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

e40
PART 1 — PRINCIPLES
RH is a 62-year-old man with a history of recurrent T3N1M0
squamous cell carcinoma of the left posterolateral pharynx fol-
lowing failed radiation treatment. He underwent a combination
transoral robotic resection with the addition of a lateral pharyn-
gotomy, and a left neck dissection. Although the pharyngotomy
was small (~15 cm2), a large portion of the pharynx (~50 cm2)
was resected from the epiglottis to the soft palate. A 6 × 9 cm
radial forearm flap was harvested. The upper pharyngeal com-
ponent was inset robotically. The remainder of the inset was
completed through the neck. The patient side cart, which was
already in position from the robotic resection and inset, was used
to perform the arterial anastomosis. The venous anastomosis was
then coupled under loupe magnification. The patient was decan-
nulated and discharged within a week, and passed a modified
barium swallow study 3 weeks postoperatively. His speech is intel-
ligible and he is tolerating a regular diet, independent of tube
feeds (Video 9.4).
CASE 9.1
Transoral Robotic Reconstruction of Oropharyngeal Defect
KM is a 48-year-old woman with a history of T1N0M0 invasive
ductal carcinoma of the right breast with 34B breasts, grade I
ptosis, and a BMI of 22. She was scheduled to undergo NAC
sparing mastectomy, sentinel lymph node biopsy, and immediate
implant-based reconstruction. At the time of mastectomy, she
underwent robotic harvest of the latissimus dorsi muscle for
lower pole coverage. A lateral mastectomy incision and the
sentinel lymph node incision were used in combination with two
ports, which were used as drain sites. No additional incisions that
would not have otherwise been present were required to harvest
the muscle. After a good expansion phase, she underwent
exchange for a 500 cc implant and a simultaneous contralateral
augmentation with a 300 cc implant (Fig. 9.8, Video 9.5).
CASE 9.2
Robotic Harvest of Latissimus Dorsi for Breast Reconstruction
Figure 9.8  This patient underwent right nipple-areolar sparing mastectomy, with robotically harvested latissimus flap at stage I. The
muscle was used along the inferior pole in much the same manner as ADM is used. At stage II, the expander was replaced with a per­
manent implant, and a contralateral augmentation mammoplasty was performed (A–C, top) preoperative views. (D–F, bottom) 6-month
follow-up. The incisions visible on the reconstructed breast in image F include the mastectomy incision, the sentinel lymph node incision,
and the camera port incision.
A
B
C
D
E
F

CHAPTER 9 — Robotic Applications in Plastic and Reconstructive Surgery
e41
Video 9.1 External view of robotic LD.
Video 9.2 Robotic harvest of rectus abdominis.
Video 9.3 Robotic microvascular anastomosis.
Video 9.4 Transoral robotic surgery.
Video 9.5 Robotic harvest of latissimus dorsi.
Video 9.6 Robotic lymphaticovenous bypass.
REFERENCES
1. Selber J. Preface: Robotics in plastic surgery. Semin Plast Surg
2014;28(1):3–5.
2. Selber J. Editorial: Robotic surgery. J Reconstr Microsurg 2012;
28(7):433–4.
3. Weinstein GS, O’Malley BW Jr, Snyder W, et al. Trans-oral robotic
surgery: supraglottic partial laryngectomy. Ann Otol Rhinol Laryn­
gol 2007;116:19–23.
4. Weinstein GS, O’Malley BW Jr, Snyder W, et al. Trans-oral robotic
surgery: radical tonsillectomy. Arch Otolaryngol Head Neck Surg
2007;133(12):1220–6.
5. Park YM, Lee WJ, Lee JG, et al. Trans-oral robotic surgery (TORS)
in laryngeal and hypopharyngeal cancer. J Laparoendosc Adv Surg
Tech A 2009;19(3):361–8.
6. Genden EM, Desai S, Sung CK. Transoral robotic surgery for the
management of head and neck cancer: a preliminary experience.
Head Neck 2009;31(3):283–9.
7. Ozer E, Waltonen J. Trans-oral robotic nasopharyngectomy: a novel
approach for nasopharyngeal lesions. Laryngoscope 2008;118(9):
1613–16.
8. O’Malley BW, Weinstein GS, Snyder W, et al. Trans-oral robotic
surgery (TORS) for base of tongue neoplasms. Laryngoscope
2006;116(8):1465–72.
9. Selber JC, Robb G, Serletti JM, et al. Transoral robotic free flap
reconstruction of oropharyngeal defects: a preclinical investiga­
tion. Plast Reconstr Surg 2010;125:896–900.
10. Selber JC. Transoral robotic reconstruction of oropharyngeal
defects: a case series. Plast Reconstr Surg 2010;126:1978–87.
11. Longfield EA, Holsinger FC, Selber JC. Reconstruction after
robotic head and neck surgery: when and why. J Reconstr Micro­
surg 2012;28:445–50.
DM is a 62-year-old man with a history of high-risk prostate
cancer. He received preoperative radiotherapy. During his
prostatectomy, the rectum was injured due to proximity of the
tumor, and a robotic imbricating repair was performed by a
GI surgeon. In order to prevent recto-vesicular fistula a robotic
rectus abdominis flap was harvested to interpose between the
colo-anal anastomosis and uretero-vesicostomy. An umbilical
hernia repair was also performed robotically using biologic
mesh. The robot was re-docked to the prostate ports and the
muscle was sutured to the pelvic floor between the rectum and
the bladder. The uretero-vesicostomy was then performed
robotically and an ileostomy was brought up laparoscopically
to protect the rectal repair.
CASE 9.3
Robotic Harvest of the Rectus
Abdominis Muscle (Fig. 9.7)
MS is a 54-year-old female with a history of breast cancer,
mastectomy, lymphadenectomy, and breast and axillary radia-
tion. She underwent successful free flap breast reconstruction,
but 1 year later developed symptomatic lymphedema of the
ipsilateral extremity. Her axilla was relatively soft, and her
lymphedema was mild to moderate with a 10% volumetric
increase from the normal side and no chronic tissue changes.
She was deemed a reasonable candidate for lymphovenous
bypass. Intraoperatively, indocyanine green was used to iden-
tify open lymphatic channels on the dorsal and ventral sur-
faces of the forearm. Isosulfan blue was then injected proximal
to three small dermal incisions to identify dermal lymphatics
and accompanying venules. The surgical robot was used to
perform the lymphovenous anastomoses using 11-0 nylon
(Fig. 9.9). Patency was confirmed by visualizing dye passing
across the anastomosis (Video 9.6).
CASE 9.4
Robotic-Assisted
Lymphaticovenous Bypass
for Lymphedema
Figure 9.9  In lymphaticovenous bypass, candidate lymphatics
are identified using ICG-9 mapping. A small incision is made and
dermal lymphatics and venules are identified. The robotic endo­
scope (1 cm in diameter) is shown here hovering over the lym­
phatic and venule, both of which are considerably smaller than
the 1 mm registry marks on the green background. A 2 cm inci­
sion is held open using 3.0 Vicryl. A Black Diamond microneedle
driver is seen on the right of the image.
Expert Commentary 
Philippe Liverneaux, MD, PhD
Microsurgical techniques have not changed since the 1960s.
Instruments are always the same, from the watchmaker’s tech-
niques. The microscope has not changed significantly, although
it is now equipped with a digital video camera. Robotics is
probably the safest way to make a technological leap in micro-
surgery. It has many advantages, including the filtration of
tremor and motion scaling.
To be accepted, robotic microsurgery must make significant
improvements to microsurgeons. Reducing the size of the skin
incision is the most important property of robotics to improve
microsurgery. Microsurgical gesture, typically a vascular anas-
tomosis, nerve, or lymphatic, requires a large incision to expose
the target in conventional microsurgery. Robotics, through
instrumental arms of several tens of centimeters, and micro-
instruments capable of evolving in the three planes of space in
a volume 10 times smaller than the human hand, can work
inside the body through small incisions.
Clinical experiments have already been reported, and our
team specializes in nerve endoscopic microsurgery robot-
assisted: minimally invasive intrathoracic harvesting of intercos-
tal nerves, neurolysis of the long thoracic nerve, neurotizations
within the brachial plexus for palsy.
Overall, endoscopic robot-assisted microsurgery is only just
beginning, but the first results are already promising in plastic
and reconstructive surgery.

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PART 1 — PRINCIPLES
18. Patel N, Pederson J. Robotic harvest of the rectus abdominis
muscle: a preclinical investigation and case report. J Reconstr
Microsurg 2012;28(7):477–81.
19. Clemens M, Kronowitz S, Selber J. Robotic assisted dorsi harvest in
delayed immediate breast reconstruction. Semin Plast Surg 2014;
28(1):20–6.
20. Selber J, Alrsheed T. Robotic microsurgical training and evalua­
tion. Semin Plast Surg 2014;28(1):5–11.
21. Parekattil S, Gudeloglu A, Brahmbhatt J, et al. Robotic assisted
versus pure microsurgical vasectomy reversal: technique and pro­
spective database control trial. J Reconstr Microsurg 2012;28(7):
435–45.
22. Lee J, Mattar T, Parisi T, et al. Learning curve of robotic assisted
microvascular anastomosis in the rat. J Reconstr Microsurg 2012;
28(7):451–7.
12. Selber J, Sarhane K, Ibrahim A, et al. Transoral robotic reconstruc­
tive surgery. Semin Plast Surg 2014;28(1):35–9.
13. Ascherman JA, Seruya M, Bartsich SA. Abdominal wall morbidity
following unilateral and bilateral breast reconstruction with pedi­
cled TRAM flaps: an outcomes analysis of 117 consecutive patients.
Plast Reconstr Surg 2008;121:1–8.
14. Kroll SS, Schusterman MA, Reece GP, et al. Abdominal wall
strength, bulging, and hernia after TRAM flap breast reconstruc­
tion. Plast Reconstr Surg 1995;96:616–19.
15. Selber JC, Baumann DP, Holsinger CF. Robotic harvest of the latis­
simus dorsi muscle: laboratory and clinical experience. J Reconstr
Microsurg 2012;28:457–64.
16. Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi
muscle harvest: a case series. Plast Reconstr Surg 2012;129:
1305–12.
17. Ibrahim A, Sarhane K, Pederson J, et al. Robotic harvest of the
rectus abdominis muscle: principles and clinical applications.
Semin Plast Surg 2014;28(1):26–32.

61
INTRODUCTION
Head and neck reconstruction presents unique challenges
to the reconstructive surgeon. Because of the visibility of this
region, defects are often difficult to conceal and the
demands on the surgeon’s reconstructive skills are greater
than they are elsewhere in the body where cosmesis may be
less vital and function less specialized. The head and neck
area includes both static and dynamic structures and con­
tains organs of special function such as the nose, the ears,
the lips, and the orbital contents, including the eyelids.
The bony skeleton of the head and neck is related to
structure and load, as are bony structures elsewhere in the
body. In addition, however, certain structures such as the
mandible have a very specialized function and therefore
have unique reconstructive requirements. The soft tissues
of the face are also unique and provide external cover,
internal mucosa, and facial animation. The external cover
provides a barrier, which in some cases is specialized such
as the hair-bearing skin of the scalp. In addition to the
external skin cover, it is frequently necessary to replace the
mucosa. The facial muscles provide a unique and very deli­
cate function for facial animation and are innervated by the
complex facial nerve. This nerve is sometimes sacrificed to
execute an effective tumor ablation and the loss of facial
nerve function will further complicate the reconstruction.
Not infrequently all of the above elements are involved in
the reconstruction. For all of the aforementioned reasons,
a thorough knowledge of the anatomy of this region is
imperative, not only for the ablative surgeon in cancer cases
but also for the reconstructive surgeon, so that the best pos­
sible reconstruction can be achieved, to optimally restore
the cosmetic and functional elements of the defect.
ANATOMY OF THE HEAD AND NECK
The anatomy of the head and neck is complex. The cal­
varium provides protection for the underlying brain and
is covered with hair-bearing soft tissue. The skin of the rest
of the face is intimately related to the underlying muscu­
lature and movement of this multifaceted unit not only
gives the skin its unique appearance, with multiple lines
and wrinkles, but also is responsible for a significant aspect
of how we communicate. For this reason, replacing large
segments of facial skin with skin from elsewhere in the
body often results not only in a color mismatch but also a
texture and movement imbalance. Within the head and
neck region, there are several structures with specialized
function and anatomic distinctiveness, including the eyelids,
the nose, the lips, and the ears. All these structures are
particularly difficult to replicate and pose significant chal­
lenges. Within the head and neck, there are also mucosa-
lined cavities, which all lead into the aerodigestive tract.
Within the mouth, there is another even more specialized
organ, the tongue, which is vital to the functions of speech
and swallowing.
ANATOMY OF THE FACIAL SKELETON
The facial skeleton is complex, made up of several individ­
ual bony structures, articulated in a complex manner (Fig.
10.1). The calvarium, consists of frontal, parietal, temporal
and occipital bones which protects the brain. The cranial
bones in turn articulate with the skull base (sphenoid
bone) and midfacial skeleton consisting of the maxilla,
ethmoid, lacrimal, zygomatic, nasal, palatine, nasal concha,
and vomer. The facial skeleton provides protection of
delicate structures such as the eye, and also provides pro­
tective passage for some vital structures such as the facial
nerve, which passes through the temporal bone. Other clini­
cally important nerves to be considered during craniofacial
surgical exposures include the supraorbital and supratroch­
lear nerves (V1), the infraorbital nerve (V2), the inferior
alveolar nerve (V3), and its terminal branch, the mental
nerve. The supraorbital nerve exits the frontal bone through
a foramen or a notch. In elevation of a bicoronal flap or
a paramedian forehead flap, transition to subperiosteal
dissection 1–2 cm above the supraorbital rim avoids injury
to the supraorbital nerve or supratrochlear neovascular
bundle. The infraorbital nerve exits the infraorbital foramen
6–11 mm below the inferior orbital rim at the midpupillary
line. The mental nerve exits the metal foramen in the body
of mandible between the root apices of the mandibular first
and second premolars. The ethmoid, sphenoid and maxil­
lary bones, house the intricate system of air cells and sinuses
that contribute to humidification of inspired air, and reso­
nance for voice reproduction. The mandible not only pro­
vides the structure that defines the appearance of the lower
Clinical Anatomy of the
Head and Neck, and
Recipient Vessel Selection
Peter C. Neligan  |  Basel Sharaf
10 
PART 2  —  CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE

62
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
the head and neck are the superficial and deep fascial
layers, which are interconnected as they envelop the various
muscles. The superficial fascia is an anatomically continu­
ous layer that is named differently according to the zone it
covers. Most cephalad, the galea aponeurotica, is a fascial
expansion that connects the paired frontalis and occipitalis
muscles and runs in an anteroposterior direction over the
vertex of the head. The lateral extension of the galea apo­
neurotica is continuous with the temporoparietal fascia
(TPF), also known as the superficial temporal fascia, lateral
to the superior temporal line. The TPF is continuous with
the galea superiorly, the frontalis muscle anteriorly, and
the SMAS inferiorly. Inconsistent nomenclature of the
face but, combined with its sister bone, the maxilla, provide
a housing for the dentition and defines the confines of the
oral cavity and all that it contains. Finally, the facial skeleton
also provides the framework from which the facial muscles
take origin.
THE FASCIA OF THE HEAD AND NECK
An understanding of the fascia of the head and neck is para­
mount (Fig. 10.2), as they provide important landmarks for
important anatomic structures during surgical exposures
such as the facial artery, facial nerve, superficial temporal
vessels, and other recipient vessels in head and neck recon­
struction. In general, the two main fascial layers investing
Figure 10.1  Skull. Anterior and lateral aspects. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Parietal bone
Occipital bone
Temporal bone
Head of condylar process
Temporal fossa
Superior temporal line
Squamous part
Lambdoid suture
External
occipital
protuberance
Zygomatic process
External acoustic
meatus
Inferior temporal line
Coronal suture
Pterion
Mandible
Coronoid process
Ramus
Body
Mastoid process
Frontal bone
Supraorbital
notch (foramen)
Glabella
Nasal bone
Lacrimal bone
Zygomatic bone
Frontal process
Temporal process
Zygomaticofacial foramen
Maxilla
Sphenoid bone
Frontal bone
Ethmoid bone
Nasal bone
Maxilla
Zygomatic bone
Lacrimal bone
Frontal process
Infraorbital foramen
Alveolar process
Anterior nasal spine
Greater wing
Orbital plate
Fossa for
lacimal sac
Temporal process
Zygomatic process
Parietal bone
Sphenoid bone
Lesser wing
Greater wing
Temporal bone
Ethmoid bone
Orbital plate
Perpendicular plate
Middle nasal concha
Inferior nasal concha
Vomer
Mandible
Ramus
Mental foramen
Mental tubercle
Mental protuberance

CHAPTER 10 — Clinical Anatomy of the Head and Neck, and Recipient Vessel Selection
63
color. The temporalis muscle fascia covers the temporalis
muscle. The temporalis muscle fascia (also known as the
deep temporal fascia) splits above the zygomatic arch into
two leaflets: the superficial layer of the deep temporal fascia,
which is adherent to the lateral zygomatic arch periosteum,
and the deep layer of the deep temporal fascia, which runs
medial (deeper) to the zygomatic arch (Fig. 10.2). The tem­
poral fat pad is located between the superficial and deep
layers of the deep temporal fascia. The buccal fat pad is
located deeper to the deep layer of the deep temporal fascia.
Caudally, the superficial temporal fascia is continuous with
the superficial musculoaponeurotic system (SMAS). The
SMAS is encountered deeper to the skin and subcutaneous
fat. The SMAS envelops the muscles of facial expression. The
parotidomasseteric fascia is a deeper facial layer that is
adherent to the parotid capsule and is continuous with the
superficial layer of the deep temporal fascia below the zygo­
matic arch. The facial nerve branches exit the parotid gland
deeper to the parotidomasseteric fascia below the zygomatic
arch and then pierce this fascia and become more superficial
as they innervate the respective mimetic muscles. The fascia
in the neck is similarly organized into the superficial and
deep fascial layers. The superficial cervical fascia envelops
the platysma muscle and is found closely associated to the
subcutaneous fat of the neck. The superficial cervical fascia
and the platysma muscle are continuous with the SMAS of
the face. The deep cervical fascia is organized concentrically
of the superficial layer of the deep cervical fascia (SLDCF),
the middle layer of the deep cervical fascia (pre-tracheal
fascia), and the deep layer of the deep cervical fascia (pre­
vertebral fascia). The SLDCF envelops the sternocleidomas­
toid muscles, trapezius muscles, and attaches onto the
cervical spinous processes. The SLDCF is an extension of the
parotidomasseteric fascia in the neck. It is an important
fascial layer, as the marginal mandibular branch of the facial
nerve is found within or deep to the SLDCF. The facial artery
and vein are found deeper to this plane. Once the platysma
muscle has been divided, care should be taken when expos­
ing the facial vessels by retracting and protecting the mar­
ginal mandibular branch of the facial nerve along with the
SLDCF. The marginal mandibular branch runs superficial to
the facial artery and vein at the premasseteric notch of the
mandible.
ANATOMY OF THE FACIAL MUSCULATURE
The facial muscles are complex. They consist of the muscles
of facial expression as well as the muscles of mastication. In
general, the muscles of facial expression are thin ribbons of
muscle arranged in a radial pattern around the sphincters
of the eye (orbicularis oculi) and the mouth (orbicularis
oris). They consist of 17 paired muscles that give the human
face the ability to move in multiple vectors or combinations
of vectors and, as already mentioned, provide a significant
contribution to non-verbal communication. The muscles of
facial expression glide over an intricate system of fat pads
in the face. Superiorly, the paired frontalis muscles insert
into the galea aponeurotica, which forms an intermediate
aponeurosis with the paired occipitalis muscles. Lateral to
the superior temporal line, the temporoparietal fascia is
continuous with the galea. The mimetic facial muscles origi­
nate from the facial skeleton and insert into the skin that
temporal fascia has generated confusion in its anatomic
descriptions.
The TPF is a thin translucent layer underneath the skin
and subcutaneous tissue of the temple. In the temple region,
nine anatomic layers exist, including – from superficial to
deep: the skin; the subcutaneous tissue; the temporoparietal
fascia (or superficial temporal fascia); the loose areolar layer
(or innominate fascia); the superficial layer of the deep
temporal fascia; the superficial temporal fat pad; the deep
layer of the deep temporal fascia; the deep temporal fat pad;
and the temporalis muscle. The superficial temporal artery
and vein run within the TPF and provide the vascular pedicle
to the temporoparietal fascia flap. After exiting the parotid
gland, the frontal branch of the facial nerve crosses over
the zygomatic arch within the innominate fascia, where it
remains for a distance of 1.5–3.0 cm above the superior
border of the arch. After that transition point, the nerve
becomes more superficial and travels on the undersurface
of the TPF (superficial temporal fascia) until reaching the
frontalis muscle.1,2 Dissection above the zygomatic arch and
lateral to the eyebrow should be carried on the temporalis
muscle fascia, deeper to the TPF, to avoid injury to the
frontal branch. The nerve can then be reflected along with
the TPF and protected. The temporoparietal fascia is distinct
from the temporalis muscle fascia, which is a deeper fascia
to the TPF, has a sturdier consistency, and a glistening white
Figure 10.2  Fascia of the face and neck showing the following
layers. Galea, periosteum on scalp, superficial temporal fascia, deep
temporal fascia, zygomatic arch, SMAS (musculo-aponeurotic),
superficial cervical fascia and deep cervical fascia.
Deep temporal fascia
Superficial temporal
fascia
Deep cervical fascia
Zygomatic
arch
Mandible
Parotid gland
Temporalis
Temporal bone
Periosteum
Skin
Galea
SMAS
(superficial facial fascia,
enclosing mimetic
muscles of face)
Superficial cervical fascia
(enclosing platysma)
Subcutaneous
fat

64
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
raphe, which separates it from the superior pharyngeal con­
strictor posteriorly. It is used in whistling and smiling, and
in the neonate, is the muscle that assists suckling. The true
muscles of mastication consist of the paired temporalis, mas­
seter and the pterygoid muscles (medial and lateral). Unlike
the muscles of facial expression, which are all innervated by
the facial nerve (CN VII), the four muscles of mastication
are all innervated by the mandibular branch of the trigemi­
nal nerve (CN V). The temporalis muscle arises from the
superior temporal line and the temporal fossa, its fan-
shaped origin coalesces inferiorly as its fibers pass medially
to the zygomatic arch to insert onto the coronoid process
of the mandible and anterior border of the ramus. This
muscle is supplied by branches the internal maxillary artery,
namely the anterior and posterior deep temporal arteries,
which enter the muscle on its deep surface anterior and
posterior to the cornoid process, respectively. An additional
arterial supply is the middle temporal artery, a branch of
the superficial temporal artery, which supplies the deep
temporalis muscle fascia. This muscle has several applica­
tions for local reconstruction of defects of the cheek, orbit
and in facial reanimation. A powerful mandibular elevator,
the masseter muscle arises from the lower border of the
zygoma and the most anterior fibers arise from the zygo­
matic process of the maxilla and inserts into the lateral
surface of the mandible. The masseter muscle is innervated
by the masseteric nerve, a branch of V3, which reaches the
deep surface of the muscle through the coronoid notch.
The blood supply to the masseter is furnished by the mas­
seteric artery, a branch of the internal maxillary artery. Indi­
viduals of these muscles are expendable so the nerve to the
masseter can be used to innervate a free functional muscle
transfer for the treatment of facial paralysis.
ARTERIAL ANATOMY OF THE HEAD AND NECK
The head and neck is one of the most highly vascularized
regions in the body (Figs 10.4 and 10.5). The external
carotid arterial system supplies most of the skin of the head,
with the exception of a central triangle that includes the
eyes, the bridge of the nose, and a central portion of the
forehead. This latter area is vascularized by the ophthalmic
branch of the internal carotid artery.3 The superficial tem­
poral, posterior auricular, and occipital arteries supply the
scalp. Most of the external carotid branches are commonly
used for microvascular anastomosis, however, the four most
commonly used recipient vessels for head and neck recon­
struction are: the facial artery; the superficial temporal
artery; the superior thyroid artery, which are branches of
the external carotid artery; and the transverse cervical
artery, a branch of the thyrocervical trunk.
FACIAL ARTERY
The facial artery (Figs 10.4–10.7) arises from the external
carotid artery and exits the neck by coursing around the
inferior border of the mandible. It crosses the inferior
border of the mandible approximately 2.6 cm anterior to
the mandibular angle.4 The artery follows a tortuous course
towards the nasal ala and lies superficial to the buccinator
and levator anguli oris (Layer 4 of the facial muscles). It lies
deep to the risorius, zygomaticus major, and the orbicularis
oris muscles (Layers 2 and 3 of the facial muscles). The
they animate. These muscles are innervated by the facial
nerve and, as a general rule, the facial nerve branches enter
the deep surfaces of these muscles, except for the mentalis,
levator anguli oris, and buccinator. They are arranged in
four layers (Fig. 10.3). Layer 1 (the most superficial) includes
the depressor anguli oris, zygomaticus minor, and orbicu­
laris oculi. Layer 2 includes the depressor labii inferioris,
risorius, platysma, zygomaticus major, and levator labii supe­
rioris alaeque nasi. Layer 3 includes the orbicularis oris and
levator labii superioris. Layer 4 (the deepest layer) includes
the mentalis, levator anguli oris, and buccinator. Layer 4
muscles are innervated by the facial nerve on their superfi­
cial surfaces. The SMAS layer, which invests the mimetic
muscles, is continuous inferiorly with the platysma. The
buccinator, also innervated by the facial nerve, and strictly
speaking not a masticatory muscle, assists in chewing, by
keeping the food bolus within the occlusal plane of the
molars. Posteriorly, it inserts into the pterygomandibular
Figure 10.3  Muscles of facial expression.
Layer 1
1. Depressor anguli oris
2. Zygomaticus minor
3. Orbicularis oculi
Layer 2
4. Depressor labii inferioris
5. Risorius
6. Platysma
7. Zygomaticus major
8. Levator labii superioris
alaeque nasi
Layer 3
9. Orbicularis oris
10. Levator labii superioris
Layer 4
11. Mentalis
12. Levator anguli oris
13. Buccinator
1
2
3
4
5
6
7
8
9
10
11
12
13

CHAPTER 10 — Clinical Anatomy of the Head and Neck, and Recipient Vessel Selection
65
Figure 10.4  Arteries and veins of the head and neck region. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Nasofrontal vein
Anterior
auricular
arteries
Retromandibular vein
Sources of arterial supply of face
Scalp
Frontal
Parietal
Common facial vein
Middle temporal artery and vein
Zygomaticoorbital artery
Transverse facial
artery and vein
Supraorbital
artery and vein
Skin and
subcutaneous tissue
Epicranial aponeurosis
(galea aponeurotica)
(cut to reveal skull)
Parietal emissary vein
Branches of
superficial temporal
artery and vein
Mastoid emissary
vein and meningeal
branch of occipital
artery (posterior
meningeal artery)
Occipital artery
and vein (cut)
Posterior auricular
artery and vein
Internal jugular vein
Internal carotid artery
External carotid artery
Common carotid artery
Lingual artery and vein
External jugular vein (cut)
Black: from internal carotid artery (via ophthalmic artery)
Red: from external carotid artery
Facial artery and vein
Deep facial vein
(from pterygoid
plexus)
Infraorbital
artery and vein
Zygomatico-
facial artery
and vein
Angular
artery
and vein
Zygomaticotemporal
artery and vein
Supratrochlear
artery and vein
Dorsal nasal
artery and vein

66
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
From
ophthalmic
artery
Supraorbital artery
Supratrochlear artery
Middle meningeal artery
Deep temporal arteries
Dorsal nasalartery
Masseteric artery
Angular artery
Infraorbital artery
Sphenopalatine artery
Descending palatine artery
Posterior superior
alveolar artery
Superior labial artery
Buccal artery
Buccinator muscle
and parotid duct (cut)
Inferior labial artery
Superior pharyngeal
constrictor muscle
Mental branch of
inferior alveolar artery
Inferior alveolar artery
and lingual branch
Facial artery
Submental artery
Mylohyoid branch of
inferior alveolar artery
Submandibular gland
Hypoglossal nerve (XII)
Suprahyoid artery
External carotid artery
Superior laryngeal artery
Superior thyroid artery
Cricothyroid artery
Common carotid artery
Vertebral artery
Subclavian artery
A
Transverse
facial
artery (cut)
Superficial
temporal artery
Maxillary artery
Posterior auricular artery
Ascending pharyngeal artery
Occipital artery and
sternocleidomastoid branch
Glossopharyngeal nerve (IX)
Ascending palatine artery
Tonsillar artery
Facial artery
Lingual artery
Ascending pharyngeal artery
Internal carotid artery
Vagus nerve (X)
Superior cervical
cardiac nerve
Sympathetic trunk
Anterior scalenemuscle
Phrenic nerve
Middle scalene muscle
Ascending cervical artery
Inferior thyroid artery
Superficial cervical artery
Suprascapular artery
Costocervical trunk
Thyrocervical trunk
Figure 10.5  (A) Arteries of oral and pharyngeal regions; arterial supply of the mouth and pharynx blood supply of the mouth and pharynx
muscles of pharynx: lateral view.

CHAPTER 10 — Clinical Anatomy of the Head and Neck, and Recipient Vessel Selection
67
the facial artery musculomucosal (FAMM) flap, described
by Pribaz.6 This is an intraoral flap that has earned its
place in the armamentarium of most head and neck sur­
geons. This flap incorporates the mucosa and buccinator
muscle, as well as the facial artery. The facial artery is more
commonly used as a recipient artery for free flaps. It is easily
accessed in the neck through a Risdon incision but can also
facial artery supplies cervical and facial branches to this
region. Cervical branches include the ascending palatine,
tonsillar, and submental artery. The latter supplies the sub­
mental artery flap. Facial branches include: the inferior
labial, superior labial, alar base, lateral nasal, and angular
artery. The facial artery passes 1–1.6 cm lateral to the oral
commissure.5 The facial artery itself is the named artery in
Supratrochlear vein
Supraorbital vein
Nasofrontal vein
Superior ophthalmic vein
Angular vein
External nasal vein
Emissary vein (of Vesalius)
communicating with
cavernous sinus
Infraorbital vein
Posterior superior
alveolar veins
Palatine vein
Pterygoid plexus
Superior labial vein
Deep facial vein
Maxillary veins
Inferior labial vein
Mental vein
Facial vein and artery
External palatine vein
Submental vein
Submandibular gland
Lingual vein
Vena comitans of
hypoglossal nerve
Dorsal lingual vein coursing
medial to hyoglossus muscle
Communication to anterior jugular vein (cut)
Superior laryngeal vein
Superior thyroid vein
Thyroid gland
Middle thyroid vein
Inferior thyroid veins
Termination of anterior jugular vein (cut)
Left brachiocephalic vein
B
Occipital vein
and artery
Superficial temporal
vein and artery
Transverse facial vein (cut)
Posterior auricular vein
Retromandibular vein
(anterior and
posterior branches)
External jugular vein (cut)
Inferior alveolar vein and artery
Occipital vein and artery
Hypoglossal nerve (XII)
Common trunk receiving
facial, anterior branch of
retromandibular, and
lingual veins (common facial vein)
External carotid artery
Internal jugular vein
Common carotid artery
Vagus nerve (X) and
sympathetic trunk
Middle scalene muscle
Anterior scalene muscle
External jugular vein (cut)
Transverse cervical
vein (cut)
Suprascapular vein (cut)
Subclavian artery
Subclavian vein
(B) Veins of oral and pharyngeal regions; venous drainage of the mouth and pharynx. (Reprinted from Netter Anatomy
Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Figure 10.5, cont’d

68
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
be accessed in the nasolabial region. The facial artery diam­
eter at its origin ranges from 2 mm to 3.7 mm, with a mean
diameter of 2.7 mm.4
Advantages and Disadvantages
The main advantage of the facial artery is its easy accessibil­
ity. If the patient is having a neck dissection, this advantage
is not as obvious as when the patient is having a head and
neck reconstruction without a neck dissection. One disad­
vantage of using the facial artery in this situation is that it
must be dissected well back towards its origin and some­
times it needs to be taken down below the posterior belly of
Figure 10.6  Topography of the external carotid artery branches.
(Bony landmarks outlined in black).
External carotid
artery
Facial artery and
vein
Superior and
inferior labial arteries
Superficial
temporal
artery
and vein
Supratrochlear
and
supraorbital
arteries
Superior
temporal
line
Angular
arteries
Infraorbital
nerve
Figure 10.7  External carotid artery* with two of its branches. The
facial and superior thyroid arteries. Note the relationship of the hypo­
glossal nerve and the posterior belly of the digastric muscle.
Hypoglossal
nerve
*External
carotid
artery
Common
carotid
artery
Sternocleidomastoid
muscle (reflected)
Facial
artery
Superior
thyroid
artery
Figure 10.8  Exposure of the facial artery. (A) Marking and incision for facial artery exposure. (B) The platysma is undermined and incised.
The marginal mandibular branch, which runs deep to this muscle, is protected. (C) The superficial layer of deep cervical fascia (retracted) is
incised. The marginal mandibular branch runs within or deeper to this layer. (D) The facial artery (red) is retracted. The facial vein is posterior
(blue).
A
B
C
D
the digastric muscle to improve access for microvascular
anastomosis.
Exposure of the Facial Artery
The facial artery can be palpated as it traverses the inferior
border of the mandible at the anterior border of the

CHAPTER 10 — Clinical Anatomy of the Head and Neck, and Recipient Vessel Selection
69
masseter muscle (Fig. 10.8). A handheld Doppler may
confirm its location and course over the face. It can be
accessed through a 2–3 cm transverse neck incision placed
1.5–2 cm below the inferior border of the mandible. After
skin incision, dissection is carried through the subcutaneous
fat and the superficial cervical fascia. The platysma muscle
is then bluntly undermined from underlying fascia (Fig.
10.8) and incised, exposing the SLDCF). The marginal man­
dibular branch of the facial nerve is within or deep to the
SLDCF. The nerve is retracted and protected superiorly.
The facial artery and vein run deeper to the nerve. Because
this vessel is located under the border of the mandible,
access can be difficult for a microvascular anastomosis, par­
ticularly when doing a mandibular reconstruction. Also, the
nearest acceptable recipient vein may be some distance
away, particularly in patients who have had a neck dissection
since the anterior facial vein is often divided in a neck dis­
section. Preoperative planning and communication with the
extirpative head and neck team is important to preserve
valuable recipient vessels for microvascular anastomosis.
SUBMENTAL ARTERY
The submental artery is a branch of the facial artery that
arises from its medial side and runs towards the midline of
the neck in the submental region. Though not used as a
recipient vessel for free tissue transfer, it is the source vessel
for the submental flap,7 which is extremely useful for recon­
struction of the lower face. The vascular pedicle can be
lengthened further proximally, taking advantage of the
reverse venous flow between the retromandibular vein and
the facial vein allowing this flap to be transferred as a free
flap.8 The advantages of this flap include excellent skin
characteristics with good texture and color match to the
lower face, and a minimal donor defect that can be closed
to result in an imperceptible submental scar. This flap can
also be transferred to include the submental lymph nodes
in the treatment of lymphedema.9 The submental artery
diameter ranges from 1.0 mm to 2.3 mm with a mean of
1.7 mm at its origin. Care to protect the marginal mandibu­
lar branch of the facial nerve should be taken during sub­
mental flap harvest. In addition, attention to preserve the
nerve to the mylohyoid muscle, which is usually located
approximately 1.6 cm deeper to the submental artery at its
origin in the submandibular triangle.4
Advantages and Disadvantages
The submental artery is small and dissection of the submen­
tal flap is challenging. The venae comitantes are also small
and easily injured and therefore temporary venous conges­
tion in the flap is not unusual in the immediate postopera­
tive period. There is a separate vein, a branch of the anterior
facial vein, which runs parallel to the submental artery and
care should be taken to incorporate this vein in the dissec­
tion. In some cases, the pedicle may be too short to allow
the flap to reach the defect. However, dividing the facial
artery distal to the submental branch take off and dissecting
it proximally can significantly increase the pedicle length.
SUPERIOR THYROID ARTERY
The superior thyroid artery (Figs 10.4, 10.7) is commonly
used for vascularization of head and neck free flaps. Its posi­
tion in the neck, arising as the first branch of the external
carotid artery, makes it useful for this purpose. Although
sometimes small in caliber, it generally has excellent flow
and there is usually a vein in close proximity to facilitate
both arterial and venous anastomoses.
Advantages and Disadvantages
As with many other vessels in the face, the superior thyroid
artery has the capacity to sustain an anastomosis from either
proximal or distal directions.10 Also, because of its close
proximity to the internal jugular vein, setting up the appro­
priate pedicle geometry for both arterial and venous anas­
tomoses is favorable in patients who have had a neck
dissection.
Exposure of the Superior Thyroid Artery
When a neck dissection has been performed, the superior
thyroid artery is easily accessible. Otherwise, an existing
neck incision can be extended along the anterior border of
the sternocleidomastoid muscle, which is then retracted lat­
erally, exposing the carotid sheath. Once the carotid sheath
is entered, the superior thyroid artery is usually found
arising from the common carotid artery or from the front
of the external carotid artery below the hyoid bone. It
courses downward and forward, deep into the infrahyoid
muscles to the superior lobe of the thyroid gland, where it
divides into infrahyoid, superior laryngeal, cricothyroid,
and glandular branches. The external branch of the supe­
rior laryngeal nerve supplies the cricothyroid muscle and
lies deeper to the superior thyroid artery and should be
preserved. The artery is typically isolated close to its take
off from the external carotid artery, where it measures
2.3–3.5 mm in diameter.11
SUPERFICIAL TEMPORAL ARTERY
The superficial temporal artery (STA) (Figs 10.4–10.6) is
one of two terminal branches of the external carotid artery.
It supplies the temporalis muscle and the scalp and, as a
donor artery, it supplies vascularity to the temporoparietal
fascia. For reconstruction within the head and neck region,
the temporoparietal fascia has many applications, including
recent use in reconstruction of the hemilarynx.12 In this
reconstruction, it is used as a carrier for a mucosal graft that
lines the reconstructed larynx and the fascia is wrapped
around a cartilaginous strut to give structural support to the
construct. However, the superficial temporal artery is more
frequently used as a recipient vessel for free flap reconstruc­
tion of the scalp and midface. While some authors tend
to avoid the superficial temporal artery, it has been our
experience that both the artery and vein are acceptable for
this indication.
Advantages and Disadvantages
The major advantage of the STA is its ease of access. A
simple preauricular incision provides easy access to both
the artery and vein. The proximity of these vessels to the
scalp and midface makes them ideal for revascularizing
flaps for scalp resurfacing, orbital, and midface reconstruc­
tion. The proximity to the STA to the defect usually obviates
the need for vein grafts. However, the vessels can be suscep­
tible to spasm and the vein tends to be thin walled and
friable. In terms of caliber, it is frequently necessary to
dissect the vessels back to the pretragal region where the

70
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
TRANSVERSE CERVICAL ARTERY
The transverse cervical artery (TCA) (Fig. 10.9) arises from
the thyrocervical trunk and can be located at the root of the
neck accompanied by the transverse cervical vein (TCV).
The artery courses laterally across the anterior scalene
muscle and the brachial plexus. It passes across the poste­
rior triangle of the neck to provide the dominant blood
supply to the trapezius muscle. When the external carotid
arterial system is not suitable for microvascular anastomosis,
the transverse cervical vessels are invariably available. Previ­
ous neck dissection, or radiation therapy pose a significant
challenge in exposing the heavily scarred neck tissues
around the carotid system. As many as 36% of explored
necks with prior neck dissection and radiation therapy have
no usable external carotid system.15 Lack of an identifiable
plane of dissection increases the risk of inadvertent carotid
injury. The left TCA is in proximity to the thoracic duct,
therefore care must be taken to avoid injury to this structure
during exposure of TCA on the left side to avoid a chyle
leak. More recently, the TCA has been used as a source
vessel for vascularized lymph node transfer using the supra­
clavicular nodes.16
Advantages and Disadvantages
The transverse cervical artery is often spared after a neck
dissection. The vessel has been reported to be less prone to
atherosclerotic disease than extremal carotid artery
branches. Distal ligation of the TCA can help provide ade­
quate recipient vessel length to reach the mid-neck area for
pedicle anastomosis. This vessel has been reported to be
prone to vasospasm. Knowledge of the pertinent anatomy
in the area of the TCA system is paramount to avoid injury
to the phrenic nerve, brachial plexus and the thoracic duct,
especially on the left neck.
Exposure of the Transverse Cervical Artery
When a neck dissection has been performed by the extirpa­
tive surgeon, an inferior extension of the neck incision will
allow access to the ipsilateral TCA system. Otherwise, a trans­
verse incision 2 cm cephalad to the mid-clavicle is made.
The landmarks for the TCA are the mid-clavicle, lateral
deep branch of the superficial temporal artery is given off.
Proximal to this branch, the caliber of both artery and vein
is superior.
Exposure of the Superficial Temporal Artery
The STA can be palpated as it crosses the zygomatic arch
anterior to the tragus. Doppler examination easily delin­
eates its course and bifurcation above the zygomatic arch.
The superficial temporal vessels are approached through a
preauricular incision. The mean depth of STA at the level
of tragus was found to be 11.9 mm from the skin.13,14 To
obtain vessels of adequate caliber, the dissection must occa­
sionally be extended proximal to the take-off of the deep
branch. However, if the caliber of the vessels distally is ade­
quate, then a straightforward anastomosis may be per­
formed. The STA ascends from its origin off the external
carotid artery within the parotid gland, traveling behind
the mandibular ramus and then piercing the superficial
fascia at the level of the tragus. The STA usually takes on a
tortuous course and release of this tortuosity may add an
extra 1–2 cm of vessel length to the pedicle. The mean
diameter of the STA at the zygomatic arch is 2–3 mm. The
STA bifurcates into a frontal and parietal branch 1–3 cm
above the zygomatic arch in 60% of dissected specimens.
The STA is found approximately 0.5–1.5 cm anterior to the
tragus, approximately 1 cm deep to the preauricular skin.13,14
The STA usually lies anterior to the superficial temporal
vein. The auriculotemporal nerve travels posterior to the
STA in the preauricular crease and supplies the adjacent
scalp region. Special attention should be paid to the frontal
branches of the facial nerve, which course obliquely across
the zygomatic arch. The frontal branch of the facial nerve
may have up to three branches at the level of zygomatic
arch, with the most posterior branch reported at 24 mm
from the tragus and the most anterior branch at 42 mm
from the tragus.14 When dissection is limited to within a
24-mm distance from the tragus above the zygomatic arch,
the frontal nerve branches can be protected. Dissection of
the vessel can be done with loupe magnification or prefer­
ably under the operating microscope. Small side branches
of the STA system can then be easily identified and ligated.
Figure 10.9  The transverse cervical artery. (A) Topography of the transverse cervical artery. (B) Exposure of the transverse cervical artery.
B
Transverse
cervical artery
Inferior belly of
omohyoid muscle
A
Transverse
cervical artery
Sternocleidomastoid
muscle
Clavicle
Superior belly
of omohyoid
muscle
Phrenic
nerve
Inferior belly of
omohyoid muscle

CHAPTER 10 — Clinical Anatomy of the Head and Neck, and Recipient Vessel Selection
71
VEINS IN THE HEAD AND NECK
There are numerous veins in the neck (Figs 10.4b, 10.5) that
may be used as recipient veins but the choice of which vein
to use will depend on individual circumstances. In patients
who have had a neck dissection, the choice of available veins
may be limited. An end-to-side anastomosis to the internal
jugular vein is jugular vein is a good option when other
vessels are not available for an end-to-end anastomosis. The
external jugular vein can be very useful if it can be pre­
served, and the transverse cervical vein is invariably intact.
The anterior jugular vein is also sometimes an option. If
there are no veins available in the local region, the cephalic
vein can be dissected and tunneled into the neck, where it
will reach the angle of the mandible.20
ADVANTAGES AND DISADVANTAGES
The main advantage of using a vein located in the neck is
the abundance of available veins and the caliber of most of
them. The main disadvantage is the extra pedicle length
needed to reach from the neck to a defect located in the
head. This, however, is rarely a major problem. One particu­
lar caution if choosing the anterior jugular vein, is that if
the patient has had a tracheostomy, this vein may have been
divided. It is important to be aware of this possibility and to
double check that it is patent.
NERVES IN THE HEAD AND NECK
Understanding the anatomy of the Trigeminal (Fig. 10.10)
and facial nerve (Figs 10.11 and 10.12) are crucial to the
success of any operation in this region. The issue of whether
or not to innervate free flaps in the head and neck contin­
ues to be controversial. While it is true that sensation can
be restored and it appears intuitive that an innervated flap
is better, it remains to be shown whether reinnervation
improves function.21 The nerves most commonly used in
head and neck reconstruction are the lingual nerve (to
provide sensory reinnervation for intraoral reconstruction)
and the facial and masseter nerves (to provide motor rein­
nervation for facial reanimation).22 It is imperative to under­
stand the anatomy and position of the facial nerve. To
restore facial motion, the facial nerve from the intact con­
tralateral side may be used for a cross-facial nerve graft in a
two-stage procedure or the motor nerve to masseter muscle
may be used to restore facial movement in a one-stage
reconstruction. Both the hypoglossal nerve and the acces­
sory nerve have also been used for facial reanimation, the
former in the form of a nerve transfer (XII/VII Transfer)
while the accessory nerve can be split and used to animate
a functioning muscle transfer such as the gracilis. The other
important nerve that one needs to know about is the great
auricular nerve. This is the nerve most frequently damaged
during a facelift. The great auricular nerve originates from
the cervical plexus, composed of branches of spinal nerves
C2 and C3. It provides sensory innervation for the skin over
the parotid gland and mastoid process, and both surfaces
of the outer ear. It arises from the second and third cervical
nerves, winds around the posterior border of the sternomas­
toid muscle, and, after perforating the deep fascia, ascends
border of the sternocleidomastoid muscle and inferior belly
of the omohyoid muscle (Fig. 10.9B). The TCA is usually
encountered first in the fibrofatty tissues cephalad to the
omohyoid muscle. The TCA is usually deeper and more
superior to the vein.17 Anatomic dissections showed the TCA
to arise from the thyrocervical trunk in 77% of the time or
directly from the subclavian artery in 20% of the time. The
TCA and TCV were reportedly clinically absent in 6% and
12% of explored necks, respectively.17,18
SUPRATROCHLEAR ARTERY
Arising from the ophthalmic branch of the internal carotid
system, the supratrochlear artery supplies the paramedian
forehead flap. This is probably the oldest flap in history and
still has a place today. The artery runs over the medial one-
third of the supraorbital rim to supply the midline forehead
up to the vertex. In raising the forehead flap, it is important
to remember that this vascular pedicle can be dissected
around the orbital rim, and extending it around the medial
brow increases the arc of rotation of the flap. This is particu­
larly important when reconstructing the nasal tip and colu­
mella. Subperiosteal dissection at this level ensures that the
artery is not injured.
VENOUS ANATOMY OF THE HEAD
AND NECK
While the venae comitantes of arteries are frequently appro­
priate for venous drainage of free flaps, there are some
particular features about the head and neck region that are
noteworthy (Figs 10.4B, 10.5).
FACIAL VENOUS SYSTEM
The anterior facial vein is located posterior/lateral to the
facial artery and, while the artery is somewhat tortuous, the
vein is relatively straight. It is generally of excellent caliber
and is very useful as a recipient for a free tissue transfer.
However, the anterior facial vein is often divided in patients
who have had a neck dissection and, therefore, is not always
available. The facial vein begins at the nasal ala as a continu­
ation of the angular vein. The vein courses under the zygo­
maticus and levator labii superioris, and descends along the
anterior border of the masseter and over it, receiving the
deep facial vein, with tributaries from the pterygoid venous
plexus along with the superior and inferior labial veins, buc­
cinator and masseter venous branches. The vein then crosses
the mandibular border deep to the platysma muscle and
joins the retromandibular vein to form the common facial
vein. The facial vein diameter is 2.2–3.2 mm. The common
facial vein is larger measuring 2.4–3.5 mm in diameter.19
ADVANTAGES AND DISADVANTAGES
The advantage of the anterior facial vein is that it has good
caliber. Also, it runs separate from the facial artery and
therefore is less likely to be damaged during dissection of
the artery. The main disadvantage is that it may not be avail­
able if the patient has had a neck dissection. While the distal
end may still be intact, venous drainage is less reliable and,
therefore, our practice is not to use it in these cases.

72
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 10.10  The trigeminal nerve. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Efferent fibers
Afferent fibers
Proprioceptive fibers
Parasympathetic fibers
Sympathetic fibers
Ophthalmic nerve (V1)
Tentorial (meningeal) branch
Nasociliary nerve
Lacrimal nerve
Frontal nerve
Posterior ethmoidal nerve
Short ciliary nerves
Anterior ethmoidal nerve
Supraorbital nerve
Supratrochlear nerve
Infratrochlear nerve
Internal nasal branches
and
External nasal branches
of anterior ethmoidal nerve
Maxillary nerve (V2)
Meningeal branch
Zygomaticotemporal
nerve
Zygomaticofacial nerve
Zygomatic nerve
Infraorbital nerve
Superior
alveolar
branches of
infraorbital nerve
Nerve (Vidian) of
pterygoid canal
(from facial nerve [VII]
and carotid plexus)
Pharyngeal branch
Greater and lesser
palatine nerves
Deep temporal nerves
(to temporalis muscle)
Tensor veli palatini and
medial pterygoid nerves
Buccal nerve
Mental nerve
Inferior dental plexus
Submandibular
ganglion
Mylohyoid nerve
Mandibular nerve (V3)
Inferior
alveolar nerve
Tensor tympani nerve
Chorda
tympani nerve
Superficial
temporal branches
Articular branch
and anterior
auricular nerves
Auriculotemporal nerve
Parotid branches
Meningeal branch
Lesser petrosal nerve (from
glossopharyngeal nerve [IX])
Trigeminal nerve (V) ganglion and nuclei
Motor nucleus
Mesencephalic nucleus
Spinal tract and nucleus
Sensory root of
ciliary ganglion
Ciliary ganglion
Long ciliary nerve
Nasal branches
(posterior superior
lateral, nasopalatine,
and posterior
superior medial)
Lateral pterygoid
and masseteric nerves
Lingual nerve
Otic ganglion
Facial nerve (VII)
Principal sensory nucleus
Pterygopalatine
ganglion

CHAPTER 10 — Clinical Anatomy of the Head and Neck, and Recipient Vessel Selection
73
Figure 10.11  The facial nerve. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Temporal
branches
Zygomatic
branches
Parotid
duct
Buccal
branches
Marginal
mandibular
branch
Cervical branch
Temporofacial division
Posterior auricular n.
Main trunk of facial n.
Cervicofacial division
Temporal branch
Zygomatic branches
Buccal branches
Marginal mandibular branch
Cervical branch
Parotid
gland
Posterior
auricular n.
Main trunk of facial
n. emerging from
stylomastoid foramen
Nerve to posterior
belly of digastric m.
and to stylohyoid m.
Nerve to posterior belly of
digastric m. and stylohyoid m.
upon that muscle beneath the platysma to the parotid gland,
where it divides into an anterior and a posterior branch.
THE FACIAL NERVE
Important anatomic landmarks to the main trunk of the
facial nerve include the tympanomastoid suture, the tragal
pointer, and the posterior belly of the digastric muscle (Fig.
10.12). The main trunk of the facial nerve exits the stylo­
mastoid foramen, where it can be found 10 mm medial and
inferior to the cartilaginous tragal pointer of the external
auditory canal. The tympanomastoid suture line is a useful
landmark and lies between the mastoid and tympanic seg­
ments of the temporal bone. The tympanomastoid suture is
approximately 6–8 mm lateral to the stylomastoid foramen.
The styloid process is deeper to the nerve trunk and usually
lies 5 cm deep to the skin surface in adults. In children, the
facial nerve is more superficial and surgical access should
take into consideration its superficial location to avoid
injury. The facial nerve supplies the postauricular muscles,
stylohyoid muscle and posterior belly of the digastric muscle
before it bifurcates into its main branches. The facial nerve
pierces the parotid gland and bisects the gland along a
plane separating the deep and superficial lobes of the gland.
In the parotid gland, it divides to two major divisions: the
temporal-facial and the cervico-facial branches.
Significant variability in facial nerve branching exists,
even between the left and right sides of the face in the same
Figure 10.12  Branches of the facial nerve exposed after super­
ficial parotidectomy on a cadaver. Superficial temporal artery. 1.
Frontal branch, 2. Zygomatic branch, 3. Buccal branch, 4. Marginal
mandibular branch. The cervical branch is not shown.
1
2
3
4

74
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
5. Niranjian NS. An anatomical study of the facial artery. Ann Plast
Surg 1988;21(1):14–22.
6. Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap: facial
artery musculomucosal (FAMM) flap. Plast Reconstr Surg 1992;
90(3):421–9.
7. Curran AJP, Neligan P, Gullane PJ. Submental artery island flap.
Laryngoscope 1997;107(11):1545–9.
8. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a
new donor site. Anatomy and clinical applications as a free or
pedicled flap. Plast Reconstr Surg 1993;92(5):867–73.
9. Becker C, Vasile JV, Levine JL, et al. Microlymphatic surgery for
the treatment of iatrogenic lymphedema. Clin Plast Surg 2012;
39(4):385–98.
10. Neligan PC, She-Yue H, Gullane PJ. Reverse flow as an option in
microvascular recipient anastomosis. Plast Reconstr Surg 1997;100:
1780–7.
11. Ozgur Z, Govsa F, Celik S, et al. Clinically relevant variations of the
superior thyroid artery: an anatomic guide for surgical neck dissec­
tion. Surg Radiol Anat 2009;31(3):151–9.
12. Gilbert R, Neligan P. Microsurgical laryngotracheal reconstruction.
Clin Plast Surg 2005;32(3):293–301.
13. Pinar YA, Govsa F. Anatomy of the superficial temporal artery and
its branches: its importance for surgery. Surg Radiol Anat 2006;
28(3):248–53.
14. Tayfur V, Edizer M, Magden O. Anatomic bases of superficial tem­
poral artery and temporal branch of facial nerve. J Craniofac Surg
2010;21(6):1945–7.
15. Hanasono MM, Barnea Y, Skoracki RJ. Microvascular surgery in the
previously operated and irradiated neck. Microsurgery 2009;29(1):
1–7.
16. Sapountzis S, Singhal D, Rashid A, et al. Lymph node flap based
on the right transverse cervical artery as a donor site for lymph
node transfer. Ann Plast Surg 2014;73(4):398–401.
17. Yu P. The transverse cervical vessels as recipient vessels for previ­
ously treated head and neck cancer patients. Plast Reconstr Surg
2005;115(5):1253–8.
18. Huelke DF. A study of the transverse cervical and dorsal scapular
arteries. Anat Rec 1958;132(3):233–45.
19. Faltaous AA, Yetman RJ. The submental artery flap: an anatomic
study. Plast Reconstr Surg 1996;97(1):56–62.
20. Mulholland S, Boyd JB, McCabe S, et al. Recipient vessels in head
and neck microsurgery: radiation effect and vessel access. Plast
Reconstr Surg 1993;92(4):628–32.
21. Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral ante­
brachial cutaneous neurosome flaps in oral reconstruction: are we
making sense? Plast Reconstr Surg 1994;93:1350–9.
22. Brenner E, Schoeller T. Masseteric nerve: a possible donor for
facial nerve anastomosis? Clin Anat 1998;11(6):396–400.
23. Tzafetta K, Terzis JK. Essays on the facial nerve: Part I. Microanat­
omy. Plast Reconstr Surg 2010;125(3):879–89.
24. Dingman RO, Grabb WC. Surgical anatomy of the mandibular
ramus of the facial nerve based on the dissection of 100 facial
halves. Plast Reconstr Surg 1962;29:266–72.
individual.23 After its bifurcation at the pes anserinus, five
major branches of the facial nerve exist: the frontal (i.e.,
temporal), zygomatic, buccal, marginal mandibular, and
cervical branches. The frontal branch of the facial nerve is
located along a line extending from 0.5 cm below the tragus
to a point 1 ± 0.45 cm superior to the supraorbital rim. After
exiting the parotid gland, the frontal branch of the facial
nerve crosses over the zygomatic arch within the innominate
fascia (see Fascia of the head and neck, above), where it
remains for a distance 1.5–3.0 cm above the superior border
of the arch. After that transition point, the nerve becomes
more superficial and travels on the undersurface of the
superficial temporal fascia (TPF) until reaching the fronta­
lis muscle.1,2 On average, three branches enter the under­
surface of the frontalis muscle.23 However, the marginal
mandibular branch of the facial nerve runs below the infe­
rior border of the mandible in 81% of dissected specimens,
whereas anterior to the facial artery, it was found above the
inferior border in 100% of specimens. Two major branches
existed in 67% of individuals; a single marginal mandibular
branch was seen in 21%, and three branches were found in
9% of specimens.24
CONCLUSION
The head and neck regional anatomy is a complex area.
This chapter has focused on the relevant anatomy related
to head and neck reconstruction, and particularly, the
approach to vascular and neural structures.
REFERENCES
1. Yang D, Yang JF, Morris S. The fascial planes of the temporal region
related to the frontal branch of the facial nerve. Plast Reconstr Surg
2011;127(2):991–2.
2. Agarwal CA, Mendenhall SD, Foreman KB, et al. The course of the
frontal branch of the facial nerve in relation to fascial planes: an
anatomic study. Plast Reconstr Surg 2010;125(2):532–7.
3. Yang D, Tang M, Geddes C, et al. Vascular anatomy of the integu­
ment of the head and neck. In: Blondeel PN, Morris SF, Hallock
GG, et al., editors. Perforator flaps: anatomy, techniques and clini­
cal applications, vol. 1. 2nd ed. St Louis, MO: Quality Medical
Publishing; 2013. p. 189–221.
4. Magden O, Edizer M, Tayfur V, et al. Anatomic study of the vascu­
lature of the submental artery flap. Plast Reconstr Surg 2004;
114(7):1719–23.

75
Clinical Anatomy and
Recipient Vessel Selection
in the Chest, Abdomen,
Groin, and Back
Joshua Fosnot  |  Joseph M. Serletti
11 
INTRODUCTION
Reconstruction of the torso is a broad topic, which in and
of itself includes techniques of local tissue rearrangement,
skin grafting, local and regional flaps, as well as complex
microsurgical reconstruction. The defects to be recon­
structed are equally diverse and can include breast recon­
struction, wounds related to spinal surgery, cardiothoracic
surgery, abdominal wall reconstruction, or inguinal vessel
exposure. The majority of these techniques are addressed
in specific chapters throughout this book; however, the
purpose of this chapter is to approach the torso in a broad
manner, specifically addressing the anatomic considerations
of muscle, vessel, nerve and lymphatic anatomy, which play
a significant role in the understanding of torso reconstruc­
tion as a whole.
MUSCULAR ANATOMY BY REGION
THE CHEST
The workhorse muscle of the thorax is the pectoralis major.
It has a dual origin from both the clavicle and the sternum
and inserts on the intertubercular groove of the lateral
humerus. Owing to its predictable, dual blood supply
through the thoracoacromial and internal mammary perfo­
rators, as well as its broad surface area, the pectoralis major
can be useful in many forms of reconstruction. The pecto­
ralis minor sits under its major counterpart and is much
more diminutive in nature (Figs 11.1, 11.2).
The serratus anterior originates from the lateral, anterior
surfaces of ribs 1 through 8 and inserts on to the anterior
surface of the medial border of the scapula. Injury to its
innervation, the long thoracic nerve, results in “winging” or
protrusion of the scapula off of the chest wall. Elevation of
the anterolateral origins of the muscle is very useful in
inferolateral muscular coverage of an expander for breast
reconstruction.
The intercostal muscles are comprised of the external
intercostal, internal intercostal, and innermost intercos­
tal, stacked on top of one another from superficial to
deep. Their membranous coverings are each synonymous
with, and contiguous with, the corollary muscle of the
abdominal wall. These muscles are intimately involved in
respiration.
THE ABDOMEN
The rectus abdominis is a vertically oriented, paired muscle
of the anterior abdominal wall. The pair is separated in the
midline by a dense fibrous line called the “linea alba.” The
pair originates on the costal margin bilaterally and inserts
on the symphysis pubis. The lateral abdominal wall is com­
prised of three muscles, the external oblique, internal
oblique and transversus abdominis. The external oblique is
the largest and most superficial of the three with fibers
oriented in a superolateral to inferomedial direction. It
originates on the external surfaces of the 5th through 12th
ribs and inserts on the linea alba, pubic tubercle and iliac
crest. The inferior edge is rolled over on itself and makes
the inguinal ligament. The internal oblique is deeper and
more vertically oriented with an origin on the thoracolum­
bar fascia, iliac crest, and inguinal ligament with an inser­
tion on the inferior border of the 10th through 12th ribs.
The transversus abdominis is the deepest of the three with
a transverse orientation as the name would suggest. It origi­
nates laterally on the thoracolumbar fascia, inguinal liga­
ment and iliac crest and inserts on the linea alba.
The rectus sheath is a strong fibrous layer surrounding
the rectus abdominis muscles. It is a fusion of the aponeu­
roses of the three lateral muscles. For the majority of the
sheath, the posterior sheath is comprised of the transversus
abdominis and half of the internal oblique. The anterior
sheath is comprised of half of the internal oblique and the
entire external oblique. That is to say that the internal
oblique bifurcates anterior and posterior to the rectus
abdominis muscles and all three merge in the midline to
form the linea alba. Midway between the umbilicus and
pubic symphysis however, is the arcuate line. Below this line,
the aponeurosis of all three muscles passes anterior to the
rectus muscles. Thus, there is no posterior rectus sheath
below the arcuate line.
PART 2  —  CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE

76
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 11.1  Axilla (dissection): anterior view. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Pectoralis minor tendon (cut)
Coracoid process
Cephalic vein
Anterior circumflex humeral artery
Deltoid muscle
Biceps brachii muscle
Musculocuta-
neous nerve
Profunda
brachii
(deep
brachial)
artery
Brachialis
muscle
Thoracoacromial artery
Acromial branch
Deltoid branch
Clavicular branch
Pectoral branch
Axillary artery
Clavicle and
subclavius
muscle
(cut)
Suprascapular artery and nerve
Dorsal scapular artery and nerve
Transverse cervical artery
Anterior scalene
muscle
Trapezius
muscle
Acromion
Musculocutaneous nerve
Coracobrachialis muscle
Pectoralis major muscle (cut)
Axillary nerve and posterior
circumflex humeral artey
Sternocleidomastoid
muscle
Phrenic
nerve
Omo-
hyoid
muscle
Radial nerve
Triceps
brachii
muscle
Brachial veins
Ulnar nerve
Median nerve
Brachial artery
Medial antebrachial
cutaneous nerve
Basilic vein
Ulnar nerve
Medial brachial
cutaneous nerve
Intercostobrachial
nerve
Circumflex
scapular artery
Lower sub-
scapular nerve
Teres major muscle
Subscapular artery
Latissimus dorsi muscle
Thoracodorsal artery and nerve
Upper subscapular nerve
Serratus anterior muscle
Lateral thoracic artery and long thoracic nerve
Medial pectoral nerve
Ansa pectoralis
Lateral pectoral nerve
Superior thoracic artery
Brachial plexus
1st rib
Subclavian
artery and vein
Pectoralis minor (cut)

CHAPTER 11 — Clinical Anatomy and Recipient Vessel Selection in the Chest, Abdomen, Groin, and Bac k
77
Figure 11.2  Anterior thoracic wall. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Medial
pectoral
nerve
Coracoid process
Costocoracoid ligament
Thoracoacromial artery (pectoral
branch) and lateral pectoral nerve
Sternocleidomastoid muscle
Posterior triangle of neck
Trapezius muscle
Perforating branches of internal
thoracic artery and anterior cutaneous
branches of intercostal nerves
Pectoralis major muscle
Cephalic vein
Acromion
Deltoid muscle
Long thoracic nerve
and lateral thoracic artery
Latissimus dorsi muscle
1
2
3
4
5
6
7
8
9
10
Digitations of
serratus anterior muscle
Lateral cutaneous branches of
intercostal nerves and
posterior intercostal arteries
External oblique
muscle
Anterior layer of rectus sheath
Sternalis muscle (inconstant)
Linea alba
Cutaneous branches of thoracoabdominal
(abdominal portions of intercostal) nerves
and superior epigastric artery
Rectus abdominis muscle
Internal oblique muscle
Body and xiphoid process
of sternum
External intercostal muscles
External intercostal
membranes anterior to
internal intercostal
muscles
Digitations of serratus
anterior muscle
Pectoralis minor
muscle invested by
Clavipectoral fascia
Clavicle
Subclavius muscle invested by
clavipectoral fascia
Invested by
cervical fascia
Sternothyroid muscle
Sternohyoid muscle
Omohyoid muscle

78
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
clavicle, acromion and spine of the scapula. It is innervated
by the accessory nerve (CN XI) and cervical roots of C3
and C4.
Inferiorly, the lower back is covered by the latissimus
dorsi, a broad, fan-like muscle incredibly versatile for local
and free flap reconstruction. It originates medially along
the spinous processes of T6 through T12, as well as the
thoracolumbar fascia, iliac crest and inferior 3 or 4 ribs. It
THE BACK
The most superficial, but dominant muscle of the upper
back is the trapezius (Fig. 11.3). It has broad attachments
medially along the ligamentum nuchae, occipital protuber­
ance and along the spinous processes of C7 through T12.
These allow for an expansive and strong action on the shoul­
der via its lateral attachments to the lateral third of the
Figure 11.3  Arteries of anterior abdominal wall. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Axillary artery
Lateral thoracic artery
Subscapular artery
Thoracodorsal artery
Anterior
intercostal arteries
Intercostal
muscles
External
Internal
Innermost
Anastomoses with lower
intercostal, subcostal,
and lumbar arteries
External,
Internal
oblique
muscles
Transversus abdominis muscle
Ascending branch of
deep circumflex iliac artery
Superficial
circumflex iliac artery
Superficial
epigastric artery (cut)
Femoral artery
Cremasteric and testicular
arteries and artery to ductus
deferens in spermatic cord
Subclavian artery
Internal thoracic arteries
Pericardiaco-
phrenic
artery with
phrenic nerve
Transversus thoracis
muscle
Branch to falciform
ligament of liver
Musculophrenic
arteries
Superior epigastric
arteries
Diaphragm
Transversus abdominis
muscle and aponeurosis
Rectus abdominis
muscles
Internal
oblique muscle
External
oblique muscle
Posterior layer of
rectus sheath
Arcuate line
Inferior epigastric
artery
Superficial epigastric
artery
Femoral artery
Superficial external
pudendal artery
Deep external
pudendal artery
Dorsal arteries of
penis (deep to
Buck’s fascia)

CHAPTER 11 — Clinical Anatomy and Recipient Vessel Selection in the Chest, Abdomen, Groin, and Bac k
79
ARTERIAL ANATOMY BY REGION
THE CHEST
The most commonly used arteries for chest reconstruction
include the thoracodorsal, thoracoacromial, and internal
mammary systems (see Figs 11.3, 16.1, 16.2, 16.4). Less com­
monly used arteries include the circumflex scapular, the
lateral thoracic (Fig. 11.1), and a perforating artery of the
internal mammary. The thoracodorsal system is used most
commonly in pedicled reconstruction using the latissimus
dorsi muscle or myocutaneous flap. The thoracoacromial or
internal mammary arteries are useful for pedicled pectoralis
major advancement or turnover muscle flaps. While all of
these arteries are useful in regional reconstruction, the
inserts along the intertubercular groove of the humerus.
Innervated by the thoracodorsal nerve, this muscle is the
main actor for adduction and medial rotation of the
humerus, as well as shoulder extension. With arm extension,
this muscle is the primary driver to lift the torso while
climbing.
Additional players of shoulder motion include the levator
scapulae, rhomboid major and rhomboid minor. All three
originate along the spine and insert along the medial border
of the scapulae to aid in scapular stability, retraction and
elevation (Fig. 11.4).
The paraspinous muscles are a group of muscles includ­
ing but not limited to the spinalis, longissimus and iliocos­
talis which aid in spinal extension and stability. These long
muscles located adjacent to the spinous processes of the
spinal column are useful in spinal hardware coverage.
Figure 11.4  Muscles: back and scapula region. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Semispinalis capitis muscle
Splenius capitis muscle
Spinous process of C7 vertebra
Levator scapulae muscle
Not connected
to upper limb
Rhomboid minor muscle
Rhomboid major muscle
Acromion
Supraspinatus muscle
Spine of scapula
Infraspinatus muscle
Teres minor muscle
Teres major muscle
Latissimus dorsi muscle
Long head
Lateral head
Spinous process of
T12 vertebra
Triceps
brachii
muscle
Trapezius muscle
Deltoid
muscle
Infraspinatus
fascia
Triangle of auscultation
Posterior view
Coracoacromial ligament
Coracoid process
Suprascapular artery and nerve
Superior transverse scapular
ligament and suprascapular
notch
Pectoralis minor tendon (cut)
Biceps brachii tendon
(short head) (cut) and
coracobrachialis tendon (cut)
Subscapularis muscle
Subscapular artery
Lower subscapular nerve
(to teres major muscle)
Circumflex scapular artery
Thoracodorsal artery and
nerve (to latissimus dorsi
muscle)
Subscapularis muscle
Teres major muscle
Anterior view
Acromion
Supraspinatus tendon
Greater tubercle of humerus
Subscapularis tendon
Intertubercular tendon sheath
Anterior circumflex humeral artery
Quadrangular space
Biceps brachii tendon
(long head) (cut)
Axillary nerve and
posterior circumflex
humeral artery
Biceps
brachii
muscle
Radial nerve
Long head
Short head
Coracobrachialis muscle
Triangular space
Latissimus dorsi muscle

80
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
usually reveals the proximal portion of the thoracodorsal
vessels and nerve. The axillary fat is usually easily dissected
off these vessels. Self-retaining retractors are helpful in
holding back the axillary fat so that these vessels can be dis­
sected and prepared. There is usually a single perforating
branch to the axillary fat at the proximal portion of the
thoracodorsal vessels. This branch should be ligated before
separating the thoracodorsal vessels from the axillary fat.
With proper retraction, it is unnecessary to remove any
of the axillary lymphatics in preparing these recipient
vessels.
If the axilla has been previously dissected, the thora­
codorsal vessels may still be usable as recipient vessels. The
skin incision is made as above. The lower portion of the
latissimus muscle border is defined by separating the lateral
chest skin off the chest wall musculature, well below the
axillary vessels. With the lower lateral border of the latissi­
mus defined, the vessels are identified as they enter the
muscle and then traced proximally. This allows for safe dis­
section up to the proximal thoracodorsal vessels as well as
the axillary vein and thoracodorsal nerve.
The circumflex scapular vessels lie just posterior to the
origin of the thoracodorsal vessels and then travel laterally
just below the inferior border of the axillary vein toward the
triangular space. Small branches coming off these vessels
are divided and the distal ends of the artery and vein can
be divided near the triangular space. This allows for rotation
of these circumflex scapular vessels medially and anteriorly,
so as to make them useful as recipient vessels within the
axilla. If the thoracodorsal vessels are found to be not useful
as a result of previous axillary dissection, the circumflex
scapular vessels should be examined since they are not
usually injured by previous axillary surgery.
THE ANATOMY AND EXPOSURE OF THE INTERNAL
MAMMARY ARTERY
The internal mammary artery originates from the corre­
sponding brachiocephalic or subclavian artery and courses
thoracodorsal and internal mammary arteries are the most
useful as recipient vessels in microsurgical cases.
THE ANATOMY AND EXPOSURE OF
THE SUBSCAPULAR SYSTEM
The subscapular system begins as a short artery arising from
the axillary artery, which divides into the thoracodorsal and
circumflex scapular arteries. The thoracodorsal artery con­
tinues for 2–3 cm before it gives off one or two branches to
the serratus muscle. For free tissue transfer, these serratus
branches or the terminal branches of the thoracodorsal
artery can be used when the donor pedicle artery is of a
smaller caliber. The circumflex scapular courses laterally as
it originates from the subscapular artery (Figs 11.1, 11.4,
and 11.5) and passes through the triangular space to become
a cutaneous artery that supplies the scapular and parascapu­
lar fasciocutaneous flaps.
If an axillary dissection has been part of the surgery that
has immediately created the chest defect, the thoracodorsal
vessels are usually exposed and require little additional dis­
section to prepare them as recipient vessels. In this setting,
the thoracodorsal nerve usually crosses anterior to the
artery and vein. This nerve should be dissected off the
vessels and the vessels dissected from several small branches
so as to free the thoracodorsals from their origin to the first
or second serratus branch. In addition, the vein should be
separated from the artery for several centimeters as well. If
the axilla has not been dissected as part of the immediate
defect, the thoracodorsal vessels are approached through a
transverse incision between the anterior and posterior axil­
lary folds. The level of the incision is just below the lower
limit of the axillary hair.
The lateral border of the pectoralis muscle is defined and
the axillary fat is entered directly posterior to this border of
the muscle. The lateral thoracic vein is usually first encoun­
tered within the axillary fat and this vein can be traced
superiorly to identify the axillary vein. Spreading the axillary
fat just posterior to the origin of the lateral thoracic vein
Figure 11.5  Axilla: branches of the axillary artery. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Anterior view
Transverse cervical a.
Suprascapular a.
Acromial anastomosis
Dorsal scapular a.
Anterior circumflex
humeral a.
Posterior circumflex
humeral a.
Subscapular a.
Circumflex
scapular a.
Brachial a.
Thoracodorsal a. Lateral thoracic a.
Thyrocervical trunk
Subclavian a.
Anterior scalene m.
Clavicle (cut)
Superior thoracic a.
Thoracoacromial a.
Clavicular branch
Acromial branch
Deltoid branch
Pectoral branch
1, 2, and 3 indicate 1st,
2nd, and 3rd parts of
axillary artery
1
2
3

CHAPTER 11 — Clinical Anatomy and Recipient Vessel Selection in the Chest, Abdomen, Groin, and Bac k
81
It typically enters the undersurface of the pectoralis major
between the middle and lateral thirds of the muscle. An
incision is made just below the lateral half of the clavicle.
The skin and soft tissue are elevated to expose the pectoralis
major muscle. The clavicular portion of the pectoralis
muscle is divided to expose the thoracoacromial vessels.
Their location can first be identified with a handheld
Doppler. After dividing the muscle, the vessels are usually
within a sheath of fatty tissue with two accompanying veins.
The vessels can be dissected away from the muscle and then
toward their origin on the axillary vessels.
ADVANTAGES AND DISADVANTAGES OF RECIPIENT
ARTERIES FOR RECONSTRUCTION OF THE
CHEST REGION
The advantages of the thoracodorsal artery include depend­
able anatomy and a generally consistent caliber. The artery
is usually easily identified along with the vein and, more
importantly, the thoracodorsal nerve. The thoracodorsal
artery is easily dissected and is not sensitive to manipulation
during dissection. It is generally useful even in the setting
of previous axillary dissection. The main disadvantage is the
need to dissect through a moderate amount of axillary fat
and lymphatic contents to expose this artery when an axil­
lary dissection has not been part of the procedure. Although
this artery can be transposed to a more superficial position
after dissection and distal division, the axilla still tends to be
a deeper, confining recipient site requiring longer instru­
ments and additional skill to perform anastomoses.
The advantages of the internal mammary artery include
dependable anatomy, a consistently large vessel caliber, and
its superficial location, which allows greater ease for per­
forming anastomoses. This artery provides for an excellent
alternative to the thoracodorsal artery in the setting of
previous axillary dissection. The disadvantages include this
artery’s susceptibility to injury even with gentle dissection.
The attachments of its intima are also fragile, with intimal
separation and injury occasionally occurring during routine
anastomoses. The accompanying vein, particularly on the
left side, can be too small despite a very adequate recipient
artery, necessitating a move to another recipient site. The
internal mammary perforators have the advantage of elimi­
nating the need for the removal of a costal cartilage. Their
primary disadvantage is a small caliber.
The advantages of the circumflex scapular include con­
sistent anatomy and a large-caliber vessel, which is usually
larger than the accompanying thoracodorsal artery. On
occasion, the thoracodorsal artery is injured as a result of
the axillary surgery; however, it would be rare to injure the
circumflex scapular in this particular setting. The circum­
flex scapular artery can be dissected as it courses toward the
triangular space and transposed into a more superficial loca­
tion in the axilla. The disadvantages include the same depth
issues in performing the anastomosis as in the thoracodorsal
vessels. Congenital absence of the circumflex scapular artery
is uncommon but has been reported.
The advantages of the lateral thoracic artery are its super­
ficial location and its very large accompanying vein. The
lateral thoracic vein is usually larger than the thoracodorsal
vein. The main disadvantage of the lateral thoracic artery is
its routinely small caliber, making the thoracodorsal artery
a better choice in this setting.
inferiorly, deep to the costal cartilages and superficial to the
pleura. As this vessel exits underneath the costal margin, it
becomes the superior epigastric artery (see Fig. 11.3). The
internal mammary artery is usually accessed by removing
the third costal cartilage. Perforating vessels just above
the second, third or fourth costal cartilages are common
and can be used as recipient vessels in this region if large
enough.
A direct incision may be made overlying the third costal
cartilage (Fig. 11.2). This can be identified by palpating the
sternal angle which is at the level of the second costal carti­
lage. Moving one cartilage lower identifies the third costal
cartilage. The skin and soft tissues are dissected just above
the pectoralis muscle fascia. The pectoralis muscle is sepa­
rated on top of this cartilage and the cartilage is removed
through a subperichondrial dissection. The deep perichon­
drium is incised and reflected lateral to medial to expose
the internal mammary vessels and lymphatics. The intercos­
tal musculature is divided up to the bottom of the second
costal cartilage. This muscle can also be divided to the top
of the fourth costal cartilage if additional pedicle length is
required. There is usually a perforating branch at the level
of each costal cartilage that needs to be divided in order to
free up these vessels. There are also other small branches
that will need to be divided as well. The artery and vein are
usually easily separated from each other. At this level, there
is usually only one vein on each side, with the left vein
tending to be smaller than the right. The vein is usually thin
walled and the artery is also subject to easy trauma, resulting
in segmental thrombosis. These vessels, in particular, require
gentle dissection. The artery’s intima separates easily and
the surgeon must be assured that the sutures capture arte­
rial adventitia in order to obtain adequate strength for the
anastomosis.
Perforators off the internal mammary system should be
evaluated as the skin and soft tissues are elevated off the
pectoralis muscle. A sufficiently large perforator can be con­
sidered as a recipient vessel, avoiding further soft tissue
dissection and removal of the costal cartilage. These perfo­
rating vessels can be traced up into the subcutaneous tissue,
dividing small branches and developing a reasonable length
of recipient vessels.
THE ANATOMY AND EXPOSURE OF THE LATERAL
THORACIC ARTERY
The lateral thoracic artery (Figs 11.1, 11.5) is a direct branch
off the axillary artery and follows with the lateral thoracic
vein (Fig. 11.8). This vessel is more superficial within the
axilla as compared to the thoracodorsal artery. The same
incision and approach are used to harvest the lateral thorac­
ics, as done in dissecting the thoracodorsal vessels. The
lateral thoracic vein is usually easily identified within the
more superficial axillary fat. The lateral thoracic vein is typi­
cally larger than the thoracodorsal vein. The lateral thoracic
artery is just posterior to the vein and is considerably smaller
in caliber. On occasion, this artery is as large as the thora­
codorsal artery.
THE ANATOMY AND EXPOSURE OF THE
THORACOACROMIAL ARTERY
The thoracoacromial artery comes off the subclavian artery
to supply the pectoralis major muscle (Figs 11.1 and 11.5).

82
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
THE ABDOMEN
THE ANATOMY AND EXPOSURE OF THE INFERIOR
EPIGASTRIC ARTERY
The deep inferior epigastric artery is a direct branch off the
external iliac artery. This artery continues moving superiorly
and medially for 4–6 cm before it enters the rectus abdomi­
nis muscle. The artery gives off several small branches as it
runs from the external iliac artery to the muscle (Fig. 11.6
and see Fig. 11.3).
Access to these vessels is usually obtained through the
anterior rectus fascia to expose the lateral border of the
rectus abdominis muscle. Retractors are placed so as to
elevate the lateral border of the muscle to expose the infe­
rior epigastric vessels. The intercostal motor nerves are kept
intact to preserve the motor innervation to the rectus
abdominis muscle. The vessels course just below these motor
nerves so they can be preserved while still preparing a useful
segment of these vessels. The inferior epigastric vessels can
be followed as they course away from the muscle, moving
inferiorly and laterally to join the external iliacs. The infe­
rior epigastrics can also be followed superiorly within the
muscle. These vessels can be dissected away from their
attachments to the rectus abdominis muscle, thus increasing
the potential length of recipient vessels.
The superior epigastric artery is an extension of the inter­
nal mammary vessels. A vertical or transverse incision can
be made in the upper portion of the abdomen. The anterior
rectus fascia is entered, also either transversely or vertically.
The medial border of the rectus abdominis muscle is identi­
fied and elevated off the posterior rectus sheath. A portion
of the medial aspect of the rectus abdominis may need to
be divided at the level of the costal margin. On the under­
surface of the muscle, along its medial aspect, the superior
epigastric vessels are seen coursing just underneath the
costal margin and then into the muscle. These vessels can
be dissected off the muscle but usable vessel length remains
limited and vessel caliber is also unpredictable at this level.
THE ANATOMY AND EXPOSURE OF
THE FEMORAL ARTERY
See Chapter 13, Figure 13.2.
THE ANATOMY AND EXPOSURE OF
THE SUPERIFICIAL INFERIOR EPIGASTRIC
AND CIRCUMFLEX ILIAC ARTERIES
The superficial inferior epigastric and superficial circum­
flex iliac arteries come off the common femoral artery (Fig.
11.6). Due to their smaller caliber, they are not commonly
used as recipient vessels in abdominal or groin reconstruc­
tion; however, knowing the anatomy can be useful in har­
vesting vascularized lymph nodes.
An incision is made parallel to and just above the inguinal
ligament. The skin and soft tissues are typically dissected
through Scarpa’s fascia. Just deep to Scarpa’s fascia, the
superficial circumflex iliac vessels can be found at or near
the anterior superior iliac spine. The superficial inferior
epigastric vessels may be found just medial to the anterior
portion of the iliac crest. The superficial inferior epigastric
vessels are also found just below Scarpa’s fascia but in a more
medial location. Both the superficial inferior epigastric
vessels and superficial circumflex iliac can be dissected back
to their origin on the femoral artery and vein. On occasion,
these two vessels will share a common origin on the femoral
vessels.
THE ANATOMY AND EXPOSURE OF
THE INTERCOSTAL ARTERY
The intercostals are located deep to the periosteum, on the
inferior border of each rib and can be dissected for what­
ever length is required (Figs 11.2 and 11.6). The more
proximal ribs tend to have larger diameters so the highest
possible rib is selected. An incision is made directly overly­
ing a rib near the site of the defect. Dissection courses
directly onto the selected rib and the periosteum is incised.
A subperiosteal dissection is performed and a segment of
rib is removed. The deep periosteum is incised along the
inferior aspect of the removed rib.
ADVANTAGES AND DISADVANTAGES OF RECIPIENT
ARTERIES FOR RECONSTRUCTION OF THE ABDOMEN
AND GROIN REGIONS
For abdominal and groin reconstruction, the femoral artery
has the advantage of consistent anatomy and a superficial
location. Its disadvantages include the need to perform end-
to-side anastomoses and the thicker wall of the femoral
artery. Other disadvantages include the presence of ather­
oma in older patients, which can make the performance of
the anastomosis challenging.
The advantages of the inferior epigastric artery include
its consistent anatomy, caliber, and length of vessel from
its origin to where it enters the rectus abdominis. This
length allows for transposition to a superficial location for
both abdominal and groin reconstruction. The disadvan­
tage with this recipient artery is the potentially smaller
caliber veins at the level of artery division and transposition.
Transposing the saphenous vein helps to get around this
potential problem. The other disadvantage is the potential
for lower abdominal wall hernia formation. The anterior
rectus sheath is incised in order to reach this artery. If the
artery is transposed to a more superficial location for
abdominal wall or groin reconstruction, some portion of the
anterior rectus sheath must remain open so as not to kink
or occlude the recipient artery. This opening, even if small,
does allow for the late development of an abdominal wall
hernia.
The advantages of the superior epigastric artery are con­
sistent anatomy and its location for upper abdominal wall
and chest reconstruction. The disadvantages are its short
length and its tendency toward a smaller caliber.
The advantages of the superficial epigastric and circum­
flex iliac arteries are their superficial location. The disad­
vantages are their very small caliber in the superficial
location and their inconsistent anatomy.
The advantage of an intercostal artery as a potential recip­
ient artery, is its close proximity to lumbar and posterior
thoracic defects. These types of defects are usually challeng­
ing because of the absence of straightforward nearby recipi­
ent vessels. Removal of an adjacent rib and dissection of the
intercostal vessels provides for usable recipient vessels in
these otherwise difficult locations. The disadvantages of the
intercostals are their small caliber.

CHAPTER 11 — Clinical Anatomy and Recipient Vessel Selection in the Chest, Abdomen, Groin, and Bac k
83
Figure 11.6  Veins of posterior abdominal wall venous drainage of the abdomen. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier
Inc. All Rights Reserved.)
Inferior phrenic veins
Inferior vena cava
Right inferior
suprarenal vein
Diaphragm
Right renal vein
Iliolumbar vein
Quadratus
lumborum muscle
1st to 4th right
lumbar veins
Subcostal vein
Psoas major
muscle (cut)
Common
iliac vein
Ovarian
(testicular)
veins and
ureter (cut)
Internal
iliac vein
Median
sacral vein
Lateral
sacral veins
Deep circumflex
iliac vein
Superficial
circumflex
iliac vein
Inferior
epigastric vein
(cut)
Superficial epigastric vein (cut)
Pubic (obturator anastomotic) vein
Femoral vein
Great saphenous vein
External pudendal vein
Anterior abdominal
wall (turned down)
Vesical venous plexus
Uterovaginal venous
plexus
Rectal venous
plexus
Inferior epigastric
vein
Round ligament
of uterus
Deep circumflex
iliac vein
Obturator vein
Superior vesical
vein
Uterine vein
Middle rectal
vein
External iliac
vein
Internal
pudendal vein
Inferior gluteal
vein
Superior gluteal
vein
Internal iliac
vein
Common iliac
vein
Ascending
lumbar veins
Ovarian (testicular)
veins
Left renal vein
Left suprarenal veins and
anastomosis with inferior
phrenic vein
Esophagus
Hepatic veins

84
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 11.7  Nerves of back. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Accessory nerve (XI)
Trapezius muscle (reflected)
Levator scapulae muscle
Transverse cervical artery
and vein
Subtrapezial plexus
Supraspinatus
muscle
Spine of
scapula
Infraspinatus
fascia
Rhomboid
minor muscle
Rhomboid
major muscle
Spinous process of
T12 vertebra
Gluteus maximus
muscle
Latissimus dorsi muscle
Thoracolumbar fascia
Iliac crest
External oblique muscle
Superior lateral brachial
cutaneous nerve (from
axillary nerve C5, 6)
Infraspinatus fascia
Lesser occipital nerve
Great auricular nerve
Trapezius muscle
Inferior clunial nerves from
posterior femoral cutaneous
nerve (sacral plexus S1, 2, 3)
Iliohypogastric nerve
(ventral ramus of L1 spinal
nerve)
Lateral cutaneous branches of
ventral rami (intercostal nerves)
Posterior cutaneous
branches (from lateral
branches of dorsal rami
of T7–12 spinal nerves)
Teres minor and
major muscles
Posterior cutaneous branches (from medial
branches of dorsal rami of C4–T6 spinal
nerves; C7, 8 are minimal)
Cervical plexus
(ventral rami of
C2, 3 spinal nerves)
3rd occipital nerve (dorsal ramus of
C3 spinal nerve)
Greater occipital nerve (dorsal ramus of
C2 spinal nerve)
Deltoid muscle
Superior clunial nerves
(dorsal rami of L1, 2, 3 spinal
nerves)
Medial clunial nerves
(dorsal rami of S1, 2, 3 spinal
nerves)
THE BACK
The common recipient artery in microsurgical reconstruc­
tion of the back is the thoracodorsal artery (Fig. 11.1). The
circumflex scapular artery and a regional intercostal artery
are less commonly used (Fig. 11.4). This can be used for
pedicled reconstruction as well. Similarly, the dorsal scapu­
lar artery and superficial cervical artery are useful in pedi­
cled reconstruction of the upper neck or occiput in the
form of a trapezius flap (Fig. 11.7). The superior and infe­
rior gluteal arteries are also available as recipient arteries
for lower back reconstruction (see Fig. 13.3).
ADDITIONAL VENOUS ANATOMY
In addition to the accompanying veins of all of the arteries
described above, a few notable additions are discussed

CHAPTER 11 — Clinical Anatomy and Recipient Vessel Selection in the Chest, Abdomen, Groin, and Bac k
85
Figure 11.8  Veins of anterior abdominal wall. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Subclavian vein
Axillary vein
Cephalic vein
Intercostal
tributaries
to axillary
vein
Lateral thoracic vein
Anterior
intercostal veins
Internal thoracic vein
Musculophrenic vein
Superior epigastric veins
Thoraco-epigastric vein
Para-umbilical veins in
round ligament of liver
Inferior epigastric veins
Tributaries to deep
circumflex iliac veins
Thoraco-epigastric vein (cut)
Superficial
circumflex iliac vein
Superficial epigastric vein
External pudendal vein
Saphenous opening
Femoral vein
Great saphenous vein
Pampiniform (venous) plexus
Superficial dorsal vein of penis
Cephalic vein
Axillary vein
Lateral thoracic vein
Areolar venous plexus
Perforating tributaries
to internal thoracic
vein
Thoraco-epigastric vein
Tributaries of
para-umbilical veins
Thoraco-epigastric vein
Superficial epigastric vein
Superficial circumflex
iliac vein
External pudendal vein
Cribriform fascia over
saphenous opening
Great saphenous vein
Anterior scrotal veins
below, which can be useful in chest, back or abdominal
reconstruction.
THE ANATOMY AND EXPOSURE OF THE
CEPHALIC VEIN
In situations where there is an adequate recipient artery
but inadequate recipient vein, either the cephalic vein or
external jugular vein can be transposed into a chest posi­
tion. The cephalic vein is a superficial vein which courses
along the anterolateral aspect of the arm and continues
into the deltopectoral groove to empty into the subcla­
vian vein (Figs 11.2, 11.8). The cephalic vein can be
approached through a direct incision or multiple short
transverse incisions anywhere along its course as it begins

86
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
on the radial aspect of the wrist and then enters the delto­
pectoral groove to enter into the axillary vein. The length
needed to transpose this vein into the required recipient
site determines how much of this vein will need to be
dissected.
THE ANATOMY AND EXPOSURE OF THE EXTERNAL
JUGULAR VEIN
The external jugular vein is formed by the posterior facial
vein and then empties into the subclavian vein (Figs 11.2,
11.8). Either of these two veins can be transposed about
their attachment to the subclavian vein and rotated into a
chest recipient site. In a similar manner, the external jugular
vein can be approached through a direct overlying inci­
sion or several shorter transverse incisions. This vein can be
divided just underneath the mandible as it exits at the pos­
terior facial vein and can be transposed about its origin on
the subclavian vein. The length of vein required is deter­
mined by the location of the recipient artery.
NERVE ANATOMY BY REGION
THE CHEST
Nerves available for creating a sensate free flap reconstruc­
tion in chest reconstructions include the intercostobrachial
nerve, the anterior and posterior branches of the lateral
cutaneous nerves, and the parasternal anterior cutaneous
nerves off of the intercostal nerves (Figs 11.2, 11.9). The
intercostobrachial nerve courses transversely in the superfi­
cial portion of the axillary fat and lymphatics, superficial to
the thoracodorsal vessels and nerves. There are several
branches to this nerve, any one of which can be used for
creating a sensate flap. The anterior and posterior branches
of the lateral cutaneous nerves exit the chest wall muscula­
ture to innervate the overlying skin. These branches can be
found following resection and/or exposure of superficial
chest wall defects.
Potential motor nerves for creating a functional flap in
chest reconstruction include the thoracodorsal, medial or
lateral pectoral, and long thoracic nerves. The need for a
functional reconstruction should outweigh the potential
loss of function in either the latissimus dorsi or serratus
anterior muscles, should these motor nerves be used (Fig.
11.1). These motor nerves are within the axilla and are
approached as described above. The thoracodorsal nerve
travels with the thoracodorsal vessels. The long thoracic
nerve courses more medially in the axilla to innervate the
serratus anterior muscle.
THE ABDOMEN AND GROIN
Nerves available for creating a sensate reconstruction in
abdominal and groin reconstruction include the anterior
branches of the lateral cutaneous nerves as well as the ante­
rior cutaneous nerves (branches of the intercostal nerves).
Other sensory cutaneous nerves include the iliohypogastric
and the ilio-inguinal nerves (Figs 11.9, 11.10). These nerves
pierce the internal oblique muscle to travel within the ingui­
nal canal to give innervation to the inguinal region. They
can be accessed by making an incision just above the ingui­
nal ligament and then opening the fascia of the lower exter­
nal oblique to expose the inguinal canal and these nerves.
Potential motor nerves include the motor branches of the
intercostals that supply segmental motor function to the
rectus abdominis muscle.
THE BACK
Nerves available to create a sensate back reconstruction
include the posterior branches of the lateral cutaneous
nerves and cutaneous branches of the dorsal rami. Potential
motor nerves include the thoracodorsal and long thoracic
nerves, as mentioned above in the chest reconstruction
section (Figs 11.1, 11.9). The dorsal rami cutaneous nerves
pierce the paraspinal musculature to supply sensation to the
overlying dorsal skin. Following resection or elevation of the
overlying skin and soft tissues, these nerves can be seen
exiting from the trapezius or latissimus muscles to enter the
skin.
CONCLUSION
In conclusion, the most common recipient vessels for chest
reconstruction include the thoracodorsal and internal
mammary systems. Less common choices include the cir­
cumflex scapular, the lateral thoracic, and the thoracoacro­
mial systems. Veins available for transposition include the
cephalic and external jugular. The most common recipient
vessels for abdominal and groin reconstruction include the
inferior epigastrics and femorals. Less commonly used are
the superior epigastrics, and the superficial inferior epigas­
tric and superficial circumflex iliac systems. The most
common recipient vessels for back reconstruction include
the thoracodorsals. Less commonly used are the circumflex
scapular and intercostal systems.
Access further reading online at

CHAPTER 11 — Clinical Anatomy and Recipient Vessel Selection in the Chest, Abdomen, Groin, and Bac k
87
Figure 11.9  Nerves of anterior abdominal wall. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Medial brachial
cutaneous nerve
Intercostobrachial
nerve (T1, 2)
Long thoracic nerve
Latissimus dorsi muscle
Serratus anterior muscle
Lateral cutaneous branches
of intercostal nerve (T2–11)
Anterior cutaneous branches
of intercostal nerve (T1–11)
Lateral cutaneous branch
of subcostal nerve (T12)
Lateral cutaneous branch
of iliohypogastric nerve (L1)
Anterior cutaneous branch
of subcostal nerve (T12)
Lateral femoral cutaneous
nerve (L2, 3)
Anterior cutaneous branch
of iliohypogastric nerve (L1)
Femoral branches of
genitofemoral nerve (L1, 2)
Anterior scrotal branch
of ilioinguinal nerve (L1)
Genital branch of
genitofemoral nerve (L1, 2)
2
External
oblique muscle (cut)
Posterior layer of
rectus sheath
Anterior layer of
rectus sheath (cut)
Rectus abdominis muscle
Transversus abdominis
muscle
Internal oblique muscle
and aponeurosis (cut)
Anterior and lateral
cutaneous branches
of subcostal nerve (T12)
Anterior branch of
iliohypogastric nerve (L1)
Ilioinguinal nerve (L1)
External oblique
aponeurosis (cut)
Anterior cutaneous branch
of iliohypogastric nerve (L1)
Ilioinguinal nerve (L1)
Cremasteric muscle
of spermatic cord
External spermatic fascia
of spermatic cord
3
4
5
6
7
8
9
10
11
1
2
3
4
5
6
7
8
9
10
11

88
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 11.10  Nerves of posterior abdominal wall. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Greater, lesser, and least
thoracic splanchnic nerves
Sympathetic trunks
Subcostal nerve (T12)
Celiac, superior mesenteric,
and aorticorenal ganglia
Iliohypogastric nerve
(L1)
Ilioinguinal
nerve (L1)
Genitofemoral
nerve (L1, 2)
Transversus
abdominis
muscle (cut)
Subcostal
nerve (T12)
and its
lateral
cutaneous
branch
Intermesenteric
(paraaortic)
plexus
Gray rami
communicantes
Femoral
nerve
(L2–L4)
Gray and
white rami
communicantes
Lateral
femoral
cutaneous
nerve
(L2, 3)
Femoral branches
Genital branch
Anterior scrotal (labial) branches of ilioinguinal nerve (L1)
Anterior cutaneous branch of iliohypogastric nerve (L1)
of genitofemoral nerve (L1, 2)
Obturator nerve (L2, 3, 4)
Pudendal nerve (S2, 3, 4)
Sacral plexus (L4–S4)
Femoral nerve
Obturator nerves
Lumbosacral
trunks (L4, 5)
Femoral branch,
Genital branch
of genitofemoral
nerve (L1, 2)
Lateral femoral
cutaneous
nerve (L2, 3)
Genitofemoral
nerve (L1, 2)
Ilioinguinal
nerve (L1)
Iliohypogastric
nerve (L1)
Psoas major
muscle (cut)
Quadratus
lumborum
muscle
Subcostal nerve (T12)
Muscular branches
from lumbar plexus
Ilioinguinal nerve (L1)
Iliohypogastric nerve (L1)
Accessory obturator
nerve (L3, 4)
(occasional)

CHAPTER 11 — Clinical Anatomy and Recipient Vessel Selection in the Chest, Abdomen, Groin, and Bac k
88.e1
FURTHER READING
Barnett GR, Carlisle IR, Gianontsos MP. The cephalic vein: an aid in
free TRAM flap breast reconstruction. Report of 12 cases. Plast
Reconstr Surg 1996;97:71–6.
Dupin CL, Allen RJ, Glass CA, et al. The internal mammary artery and
vein as a recipient site for free-flap breast reconstruction: a report of
110 consecutive cases. Plast Reconstr Surg 1996;98:685–9.
Lieu S, Hunt J, Penning MD. Sensory recovery following free TRAM
flap breast reconstruction. Br J Plast Surg 1996;49:210–13.
McAllister E, Wells K, Chaet M, et al. Perineal reconstruction after
surgical extirpation of pelvic malignancies using the transpelvic
transverse rectus abdominal myocutaneous flap. Ann Surg Oncol
1997;1(2):164–8.
Moran SL, Serletti JM, Fox I. Immediate free TRAM reconstruction in
lumpectomy and radiation failure patients. Plast Reconstr Surg
2000;106(7):1527–31.
Moran SL, Guillermina N, Behnam AB, et al. An outcome analysis
comparing the thoracodorsal and internal mammary vessels as recipi­
ent sites for microvascular breast reconstruction: a prospective study
of 100 patients. Plast Reconstr Surg 2003;111(6):1876–82.
Ninkovic M, Kronberger P, Harpf C, et al. Free innervated latissimus
dorsi muscle flap for reconstruction of full-thickness abdominal wall
defects. Plast Reconstr Surg 1998;101(4):971–8.
Place MJ, Song T, Hardesty RA, et al. Sensory reinnervation of autolo­
gous tissue TRAM flaps after breast reconstruction. Ann Plast Surg
1997;38:19–22.
Rohrich RJ, Lowe JB, Hackney FL, et al. An algorithm for abdominal
wall reconstruction. Plast Reconstr Surg 2000;105(1):202–16.
Serletti JM, Moran SL, Orlando GS, et al. Thoracodorsal vessels as
recipient vessels for the free TRAM in delayed breast reconstruction.
Plast Reconstr Surg 1999;104:1649–55.

89
Clinical Anatomy and
Recipient Vessel Selection
in the Upper Extremity
Karim Bakri
12 
INTRODUCTION
Reconstructive microsurgery of the upper extremity requires
detailed knowledge of the regional anatomy of the arm,
forearm and hand. Specific familiarity with the anatomy of
the neurovascular structures allows safer, more expeditious
flap elevation and recipient vessel exposure. This chapter
reviews anatomy pertinent to upper extremity reconstruc­
tion, and describes the anatomy of common recipient vessel
approaches.
ANATOMY OF THE ARM
The arm is divided into anterior and posterior compart­
ments by the medial and lateral intermuscular septa (Fig.
12.1). The anterior compartment contains the biceps, bra­
chialis and coracobrachialis muscles, the brachial artery and
veins, and the median and musculocutaneous nerves (Fig.
12.2). The posterior compartment contains the three heads
of the triceps and profunda brachii (Fig. 12.3). The ulnar
and radial nerves traverse both compartments.
A line drawn from the lateral epicondyle of the humerus,
to the insertion of the deltoid corresponds with the lateral
intermuscular septum. This landmark is useful when
marking the axis of the lateral arm flap, or for exposing the
radial collateral artery.
The medial intermuscular septum runs along the medial
epicondylar ridge, beginning at the medial epicondyle of
the humerus distally and blending with the coracobrachialis
fascia proximally. The anterior and posterior compartments
in the arm are enveloped by a layer of deep fascia, and the
only notable structures found superficial to this layer are the
cutaneous nerves and superficial veins.
VASCULAR ANATOMY OF THE ARM
THE BRACHIAL ARTERY
The brachial artery is the continuation of the axillary
artery, beginning at the distal edge of the teres major and
ending approximately 2–3 cm distal to the elbow where it
Figure 12.1  Cross-sectional anatomy of the arm. (Reprinted from
Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
PART 2  —  CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE

90
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
muscle, and eventually medial to the biceps. Its final
position is anteromedial to the elbow joint, where it runs
under the bicipital aponeurosis (lacertus fibrosis), entering
the forearm superficial and medial to the biceps tendon
(Fig. 12.4).
In the proximal arm the brachial artery is surrounded
by the terminal branches of the brachial plexus (Fig.
12.5). An appreciation of these neurovascular relationships
bifurcates into the radial and ulnar arteries at the level of
the radial neck (Fig. 12.2). It is accompanied along its
course by two interconnected venae comitantes, which
are large enough to be used as recipient veins in micro­
vascular reconstruction. The artery lies under the deep
fascia of the arm and is easily palpable along its course
commencing anteromedial to the triceps in the upper arm,
gradually becoming more anterior to lie along the brachialis
Figure 12.2

CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
91
The ulnar nerve is initially found medial to the brachial
artery in the proximal arm, along with the medial ante­
brachial cutaneous nerves. As the brachial artery gradually
courses in an anterior direction towards the antecubital
fossa, the ulnar nerve heads posteriorly away from the artery,
piercing the medial intermuscular septum half way down
the arm to enter the posterior compartment of the arm
medial to the triceps (Fig. 12.2). It eventually lies posterior
is necessary to avoid intraoperative nerve injuries in recipi­
ent vessel exposure, and is also useful when performing
complex peripheral nerve reconstruction and nerve
transfers.
Along its entire course, the brachial artery remains inti­
mately related to the median nerve. Proximally, the median
nerve lies anterior to the artery but crosses it to lie medial
to the brachial artery in the distal arm (Fig. 12.3).
Figure 12.3  Brachial artery and medial arm. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Coracoid process
Deltoid muscle
Anterior circumflex
humeral artery
Humerus
Pectoralis major
muscle and tendon (cut)
Biceps
brachii
muscle
Long head
Short head
Coracobrachialis muscle
Brachial artery
Muscular branch
Median nerve
Muscular branch
Biceps brachii muscle
Brachialis muscle
Radial recurrent artery
Biceps brachii tendon
Radial artery
Axillary artery
Pectoralis minor muscle (cut)
Lateral cord,
Medial cord
of brachial plexus
Musculocutaneous nerve
Subscapularis muscle
Anterior and posterior
circumflex humeral arteries
Teres major muscle
Latissimus dorsi muscle
Profunda brachii (deep
brachial) artery
Medial brachial cutaneous nerve
Ulnar nerve
Medial antebrachial cutaneous nerve
Long head
Medial head
of Triceps brachii muscle
Superior ulnar collateral artery
Medial intermuscular septum
Inferior ulnar collateral artery
Medial epicondyle of humerus
Bicipital aponeurosis
Pronator teres muscle
Ulnar artery
Flexor carpi radialis muscle
Brachioradialis muscle

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PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Superficial layer
Acromion
Supraspinatus muscle
Greater tubercle of humerus
Infraspinatus muscle
Teres minor muscle
Deltoid muscle (cut and reflected)
Superior lateral brachial cutaneous nerve
of Triceps brachii muscle
Long head
Lateral head
Tendon
Brachioradialis muscle
Teres major muscle
Medial inter-
muscular septum
Ulnar nerve
Medial epicondyle
of humerus
Olecranon of ulna
Anconeus muscle
Extensor carpi
radialis longus muscle
Extensor carpi ulnaris muscle
Extensor digitorum muscle
Extensor carpi radialis brevis muscle
Capsule of shoulder joint
Supraspinatus tendon
Axillary nerve
Posterior circumflex
humeral artery
Superior lateral brachial
cutaneous nerve
Profunda brachii (deep
brachial) artery
Radial nerve
Middle collateral artery
Radial collateral artery
Lateral intermuscular
septum
Lateral epicondyle
of humerus
Teres
major
muscle
Medial epicondyle
of humerus
Ulnar nerve
Olecranon of ulna
Anconeus muscle
Deep layer
Axillary nerve and posterior
circumflex humeral artery
Flexor carpi
ulnaris muscle
Long head of
triceps brachii muscle
Lateral head of triceps
brachii muscle (cut)
Medial head of
triceps brachii muscle
Infraspinatus and
Teres minor tendons (cut)
Inferior lateral brachial
cutaneous nerve
Nerve to anconeus and
medial head of
triceps brachii muscle
Posterior brachial
cutaneous nerve
(from radial nerve)
Posterior antebrachial
cutaneous nerve (from
radial nerve)
Posterior antebrachial
cutaneous nerve
Figure 12.4  Posterior compartment of the arm. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
to the medial epicondyle of the humerus where it can be
reliably located, as it enters the forearm (Fig. 12.6).
The radial nerve lies posterior to the brachial artery in
its proximal portion (Fig. 12.4) but rapidly heads in a
much deeper and lateral direction. Along with the pro­
funda brachii (deep brachial artery), it passes through the
triangular interval between teres major, the long and lateral
heads of triceps, to lie posterior to the humerus and away
from the brachial artery for the remainder of its course in
the arm (Fig. 12.3). After the radial nerve winds posteriorly
around the humerus in the spiral groove, it pierces the
lateral intermuscular septum leaving the posterior compart­
ment, to enter the anterior compartment in the distal arm.
From here, it enters the forearm anterolaterally between
the brachioradialis and brachialis (Fig. 12.6), before divid­
ing into its two terminal branches (Fig. 12.4).

CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
93
Figure 12.5
BRANCHES OF THE BRACHIAL ARTERY
The brachial artery gives rise to four important named
branches in the arm (the profunda brachii, the nutrient
artery to the humerus, and the superior and inferior col­
lateral arteries) (Fig. 12.5).
The profunda brachii (the deep brachial artery) is the
first and largest branch of the brachial artery arising just
past the distal border of the teres major on the posterome­
dial aspect of the brachial artery. It eventually supplies the
territory of the lateral arm flap via its radial collateral
branch.
In its proximal portion the profunda brachii gives rise to
a small branch that ascends between the long and lateral
heads of the triceps (the ascending deltoid branch) that
anastomoses with the posterior circumflex humeral artery.

94
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Table 12.1  Arterial anastomoses around the
elbow
Location
Vessels
Anterior to medial
epicondyle
Anterior branch of inferior ulnar
collateral
Anterior ulnar recurrent
Anterior branch of superior ulnar
collateral
Anterior to lateral
epicondyle
Radial recurrent artery (RRA)
Anterior radial collateral branch of
profunda (ARCA)
Posterior to medial
epicondyle
Middle collateral branch of profunda
Inferior ulnar collateral
Posterior to lateral
epicondyle
Posterior radial collateral
The profunda brachii then passes into the posterior com­
partment of the arm with the radial nerve between the
lateral and long heads of the triceps, and teres major (tri­
angular interval). It runs with the radial nerve in the spiral
groove posterior to the humerus and eventually branches
into two terminal divisions – the radial collateral artery and
the middle collateral artery (Fig. 12.3). The middle collat­
eral artery enters the medial head of the triceps and ends
in the olecranon plexus of the posterior elbow.
The radial collateral artery follows the course of the radial
nerve before dividing into anterior and posterior divisions.
The anterior division (ARCA) continues to accompany the
radial nerve into the flexor compartment between brachia­
lis and brachioradialis to eventually anastomose with the
radial recurrent artery (RRA).
However, the posterior division of the radial collateral
artery (PRCA) stays in the posterior compartment and even­
tually reaches the lateral intermuscular septum, where it can
be found between the triceps posteriorly and the brachialis
anteriorly. It gives rise to several septocutaneous perforators
(1–15 cm proximal to the lateral epicondyle) that supply
the overlying skin, which corresponds with the vascular ter­
ritory of the lateral arm flap,1 before ending in a plexus of
vessels around the lateral epicondyle and olecranon. This
plexus is also supplied by the ARCA, the interosseous recur­
rent, inferior ulnar collateral, and the radial recurrent artery
(Fig. 12.7). These vessels provide retrograde flow to the
PRCA giving the basis for the distally-based lateral arm flap.2
The next branch of the brachial artery is the superior
ulnar collateral artery. This arises from the brachial artery
just distal to the mid-arm in 78% of specimens, or from the
profunda brachii in 22%. It pierces the medial intermuscu­
lar septum to join the ulnar nerve in the posterior compart­
ment medial to the triceps (Fig. 12.1), and follows the nerve
around the medial epicondyle into the forearm (Fig. 12.2).
It eventually anastomoses with either the posterior ulnar
recurrent artery or a branch of the inferior ulnar collateral
artery (Fig. 12.7).
The last branch of the brachial artery in the arm is the
inferior ulnar collateral artery. This arises from the medial
aspect of the brachial artery 5 cm proximal to the elbow and
divides into anterior and posterior branches. The posterior
branch runs behind the humerus under the triceps, joining
the middle collateral artery to form an anastomotic arch just
proximal to the olecranon. The anterior branch passes ante­
rior to the medial epicondyle to anastomose with the ante­
rior ulnar recurrent artery (Fig. 12.7).
ANASTOMOSES AROUND THE ELBOW
Complex anastomoses around the elbow allow for excellent
collateral circulation and can be simplified into those that
run anterior versus posterior to either the medial or lateral
epicondyle (Table 12.1, Fig. 12.7).
EXPOSURE OF THE BRACHIAL ARTERY IN
THE MEDIAL ARM
The brachial artery can be exposed easily and expeditiously
anywhere along its course in the medial arm. With the
patient supine, the arm extended on a hand table, and the
forearm supinated, a longitudinal incision is marked over
the medial biceps groove (Fig. 12.6). Useful surgical land­
marks during this dissection include the bicipital groove,
the medial epicondyle, the basilic vein and the medial inter­
muscular septum. The incision can be made anywhere from
the elbow crease to the axilla, depending on the surgical
requirements (Fig. 12.8A). The skin and subcutaneous fat
are incised and attention should be paid to avoiding injury
to the basilic vein, which runs in the subcutaneous plane in
the distal two-thirds of the arm, and is accompanied by the
median antebrachial cutaneous nerve (Fig. 12.8B).
Distally, the brachial artery pulse is easily palpable and
the overlying deep fascia is incised to expose the neurovas­
cular bundle. The median nerve lies medial to the brachial
artery at this level, and there are also usually two sizeable
venae comitantes surrounding the vessel (Fig. 12.8C).
When a proximal approach is necessary, the basilic vein
can be a useful landmark as it pierces the deep fascia of the
arm to join the neurovascular bundle in the middle to proxi­
mal thirds of the arm. The vein can be followed proximally
and the sheath incised at this point.
The brachial artery can be used in an end-to-side manner
to provide excellent inflow to microvascular reconstruc­
tions, or large side branches can be sacrificed for an end-to-
end anastomosis.
GROSS REGIONAL ANATOMY OF THE
ANTECUBITAL FOSSA
The antecubital fossa is an anatomically complex area, and
knowledge of this anatomy allows exposure of multiple
structures that may be required for complex upper extrem­
ity reconstruction, including exposure of recipient vessels as
well as nerves for complex peripheral nerve reconstruction
and functional muscle transfer. Important anatomic land­
marks include the elbow flexion crease proximally, the bra­
chioradialis laterally, and the pronator teres medially (Fig.
12.9). The floor of the fossa comprises the brachialis muscle
for the most part.
The biceps tendon and aponeurosis are centrally located
and somewhat divide the fossa into medial and lateral

CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
95
Figure 12.8  Cross-sectional anatomy of the forearm. (Reprinted
from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
compartments. In the superficial plane, the antecubital
fossa has a rich subcutaneous veno us network that can be
used for recipient venous anastomoses or vein grafts harvest
(Fig. 12.10). The lateral antebrachial cutaneous nerve also
lies in the subcutaneous plane, on the lateral side of the
fossa having exited the deep fascia of the distal arm just
lateral to the biceps (Fig. 12.11), and this nerve can be
harvested as a nerve graft, although results in a distal sensory
deficit (Fig. 12.12)
On the medial side of the fossa, lying deep to the fascia
and lacertus fibrosus, are the median nerve and the brachial
artery. Lateral to the artery is the biceps tendon that heads
deep into the fossa to insert on the radial tuberosity, and
this insertion may need to be exposed in functional muscle
transfers for elbow flexion. Lateral to the biceps tendon, the
radial nerve enters the antecubital region deep to the bra­
chioradialis muscle belly, and divides into its two terminal
branches (Fig. 12.4).
EXPOSURE OF THE DISTAL BRACHIAL ARTERY
AND ITS BIFURCATION
At the elbow crease, the brachial artery becomes an anterior
structure laying on the brachialis muscle in the middle of
the antecubital fossa. At this level, it is covered only by the
lacertus fibrosus, the median cubital veins and skin. It is
located between the muscle bellies of the pronator teres and
brachioradialis until it bifurcates approximately 2–3 cm
distal to the elbow crease (Fig. 12.7).
With the arm extended and the forearm supinated, a skin
incision is made along the medial bicipital groove starting
4–5 cm proximal to the flexion crease of the elbow. At
the crease, the incision continues obliquely or transversely,
then distally along the medial border of the brachioradialis
muscle (Fig. 12.13A). Subcutaneous veins can be ligated
and divided, or preserved for use as recipient outflow
vessels. Specific attention should be paid to sizeable cutane­
ous nerve branches that may be encountered during this
approach, as injury leads to distal paresthesias and painful
neuroma formation. The medial antebrachial cutaneous
nerve lies with the basilic vein on the medial aspect of the
exposure in the distal arm (Fig. 12.13B), and the lateral
antebrachial cutaneous nerve is located on the lateral side
of the exposure (Fig. 12.13D).
The lacertus fibrosus can be seen arising from the biceps
tendon, fanning out medially over the pronator teres and
flexor muscle mass (Fig. 12.13B). It is essentially continuous
with the distal aspect of the deep fascia of the arm. To access
the distal brachial artery, this deep fascia is incised and
reflected, exposing the median nerve, which, by now has
become medial to the brachial artery (Fig. 12.13C). Sizeable
venae comitantes can be preserved and used for outflow
anastomoses.
In order to access and expose the bifurcation of the bra­
chial artery in the antecubital fossa, the fascial opening is
continued distally by incising the lacertus longitudinally
over the pronator and reflecting it proximally (Fig. 12.13C).
Directly underlying the lacertus is the continuation of the
brachial artery, lying between the biceps tendon and the
median nerve. The median nerve gives off several nerve
branches medially, supplying the muscles of the flexor-
pronator mass, then heads deep to pronator teres. The
nerve and its branches should all be preserved, and the
brachial artery can be bluntly dissected distally as it moves
away from the nerve, running towards the biceps tendon to
become centrally located in the fossa, between the pronator
teres medially and the brachioradialis laterally. The lateral
antebrachial cutaneous nerve also lies on the lateral side of
the fossa and should be preserved.
The deep fascial incision is extended distally and the
pronator teres and brachioradialis muscles are separated
and retracted, exposing the bifurcation approximately
2–3 cm distal to the elbow crease (Fig. 12.13E). The larger
and more medial of the branches is the ulnar artery and this
dives deep, under the flexor-pronator mass before giving off
the common interosseous branch on its lateral and deep
side (Fig. 12.13F).
The radial artery branch remains at a more superficial
level, lying on or lateral to the pronator muscle belly, directly
under and medial the brachioradialis. It gives off multiple
branches on the radial side, the first and largest of which is

96
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
the radial recurrent artery (Fig. 12.13E), arising just distal
to the brachial artery bifurcation and is large enough to be
used as a recipient vessel for microvascular tissue transfer.
GROSS REGIONAL ANATOMY OF
THE FOREARM
The arrangement of compartments in the forearm is more
complex than the arm. There are three fairly well-defined
compartments – the volar compartment, the dorsal com­
partment, and the mobile wad (Fig. 12.8).
The volar compartment is further divided into superficial,
intermediate, and deep layers. In the superficial layer (Fig.
12.9), the pronator teres, flexor carpi radialis, palmaris
longus and flexor carpi ulnaris arise from the common
flexor origin (the medical epicondyle of the humerus). The
middle layer is the flexor digitorum superficialis (Fig.
12.10), and the deep layer (Fig. 12.4) contains the flexor
digitorum profundus, flexor pollicis longus, and the
Figure 12.9  Volar compartment of the forearm (superficial layer). (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Biceps brachii muscle
Brachial artery and median nerve
Lateral antebrachial cutaneous nerve
(terminal musculocutaneous nerve)
Brachialis muscle
Biceps brachii tendon
Radial artery
Bicipital aponeurosis
Ulnar nerve
Triceps brachii muscle
Medial intermuscular septum
Ulnar artery
Medial epicondyle of humerus
Common flexor tendon
Pronator teres muscle
Flexor carpi
radialis muscle
Palmaris longus
muscle
Flexor carpi
ulnaris muscle
Flexor digitorum
superficialis muscle
Superficial
flexor
muscles
Brachioradialis muscle
Extensor carpi
radialis longus muscle
Extensor carpi
radialis brevis muscle
Flexor pollicis longus
muscle and tendon
Radial artery
Median nerve
Palmar carpal ligament
(continuous with
extensor retinaculum)
Thenar muscles
Palmar aponeurosis
Hypothenar muscles
Palmar branch of median nerve
Pisiform
Ulnar artery and nerve
Dorsal branch of ulnar nerve
Palmaris longus tendon
Medial antebrachial cutaneous nerve

CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
97
Figure 12.10  (A,B) Volar compartment of the forearm (intermediate and deep layers). (Reprinted from Netter Anatomy Illustration Collection.
©Elsevier Inc. All Rights Reserved.)
Ulnar nerve
Median nerve
Flexor digitorum superficialis
muscle (humeroulnar head)
Brachialis muscle
Lateral antebrachial cutaneous nerve (cut)
(from musculocutaneous nerve)
Radial nerve
Deep branch
Superficial branch
Biceps brachii tendon
Radial recurrent artery
Radial artery
Supinator muscle
Brachioradialis muscle
Pronator teres muscle (cut)
Flexor digitorum superficialis
muscle (radial head)
Ulnar artery
Ulnar nerve and dorsal branch
Median nerve
Pisiform
Flexor retinaculum
(transverse carpal ligament)
Superficial branch of ulnar nerve
Flexor carpi radialis
tendon (cut)
Biceps brachii muscle
Flexor pollicis longus muscle
Palmar carpal ligament
(continuous with extensor
retinaculum) with palmaris
longus tendon (cut and reflected)
Superficial palmar branch
of radial artery
Deep palmar branch of ulnar artery
and deep branch of ulnar nerve
Palmar branches of median and ulnar nerves (cut)
Flexor digitorum superficialis muscle
Flexor carpi ulnaris muscle
Anterior interosseous artery
Pronator teres muscle (ulnar head) (cut)
Common interosseous artery
Ulnar artery
Anterior ulnar recurrent artery
Flexor carpi radialis and palmaris
longus tendons (cut)
Medial epicondyle
Pronator teres muscle (humeral head)
(cut and reflected)
Medial intermuscular septum
Brachial artery
A
pronator quadratus. The major neurovascular bundles are
present on the volar aspect of the forearm, lying deep in the
proximal forearm, but are immediately subfascial in the
distal third of the forearm.
The dorsal compartment is arranged in two layers. There
are four superficial muscles that fan out from the lateral
epicondyle and these are the: anconeus, extensor carpi
ulnaris, extensor digiti minimi, and extensor digitorum
communis. The deeper layer contains three muscles that
power the thumb (abductor pollicis longus, extensor polli­
cis brevis, extensor pollicis longus), and the supinator and
extensor indicis muscles. The posterior interosseous nerve
innervates the extensor muscles and is the key anatomic
structure from an operative standpoint (Fig. 12.6). The pos­
terior interosseous artery runs under the superficial layer,
close to the interosseous membrane and gives off multiple
septocutaneous perforators between the extensor digiti
minimi and the extensor carpi ulnaris.
Continued

98
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
The mobile wad comprises three muscles on the radial
side of the forearm – the brachioradialis, extensor carpi
radialis longus, and brevis.
VASCULAR ANATOMY OF THE FOREARM
THE ULNAR ARTERY
The ulnar artery is a direct continuation of the brachial
artery and is the larger of its two terminal branches. It origi­
nates at the level of the radial neck approximately 2–3 cm
distal to the elbow crease, and is accompanied by two venae
comitantes. It reaches the ulnar margin of the forearm
approximately half way between the elbow and the wrist
(Fig. 12.4).
Proximally, it is deep to the pronator teres, flexor carpi
radialis, and flexor digitorum superficialis muscles, lying
initially on the brachialis then flexor digitorum profundus
muscle bellies. Distally, it continues to lie superficial to the
flexor digitorum profundus muscle belly between the flexor
carpi ulnaris (ulnarly) and the flexor digitorum superficialis
(radially), and is quite superficial in the distal third of the
Musculocutaneous nerve
(becomes)
Lateral antebrachial cutaneous nerve
Radial nerve
Ulnar nerve
Median nerve
Flexor carpi radialis,
palmaris longus,
flexor digitorum superficialis
(humeroulnar head), and
flexor carpi ulnaris
muscles (cut)
Common interosseous artery
Supinator muscle
Posterior and anterior
interosseous arteries
Radius
Pronator quadratus muscle
Brachioradialis tendon (cut)
Radial artery and
superficial palmar branch
Flexor pollicis longus tendon (cut)
Flexor carpi radialis tendon (cut)
Ulnar nerve and dorsal branch
Hook of hamate
Abductor pollicis longus tendon
Extensor pollicis brevis tendon
1st metacarpal bone
B
Flexor pollicis longus
muscle and tendon (cut)
Radial artery
Pronator teres muscle
(cut and reflected)
Flexor digitorum superficialis
muscle (radial head) (cut)
Radial artery
Radial recurrent artery
Biceps brachii tendon (cut)
Lateral epicondyle
Lateral intermuscular septum
Brachialis muscle
Medial intermuscular septum
Pronator teres muscle
(humeral head cut and reflected)
Brachial artery
Anterior ulnar recurrent artery
Medial epicondyle of humerus
Posterior ulnar recurrent artery
Ulnar artery
Pronator teres muscle (ulnar head) (cut)
Median nerve (cut)
Flexor digitorum profundus muscle
Anterior interosseous artery and nerve
Palmar carpal branches of radial and ulnar arteries
Flexor carpi ulnaris tendon (cut)
Pisiform
Deep palmar branch of ulnar artery
and deep branch of ulnar nerve
5th metacarpal bone
Figure 12.10, cont’d

CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
99
common interosseous) and multiple muscular branches
(Fig. 12.7).
The anterior ulnar recurrent artery is the most proximal
branch of the ulnar artery arising medially just distal to the
origin of the ulnar artery, heads proximally and anteriorly
between the brachialis and pronator muscle bellies. It anas­
tomoses anterior to the medial epicondyle with the inferior
ulnar collateral artery.
The posterior ulnar recurrent artery is usually larger
than the anterior ulnar collateral, arises more distally and
heads posteriorly and proximally between the deep and
superficial finger flexors. It ascends posterior to the medial
epicondyle to anastomose with the superior and inferior
ulnar collaterals.
The common interosseous artery is the third and largest
branch of the ulnar artery, although it can occasionally
arise from the brachial artery. It has a short course of about
1 cm, arising from the posterolateral aspect of the ulnar
artery at the level of the bicipital tuberosity of the radius
(Fig. 12.7). It divides early into anterior and posterior
branches that pass to their respective sides of the interosse­
ous membrane.
The anterior interosseous artery courses through the
deep flexor compartment accompanied by the anterior
interosseous nerve, lying on the interosseous membrane
forearm, covered only by deep and superficial fascia and
skin (Fig. 12.9), allowing for expeditious exposure with
minimal dissection. The ulnar artery gives rise to an average
of three (1–6) perforators in its mid-portion. Most of the
septocutaneous perforators can be found along a line drawn
from the medial epicondyle to the pisiform, ~7–15 cm prox­
imal to the pisiform, or within a 3 cm radius of the midpoint
of the forearm.3,4 Additional perforators may be located
more proximally, however these are usually musculocutane­
ous through the flexor carpi ulnaris muscle belly and are of
limited use in microvascular reconstruction. However, the
flexor carpi ulnaris can be used as a pedicled turnover
muscle flap based on one or more of these perforators for
coverage of small elbow defects.
The ulnar nerve joins the ulnar artery in the proximal
forearm and accompanies it on the ulnar side throughout its
course (Fig. 12.4). Both structures descend the forearm
superficial to the flexor digitorum muscle belly, eventually lie
ulnar to the flexor tendons, and pass across the wrist enter­
ing Guyon’s canal superficial to the flexor retinaculum.
BRANCHES OF THE ULNAR ARTERY
The ulnar artery gives rise to several named branches
(anterior ulnar recurrent, posterior ulnar recurrent,
Figure 12.12  Arterial anatomy of the upper extremity and deep dissection of the palm. (Reprinted from Netter Anatomy Illustration Collection.
©Elsevier Inc. All Rights Reserved.)
1
3
6
7
8
4
5
2
Arteries: Elbow, Wrist, and Hand
Comment: The radial artery passes over the pronator
teres muscle and under the brachioradialis muscle.
Distally, it separates into the palmar carpal, dorsal carpal,
and superficial palmar branches. The ulnar artery crosses
between the flexor digitorum superficialis and profundus
muscles and forms four branches distally: the palmar and
dorsal carpal branches, the deep palmar branch, and the
superficial palmar arch.
1. Brachial artery
2. Radial artery
3. Ulnar artery
4. Deep palmar branch of ulnar artery
5. Superfi cial palmar arch (cut)
6. Superfi cial palmar branch of radial artery
7. Deep palmar arch
8. Common palmar digital arteries

100
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
previously, this provides for retrograde perfusion of a
distally-based posterior interosseous artery flap that can be
used for dorsal hand coverage.
EXPOSURE OF THE ULNAR ARTERY IN THE
DISTAL FOREARM AND GUYON’S CANAL
The ulnar artery can be exposed proximally in the antecu­
bital fossa as described earlier, otherwise it is best exposed
in the distal half of the forearm where it is relatively super­
ficial (Fig. 12.11).
The ulnar artery in the proximal arm is deep and of
limited use as a recipient vessel, unless there is a large pre-
existing defect. In the distal half of the forearm, the ulnar
artery lies under the flexor carpi ulnaris muscle and tendon.
Its course can be marked by drawing a line from the medial
epicondyle to the pisiform and a skin incision can be made
distally anywhere along this line (Fig. 12.17A). The ante­
brachial fascia (Fig. 12.17B) is incised and the flexor carpi
ulnaris tendon is retracted ulnarly to expose the neurovas­
cular bundle (Fig. 12.17C). The ulnar artery lies radial to
the ulnar nerve, just medial to the flexor digitorum muscles
and tendons. There are usually no large arterial side
branches in the distal half of the forearm, and given that
the ulnar artery is the dominant supply to the hand, an end-
to-side arterial anastomosis is preferable. There are typically
two accompanying veins that can be used for end-to-end
venous anastomoses.
(Fig. 12.4). Distally, it divides into terminal palmar and
dorsal branches. The palmar branch contributes to the
palmar carpal arch and eventually anastomoses with recur­
rent vessels off the deep palmar arch (Fig. 12.15), while the
dorsal branch pierces the interosseous membrane just prox­
imal to the DRUJ to communicate with the posterior inter­
osseous artery and eventually the dorsal branch of the radial
artery, supplying the dorsal carpal arches. These arches (Fig.
12.16) form the basis of several pedicled distal radius vascu­
larized bone grafts, and also provide retrograde flow to the
distally-based posterior interosseous artery flap.5–7
The posterior interosseous artery is smaller than its ante­
rior counterpart, runs on the dorsal surface of the interos­
seous membrane between the extensor muscle bellies (Fig.
12.14). Early in its course, it gives rise to the interosseous
recurrent artery (Fig. 12.7) that heads superiorly back
towards the elbow, anastomosing with the middle collateral,
inferior ulnar collateral, and posterior ulnar collateral
arteries.
In the mid-forearm, the posterior interosseous artery
gives off an average of 7–14 septocutaneous perforators
along its course, which can be located along a line drawn
from the lateral epicondyle to the midpoint of the DRUJ.
The posterior interosseous artery receives the dorsal
branch of the anterior interosseous artery just proximal to
the DRUJ, and continues on the dorsal aspect of the wrist
forming several dorsal arches that communicate with
branches of the radial and ulnar arteries. As mentioned
Figure 12.14  Median, ulnar, and radial nerves in the forearm. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
1
3
6
7
8
9
10
11
4
5
2
Nerves: Elbow, Wrist, and Hand
1. Median nerve
Anterior interosseous nerve
Palmar branch of median nerve
Ulnar nerve
Dorsal branch of ulnar nerve
Palmar branch of ulnar nerve
Superficial branch of ulnar nerve
Deep branch of ulnar nerve
Radial nerve
Posterior interosseous nerve
Superficial branch of the radial nerve
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Comment: The median nerve (C5-T1) passes anteriorly and centrally
through the elbow to supply the anterior compartment of the
forearm; then it passes into the hand through the carpal tunnel,
where it provides innervation to the thumb, index, and middle fingers.
The ulnar nerve (C7-T1) arises from the medial cord of the brachial
plexus, passes the elbow just posterior to the medial epicondyle, and
moves into the wrist through the Guyon canal. It supplies the flexor
digitorum profundus and carpi ulnaris muscles. It also has both
motor and sensory supplies to the ulnar aspect of the palm. The
radial nerve (C5-T1) divides into superficial and deep branches at the
elbow and innervates the wrist extensors and sensation to the
posterior forearm and dorsal hand (thumb, index finger, middle
finger, and half of the ring finger).

CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
101
THE RADIAL ARTERY
After the brachial artery bifurcates approximately 2–3 cm
distal to the elbow crease, the radial artery continues along
the radial aspect of the forearm along with its two venae
comitantes (Fig. 12.12). It is slightly smaller than the ulnar
artery, and runs just under the brachioradialis muscle.
Along its course in the forearm it remains superficial to the
biceps insertion, supinator, pronator teres, flexor digitorum
superficialis, and flexor pollicis longus muscles. In the
middle third, it runs alongside the superficial branch of the
radial nerve. In the distal third of the forearm, it becomes
even more superficial, lying between the brachioradialis and
flexor carpi radialis tendons, covered only by deep and
superficial fascia and skin, where the radial pulse is typically
palpated. Proximally, it gives off the radial recurrent artery,
which is a large, consistent well-defined branch and this
provides the vascular basis for the pedicled brachioradialis
muscle flap. It is also a reliable recipient vessel for end-to-
end microvascular anastomosis.
Distal exposure of the artery in Guyon’s canal can be
achieved by curving the incision across the volar wrist crease
around the pisiform (Fig. 12.17A) and this exposure is
useful for arterial bypass grafts or revascularization of the
hand. The subcutaneous tissues in this region are thicker
and less pliable requiring more dissection than those of the
forearm. The volar carpal ligament is a well-defined fascial
layer that covers the ulnar artery at this level and this needs
to be released (Fig. 12.17D), exposing the contents of
Guyon’s canal. The artery can be dissected distally under
the palmaris brevis into the palm if required (Fig. 12.17E).
Care should be taken to avoid injury to the ulnar nerve and
its branches, as these are intimately related to the artery in
the canal. Adequate exposure of the artery at this level does
not typically require significant dissection of the nerve,
which could lead to neuropraxia or trauma to its branches.
Specific care should be paid not to damage the deep
(motor) branch, which arises posteriorly and therefore may
not be easily visible in the field (Fig. 12.17F – nerve dissec­
tion shown for anatomic demonstration purposes only).
Figure 12.15  Dermatomes of the upper extremity.
Supraclavicular, C3, 4
Upper lateral cutaneous of arm, C5, 6
Posterior cutaneous of arm, C5, 6, 7, 8
Intercostobrachial, T2
Medial cutaneous of arm, C8, T1
Posterior cutaneous of forearm, C5, 6, 7, 8
Medial cutaneous of forearm, C8, T1
Lateral cutaneous of arm, C5, 6
Lower lateral cutaneous of arm, C5, 6
Superficial branch of radial, C7, 8
Median, C6, 7, 8
Ulnar, C8, T1

102
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
to harvest a thin antecubital skin flap for microvascular
transfer. Alternatively, these proximal perforators can be
used to design a distally-based, reversed radial forearm flap
for dorsal hand coverage.
Distally, multiple septocutaneous perforators can be
found grouped closely within 5 cm of the wrist crease. These
perforators provide perfusion to the classic radial forearm
Multiple septocutaneous perforators arise from the radial
artery along a line drawn from the middle of the antecubital
fossa to the radial styloid (between the brachioradialis
and flexor carpi radialis). Proximally, the perforators are
few and widely-spaced but include a large, well-defined,
named perforator – the inferior cubital artery – that arises
approximately 4–5 cm distal to the elbow and can be used
Figure 12.16  Superficial dissection of the palm. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Palmaris longus tendon
Branch of superficial
radial nerve to skin of
lateral thenar area
Thenar muscles
Palmar branch of
median nerve
Anterior (palmar) views
Palmar aponeurosis
Transverse fasciculi
Palmar digital arteries and nerves
Superficial transverse metacarpal ligaments
Palmaris brevis
muscle (reflected)
Palmar branch of ulnar nerve
Superficial branch of ulnar nerve
Ulnar artery
Palmaris brevis muscle
Hypothenar muscles
Palmar aponeurosis
Pisiform
Deep palmar branch of ulnar artery and deep
branch of ulnar nerve
Palmar carpal ligament
(thickening of deep
antebrachial fascia
continuous with
extensor retinaculum)
Recurrent
(motor)
branch of
median
nerve to
thenar
muscles
Minute fasciculi
attach palmar
aponeurosis to dermis
Palmar digital
nerves from
superficial
branch of ulnar
nerve to 5th and
medial half of
4th fingers

CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
103
anastomoses with the superficial palmar arch in the hand
(Fig. 12.4). However, the main continuation of the radial
artery curves dorsally passing under the tendons of the first
dorsal compartment to enter the anatomic snuffbox super­
ficial to the scaphoid (Fig. 12.18). Here, it can easily be
located for recipient vessel preparation in microvascular
flap, and can be used to design pedicled perforator flaps
from the distal forearm for coverage of small hand defects
without sacrificing the main artery.8,9,10
At the level of the radial styloid, the radial artery gives
off a superficial palmar branch that heads volar to the scaph­
oid to contribute to the intercarpal arches and usually
Figure 12.17  Deep dissection of the palm. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Radial artery and venae comitantes
Flexor carpi radialis tendon
Tendinous sheath of
flexor pollicis longus
(radial bursa)
Median nerve
Palmaris longus tendon and
palmar carpal ligament
Transverse carpal
ligament (flexor
retinaculum)
Thenar muscles
Proper palmar
digital nerves
of thumb
(Synovial)
tendinous
sheath of flexor
pollicis longus
(radial bursa)
Probe in 1st
lumbrical
fascial sheath
Common palmar
digital artery
Proper palmar
digital arteries
Septa from palmar
aponeurosis forming canals
Palmar aponeurosis
(reflected)
Ulnar artery with venae comitantes and ulnar nerve
Flexor carpi ulnaris tendon
Common flexor sheath (ulnar bursa) containing
superficialis and profundus flexor tendons
Pisiform
Deep palmar branch of ulnar artery and deep
branch of ulnar nerve
Superficial branch of ulnar nerve
Palmar digital nerves to 5th finger and
medial half of 4th finger
Median nerve
Common flexor sheath (ulnar bursa)
Superficial palmar arterial and venous arches
2nd, 3rd, and 4th lumbrical muscles (in fascial sheaths)
(Synovial) flexor tendon sheaths of fingers
Anterior (palmar) views
Proper palmar digital nerves of thumb
Fascia over adductor pollicis muscle
1st dorsal interosseous muscle
Probe in dorsal extension of thenar
space deep to adductor pollicis muscle
Thenar space (deep to flexor tendons
and 1st lumbrical muscle)
Septum separating thenar from midpalmar space
Common palmar digital artery
Proper palmar digital arteries and nerves
Ulnar artery
and nerve
Common palmar
digital branches
of median nerve (cut)
Hypothenar
muscles
Common flexor
sheath (ulnar
bursa)
5th finger
(synovial)
tendinous sheath
Probe in
midpalmar space
Midpalmar space
(deep to flexor
tendons and
lumbrical muscles)
Insertion of
flexor digitorum
superficialis tendon
Insertion of flexor digitorum
profundus tendon
Annular and cruciform parts of fibrous sheath
over (synovial) flexor tendon sheaths
Superficial
palmar branch
of radial artery
and recurrent
branch of
median nerve
to thenar
muscles

104
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
reconstruction or replantation. It exits the snuffbox distally
by passing under the extensor pollicis longus tendon,
dorsal to the interval between the thumb and index meta­
carpal bases. It then passes between the two heads of the
first dorsal interosseous to enter the palm and form the
deep palmar arch (Fig. 12.16). Just before this, it gives a
contribution to the dorsal metacarpal arch, and also gives
rise to the first dorsal metacarpal artery as a distinct branch
that supplies the dorsal skin of the first web space and index
finger.
EXPOSURE OF THE RADIAL ARTERY IN THE
DISTAL FOREARM AND ANATOMIC SNUFFBOX
The radial artery is easily exposed in the antecubital fossa
as previously described, and in the distal half of the forearm,
where it is very superficial. It can also be exposed in the
proximal forearm if required, although is covered by the
brachioradialis muscle. The course of the artery can be
marked by drawing a line from the middle of the antecubital
fossa to the radial styloid. In the distal forearm, a skin
Figure 12.18  Superficial dissection of the dorsum of the hand. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Posterior (dorsal) view
Posterior antebrachial cutaneous
nerve (from radial nerve)
Cephalic vein
Superficial branch of radial nerve
Extensor retinaculum (thickening
of posterior antebrachial fascia)
Communicating branches of
radial and ulnar nerves
Basilic vein
Dorsal branch of ulnar nerve
Dorsal venous
network of hand
Dorsal metacarpal veins
Intercapitular veins
Dorsal digital nerves and veins
Dorsal branches of
proper palmar digital nerves
Note: Lymphatic pathways shown in black;
arrows indicate direction of drainage
Probe in dorsal
subaponeurotic space
(between opened
dorsal fascia of hand and
dorsal interosseous
fascia)

CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
105
artery deep to the brachioradialis until approximately 8 cm
proximal to the wrist crease when it emerges dorsal to the
tendon to become a superficial structure.
The radial artery can be exposed distal to the wrist crease,
in the anatomic snuffbox, where it can be used as a recipient
vessel in free flaps, toe transfers and thumb replantation.
Important landmarks for the snuffbox are the 1st compart­
ment tendons on the radial side (abductor pollicis longus
(APL) and extensor pollicis brevis (EPB)), the 3rd compart­
ment tendon (extensor pollicis longus (EPL)) on the ulnar
side, the tip of the radial styloid proximally, and the scaphoid
and trapezium form the floor. The skin is incised longitudi­
nally over the snuffbox, preserving large dorsal veins. Sensory
branches of the superficial radial nerve should be protected
and retracted away from the surgical field as trauma will
incision is made directly overlying the palpable radial pulse,
just radial to the flexor carpi radialis tendon (Fig. 12.13).
The deep fascia is incised immediately exposing the artery
and its venae comitantes, lying between the flexor carpi
radialis and brachioradialis tendons (Fig. 12.19A). The
radial artery is usually large enough to allow end-to-side
anastomosis, so as to preserve distal perfusion. Distal dissec­
tion towards the radial styloid allows identification of the
superficial palmar branch (Fig. 12.19F) that may be of suf­
ficient caliber to use in an end-to-end anastomosis, depend­
ing on the degree of size mismatch with the flap vessels. If
more proximal exposure is required, the artery can be fol­
lowed under the brachioradialis tendon and muscle belly,
taking care to avoid injury to the superficial branch of the
radial nerve. This nerve is in close proximity to the radial
Figure 12.19  The radial side of the hand and anatomic snuffbox. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Extensor retinaculum
Dorsal carpal branch
of radial artery
Extensor carpi
radialis brevis
tendon
Extensor carpi
radialis longus
tendon
Radial artery
Deep fascia (cut)
1st dorsal interosseous muscle
Lateral (radial) view
Superficial branch of radial nerve
Medial branch
Lateral branch
Dorsal digital branches of radial nerve
Scaphoid
Radial artery in anatomical snuffbox*
Trapezium
Insertion of abductor
pollicis longus tendon
1st metacarpal bone
Insertion of extensor
pollicis brevis tendon
Insertion of extensor
pollicis longus tendon
Radial nerve (dorsal digital branch)
Cephalic vein branches (cut away)
Radial artery and branches
Scaphoid bone
*Snuffbox contents (superficial to deep)