106
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
likely cause painful neuromas (Fig. 12.19B). The deep fascial
layer is incised between the EPL and APL tendons (Fig.
12.19C), and careful blunt dissection will expose the radial
artery in the base of the snuffbox (Fig. 12.19A).
NERVE ANATOMY OF THE ARM
AND FOREARM
The terminal branches of the brachial plexus exit the axilla
intimately related to the proximal brachial artery (Fig.
12.5). This arrangement is complex but consistent, and
their position in relation to the brachial artery, as well as
their branching patterns allows for intraoperative identifica
tion of the required nerve.
THE ULNAR NERVE
The ulnar nerve is the direct continuation of the medial
cord of the brachial plexus. It does not innervate any struc
tures in the arm, however it innervates the flexor carpi
ulnaris and the ulnar half of the flexor digitorum profundus
in the forearm. In the hand, it supplies motor innervation
to all interossei, adductor pollicis, the ulnar-sided lumbri
cals, the hypothenar muscles, and the deep head of flexor
pollicis brevis (Fig. 12.14). It also supplies sensory innerva
tion to the small finger, the ulnar half of the ring finger, and
the ulnar half of the volar and dorsal aspects of the hand
(Fig. 12.15).
The ulnar nerve lies medial to the brachial artery in the
proximal arm, along with the medial antebrachial cutane
ous nerves (Fig. 12.2). Proximally, it is located in the ante
rior compartment but 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. From here, it passes just posterior to
the medial epicondyle of the humerus where it can reliably
be found as it enters the forearm between the two heads of
the flexor carpi ulnaris muscle (Fig. 12.6).
The ulnar nerve joins the ulnar artery in the proximal
forearm and accompanies it between the flexor digitorum
superficialis and profundus muscles throughout its course
(Fig. 12.4). It gives off a dorsal sensory branch 6–8 cm proxi
mal to the wrist. Approximately 5 cm proximal to the pisi
form, this branch pierces the antebrachial fascia dorsal to
the flexor carpi ulnaris tendon to lie in a subcutaneous
plane and supplies the ulnar aspect of the dorsum of the
hand (Fig. 12.10).
The ulnar nerve enters the hand through Guyon’s canal,
bound by the volar carpal ligament on its superficial surface
(Fig. 12.20). It passes deep to the palmaris brevis muscle,
medial to the hook of the hamate, and divides into a deep
motor branch and its two distal sensory branches.
THE MEDIAN NERVE
The median nerve is formed from contributions of the
medial and lateral cords of the brachial plexus. It does not
innervate any structures in the arm, however supplies motor
innervation to the flexor carpi radialis, pronator teres,
flexor digitorum superficialis, radial half of flexor digito
rum profundus, flexor pollicis longus, and the pronator
quadratus in the forearm. In the hand, it supplies the
muscles of the thenar eminence and the first two lumbricals.
It also supplies sensory innervation to the volar side of the
thumb, index, middle and radial half of the ring finger as
well as the radial side of the palm (Fig. 12.12).
The median nerve lies anterior to the brachial artery in
the proximal arm (Fig. 12.2), and remains in the anterior
compartment intimately related to the artery along its whole
course in the arm. It crosses the brachial artery to lie medial
to it in the distal arm and antecubital fossa. It enters the
forearm passing between the two heads of the pronator
teres to lie deep to the flexor digitorum superficialis muscle
belly for the remainder of its course in the forearm (Fig.
12.6). It sequentially innervates the majority of the afore
mentioned forearm muscles directly, however supplies the
flexor pollicis longus, the radial half of flexor digitorum
profundus, and pronator quadratus via its anterior interos
seous branch (Fig. 12.4). In the distal forearm, the median
nerve can be reliably found as a superficial structure on the
radial side of the flexor digitorum superficialis muscle
where it gives rise to the palmar cutaneous nerve approxi
mately 8 cm proximal to the distal wrist crease. This branch
pierces the deep fascia between the palmaris longus and
flexor carpi radialis tendons to become a superficial struc
ture at the wrist, supplying sensation to the palm and thenar
eminence (Fig. 12.10). At the wrist level, it runs just ulnar
to the flexor carpi radialis, and could potentially be injured
during harvest of a radial forearm flap (Fig. 12.9).
The median nerve remains deep to the fascia and passes
through the carpal tunnel under the transverse carpal liga
ment. After entering the carpal tunnel, the median nerve
divides into four main branches (Fig. 12.20). The recurrent
motor branch of the median nerve is the most anterior of
the fascicular bundles and supplies the thenar muscles. The
next branch usually divides into three terminal branches
supplying sensation to the ulnar and radial sides of the
thumb and the radial side of the index finger. The remain
ing two branches form the common digital nerves to the
second and third web spaces, but despite being predomi
nantly sensory nerves, they also innervate the second and
third lumbrical muscles, respectively.
THE MUSCULOCUTANEOUS NERVE
The musculocutaneous nerve forms from the lateral cord
of the brachial plexus. It innervates the biceps, brachialis
and coracobrachialis in the anterior compartment of the
arm, and provides sensory innervation to the lateral aspect
of the forearm through its terminal branch, the lateral ante
brachial cutaneous nerve.
The musculocutaneous nerve is well known to have sig
nificant variability, frequently adhering to the median nerve
with which it may exchange fibers. Typically, it leaves the
axilla laterally piercing the coracobrachialis (Fig. 12.2).
After passing through this muscle, it descends the arm
between the brachialis and biceps muscles providing several
motor branches to each muscle (Fig. 12.11). In the distal
arm, it emerges lateral to the biceps tendon and pierces
the deep fascia to become a more superficial structure
that continues into the proximal forearm as the lateral
CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
107
Medial antebrachial
cutaneous nerve
Posterior antebrachial
cutaneous nerve
(branch of radial nerve)
Extensor retinaculum
Dorsal branch of ulnar nerve
Dorsal carpal branch
of ulnar artery
Extensor carpi ulnaris tendon
Dorsal carpal (arterial) arch
Dorsal metacarpal arteries
Posterior (dorsal) view
Dorsal digital arteries
Extensor carpi radialis brevis
tendon
Extensor carpi radialis longus
tendon
Extensor pollicis longus tendon
Extensor pollicis brevis tendon
Abductor pollicis longus tendon
Radial artery in anatomical snuffbox
Extensor digitorum, extensor digiti minimi,
and extensor indicis tendons (cut)
Superficial branch of radial nerve
Dorsal digital branches
of dorsal branch
of ulnar nerve
Dorsal branches of proper
palmar digital branches
of ulnar nerve and of
proper palmar digital
arteries to dorsum
of middle and
distal phalanges of
5th and ulnar half
of 4th fingers
Dorsal branches of proper palmar digital
branches of median nerve and of
proper palmar digital arteries to
dorsum of middle and distal phalanges
of 2nd, 3rd, and radial half of 5th
fingers
Dorsal digital branches of superficial
branch of radial nerve to 1st, 2nd,
3rd, and radial half of 4th fingers
Lateral antebrachial cutaneous nerve
(terminal part of musculocutaneous nerve)
antebrachial cutaneous nerve (Fig. 12.21). This direct con
tinuation of the musculocutaneous nerve remains superfi
cial to the brachioradialis to provide sensory innervation to
the lateral aspect of the forearm (Fig. 12.12).
THE RADIAL NERVE
The radial nerve is the direct continuation of the posterior
cord of the brachial plexus. In the arm, it classically only
innervates the triceps muscle, however also contributes a
motor branch to the brachialis muscle in approximately
65–90% of patients. While the radial nerve only contributes
11% of the relative innervation of the brachialis,11 acknowl
edging its presence can avoid confusion, as it may be
encountered while dissecting a lateral arm flap. In the
forearm, the radial nerve innervates the brachioradialis,
anconeus, the wrist extensors, supinator and all the exten
sor of the fingers and thumb, including the abductor pol
licis longus. It does not supply any muscles within the hand,
however provides sensory innervation to the dorsum of the
radial side of the hand and radial digits (Fig. 12.12).
The radial nerve lies immediately posterior to the bra
chial artery in the proximal arm but rapidly heads deeper
and more lateral through the triangular interval into the
posterior compartment. Here, it lies adjacent to the poste
rior aspect of the midshaft of the humerus where it gives off
Figure 12.20 Deep dissection of the dorsum of the hand. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
108
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 12.21 Arterial anatomy of the hand. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Radial artery
Median nerve and palmar branch
Superficial palmar branch of radial artery
Abductor pollicis brevis muscle (cut)
Opponens pollicis muscle
Flexor pollicis brevis muscle
Recurrent (motor) branch of
median nerve to thenar muscles
Proper digital nerves
and arteries to thumb
Adductor pollicis muscle
Branches of median nerve to
1st and 2nd lumbrical muscles
Flexor tendons, synovial
and fibrous sheaths
Ulnar artery and nerve
Palmar carpal ligament (continuous
with extensor retinaculum)
Flexor retinaculum (transverse
carpal ligament)
Deep palmar branch of ulnar artery
and deep branch of ulnar nerve
Superficial branch of ulnar nerve
Common flexor sheath
(ulnar bursa)
Superficial palmar (arterial) arch
Common palmar digital nerves
and arteries
Communicating branch of
median nerve with ulnar nerve
Proper palmar digital nerves
and arteries
Branches of proper palmar
digital nerves and
arteries to dorsum of
middle and distal
phalanges
Radial artery
Median nerve
Superficial palmar branch of radial artery
Deep palmar (arterial) arch and
deep branch of ulnar nerve
Princeps pollicis artery
Proper digital arteries
and nerves of thumb
Distal limit of
superficial palmar arch
Radialis indicis artery
Palmar metacarpal arteries
Common palmar digital arteries
Proper palmar digital arteries
Proper palmar digital nerves from median nerve
Ulnar artery and nerve
Palmar carpal branches of
radial and ulnar arteries
Pisiform
Deep palmar branch of
ulnar artery and deep
branch of ulnar nerve
Branches to hypothenar
muscles
Superficial branch of
ulnar nerve
Hook of hamate
Communicating branch
of median nerve with
ulnar nerve
Proper palmar digital
nerves from ulnar nerve
Deep palmar branch of
ulnar nerve to 3rd and
4th lumbrical, all
interosseous, adductor
pollicis, and deep head
of flexor pollicis brevis
muscles
the inferior lateral brachial and posterior antebrachial cuta
neous nerves (Fig. 12.3). After winding around the humerus
in the spiral groove, it pierces the lateral intermuscular
septum leaving the posterior compartment, to enter the
anterior compartment in the distal arm. From here, it enters
the forearm anterolaterally under the brachioradialis. The
deep branch of the radial nerve pierces the supinator to
eventually lie in the dorsal compartment supplying all
extensor muscles in the forearm and terminating as the
posterior interosseous nerve (Fig. 12.6). The superficial
branch of the radial nerve accompanies the radial artery in
the forearm, deep to brachioradialis until a point
CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
109
approximately 8–10 cm proximal to the wrist, where it
becomes superficial and dorsal to the brachioradialis
tendon. At this level, it heads distally along the radial border
of the wrist where it arborizes into multiple branches sup
plying the radial aspect of the dorsum of the hand and
radial digits (Fig. 12.17).
CUTANEOUS NERVES OF THE FOREARM
The cutaneous nerves of the forearm (Fig. 12.10) are rela
tively constant structures proximally although can have vari
able branching patterns distally. An appreciation of their
anatomic relationships helps prevent nerve injury that
results in numbness and painful neuromas. Alternatively
some of these nerves can be purposely harvested for use as
nerve grafts.
The medial antebrachial cutaneous nerve enters the
arm on the medial side of the brachial artery (Fig. 12.5),
then accompanies the basilic vein as it pierces the deep
fascia to become subcutaneous at the mid-portion of the
arm (Fig. 12.21). It can be prone to injury while exposing
the brachial artery, ulnar nerve, basilic vein or other oper
ative approaches in the arm and forearm. Approximately
15 cm proximal to the medial epicondyle, the nerve
divides into anterior and posterior branches. The poste
rior branches head towards the ulnar side of the forearm,
to cross over the medial intermuscular septum and ulnar
nerve, and ~90% of these branches cross at or proximal to
the level of the medial epicondyle. The anterior branch
crosses the elbow crease between the medial epicondyle
and the biceps tendon, usually 2–3 cm lateral to the epi
condyle. It supplies the medial aspect of the forearm
(Fig. 12.12).
The lateral antebrachial cutaneous nerve is a direct con
tinuation of the musculocutaneous nerve. In the arm, the
musculocutaneous nerve passes from medial to lateral
between the biceps and brachialis muscles (Fig. 12.11). At
the level of the elbow, it emerges from under the biceps
distally at its lateral border to become the lateral antebrach
ial cutaneous nerve. At a point just distal to the elbow, it
pierces the deep fascia lateral to the biceps tendon and
descends distally in the subcutaneous tissues of the antero
lateral forearm and wrist to supply sensation to this area
(Fig. 12.12). Proximally, it crosses deep to the cephalic vein,
however can give rise to a small recurrent branch at this
level that then travels proximally with the cephalic vein to
supply the skin of the distal third of the anterolateral arm.
The posterior cutaneous nerve of the forearm arises from
the radial nerve in the spiral groove (Fig. 12.3), and pierces
the triceps fascia in the distal lateral arm, to become a
superficial structure innervating the dorsal aspect of the
forearm (Fig. 12.12).
GROSS REGIONAL ANATOMY OF
THE HAND
The palmar aspect of the hand is a complex anatomic
region. The important surface landmarks that should be
noted include the thenar and hypothenar eminences, the
thenar, mid-palmar, distal palmar and digital creases, and
the pisiform bone.
Directly underlying the glabrous skin of the palm is
the palmar aponeurosis (Fig. 12.16), a thick well-defined
fascial layer deep to which lie all the major neurovascular
structures in the palm (Fig. 12.22). More proximally, overly
ing the volar side of the carpus is the transverse carpal liga
ment (also termed the “flexor retinaculum”) forming the
roof of the carpal tunnel.
The flexor tendons enter the hand through the carpal
tunnel and lie deep to the main neurovascular bundles in
the palm (Fig. 12.17). The flexor digitorum profundus and
superficialis tendons enter their respective fibro-osseous
tunnels at the level of the metacarpophalangeal joints cor
responding to the position of the distal palmar crease (Fig.
12.20). The lumbrical muscles take origin on the radial
aspect of each of the profundus tendons, and the deep
palmar arch is located deep to this layer of tendons and
lumbrical muscles, essentially lying on the palmar interossei
and metacarpals (Fig. 12.11).
The median nerve enters the hand with all nine flexor
tendons deep to the retinaculum, however prior to this, the
median nerve gives rise to the palmar cutaneous nerve
which does not enter the carpal tunnel (Fig. 12.9). After
entering the carpal tunnel, the median nerve divides into
four main branches, supplying the thenar muscles, sensa
tion to the volar aspect of the thumb, the radial side of the
index finger and the common digital nerves to the second
and third web spaces.
After forming the roof of the carpal tunnel, the transverse
carpal ligament continues ulnarly to form the floor of
Guyon’s canal on the ulnar side of the hand (Fig. 12.20).
The ulnar neurovascular bundle enters the hand through
this tunnel as previously described, and the ulnar artery
then forms the superficial arch. Within the canal, the ulnar
nerve divides into its terminal branches. The deepest of
the ulnar nerve fascicles forms the motor branch (deep
branch) that dives directly posteriorly and eventually enters
the palm deep to the flexor tendons but superficial to the
interosseous muscles, and supplies all seven interossei, the
third and fourth lumbricals, adductor pollicis, flexor pollicis
brevis and the hypothenar muscles (Fig. 12.6).
The remaining two branches of the ulnar nerve leave
Guyon’s canal distally to form the common digital nerve to
the fourth web space, and the ulnar digital nerve to the
small finger.
The dorsal aspect of the hand is slightly less complex.
Within the subcutaneous tissues there are abundant super
ficial veins that can be used for recipient anastomosis, and
these eventually form the cephalic and basilic systems at the
wrist level (Fig. 12.18). Also in this plane, are the superficial
branch of the radial nerve supplying the radial half of the
dorsum, and the dorsal sensory branch of the ulnar nerve
which supplies the ulnar half (Fig. 12.12).
Deep to the superficial veins and sensory nerves are the
extensor tendons. These are bound to the dorsal aspect of
the hand at the, radiocarpal level, by the extensor retinacu
lum dividing the tendons into six compartments. The first
compartment (extensor pollicis brevis and abductor pollicis
longus) and the third compartment (extensor pollicis
longus) form the radial and ulnar borders of the anatomic
snuffbox respectively (Fig. 12.19), and are useful landmarks
when exposing the radial artery on the dorsal aspect of the
hand (Fig. 12.18). The floor of the fourth compartment
110
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
VASCULAR ANATOMY OF THE HAND
The gross vascular anatomy of the hand is well-defined,
however there are several arterial branching patterns that
can be clinically relevant, most importantly completeness of
the superficial and palmar arches.12 Conventional angiogra
phy (rather than CT angiography) is the gold standard for
defining these patterns clinically if the specific arterial
anatomy is deemed crucial to the operation.
(extensor digitorum and indicis tendons) contains the pos
terior interosseous nerve, which can be harvested for use as
a graft in digital nerve reconstruction.
Directly underlying the extensor tendons are the carpal
bones and the metacarpals. The dorsal interossei lie be
tween the metacarpals covered by a layer of deep fascia. The
dorsal metacarpal arteries can be located on or under
this fascia, although are occasionally found intramuscularly
(Fig. 12.20).
Figure 12.22 Superficial veins and cutaneous nerves of the forearm. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All
Rights Reserved.)
Anterior (palmar) view
Posterior (dorsal) view
Cephalic vein
Posterior antebrachial
cutaneous nerve
(from radial nerve)
Lateral antebrachial
cutaneous nerve
(from musculo-
cutaneous nerve)
Accessory
cephalic vein
Median
cephalic vein
Cephalic vein
Median
antebrachial vein
Superficial branch
of radial nerve
Palmar branch
of median nerve
Intercapitular veins
Basilic vein
Anterior branch
and
Posterior branch
of medial
antebrachial
cutaneous
nerve
Median
basilic vein
Bicipital
aponeurosis
Basilic vein
Perforating
veins
Posterior
antebrachial
cutaneous
nerve (from
radial nerve)
Accessory
cephalic
vein
Posterior
branch of
lateral
antebrachial
cutaneous
nerve (from
musculocu-
taneous nerve)
Cephalic vein
Basilic vein
Posterior
branch
of medial
antebrachial
cutaneous
nerve
Palmar branch
of ulnar nerve
Dorsal branch
of ulnar nerve
Palmar carpal
ligament
(continuous
with extensor
retinaculum)
Palmar
aponeurosis
Superficial
transverse
metacarpal
ligament
Proper palmar digital nerves
and palmar digital veins
Dorsal digital nerves and veins
Superficial branch
of radial nerve
Dorsal
venous
network
Dorsal branch
of ulnar nerve
Dorsal
metacarpal
veins
Intercapitular
veins
Extensor
retinaculum
Note: In 70% of cases,
a median cubital
vein (tributary to
basilic vein) replaces
median cephalic
and median basilic
veins (see Plate 479).
CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
111
The arterial supply to the hand is usually derived from
the ulnar and radial arteries alone, although a persistent
median artery can contribute to the superficial arch in up
to 10% of specimens. In general, the ulnar artery is the
dominant artery and supplies the superficial palmar arch,
giving rise to the common and proper digital arteries, while
the radial artery is typically nondominant and supplies the
deep palmar arch, the princeps pollicis, and the radial
digital artery to the index finger.
When the ulnar artery fails to reach the thumb and index
finger, an arch is considered incomplete.
In a large series of cadaveric dissections, the deep palmar
system has been found to be a complete arch (i.e., the radial
artery anastomoses with the deep branch of the ulnar artery)
in approximately 97% of specimens, but can be incomplete
in 3%.12
The superficial palmar system is a complete arch (ulnar
artery supplies all digits and the thumb) in approximately
80% of specimens, and in the remaining 20% an incomplete
superficial arch can exhibit a number of variable branching
patterns in the palm. Identification of an incomplete super
ficial system is important when considering reverse flow
pedicled flaps for coverage of hand defects, most commonly
the distally-based radial forearm flap, as sacrificing the
radial artery would likely result in an ischemic hand. Com
pleteness of the superficial arch can be confirmed preopera
tively by an Allen’s test or arteriography. Intraoperatively,
this can be confirmed by occluding flow in the radial or
ulnar artery using microvascular clamps, then examining
distal perfusion.
A dorsal carpal arch is also present, fed by branches of
the radial, ulnar and posterior interosseous arteries. This
arch supplies the carpal bones and dorsal metacarpal arter
ies and can be used to design pedicled bone or fasciocutane
ous flaps from the dorsum of the hand and wrist.
THE SUPERFICIAL PALMAR ARCH AND
THE DIGITAL ARTERIES
The superficial palmar arch is formed from the continua
tion of the ulnar artery, with contributions from the super
ficial palmar branch of the radial artery, although there are
several variations. The ulnar artery passes through Guyon’s
canal initially deep to the ulnar nerve and palmaris brevis.
It runs distally superficial to the flexor digiti minimi but
remains deep to the palmar fascia, curving radially to form
the arch proximal to the mid-palmar crease. As it continues
radially, it remains superficial to all the flexor tendons and
the branches of the median and ulnar nerves. The superfi
cial arch gives rise to the proper digital artery to the ulnar
side of the small finger, and three common digital arteries
(to the 4th, 3rd, and 2nd web space) (Fig. 12.15). Each of
these vessels receives a contribution from a corresponding
palmar metacarpal artery that arises from the deep palmar
arch. Proximal to the metacarpal neck, each common
digital artery is superficial to each of the associated common
digital nerves, however distal to this level, the proper digital
artery becomes deep to its corresponding nerve and this
relationship is maintained throughout the digit where they
are bound by Cleland’s ligament dorsally, and Grayson’s
ligament on the volar side.
The proper digital arteries communicate across each
finger via arcades usually located at the level of each joint.
This allows for distally based homodigital island flaps to be
designed based on retrograde flow.
The digital arteries to the thumb and radial side of the
index finger typically arise from the radial artery or the first
part of the deep palmar arch.
THE DEEP PALMAR ARCH AND
PRINCEPS POLLICIS
The deep palmar arch is the continuation of the radial
artery, traversing the palm at the level of the metacarpal
bases, and is proximal to the superficial arch in the majority
of cases (Fig. 12.21). It is located in a plane deep to the
flexor tendons, lumbricals and adductor pollicis, but super
ficial to the interossei. It gives off 3–4 palmar metacarpal
arteries that eventually join the common digital arteries of
the superficial arch just proximal to the web spaces, and
several perforating branches that dive deep between the
second, third and fourth intermetacarpal spaces and anas
tomose with the dorsal metacarpal arteries on the dorsum
of the hand. The distal perforating branches are located at
the level of the metacarpal neck and provide the inflow and
pivot point for distally based dorsal metacarpal artery island
flaps.
Just prior to forming the deep palmar arch, the radial
artery gives rise to the princeps pollicis and radialis indicis
arteries.
The princeps pollicis artery arises immediately after the
radial artery enters the deep palm by passing from its ter
minal location dorsal to the thumb base, through the two
heads of the first dorsal interosseous (Fig. 12.16). It contin
ues along the ulnar aspect of the thumb metacarpal, deep
to the first dorsal interosseous, adductor pollicis and flexor
pollicis longus tendons, and divides at the level of the meta
carpal neck into radial and ulnar proper digital arteries that
continue to the thumb tip. The radialis indicis (radial digital
artery to the index finger) arises just distal to the princeps
pollicis. Occasional these two vessels arise from a common
trunk rather than directly from the radial artery.
VENOUS ANATOMY OF THE ARM,
FOREARM, AND HAND
The veins of the upper extremity are divided into superficial
and deep groups. There is significant variability in the
anatomy of both groups, however the superficial veins are
found in the subcutaneous tissues, with the deep veins being
located deep to the deep fascia, typically accompanying
named arteries (Figs 12.10, 12.21, 12.23). The brachial,
radial, and ulnar arteries all have sizeable concomitant veins
that can be used as recipient veins in microsurgical cases.
The superficial and deep systems have multiple connections
throughout the upper extremity, and there is usually
an abundance of veins available at all levels for use as recipi
ent vessels or vein graft. The basilic vein is superficial
(Fig. 12.21).
The majority of the venous drainage of the hand is
directed from the small, fragile superficial palmar veins and
deep veins into the superficial venous network on the
dorsum of the hand. The dorsal digital veins coalesce to
form multiple large veins over the metacarpals. The radial
side of this plexus eventually forms the cephalic vein, while
112
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
ial nerve. It continues proximally in the arm along the
lateral groove of the biceps muscle, eventually entering the
groove between the deltoid and pectoralis muscles (Fig.
12.21). It then continues heading towards the clavicle,
passes deep to the clavicular head of the pectoralis major
and pierces the clavipectoral fascia, crossing anterior to the
axillary artery to drain into the axillary vein just inferior
to the clavicle (Fig. 12.23). The cephalic vein is usually of
large caliber and can be used for venous drainage of a flap
the ulnar side forms the basilic vein. There are numerous
patterns of superficial venous anatomy, although the
anatomy of the cephalic, basilic and median cubital veins is
fairly constant (Fig. 12.22).
The cephalic vein is formed at the level of the anatomic
snuffbox, and runs proximally on the radial aspect of the
forearm receiving tributaries from both sides of the forearm.
The main trunk of the cephalic vein crosses the antecubital
fossa on the lateral side, superficial to the lateral antebrach
Figure 12.23 Superficial veins and cutaneous nerves of the arm. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Anterior view
Supraclavicular nerves
(from cervical plexus)
Medial
Intermediate
Lateral
Acromial branches of
thoracoacromial vein
Medial brachial
cutaneous nerve
Intercostobrachial
nerve
Superior lateral
brachial cutaneous
nerve (from
axillary nerve)
Inferior lateral
brachial cutaneous
nerve (from
radial nerve)
Cephalic vein
Posterior
antebrachial
cutaneous
nerve (from
radial nerve)
Accessory
cephalic
vein
Branches of medial
antebrachial
cutaneous nerve
Basilic vein
Lateral antebrachial
cutaneous nerve
(terminal part of
musculocutaneous nerve)
Median cubital vein
Intermediate (median)
antebrachial vein
Basilic vein
Perforating veins
Cephalic vein
Branches of
lateral antebrachial
cutaneous nerve
(terminal part of
musculocutaneous nerve)
Branches
of medial
antebrachial
cutaneous
nerve
Posterior
antebrachial
cutaneous
nerve
(from radial
nerve)
Inferior lateral
brachial cutaneous
nerve (from
radial nerve)
Posterior brachial
cutaneous nerve
(from radial nerve)
Superior lateral
brachial
cutaneous nerve
(from axillary
nerve)
Medial brachial
cutaneous nerve
Intercosto-
brachial nerve
Superficial
branches of
posterior
circumflex
humeral vein
Posterior view
Lateral supraclavicular nerve
Acromial branch of
thoracoacromial vein
CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity
113
Table 12.2 Vessel lumens in the hand
Vessel
Average lumen
diameter (mm)
Radial
2.6
Ulnar
2.5
Superficial arch
1.8
Deep arch
1.5
Superficial palmar branch of radial artery
1.4
Common digital
1.6
Common palmar metacarpal
1.2
anywhere along its length in the upper extremity. Addition
ally, it may be useful as a vein graft, or can be harvest distally
and pedicled proximally to provide microvascular drainage
in the chest or trunk.
The basilic vein arises on the dorsal ulnar side of the
hand, and remains on the dorsal ulnar side of the forearm
until the proximal third. Here it curves medially to cross the
elbow anteriorly, on the medial side of the antecubital fossa.
At this level, it receives the median antecubital vein a tribu
tary rising from the cephalic vein in the proximal forearm
(Fig. 12.10). It continues proximally in the anteromedial
arm, along the medial border of the biceps, superficial to
the brachial artery, and can be intimately related to branches
of the medial antebrachial cutaneous nerve. It pierces the
deep fascia of the arm just distal to its midpoint (Fig. 12.21)
to run on the medial side of the brachial artery. The basilic
vein then joins the brachial veins to form the axillary vein
at the distal border of the teres major (Fig. 12.5).
RECIPIENT VESSEL SELECTION IN
THE UPPER EXTREMITY
The anatomy of the major upper extremity vessels is well-
defined, and many of these structures are easily accessed.
However, there can be significant variability in vascular
branching patterns and collateral anastomoses. Careful dis
section and confirmation of distal vascular sufficiency, after
clamping potential recipient vessels prior to division, avoids
unnecessary complications. Additionally, knowledge of the
gross regional anatomy of the upper extremity allows for
an appreciation of the critical structures that may be encoun
tered during vessel exposure. In general terms, the location
and course of the major upper extremity nerves can be
described in relation to the arterial system, whereas the
abundant superficial venous network may be more inti
mately related to the named cutaneous nerve branches.
Workhorse recipient vessels that are easily exposed for
reconstructive microsurgery of the upper extremity include:
• The brachial artery along its course in the medial arm
(Fig. 12.2)
• The brachial artery bifurcation, including large branches
arising from the proximal radial artery (recurrent radial
artery) and proximal ulnar artery (ulnar recurrent and
interosseous arteries) (Fig. 12.4)
• The ulnar artery in the distal forearm and Guyon’s canal
(Fig. 12.4)
• The radial artery along its course in the forearm and the
superficial palmar branch at the wrist (Fig. 12.4)
• The radial artery in the anatomic snuffbox (Fig. 12.17).
The brachial, ulnar, and radial arteries are of sufficient
caliber to be used in an end-to-side manner without diffi
culty at any point along their course. Vessel diameter in the
distal part of the upper extremity and hand can be variable
depending on branching and dominance patterns (Table
12.2). The superficial palmar branch of the radial artery is
almost always present, however its diameter may vary (0.8–
3.0 mm).13 It can be used in end-to-end fashion for a
suitably-sized flap pedicle (e.g., medial femoral condyle
flap), however if the vessel is larger than average, an
incomplete arch or radial dominant system may be present
and distal perfusion should be confirmed with the vessel
clamped. Digital artery dominance varies for each digit,
typically corresponding to the more median of the two
vessels14 (i.e., the ulnar side of the thumb, index and long
fingers, the radial side of the ring and small fingers), and
should be considered when planning revascularization,
replantation or toe transfers.
ANESTHETIC AND INTRAOPERATIVE
CONSIDERATIONS
For lengthy upper extremity procedures, general anesthesia
may be required. However, regional anesthesia by axillary
or subclavian regional nerve blocks also provides some sym
pathetic blockade. This may facilitate dissection and anasto
moses as it encourages vasodilatation of smaller branches,
and can be used as an adjunct to general anesthesia.
Routine use of a tourniquet allows for more expeditious
and careful dissection in the upper extremity, however
complete exsanguination prior to application of the tourni
quet may hinder vessel identification. Incomplete exsangui
nation by elevation alone allows for easier visualization of
small vessels and venae comitantes. Superficial veins can be
marked preoperatively with the arm dependent or after
applying a venous tourniquet.
Access Figures 12.6, 12.7, 12.11 and 12.13, as
well as case examples 1, 2, 3 and 4 online at
REFERENCES
1. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm
flap: anatomy and clinical applications. Ann Plast Surg 1984;12(6):
489–500.
2. Casoli V, Kostopoulos E, Pélissier P, et al. The middle collateral
artery: anatomic basis for the “extreme” lateral arm flap. Surg
Radiol Anat 2004;26(3):172–7.
3. Yu P, Chang EI, Selber JC, et al. Perforator patterns of the
ulnar artery perforator flap. Plast Reconstr Surg 2012;129(1):
213–20.
4. Mathy JA, Moaveni Z, Tan ST. Perforator anatomy of the ulnar
forearm fasciocutaneous flap. J Plast Reconstr Aesthet Surg 2012;
65(8):1076–82.
5. Angrigiani C, Grilli D, Dominikow D, et al. Posterior interosseous
reverse forearm flap: experience with 80 consecutive cases. Plast
Reconstr Surg 1993;92(2):285–93.
CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity 113.e1
CASE 12.1 Exposure of the Brachial Artery in the Medial Arm
Figure 12.6 Case 12.1: Exposure of the brachial artery in the medial arm. (A) The brachial artery is palpated in the medial arm and an
incision is made in the bicipital groove, medial to the biceps tendon (white arrow, medial epicondyle; blue line, bicipital groove). (B) The
basilic vein is located in the subcutaneous plane in the distal half of arm, and is accompanied by the medial antecubital cutaneous nerve
(MABC). These structures are preserved and retracted posteriorly, and the deep fascia of the anterior compartment is incised. (C) The
deep fascia is incised and blunt dissection reveals the median nerve, brachial artery and its venae comitantes. (D) The median nerve lies
anterior to the artery proximally, but crosses to lie more medial to the artery in the distal arm.
A
B
Proximal
Proximal
Proximal
Medial
Medial
Medial
Distal
Distal
Distal
C
D
Median nerve
Median nerve
Deep fascia
Basilic vein/MABC
Basilic vein/MABC nerve
Brachial
artery
Brachial artery
113.e2 PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
CASE 12.2 Exposure of the Distal Brachial Artery and Its Bifurcation in the
Antecubital Fossa
Figure 12.7 Case 12.2: Exposure of the distal brachial artery and its bifurcation in the antecubital fossa. (A) The brachial artery is easily
palpable in the distal arm medial to the biceps tendon. An incision (blue dotted line) is made directly overlying the artery. If more distal
exposure is required, the incision can be extended laterally into the elbow crease and continues distally in the radial aspect of the proximal
forearm along the medial aspect of the brachioradialis muscle belly. (B) The median antecubital vein (blue loop) and branches of the medial
antecubital cutaneous nerve (white loop) are protected. The deep fascia of the arm and the lacertus fibrosus (black arrow) are exposed.
(C) The deep fascia is incised identifying the median nerve (white loop) medially and the brachial artery (red loop) with its venae comitantes
(blue loop) lateral to the nerve. (D) To expose the brachial artery bifurcation, the lacertus fibrosus is incised, the pronator teres muscle is
retracted medially and the brachioradialis muscle belly is retracted. The lateral antebrachial cutaneous nerve (LABC) lies on the lateral
side of the fossa, on the brachioradialis muscle and should be protected. (E) With the muscles retracted, the bifurcation is easily accessed.
The radial artery (RA) gives off a large recurrent radial branch (RRA) early and this can be used as a recipient vessel. (F) Dissection of
the ulnar artery (UA) exposes the anterior ulnar recurrent (AUR), and the common interosseous artery (IA), which usually arises on its
lateral side.
Biceps
Proximal
Distal
Proximal
Distal
Proximal
Distal
Medial
Medial
Proximal
Distal
Medial
Proximal
Distal
Medial
Proximal
Distal
Medial
Brachial artery
and
median nerve
Medial
epicondyle
Ulnar nerve
and artery
Lacertus
Pronator teres
Brachioradialis
LABC
LABC
RRA
RA
RA
IA
UA
AUR
Ulnar artery
Radial artery
A
B
C
D
E
F
E
CHAPTER 12 — Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity 113.e3
CASE 12.3 Exposure of the Ulnar Artery at the Wrist and Guyon’s Canal
Figure 12.11 Case 12.3: Exposure of the ulnar artery at the wrist and Guyon’s canal. (A) A longitudinal incision is made radial to the
flexor carpi ulnaris (FCU) tendon. For more distal exposure, the incision can be curved around the pisiform (P), into the palm (lateral defect
is from previous radial artery exposure on this specimen). (B) The antebrachial fascia is exposed and the FCU tendon can be seen on the
medial side of the surgical field. (C) After the deep fascia is incised, the ulnar neurovascular bundle is easily identified. The artery lies
radial to the nerve at this level. (D) For more distal exposure, note that the palmar soft tissues are significantly thicker. The volar carpal
ligament (VCL), which forms the roof of Guyon’s canal is incised to allow access to the ulnar artery in the proximal palm. (E) The ulnar
artery lies more superficial to the nerve at this level. (F) The branching pattern of the ulnar nerve (UN) at this level includes a deep motor
branch (D) that is not usually visible from the superficial exposure, and care should be taken not to inadvertently injure this branch.
Proximal
Distal
Medial
Proximal
Distal
Medial
Proximal
Distal
Medial
Proximal
Distal
Medial
P
Proximal
Distal
Medial
Proximal
Distal
Medial
FCU
UN
D
VCL
Ulnar artery
Ulnar nerve
Antebrachial
fascia
Antebrachial
fascia
A
B
C
D
E
F
113.e4 PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
CASE 12.4 Exposure of the Radial Artery in the Wrist and Anatomic Snuffbox
Figure 12.13 Case 12.4: Exposure of the radial artery in the wrist and anatomic snuffbox. (A) A longitudinal incision is made radial to
the flexor carpi radialis (FCR) tendon in the distal forearm, directly overlying the palpable radial artery. The deep fascia is incised and the
FCR tendon is retracted medially exposing the radial artery (RA). (B) For exposure of the radial artery (red loop) distally, an incision is
made over the radial side of the anatomic snuffbox. Branches of the superficial radial nerve (white loops) and cephalic vein (blue loop)
are preserved. (C) The deep fascia is identified overlying the extensor pollicis longus (EPL) tendon ulnarly, and the 1st compartment (APL/
EPB) tendons radially. (D) The deep fascia is opened between the tendons, blunt dissection exposes the radial artery (red loop) deep in
the snuffbox, entering under the first compartment tendons. (E) The radial artery dives into the palm (red loops) between the two heads
of the first dorsal interosseous (FDI). Immediately prior to this, it gives rise to the first dorsal metacarpal artery. (F) The radial artery gives
off a smaller palmar branch (red loop) prior to entering the snuffbox, and this can also be used as a recipient vessel in end-to-end fashion.
A
B
C
D
E
F
Proximal
Distal
Proximal
Distal
Proximal
Distal
Proximal
Distal
Proximal
Distal
Index
metacarpal
Thumb
metacarpal
RA
FCR
FCR
FDI
EPL
Snuffbox
APL/EPB
114
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
11. Bendersky M, Bianchi HF. Double innervation of the brachialis
muscle: anatomic-physiological study. Surg Radiol Anat 2012;34(9):
865–70.
12. Gellman H, Botte MJ, Shankwiler J, et al. Arterial patterns of the
deep and superficial palmar arches. Clin Orthop Relat Res
2001;383:41–6.
13. Omokawa S, Ryu J, Tang JB, et al. Vascular and neural anatomy of
the thenar area of the hand: its surgical applications. Plast Reconstr
Surg 1997;99(1):116–21.
14. Leslie BM, Ruby LK, Madell SJ, et al. Digital artery diameters: an
anatomic and clinical study. J Hand Surg [Am] 1987;12(5 Pt 1):
740–3.
6. Hubmer MG, Fasching T, Haas F, et al. The posterior interosseous
artery in the distal part of the forearm. Is the term “recurrent
branch of the anterior interosseous artery” justified? Br J Plast Surg
2004;57(7):638–44.
7. Mei J, Morris SF, Ji W, et al. An anatomic study of the dorsal
forearm perforator flaps. Surg Radiol Anat 2013;35(8):695–700.
8. Weinzweig N, Chen L, Chen ZW. The distally based radial forearm
fasciosubcutaneous flap with preservation of the radial artery: an
anatomic and clinical approach. Plast Reconstr Surg 1994;94(5):
675–84.
9. Saint-Cyr M, Mujadzic M, Wong C, et al. The Radial Artery Pedicle
Perforator Flap: Vascular Analysis and Clinical Implications. Plast
Reconstr Surg 2010;125(5):1469–78.
10. Ho AM, Chang J. Radial artery perforator flap. J Hand Surg [Am]
2010;35(2):308–11.
115
INTRODUCTION
The reconstructive microsurgeon is often consulted for
management of lower extremity bone and soft tissue defects.
Defects can arise from multiple causes, including trauma,
oncologic resection, infection, or pre-existing vascular
disease. By far, trauma is the most common etiology for
lower extremity defects that require microsurgical recon
struction. This chapter delineates clinically relevant anatomy
in the lower extremity and provides anatomic and technical
descriptions of exposing recipient vessels in this region.
ANATOMY OF THE THIGH
Thigh muscles are divided into anterior, medial, and poste
rior compartments (see Fig. 13.1). Within the anterior com
partment are the sartorius and quadriceps muscles, which
include the rectus femoris (see Figs 13.1 and 13.2), vastus
lateralis, vastus medialis, and vastus intermedius. The
femoral nerve provides innervation to these muscles. The
psoas major and iliacus muscles are also found in the upper
part of this compartment. The rectus femoris crosses the hip
joint and knee joint, whereas the vastus muscles originate
on the femur and cross the knee joint only. The posterior
compartment contains the hamstring muscles including the
semitendinosus, semimembranosus and biceps femoris,
which are all innervated by the sciatic nerve. (see Fig. 13.3)
The medial compartment contains the gracilis, pectineus,
adductor longus, adductor brevis, adductor magnus, and
obturator externus. The obturator nerve supplies innerva
tion to all these muscles except the pectineus (femoral
nerve) and part of the adductor magnus (sciatic nerve).
NERVES
Three main nerves traverse the thigh, the femoral nerve
(L2–L4) (see Fig. 13.1), the sciatic nerve (L4–S3), and the
obturator nerve (L2–L4) (see Fig. 13.3). The femoral nerve
passes through the anterior compartment; the obturator
through the medial compartment; and the sciatic through
the posterior compartment. The femoral nerve above the
inguinal ligament gives off branches that supply the iliacus
and psoas muscles, then below, the inguinal ligament gives
off branches that supply the anterior compartment muscles.
Below the ligament, the femoral nerve also gives off an
anterior cutaneous branch supplying the anterior thigh and
knee skin, and the saphenous nerve which supplies the
medial side of the leg and foot. The obturator nerve passes
through the obturator canal into the medial compartment
and divides into a posterior and anterior branch. The ante
rior branch supplies innervation to the adductor longus,
gracilis, adductor brevis and the skin on the medial aspect
of the thigh. The sciatic nerve supplies all the muscles of
the posterior compartment and continues on to the knee,
dividing into the tibial and common peroneal nerve.
The lateral femoral cutaneous nerve (L2–L3) is a direct
branch of the lumbar plexus and enters the thigh deep to
the lateral end of the inguinal ligament. It travels under the
tensor fascia lata for ~10 cm before rising through it and
dividing into anterior and posterior branches that supply the
skin of the anterolateral thigh. It is found in the deep subcu
taneous tissue just above the fascia. The motor branch to
vastus lateralis muscle originates from the femoral nerve and
accompanies the descending branch of the lateral femoral
circumflex artery (LCFA) along the intermuscular septum.
ARTERIAL ANATOMY OF THE THIGH
COMMON FEMORAL ARTERY
The external iliac artery becomes the common femoral
artery (Fig. 13.3) as it passes underneath the inguinal liga
ment. In the proximal thigh, the common femoral artery
passes through the femoral triangle, bounded by the sarto
rius laterally, the adductor longus medially, and the inguinal
ligament superiorly. Just distal to the inguinal ligament, the
superficial circumflex iliac artery (SCIA) and superficial
inferior epigastric artery (SIEA) originate from the lateral
and medial surface of the common femoral artery, respec
tively. Alternately, they can arise as a common trunk from
the anterior surface in 48% of patients.1 The SCIA runs
Clinical Anatomy and
Recipient Vessel Selection
and Exposure in the Lower
Extremity
Christopher J. Pannucci | T. Shane Johnson | L. Scott Levin
13
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
116
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
laterally approximately two fingerbreadths below and paral
lel to the inguinal ligament and supplies the groin flap
and superficial circumflex iliac artery perforator flap. The
common femoral artery divides into the superficial and
deep femoral arteries. The bifurcation typically occurs 5 cm
distal to the inguinal ligament.
EXPOSURE OF THE COMMON FEMORAL ARTERY
The common femoral artery (Fig. 13.2) can be palpated just
distal to the inguinal ligament halfway between the anterior
superior iliac spine and the symphysis pubis (see Fig. 13.5).
The femoral vein is medial and the femoral nerve is lateral
to the common femoral artery. The great saphenous vein
drains into the medial surface of the femoral vein. In the
femoral triangle, the vessel lies superficially below the fascia
of the thigh and can be approached directly.
DEEP FEMORAL ARTERY (PROFUNDA FEMORIS) (Fig. 13.2)
The lateral femoral circumflex artery is the largest branch
of the deep femoral artery, arising from its lateral aspect. The
vessel typically arises 1.5 cm distal to the origin of the deep
femoral artery, although it branches directly from the
common femoral artery in approximately 30% of patients
(Fig. 13.3). It courses deep to the sartorius and rectus femoris
and divides into ascending, transverse, and descending
Superficial dissections
Tensor fasciae latae
muscle (retracted)
Lateral cutaneous nerve of thigh (cut)
Sartorius muscle (cut)
Gluteus
minimus
and medius
muscles
Iliopsoas muscle
Femoral nerve,
artery and vein
Pectineus muscle
Deep artery
of thigh
Adductor
longus muscle
Adductor canal
(opened by re-
moval of sartorius
muscle)
Saphenous nerve
Nerve to vastus
medialis muscle
Adductor
magnus muscle
Anteromedial
intermuscular
septum covers
entrance of
femoral vessels to
popliteal fossa
(adductor hiatus)
Sartorius
muscle (cut)
Lateral
circumflex
femoral
artery
Rectus
femoris
muscle
Vastus
lateralis
muscle
Saphenous nerve
and saphenous
branch of descending
genicular artery
Infrapatellar branch
of saphenous nerve
Vastus
medialis
muscle
Anterior superior iliac spine
Inguinal ligament
Iliopsoas muscle
Superficial circumflex
iliac vessels
Superficial
epigastric vessels
Superficial and
Deep external
pudendal vessels
Femoral sheath
Pectineus
muscle
Deep artery
of thigh
Gracilis
muscle
Adductor
longus
muscle
Sartorius
muscle
Vastus medialis muscle
Fascia lata (cut)
Rectus femoris muscle
Vastus lateralis muscle
Tensor fasciae latae muscle
Femoral nerve,
artery and vein
Figure 13.1 Regional anatomy of the thigh. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
117
from the rectus femoris branch pass between the rectus
femoris and vastus medialis/sartorius to supply the antero
medial thigh flap.3
The medial femoral circumflex artery usually originates
from the posteromedial aspect of the profunda femoris at
the same level or close to the lateral femoral circumflex
artery, but it may arise from the common femoral artery
directly in 25% of patients. It divides into ascending and
branches. The ascending branch can be identified in the
interval between tensor fascia lata muscle and rectus femoris,
and supplies the tensor fascia lata and gluteus muscles. The
descending branch runs in the interval between the rectus
femoris and vastus lateralis, and is the blood supply to the
anterolateral thigh flap.2 The rectus femoris branch is a
direct branch from the descending branch of the lateral
femoral circumflex artery. In 51% of patients, perforators
Figure 13.2 Branching pattern of the deep femoral artery. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Deep dissection
Deep circumflex iliac artery
Lateral femoral
cutaneous nerve
Sartorius muscle (cut)
Iliopsoas muscle
Tensor fasciae latae
muscle (retracted)
Gluteus medius and
minimus muscles
Femoral nerve
Rectus femoris muscle (cut)
Ascending, transverse and
descending branches of
Lateral circumflex femoral artery
Medial circumflex femoral artery
Pectineus muscle (cut)
Profunda femoris (deep femoral) artery
Perforating branches
Adductor longus muscle (cut)
Vastus lateralis muscle
Vastus intermedius muscle
Rectus femoris muscle (cut)
Saphenous nerve
Anteromedial intermuscular
septum (opened)
Vastus medialis muscle
Quadriceps femoris tendon
Patella and patellar
anastomosis
Medial patellar retinaculum
Patellar ligament
External iliac artery and vein
Inguinal ligament (Poupart’s)
Femoral artery and vein (cut)
Pectineus muscle (cut)
Obturator canal
Obturator externus muscle
Adductor longus muscle (cut)
Anterior branch and
Posterior branch of
obturator nerve
Quadratus femoris muscle
Adductor brevis muscle
Branches of posterior branch
of obturator nerve
Adductor magnus muscle
Gracilis muscle
Cutaneous branch of obturator nerve
Femoral artery and vein (cut)
Descending genicular artery
Articular branch
Saphenous branch
Adductor hiatus
Sartorius muscle (cut)
Adductor magnus tendon
Adductor tubercle on
medial epicondyle of femur
Superior medial genicular artery
(from popliteal artery)
Infrapatellar branch of
Saphenous nerve
Inferior medial genicular artery
(from popliteal artery)
118
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 13.3 Vascular anatomy of the thigh. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Superior clunial nerves
Gluteus maximus muscle (cut)
Medial clunial nerves
Inferior gluteal artery and nerve
Pudendal nerve
Nerve to obturator internus
(and superior gemellus)
Posterior femoral
cutaneous nerve
Sacrotuberous ligament
Ischial tuberosity
Inferior clunial nerves (cut)
Adductor magnus muscle
Gracilis muscle
Sciatic nerve
Muscular branches of sciatic nerve
Semitendinosus muscle (retracted)
Semimembranosus muscle
Sciatic nerve
Articular branch
Adductor hiatus
Popliteal vein and artery
Superior medial genicular artery
Medial epicondyle of femur
Tibial nerve
Gastrocnemius muscle (medial head)
Medial sural cutaneous nerve
Small saphenous vein
Iliac crest
Gluteal aponeurosis and
gluteus medius muscle (cut)
Superior gluteal artery and nerve
Gluteus minimus muscle
Tensor fasciae latae muscle
Piriformis muscle
Gluteus medius muscle (cut)
Superior gemellus muscle
Greater trochanter of femur
Obturator internus muscle
Inferior gemellus muscle
Gluteus maximus muscle (cut)
Quadratus femoris muscle
Medial circumflex femoral
artery
Vastus lateralis muscle
and iliotibial tract
Adductor minimus part of
adductor magnus muscle
1st perforating artery (from
profunda femoris artery)
Adductor magnus muscle
2nd and 3rd perforating arteries
(from profunda femoris artery)
4th perforating artery (from
profunda femoris artery)
Long head (retracted)
Short head
Superior lateral genicular artery
Common fibular (peroneal) nerve
Plantaris muscle
Gastrocnemius muscle (lateral head)
Lateral sural cutaneous nerve
Deep dissection
Biceps femoris
muscle
transverse branches. The ascending branch runs between
the adductor longus and magnus and is the primary pedicle
for the gracilis muscle flap.
The perforating branches of the deep femoral artery
typically include three separate, numbered branches and
the terminal segment of the deep femoral which is
referred to as the fourth perforating branch. They perfo
rate the adductor magnus to reach the posterior thigh
(Fig. 55.1).
EXPOSURE OF BRANCHES OF THE DEEP
FEMORAL ARTERY
Branches of the deep femoral artery can be used for recipi
ent vessels in the thigh. The descending branch of the
lateral femoral circumflex vessels can be approached as if
the surgeon is performing an anterolateral thigh flap (Fig.
59.1). A line is drawn between the anterior superior iliac
spine and the lateral border of the patella, the so-called
“AP” line. An axial incision 1 cm medial to the AP line can
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
119
lateral leg compartment is separated from the posterior
compartment by the posterior intermuscular septum (see
Fig. 13.6).
The anterior compartment has four muscles: the extensor
digitorum longus, extensor hallucis longus, peroneus
tertius, and tibialis anterior (see Fig. 13.7). These muscles
are supplied by the anterior tibial vessels and are innervated
by the deep peroneal nerve, all traveling deep to the muscles
along the interosseous membrane (see Fig. 13.8).
The posterior compartment is divided into superficial
and deep compartments by a thin fascia termed the “trans
verse intermuscular septum (see Fig. 13.6).” Three muscles
are located in the superficial compartment: the gastrocne
mius, soleus, and plantaris (see Fig. 13.9). The gastrocne
mius and plantaris originate from the femur, while the
soleus originates from the posterior surface of the fibula
and tibia. The gastrocnemius and soleus join together at
midcalf to form the Achilles tendon, which inserts into the
calcaneal bone. The plantaris is a thin, small muscle. The
plantaris tendon follows the larger Achilles tendon to insert
into the medial portion of the calcaneus. All these muscles
flex the foot in a plantar direction (the gastrocnemius also
flexes the knee) with slight inversion. The muscles are vas
cularized by branches from the popliteal and posterior tibial
arteries and innervated by branches of the tibialis nerve
from the popliteal fossa.
The deep posterior leg compartment contains four
muscles: the popliteus, flexor digitorum longus, flexor hal
lucis longus, and tibialis posterior (see Figs 13.6 and 13.10).
The popliteus performs knee flexion and medial rotation
of the leg. The flexor hallucis longus muscle originates from
the distal two-thirds of the fibula posteriorly, transverse
intermuscular septum, and the interosseous membrane.
The tibialis posterior muscle is the most deeply situated
muscle in the deep posterior compartment, lying between
the flexor hallucis longus and flexor digitorum longus
muscles. It arises from the upper two-thirds of the fibula
posteromedially, the interosseous membrane, posterolateral
tibia, and transverse intermuscular septum that separates it
from the soleus.
The lateral compartment contains two muscles: the pero
neus longus and brevis (see Figs 13.6 and 13.7). The pero
neus longus muscle arises from the upper two-thirds of the
compartment, whereas the peroneus brevis muscle arises
from the lower two-thirds. Their action consists of extension
and eversion of the foot. They are vascularized by vessels
from the peroneal artery and innervated by the superficial
peroneal nerve, which runs deeply in the upper two-thirds
of the leg and then becomes superficial distally, supplying
sensory innervation to the lower third of the anterior leg
skin as the medial and intermediate dorsal cutaneous
nerves.
NERVES
The common peroneal nerve runs subcutaneously at the
level of the head of the fibula, where it passes around its
neck and divides into a superficial and deep peroneal
branch. Motor innervation to muscles of the lateral com
partment is supplied by the superficial peroneal nerve,
which initially runs deep to the peroneus longus muscle in
the proximal leg and then becomes superficial more distally
as the medial and intermediate dorsal cutaneous nerves.
be carried down to the rectus femoris muscle. Slightly
lateral, the interval between the rectus femoris and vastus
lateralis can be identified; a fat stripe is usually present at
this junction. The descending branch can reliably be located
within the largely avascular plane between the two muscles
(Fig. 13.2).2,4 A more superior incision can allow identifica
tion of the ascending branch of the lateral femoral circum
flex vessels in the interval between rectus femoris and the
vastus intermedius, deep to the tensor fascia lata.5
SUPERFICIAL FEMORAL ARTERY
The common femoral artery becomes the superficial femoral
artery after the take-off of the profunda femoris (Fig. 13.2).
The superficial femoral artery continues through the distal
femoral triangle, courses through the subsartorial canal, and
ends at the hiatus of the adductor magnus, where it continues
as the popliteal artery (Fig. 13.2). At the entrance to the adduc
tor hiatus (also known as Hunter’s canal), the descending
genicular branch arises from the anterior portion of the super
ficial femoral artery (Figs 13.4, 13.5, 55.1). This vessel runs
deep to the vastus medialis muscle on the surface of the medial
femoral condyle to supply the medial femoral condyle flap.
The saphenous artery, a medial branch of the descending
genicular artery, supplies a reliable skin island that can be
included with the medial femoral condyle flap (Fig. 13.5).
EXPOSURE OF THE SUPERFICIAL FEMORAL ARTERY
AND ITS BRANCHES
After giving rise to the deep femoral artery, the superficial
femoral artery passes inferiorly, deep to the sartorius, and
passes into the adductor canal. Distal to the femoral tri
angle, the superficial femoral artery can be exposed
through a longitudinal thigh incision along the lateral
edge of the sartorius (Fig. 13.5). The incision is deepened
through the muscle fascia and the lateral edge of sartorius
is reflected medially; this preserves the segmental inferior-
medial perforators entering the muscle. In the middle
one-third of the thigh, the superficial femoral artery runs
on the surface of the adductor longus. In the distal one-
third, it passes through the adductor hiatus. Access requires
division of the fascial connection between the adductor
magnus and vastus medialis which forms the canal’s roof.
End-to-side anastomosis to the superficial femoral artery
requires temporary interruption to the blood supply below
the knee. When present, prominent perforators including
the descending genicular vessels at the adductor hiatus
may be preferable to allow end-to-end anastomosis.
ANATOMY OF THE LEG
The framework of the lower leg is composed of two long
bones, the fibula and the tibia, which are arranged in paral
lel and connected along their length by a fibrous membrane
termed the interosseous membrane These three structures
together divide the leg into two anatomic sections: the ante
rior and posterior compartments. The anterior compart
ment is further divided into anterior and lateral sections
separated by a thick anterior intermuscular septum. The
120
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 13.4 Collateral pathways between the superficial femoral artery and deep femoral artery around the knee. (Reprinted from Netter
Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
External iliac artery
Inferior epigastric artery
Superficial epigastric artery
Superficial external pudendal artery
Obturator artery
Deep external pudendal artery
Medial circumflex femoral artery
Femoral artery
Muscular branches
Descending genicular artery
Articular branch
Saphenous branch
Superior medial genicular artery
Popliteal artery (phantom)
Middle genicular artery (phantom)
Inferior medial genicular artery
(partially in phantom)
Anterior tibial recurrent artery
Posterior tibial artery (phantom)
Fibular (peroneal) artery (phantom)
Deep circumflex iliac artery
Superficial
circumflex iliac artery
Femoral artery
Ascending branch,
Transverse branch,
Descending branch of
Lateral circumflex
femoral artery
Profunda femoris
(deep femoral)
artery
Perforating branches
Femoral artery passing
through adductor hiatus
Superior lateral genicular artery
Patellar anastomosis
Inferior lateral genicular artery
(partially in phantom)
Posterior tibial recurrent artery
(phantom)
Circumflex fibular branch
Anterior tibial artery
Interosseous membrane
The deep peroneal nerve runs in the anterior compart
ment, innervating its musculature and providing sensation
to the first web space of the foot. The tibial nerve provides
innervation to the posterior compartment and runs deeply
in the proximal half of the leg and then shifts medially to
provide motor and sensory innervation to the foot (see Figs
13.6, 13.7, 13.8, 13.9 and 13.11).
ARTERIAL ANATOMY OF THE LEG
POPLITEAL ARTERY
The popliteal artery runs from medial to lateral in the
popliteal fossa (see Figs 13.9 and 13.10). The diamond-
shaped fossa is bounded superiorly by the hamstrings (medi
ally: semitendinosus and semimembranosus; and laterally:
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
121
between the gastrocnemius heads is sufficient, thus avoiding
the flexion crease. Below the fascia, the tibial nerve, and
popliteal vein and artery (from superficial to deep) lie verti
cally in the fossa. The popliteal vein lies superficial to the
artery in the same sheath, at first posteromedial of the artery
and lateral to the nerve; more superiorly, it lies posterior
to the artery, between this vessel and the overlying tibial
nerve. The tibial nerve crosses the vessels from lateral to
medial. The common peroneal nerve has already bifurcated
from the sciatic nerve at the entry into the popliteal fossa.
It runs laterally following the tendons of the long and short
heads of the biceps femoris, then passes over the fibula head
before dividing into the superficial peroneal nerve to the
lateral compartment and the deep peroneal nerve to the
anterior compartment (Fig. 13.8). Often the popliteal artery
does not need to be completely exposed as the geniculate
or sural arteries can be used as recipient vessels.
POSTERIOR TIBIAL ARTERY
The posterior tibial artery is the larger of the two terminal
branches of the popliteal artery (see Figs 13.6 and 13.10).
It originates just distal to the ring in the soleus muscle and
inclines medially as it descends in the deep posterior
compartment of the leg. It runs in the deep posterior com
partment between the flexor digitorum longus muscle (in
the deep posterior compartment) and the soleus muscle (in
the superficial posterior compartment). Distally it lies more
superficial and medial to the Achilles tendon. The posterior
biceps femoris). Inferiorly, the fossa is bounded by the two
heads of the gastrocnemius and the plantaris muscle. In
addition to smaller branches, the popliteal artery gives rise
to the medial and lateral sural arteries (the primary pedicles
to the medial and lateral gastrocnemius flaps) and the supe
rior and inferior genicular arteries. The latter are an impor
tant source of collateral flow around the knee. At the
inferior border of the popliteus, the popliteal artery divides
into the anterior and posterior tibial artery. As the peroneal
(fibular) artery arises from the posterior tibial artery, some
refer to the proximal segment of the posterior tibial artery
as the “tibial-peroneal trunk” (Fig. 13.6). All three vessels
can serve as recipient arteries in the lower leg.
EXPOSURE OF THE POPLITEAL ARTERY
The popliteal artery (Fig. 13.12) can be felt pulsating in the
popliteal fossa with the knee bent. It corresponds to a line
joining a point at the middle and lower thirds of the thigh,
2.5 cm medial to its posterior midline with the midpoint
between the femoral condyles. It continues inferior and
laterally to the level of the tibial tuberosity, medial to the
fibular neck. For exposure in the fossa, the muscular out
lines as mentioned above are marked. Using the posterior
approach, the patient is placed prone. For the more difficult
medial approach, the patient lies supine, the contralateral
hip is supported with a cushion, and legs are in a “frog
position” (hip and knee flexed and externally rotated).
The incision in the flexion crease should be transverse and
extended stepwise. However, often a longitudinal incision
Figure 13.5 (A–E) Surgical exposure of the femoral vessels in the groin and proximal thigh.
Inguinal ligament
Femoral vein
Great saphenous
vein
Femoral nerve
Common femoral
artery
Femoral vein
Subsartorial canal
A
B
C
D
E
Superficial femoral
artery
Profunda femoris (deep femoral)
artery
Common femoral
artery
Lateral circumflex
artery
Sartorius muscle
122
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
EXPOSURE OF THE POSTERIOR TIBIAL ARTERY
The posterior tibial artery (Fig. 13.13) corresponds to a line
joining: (1) a point, 2 cm medial to the calf’s midline at
the fibular neck level; and (2) a point, just posterior to the
posterior edge of the medial malleolus. This line lies ~1 cm
posterior to the posterior-medial border of the tibia. After
making a skin incision along this line and through the
subcutaneous tissue, the fascia cruris is incised. Further
dissection continues posterior to the tibia, leaving the
soleus muscle posterior and the flexor digitorum longus
muscle anterior. If the surgeon sees the plantaris tendon,
the plane between the gastrocnemius and soleus has incor
rectly been opened (Fig. 13.12). Blunt dissection in the
correct plane shows the posterior tibial artery and venae
comitantes together with the tibial nerve between the
soleus and flexor digitorum longus muscle. Distally, these
structures run posterior to the medial malleolus below the
flexor retinaculum, where the artery can be easily palpated.
The anatomic structures from anterior to posterior are the
tibialis posterior tendon, flexor digitorum longus tendon,
posterior tibial vessels, tibial nerve, and flexor hallucis
longus tendon.
tibial artery gives off cutaneous branches to the anterome
dial and posterior part of the skin of the leg. In the upper
third of the leg, the perforating vessels are mostly muscular
and periosteocutaneous vessels. In the lower third, the per
forating vessels are mostly direct septocutaneous and over
the medial aspect of the Achilles tendon they are tendino
cutaneous. These cutaneous vessels, particularly in the distal
one-third, can supply propeller flaps for medial malleolus
coverage (see Ch. 61). The posterior tibial vessel passes
posterior and medial to the medial malleolus. At this level,
the posterior tibial artery is posterior to the tendon of the
flexor digitorum longus muscle and anterior to the tibial
nerve. In the foot it divides into the medial and lateral
plantar arteries. Although technically possible, these
branches are not commonly used for free flap anastomosis
and arteries of the distal lower leg are preferred. The tibial
nerve divides from the sciatic nerve within the popliteal
fossa. It runs medial to the posterior tibial artery in the calf
before passing posterior to the medial malleolus, where it
is posterior to the posterior tibial artery and anterior to the
tendon of the flexor hallucis longus muscle. Distal to the
medial malleolus, it divides into the medial and lateral
plantar nerves (Figs 13.9, 13.10).
Figure 13.6 Cross-sectional anatomy of the lower leg. The four distinct compartments include the anterior compartment (tibialis anterior,
extensor hallucis longus, extensor digitorum longus, deep peroneal nerve, anterior tibial artery); the lateral compartment (peroneus longus,
peroneus brevis, superficial peroneal nerve); deep posterior compartment (tibialis posterior, flexor hallucis longus, flexor digitorum longus,
peroneal artery, posterior tibial artery, tibial nerve); and the superficial posterior compartment (soleus, gastrocnemius, plantaris). (Reprinted from
Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Deep fascia of leg
Anterior compartment
Anterior intermuscular septum
Lateral compartment
Posterior intermuscular septum
Fibula
Deep fascia of leg
Superficial posterior
comparatment
Transverse intermuscular
septum
Deep posterior compartment
Tibia
Interosseous membrane
Cross section just above middle of leg
Tibialis anterior muscle
Extensor hallucis longus muscle
Extensor digitorum longus muscle
Superficial fibular (peroneal) nerve
Anterior intermuscular septum
Deep fascia of leg
Fibularis (peroneus) longus muscle
Fibularis (peroneus) brevis muscle
Posterior intermuscular septum
Fibula
Lateral sural cutaneous nerve
Transverse intermuscular septum
Soleus muscle
Gastrocnemius muscle (lateral head)
Sural communicating branch
of lateral sural cutaneous nerve
Small saphenous vein
Medial sural cutaneous nerve
Gastrocnemius muscle (medial head)
Plantaris tendon
Deep fascia of leg
Flexor hallucis longus muscle
Posterior tibial artery and veins
and tibial nerve
Fibular (peroneal) artery and veins
Flexor digitorum longus muscle
Tibialis posterior muscle
Great saphenous vein
and saphenous nerve
Interosseous membrane
Tibia
Anterior tibial artery and veins
and deep fibular (peroneal) nerve
Anterolateral
incision
Medial
incision
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
123
EXPOSURE OF THE PERONEAL ARTERY
The peroneal artery is uncommonly used as an inflow vessel
because a fibulectomy is required for access. The peroneal
artery can be accessed using an approach through the
lateral and anterior compartments, similar to the approach
to the fibula flap (Fig. 13.6). The peroneus musculature can
be split to gain access to the lateral portion of the
fibula. Dissection anteriorly along the fibula and then
through the intermuscular septum will allow access to the
anterior compartment and the interosseus membrane. The
fibula can be cut proximally and distally and the interosseus
membrane divided. This exposes the tibialis posterior
muscle, which can be split to expose the underlying pero
neal vessels.
PERONEAL ARTERY
The peroneal (fibular) artery arises from the posterior tibial
artery on the surface of the tibialis posterior muscle, distal
to the take-off of the anterior tibial artery. It descends pos
terior and medial to the fibula in the deep posterior com
partment and terminates on the lateral surface of the
calcaneus as the lateral calcaneal artery. Peroneal artery
perforators are particularly prominent in the lower one-
third of the lower leg. Perforators run within the intermus
cular septum between the lateral and superficial posterior
compartment, and supply the skin island for a fibula flap.
Perforators 5 cm above the lateral calcaneus have anastomo
ses with the sural vessels to supply the reverse sural artery
flap (see Ch. 48).
Figure 13.7 Anatomy of the anterior compartment. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Superficial dissection
Common fibular (peroneal) n.
Head of fibula
Fibularis longus m.
Fibula
Superior extensor retinaculum
Inferior extensor retinaculum
Extensor digitorum longus tendons
Fibularis tertius tendon
Dorsal digital nn.
Tibial tuberosity
Tibia
Gastrocnemius m.
Medial malleolus
Tibialis anterior tendon
Extensor hallucis longus tendon
Extensor hallucis brevis tendon
Fibularis brevis m.
Deeper dissection
Common fibular n.
Fibularis longus m. (cut)
Anterior tibial a.
Superficial fibular n.
Deep fibular n.
Fibularis longus m.
Anterior tibial recurrent
a. and recurrent branch
of deep fibular n.
Tibia
Medial malleolus
and arterial network
Dorsalis pedis a.
Tibialis anterior tendon
Arcuate a.
Perforating branch of fibular a.
Lateral malleolus and arterial network
Extensor digitorum brevis and
extensor hallucis brevis mm. (cut)
Dorsal digital aa.
Tibialis anterior m.
Extensor hallucis longus m.
Extensor digitorum longus m.
Extensor digitorum longus m.
Tibialis anterior m. (cut)
Extensor hallucis longus
m. and tendon (cut)
124
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 13.8 Anatomy of the common peroneal nerve and its branches. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All
Rights Reserved.)
Common fibular
(peroneal) nerve
(phantom)
Biceps femoris tendon
Common fibular (peroneal)
nerve (L4, 5, S1, 2)
Head of fibula
Fibularis (peroneus)
longus muscle (cut)
Superficial fibular
(peroneal) nerve
Branches of lateral
sural cutaneous nerve
Fibularis (peroneus)
longus muscle
Fibularis (peroneus)
brevis muscle
Medial dorsal cutaneous nerve
Intermediate dorsal
cutaneous nerve
Inferior extensor
retinaculum (partially cut)
Lateral dorsal cutaneous nerve
(branch of sural nerve)
Dorsal digital nerves
Lateral sural cutaneous nerve (phantom)
Articular branches
Recurrent articular nerve
Extensor digitorum longus muscle (cut)
Deep fibular (peroneal) nerve
Tibialis anterior muscle
Cutaneous innervation
Extensor digitorum
longus muscle
Extensor hallucis
longus muscle
Lateral sural
cutaneous nerve
Superficial fibular
(peroneal) nerve
Lateral branch of
deep fibular
(peroneal) nerve to
Extensor hallucis brevis
and
Extensor digitorum brevis
muscles
Medial branch of
deep fibular
(peroneal) nerve
Deep
fibular
(peroneal)
nerve
Sural nerve
via lateral dorsal
cutaneous branch
ANTERIOR TIBIAL ARTERY
The anterior tibial artery is the first end branch of the pop
liteal artery. The anterior tibial artery arises from the pop
liteal artery distal to the popliteus muscle and on the surface
of the tibialis posterior. It passes through the interosseus
membrane to run in the anterior compartment between the
extensor hallucis longus (lateral) and the anterior tibialis
muscle (medial). The deep peroneal nerve branches from
the common peroneal nerve at the fibula head and enters
the anterior compartment to run lateral to the artery. At the
ankle, it passes deep to the retinaculum midway between
the malleoli and is crossed from lateral to medial by the
tendon of the extensor hallucis longus tendon (Fig. 13.14).
EXPOSURE OF THE ANTERIOR TIBIAL ARTERY
The anterior tibial artery (Fig. 13.14) corresponds to a line
joining a point 2.5 cm distal to the medial side of the fibular
head and a point midway between the malleoli anteriorly.
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
125
Figure 13.9 Anatomy of the (A) superficial posterior compartment;
Muscles of Leg (Superficial Dissection):Posterior View
Semitendinosus muscle
Popliteal artery and vein
Sartorius muscle
Gastrocnemius muscle (medial head)
Nerve to soleus muscle
Flexor digitorum longus tendon
Tibialis posterior tendon
Posterior tibial artery and vein
Tibial nerve
Medial malleolus
Flexor hallucislongus tendon
Flexor retinaculum
Iliotibial tract
Biceps femoris muscle
Tibial nerve
Common fibular (peroneal) nerve
Plantaris muscle
Gastrocnemius muscle (lateral head)
Fibularis (peroneus) brevis tendon
Calcaneal (Achilles) tendon
Lateral malleolus
Superior fibular (peroneal) retinaculum
Calcaneal tuberosity
A
Gracilis muscle
Semimembranosus muscle
Superior medial genicular artery
Small saphenous vein
Gastrocnemius muscle
Soleus muscle
Plantaris tendon
Calcaneal branch of
posterior tibial artery
Calcaneal branches of fibular (peroneal) artery
Fibular (peroneal) artery
Fibularis (peroneus) longus tendon
Soleus muscle
Medial sural cutaneous nerve (cut)
Lateral sural cutaneous nerve (cut)
Superior lateral genicular artery
Text continued on p. 127
Continued
126
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Muscles of Leg (Intermediate Dissection): Posterior View
Adductor magnus tendon
Popliteal artery and vein
Tibial collateral ligament
Semimembranosus tendon (cut)
Popliteus muscle
Gastrocnemius muscle (cut)
Flexor digitorum longus tendon
Tibialis posterior tendon
Posterior tibial artery and vein
Tibial nerve
Medial malleolus
Flexor retinaculum
B
Calcaneal (Achilles) tendon
Gastrocnemius muscle
(medial head) (cut)
Tibial nerve
Fibular collateral ligament
Biceps femoris tendon (cut)
Plantaris muscle
Head of fibula
Nerve to soleus muscle
Fibularis (peroneus) brevis tendon
Lateral malleolus
Superior fibular (peroneal) retinaculum
Superior medial genicular artery
Inferior medial genicular artery
Tendinous arch of
Soleus muscle
Plantaris tendon
Soleus muscle inserting into
calcaneal (Achilles) tendon
Flexor hallucis longus tendon
Calcaneal branch of
posterior tibial artery
Calcaneal branches
of fibular (peroneal) artery
Calcaneal tuberosity
Fibular (peroneal) artery
Fibularis (peroneus) longus tendon
Soleus muscle
Fibularis (peroneus) longus muscle
Common fibular (peroneal) nerve (cut)
Inferior lateral genicular artery
Gastrocnemius muscle (lateral head) (cut)
Lateral and medial sural cutaneous nerves (cut)
Superior lateral genicular artery
Common fibular (peroneal) nerve (cut)
(B) intermediate posterior. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Figure 13.9, cont’d
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
127
Figure 13.10 Branching pattern of the popliteal artery and the tibio-peroneal trunk (posterior). (Reprinted from Netter Anatomy Illustration Col
lection. ©Elsevier Inc. All Rights Reserved.)
Superior lateral genicular artery
Plantaris muscle (cut)
Gastrocnemius muscle (lateral head) (cut)
Fibular collateral ligament
Biceps femoris tendon (cut)
Inferior lateral genicular artery
Head of fibula
Fibular (peroneal) artery
Interosseous membrane
Perforating branch
Communicating branch
of fibular
(peroneal) artery
Superior medial genicular artery
Gastrocnemius muscle (medial head) (cut)
Sural (muscular) branches
Popliteal artery and tibial nerve
Tibial collateral ligament
Semimembranosus tendon (cut)
Inferior medial genicular artery
Popliteus muscle
Posterior tibial recurrent artery
Tendinous arch of soleus muscle
Posterior tibial artery
Flexor digitorum longus muscle
Tibial nerve
Tibialis posterior muscle
Calcaneal (Achilles) tendon (cut)
Flexor digitorum longus tendon
Tibialis posterior tendon
Medial malleolus and posterior medial
malleolar branch of posterior tibial artery
Flexor retinaculum
Medial calcaneal branches of
posterior tibial artery and tibial nerve
Tibialis posterior tendon
Medial plantar artery and nerve
Lateral plantar artery and nerve
Flexor hallucis longus tendon
1st metatarsal bone
5th metatarsal bone
Flexor digitorum longus tendon
Fibularis (peroneus) longus tendon
Fibularis (peroneus) brevis tendon
Inferior fibular (peroneal) retinaculum
Lateral calcaneal branch of sural nerve
Lateral calcaneal branch
of fibular (peroneal) artery
Superior fibular (peroneal) retinaculum
Lateral malleolus and posterior lateral
malleolar branch of fibular (peroneal) artery
Fibularis (peroneus) brevis tendon
Fibularis (peroneus) longus tendon
Flexor hallucis longus muscle (retracted)
Fibular (peroneal) artery
Anterior tibial artery
Soleus muscle (cut and reflected)
Common fibular (peroneal) nerve
For exposure, an incision is performed longitudinally 1 cm
lateral to the anterior surface of the tibia. After dissection
of the fascia cruris, blunt dissection is performed between
the tibialis anterior muscle medially and the extensor hal
lucis longus and extensor digitorum longus (from medial
to lateral) tendons laterally.
ANATOMY OF THE FOOT
NERVES
The deep and superficial peroneal nerves and the sural
nerve provide sensory innervation for the dorsal surface
128
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 13.11 Anatomy of the tibial nerve and its branches. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Tibial nerve
(L4, 5, S1, 2, 3)
Medial sural
cutaneous nerve (cut)
Articular branches
Plantaris muscle
Gastrocnemius
muscle (cut)
Nerve to popliteus muscle
Popliteus muscle
Interosseous nerve of leg
Soleus muscle (cut and
partly retracted)
Flexor digitorum
longus muscle
Tibialis posterior muscle
Flexor hallucis
longus muscle
Sural nerve (cut)
Lateral calcaneal branch
Medial
calcaneal branch
Flexor retinaculum (cut)
Lateral dorsal
cutaneous nerve
Common fibular (peroneal) nerve
Lateral sural cutaneous nerve (cut)
Cutaneous innervation of sole
Note: Articular branches not shown
Medial calcaneal
branches
(S1, 2)
Medial
plantar nerve
(L4, 5)
Lateral
plantar nerve
(S1, 2)
From
tibial nerve
Saphenous nerve
(L3, 4)
Sural nerve
(S1, 2) via
lateral calcaneal
and lateral dorsal
cutaneous
branches
Flexor
retinaculum
(cut)
Tibial
nerve
Medial
calcaneal
branch
Medial plantar
nerve
Flexor digitorum
brevis muscle
and nerve
Abductor hallucis
muscle and nerve
Flexor hallucis
brevis muscle
and nerve
1st lumbrical
muscle and
nerve
Common
plantar
digital
nerves
Proper
plantar
digital
nerves
Lateral calcaneal
branch of sural nerve
Lateral plantar
nerve
Quadratus plantae
muscle and nerve
Nerve to abductor
digiti minimi muscle
Abductor digiti
minimi muscle
Adductor hallucis
muscle
and
Deep branch
to interosseous
muscles,
2nd, 3rd, and 4th
lumbrical muscles
Flexor digiti minimi
brevis muscle
and
Superficial
branch to
4th interosseous
muscle
Proper plantar
digital nerves
Common and
Articular branch
of the foot (Fig. 13.15). The superficial peroneal nerve
pierces the fascia cruris in the distal third of the leg and
divides into the intermediate and medial branches, which,
through their terminal branches, give sensation to the first
three toes and the dorsomedial half of the 4th toe. Branches
of this nerve to the first web space are very thin and often
join the deep peroneal nerve. The deep peroneal nerve
becomes subcutaneous in the first intermetatarsal space and
is distributed mainly to the first web space. Plantarly, the
medial plantar nerve, a branch of the tibial nerve, provides
sensation through the proper plantar digital nerves to the
great, 2nd, 3rd, and medial half of the 4th toe. The lateral
plantar nerve supplies the lateral side of the 4th toe and
both sides of the 5th toe (see Figs 13.8, 13.9, 13.15, 13.19).
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
129
Lateral
Medial
Crural fascia
opened
Incision
A
B
C
D
E
F
Gastrocnemius medial
Gastrocnemius artery
(lateral/ medial)
Gastrocnemius lateral
Tibial nerve
Medial sural cutaneous
nerve
Popliteal
vein
Tibial nerve
Lesser saphenous
vein
Tibial nerve
Common peroneal nerve
Popliteal artery
Figure 13.12 (A–F) Surgical exposure (posterior) to the popliteal vessels at the knee.
Figure 13.13 (A–F) Surgical exposure of the posterior tibial artery.
Great saphenous vein
Tibial nerve
Great saphenous vein
m. flexor digitorum
longus tendon
Posterior tibial artery
Approach between superficial posterior
compartment (soleus/ gastrocnemius)
and deep posterior compartment
Medial malleolus
m. flexor digitorum longus
m. soleus
Tibial nerve
Posterior tibial artery
Fascia of deep posterior compartment
partially opened
Tibial nerve
Posterior tibial artery
m. tibialis posterior tendon
m. flexor hallcis
longus tendon
m. flexor digitorum longus
Crural fascia closed
A
B
C
D
E
F
E
130
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
ARTERIAL ANATOMY OF THE FOOT
THE DORSALIS PEDIS ARTERY
On the dorsum of the foot, the dorsalis pedis artery (see
Fig. 13.15) is the end branch of the anterior tibial artery. It
passes under the tendon of the extensor hallucis longus at
the extensor retinaculum then runs lateral to the tendon of
the extensor hallucis longus (Fig. 13.16). Not uncommonly,
vascular anomalies are present. The dorsalis pedis artery has
been shown to be absent in 6.7% or to arise from the pero
neal artery in 6.7% of patients.6 Coursing above the tarsus,
the dorsalis pedis is partially covered by the extensor hallucis
brevis before giving off a lateral branch, the arcuate artery.
From this artery the second, third, and fourth metatarsal
arteries take origin. When considering the harvest of isolated
or combined 3rd and 4th toes, the vascular dissection can be
based on these arteries up to the arcuate artery. The arcuate
artery is absent in 40% of cases. The dorsalis pedis artery
reaches the first intermetatarsal space and divides into two
terminal branches: the first dorsal metatarsal artery and the
deep plantar artery (or proximal perforating artery).
The first dorsal metatarsal artery (FDMA) runs forward,
towards the first web space. Regardless of its relation with
the interosseous muscles, its terminal course lies above the
deep transverse metatarsal ligament, after which it gives
origin to three terminal branches consisting of two dorsal
digital arteries, one for the lateral side of the great toe and
one for the medial side of the 2nd toe, and the anterior
communicating branch (or distal perforating artery) to the
first plantar metatarsal artery (FPMA).
The deep plantar artery represents the first communicat
ing branch between the dorsal and the plantar system. After
traversing the first intermetatarsal space the artery communi
cates with the deep plantar arch of the foot (see Fig. 13.17).
PLANTAR VASCULAR SYSTEM
The lateral plantar artery, which is the lateral division of the
posterior tibialis artery, constitutes the major part of the
deep plantar arch of the foot, which is completed medially
by the deep plantar artery coming from the dorsalis pedis
artery. The plantar arch crosses the foot from the base of
the fifth metatarsal to the first intermetatarsal space, giving
origin during its course to the second, third, and fourth
plantar metatarsal arteries, which are present in 97.7%,
100%, and 93.9% of cases, respectively. This must be taken
into account during the transfer of the 3rd, and 4th toes.
Each artery divides, at the corresponding web space distal
Figure 13.14 (A–F) Surgical exposure of the anterior tibial artery.
Patella
Crural fascia
Anterior tibial artery/vein
deep peroneal nerve
Tibialis anterior muscle
Lateral malleolus
Anterior tibial artery
Crural fascia
opened
Tibialis anterior muscle
A
B
C
D
E
F
Tuberositas tibiae
Great saphenous vein
Extensor hallucis longus
tendon medial to
dorsalis pedis artery
Anterior tibial artery
- midpoint between
both malleoli
Extensor digitorum longus
Extensor hallucis longus
E
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
131
to the metacarpophalangeal (MCP) joint, into two plantar
digital arteries, which supply the lateral and medial sides of
adjacent toes, and the anterior perforating artery, which
represents the distal communication to the dorsal system
(Fig. 13.16).
The first plantar metatarsal artery arises in most in
stances from the medial aspect of the plantar arch at
the base of the first metatarsal bone, but it may also take
origin from the dorsalis pedis or first dorsal metatarsal
artery.
From a clinical point of view, it is of crucial importance
to understand that the FDMA and FPMA meet distal to the
deep metatarsal ligament through the distal perforating
artery. This artery gives origin to two digital arteries (proper
plantar digital arteries), which run plantar to the midlateral
line of the toe and are responsible for the vascular supply
Figure 13.15 Anatomy of the dorsalis pedis artery. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Tibialis anterior tendon
Anterior tibial artery and
deep fibular (peroneal) nerve
Tibia
Extensor hallucis longus tendon
Tendinous sheath of
extensor digitorum longus
Medial malleolus
Tendinous sheath of
tibialis anterior
Tendinous sheath of
extensor hallucis longus
Anterior medial malleolar artery
Dorsalis pedis artery and medial branch
of deep fibular (peroneal) nerve
Medial tarsal artery
Arcuate artery
Deep plantar artery passing between
heads of 1st dorsal interosseous
muscle to join deep plantar arch
Extensor hallucis longus tendon
Extensor expansions
Dorsal digital branches of
deep fibular (peroneal) nerve
Dorsal digital branches
of superficial fibular
(peroneal) nerve
Superficial fibular (peroneal) nerve (cut)
Fibularis (peroneus) brevis muscle
Fibularis (peroneus) longus tendon
Extensor digitorum
longus muscle and tendon
Superior extensor retinaculum
Fibula
Perforating branch of
fibular (peroneal) artery
Lateral malleolus and anterior
lateral malleolar artery
Inferior extensor retinaculum
Lateral tarsal artery and lateral
branch of deep peroneal nerve
(to muscles of dorsum of foot)
Fibularis (peroneus) brevis tendon
Fibularis (peroneus) tertius tendon
Tuberosity of 5th metatarsal bone
Extensor digitorum brevis and
extensor hallucis brevis muscles
Extensor digitorum
longus tendons
Lateral dorsal cutaneous
nerve (continuation of
sural nerve) (cut)
Dorsal metatarsal arteries
Dorsal digital arteries
Dorsal branches of
proper plantar digital
arteries and nerves
132
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Figure 13.16 Anatomic structures passing posterior to the medial malleolus. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier
Inc. All Rights Reserved.)
Soleus muscle
Fibularis (peroneus)
longus muscle
Fibularis (peroneus)
brevis muscle
Calcaneal (Achilles) tendon
Common tendinous sheath
of fibularis (peroneus)
longus and brevis
Subcutaneous calcaneal bursa
(Subtendinous) bursa
of calcaneal tendon
Superior and
Inferior
fibular (peroneal)
retinacula
Calcaneus
Extensor digitorum brevis muscle
Abductor digiti minimi muscle
Lateral view
Extensor digitorum longus muscle
Superior extensor retinaculum
Tendinous sheath of tibialis anterior
Lateral malleolus and subcutaneous bursa
Inferior extensor retinaculum
Tendinous sheath of extensor digitorum
longus and fibularis (peroneal) tertius
Tendinous sheath of
extensor hallucis longus
Fibularis (peroneus) tertius tendon
Tuberosity of 5th metatarsal bone
Fibularis
(peroneus)
longus
tendon
Fibularis
(peroneus)
brevis
tendon
Medial view
Tibialis anterior tendon and sheath
Tibia
Calcaneal (Achilles)
tendon
Tendinous sheath of
flexor digitorum longus
Posterior tibial artery
and tibial nerve
Tendinous sheath of
flexor hallucis longus
Subcutaneous
calcaneal bursa
(Subtendinous) bursa
of calcaneal tendon
Flexor retinaculum
Calcaneus
Abductor hallucis muscle (cut)
Plantar aponeurosis (cut)
Flexor digitorum brevis muscle (cut)
Sheath of tibialis posterior tendon
Superior extensor retinaculum
Medial malleolus and subcutaneous bursa
Inferior extensor retinaculum
Tibialis posterior tendon and sheath
Tibialis anterior tendon and sheath
Tendinous sheath
of extensor hallucis longus
1st metatarsal bone
Tendinous sheath of flexor hallucis longus
Medial plantar nerve
Tendinous sheath of
flexor digitorum longus
Lateral plantar nerve
of the transfer. The dorsal digital arteries, which originate
from the FDMA, are of much smaller caliber and have no
clinical significance.
ANATOMIC VARIATIONS
The dorsalis pedis artery may be absent in 3–12% of cases,
but its absence does not preclude the execution of the
procedure. The most common and reported variations of
the FDMA are related especially to its position in regard to
the first interosseous muscle. In 50–80% of cases the FDMA
is bigger than its corresponding plantar artery and can lie
either superficial or deep in the context of the interosseous
muscle, coursing always above the deep transverse metatar
sal ligament. In 80% of cases, the dorsalis pedis gives rise to
the first dorsal metatarsal artery that supplies the free great
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
133
toe and 2nd toe flaps.7 When the FDMA is inadequate or
absent, the plantar system is selected as a dominant supply
for the transfer. In about 10% of cases, the dorsal and
plantar system have the same caliber and, because of its
easier approach, the toe flap is harvested based on the
dorsal system. Symmetry of the vascular pattern in both feet
has been described in about 79% of patients.
EXPOSURE OF THE ANTERIOR TIBIAL AND DORSALIS
PEDIS ARTERIES
A similar exposure to the anterior tibial artery is performed,
the anterior tibial artery will be found on the interosseus
membrane running with the deep peroneal nerve. The dor
salis pedis artery (Fig. 13.17) can be palpated on the dorsum
of the foot. It can be approached directly and will be found
lateral to the tendon of the extensor hallucis longus (Fig.
13.18).
CHOOSING AN INFLOW VESSEL
The selection of the recipient artery is an important deci
sion in the microsurgical reconstruction of the lower
extremity. The first consideration in the decision-making
process is the location of the defect. Which artery is ana
tomically available in this area, is patent, and lies outside
the zone of injury? In addition to a clinical exam, an angio
gram is recommended to confirm patency in patients
with vascular disease or in cases where previous trauma
or vascular reconstruction may have resulted in alteration
of normal anatomy. If there is more than one vessel is avail
able, the difficulty of surgical dissection, the defect location,
and patient positioning, determine which artery is selected.
For reconstruction of the thigh, the superficial femoral,
deep femoral, lateral, or medial circumflex arteries and
their branches are possible recipient vessels. All of these
vessels provide a sufficient diameter and any vessel that is
accessible can be used. The caliber of the lateral and medial
femoral circumflex vessels are typically suitable for end-to-
end anastomosis. End-to-side anastomosis is necessary when
the common, superficial, or deep femoral vessels are used
as inflow for both vessel size mismatch and to avoid down
stream ischemia. For reconstruction of the knee and proxi
mal lower leg, the superficial femoral and popliteal arteries
are available. As the popliteal artery can only be accessed
from a posterior or medial approach and the superficial
femoral artery from an anterior approach, the defect loca
tion and positioning of the patient determine which vessel
is used. The superficial femoral artery can be accessed deep
to the sartorius muscle until it passes through the adductor
hiatus. Prominent side branches (such as the descending
genicular artery) can provide acceptable size for end-to-end
microvascular anastomosis. In the popliteal fossa, the genic
ular and sural arteries can be used; these lie superficial to
the popliteal artery.
For reconstruction of the distal lower leg, ankle, and foot,
three arteries are available as recipient vessels. In order of
decreasing frequency of usage, these are the posterior tibial,
the anterior tibial, and the peroneal artery.
The posterior tibial artery is the most commonly used. It
is easily accessible by a medial approach and found between
the deep posterior compartment (containing the tibialis
posterior, flexor hallucis longus, and flexor digitorum
longus muscles) and the superficial posterior compartment
(containing the soleus and gastrocnemius muscles). For the
surgical approach to the posterior tibial artery, the favored
patient position is lateral, although supine is acceptable.
Figure 13.17 Arterial branches between the dorsalis pedis and posterior tibialis/medial plantar arteries.
Deep plantar
artery
Lateral plantar
artery
Medial plantar
artery
2nd to 4th proximal
perforating arteries
Distal perforating
branches
First dorsal
metatarsal artery
Deep plantar
arch
Posterior
tibialis artery
Dorsalis pedis
artery
134
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
long segment of vein graft, typically from the great saphe
nous vein (see below).
LOWER EXTREMITY VENOUS ANATOMY
Two venous systems can serve as recipient vessels in free flap
surgery: the deep and the superficial (Fig. 13.19). The deep
veins are the venae comitantes that parallel the axial arter
ies. The superficial veins run above the deep fascia in the
subcutaneous tissue. They drain into the deep venous system
via either perforating veins or the great or small saphenous
vein.
The deep system venae comitantes are typically used as
outflow for free flaps. However, the superficial system, which
runs in the subcutaneous tissue above the muscle fascia, can
also be used. These can also be used as easily accessible
sources of vein graft. The most prominent superficial veins
in the lower extremity are the great saphenous vein and the
small saphenous vein.
The posterior tibial vessels are used for free flaps of the heel,
sole or anterior-medial lower leg.
The anterior tibial artery is preferred for free flap cover
age of the dorsum of the foot, the lateral malleolus, or if
the patient is in the supine position. It is accessible in the
anterior compartment, running on the interosseus mem
brane between the tibialis anterior and extensor hallucis
longus. In the foot, the dorsalis pedis artery, as the continu
ation of the anterior tibial artery, is commonly used. To
leave the dorsalis pedis intact, the lateral tarsal or arcuate
arteries can be used.
The peroneal artery is usually the last choice, because
diameter and accessibility offer no advantage over either the
posterior or anterior tibial artery. The peroneal vessels can
be used as donor vessels for free flap reconstructions of the
lateral lower leg. However, this approach requires removal
of a portion of the fibula.
If an angiogram confirms that none of these vessels are
available in the lower leg, an arteriovenous loop can always
provide access to more proximal vessels. This requires a
Figure 13.18 (A–D) Surgical exposure of the dorsalis pedis artery.
Great saphenous vein
Superficial peroneal nerve
Great saphenous vein
Extensor hallucis longus
tendon medial to
dorsalis pedis artery
Anterior tibial artery
Extensor hallucis longus
Fascia intact
Dorsalis pedis artery
Superficial peroneal nerve
Deep peroneal nerve
A
B
C
D
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
135
overlying the femoral triangle via the fossa ovalis (an oval
opening in the medial femoral sheath) to enter the femoral
sheath. The great saphenous vein drains into the medial
aspect of the common femoral vein just inferior to the
common origin of the superficial circumflex iliac and super
ficial inferior epigastric veins (Fig. 13.19).
ANATOMY AND EXPOSURE OF THE SMALL
SAPHENOUS VEIN
The small saphenous vein can be identified at the lateral
malleolus or in the midline posterior calf. It passes inferior
and posterior to the lateral malleolus and crosses onto the
posterior aspect of the leg. The vein then crosses the lateral
ANATOMY AND EXPOSURE OF THE GREAT
SAPHENOUS VEIN
The great saphenous vein can be identified in the subcuta
neous tissues anterior to the medial malleolus. It runs supe
riorly in the subcutaneous tissues on the anterior-medial
surface of the lower leg. The great saphenous vein passes
posterior to the medial femoral condyle and runs superficial
to the muscle fascia overlying the medial gastrocnemius and
semitendinosus and semimembranosus (e.g., along the
medial border of the popliteal fossa). The great saphenous
vein then runs along the anterior-medial thigh superficial
to the femoral triangle. It passes through the facial layer
Figure 13.19 Anatomy of the great and small saphenous veins. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Inguinal lig.
(Poupart)
Superficial
circumflex iliac v.
Lateral cutaneous n.
of thigh
Saphenous opening
(fossa ovalis)
Anterior femoral
cutaneous nn.
of thigh (from
femoral n.)
Superficial epigastric v.
Femoral v.
Superficial external
pudendal v.
Great saphenous v.
Cutaneous branches
of obturator n.
Infrapatellar branch
of saphenous n.
Saphenous n. (terminal
branch of femoral n.)
Great saphenous v.
Branches of lateral
sural cutaneous
n. (from common
fibular [peroneal] n.)
Superficial fibular
(peroneal) n.
Small saphenous v. and
lateral dorsal cutaneous
n. (from sural n.)
Dorsal metatarsal vv.
Dorsal digital
nn. and vv.
Dorsal venous arch
Dorsal digital n. and v. of
medial side of great toe
Dorsal digital branch of
deep fibular (peroneal) n.
Medial cluneal
nn. (from dorsal
rami of S1, 2, 3)
Branches of posterior
cutaneous n. of thigh
Cutaneous branch
of obturator n.
Great saphenous v.
Small saphenous v.
Branches of saphenous n.
Medial calcaneal
branches of tibial n.
Plantar cutaneous branches
of medial plantar n.
Superior
cluneal nn.
(from dorsal
rami of L1, 2, 3)
Inferior cluneal nn.
(from posterior
cutaneous n. of thigh)
Branches of
lateral cutaneous
n. of thigh
Lateral sural cutaneous n.
(from common
fibular [peroneal] n.)
Plantar cutaneous branches
of lateral plantar n.
Medial sural cutaneous n.
(from tibial n.)
Sural n.
Lateral calcaneal
branches of sural n.
Anterior view
Posterior view
136
PART 2 — CLINICAL ANATOMY AND RECIPIENT VESSEL ANATOMY, SELECTION, AND EXPOSURE
Patients with lower extremity trauma can have lower
extremity deep venous thromboses. These may be known
preoperatively but can also be diagnosed by the recon
structive surgeon during recipient vein dissection.8
Same-extremity deep venous thrombosis is not a contrain
dication to free flap surgery, and high rates of free flap
survival have been reported.9 However, when same-extremity
deep venous thrombosis is known, use of the superficial
system or a dual outflow (anastomoses to both the superfi
cial and deep system) is preferable.
Patients with known venous stasis disease may have
particularly dilated and stiff-walled superficial veins. The
proximal edge of the cut vessel may show “spurting” blood,
indicative of high venous pressure. In this patient popula
tion, use of the deep system may be preferable.
ADDITIONAL CONSIDERATIONS FOR
RECIPIENT VESSEL SELECTION
Microsurgical reconstruction in the lower extremity carries
a high risk of vascular complications. This is usually due to
one of the following causes.
HIGH INCIDENCE OF POST-TRAUMATIC DEFECTS
Trauma causes hidden vascular damage, endothelial disrup
tion, or increased thrombogenicity in the subacute setting.
To minimize the risk of this problem, the recipient vessels
can be dissected outside the zone of injury, in order to
exclude hidden vascular damage. This zone is, however, dif
ficult to delineate. Godina’s seminal work on lower extrem
ity free flaps in 1986, showed that coverage within 72 h was
associated with lower flap loss rates (0.75% for flaps done
within 72 h vs 12% for flaps done at 72 h to 3 months).10
However, more recent papers have confirmed that lower
extremity reconstruction can safely be performed at later
time periods.11,12
VASCULAR PATHOLOGY WITH A TWO-
OR ONE-VESSEL LEG
Patients may have compromised blood supply secondary
to trauma or pre-existing medical comorbidities such as
peripheral arterial disease, prior radiation therapy, or dia
betes. When feasible for elective cases, vascular stenting or
bypass may be required prior to free flap surgery. In selected
cases, bypass and coverage can be performed simultane
ously, with the free flap being sewn directly to the bypass
graft.13 In cases where bypass is not feasible or not indicated,
end-to-side anastomosis allows preservation of the existing
distal blood supply. A flow-through type free flap requires
two separate anastomoses but similarly allows flap revascu
larization with preservation of distal blood flow. In cases
where distal targets are not available, an arteriovenous loop
from a more proximal source is an option.
VASCULAR SPASM
Injury severity, environmental factors (hypotension, hypo
thermia, hypovolemia), and poor surgical dissection have
all been cited as etiologies for arterial spasm. When it occurs,
border of the Achilles tendon to run in the midline subcu
taneous tissue superficial to the medial and lateral gastroc
nemius muscle bellies. The small saphenous vein pierces the
muscle fascia at the inferior apex of the popliteal fossa.
Alternatively, it occasionally perforates the fascia cruris in
the upper third of the leg to run subfascially toward the
popliteal fossa. It enters the popliteal vein on its lateral
surface at the superior apex of the popliteal fossa (Figs
13.12, 13.19).
ANATOMY AND EXPOSURE OF THE DORSAL
VENOUS ARCH
The dorsal venous arch arcs across the dorsum of the
midfoot superficial to the extensor tendons. The arch has
connections with both the great and small saphenous veins.
It can be approached directly.
The venous drainage of the foot consists of a dorsal and
a plantar system, each of which is provided with a superficial
and deep network. The superficial veins can be approached
directly. The deep veins run along the corresponding arter
ies and are found through the approach mentioned earlier.
When harvesting toe flaps, the superficial dorsal system is
used. At the web space, the superficial collateral veins
coming from the distal phalanx unit become bigger in
caliber and form the superficial intermetatarsal veins which
run longitudinally for about 5 cm and end at the midfoot
at the dorsal superficial venous arch. Medial and lateral to
the venous arch is the origin of the great and lesser saphe
nous veins. The former is the most commonly utilized in toe
transfer. The deep dorsal system is essentially represented
by the venae comitantes that run adjacent to the digital and
metatarsal arteries.
CHOOSING AN OUTFLOW VESSEL
Any superficial vein with adequate caliber can be used as a
recipient vein. However, the larger caliber great or small
saphenous veins are preferred over smaller side branches.
Distal mobilization and transposition into the operating
field are usually sufficient to use one of these two veins. The
great saphenous vein runs along the entire length of the
medial leg, while the small saphenous vein is available only
in the lower leg. Both the great and small saphenous veins
can be dissected over long distances and “turned up” into a
more proximal operative field in cases where local veins are
unavailable or unusable. This would allow the small saphe
nous vein to drain a free flap to the posterior thigh, and the
great saphenous vein to drain a free flap to the anterior
thigh (using the great saphenous vein from the calf) or a
free flap to the groin or abdomen (using the great saphe
nous vein from the thigh).
The deep venous system consists of venae comitantes of
the major arteries. They are commonly used as recipient
veins. The approach is performed by exposing the recipient
artery.
The surgical approach to recipient vessels should always
preserve the superficial veins in cases of “take-back” where
another venous system is needed. Where possible, anasto
mosis of two recipient veins for each artery is desirable.
Anastomoses are ideally made at least 1 cm away from
venous valves.
CHAPTER 13 — Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity
137
REFERENCES
1. Taylor G, Daniel R. The anatomy of several free flap donor sites.
Plast Reconstr Surg 1975;56(3):243–53.
2. Yu P. Characteristics of the anterolateral thigh flap in a Western
population and its application in head and neck reconstruction.
Head Neck 2004;26(9):759–69.
3. Yu P, Selber J. Perforator patterns of the anteromedial thigh flap.
Plast Reconstr Surg 2011;128(3):151e–157e.
4. Hallock GG. The vascular pedicle of the anterolateral thigh flap as
an alternative recipient site for thigh free flaps. J Reconstr Micro
surg 2008;24(2):131–6.
5. Gurunluoglu R. The ascending branch of the lateral circumflex
femoral vessels: review of the anatomy and its utilization as recipi
ent vessel for free-flap reconstruction of the hip region. J Reconstr
Microsurg 2010;26(6):359–66.
6. Yamada T, Gloviczki P, Bower TC, et al. Variations of the arterial
anatomy of the foot. Am J Surg 1993;166(2):130–5.
7. Gilbert A. Vascular anatomy of the first web space of the foot. In:
Landi A, editor. Reconstruction of the thumb. London: Chapman
and Hall Medical; 1989. p. 199.
8. Miyamoto S, Fujiki M, Sakuraba M. Preexisting deep venous throm
bosis in the peroneal vein of a free vascularized fibular graft. Plast
Reconstr Surg 2013;132(4):694e–6e.
9. Valerio I, Sabino J, Heckert R, et al. Known preoperative deep
venous thrombosis and/or pulmonary embolus: to flap or not to
flap the severely injured extremity? Plast Reconstr Surg 2013;
132(1):213–20.
10. Godina M. Early microsurgical reconstruction of complex trauma
of the extremities. Plast Reconstr Surg 1986;78(3):285–92.
11. Karanas YL, Nigriny J, Chang J. The timing of microsurgical recon
struction in lower extremity trauma. Microsurgery 2008;28(8):
632–4.
12. Fischer JP, Wink JD, Nelson JA, et al. A retrospective review of
outcomes and flap selection in free tissue transfers for complex
lower extremity reconstruction. J Reconstr Microsurg 2013;29(6):
407–16.
13. Moran SL, Illig KA, Green RM, et al. Free-tissue transfer in
patients with peripheral vascular disease: a 10-year experience.
Plast Reconstr Surg 2002;109(3):999–1006.
14. Gardiner MD, Nanchahal J. Strategies to ensure success of micro
vascular free tissue transfer. J Plast Reconstr Aesthet Surg 2010;
63(9):e665–73.
15. Hagau N, Longrois D. Anesthesia for free vascularized tissue trans
fer. Microsurgery 2009;29(2):161–7.
16. Eley KA, Young JD, Watt-Smith SR. Epinephrine, norepinephrine,
dobutamine, and dopexamine effects on free flap skin blood flow.
Plast Reconstr Surg 2012;130(3):564–70.
spasm can be relieved with topical lidocaine, intraluminal
heparin solution, and adventitial stripping.14 A Fogarty
maneuver can relieve spasm while dilating the recipient
artery. In the majority of cases, patience, time and the appli
cation of wet and warm sponges are the only treatment
required for spasm.
PATIENT POSITIONING
The defect location determines how the patient will be opti
mally positioned. Both flap choice and recipient arteries are
determined by how the patient is positioned. Anterior
defects favor the use of “anterior free flaps,” such as the
anterolateral thigh flap, gracilis flap, rectus flap, or radial
forearm flap. Lateral positioning favors “lateral free flaps”
such as the scapular flap, thoracodorsal artery perforator
flap, or latissimus dorsi flap.
ANESTHETIC CONSIDERATIONS
The lower extremity can be anesthetized using a spinal epi
dural block. In addition, a regional blockade helps mini
mize the risk of postoperative vasospasm. In selected cases,
when the patient is supine and the donor site is also in the
lower extremity, regional block is sufficient as a sole anes
thesia source. However, general anesthesia will be used in
the majority of cases.15 Vasopressors should be avoided as
they will constrict the recipient vessel. However, if vasopres
sors are required, norepinephrine is the vasopressor of
choice.16
CONCLUSION
A detailed understanding of lower extremity vascular
anatomy is an essential tool for the reconstructive microsur
geon. Choice of recipient vessel is guided by location of the
defect requiring coverage and the vascular status of the
affected extremity.
138
Head and Neck
Reconstruction
Michael Sosin | Mark Fisher | Eduardo D. Rodriguez
14
INTRODUCTION
The head and neck is a unique anatomic region of the
human body with specialized function. The sophisticated
arrangement of multiple tissue types comprises unique
physical traits from individual to individual. Regions of the
head, face, and neck are responsible for multiple high func
tioning mechanisms, including mastication, swallowing,
phonation, articulation, respiration, vision, periorbital pro
tective mechanisms, audition, and olfaction, all of which
have been characteristic in the evolutionary development
of man. Moreover, interpersonal communication and rec
ognition of social cues are all delivered and interpreted via
facial contour and movement. The subtleties of facial
anatomy contribute to individual identity, and although
phenotypic differences are recognized among ethnicity, sex,
and various individuals, there is an overarching commonal
ity of features that permeates a sense of normal. Understand
ing these relationships, patient expectations, and the limits
of reconstruction are certainly enhanced with surgeon expe
rience in the treatment of craniofacial injury and deformity.
However, a systematic approach to craniofacial reconstruc
tion that abides by several tenets is essential in optimizing
outcomes. Unlike other regions of the body, aesthetic
outcomes may be just as important as functional outcomes
in the head and neck due to the social implications of
deformity.
The deformities of the head or neck are often the result
of trauma, oncologic resection, infection, osteoradionecro
sis, and congenital or developmental pathology. Multiple
tissue types that compose the craniofacial region includ
ing bone, cartilage, nerve, fat, muscle, mucosa, and varying
dermal and epidermal thickness, as well the inherently
intricate contours of the craniofacial skeleton can compli
cate reconstruction. However, significant advances in micro
vascular and craniomaxillofacial surgery over the past 50
years have resulted in dramatically improved outcomes.1–15
The purpose of this chapter is to provide a methodologi
cal approach to microvascular reconstruction of the head
and neck while optimizing aesthetic and functional out
comes, as well as developing an effective means of achiev
ing reliable and replicable results. The workhorse flaps
used in reconstructing the various regions of the head
and neck are described with an emphasis on their applica
tion to the craniofacial segments, their advantages, and
disadvantages.
PREOPERATIVE CONSIDERATIONS
As with all reconstructive procedures, meticulous assess
ment of wounds and careful reconstructive planning are
essential to achieving successful outcomes. However, strict
adherence to several critical principles specific to the
demands of craniofacial surgery is paramount to addressing
complex injury or deformity of the head and neck. These
concepts are:
• Aesthetic subunit appearance
• Defect boundaries
• Tissue requirements
• Establishment of a skeletal buttress framework
• Generous soft tissue volume
• Early or immediate reconstruction
• Local revisions through multi-stage planning
Consideration of these principles is essential in attaining
a functional and aesthetic outcome that is predictable and
reproducible. A methodical structure to plan and perform
segmental or multi-segment craniomaxillofacial reconstruc
tion of composite defects provides consistency in surgical
approaches and optimizes flap selection. Furthermore,
these principles mark a paradigm shift in head and neck
reconstruction as they synthesize an amalgam of advance
ments from aesthetic surgery, craniofacial surgery, trauma
surgery, and radiation, wound, and scar biology.
CRITICAL CONCEPTS OF CRANIOFACIAL
MICROVASCULAR RECONSTRUCTION
AESTHETIC SUBUNIT APPEARANCE
It is well established that replacing “like with like” is the gold
standard of aesthetically pleasing reconstructions. However,
this is often difficult to achieve because the face can be
divided into discrete aesthetic subunits based on variations
in skin texture, color, thickness, and histology.16 Injury can
affect multiple subunits or portions of subunits that makes
flap selection more challenging. Understanding the lines of
demarcation between facial segments and appreciating the
variation in skin thickness throughout the face can aid the
surgeon in using skin grafts from areas with similar charac
teristics to the site being reconstructed. Pioneered by Mario
PART 3 — RECONSTRUCTION
CHAPTER 14 — Head a nd Nec k Reconstruction
139
wound edges of various defects are prone to infectious com
plications and if not maintained in a pristine environment,
the wound is prone to desiccation and breakdown. Expan
sion or rearrangement of wound borders allows for a
decreased microbial burden and a healthy wound edge
comprised of collagenous, elastic, and a well-vascularized
environment facilitating better wound healing. Second, the
dogmatic principles of aesthetic subunit reconstruction
dictate that certain defects can be made larger in order to
resurface the entire unit. This allows for incisions to be
hidden in skin creases and behind or within specific struc
tures. For defects that comprise >60% of an aesthetic
subunit, resection of the entire subunit may be indicated
since free flap reconstruction can reconstruct the expanded
defect and achieve superior cosmetic results. Flap homoge
neity throughout the entire subunit conforms to a more
uniform distribution of color, thickness, and texture while
disguising incisions at the junctions of subunits. This is
depicted in Figure 14.1, where a large forehead defect
prompts extension of the borders of resection, making the
forehead defect larger than initially encountered. Free
tissue transfer allows for scars to be hidden in the pretrichial
hairline and just superior to the eyebrows.34
The concept of extending the boundary of defects when
>60% deformity to an aesthetic subunit is present, is not
absolute. The inherent characteristics of the subunit at
hand must dictate the reconstructive effort because not all
aesthetic subunits are as easy to re-create as others with free
tissue transfer. For example, re-creation of the vermillion
lip is challenging, since no autologous free flap options exist
to re-create a satisfactory semblance of the subunit. In the
case of a partial vermillion lip defect, resection and replace
ment of the entire unit would not result in a superior
González-Ulloa,17,18 these concepts permeate throughout
multiple facets of plastic surgery but were lacking in early
microvascular surgery of the head and neck. Perhaps, these
principles were considered secondary because early micro
vascular flap failure rates were initially too high.19–22 Over
time, advancements in technique and instrumentation23–30
have precluded the surgeon from simply trying to recon
struct a defect by “filling a hole,” and have permitted resto
ration of entire aesthetic subunits, even when removing
healthy tissue may be required. This allows the surgeon to
achieve superior reconstruction with concomitant consider
ation of cosmetic results.
It is imperative to recognize that aesthetic facial subunits
are not just “skin deep.” Each facial region is comprised of
vertical and horizontal skeletal buttresses that provide criti
cal soft tissue support and shape.31 In addition, the subcu
taneous fat is partitioned into discrete compartments of the
face, a concept championed in cosmetic facial surgery.32
The perception of facial aesthetic subunit is actually depen
dent on multiple elements, representing an amalgam of
interactions between composite soft and hard tissue. There
fore, a “defect-oriented approach,” in which a soft tissue-
only flap is used to solve the immediate goal of wound
closure will often result in suboptimal cosmesis. Recon
structing a composite tissue defect of an aesthetic subunit
of the face with free tissue transfer requires the necessary
elements that are absent in a wound including the underly
ing skeletal support with the coverage of soft tissue.
DEFECT BOUNDARIES
Rearrangement of defect boundaries affords the surgeon
several benefits toward improving outcomes. First, the
Figure 14.1 (A) Wound covered with silver-coated dressing with preoperative markings showing extension of the wound boundary. (B) Iatro
genic extension of the wound boundaries allows for the incision line to be hidden in the hairline. (Reprinted from Fisher M, Dorafshar A, Bojovic
B, et al. The evolution of critical concepts in aesthetic craniofacial microsurgical reconstruction. Plast Reconstr Surg 2012;130:389–98. Wolters
Kluwer Health, 2012.)33
A
B
140
PART 3 — RECONSTRUCTION
both soft and hard tissue. The advent of prosthetic implants,
fixation plates, and non-vascularized bone grafts has bridged
the surgeon’s understanding of the crucial relationship of
bony stabilization and soft tissue re-draping. Options for
reconstructive approaches may seem vast at times, but a
means of providing an optimal relationship of hard and soft
tissue, similar to the premorbid state, should drive the
decision-making process.
Historically, non-vascularized bone grafts were the main
stay of bony reconstruction and still have a limited role in
treatment of small skeletal defects. The disadvantage of non-
vascularized bone grafts includes unpredictable resorption
rates and the inability to replace large structural defects.39
The unfortunate result of excessively using non-vascularized
bone grafts for inappropriately sized defects will necessitate
further reconstructions over time. Additionally, bone grafts
generally provide insufficient bone stock to allow placement
of osseointegrated implant prostheses. In certain cases, cra
niofacial bone defects can be reconstructed with an allo
plastic implant covered by a vascularized soft tissue flap.
However, successful incorporation of alloplastic material
requires wide debridement and clearance of marginal tissue
edges to minimized dehiscence and infection. Osteoradio
necrosis and prior chronic infections are not absolute con
traindications for using alloplastic material, but the surgeon
must be vigilant in ensuring the maximal removal of any
infectious burden to the defect. Alloplastic materials are
prone to late infection and tend to extrude over time,
leading to implant exposure. Undoubtedly, situations will
call for wider resection of the wound and acknowledging
that sacrificing tissue cannot be afforded to certain defects
may preclude the use of prosthetic materials for reconstruc
tion. As with non-vascularized bone grafts, the long-term
complications may require further surgical interventions
later down the line. Vascularized bone obviates many of the
unforeseen complications that are associated with non-
vascularized bone grafts and alloplastic materials, and there
fore should be used for hard tissue reconstruction whenever
possible. Adequate soft tissue and bone can often be incor
porated in the same free flap; however, multiple flaps may
sometimes be required to provide sufficient quantities of
both types of tissue.
SOFT TISSUE VOLUME
The soft tissue volume included in a free flap should be in
slight excess of the actual amount of tissue that is deficient.
If postoperative radiation therapy is anticipated, the excess
volume should be further increased, since significant soft
tissue contraction can result from radiation exposure.40 The
degree of soft tissue resorption and atrophy is unpredict
able. Including excess soft tissue affords the surgeon insur
ance of coverage in the event of excessive contracture or
atrophy. It is always easier to debulk excess soft tissue at a
later stage than to add volume secondarily.41 The inclusion
of ample volumes of well-vascularized fat in particular will
minimize subsequent fat necrosis and soft tissue resorption.
Healthy adipose tissue will also provide the necessary volume
for future revisionary reshaping procedures as the trans
ferred tissue settles. Options for debulking via direct exci
sion and/or liposuction in a revisionary procedure allow the
surgeon to focus on cosmesis after the initial healing period
aesthetic outcome. When considering resection of addi
tional local tissue the degree of resection may be dictated
by plans for future revisionary procedures. In order to
achieve total aesthetic subunit reconstruction, the option
for potentially advancing local cutaneous tissue with succes
sive revisionary procedures (or with tissue expansion) can
lead to complete excision of the initial free flap skin paddle
and reestablish the native skin of the original defect. This
concept is further discussed in the revisionary procedures
portion of this chapter.
TISSUE REQUIREMENTS
Adhering to the principles of replacing missing components
such as bone, soft tissue, or oral lining can guide the surgeon
in planning and executing the replacement of “like with
like” tissue to herald better results. The concept of consider
ing the tissue types and establishing their continuity or oblit
erating an apparent discontinuity is particularly important
when some form of “lining” tissue (e.g., conjunctiva, nasal
mucosa, sinus mucosa, or oral mucosa) is deficient. Failure
to provide an adequate lining can severely compromise
results after free flap reconstruction, leading to contracture,
fibrosis, and chronic infection. Meticulous preoperative
planning and anticipation for such defects, although not
initially obvious can help the surgeon to better predict
which tissue types are deficient. Furthermore, reconstruc
tions should be predicated on re-creation of the defect,
especially in cases of delayed reconstruction where scarring
and contracture may have obscured the initial defect,
making it more difficult to appreciate a lining deficiency.
The choice of free flap should not only include the ade
quate components required for skin coverage, soft tissue
bulk, and skeletal support, but also a surplus of skin, fascia,
or muscle that can be used to provide lining. This approach
ensures that all lining deficiency is addressed. The impor
tance of restoring tissue types and their subsequent continu
ity was stressed in the early years of plastic surgery by Gillies
and Keegan, but despite the importance stressed on such
structures by the pioneers of plastic surgery, the need for
lining reconstruction is still often underestimated by con
temporary microvascular surgeons.35,36
BONE AND SOFT TISSUE SUPPORT
It is imperative that the microsurgeon address the need for
hard tissue reconstruction in free tissue transfer. When
facing a large composite facial defect in which both bone
and soft tissue are missing, selecting a flap consisting of
abundant soft tissue rather than both bone and soft tissue
is not recommended. This approach succeeds in “filling the
hole,” but falls short of the fundamental reconstructive goal
of replacing “like with like.”37 The importance of skeletal
structure as a means of providing structural support and
aesthetic guidance anchoring soft tissue has been well
described by Rodriguez and colleagues by preserving
craniofacial skeletal buttresses.38,33 Emphasis on skeletal
reconstruction has largely been championed by craniofacial
surgeons, but restoration of the deficient soft tissues may be
overlooked when skeletal reconstruction is overemphasized.
With the synthesis of microsurgery and craniofacial surgery,
surgeons now recognize the importance of reconstructing
CHAPTER 14 — Head a nd Nec k Reconstruction
141
of complexity, although feasible, successful outcomes may
vary in each individual surgeon’s hands.
SECONDARY REVISIONS
Secondary revisions must not be considered failure of the
initial surgery, but instead be incorporated in the overall
reconstructive approach as a method of optimizing out
comes. There is often an impetus to minimize the number
of reconstructive procedures a patient requires. As a result,
microsurgeons attempt single-stage procedures aimed at
definitive reconstruction. However, this approach will gen
erally compromise long-term outcomes due to skin color
mismatch and soft tissue contracture. Ambitious single-stage
procedures do not capture all of the tools in the plastic
surgeon’s armamentarium in solving large craniofacial
defects. With the understanding that secondary revisions
are often inevitable in optimizing complex defects, the
initial reconstructive procedure no longer assumes the
burden of complete reconstruction but is the first of mul
tiple approaches.
Secondary revisions are fundamental for achieving suc
cessful reconstruction of the facial aesthetic units since
injury is likely to cross multiple subunits and resultant scar,
contracture, and contour and color mismatch are much
more pronounced to the lay observer. The aforementioned
concept of aesthetic subunits and establishing homogeneity
of skin characteristics is reiterated as the eventual need for
revisionary procedures should be anticipated at the time of
the initial free tissue transfer. In accordance with the concept
of defect boundaries, if a defect comprises <60% of the unit,
maximal preservation of local surrounding tissue is required,
as it may be successively recruited with local tissue rear
rangement during secondary procedures. If the previously
mentioned concept of soft tissue is employed, the initial free
flap should include excess soft tissue, which can later be
debulked, shaped, and ultimately covered by local cutane
ous advancement. For example, consider a cheek defect
comprising 40% of the aesthetic unit being reconstructed
with a free ALT flap. Excision of the entire unit during the
first reconstruction is not ideal because this leaves an obvious
area of color-mismatched and hair-bearing skin, demarcat
ing a stark contrast of the cheek aesthetic unit. Recruiting
distant tissue transfer serves as a base for local tissue advance
ment and resurfaced to provide a more favorable cutaneous
texture and color match. The foresight of future revisions
allows initial free tissue transfer to be planned and executed
with more success. In this case, the free flap can be selec
tively de-epithelialized and the remaining dermis can serve
as a substantial anchor from which to re-suspend advanced
local skin.
Other secondary procedures may include dermabrasion,
soft tissue re-suspension, excision of soft tissue, suction
lipectomy, and fat grafting. At this juncture, skin excision
from the free flap with full-thickness skin grafting from a
donor site similar in color and texture to the facial subunit,
remains an option.
The goal of craniofacial microsurgery is to reestablish
a necessary structural foundation with hard and soft
tissue, and the goal of subsequent revision surgery is
to refine contour and volume while modifying the “un
like” flap skin with “like” local skin. Integration of the
and after flap survival is assured. In contrast to adipose
tissue, denervated muscle flaps tend to atrophy significantly
over time, compromising long-term aesthetic outcome and
failing to provide durable coverage for alloplastic implants.42
For example, latissimus dorsi muscle flaps have been con
sidered the workhorse flap and traditional choice for scalp
coverage of titanium mesh cranioplasties,43 but such flaps
have shown to thin significantly over time, often resulting
in tenuous coverage or ultimate exposure of the underlying
mesh.
Selection of the donor site for free soft tissue transfer
must be guided in a patient-centered, individualized basis.
Patient-specific needs must be considered in the risk–benefit
analysis of selecting a flap, especially in the elderly, with
respect to donor site morbidity,42 those with physical dis
abilities,44 and in the actively growing young person. A color
match and the compatibility between donor site soft tissue
volume and recipient site soft tissue deficit then becomes
the priority. For instance, the variability in subcutaneous fat
among patients is apparent when considering an anterolat
eral thigh (ALT) flap. Although some advocate aggressive
thinning of the ALT flap at the primary stage,45 this practice
is not recommended for craniofacial reconstruction. It is
preferable to err on the side of caution with a thicker flap,
which can be debulked secondarily.46
TIMING
In the face of trauma or oncologic resection, the microsur
geon must not prolong the time to reconstruction. Recon
structing the injury acutely minimizes the cascade of scar
formation associated with the initial injury and confines
the deleterious effects to a single period of postoperative
wound contracture.47–53 The advantages of initiating early
free tissue transfer to avoid these effects are two-fold. First,
dissection of the recipient site and its vessels is simplified
when not operating in a scarred bed. Second, the functional
and cosmetic results of the reconstruction are improved by
reducing the overall scar burden of the soft tissues in that
area.
In the approach to congenital deformity reconstruction,
the timing for intervention differs since there is no scarring
associated with creation of the initial defect. In these
instances, delaying surgery to an extent may be more appro
priate for the patient. Determining time to intervention is
on an individualized basis because of multiple factors and
comorbidity issues to contemplate. Ongoing child develop
ment and whether he or she will ultimately “outgrow” their
free flap reconstruction is difficult to predict, which signifi
cantly contributes to the decision-making process of timing
reconstruction. Additionally, the distribution of body surface
area differs in the pediatric patient, as the head compro
mises a greater percentage of the total surface area. Ensur
ing ample tissue may be a challenge in the pediatric patient,
especially when considering free tissue transfer to the pedi
atric craniofacial region. For example, a latissimus dorsi flap
can easily cover a large adult scalp defect, but it may not
provide sufficient size for coverage in the pediatric patient.
A final concern that may affect timing of reconstruction
is the practical consideration of vascular pedicle size. The
microsurgeon must understand one’s limitation when
dealing with smaller-caliber vessel anastomoses. At this level
142
PART 3 — RECONSTRUCTION
Certain principles can be broadly applied to forehead
reconstruction to obtain a successful result:
• Brow symmetry must be maintained.
• Hairline symmetry (frontal and temporal) must be
maintained.
• Scars should be concealed within relaxed skin tension
lines, borders of aesthetic subunits, or within the hairline.
• Motor and sensory innervation should be preserved.
Commonly, full-thickness forehead defects will involve
the frontal muscle. This can cause significant eyebrow ptosis
with subsequent asymmetry and may require botulism toxin
injection or secondary revisions. Beyond the forehead lies
the scalp, which poses unique challenges.
Scalp reconstruction often involves a hair-bearing region
that is unique to patient identity. Hair is both a crutch and
a challenge. Contour deformities and scars can be well
hidden, but replacing non-glabrous with glabrous skin
requires that hair restoration be included in the reconstruc
tive plan.
Free tissue reconstruction of the scalp and forehead is
generally reserved for large, full-thickness defects. Current
recommendations suggest free flap coverage is indicated for
forehead defects >50 cm2. Due to the skeletal architecture
of this area, as well as the potential need for large skin
paddles, the most common flaps in our experience are the
fibula flap (when bone is needed); anterolateral thigh
flap (when bulk and surface area are needed); and the
ulnar flap (when there is a minimal requirement for hair
and the wound bed will be spared from radiation treat
ment). The superficial temporal artery is commonly used
for anastomosis due to its predictable location, ease of
access, and adequate diameter and length, but other vessels
can be used.
PERIORBIT
The periorbital region is composed of the superior, lateral,
and inferior orbit and anteromedial portion of the tem
poral region. It is known to be the first part of the face
that a stranger sees. The periorbital region supports for
the orbit and extraocular function. Both are important
in establishing a reconstructive goal. Blink depends on
functional orbicularis oris and palpebral levator muscles.
In addition, blink can be disrupted by ectropion, entro
pion, exophthalmos, enophthalmos, and eyelid ptosis or
retraction. Any of these may be present as a result of the
original defect or may occur during reconstruction. Their
prevention and repair is a major functional goal in perior
bital reconstruction.
Aesthetic outcomes are largely dependent on the
underlying skeletal structure of the region. Similarly,
attachments of the medial and lateral canthi must be pre
cisely re-created to achieve a symmetric and aesthetic
result.
Defects of the orbital rim and skeletal buttresses
are best reconstructed with vascularized bone. The fibula
free flap is an excellent choice with adequate length
and thickness. Although soft tissue alone may be used to
camouflage small skeletal defects, the lack of bony attach
ment for surrounding soft tissue increases the risk of
aforementioned concepts is crucial in replacing missing tis
sue, maximizing craniofacial function, and optimizing aes
thetic results.
INDICATIONS
The application of microsurgery to craniofacial surgery has
been successfully established, largely due to the synthesis of
multiple disciplines and their respective collaborations in
the treatment of complex disease processes. The indications
for microvascular intervention in head and neck surgery are
constantly evolving and must not be restricted to a certain
measurement of defect, anatomic location, or disease
process. Although the reconstructive ladder is dogmatic
to the practice of many plastic surgeons, free tissue trans
fer has long been established as a form of “jumping” the
“steps” of the ladder. Free tissue transfer to the head and
neck is most frequently incorporated following oncologic
resection, trauma, infection, osteoradionecrosis, or congen
ital deformity or malformation, or as a means of reconstruct
ing a failed prior flap. However, indications for free tissue
transfer to the craniofacial region must broadly be consid
ered from an anatomic, functional, and aesthetic perspec
tive, all while considering alternative options. Essentially,
fixed indications are difficult to define as anatomic, func
tional, and aesthetic components vary considerably and a
single component of the three can skew an evaluation to
necessitate microsurgical intervention, rather than using
other reconstructive methods.
To simplify the approach to numerous defects of the head
and neck, and to facilitate a comprehensive understanding
of workhorse flaps that have been developed, refined, and
proven to yield successful outcomes throughout the last
decade, surgical technique, advantages, disadvantages, pit
falls, and their application are reviewed below. These flaps
include the ulnar forearm flap; anterolateral thigh (ALT)
flap; latissimus dorsi flap; deep circumflex iliac artery
(DCIA) flap; and free fibula flap. Each flap is dynamic and
can be altered slightly to incorporate various characteristics
necessary for specific craniofacial defects. Their application
to a variety of anatomic locations, including the scalp, peri
orbital region, midface, and mandible, is now described
with corresponding cases and figures.
REGIONS OF THE HEAD AND NECK
SCALP AND FOREHEAD
The forehead is defined by the hairline superiorly and
by the eyebrows and frontonasal groove inferiorly. The
hairline varies with age, among genders, and ethnici
ties. The forehead can be further divided into aesthetic
subunits: central, paramedian, and lateral. The central
subunit is bordered by the medial eyebrows and extends
vertically from the glabella to the frontal hairline. The para
median subunit extends from the lateral border of the
central subunit to the lateral eyebrow, or slightly past the
convexity of the forehead. Finally, the lateral subunit spans
the area lateral to the paramedian subunit until the tempo
ral hairline.
CHAPTER 14 — Head a nd Nec k Reconstruction
143
NOSE
Nasal reconstruction dates back to approximately 3000bc,
and the nascent art of reconstructive surgery evolved from
the early work of Samhita, Branca, Carpue, and von Graefe
and their contributions to nasal reconstruction.54 Variations
in defect size and aesthetic units will demand specific local
flaps (cheek flap), skin grafts, rotation flaps (forehead flap),
and potential use of cartilage and mucosal grafts. Coverage
of extensive nasal defects can be completed using a pros
thetic attachment or using autologous tissue to permanently
restore nasal form, nasal respiration, and vocal tone.
Although a combination of the aforementioned nasal
reconstructive techniques can be successfully used in com
posite tissue nose defects,54,55 the following text focuses on
microsurgical reconstruction of the nose.
Historically, replantation of composite nasal tissue defects
following traumatic amputation (often a dog bite or a form
punishment)54,56 have resulted in a high failure rate or led
to deforming contracture and nasal passage stenosis.
However, the 1990s heralded an era of promise using micro
surgical replantation yielding excellent results.57–60 The chal
lenge of nasal microsurgical replantation is two-fold.
• Veins may be difficult to identify within the amputated
nose.
• Once identified, vessel replantation may require supermi
crosurgery.
Selecting subcutaneous veins may be advantageous when
named veins are difficult to isolate within an amputated
segment,61 but Stillaert et al. showed success with arterial-
only anastomosis using adjunct leech therapy in two
patients.62 The success of replantation allowed microsurgi
cal free flaps for nasal reconstruction to gain momentum as
a viable option.
Currently, free flap options for nasal reconstruction are
ample, likely owing to a lack of one specific flap to distin
guish itself as the best option for reconstruction. Typically,
selected free flaps have contained the necessary compo
nents for reconstructing nasal mucosa, bone, cartilage, and
skin. Variations of an ear flap have been popularized63–68
including the helical rim,69 chondrocutaneous ear flap
(combined with osteocutaneous femur),70 and reversed
superficial temporal artery (STA) auricle flap.68 Tailoring
the ear flap to a specific aesthetic subunit is ideal,68,69,71,72 but
some defects may be too large, requiring a larger volume of
tissue such as the radial forearm flap;73,74 prelaminated
radial forearm flap;73,75 dorsalis pedis flap;76 composite rib;
serratus, latissimus, and skin island flap; and others.73 The
facial vessels are the most common recipient sites of anas
tomosis, and the absence of the facial vein may necessitate
a vein graft. Conscientiously reconstructing the nasal mucosa
is critical in avoiding stenosis, and the liberal use of skin
grafts or flap folding is recommended in achieving ade
quate nasal lining.
MANDIBLE
The mandible is one of the few instances where free-
tissue transfer has become the standard of care in recon
struction of large defects. The need for dental rehabilitation
the aforementioned complications. In addition, bone (pref
erably vascularized) is necessary for bone-anchored pros
thetic rehabilitation either immediately or in a delayed
fashion.
Soft-tissue requirements differ throughout the periorbital
areas and should be matched by thickness, texture, and
color. Guided by the critical concepts described above, soft
tissue reconstruction should include excess soft tissue with
the expectation that volume loss will occur. Volume loss
will be even greater if the patient undergoes radiation
therapy and must be anticipated. Vascularized fat can be
used to provide soft tissue bulk and minimize atrophy.
When thin soft tissue is needed with a long pedicle, the
ulnar forearm flap is a good choice, with the additional
benefit of a favorable donor site and hairless skin. Alter
natively, if bulk and a short pedicle are needed, the groin
flap may be used. Alternatively, the anterolateral thigh flap
may be used if large amount of skin and soft tissue
is required.
MIDFACE
The goals of midface reconstruction are to preserve
projection of the midface and to restore the skeletal but
tresses. The skeletal buttresses are areas of thick bone that
function to transfer forces from mastication to the cranial
base. They also absorb any impact to the facial skeleton and
protect surrounding fragile structures. There are three
paired vertical buttresses: nasomaxillary, zygomaticomaxil
lary, and pterygomaxillary. Additionally, there is a midline
frontoethmoid-vomerine buttress. The function of these
vertical buttresses is mainly the transmission of mastication
forces to the skull base. The weaker, horizontal buttresses
are comprised of the superior and inferior orbital rims and
the alveolar ridge. The vertical buttresses, inferior orbital
rim, and alveolar ridge fall within the scope of midface
reconstruction. Their repair is critical to midface recon
struction. Vascularized bone is the preferred choice when
defects of the midface require free tissue transfer (such as
a free fibula flap).
In the midface, is it critical to assess which tissue types are
missing and to reconstruct them accordingly. Lining is often
a missed element of reconstruction, which if not restored
can lead fistula formation or contracture. Although the
midface is an area that tends to be reconstructed with
soft tissue free flaps, bone is necessary to restore the skeletal
buttresses and maintain projection of the midface. When
bone is required, both the fibula and iliac crest flaps (DCIA
flap) are good choices depending on the shape of bone
and length of pedicle required. Soft tissue–only flaps may
be used for small defects, for which the rectus femoris
and ALT can both be used depending on the amount of
skin required.
Although multiple classification systems for midface
defects exist, their attempts to define the best free flap
choice for reconstruction have not been universally
accepted. Ultimately, the specific defect and its components
must guide reconstruction. The application of the previ
ously described seven head and neck concepts will dictate
which elements must be reconstructed as the best flap
choice, since optimal reconstruction is not restricted to one
type of flap.
144
PART 3 — RECONSTRUCTION
Glossectomy has a larger impact on quality of life than
other resections of head and neck structures.79,100 Contem
porary reconstructions attempt sophisticated free flap tech
niques to preserve motor or sensory innervation to the
tongue to maximize function and in turn improve health-
related quality of life.83 Examples of such flaps include the
radial forearm flap and the ALT flap, which allow for nerve
coaptation of the lingual nerve for sensation and hypoglos
sal nerve to minimize atrophy and maximize function. The
use of functional muscle flaps for tongue reconstruction
boasts increased speech intelligibility, better palatal occlu
sion, and improvement in deglutition.80,101 Despite optimal
flap selection, the function and mobility of the tongue are
dependent on re-creating the form of the tongue. This can
be accomplished by re-creating the glossoalveolar and buc
coalveolar sulcii, with the option of laryngeal suspension
and esophageal widening depending on anatomic flap
inset.80,81,83 In the event of a unilateral deficit, a unilateral
Z-plasty can tailor a neotip (from the intact tongue to cross
toward the flap site) to improve tongue tip function and
sensation.102
Postoperatively, all patients should be enrolled in
speech and swallowing rehabilitation with a skilled pro
fessional to optimize speech intelligibility, swallowing time,
and palatal-tongue articulation, and improve their overall
quality of life.103 Patients are at increased risk of devel
oping obstructive sleep apnea and should be considered
for assessment and treatment following recovery from
reconstruction.104
ESOPHAGUS
Esophageal reconstruction can be accomplished using mul
tiple tissue types as conduits. The most commonly used
replacement organ for the esophagus is the stomach, either
completely intact or tabularized, depending on the extent
of esophageal excision and gastric involvement.105 Other
tissue types such as pedicled muscle flaps, colon interposi
tion (based on the ascending branch of the left colic artery),
and pedicled jejunal flaps (often supercharged) have been
successfully employed. Reestablishing a conduit for appro
priate gastrointestinal continuity for transit of solid and
liquid food contents is the primary goal of reconstruction.
The rate of conduit stricture following gastric reconstruc
tion is approximately 14%, and colonic interposition grafts
are more likely to manifest redundancy and subsequent
recurrent luminal collapse in 15–30% of cases.105,106 Known
disadvantages of the stomach and colonic conduits include
insufficient length, tenuous blood supply following gastric
surgery, and aberrant colonic vascular anatomy, and grafts
are susceptibility to gastric reflux resulting in secondary
metaplastic changes. Patients may be better candidates for
initial reconstruction with microsurgical free tissue transfer
in the event of:
• Extensive oncological extirpation or other tissue damage
(lye ingestion) that involves excision of a lengthy esopha
geal segment
• Impaired use of other donor organs such as the
stomach
• The cervical esophagus (in the setting of laryngectomy or
glossectomy) is involved
as well as the high complication rate associated with long-
term use of hardware has made vascularized bone an ideal
choice for mandibular reconstruction. Defects >5 cm are
best reconstructed with free tissue, whereas smaller defects
may be reconstructed with bone grafts or hardware in
select cases. Vascularized bone, however, enables immediate
or delayed dental rehabilitation with osseointegrated dental
implants. The fibular free flap has become the workhorse
flap due to its shape and long pedicle. The iliac crest (DCIA
flap) is frequently another viable option, especially given its
similar angular structure to the ipsilateral mandible and the
ample bone height it provides for dental implants. Both the
FFF and DCIA contain the elements necessary to restore
oral mucosal defects, soft tissue, and bony deformities.
TONGUE
Tongue defects vary in size and location (tongue base, oral
tongue, or both). Small defects involve less than one-quarter
of tongue segment, which are amenable to secondary inten
tion healing, primary closure, skin grafts, or local flaps.
Prior to the adoption of clinical microsurgery, the tradi
tional tongue reconstruction following total or subtotal
glossectomy was pectoralis or trapezius pedicled flaps, pri
marily to achieve wound closure. With time, free tissue
transfer has become the gold standard in reconstructing
large or total tongue defects with multiple flaps including
the radial forearm flap;77–80 ALT flap;80 infrahyoid myofacial
flaps;81,82 latissimus dorsi;77,83–85 rectus abdominis muscle
flap;86–89 gracilis flap;90 medial gastrocnemius flap;91 pecto
ralis flap;77,78 parascapular flap;77,78 DCIA flap; and fibula
flap;92 all serve as suitable options depending on the details
and extent of the defect. The complexity of the tongue
includes its innervations and proprioceptive biofeedback,
and specialized movements make full functional recovery
extremely challenging. The purpose of repairing tongue
defects is to reestablish its function to propel a bolus of food
toward the pharynx, restore ability to vocalize intelligible
speech, prevent aspiration, and optimize aesthetic appear
ance of the oral cavity and face. Flaps with excess bulk and
length facilitate contact between the palate and tongue
owing to improved long-term outcomes in deglutition and
speech.92–96 Large defects that involve >50% of resection,
harvesting 20–30% of excess muscle to accommodate for
atrophy, de-epithelialization, and folding a flap will preserve
tongue height and length. Also, harvesting fascia or chime
ric flaps incorporating fascia or excess soft tissue can aid in
protecting adjacent defects from fistula formation or
excess.97 If composite defects accompany tongue resection,
the fibula flap and DCIA are ideal sites for obtaining bone,
muscle, and skin.
When smaller defects are encountered, preservation of
remaining tongue tissue is of paramount importance to
restoring optimal mobility of the tongue and subsequent
free flap. The boundaries of the defect will often spare
adjacent structures and preserved tissue of the tongue will
retain partial function, at which point a thin and smaller
flap is optimal because it is less likely to impede an already
functioning tongue.81,98 The principles of constructing the
neotongue are to accurately reapproximate the biomechan
ics of the original tongue as this will lead to better cortical
adaptation.99
CHAPTER 14 — Head a nd Nec k Reconstruction
145
Figure 14.2 Free jejunal flap for voice reconstruction in the setting
of concomitant esophageal reconstruction.34
In the setting of simultaneous esophageal and voice
reconstruction, the restoration of voice using autologous
free tissue transfer is based on the re-creation of the TE tract
with mucosa from a neoesophagus. Free jejunum and ileo
colon flaps (Figs 14.2, 14.3) are able to restore voice with
excellent long-term patency while simultaneously serving as
conduits in esophageal reconstruction.121 Those patients
requiring only voice reconstruction have two microsurgical
options. The ileo-ileocecal valve flap (Fig. 14.4), which
incorporates a cecal anastomosis to the esophageal wall,
preserves the ileocecal valve, and requires an ileal anasto
mosis to the trachea. Another option is the appendix, which
can be used as the TE conduit for communication between
the esophagus and trachea. The extent of resection, involve
ment of esophageal resection, exposure to radiation, prog
nosis, prior abdominal surgeries, and previously failed voice
rehabilitation aid the microsurgeon in selecting optimal
patients and optimal approaches to reconstruction.
FREE FLAP CHOICES FOR CRANIOFACIAL
RECONSTRUCTION
ULNAR FOREARM FLAP
The radial forearm flap has become a workhorse flap for
head and neck reconstruction given its ease of harvest, long
vascular pedicle, and thin, supple skin paddle. The ulnar
forearm flap (Fig. 14.5) shares similar traits and offers
Furthermore, a subset of patients may require a second
reconstruction due to complications of the initial recon
struction requiring microsurgical free tissue transfer.
The most commonly used free flap employed in restoring
esophageal continuity is the jejunum.107,108 The jejunum can
be used as a total microsurgical free flap or a supercharged
pedicled jejunal flap, which was developed by Longmire in
1946,109 and is a modification of Carrel’s and Roux’s tech
niques developed in dogs circa 1906,110 and humans in
1907,111 respectively. The advantages of the jejunal free
flap include its durability, sufficient quantity, and limited
effect on physiologic effect of gastrointestinal function.
Furthermore, the diameter of the jejunum best approxi
mates the native esophagus, and peristaltic activity can be
preserved.112–115 The functional results of jejunal interposi
tion and safety profile demonstrate superior outcomes in
swallowing, hospitalization time, and mortality.107,116 The
span of the esophagus throughout the entire thorax explains
the variety of recipient vessels used for anastomoses includ
ing internal mammary vessels, superior thyroid artery, trans
verse cervical, external carotid artery, external jugular vein,
internal jugular vein, cephalic vein, or facial vessels. The
inset of the flap may require increasing the anterior medi
astinal space that can be accomplished with partial manu
brial excision, extending the diaphragmatic esophageal
hiatus, and tunneling a pliable, soft dilating catheter from
the stomach to the mediastinum. In pediatric esophageal
replacement, a meta-analysis found that stricture rates were
higher in jejunal free flaps compared with colonic and
gastric conduits.117 This may be due to small anatomy and
local ischemic effects or a discrepancy in the rate of ana
tomic growth in the growing infant/child, but to date, there
is a lack of consensus regarding optimal conduit selection
in all ages.118
VOICE
The larynx is the second most common site for cancer in
the upper aerodigestive tract and commonly requires total
laryngectomy, which involves separation of the aerodigestive
tract (tracheostoma) and closure of the pharynx or
reestablishing a conduit for swallowing. The direct result is
a profound alteration in speech or a complete impairment
of vocal function that is largely responsible for psychoso
cial and emotional patient anguish.119 There are multiple
methods of alaryngeal speech including electrolarynx,
esophageal speech, and tracheoesophageal (TE) speech,
which has become the gold standard in measuring success
of speech. Often this requires speech therapy with a spe
cially trained speech pathologist. However, novel modalities
of reconstruction have introduced several flaps that attempt
to augment the voice. These mechanics of speech mimic the
motion of air in TE speech, that is to protract tracheal air
passage toward a communication created with the esopha
gus. This iatrogenic fistula is subject to reflux of esophageal
content, secretions, and subject to aspiration and stricture.
The technique of puncture and valve placement can be
employed in the native esophagus or the neoesophagus.
Although prosthetic one-way valves are low-cost, easily
reproducible, and attempt to mitigate these risks, there are
several surgical methods of voice reconstruction that may
obviate their use.
146
PART 3 — RECONSTRUCTION
Figure 14.3 Ileocolonic flap for voice reconstruction in the setting
of concomitant esophageal reconstruction.120
Figure 14.4 Ileal-ileocecal valve for voice reconstruction.122
Figure 14.5 Illustration of a raised ulnar flap with anatomy depicted, and depicting a proximally based flap.122
Ulnar artery
Flexor digitorum
profundus
Flexor digitorum superficialis
Flexor carpi ulnaris
CHAPTER 14 — Head a nd Nec k Reconstruction
147
The basilic vein is traced using the Doppler probe as well.
The flap is designed with its central axis along the course
of the ulnar artery in the mid- and distal forearm.
The extremity is then elevated and exsanguinated, and
the upper arm tourniquet is applied. Dissection begins at
the distal aspect of the free flap. A skin incision is made and
dissection proceeds to between the flexor carpi ulnaris and
flexor digitorum superficialis tendons to identify the ulnar
artery and nerve. The artery is dissected from the nerve and
ligated distally. If the basilic vein can be identified, it is
ligated at this time. Raising the skin paddle begins in the
suprafascial plane, oriented from radial to ulnar direction
until the muscular septum, found between the flexor digi
torum superficialis and flexor carpi ulnaris is encountered.
Once the fascia is identified it is incised, and the ulnar
vessels are elevated with the skin flap to preserve septocuta
neous perforators. Dissection of the ulnar artery (and the
basilic vein) is continued proximally to achieve sufficient
pedicle length. Pedicle length is maximized if dissection is
carried to the common interosseous artery.
The donor site is best closed over a closed suction drain
due to the potential space created by the flap harvest.
Primary closure is possible, but skin grafting may be neces
sary. A full-thickness skin graft will yield superior cosmetic
results and provides durable coverage of exposed muscles
and tendons. However, a split-thickness skin graft may be
used.
APPLICATION, ADVANTAGES,
AND DISADVANTAGES
As with the radial forearm flap, the ulnar flap provides a
thin, pliable skin paddle with lengthy vascular pedicle of
relatively large caliber. The ulnar forearm flap surpasses the
radial flap both in cosmetic outcomes of the donor and
recipient sites. The ulnar forearm skin is usually less hirsute
than the radial skin, allowing the surgeon to circumvent
transfer of dense hair-bearing tissue to reconstruct a defect
in a non–hair-bearing region. The donor site is also better
concealed along the ulnar aspect of the forearm, especially
in repose as it sits along the body and out of sight during
face-to-face interaction. The donor site is also prone to supe
rior skin graft take because the ulnar region is subjected to
less tendon glide and mechanical shear forces as there are
more underlying muscle bellies rather than tendons in this
region.
Reluctance to utilize the ulnar forearm flap, out of
concern for compromising hand perfusion, still pervades
the microsurgical community. Additionally, the close rela
tionship of the ulnar artery and nerve has evoked concerns
about injury to the nerve during flap elevation. However,
multiple studies have failed to demonstrate any significant
long-term motor, sensory, or vascular impairments following
ulnar forearm flap harvest.123–125
The ulnar forearm flap can be utilized in small, soft tissue
midface defects, periorbital contracture or missing tissue
(Fig. 14.6), and forehead defects. However, the advantages
of the ulnar flap are its similar skin composition of facial
components and relative soft tissue paucity that can act as a
“double-edged sword,” in scenarios where more soft tissue
is necessary. The denervated flap may thin over time, which
is why an already minimal volume of soft tissue can thin and
may expose underlying hardware.42
additional benefits over the radial forearm flap (discussed
below). However, concerns about donor site morbidity have
prevented the ulnar forearm flap from achieving the popu
larity of its radial counterpart.
ANATOMY
Blood supply is based on the ulnar artery and its venae
comitantes, but the basilic vein can be utilized for venous
outflow. The arterial and venous pedicles are both approxi
mately 2.5 mm in diameter; however, the venous diameter
varies depending on whether the vena comitantes or basilic
vein is used for anastomosis. The arterial pedicle length can
be maximally harvested to the take off of the common inter
osseus artery (about 15 cm), and will consistently be shorter
than the arterial pedicle of the radial artery forearm flap,
which can be dissected to the bifurcation of the brachial
artery. The maximum skin paddle size measures approxi
mately 15 × 10 cm, similar to the area of the radial forearm
skin paddle. Preservation of the medial antebrachial cutane
ous nerve will yield a sensate flap, if it is desired for the
reconstruction. An osteocutaneous ulnar forearm flap
incorporating a portion of ulna bone is possible, but it is
not commonly used.
The forearm is supplied by the brachial artery, which
divides into the radial and ulnar arteries at the level of the
antecubital fossa. However, anatomic variations in the origin
of the ulnar artery do exist. Distally, the ulnar artery gives
off the anterior and posterior ulnar recurrent arteries, fol
lowed by the common interosseous artery. The ulnar artery
courses ulnar and deep to the pronator teres, flexor carpi
radialis, and flexor digitorum superficialis running along
the flexor digitorum profundus. It assumes an ulnar route
as it reaches the midpoint of the forearm. Traveling between
the flexor digitorum superficialis and flexor carpi ulnaris,
it then passes through Guyon’s canal at the wrist and divides
into superficial and deep palmar branches. The ulnar artery
runs adjacent to the ulnar nerve and often courses deep to
the nerve. The ulnar forearm flap drains via a deep or
superficial venous system. The deep system is comprised of
two venae comitantes accompanying the ulnar artery along
its course through the intermuscular septum and drain into
the median cubital vein at the level of the elbow. The super
ficial system consists of the basilic vein and its associated
branching veins. The basilic vein drains the dorsum of the
hand via the dorsal venous complex of the hand running
proximally along the dorsal ulnar aspect of the forearm.
The ulnar nerve is intimately associated with the ulnar
artery as it courses over the distal two-thirds of the forearm
and is found just ulnar and slightly superficial to the artery.
The medial antebrachial cutaneous nerve travels with the
basilic vein in the upper arm, exits the deep fascia above the
elbow, and divides into anterior and posterior branches.
The anterior branch follows the course of the basilic vein
distal to the elbow and innervates the medial half of the
anterior forearm.
SURGICAL TECHNIQUE
Preoperative markings begin with a line drawn from the
medial epicondyle of the humerus to the lateral edge of the
pisiform bone, estimating the course of the ulnar artery
in the forearm. Alternatively, a more accurate method of
tracing the ulnar artery is completed with a Doppler probe.
148
PART 3 — RECONSTRUCTION
APPLICATION, ADVANTAGES,
AND DISADVANTAGES
The ALT flap can be tailored to contain variable tissue com
ponents and skin paddle dimensions. The versatility and
potential size make the ALT flap suitable for reconstruction
of some of the most extensive soft tissue maxillofacial
defects. Furthermore, the pedicle length provides multiple
options in selecting recipient vessels in the head and neck.
The flap can also include a variety of soft tissue elements in
ANTEROLATERAL THIGH (ALT) FLAP
Although similar leg flaps were described prior to the ALT
flap,126 following its introduction in 1984,11 the ALT flap
gained widespread popularity due to the relatively large skin
paddle and the ability to selectively include fascia, muscle,
adipose, or skin.127–130 Over the past decade, the use of the
ALT flap has become increasingly prevalent and has estab
lished itself as the workhorse flap for head and neck
reconstruction.
Figure 14.6 (A) Defect after motor vehicle collision. (B) Outcome following two revision procedures. (C) Preoperative flap markings. (D) Post
operative results following an ulnar flap. (Reprinted from St-Hilaire H, Mithani SK, Taylor J, et al. Restoring the failed cranioplasty: nonanatomical
titanium mesh with perforator flap. Plast reconstr surg 2009;123:1813–17.)122
A
B
C
D
CHAPTER 14 — Head a nd Nec k Reconstruction
149
an ALT flap.34,133,134 The ease of customizing the ALT flap to
accommodate defects that require bone or prosthetic cover
age, dural protection, mucosal lining, or defects that will
require post surgical radiation have made the ALT flap a
dominant choice overshadowing the radial forearm flap.
GROIN FLAP
The groin flap was originally developed as a random pat
terned flap for reconstructing upper and lower extremity
defects. Traditionally, the flap was implemented in a delayed
fashion by initially covering the defect and later dividing the
pedicle. In the 1970s, recognition of an axial-based blood
the form of skin, adipose tissue, fascia, and muscle, which
can retain innervation by incorporation of the lateral
femoral cutaneous nerve. The main disadvantage to the
ALT flap is that it tends to be bulky, especially in an obese
patient population. This can be rectified by secondary revi
sionary procedures to achieve appropriate contour. The
musculocutaneous flap is also susceptible to atrophy of
which the severity is difficult to predict. Furthermore, the
skin paddle is also often hirsute, which may result in unde
sired hair growth at the recipient location.
Nevertheless, locations such as the scalp (Figs 14.7, 14.8),
forehead, midface, cheek, periorbital region (Fig. 14.9),
cranial base, and intraoral cavity can be reconstructed with
Figure 14.7 (A) A large temporoparietal contour deformity prompted microsurgical reconstruction. (B) The cranioplasty skin flap is reflected
anteriorly and the methylmethacrylate was replaced with titanium mesh. (C) An adipocutaneous ALT flap was used for soft tissue coverage.
(D) The 12-month postoperative result demonstrated improvement in scalp contour. (Reprinted from St-Hilaire H, Mithani SK, Taylor J, et al.
Restoring the failed cranioplasty: nonanatomical titanium mesh with perforator flap. Plast reconstr surg 2009;123:1813–17.)122
A
C
B
D
150
PART 3 — RECONSTRUCTION
concentration of hair follicles. The flap is also unique in
that the donor site can be easily concealed and is rarely
visible, even in a bathing suit. In addition, most of the dis
section is limited to the subcutaneous layer often preclud
ing extensive muscle dissection. The thickness of the flap is
adjustable to the depth of the defect. Lastly, the groin flap
can be elevated in combination with a bone, nerve, and
lymph nodes owing to a more functional free tissue trans
fer. The main disadvantages of the groin flap are its short
pedicle length, small vessel caliber, and variable vascular
anatomy. Due of this short vascular pedicle, the surgeon
should carefully plan the distance to recipient vessels when
utilizing the free groin flap. To obviate concerns of a
supply based on the superficial circumflex iliac vessels
allowed for free tissue transfer of the groin flap to be used
in lower extremity reconstruction.135 Shortly thereafter in
1977, microsurgical reconstruction of an intraoral defect
was successfully achieved with a free groin flap.136 Although
its popularity is limited, the groin flap offers the patient and
surgeon several benefits to head and neck reconstruction
that must be considered.
APPLICATION, ADVANTAGES,
AND DISADVANTAGES
The free groin flap can supply a large volume of supple
cutaneous tissue that tends to have a relatively lower
Figure 14.8 (A) Preoperative markings of the vascular pedicle, branches, with the total skin island are outlined. (B) The defect was recon
structed with an adipocutaneous anterolateral thigh flap. Additional adipose tissue is incorporated beyond the flap margin. (Reprinted from
Borsuk D, Christensen J, Dorafshar A, et al. Aesthetic microvascular periorbital subunit reconstruction: beyond primary repair. Past Reconstr Surg
2013;131:337–47.)120
A
B
Figure 14.9 (A) The anticipated boundary of resection. (B) The defect following exenteration. (C) The myocutaneous ALT with a vastus lateralis
flap before inset. (D) Result following reconstruction, radiation therapy, and revision procedures. (Reprinted from Muresan C, Dorafshar A, Rodri
guez, E. A reappraisal of the free groin flap in aesthetic craniofacial reconstruction. Ann Plast Surg 2012;68:175–9.)131
A
C
B
D
CHAPTER 14 — Head a nd Nec k Reconstruction
151
DEEP CIRCUMFLEX ILIAC ARTERY FLAP
The use of non-vascularized iliac bone grafts for mandibular
reconstruction has been well established, especially given
the structural similarity between the iliac crest and mandi
ble.138 However, for complex composite tissue defects the
use of vascularized bone (in the context of vascularized
composite tissue) is unmatched. The late 1970s ushered in
the early era of vascularized bone for reconstruction as
the vascular anatomy of the iliac bone was accurately
defined.139–141 The deep circumflex iliac artery (DCIA) is the
main vascular supply to the anterior ilium with its corre
sponding perforators supplying the overlying skin and inter
nal oblique muscle, as evidenced by perfusion studies.142
The application of the DCIA flap for craniofacial composite
tissue defects has revolutionized the management of disfig
uring and nonfunctional facial anatomy. Furthermore, the
narrow-caliber vessel, it is recommended to extend the
pedicle length all the way to the origin of the superior
circumflex iliac vessels, which should maximize pedicle
diameter.
Application of the groin flap is suitable for partial
tongue defects, auriculotemporal defects, unilateral defects
in the floor of the mouth, pharyngeal defects, periorbital
defects (Fig. 14.10), cheek defects (Fig. 14.11), and fore
head defects. Furthermore, identifying multiple perfora
tors has led to the design of multiple skin paddles
for addressing severe contractures of the mandibular soft
tissue aiding in restoration of the oral cavity lining.137
Although groin flaps have been incorporated with iliac
bone for mandibular reconstruction, the groin flap is not
the ideal flap choice for composite mandibular defects.
Other suitable flaps for mandibular reconstruction are dis
cussed below.
Figure 14.10 (A,B) Right facial deformity. (C) Markings outlining planned location of flap and pedicle for SCIA-based groin flap. (D) Intraopera
tive groin dissection depicting SCIA (blue arrow), femoral vessels (yellow arrow) and SIEA (green arrow). (E,F) The patient 13 months following
periorbital and cheek soft tissue reconstruction with a free groin flap. (Reprinted from Muresan C, Dorafshar A, Rodriguez, E. A reappraisal of the
free groin flap in aesthetic craniofacial reconstruction. Ann Plast Surg 2012;68:175–9.)131
A
D
E
F
B
C