of, 554f, 555
flap modification of, 555
flap usage of, 555
for lower leg anterior defect, 556.e3b,
556.e3f
outcomes of, 555
patient positioning for, 555
postoperative care for, 555
preoperative preparation for, 554
special instruments for, 555
technical tips to optimize outcomes and
avoid complications for, 555
technique of flap harvest in, 555, 554.e1f
venous drainage of, 554
Lateral sural artery perforator flap, 575
Lateral thoracic artery
in chest, 81
direct cutaneous perforators from,
650–651
Lateral thoracic perforator flap, 650–651
neck defect resurfaced with, 667.e2b,
667.e2f
Lateral thoracic region
network of perforators in, 650f
perforator flaps in, 648–667, 648f
anatomy of, 649–652
anesthetic considerations of, 656
component of, 652–653
donor site closure and management of,
661
flap anatomy of, 649–652
flap design of, 653–655
flap dimensions of, 655
flap usage of, 663–665
modification/handling, 657–660
outcomes of, 665–667
patient positioning of, 655–656
postoperative care of, 665
preoperative preparation of, 653
technical tips to optimize outcomes and
avoid complication, 661–663, 662f
technique of flap harvest, 656–657
Lateral V-Y advancement flaps, in distal
fingertip transverse and oblique
defect reconstruction, 228–229, 228f
Latissimus dorsi detrusor myoplasty
(LDDM), 288, 288b
Latissimus dorsi flap, 283f–284f, 285–289,
287f, 446–463, 446f, 452f
anatomy of, 447–449
bilobed split, 455
in breast reconstruction, 194, 195f
components of, 449–450
craniofacial microvascular reconstruction
and, 140–141
design of, 450–451
dimensions of, 451
donor site closure and management for,
456
extended
for reconstruction, 459b, 459f
without additional implant, 461b, 461f
flap modification/ flap handling of,
454–456
innervation of, 449
outcomes of, 458
patient positioning for, 451
pedicled extended, for breast
reconstruction, 463.e2b, 463.e2f
postoperative care for, 457–458
preoperative preparation for, 450
soft tissue coverage, 463.e1b, 463.e1f
technical tips for, 456
technique of flap harvest for, 452–454,
453f
usage of, 456–457
Latissimus dorsi muscle (LDM), 288
in back, 78–79
conventional, 648
in elbow and proximal forearm soft tissue
defect reconstruction, 236
flap harvest, based on paraspinal
perforators, 460b, 460f
pedicled transfer, for breast or chest wall
reconstruction, 453–454
reconstruction of
in anterolateral chest, 206, 206f
in posterior torso, 209, 210f
robotic harvest of, e38, e38f
for breast reconstruction, e40b, e40f
Latissimus dorsi perforator flap, 649
thumb skin defect resurfaced with,
667.e1b, 667.e1f
Latissimus dorsi perforator-based free flap,
658f
Lazy “s” pattern, in nerve coaptation,
299f
LDDM. see Latissimus dorsi detrusor
myoplasty (LDDM)
LDM. see Latissimus dorsi muscle (LDM)
LEAP. see Lower Extremity Assessment
Project (LEAP)
Leg
anatomic variations in, 132–133
anatomy of, 130f
anterior compartment of, 119
anterior tibial artery in, 124–127
cross-sectional anatomy of, 129f
deep posterior leg compartment of, 119
lateral compartment of, 119
muscles of, 129f
nerves in, 119–120
peroneal artery in, 123
popliteal artery in, 120–121
posterior compartment of, 119
posterior tibial artery in, 121–122
Leg reconstruction, 262–263, 262f
Leg tourniquet, release of, 628
“Lethal triad”, 255–256
Levator muscles, of upper lip and orbicularis
oris, facial paralysis in, 165–166
Levator scapulae muscle, e135
Level I injury, in adult brachial plexus, 242,
247–249
Level II injury, in adult brachial plexus, 242,
249
Level III injury, in adult brachial plexus,
242, 249
Level IV injury, in adult brachial plexus,
242, 249
Limb, free-style flap from, 731
Limb procurement, 757f, 758
Linea alba, in abdomen, 75
Lipoaspirate, 34
Lips, 276
L’Nard splint, for local flaps, in foot, 556
Local flaps
in abdominal wall reconstruction,
221–222
in foot, 540–558, 556b
abductor digiti minimi flap, 544–546
abductor hallucis flap, 546–549
extensor digitorum brevis flap,
551–553
flexor digitorum brevis flap, 549–551
lateral supramalleolar flap, 554–555
postoperative care for, 555–556
sural flap, 540–544, 541f
mucosal, composite ala defect and, 370b,
370f
Local tissue, for phalloplasty, e47
Locoregional flaps, in phalloplasty, e46
Long operation time, in lateral thoracic
region, 653
Longitudinal splitting, of flap, e67–e68

814
Index
Long-term outcomes, in toe flaps, 631–632,
631t
Louisville transplant, 754
Loupe magnification, during dissection,
706
Lower abdominal skin flap, skin island
dimensions in, 420
Lower extremity
clinical anatomy and recipient vessel
selection in, 115–137
dorsal venous arch in, 136
flap usage of, 663–664
free flap usage in, 680
great saphenous vein in, 135
iliac flap for, 472
of medial femoral condyle, 644
scapular and parascapular flaps for,
442
small saphenous vein in, 135–136
soft tissue defect of, latissimus dorsi flap
for, 450–451
of soleus flap, 591
Lower Extremity Assessment Project (LEAP),
256–257
Lower extremity reconstruction, 255–274
in anterolateral thigh flap, 703
in anteromedial thigh flap, 710
complications in, 266–267
etiology of defect in, 255–256, 255.e1t
oncologic, 256
traumatic, 255–256, 255.e1t–255.e2t
indications of, 256–261
level of defect in, 256
outcomes in, 267–271
postoperative considerations in, 264–266
preoperative considerations in, 255–256
reconstruction by region in, 261–264
knee defect reconstruction, 261–262
leg reconstruction, 262–263
thigh reconstruction in, 261
Lower face, facial paralysis in, 166
reanimation for, 172–173, 172f–173f
Lower limb post-traumatic contour defect
reconstructed with free DIEAP flap,
686.e1b, 686.e1f
Lower lip resection, full-thickness, 277b,
277f–279f
Lower neck cutaneous defect, island
deltopectoral flap for, e95b, e95f
Lower-third leg, soft tissue reconstruction in,
262–263, 263f
L-shaped deltopectoral flap, e91
Lumbar perforator, in posterior torso,
reconstruction of, 210
LVA. see Lymphovenous anastomosis
(LVA)
Lymph, transport of, in lymphatic system, 40
Lymph node transfer, for lymphedema, 48
Lymphatic etiology, in lower extremity
reconstruction, 256
complications of, 267
indications of, 260–261
Lymphatic surgery, and indocyanine
green (ICG) angiography, e18–e19,
e19f
Lymphatic system, 40
Lymphaticovenous bypass, robotic assisted,
for lymphedema, e41b, e41f
Lymphaticovenular anastomosis, 48–49
operative technique for, 48–49, 49f
postoperative management for, 49
side-to-end arrangement for, 48–49
upper extremity lymphedema following
mastectomy treated with, 59.e1b,
59.e1f
vs. vascularized lymph node transfer, 48
Lymphedema
anatomic imaging of, 46–47, 46f
functional imaging for, 47–48
indocyanine green lymphangiography
(IGL) as, 47–48, 47f
lymphoscintigraphy as, 47
initial patient visit in, 45–48
in lower extremity reconstruction
complications, 267
outcomes, 268
lymphatic anatomy and physiology in,
40–42, 41f, 43f–44f
lymphaticovenular anastomosis for, 48–49
operative technique for, 48–49, 49f
postoperative management for, 49
upper extremity lymphedema following
mastectomy treated with, 59.e1b,
59.e1f
versus vascularized lymph node transfer,
48
microsurgical reconstruction of, 40–60,
57b
outcomes for, 56–57
pathophysiology of, 42
physiologic procedures for,
contraindications to, 45
robotic assisted lymphaticovenous bypass
for, e41b, e41f
surgery for, indications for, 42–45
vascularized axillary lymph node transfer
with reverse lymphatic mapping for,
53–55
donor site for, 53–54, 54f
medial sural vessels in, 54–55, 55f
recipient site preparation in, 54–55
vascularized groin lymph node transfer
with reverse lymphatic mapping for,
50–53
anatomy and flap design in, 50–53,
51f–53f
vascularized lymph node transfer
for lower extremity, 53, 58b, 58f
for upper extremity, 49–50, 50f
vascularized supraclavicular lymph node
transfer with reverse lymphatic
mapping for, 55–56
flap markings and elevation for, 56, 56f
postoperative management in, 56
work-up for, 45–46
Lymphoscintigraphy, e18
for lymphedema, 40, 47
Lymphovenous anastomosis (LVA), 42–44
Lymphovenous bypass, e18
M
Magnetic resonance angiography (MRA)
in breast reconstruction, 185–186
for lymphadenopathy, 46, 46f
Magnetic resonance lymphangiography
(MRL), 47
Maintenance therapy, immune suppression
and, 740
Maintenance treatment, in uterus
transplantation, 776
Major histocompatibility complex (MHC)
genes, e210
Major histocompatibility complex I
(MHC-1), 782
Malignancy, in hand and upper extremity
transplantation, 754
Malignant disease, as indication for face
transplantation, 742
Malignant melanoma defect, V-Y flap for,
728.e2b, 728.e2f
Mammary artery, internal, in chest, 80–81
Mandible
defect of, reconstructed with pedicled
pectoralis major myocutaneous flap,
413b, 413f
in facial skeleton, 61–62
fibula for, 607b, 607f–609f
osteocutaneous defects on, trapezius flap
for, e143
reconstruction of, 143
using free fibula flap, 158f, 160b
Mandibular defect
composite iliac and internal oblique flap
for, 474b, 474f
free iliac bone flap and free radial
forearm flap for, 475b, 475f
pectoralis major flap for, 409
Mandibular reconstruction
chimeric free flap, 445b, 445f
free iliac bone flap for, 475b, 475f
iliac flap for, 473
with pedicled osteomyocutaneous flap,
410
Mangled Extremity Severity Score (MESS),
255.e1t
Marginal mandibular branch, in head and
neck, 63
Markings, for latissimus dorsi flap, 451,
452f
Masseter muscle, in face, 63–64
Mastectomy
defect, free SGAP flap for, e174b,
e174f
skin flap necrosis in, e18
Master-slave model, e36
Mastication, muscles of, 63–64
Matrices, de-novo assembly of, e29–e30
Maturation, 19
Maxillary reconstruction
iliac flap for, 473–477
using DCIA-based iliac crest and internal
oblique flap, 156f, 160b
Maxillectomy defect, free iliac crest flap with
internal oblique muscle for, 476b,
476f
“Meaning recovery”, 794
Medial antebrachial cutaneous nerve
in forearm, 109
graft, 780t–781t
Medial approach, of soleus flap, 586–588,
587f
flap harvest and, 588
Medial femoral circumflex artery, thigh and,
117–118
Medial femoral condyle (MFC), and
descending genicular artery
perforator flaps, 636–647, 636f
donor site closure and management of,
642
flap anatomy of, 636–639
flap components of, 639
flap design of, 639–641, 640f
flap usage and outcomes of, 643–645
patient positioning of, 641
postoperative care, 643
preoperative preparation of, 639
technical tips to optimize outcomes and
avoid complications, 642–643
untoward outcomes of, 645
Medial femoral cutaneous nerve, of medial
femoral condyle, 639
Medial gastrocnemius flap, 573–574, 574f,
580.e2b, 580.e2f
Medial head, gastrocnemius flap in, 577
Medial intermuscular septum, in arm, 89
Medial malleolar defect, abductor hallucis
(AH) flap for, 558b, 558f

Index
815
Medial malleolus
anatomic structures passing posterior to,
127f
defect with exposed tibia reconstructed
with V-Y fasciocutaneous posterior
tibial artery perforator flap, 726b,
726f
Medial perforator, dissection of, 678f
Medial plantar flap, e181–e183
anatomy of, e181–e182
arterial supply of, e181–e182
free, e183
patient positioning of, e183
preoperative preparation of, e182
typical indications for use of, e183
vascular anatomy of, e188b, e188f
venous drainage of, e182
Medial plantar perforators, e176–e177
Medial soleus, 583
proximally-based, 588
Medial sural artery perforator flap, 575
Medial sural vessels, in vascularized axillary
lymph node transfer with reverse
lymphatic mapping, 54–55, 55f
Medial thigh flaps, in breast reconstruction,
196–197
Median nerve
in arm and forearm, 106
brachial artery and, 91
in exposure of distal brachial artery, 95
in forearm, 100f
in hand, 109
Mediastinum
defects of, pectoralis major flap for, 409
infected, reconstructed with pedicled
omentum flap, e108b, e108f
Medical optimization, for flap compromise,
336
Medications, for flap re-exploration,
334–335
Mental nerve, in facial skeleton, 61–62
Mesenchymal stem cells (MSCs), e217
Mesentery, regional anatomy for, e112
Mesh infections, in abdominal wall
reconstruction, 223–224
MESS. see Mangled Extremity Severity Score
(MESS)
Metacarpal hand, 629
type IIB, reconstructed with multiple toe
transfers, 635.e2b, 635.e2f
Metatarsophalangeal (MTP) joint, 613
transfer, 627
vascularized MTP joint transfer for
reconstruction of, 635.e3b, 635.e3f
MFC corticocancellous graft, scaphoid
proximal pole fracture non-union
treated with, 647.e1b
MFC corticoperiosteal sheet graft, ulnar
non-union reconstructed with, 645b
MHC class I molecules, e210
MHC class II molecules, e210
MHC/HLA antigens, role of, e210
Microbipolar cautery
for homodigital island flap, 502
for posterior interosseous artery flap, 507
Microdissection, of flap, e64–e68, e65f, e68f
Microsurgery
future of, 4
reconstructive, 3–4
Microsurgical instruments, 312–313, 312f
Microsurgical technique, for second free
flap, 362
Microtia, reconstructed with autologous rib
cartilage, pedicled temporoparietal
fascia flap and skin grafting, e83b,
e83f
Microvascular anastomosis, robotic, e39
indications for, e39
Microvascular coupler system, 314f
Microvascular phalloplasty, e47
Microvascular tissue transfer, radial
recurrent artery as, 95–96
MICS techniques. see Minimally invasive
component separation (MICS)
techniques
Middle collateral artery, in arm, 93–94
Middle descending branch, in UTA, 638
Middle face, facial paralysis in, 165–166
reanimation for, 171–172, 172f
Middle forearm, transplant, technique for,
762
Middle-third leg, soft tissue reconstruction
in, 262, 263f
Midface, reconstruction of, 143
Midline laparotomy, in local flap, 221
MiHA. see Minor histocompatibility antigens
(MiHA)
Milking test, 344f
Minimally invasive component separation
(MICS) techniques, in abdominal
wall reconstruction, 219
Minitendon technique, 175, 175f
Minor histocompatibility antigens (MiHA),
e211
Mitogenic cytokines, 779–780
Mixed chimerism, e215
“Mixed pattern injuries”, 296–297
Moberg flap, 497–500
anesthesia considerations for, 499
for avulsion of volar tissue of thumb, 499b,
499f
donor site closure in, 500
flap anatomy of, 497–498
flap design of, 498–499
flap dimensions of, 499
handling of, 500
outcomes of, 500
preoperative preparation for, 498
technique of harvest in, 499–500
for thumb tip amputation, 498b,
498f
Moebius syndrome, bilateral functional
segmental gracilis flaps, for
facial reanimation, of, 568.e3b,
568.e3f
Monofascicular, defined, 296
Motor examination, for adult brachial
plexus injury, 244
Motor innervation, of anterolateral thigh
(ALT) flap, 701
Motor nerve, between vessel branches, in
anteromedial thigh flap, 709
Motor rehabilitation, 630
Motor unit potentials, 297
Mouth, floor of, defect of, reconstructed
with pedicled pectoralis major
myocutaneous flap, 413b, 413f
MR neurography, for hand and upper
extremity transplantation, 755,
756f
MRA. see Magnetic resonance angiography
(MRA)
MRL. see Magnetic resonance
lymphangiography (MRL)
MSCs. see Mesenchymal stem cells
(MSCs)
Multidetector spiral CT-scan, 673, 674f
Multidisciplinary team, facial transplantation
and, 739–740
Multiple skin islands
flap, for pectoralis major flap, 406
in free-style flap, 732
Multiple toe transfers, metacarpal hand type
IIB reconstructed with, 635.e2b,
635.e2f
Multiple-digit amputation, 628–629
Multipotent stem cells, in tissue engineering,
e27
Muscle
component, in anterolateral thigh flap,
707
facial, reinnervation of, 747
inclusion of, in flaps, e1
at recipient site, in free-style flap, 732
Muscle dimensions, 655
in anterolateral thigh flap, 704
in external oblique flap, e104
in gluteus flap, e161
in iliac flap, 468
in internal oblique flap, e107
in lateral arm flap, 514
in latissimus dorsi flap, 451
in posterior tibial artery perforator flap,
721
in rectus abdominis flap, 420
in tensor fascia lata flap, e193
Muscle flaps, e4
denervated, craniofacial microvascular
reconstruction and, 140–141
Mathes and Nahai classification of, e4, e5f
in rectus abdominis flap, 421–424
soft tissue coverage and, 6
Taylor classification of, e4, e5f
Muscle harvest, robotic, e37–e39, e38f–e39f
indications for, e38–e39
Muscle only flap, 562, 563f
Muscle perforator flaps, 11, 11f
Muscle sparing, classification of, 187t
Muscle-sparing flap, in rectus abdominis
flap, 424
Muscle/tendon reconstruction, in hand
and upper extremity transplantation,
760f
Muscular branch, of DGA, 638
Musculature, facial, anatomy of, 63–64
Musculocutaneous arteries, e1
Musculocutaneous flap
design, of external oblique flap, for chest
wall defects, e104
of soleus flap, 588
tensor fascia lata, e195–e196, e196f
Musculocutaneous nerve, in arm and
forearm, 106–107
Musculocutaneous perforators, 584
topographic distribution of, from DIEA,
670b
Musculo-osseous flap, e196
Musculotendinous flap, for lateral arm flap,
516–517
Myelinating SCs, 295
Myocardium, cell therapy for, e32
Myocutaneous flap, 4, 405, 648, e67
based on the ascending branch of the
SCA
for flap harvest, e145, e146f
for lower cheek soft tissue defect, e151b,
e151f
based on the dorsal scapular artery,
e140f
pedicled, e152b, e152f
extended trapezius, e146–e147
for flap harvest, based on the descending
branch of the SCA, e145–e146
pedicled, 400
floor of the mouth and mandible defect
reconstructed with, 413b, 413f
partial pharyngeal defect reconstructed
with, 414b

816
Index
partial trachea defect reconstructed
with, 414b, 414f
pharyngogastric cutaneous fistula closed
with, 412b, 412f
simultaneous ipsilateral pectoralis major,
deltopectoral flap and, e92
Myocutaneous free flap, trapezius flap and,
e149
Myocutaneous latissimus flap, 284f
N
Nasal defect, 381b, 381f
Nasolabial flap, 379
anatomic landmarks of, 380
anatomy of, 379
arterial supply of, 379–380
design of, 380
dimension of, 381
donor site closure and management for,
382
expected outcomes of, 382
innervation of, 380
postoperative care of, 382
technique of flap harvest for, 381–382,
381b, 381f
usage of, 382
venous supply of, 379–380
Natural polymers, in skin tissue engineering,
e28
Near infrared angiography, 352
Near infrared spectroscopy (NIR), in breast
reconstruction, 198
Neck, 61–74
arteries and veins of, 66f–67f
defect
reconstructed with pedicled free-style
flap, 734b, 734f
trapezius flap for, e143, e147–e148
facial artery in, 64–69
facial nerve in, 73–74
fascia of, 62–63, 63f
local flaps of, 367–386
reconstruction of, 138–161. see also
Craniofacial microvascular
reconstruction
complications of, 154–155
expert commentary for, 160b–161b
indications for, 142
latissimus dorsi flap for, 450
outcomes of, 156
postoperative considerations for,
153–154
preoperative considerations for, 138
scapular and parascapular flaps for, 442
submental artery in, 69
superficial temporal artery in, 69–70
superior thyroid artery in, 69
supratrochlear artery in, 71
transverse cervical artery in, 70–71
veins in, 71
Necrotic bone, open fracture of upper third
of tibia with, 595.e1b, 595.e1f
Negative pressure wound therapy (NPWT),
266
in abdominal wall reconstruction, 218
Neo-mandible, shaping of, 470–471
Neourethral plate, in urethroplasty, e48–e49
Neovascularization, 19
Nerve allografts
conduits and processed, 788–794
definition of, 781
premature immunosuppression, effects of,
783f
Schwann cell migration in, 782, 782f
Nerve allotransplantation
clinical experience with, 783–785, 784t,
786f–787f
current immunosuppressive protocol for,
787t
current strategies for, 782–783
immunology of, Schwann cells of,
781–782, 782f–783f
peripheral. see Peripheral nerve
allotransplantation
Nerve autograft, 779
substitutes for, 788–794
Nerve avulsion, nerve rupture vs., 244t
Nerve conduits, 788–792, 789t–791t, 792f,
793t
Nerve dimensions, of lateral arm flap, 514
Nerve dysfunction, in traumatic
reconstruction, 265
Nerve graft, 300–304
interfascicular, 302–303, 303f
lateral antebrachial cutaneous nerve as,
94–95
nerve transfer and, comparison of, 304t
options, characteristics of suitable
interpositional, 780t–781t
sural, 301, 301f–302f
vascularized, 301, 303–304, 303f
Nerve injury
classification of, 296–297, 779t
degrees of, 296t
planning the reconstruction of, 297–298
Nerve injury/ischemia/soft tissue/skeletal
injury/shock /age (NISSSA) scoring
system, 255.e2t
Nerve regeneration
in hand and upper extremity
transplantation, 766
in vascularized composite
allotransplantation, 785–788, 788f
Nerve repair/ reconstruction, 300–305
equipment for, 298
in hand and upper extremity
transplantation, 760–761
in lower extremity, 258
operative considerations in, 298–300
principles of, 298–300
timing of, 297–298
Nerve rupture, nerve avulsion vs., 244t
Nerve suturing, 299f
Nerve transfers, 304–305
for facial paralysis, 162–163
accessory, 174
babysitter procedure in, 173–174
C7 root, 174
for level I injury, of adult brachial plexus,
247
nerve grafting and, comparison of, 304t
Nerves, 295–309
anatomical considerations in, 295–296,
295f
classification of nerve injury, 296–297,
296t
introduction and historical notes on, 295
rejection of, in composite tissue allograft,
788f
in trapezius muscle, e136, e137f–e138f
Neurapraxia, 296, 779, 779t
Neurocutaneous flaps, e4
Neurogenic bladder dysfunction, 287
Neurologic outcomes, in lower extremity
reconstruction, 267
“Neuromas-in-continuity”, 296–297
Neuromusculotendinous transfer, treatment
of drop foot, 289–292
complications of, 292
indications for, 291, 291b
outcomes of, 292
postoperative considerations for, 289–292
technique for, 291–292
Neuroregeneration, 297
Neurorrhaphy techniques, 298–300
Neurosensory flap
for lateral arm flap, 517
of tensor fascia lata flap, e196
Neurosensory free flaps, 627
Neurotization, 281
Neurotmesis, 296–297, 779t
Neurotropism, 789
Neurovascular island flap, vascular anatomy
of, e185b, e185f
Neurovascular pudendal thigh flap, in vulvar
and vaginal reconstruction, e52–e54,
e53f, e54b
NIR. see Near infrared spectroscopy (NIR)
NISSSA scoring system. see Nerve injury/
ischemia/soft tissue/skeletal injury/
shock /age (NISSSA) scoring system
Non-free GAP flaps, 696
Non-HLA antigens, e211
Non-immunologic complications, of
immunosuppression, 746
Non-immunologic factors, of chronic
rejection, e213
Non-microsurgical options, for
reconstructive, 361, 361f
Non-myelinating SCs, 295
Non-pneumatic tourniquet, in hand and
upper extremity transplantation,
757
Non-tissue-based limb reconstruction, 766
“No-reflow phenomenon”, 336–337
Normal blink reflex, facial paralysis in, 165
Nose, reconstruction of, 143
NPWT. see Negative pressure wound therapy
(NPWT)
Nutritional status, in abdominal wall
reconstruction, 220
O
Obese patients, excess fat in, anteromedial
thigh flap, 709
Obesity, as contraindication to physiologic
lymphatic procedures, 45
Oblique muscles, in abdomen, 75
Obturator nerve, in thigh, 115
Olecranon bursitis, pedicled lateral arm flap
for, 521b, 521f
Oligofascicular, defined, 296
Omentum flap, e98–e99
advantages of, e99
anatomic landmarks of, e99, e99f
arterial and venous supply of, e98
disadvantages of, e99
flap anatomy of, e98–e99, e98f
flap components of, e99
flap design of, e99
flap dimensions in, e99
flap innervation of, e99
flap markings in, e99
flap modification/flap handling of, e100
flap usage in, e100
laparoscopic harvest in, e100
outcomes of, e101
patient positioning for, e99–e100
postoperative care for, e100
preoperative preparation for, e99–e101
special considerations for, e99
special instruments for, e100
technical tips to optimize outcomes and
avoid complications, e100
technique of flap harvest in, e100
Myocutaneous flap (Continued)

Index
817
typical indications for, e100
venous drainage of, e99
Omentum reconstruction
in anterolateral chest, 206, 206f
in posterior torso, 210
Oncologic reconstruction
in lower extremity, 256
indications of, 260
outcomes of, 268–271
postoperative considerations in, 264
reconstructive microsurgery and, 3
“One way up anastomosis”, 316, 316f
Operating microscope, 1
Operative set-up, for flap re-exploration, 335
Operator experience, in avoiding
complications, 326
OPO. see Organ procurement organization
Opportunistic infections, 741
Opposition reconstruction, 629
Oral sphincter restoration, platysma for, 178
Orbicularis oculi muscle (OOM)
substitution, for facial paralysis,
175–176
Orbicularis oris (OOrM), levator muscles of,
facial paralysis in, 165–166
Orbital reconstruction
using ALT free flap, 150f, 159b
using free fibula flap, 159f, 160b
Orbital region, soft tissue defects on,
trapezius flap for, e143
Organ procurement organization (OPO),
reconstructive transplantation
program and, e207–e208
Organ transplantation, 739
Osseofasciocutaneous flap, for lateral arm
flap, 516
Osseo-muscle flap, of tensor fascia lata flap,
e196
Osseo-musculocutaneous flap, of tensor
fascia lata flap, e196
Osseus flap, of fibula flap, 600
Osteocutaneous flap
of fibula flap, 599–603, 602f
for scapular flaps, 440
Osteocutaneous radial forearm flap, 531,
532f, 538b, 538f
Osteomuscular flap, of fibula flap, 600
Osteomusculocutaneous flap
clavicular head, 407
rib-latissimus dorsi, 455
tensor fascia lata, e196
Osteomyocutaneous flap, 405, 406f
based on the ascending branch of the
superficial scapular artery, e139f
pedicled, 400
for flap harvest, e145
mandibular reconstruction with, 410
Osteoseptocutaneous flap, fibula, 597, 603f
Osteosynthesis, 760
Osteotomies
for ipsilateral hemi-mandible
reconstruction, 467f
multiple segment, of iliac bone, 471
Outcomes
of fibula flap, 605–606
of glabrous skin flaps, e184
of lateral thoracic region, 665–667, 666f
of soleus flap, 592–593
in toe flaps, 630–632
P
Palate defect
anteromedial thigh flap for, 715b, 715f
free radial forearm flap for, 539.e1b,
539.e1f
PALF. see Percutaneous aponeurotomy and
lipofilling (PALF)
Palm
deep dissection of, 103f
superficial dissection of, 102f
Palm & Pinch Test, 33
Palmar aponeurosis, in hand, 109
Palmar branch, of anterior interosseous
artery in forearm, 99–100
Palmar defects, e176
Palmar hand defect reconstruction,
231–235, 233b, 233f–234f, 235b
Palpebral spring, 174–175, 174f
Panfacial reanimation, 179
treatment algorithm in, 181f
PAP flap. see Profunda artery perforator
(PAP) flap
Pararectal perforators, 677, 679f
Parascapular cutaneous flap, arterial supply
of, 435
Parascapular flap, 432–445, 432f, 452f
anatomic landmarks and markings of,
436, 437f
arterial supply of, 433–435, 433f
components of, 436
design of, 436–438
dimensions of, 438
donor site closure and management for,
441
flap modification/flap handling of,
440–441
innervation of, 435
for leg soft tissue defect, 445.e1b,
445.e1f
outcomes of, 443
patient positioning for, 438–439
postoperative care for, 443
preoperative preparation for, 436
technical tips for, 441–442
technique of flap harvest for, 439–440,
439f
usage of, 442–443
venous drainage of, 435
Parascapular perforator flap, in anterolateral
chest, reconstruction of, 207–208
Paraspinal perforators, latissimus muscle
flap harvest for, 460b, 460f
Paraspinous muscle
in back, 79
in posterior torso, reconstruction of, 209
Parotidomasseteric fascia, of head and neck,
63
Partial horizontal splitting, e68
Patch, jejunum as, e118, e120f
free or pedicled, e123, e124f
repair of esophageal stricture using, e126
Patient positioning, recipient vessel selection
in lower extremity, 137
Patient selection, in face transplantation,
743–744, 743t
Patient-centered decision-making, 357–361,
358b, 358f, 362b
assess the recipient vessels for, 360
characterize the defect in, 359–360
clinical status of the patient in, 357–358
examine reconstructive choices in,
360–361, 360f
root cause analysis of flap failure, 358–359
Pectoral artery, in pectoralis major flap, 397
Pectoralis major flap, 396–415, 396f
advantages of, 398–399
anatomic landmarks for, 400, 400f
anesthetic considerations for, 403
arterial supply of, 397–398
atypical indications for, 409
disadvantages of, 399
donor site closure and management in,
407
flap anatomy of, 397–398, 397f
flap components of, 398–399
flap design for, 400–401
flap dimensions of, 401–402
flap harvest in, technique of, 403–404
clavicular head, of pectoralis major
muscle, 404
sternocostal head, of pectoralis major
muscle, 403–404, 403f–404f
flap innervation of, 398
flap markings for, 402, 403f
flap modification/flap handling in,
404–407
flap usage of, 408–409
muscle dimensions of, 401
muscle preserving method of flap harvest
in, 405
outcomes of, 410
patient positioning for, 402–403
pedicled
bilateral, sternal and neck defect
reconstructed with, 411b, 411f
under clavicle, 405
or free, difference in design, 401
postoperative care for, 409–410
preoperative preparation for, 399–400,
399f
reverse flap/turnover flap for, 405
skin island dimensions of, 402
special considerations for, 400–401,
401f–402f
technical tips to optimize outcomes and
avoid complications in, 407,
407f–408f
venous supply for, 398
Pectoralis major muscle
in anterolateral chest, reconstruction of,
204–208
in chest, 75
Pectoralis major myocutaneous flap,
simultaneous ipsilateral, deltopectoral
flap and, e92
Pectoralis minor muscle, transfer of, for
smile restoration, 177, 178f
Pedicle
injury during dissection, in lateral
thoracic region, 653
length and caliber, of donor flap, avoiding
complications in, 325
twisting of, in anteromedial thigh flap,
709
Pedicle TRAM flap, in breast reconstruction,
193–194, 193f–194f
Pedicled anterolateral thigh flap, in vulvar
and vaginal reconstruction, e54
Pedicled bone flaps, for hip reconstruction,
472
Pedicled cervicofacial rotation flap, 384b,
384f
Pedicled costomyocutaneous flap, 400
Pedicled extended latissimus
dorsimyocutaneous flap, for breast
reconstruction, 463.e2b, 463.e2f
Pedicled flaps, 3
in abdominal wall reconstruction, 222
in anterolateral thigh flap, 707–708
in anteromedial thigh flap, 709
flap selection and, 6
functional, in gracilis flap, 564
for gluteus flap, e165–e166, e168–170
of hand, 491–510, 491f
cross finger flap, 494–497
distal ulnar artery perforator flap,
505.e1–505.e2

818
Index
first dorsal metacarpal artery flap,
492–494
homodigital island flap, 500–505
Moberg flap, 497–500
posterior interosseous artery flap,
505–509, 505b
jejunum flap as
harvest of, e122, e123f
indications for, e125
lengthening, e126, e126f
reconstruction after total
esophagectomy using, e127
reconstruction of thoracic esophagus
with, e127
supercharging, e123
for latissimus dorsi flap, 451
for breast or chest wall reconstruction,
453–454
usage of, 456–457
non-functional, in gracilis flap, 564
in phalloplasty, e46
reconstruction, e63, e64f
in rectus abdominis flap
atypical indications of, 426–427
based DIEA, 424–425
indications of, 426
typical indications of, 426
regional reconstruction with, 682
SGAP
for pelvic reconstruction, e161
for sacral ulcer, e172b, e172f
in temporoparietal fascia flap, e80
microtia reconstructed with, e83b, e83f
rotation of, e78
in tensor fascia lata flap, e198
usage
in lateral thoracic region, 663
of posterior tibial artery perforator, 724
Pedicled free-style flap
forefoot defect reconstructed with, 736b,
736f
left neck defect reconstructed with, 734b,
734f
Pedicled gluteal perforator flaps, e165, e167f
Pedicled gluteus maximus flaps, e170
Pedicled groin flap, flap harvest of, 482–483,
482f
Pedicled lateral arm flap, 518, 521b, 521f
Pedicled latissimus muscle transfer, for
restoration of biceps function,
463.e3b, 463.e3f
Pedicled lower island trapezius flap, e154b,
e154f
Pedicled muscle flaps, robotic harvest of,
e37–e38
Pedicled musculocutaneous flap, e165–e166,
e168f
Pedicled myocutaneous flap, 400
based on the DSA, for occipital defect,
e152b, e152f
for flap harvest, e145, e146f
floor of the mouth and mandible defect
reconstructed with, 413b, 413f
partial pharyngeal defect reconstructed
with, 414b
partial trachea defect reconstructed with,
414b, 414f
pharyngogastric cutaneous fistula closed
with, 412b, 412f
Pedicled omentum flap
exposed aortic graft and infected
mediastinum reconstructed with,
e108b, e108f
sternal osteomyelitis defect reconstructed
with, e109b, e109f
Pedicled osteomyocutaneous flap, 400
for flap harvest, e145
mandibular reconstruction with, 410
Pedicled posterior tibial artery perforator
flap, distal third tibia defect
reconstructed with, 728.e5b, 728.e5f
Pedicled radial forearm flap, 533
Pedicled SCIP flaps, for penile
reconstruction, 487
Pedicled sternocostal portion, for
intrathoracic defects, 409
Pedicled submental flap, 377b, 377f
Pedicled superiorly-based nasolabial flap,
381b, 381f
Pedicled TFL myocutaneous flap, for
reconstruction of trochanteric
decubitus ulcer, e199b, e199f
Pedicled TFL perforator flap, trochanteric
defect reconstructed with, e202b,
e202f
Pelvic floor reconstruction, e56–e57
Pelvic reconstruction, e43–e61
anterolateral thigh flap, e51, e51b
cases, e57b–e59b, e57f–e59f
expert commentary in, e60b
free fibular phalloplasty, e51–e52, e51f
glansplasty, e49, e50f
gluteus flap for, e161
indications to, e45
phalloplasty, e46–e47
postoperative considerations after, e52
preoperative considerations in, e45
radial forearm free flap phalloplasty,
e50–e51
by region, e46–e52
urethroplasty, e47–e49
Pelvic ring reconstruction, with bilateral free
fibula osseus flaps, 612.e1b, 612.e1f
Penile reconstruction
bilateral pedicled SCIP flaps for, 487,
488b, 488f
groin and SCIP flap for, 486
in lateral arm flap, 519
Penis, anatomy of, e43–e45, e45f
Percutaneous aponeurotomy and lipofilling
(PALF), 28–36, 28f–29f, 35b
2-D application of, 29–31, 30f–31f
3-D application of, 31–32
cicatrix to matrix as, 31–32, 32f
3-D rigottomy of, 32
fat grafting in, 32–33
ability to differentiate necrotic cysts
from cancer, 33
fat delivery in, 34–35, 34f, 37f
fat harvest in, 33
fat processing in, 33–34, 34f
interstitial fluid pressure in, 32–33, 33f
recipient site vascularity in, 33
surface area-to-volume ratio in, 32
techniques for, 33–35
postoperative support for, 35
reverse abdominoplasty and fat transfer
in, 35, 38f
“Perforasome”, 382–383
Perforating vessels, 688
Perforator flaps, 4, e7
in abdominal wall reconstruction,
221–222
designs of, 656f
for gluteus flap, e166–e167, e170
in lateral thoracic region, 648–667,
648f
outcomes of, 665
recipient donor and, 665
in rectus abdominis flap, 424
of tensor fascia lata flap, e197, e197f
Perforator propeller flaps, 6
Perforator-based chimeric flaps, e6
Perforator-based conjoined flaps, e5
Perforator-based flap, 657, 664–665
Perforator-based radial forearm flap, 532
Perforators, of peroneal artery, in leg, 123
Perineal reconstruction, groin and SCIP flap
for, 486
Perineum
anatomy of, e43–e45
gender nonspecific, e43, e44f
pertinent female, e45
pertinent male, e43–e45, e45f
penile reconstruction and, in
anteromedial thigh flap, 710
reconstruction of, e56–e57
Perineural coaptation, for
neuromusculotendinous transfer, 292
Perineurial suture, 299–300, 299f–300f
Perioperative management, in second flap,
362
Perioperative risk reduction, 348–351
deep vein thrombosis and, 348–350
hyperglycemic control and, 350
pneumonia, pulmonary prophylaxis and,
350
postoperative cardiac complications and,
prevention of, 348
pulmonary embolism prophylaxis and,
348–350
smoking cessation and, 351
wound infection prophylaxis and, 350–351
Periorbit, reconstruction of, 142–143
using SCIA-based free groin flap, 151f,
159b
using ulnar free flap, 148f, 158b
Periosteum, arterial supply of, 638
Peripheral nerve allotransplantation,
779–797
Peripheral nerve regeneration, 779–780
Peripheral nervous system (PNS), 295
Periumbilical defects, abdominal wall
reconstruction for, 221t
Peroneal artery
flap and, 134
in leg, 123
Peroneal nerve, 598
anatomy of, 124f
in leg, 119–120
superficial, 603f
of fibula flap, 599
Peroneus muscle, in leg, 119
Pfannenstiel incision, 288
Phalloplasty, e46–e47
for congenital cases, timing of, e49
flap design, e47, e48f–e49f
free fibular, e51–e52, e51b, e51f
general principles of, e46–e47
local tissue, e47
microvascular, e47
postoperative considerations after, e52
radial forearm free flap, e50–e51, e51b
recipient neurovascular structures, e47,
e47f
Pharyngeal defects
circumferential, pectoralis major flap for,
409
partial
pectoralis major flap for, 408–409, 409f
reconstructed with pedicled pectoralis
major myocutaneous flap, 414b
Pharyngocutaneous fistula
island deltopectoral flap for, e96b, e96f
pectoralis major flap for, 408–409
Pharyngoesophageal reconstruction, in
anterolateral thigh flap, 703
Pedicled flaps (Continued)

Index
819
Pharyngogastric anastomosis,
pharyngocutaneous fistula after,
pectoralis major flap for, 408–409
Pharyngogastric cutaneous fistula, closed
with pedicled pectoralis major
myocutaneous flap, 412b, 412f
Photo-cross-linkable gelatin methacrylate,
e26
Photodynamic Eye, e16
ICG angiography and, e20–e21
Physical therapy and rehabilitation services,
for lower extremity reconstruction,
267–268
Pierse forceps, 312–313, 312f–313f
Pitfalls, 289b
Plain x-rays, in adult brachial plexus injury,
245, 245f
Planning, failure of, 323–326, 323b
Plantar arch, foot and, 130–131
Plantar artery
arterial branches between dorsalis pedis
and posterior tibialis/medial, 132f
dissection of, 628
Plantar dissection, of flap harvest, 618–619,
619f
Plantar nerve, in foot, 127–128
Plantar vascular system, in foot, 130–132
Plantaris muscle, in leg, 119
Plastic surgery, robotic applications in,
e36–e42, e36f–e37f, e41b
Platysma muscle
facial paralysis in, 166
for oral sphincter restoration, 178
for orbicularis oculi substitution, 175–176,
176f
transfer of, for depressor restoration, 178
Pluripotent stem cells, in tissue engineering,
e27
induced, e27
PNS. see Peripheral nervous system (PNS)
Poland syndrome, SGAP reconstruction of,
699.e2b, 699.e2f
Polyfascicular, defined, 296
Popliteal artery
branching pattern of, 122f
in leg, 120–121
in reconstruction of knee, 133
superficial femoral artery and, 119
Popliteal fossa, in leg, 120–121
Popliteal vessels, surgical exposure to, 123f
Posterior anal triangle, e43
Posterior antebrachial cutaneous nerve, in
forearm, 109
Posterior branch, in CLA, 638
Posterior cervical triangle, origins of the
arteries and trunks in, e141t
Posterior cutaneous nerve, 780t–781t
Posterior division of radial collateral artery
(PRCA), in arm, 94
Posterior heel defect, abductor digiti minimi
(ADM) flap for, 557b, 557f
Posterior interosseous artery, in forearm, 97,
100
Posterior interosseous artery flap, 505–509,
505b
anesthetic considerations for, 506
atypical indications for use of, 508–509
for chronic wound over olecranon, 509b,
509f
donor site closure in, 507
in dorsal and palmar hand defect
reconstruction, 234
for dorsal hand soft tissue defect, 508b,
508f
flap anatomy of, 505
flap components of, 505
flap design of, 506, 506f
flap dimensions of, 506
flap innervation of, 505
flap markings of, 506
flap modification of, 507
flap usage of, 508
handling of, 507
outcomes of, 509
patient positioning for, 506
postoperative care for, 509
preoperative preparation for, 505
special instruments for, 507
technical tips to optimize outcomes and
avoid complications in, 507–508
technique of flap harvest in, 506–507
venous drainage of, 505
Posterior interosseous nerve, 780t–781t
for digital nerve reconstruction, 109–110
in forearm, 97
Posterior subfascial dissection, of fibula flap,
602f
Posterior thigh flaps, in breast
reconstruction, 198
complications of, 199
Posterior thorax, in breast reconstruction,
194–195
complications of, 199
latissimus dorsi flap, 194, 195f
TDAP flap, 195
Posterior tibial arterial system, e176
Posterior tibial artery
inflow vessel and, 133–134
in leg, 121–122
surgical exposure of, 128f
Posterior tibial artery perforator flap,
717–728, 717f
anatomic landmarks of, 719
anatomical study of, 718.e1t
anatomy of, 718–719
anesthetic considerations, 721
arterial supply of, 718
atypical indications for, 724
bone dimensions in, 721
calf wound reconstructed with V-Y
advancement of, 728.e1b, 728.e1f
chimeric flap in, 722–723
components, 719
design, 719–720
difference in design of, 719–720, 720f
different indications in, 724–725
dimensions, 720–721
donor site of, 724–725
closure and management, 723
expected outcomes, 724
extended flap in, 723f
fascial flap in, 723
flow-through flap in, 722
free flap usage of, 724
general thoughts in design of, 719
harvest, 721–722, 722f
innervation, 718–719
long-term outcomes, 725
markings, 721, 721f
modification/handling, 722–723, 723f
muscle dimensions in, 721
outcomes, 724–725
patient positioning, 721
pedicled, distal third tibia defect
reconstructed with, 728.e5b, 728.e5f
pedicled flap usage of, 724
postoperative care of, 724
preoperative preparation, 719
propeller type, large medial malleolus
defect reconstructed with, 727b, 727f
skin island dimensions in, 720
special considerations in design of, 719
tips to optimize outcomes and avoid
complications, 724
typical indications for, 724
untoward outcomes, 725
usage, 724
venous drainage of, 718
V-Y fasciocutaneous, medial malleolus
defect with exposed tibia
reconstructed with, 726b, 726f
Posterior torso, reconstruction in, 208–210
external oblique, 210
intercostal perforator flap, 209
latissimus dorsi, 209, 210f
lumbar perforator, 210
omentum, 210
paraspinous (erector spinae) muscle,
209
trapezius, 208, 209f
Posterior ulnar recurrent artery, as branch
of ulnar artery, 99
Posterolateral approach, of soleus flap, 588
flap harvest, 589
Post-mastectomy and radiation breast defect
underwent delayed reconstruction,
with free DIEAP flap, 684b, 684f
Postoperative anticoagulation, for second
free flap, 363
Postoperative cardiac complications,
prevention of, 348
Postoperative care, 348–356
clinical assessment for, 351
discharge care in, 353–354
failure of, 329–331, 329b
late complications and, 330–331
monitoring and, 329
vascular compromise and, 329–330
flap monitoring in, 351–353
introduction to, 348
management of surgical complications in,
353
perioperative risk reduction in, 348–351
Postoperative fluid management, for second
free flap, 363
Postoperative immunosuppression, risks of,
743
Postoperative management, for second free
flap, 362–364
Postoperative monitoring, for second free
flap, 363
Postoperative pain control, for second free
flap, 362–363
Postoperative vasoactive drug use, for
second free flap, 363
Post-traumatic defects, recipient vessel
selection in lower extremity, 136
Post-traumatic facial paralysis, acute,
microsurgical management for,
168–169
Pre-collectors, 42
Prednisolone, 776
Prefabricated flaps, 4
Prefabrication, 16–27, 16f
clinical applications of
in facial skeleton, 18t
in facial soft tissue subunits, 17t
in facial soft tissue with cartilage, 17t
in oropharynx and esophagus, 18t
in penis, 18t
definition of, 16
of flap, 18–20
clinical examples of, 19–20, 20f–22f
concept of, 18
flap maturation in, 19
flap transfer in, 19, 19f
technique for, 16f, 18–19
Pre-grafting expansion, 32

820
Index
Prelaminated flaps, 4
Prelamination, 16–27
clinical applications of
in facial skeleton, 18t
in facial soft tissue subunits, 17t
in facial soft tissue with cartilage, 17t
in oropharynx and esophagus, 18t
in penis, 18t
definition of, 16
distant, 23
of flap, 20–23
clinical examples of, 23, 24f–26f
concept of, 20
definition of, 20
flap maturation in, 23
flap transfer in, 23
technique for, 20–23
Preoperative considerations, in flap
re-exploration, 334
Preoperative CT angiography, of fibula flap,
599
Pressure sore reconstruction, 697
reconstruction elevator and, 2
Pressure sores, superior gluteal flap for,
e160f
Primary adventitiectomy, 628
Primary nerve repair, 300
for acute post-traumatic facial paralysis,
169
Princeps pollicis artery, in hand, 111
Processed nerve allografts, 792–794
Profunda artery perforator (PAP) flap, in
breast reconstruction, 198
Profunda brachii, in arm, 93
Profunda femoris, thigh and, 116–119
Progenitor cells, unipotent, in tissue
engineering, e27
Prolonged surgery, general complications of,
330b
“Prope” tolerance, e215
Propeller posterior tibial artery cutaneous-
muscle perforator flap, distal third
full soft tissue with bony defect
reconstructed with, 728.e4b, 728.e4f
Propeller type posterior tibial artery
perforator flap, large medial
malleolus defect reconstructed with,
727b, 727f
Prophylaxis, in uterus transplantation, 777
Provision of volume, e62
Proximal forearm, transplant, technique for,
762
Proximal forearm soft tissue defect
reconstruction, 235–238, 235b, 237b,
237f–240f
Proximal interphalangeal (PIP) joint
transfer, 627
Proximal nerve transfers, distal nerve
transfer vs., 248t
Proximally based hemi-soleus flap, 591
typical indication of, 591
Proximally-based free composite soleus,
atypical indication of, 591–592
Proximally-based medial soleus muscle,
588
Proximally-based pedicled medial
hemisoleus flap
chronic lower one-third of leg wound with
bone exposed reconstructed, 593b,
593f
open wound in middle of leg with
exposed bone reconstructed, 594b,
594f
Proximally-based soleus muscle flap, 588
atypical indication of, 591–592
typical indication of, 591
Proximally-based soleus muscle free flap,
atypical indication of, 591
Psychiatric outcomes, in lower extremity
reconstruction, 267
Psychosocial considerations, 743–744
Pulmonary embolism prophylaxis,
postoperative care for, 348–350
Pulmonary prophylaxis, postoperative care
for, 350
Pulse oximetry, 352
R
Radial artery
in arm, 93f
branch, in exposure of distal brachial
artery, 95–96
in distal forearm and anatomic snuffbox,
exposure of, 104–106
in forearm, 101–104
in hand, 111
superficial palmar branch, recipient vessel
selection and, 113
in wrist and anatomic snuffbox, exposure
of, 113.e4b, 113.e4f
Radial collateral artery, in arm, 94
Radial component reconstruction, 629
Radial forearm flap, 525–539, 525f, 533b
adipofascial, 532, 539.e1b, 539.e1f
anesthetic considerations for, 530
arterial supply of, 525–526, 526f
bone dimensions of, 529
donor site management of, 533
fascial, 532
flap anatomy of, 525–527
flap application of, 533–534
flap components of, 526f, 527
flap design of, 527–529
anatomic landmarks in, 527–528,
528f
design differences in, 528–529
general considerations in, 528, 529f
special considerations in, 528
flap dimensions of, 529
flap handling of, 531–532
flap innervation of, 527
flap markings of, 529–530
flap modification of, 531–532
flow-through, 532, 538b, 538f
free, 533, 536b, 536f, 538b, 538f, 539.e1b,
539.e1f
indications of, 533–534
in lip reconstruction, 279–280
for mandibular defect, 475b, 475f
osteocutaneous, 531, 532f, 538b, 538f
outcomes of, 534
patient positioning for, 530
pedicled, 533
perforator-based, 532
postoperative care for, 534
preoperative preparation for, 527
reverse, 531
sensate, 532
skin island dimensions of, 529
split, 532
suprafascial, 531, 535b, 535f
technique of flap harvest (subfascial) in,
530–531, 530f
tendinocutaneous, 531
tissue expansion of, 531–532
venous drainage of, 526–527, 527f
Radial forearm free flap phalloplasty
(RFFFP), e50–e51, e51b
Radial nerve
antecubital fossa and, 95
in arm and forearm, 107–109
brachial artery and, 92
in forearm, 100f
Radial recurrent artery
for microvascular tissue transfer, 95–96
radial artery and, 101
Radiation skin necrosis, fasciocutaneous
lateral arm flap for, 524.e1b, 524.e1f
Radical cystectomy, e30
Radiographic evaluation, for hand and
upper extremity transplantation, 755,
756f
RAFT. see Reverse abdominoplasty and fat
transfer (RAFT)
“Random pattern flap”, e67–e68
Random skin flaps, e1
Rapid prototype modeling, e11–e15,
e12f–e13f
RCA. see Root cause analysis (RCA)
RCRI. see Revised cardiac risk index (RCRI)
Recipient artery, 311
assessing the quality of, 311
for reconstruction
of abdomen and groin, 82
of chest, 81
Recipient neurovascular structures, in
phalloplasty, e47, e47f
Recipient site
of anteromedial thigh flap, 711
complications, in chest and back
reconstruction, 211
of expected outcomes, in fibula flap, 605
of fibula flap, 605
in flap selection, 6–11, 11f
of internal oblique flap, postoperative
care for, e108
of omentum flap, postoperative care for,
e100
of pectoralis major flap
expected outcomes of, 410
long-term outcomes of, 410
postoperative care for, 409–410
untoward outcomes of, 410
of posterior tibial artery perforator flap,
724
postoperative care in, of DIEAP/SIEA
flaps, 682
of superior epigastric flap, postoperative
care for, e102
of supraclavicular artery flap
long-term outcomes of, 391
postoperative care for, 390
untoward outcomes of, 391
of tensor fascia lata flap, e198
of untoward outcomes, 631, 631t
in fibula flap, 605–606
vascularity of, in fat grafting, 33
Recipient vein, 311
assessing the quality of, 311
Recipient vessel selection
in chest, abdomen, groin, and back,
75–88
in head and neck, 61–74
in lower extremity, 115–137
anesthetic considerations for, 137
high incidence of post-traumatic defects
in, 136
inflow, 133–134
outflow, 136
patient positioning in, 137
vascular pathology with two-or
one-vessel leg, 136
vascular spasm in, 136–137
in upper extremity, 89–114
Recipient vessels
in abdominal wall reconstruction,
222–223

Index
821
of donor flap, avoiding complications in,
325–326
preparation of, 310–311
selection of, 310
Recombinant tissue plasminogen activator,
341–343
Reconstruction
craniofacial microvascular, 138–142
of defects, in free-flap style, 732–733
of head and neck, 138–161
of knee, 133
recipient arteries for
of abdomen and groin, 82
of chest, 81
of thigh, 133
Reconstructive choices, 357, 360–361, 360f
Reconstructive elevator, 2
modified, 3, 3f
Reconstructive ladder, 1–2
modified, 3, 3f
Reconstructive microsurgery, 3–4
Reconstructive surgery, e204
computed tomography angiography and,
preoperative planning with, e19–e21
definition of, 1
emerging technology in, e11–e24, e23b
history of, 1
indocyanine green angiography in, tissue
perfusion assessment with, e15–e19,
e16f
modified reconstructive ladder/elevator
in, 3, 3f
present state of, 2–3
problem analysis in, 1–5, 5b
reconstructive elevator and, 2
reconstructive ladder and, 1–2
reconstructive microsurgery and, 3–4
robotic applications in, e36–e42, e36f–e37f,
e41b
surgical judgment and, 2–3
three-dimensional imaging systems in,
e21–e22, e21f–e22f
virtual surgical planning and rapid
prototype modeling, e11–e15,
e12f–e13f
intraoperative stereotactic navigation,
e14–e15, e15f
mandibular and maxillary
reconstruction with, e11–e14,
e13f–e14f
orbital reconstruction with, e14, e14f
Reconstructive transplant team, e205
Reconstructive transplantation
immunology and research in, e210–e220
program
active, maintenance of, e208
committee approvals and, e207
conclusions for, e208–e209
definition of, e204
development of, institution and, e205
forming the team for, e205–e207,
e206f
funding for, e207
going live in, e208
organ procurement organization and,
e207–e208, e208f
research or clinical practice, e207
Rectus abdominis flap, 416–431, 416f
in abdomen, 75
advantages of, 418
anatomic landmarks of, 419, 419f
anesthetic considerations for, 421
in anterolateral chest, reconstruction of,
205–206, 205f
arterial supply of, 417
bone dimensions in, 420
chest wall and breast reconstruction in,
419
delay of, 424
disadvantages of, 418
donor site
closure and management, 426
expected outcomes, 427
long-term outcomes in, 428, 428f
postoperative care for, 427
untoward/unfavorable outcomes in, 427
flap anatomy in, 417–418
flap components in, 418
flap design in, 419–420
flap dimensions in, 420
flap innervation in, 417
flap markings in, 420, 420f
flap modification/flap handling in,
424–425
flap usage in, 426–427
free microvascular transfer of, based on
deep superior epigastric artery,
425–426
functional muscle transfer in, 424
between lateral and medial row
perforators, 425
muscle dimensions in, 420
muscle flap in, 421–424
myocutaneous flap in
free, based DIEA, 419
superiorly-based bipedicled, 419
superiorly-based unipedicled, 419
other reconstruction on, 419–420
patient positioning for, 420–421
pedicle extension of
inferiorly-based flap in, 425
superiorly-based flap in, 425
pedicled or free, difference in design, 420
perforator flap in, 424
postoperative care for, 427
preoperative preparation for, 418
recipient site of, 427
sensory reinnervation of, 424
supercharged flap in, 425
superiorly-based or inferiorly-based flap
as, method of rotation and inset of,
425–426
superiorly-based pedicled tram flap in,
421
technical tips to optimize outcomes and
avoid complications in, 426
technique of flap harvest in, 421–424,
422f–423f
transverse superior skin island and
submammary portion of, 425
variations of, 426
with vascularized rib, 425
venous drainage of, 417
Rectus abdominis muscle
for functional muscle transfer, 289
robotic harvest of, e38, e39f, e41b
Rectus femoris branch
of LCFA, 708
thigh and, 116–117
Rectus sheath, in abdomen, 75
“Recycling,” in free-style flap, 732
Regeneration, peripheral nerve, 779–780
“Regenerative sprouting”, 304–305
Region
arterial anatomy of, e176
nerves in, e177
venous anatomy of, e176–e177
Regional axial flaps, in elbow and proximal
forearm soft tissue defect
reconstruction, 235
Regional flaps, in abdominal wall
reconstruction, 222
Regional reconstruction, with pedicled flaps,
682
Reinnervation, in laryngeal
allotransplantation, 771
Rejection
genetic incompatibility as caused by, 740
of nerves, in composite tissue allograft,
788f
in reconstructive transplantation,
e212–e213
Reliable perforator, in lateral thoracic
region, 653
Renal transplant patients, side-effects of
tacrolimus in, 741t
Rescue therapy, immune suppression and,
740
Retrograde dissection, 628
Revascularization, in hand and upper
extremity transplantation, 761f
Reverse abdominoplasty and fat transfer
(RAFT), 35, 38f
breast augmentation with, 39b, 39f, 35.e2b,
35.e2f
breast reconstruction with, 37b–38b,
37f–38f
Reverse end-to-side nerve transfers, 305, 305f
Reverse flap
for lateral arm flap, 515–516
for latissimus dorsi flap, 455
for pectoralis major flap, 405
Reverse forearm flap, 531
Reverse sural flap, 542
Reversed cross finger flap, 495
Revised cardiac risk index (RCRI), 348,
348t
Revisions
for facial reanimation, 179–180
secondary, craniofacial microvascular
reconstruction and, 141–142
RFFFP. see Radial forearm free flap
phalloplasty (RFFFP)
Rhabdosarcoma, congenital, free
musculocutaneous latissimus dorsi
transfer for, 462b, 462f
Rhesus factor (Rh), e211
Rhomboid major muscle, e135
Rhomboid minor muscle, e135
Rib cartilage, autologous, microtia
reconstructed with, e83b, e83f
Rib-latissimus dorsi osteomusculocutaneous
flap, 455
Rib-serratus anterior composite flap, 258
Right back, free-style flap from, left upper
back defect reconstructed with, 737b,
737f
Right cheek and lip defect, 377b, 377f
Right face defect, TFL perforator flap for,
e202b, e202f
Right foot defect reconstructed with
free-style flap, from previous
transferred anterolateral thigh flap,
735b, 735f
Right leg, malignant melanoma, wide
extension of, 728.e3b, 728.e3f
Robotic applications, in plastic and
reconstructive surgery, e36–e42,
e36f–e37f, e41b
future directions for, e39
operating interface for, e36–e37
robotic microvascular anastomosis, e39
robotic muscle harvest in, e37–e39,
e38f–e39f
robotic operating team in, e37
transoral robotic surgery, e37, e38f
Robotic microvascular anastomosis, e39
indications for, e39

822
Index
Robotic muscle harvest, e37–e39, e38f–e39f
indications for, e38–e39
Robotic surgery, 4
Rodriguez Maxillary Defect Classification
System, 157f
Root cause analysis (RCA), 358
Root injury pain, in adult brachial plexus
injury, 245
Rotation, of pedicled temporoparietal fascia
flap, e78
Routine preoperative work-up, 584
S
Sacral defects
bilateral gluteus maximus advancement
flaps for, e172b, e172f
gluteus flap for, e170
musculocutaneous pedicled flap for,
e168f
“Sacral neuromodulation”, 287
Sacral ulcer, bilateral pedicled SGAP flaps
for, e172b, e172f
Salvage, versus amputation, in lower
extremity reconstruction, 256–257
Saphenous artery, superficial femoral artery
and, 119
Saphenous branch
of DGA, 638
of skin paddle, 638
Saphenous nerve, 780t–781t
of medial femoral condyle, 639
Scaffolds, e27
Scalp, reconstruction of, 142
using ALT free flap, 149f–150f, 159b
Scaphoid proximal pole fracture non-union
treated, with MFC corticocancellous
graft, 647.e1b
Scapula, muscles of, 79f
Scapular bone
chimeric free flap, mandibular
reconstruction with, 445b, 445f
flap
arterial supply of, 435
dimension of, 438
lateral, 438, 440
medial, 438, 440
Scapular cutaneous flap, arterial supply of,
434–435
Scapular flap, 432–445, 432f, 452f
anatomic landmarks and markings for,
436, 437f
for ankle soft tissue defect, 445.e2b,
445.e2f
arterial supply of, 433–435, 433f
components of, 436
design of, 436–438
dimensions of, 438
donor site closure and management for,
441
flap modification/flap handling of,
440–441
innervation of, 435
for neck contracture release, 445.e3b,
445.e3f
outcomes of, 443
patient positioning for, 438–439
postoperative care for, 443
preoperative preparation for, 436
technical tips for, 441–442
technique of flap harvest for, 439–440,
439f
usage of, 442–443
venous drainage of, 435
Scapular perforator flap, in anterolateral
chest, reconstruction of, 207–208
Scapular system, in elbow and proximal
forearm soft tissue defect
reconstruction, 238
Scapular tip bone
based on the angular artery, 440–441, 441f
flap
arterial supply of, 435
venous drainage of, 435
Scapular winging, in chest and back
reconstruction, 211
Scarpa’s fascia
in abdomen, 82
superficial inferior epigastric artery in,
670, 671f
Schwann cells, 295
immunology of nerve allotransplantation
and, 781–782, 782f
SCIA. see Superficial circumflex iliac artery
(SCIA)
SCIA-based free groin flap, periorbital and
cheek reconstruction using, 159b
Sciatic nerve, in thigh, 115
Sclerosing basosquamous cancer, 277f
SCPGs. see Chondroitin sulfate proteoglycans
(SCPGs)
Second free flap, 361–364
perioperative management for, 362
postoperative management for, 362–364
system-based practice for, 361–362
Second toe pulp flap, e177–e181
anatomy of, e177–e178
arterial supply of, e177
free, e181
preoperative preparation of, e178
typical indications for use of, e181
venous drainage of, e177–e178
Secondary breast reconstruction, DIEAP/
SIEA flap in, 680, 681f
Secondary revisions, craniofacial
microvascular reconstruction and,
141–142
Segmental functional gracilis flap, 562–563,
564f
Segmental functional transfer, gracilis flap
and, 564, 564f
Self-retaining retractors, 694–695
Semi-direct pathway, in allorecognition, e211
Semmes-Weinstein monofilament tests, in
lower lip reconstruction, 281
Sensate DIEAP flap, 678, 678f
Sensate flaps, 658, 658f, 664, 703
in deltopectoral flaps, e91–e92
Sensate radial forearm flap, 532
Sensory examination, for adult brachial
plexus injury, 244–245
Sensory flap, for pectoralis major flap, 406
Sensory innervation
of anterolateral thigh flap, 701
of deep inferior epigastric artery
perforator flap, 672, 672f
Sensory protection, of denervated muscle,
298
Sensory rehabilitation, 630
Septocutaneous direct perforators, 718
Septocutaneous perforators, 650
in forearm, 98–99
multiple, in forearm, 102
posterior interosseous artery and, 100
Septocutaneous vessels, 718
of LCFA, 701
Seroma, formation of
in abdominal wall reconstruction, 223
in chest and back reconstruction, 211
Serratus anterior muscle flap, 452f
in anterolateral chest, reconstruction of,
207
Serratus fascia flap, 452f
Serratus muscle, latissimus dorsi flap and,
454
Severe facial deformity, reconstructed with
full face allograft
from animal attack, 751b, 751f
from burn injury, 749b–750b, 749f–750f
Sex reassignment surgery, bilateral pedicled
SCIP flaps for, 487
SGA. see Superomedial genicular artery
(SGA)
SGAP. see Superior gluteal artery perforator
(SGAP) flaps
SGAP/DIEP flaps, bilateral combined,
breast reconstruction with, 699.e3b,
699.e3f
Short gut syndrome, pedicled jejunum for,
e127–e128
Shoulder
adult brachial plexus injury reconstruction
in, 247–248, 250
soft tissue defects of, 518
Siamese flap, 677, e5
SIEA. see Superficial inferior epigastric artery
(SIEA) perforator flap
SIEV. see Superficial inferior epigastric vein
(SIEV)
Simultaneous ipsilateral pectoralis major
myocutaneous flap, deltopectoral flap
and, e92
Singapore flap, in vulvar and vaginal
reconstruction, e52–e54, e53f, e54b
Single-digit amputation, 629
Site
of defect, avoiding complications in, 324
of donor flap, avoiding complications in,
325–326
Size mismatch, failure of execution and,
326–329, 328f
Skeletal alignment, facial transplantation of,
744
Skeletal fixation, facial transplantation of,
744
Skeleton, facial, 61–63, 62f
Skeletonization, 628
for Moberg flap, 500
Skin
closure, tunneling and, in flap
compromise, 338–339, 338f–339f
de-novo assembly of matrices in, e29–e30
of face, 61
ready-to-wear custom-made, e30
substitutes for, e29t
acellular, e28
cellular, e28
compound, with epidermal and dermal
elements, e28–e29
dermal, e28
epidermal, e28
tissue engineering-based clinical
applications for, e28–e30
Skin flap surgery, purpose of, e62
Skin graft
of hindfoot, 271.e2b, 271.e2f
for lip reconstruction, 281–282
pedicled omentum flap and, sternal
osteomyelitis defect reconstructed
with, e109b, e109f
temporoparietal fascia flap and
dorsal foot defect reconstructed with,
e85b, e85f
dorsal hand defect reconstructed with,
e84b, e84f
dorsal hand injury reconstructed with,
e82b, e82f
microtia reconstructed with, e83b, e83f

Index
823
Skin incisions, of facial transplantation, 744,
745f
Skin island
of fibula flap
design, 600–602
length, 599
width, 599
of tensor fascia lata flap
dimensions, e194
expanded, e196
transverse, e196
Skin island dimensions, 655
of anterolateral thigh flap, 703–704
of deltopectoral flaps and internal
mammary artery perforator flap,
e90
of external oblique flap, e104
of flap, 675
of gluteus flap, e161
of great toe pulp flap and second toe
pulp flap, e179
of iliac flap, 468
of internal oblique flap, e107
of lateral arm flap, 514
of latissimus dorsi flap, 451
of medial femoral condyle, 641
of medial plantar flap, e182
of posterior tibial artery perforator flap,
720
of radial forearm flap, 529
of soleus flap, 586
of superior epigastric flap, e101
of supraclavicular artery flap, 389
Skin paddle
angiosome of, 638
design, for sural flap, 542
variations, gracilis, 563
Skin resurfacing, of flap, 664
Skin vessels, lack of adequate, in
anteromedial thigh flap, 709
Skull, 62f
Skull base and lateral facial composite
defect, reconstructed with free VRAM
flap, 430b, 430f
Small intestine, regional anatomy for, e112,
e113f
Small saphenous vein
anatomy of, 135f
in lower extremity, 135–136
SMAS. see Superficial musculoaponeurotic
system (SMAS)
Smile, facial paralysis, surgical technique for,
176–179
Smoking cessation, 351
Snuffbox, anatomic
exposure of radial artery in, 104–106,
113.e4b, 113.e4f
radial side of, 105f
Soft tissue
coverage, in lower extremity, 258–259,
259f–260f
support of, craniofacial microvascular
reconstruction and, 140
volume of, craniofacial microvascular
reconstruction and, 140–141
Soft tissue augmentation
groin and SCIP flap for, 486
of neck, anteromedial thigh free flap for,
716.e3b, 716.e3f
Soft tissue defect, 595.e3b, 595.e3f
in knee, gastrocnemius flap for, 580.e1b,
580.e1f
Soft tissue flap reconstruction, in abdominal
wall, 218
Soft tissue reconstruction, in lower
extremity, timing of, 257–258
Soleus flap, 581–595, 581f
anesthetic considerations of, 588
donor site closure and management of,
589–591
flap anatomy of, 581–583
flap components of, 583–584
flap design of, 584–586
flap dimensions of, 586
flap markings of, 586–588
flap usage of, 591–592
modifications/handling of, 589
outcomes of, 592–593
patient positioning of, 588
postoperative care of, 592
preoperative preparation of, 584
recipient site and donor site and, 592
technical tips to optimize outcomes and
avoid complications, 591
technique of flap harvest, 588–589
Soleus muscle, 586
in leg, 119
Soleus-fibula transfer, 582f
Solid organ allotransplantations, 770
Solid organ transplantation, e204
Sparing mastectomy, bilateral skin,
transverse upper gracilis flaps for,
568.e4b, 568.e4f
Spasm, vascular, recipient vessel selection in
lower extremity, 136–137
Speech evaluation, for facial paralysis, 168,
168t
Spinal defect, extended pedicled chimeric
SGAP flap for, e173b
Spiral interrupted suturing, 316, 318f
Split anterolateral thigh flap, reconstruction
of bilateral buccal mucosa defects
with, 716.e4b, 716.e4f
Split cutaneous flap, 658, 659f–660f
for lateral arm flap, 517
Split deltopectoral flap, e91
“Split” iliac crest, 471
Split radial forearm flap, 532
Split skin grafts, 1
Split-thickness skin graft (STSG), e176
“Spontaneous collateral sprouting”, 304–305
Spring tension, of microsurgical
instruments, 312–313
SPY 20001 Imaging System, e18
Spy Elite System, e16
analysis software with, e16
Standard microsurgery instruments, of
medial femoral condyle, 642
Stapedius muscle, facial paralysis in, 166
Static procedure, for facial paralysis,
174–176
Stem cells, tissue engineering and, e27
multipotent, e27
pluripotent, e27
induced, e27
Stereolithography, e11
Stereophotogrammetry, e21–e22, e21f–e22f
Sterile tourniquet, 641
in hand and upper extremity
transplantation, 760
Sternal and neck defect, reconstructed with
bilateral pedicled pectoralis major
flaps, 411b, 411f
Sternal osteomyelitis defect, reconstructed
with pedicled omentum flap and skin
graft, e109b, e109f
Sternocostal head, of pectoralis major
muscle, flap harvest in, 403–404,
403f–404f
Stomach, as replacement organ for
esophagus, 144
Streptokinase, 341
“Stress hyperglycemia”, 350
STSG. see Split-thickness skin graft (STSG)
Subclavian artery, e139f, e141t
Subcutaneous route, of jejunum flap,
technical steps for, e127
Subcutaneous veins, in exposure of distal
brachial artery, 95
Subdermal plexus, in FAMM flap, 373
Subfascial dissection, of anterolateral thigh
flap, 705f, 706
Submandibular flap, for lymph node
transfer, 50
Submental artery
in head and neck, 69
in submental flap, 376
Submental flap, 375–379
anatomic landmarks of, 376–378, 377b,
377f
anatomy of, 376
arterial supply of, 376
design of, 376–378
dimensions of, 378
donor site closure and management of,
379
expected outcomes of, 379
innervation of, 376
for lymph node transfer, 50
postoperative care for, 379
submental artery in, 376
submental vein in, 376
technique of flap harvest for, 378–379
usage of, 379
venous drainage of, 376
Submental vein, in submental flap, 376
Subscapular artery, in latissimus dorsi flap,
447f, 448
Subscapular system, in chest, 80, 80f
Substernal route, of jejunum flap, technical
steps for, e127
Supercharge (or reverse end-to-side) nerve
transfers, 305, 305f
Supercharged flap, in rectus abdominis flap,
425
Superficial cervical artery, trapezius flap
based on
advantages of, e141
anatomic landmarks of, e142, e142f
arterial supply of, e137
ascending branch of
donor site closure and management for,
e147
flap usage for, e147–e148
components of, e141
descending branch of
donor site closure and management for,
e147
flap usage for, e147–e149
disadvantages of, e141–e142
flap anatomy of, e136, e139f
flap design of, e143
flap dimensions of, e144, e144f
patient positioning in, e145
variation of arterial origin of, e138, e139f,
e141t
venous drainage of, e139–e141
Superficial cervical fascia, of head and neck,
63
Superficial circumflex iliac artery (SCIA),
465, 467f
in abdomen, 82
femoral artery in thigh and, 115–116
in groin flap, 479–480, 479f
Superficial circumflex iliac artery perforator
flap, 478–490, 478f
anatomy of, 478–480
for ankle soft tissue defect, 487

824
Index
bilateral pedicled, for penile
reconstruction, 487
components of, 480
design of, 481
dimensions of, 481
donor site closure and management of,
485
flap modification/flap handling of,
484–485
outcomes of, 486–487
patient positioning for, 481–482
postoperative care for, 486
preoperative preparation for, 480–481
technical tips for, 485–486
technique of flap harvest for, 479f, 483,
484f
usage of, 486
Superficial fascia, in head and neck, 62–63
Superficial femoral artery
deep femoral artery and, collateral
pathways between, 118f
in reconstruction of knee, 133
thigh and, 119
Superficial inferior epigastric artery, in
abdomen, 82
Superficial inferior epigastric artery (SIEA)
perforator flap, 668–686, 668f, e20
anatomic landmarks, 673, 674f
anatomy of, 669–672
arterial supply of, 669–670
in breast reconstruction, 191–193, 193f
components of, 672–673
design of, 673–675
differences in design of, 674–675
dimensions, 675
donor site closure and management of,
679
expected outcomes, 682
general thoughts in design of, 673–674
harvest, 675–677, 676f, 677b
innervation of, 671–672, 672t
long-term outcomes, 683
markings, 675, 675f
modification/handling, 677–679
outcomes, 682–683
preoperative preparation in, 673, 674f
in Scarpa’s fascia, 670, 671f
special considerations in design of, 674
tips to optimize outcomes and avoid
complications of, 679–680
unilateral congenital breast hypoplasia
reconstructed with, 685b, 685f
untoward outcomes, 682
usage, 680–682
atypical indications for, 681–682
free flap, 680
pedicled, 680
typical indications for, 680–681
Superficial inferior epigastric vein (SIEV),
670, 671f
Superficial layer of deep cervical fascia
(SLDCF), of head and neck, 63
Superficial musculoaponeurotic system
(SMAS), e72–e74
in head and neck, 63
Superficial palmar arch, in hand, 111
Superficial palmar branch, of radial artery,
recipient vessel selection and, 113
Superficial palmar system, in hand, 111
Superficial peroneal nerve, 603f, 780t–781t
of fibula flap, 599
in foot, 127–128
in leg, 119–120
Superficial radial nerve, 780t–781t
Superficial scapular artery,
osteomyocutaneous flap based on,
e139f
Superficial temporal fascia, of head and
neck, 62–63
Superficial veins
of arm, 112f
of forearm, 110f
Superior epigastric artery, in abdomen, 82
Superior epigastric flap, e101
advantages of, e101
anatomic landmarks of, e101
arterial and venous supply of, e101
disadvantages of, e101
flap anatomy in, e101
flap components of, e101
flap design in, e101–e102
flap innervation of, e101
flap markings in, e101–e102, e102f
flap modification/flap handling in, e102
flap usage in, e102
outcomes of, e102–e103
patient positioning for, e102
postoperative care of, e102
preoperative preparation for, e101–e103
skin island dimensions of, e101
special considerations in, e101
special instruments for, e102
technical tips to optimize outcomes and
avoid complications in, e102
technique of flap harvest in, e102
venous drainage of, e101
Superior gluteal artery (SGA), 688
of gluteus flap, e157
Superior gluteal artery perforator (SGAP)
flaps, 196, 197f, 687–699, 687f, e157
anatomic landmarks, 690, 691f
anesthetic considerations in, 694
arterial and venous supply of, 688, 689f
for breast reconstruction, e161
components, 689–690, 690t
dimensions, 691–692
expected outcomes, 697
extended pedicled chimeric, for spinal
defect, e173b, e173f
free flap, e161f, e162, e163f
general thoughts about design of, 690,
692f
harvest, 694–696, 695f
innervation, 689
long-term outcomes, 697
markings, 692–694, 693f
for mastectomy defect, e174b, e174f
outcomes, 697
patient positioning, 694
pedicle length of, e159f
pedicled flap, e167f
for pelvic reconstruction, e161
for sacral ulcer, e172b, e172f
postoperative care for, 697
preoperative preparation in, 690
reconstruction, of Poland syndrome,
699.e2b, 699.e2f
typical indications for use of, 697
untoward outcomes, 697, 697t
usage, 697
venous drainage of, 688
Superior gluteal myocutaneous free flap,
687
Superior gluteus maximus muscle free flap,
e162, e164f
Superior thyroid artery, in head and neck,
69
Superior ulnar collateral artery, in arm, 94
Superiorly-based pedicled FAMM flap, 374b,
374f
Superiorly-based pedicled tram flap, 421
Supermicrosurgery, 4, 321–322
Superomedial genicular artery (SGA),
636–637, 637f
Supraclavicular artery flap, 387–395, 387f
advantages of, 388
anatomic landmarks of, 389
anesthetic considerations for, 389
arterial supply of, 387
case on, 394b, 394f
disadvantages of, 388
donor site of
closure and management of, 390
postoperative care of, 390
flap anatomy in, 387–388
flap components of, 388, 388f
flap design of, 389, 389f
flap dimensions of, 389
flap markings of, 389
flap modifications of, 390
flap usage, 390
innervation of, 388
outcomes of, 391
patient positioning of, 389
postoperative care for, 390
preoperative preparation for, 388–389
recipient site of
long-term outcomes of, 391
postoperative care for, 390
untoward outcomes of, 391
technical tips to optimize outcomes and
avoid complications in, 390
technique of flap harvest in, 389–390,
389f
venous drainage of, 388
Supraclavicular brachial plexus, exploration
of, 246, 246f
Supraclavicular flap, 392b, 392f–393f
for lymph node transfer, 50, 55
Suprafascial anterolateral thigh flap, tongue
defect reconstructed with, 712b, 712f
Suprafascial dissection
of anterolateral thigh flap, 704f, 706
of radial forearm flap, 528, 529f
Suprafascial radial forearm flap, 531, 535b,
535f
“Supramicrosurgery”, 310
Supraorbital nerve, in head and neck, 61–62
Suprascapular artery, variation of arterial
origin of, e139, e141t
Supratrochlear artery
in forehead flap, 368
in head and neck, 71
Sural flap, 540–544, 541f
anesthetic considerations for, 543
arterial and venous supply of, 541–542
atypical indications of, 543
donor site closure and management of,
543
flap anatomy of, 541–542
flap components of, 542
flap design of, 542
flap dimensions of, 543
flap innervation of, 542
flap markings of, 543
handling of, 543
modification of, 543
outcomes of, 543–544
patient positioning for, 543
pedicled, retrograde, for calcaneus defect,
556.e1b, 556.e1f
postoperative care for, 543
preoperative preparation for, 542
special instruments for, 543
technical tips to optimize outcomes and
avoid complications for, 543
Superficial circumflex iliac artery perforator
flap (Continued)

Index
825
technique of flap harvest in, 543
typical indications of, 543
usage of, 543
venous drainage of, 542
Sural nerve, 301, 301f–302f
grafting, 301, 302f, 780t–781t
Surface 3-dimensional photography, e11
Surface area-to-volume ratio, in fat grafting,
32
Surface coverage, e62
Surgery
reconstructive, e204
traumatic indications for, 256–257
Surgical exploration, in management of
surgical complications, 353
Surgical judgment, 2–3
Surgical planning
in abdominal wall reconstruction, 219
in face transplantation, 744
Surgical technique, of medial femoral
condyle, 641, 642f
Sushruta Samhita, 379
Suture material, for vessels, 313
Suture tying techniques, for microsurgery,
321
Suturing techniques, for vessel, 315–322
Synthetic materials, in skin tissue
engineering, e28
System-based practice, for second free flap,
361–362
Systemic disease, of patients, in avoiding
complications, 324
Systemic factors, of flap failure, 358
Systemic immunosuppression, 781
T
Tacrolimus, 783
side-effects of, in renal transplant patients,
741t
Tailoring, of flap, e62–e71
T-anastomosis, 662–663, 662f–663f
T-cell activation, e211–e212, e211f–e212f
TDAP. see Thoracodorsal artery perforator
(TDAP) flap
Temporal artery, superficial, of head and
neck, 69–70
Temporal calvareal osteofascial flap, e80
Temporal fascia, in head and neck, 62–63
Temporal fat pad, in head and neck, 63
Temporalis muscle
for eye reanimation, 176
of face, 63–64
transfer of, for smile restoration, 177–178
Temporalis muscle fascia, in head and neck,
63
Temporoparietal fascia (TPF), e72–e74, e74f
in head and neck, 62–63
Temporoparietal fascia flap, e72–e86, e72f
advantages of, e76
anatomic landmarks of, e77, e77f
anesthetic considerations for, e79
arterial supply of, e74, e75f
disadvantages of, e76, e77f
in elbow and proximal forearm soft tissue
defect reconstruction, 236–237
endoscopic-assisted harvest of, e79–e80
flap anatomy, e72–e76, e73f
flap components, e75–e76
flap design of, e77–e78, e77f
flap dimensions in, e77–e78
flap innervation, e75, e76f
flap markings in, e78–e79, e78f
flap usage of, e80–e81
harvest of, technique of, e79–e80, e79f
modification of, e80
patient positioning for, e79
postoperative care for, e81
preoperative preparation for, e79
rotation of pedicled flaps in, e78
technical tips to optimize outcomes and
avoid complications, e80
untoward outcomes of, e81
venous drainage of, e74–e75
Tendinocutaneous radial forearm flap, 531
Tendon dimensions, of lateral arm flap, 514
Tendon transfers, in traumatic
reconstruction, 265
Tensor fascia lata (TFL) flap, e190–203,
e190f, e195f
anatomic landmarks of, e192, e193f
anatomy of, e190–e191, e191f
anesthetic considerations in, e194–e195
arterial supply of, e190–e191
atypical indications for, e198
components, e192
design, e192–e193
difference in design of, e193
dimensions, e193–e194
donor site closure and management of,
e197
expected outcomes, e198–e199
free microvascular transfer of muscle, e195
general thoughts about design of,
e192–e193, e193f
harvest, e195–e196
innervation, e191–e192
markings, e193f, e194, e195f
modifications/handling, e196–e197
muscle flap, e195, e195f
musculocutaneous flap, e195–e196, e196f
osteomusculocutaneous flap, e196
outcomes, e198–e199
patient positioning, e194–e195
postoperative care for, e198
preoperative preparation of, e192
special considerations in design of, e193
special instruments in, e197
tips to optimize outcomes and avoid
complications, e198
typical indications for, e198
untoward outcomes, e199
usage, e198
venous drainage of, e191
Tensor fascia lata musculocutaneous flap,
e195–e196, e196f
Tensor fascia lata osteomusculocutaneous
flap, e196
“Territory cones”, e68, e68f
TFL myofasciocutaneous flap, Achilles
tendon and soft tissue reconstruction
of lower extremity with, e200b,
e200f
TFL perforator flap, right face defect
reconstructed with, e202b, e202f
TFL perforator-based flap, for
reconstruction of head and neck
external soft tissue defect, e200b,
e200f
Thenar crease flap, in distal fingertip
reconstruction, 229, 230f
Thigh
anatomy of, 115
femoral artery in, 115–119
flap, anterolateral and anteromedial,
700–716
muscles of, 115
nerves of, 115
reconstruction of, 133
surgical exposure of femoral vessels in,
117f
vascular anatomy of, 116f
Thigh GAP flap (TGAP), 696
inferior, breast reconstruction with, 698b,
698f
Thigh reconstruction, 261
bone reconstruction in, 261
soft tissue reconstruction in, 261, 261f
Thigh-based flaps, in abdominal wall
reconstruction, 222, 225f
Thin flap, 706
Thin paraumbilical perforator-based flap,
678–679
Thin suprafascial anterolateral thigh flap,
dorsal foot defect reconstructed with,
716.e1b, 716.e1f
Thinned flaps, 657, 657f
muscle, for latissimus dorsi flap, 455–456
Thinning method, for flap, e63–e64
Third toe transfer, 625
Thoracic artery, lateral, in chest, 81
Thoracic esophagus, reconstruction of, with
pedicled jejunum flap, e127
Thoracic nerve, in chest, 86
Thoracic wall, anterior, 77f
Thoracoacromial artery, in chest, 81
Thoracodorsal artery
in chest, 80–81
in latissimus dorsi flap, 447–448, 447f
Thoracodorsal artery perforator (TDAP)
flap, 455
in breast reconstruction, 195
Thoracodorsal nerve
in chest, 80, 86
in latissimus dorsi flap, 449
Thoracodorsal perforator flap, 649–650
tongue defect reconstructed with, 667.e1b,
667.e1f
Thoracodorsal vein, in latissimus dorsi flap,
448
Thoracodorsal vessels, 649
Thoraco-epigastric flap, in fingertip and
distal finger reconstruction, 230, 231f
Three perforator rows, 651f
3-D technology, in reconstructive
transplantation program, e205–e207,
e206f
Three-dimensional imaging systems, e21–e22,
e21f–e22f
Three-dimensional printing, e11, e13f
Thrombolytic therapy, in management of
surgical complications, 353
Thrombolytics, for flap re-exploration, 335
Thrombophilia, 359
Thrombosis, venous, 631
Thumb defect, reconstruction of,
vascularized hemipulp transfer for,
634b, 634f
Thumb distal phalanx defect
distal ulnar artery perforator flap for,
496b, 496f
FDMA flap for, 494b, 494f
first dorsal metacarpal artery flap for,
494b, 494f
Thumb neurovascular volar advancement
flap, 497–498
Thumb reconstruction, 621
Thyrocervical trunk, e139f, e141t
Thyroid artery, superior, in head and neck,
69
Tibial nerve
anatomy of, 125f–126f
in leg, 119–120
posterior tibial artery and, 121–122
Tibial reconstruction, iliac flap for, 468
Tibialis posterior muscle, in leg, 119
Tibial-peroneal trunk, popliteal artery in leg
and, 120–121

826
Index
Tibio-peroneal trunk, branching pattern of,
122f
Timing, for craniofacial microvascular
reconstruction and, 141
Tissue, requirements, craniofacial
microvascular reconstruction and,
140
Tissue engineering, e25–e35, e25f, e33b
cells and stem cells in, e27
clinical applications based on, e27–e32
for bone, e30
for cardiovascular system, e32
for skin, e28–e30
for trachea, e30–e32, e31f
for urethra and bladder, e30
current strategies in, e26
complex scaffolds and matrices as, e26
proangiogenic, e26–e27
decellularization of tissues in, e27
in hand and upper extremity
transplantation, 766
mechanisms of action of, e26–e27
vascularization and, fundamental role of,
e26–e27
Tissue expanded flap, 440
Tissue expansion, 19
in pectoralis major flap, 405
of tensor fascia lata flap, e196
TMG flap. see Transverse musculocutaneous
gracilis (TMG) flap
Tobacco smoking, of patients, in avoiding
complications, 324
Toe
principal function of, 613–614
second
cosmesis of, improving, 624, 625f
wrap-around, 624–625
Toe flaps, 613–635, 613f
anatomy of, 613–614
arterial supply of, 614
atypical indications for, 629–630
combined toe transfer of, 625–627, 626f
components of, 614–615
great, second, and combined second and
third, 614
great toe transfer of, 616–619, 617f
innervation of, 614
isolated third, combined third and fourth,
614
outcomes in, 630–632
patient positioning of, 616
postoperative care of, 630
preoperative preparation of, 615–616,
616f
recipient site preparation and flap inset,
630
second procedures to optimized outcomes
of, 630
second toe transfer of, 621–624, 622f,
624f
second toe wrap-around, 624–625
third toe transfer, 625
trimmed great toe transfer, 619–620
twisted-toe technique of, 621, 622f
typical indications for, 629
usage of, 629–630
vascularized joint transfer and, 627–630,
633b, 633f
venous drainage of, 614
wrap-around technique of, 620–621, 621f
Toe pulp flaps, thumb pulp reconstruction
with, e184
Toe transfer
guidelines in, 615f
second, 621–624, 622f, 624f
third, 625
Toe transplantation, 613–635
Toe-to-hand transfer, 631
Tolerance, in reconstructive transplantation,
e214–e217, e215f
Tongue
defect, suprafascial anterolateral thigh
flap for, 712b, 712f
reanimation for, 179
reconstruction of, 144
Total esophagectomy, reconstruction after,
using pedicled jejunum flap, e127
Total laryngectomy, pharyngocutaneous
fistula after, pectoralis major flap for,
408–409
Tourniquet
in hand and upper extremity
transplantation
non-pneumatic, 757
sterile, 760
use of, in upper extremity procedures,
113
TPF. see Temporoparietal fascia (TPF)
Trachea
partial defects in
pectoralis major flap for, 409
reconstructed with pedicled pectoralis
major myocutaneous flap, 414b, 414f
tissue engineering-based clinical
applications for, e30–e32, e31f
TRAM. see Transverse rectus abdominis
musculocutaneous (TRAM) flap
Transdifferentiation, e27
Transhumeral transplant, technique for,
762–764, 765f
Transoral robotic surgery, e37, e38f
indications for, e37
reconstruction of oropharyngeal defect
with, e40b
Transplantation
hand and upper extremity, 754–769
immunology, basics of, e210–e211
organ, 739
reconstructive, e204
uterus, 773–776
Transverse cervical artery, e139, e139f
in head and neck, 70–71, 70f
and vascular supraclavicular lymph node
transfer with reverse lymphatic
mapping, 55
Transverse facial artery, in cervicofacial flap,
382–383
Transverse gracilis musculocutaneous (TUG)
flap, 563
Transverse intermuscular septum, in leg, 119
Transverse musculocutaneous gracilis
(TMG) flap, in breast reconstruction,
196
Transverse rectus abdominis
musculocutaneous (TRAM) flap, 668
in breast reconstruction
free, 190–191, 190f–192f, 191t
pedicle, 193–194, 193f–194f
Transverse skin island, of tensor fascia lata
flap, e196
Transverse upper gracilis (TUG) flap, in
breast reconstruction, 196–197
Transversus abdominis, in abdomen, 75
Trapezius flap, e134–e156, e134f
advantages of, e141
anatomic landmarks of, e142, e142f
anatomy of, e136–e141, e137f–e139f
arterial supply of, e135f, e137–e139
components of, e141–e142
design of, e142–e144
dimensions of, e144–e145
disadvantages of, e142
donor site closure and management for,
e147
flap modification/flap handling of,
e146–e147
free flap, based on the DSA, e153b, e153f
innervation of, e141
lateral island, e155b, e155f
myocutaneous flap
based on the ascending branch of the
SCA, e151b, e151f
based on the DSA, e152b, e152f
outcomes of, e149–e150
patient positioning in, e145
pedicled lower island, e154b, e154f
postoperative care for, e149
preoperative preparation for, e142
regional anatomy of, e135–e136
special considerations for, e143–e144
technical tips for, e147
technique of flap harvest for, e145–e146,
e146f
usage of, e147–e149
variation of arterial origin for, e137–e139,
e139f, e141t
venous drainage of, e139–e141
Trapezius muscle
anatomy of, e134–e136
in back, 78
flap, e147
design, e144f
reconstruction of
in anterolateral chest, 208
in posterior torso, 208, 209f
turnover flap, e147
Trapezoidal-shaped flap, 497b, 497f
Trauma
in facial paralysis, 165
as indication for face transplantation,
741–742
Traumatic reconstruction, of lower extremity
complications in, 266–267
etiology of, 255, 255.e1t–255.e2t
indications of, 255–257
outcomes in, 267–271
postoperative considerations in, 264–266,
265f–266f
Treacher-Collins syndrome, 742
T-regulatory cells, e216
Trigeminal nerve, in head and neck, 73f
Trimmed great toe transfer, 619–620, 620f
“Tripod pinch”, 317–319
Trochanteric decubitus ulcer, reconstruction
of, pedicled TFL myocutaneous flap
for, e199b, e199f
Trochanteric defects
gluteus flap for, e170
pedicled TFL perforator flap for, e202b,
e202f
True antigen-specific tolerance, e214–e215
Trunk
defects, gluteus flap for, e170
flap usage of, 663
free flap usage in, 680
scapular and parascapular flaps for, 442
soft tissue defects on, trapezius flap for,
e148
of soleus flap, 591
Tubed flap, 660, 661f
Tubed skin graft, in urethroplasty, e48
Tube-in-tube design, in urethroplasty, e48,
e48f
Tubularization, in urethroplasty, e48–e49
TUG flap. see Transverse upper gracilis
(TUG) flap
Tunneling, skin closure and, in flap
compromise, 338–339, 338f–339f