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

CHAPTER 16 — Breast Reconstruction
199
formation, lymphedema, and delayed healing.48,49 Other
morbidities can include hematoma and sensory changes of
the anterior thigh. The diagonal upper gracilis flap may
reduce the incidence of lymphedema based on the orienta­
tion of the flap and avoidance of the lymphatic basins. The
PAP flap is the most recent of the thigh flaps and seems
to be associated with fewer adverse events. Seroma and
hematoma have been reported and fat necrosis can also
occur. Similar to the DUG flap, the location of the PAP flap
avoids the lymphatics and may reduce the incidence of
lymphedema.
OUTCOME ANALYSIS
Outcome analysis following autologous breast reconstruc­
tion has become an important determinant to measure the
success associated with these procedures.60,61 Factors such as
obesity, patient comorbidities, prior radiation, etc. have
been demonstrated to be relevant parameters to measure.
Obesity has been demonstrated to affect outcomes adversely
in virtually all studies performed. Donor site issues such a
delayed healing, seroma, and hematoma are more common
in patients with a BMI >30. Obese patients are more likely
to develop venous thromboembolic disorders, pulmonary
compromise, and medical complications in general. Flap-
related outcomes in obese patients includes an increased
take-back rate and higher flap failure.
Tobacco use and radiation therapy are also associated
with poor outcomes as it relates to the donor site and to the
flap. Skin and fat necrosis is more common in this cohort
of patients and donor site healing is associated with a higher
incidence of delayed healing, dehiscence, and infection.
Radiation effects include flap shrinkage, skin contracture,
increased infection, delayed healing, and need for revi­
sional surgery to a greater extent than the non-radiated
patient or flap.
Another outcome measure that is becoming relevant is the
cost associated with autologous reconstruction, especially as
it compares with prosthetic reconstruction. Studies have
demonstrated that reconstructive failure associated with
prosthetic reconstruction is five-fold higher than autologous
(7.3% vs 1.3%) when evaluated in the long term. Short-term
(<30 days) outcomes have demonstrated that autologous
reconstructions may result in more complications (12.5% vs
5.4%). Other benefits of autologous reconstruction include
fewer procedures, fewer postoperative visits, and a faster
time to completion of the final reconstruction.
CONCLUSIONS
As microvascular surgeons continue to expand upon the
armamentarium of autologous tissue options for breast
reconstruction, our outcomes will continue to improve. The
goal with reconstructive breast surgery is no longer to create
just a breast mound but to create a breast with natural
shape, volume, contour, and symmetry. Patient expectations
following mastectomy and reconstruction have increased
and we, as reconstructive plastic surgeons, should continue
to strive for excellence.
The relative incidence of these adverse events is directly
correlated to the amount of rectus abdominis muscle
removed and the laterality of the reconstruction with bilat­
eral procedures being associated with an increased inci­
dence. With the pedicle TRAM, the risk of a contour
abnormality ranges from 10% to 20% and abdominal weak­
ness is considered to be 40% following a unilateral and 70%
following bilateral total muscle harvest. With the free TRAM,
a contour abnormality occurs in 5–15% and weakness occurs
in 10–20% of patients. With the DIEP flap, a contour abnor­
mality occurs in 1–5% and weakness occurs in 2–10% of
patients. With the SIEA flap, contour abnormalities and
abdominal weakness do not occur.
Other adverse events include total free flap failure that
typically ranges from 1% to 4% based on the surgeon, the
type of flap, and the institutions at which they are
performed.57–59 The incidence of reoperation or take-back
ranges from 5–20% and is usually based on the flap. SIEA
flaps usually are associated with the highest take-back rate
15–20% and higher flap failure rates 3–4%. The incidence
of total failure of a pedicle TRAM is usually 1% or less. Fat
necrosis is typically observed in 1–10% of patients. Partial
flap necrosis can occur following pedicle of free flap recon­
struction with an incidence of 0–5%.
POSTERIOR THORAX
Complications following the latissimus dorsi flap are typi­
cally related to the donor site.36 Seroma formation is known
to occur in 20–30% of patients primarily because of shear
forces associated with arm and shoulder movement. Closed
suction drains are always placed and usually remain in
place for 2 weeks. Quilting sutures may also be effective
at minimizing seroma formation. Other donor site compli­
cations include bleeding and infection but are relatively
infrequent at 1–2%. Flap-related complications are also
infrequent because the blood supply to the flap is not inter­
rupted. Total failure is possible and most likely related to
anatomic anomalies such as prior surgery or radiation.
Complication rates in obese and non-obese patients have
been found to be similar following latissimus dorsi flap
breast reconstruction.
GLUTEAL FLAPS
Complications related to gluteal flaps are often related to
the short caliber and length of the vascular pedicle.40,41 Flap
failure rates with this flap are reported at 1–5%. The IGAP
flap typically has a longer vascular pedicle that may facilitate
the microvascular anastomosis and minimize operative take-
back and failure. Other adverse events include seroma for­
mation and contour abnormalities of the donor site. The
unilateral SGAP can cause scalloping of the upper buttock
and distortion of the gluteal crease. The IGAP can result in
wound healing issues and dehiscence because of the loca­
tion. In addition, the proximity of the IGAP flap to the
sciatic nerve may be associated with more pain.
POSTERIOR THIGH
Complications associated with the TUG flap are primarily
related to the donor site and include complex scar

200
PART 3 — RECONSTRUCTION
inferior epigastric artery perforator, and superior gluteal artery
perforator flaps early and long-term comparison of perfusion
changes in free flaps following breast reconstruction. Ann Plast
Surg 2005;55:117–21.
7. Rozen WM, Phillips TJ, Ashton MW, et al. Preoperative imaging of
DIEA perforator flaps: a comparative study of computed tomo­
graphic angiography and Doppler ultrasound. Plast Reconstr Surg
2008;121:1–8.
8. Masia J, Clavero JA, Larranaga JR, et al. Multidetector-row com­
puted tomography in the planning of abdominal perforator flaps.
J Plast Reconstr Aesthet Surg 2006;59:594–9.
9. Masia J, Kosutic D, et al. In search of the ideal method in perfora­
tor mapping: noncontrast magnetic resonance imaging. J Reconstr
Microsurg 2010;26(1):29–35.
10. Casey WJ, Chew RT, Rebecca AM, et al. Advantages of preopera­
tive computed tomography in deep inferior epigastric artery per­
forator flap breast reconstruction. Plast Reconstr Surg 2009;123:
1148–55.
REFERENCES
1. Nahabedian MY. Breast reconstruction: a review and rationale for
patient selection. Plast Reconstr Surg 2009;124:55–62.
2. Rozen WM, Garcia-Tutor E, Alonso-Burgos A, et al. The effect of
anterior abdominal wall scars on the vascular anatomy of the
abdominal wall: a cadaveric and clinical study with clinical implica­
tions. Clin Anat 2009;22:815–23.
3. Hamdi M, Wolfi J, Van Landuyt K. Partial mastectomy reconstruc­
tion. Clin Plast Surg 2007;34:51–62.
4. ASPS. ASPS procedural statistics. Online. Available: .plasticsurgery.org> [Accessed April 5, 2014].
5. Alonso-Burgos A, Garcia-Totor E, Bastarrika G, et al. Preoperative
planning of deep inferior epigastric artery perforator flap recon­
struction with multislice-CT angiography: imaging findings and
initial experience. J Plast Reconstr Aesthet Surg 2006;59:585–93.
6. Heitland AS, Markowicz M, Koellensperger E, et al. Duplex ultra­
sound imaging in free transverse rectus abdominis muscle, deep
Expert Commentaries 
David W. Chang, MD, FACS
This chapter on breast reconstruction by Dr Maurice Nahabe-
dian is a well-written, concise, and comprehensive overview of
autologous breast reconstruction by one of the world’s most
renowned breast reconstructive surgeon. The chapter starts
with the pertinent anatomy of the breast, including the concept
of the natural footprint of the breast, which is important to
consider when performing autologous breast reconstruction. I
agree with the author on the importance of proper patient
selection in order to obtain optimal outcome, including consid-
eration of patient’s body mass index, as well as selecting a
proper flap for each particular patient and the type of defect
the surgeon is trying to reconstruct. Recent introduction of
preoperative imaging techniques, such as computerized tomo-
graphic angiography (CTA) and magnetic resonance angiogra-
phy (MRA), is discussed. While I personally do not routinely use
preoperative imaging studies, these new technologies have
enabled detection of perforators with high accuracy and reli-
ability and have been beneficial for many surgeons for preop-
erative planning and facilitation of surgical operation. Commonly
used flaps including free TRAM, DIEP, and SIEA flap, as well
as more recently introduced flaps such as thoracodorsal artery
perforator (TDAP) flap, posterior thigh flap, profunda artery
perforator (PAP), and other less used flaps including superior
gluteal artery perforator (SGAP) flap, inferior gluteal artery per-
forator (IGAP) flap, and transverse upper gracilis (TUG) flap, and
diagonal upper gracilis (DUG) flap, are also discussed with
pertinent anatomy and useful pearls on how to successfully
perform these procedures. My personal preference is free DIEP
or MS-TRAM flap followed by SIEA flap. When the abdomen
is not available, my alternative option is SGAP flap. Other flaps
such as PAP, TUG flaps are limited by their size and often two
flaps need to be combined for total autologous breast recon-
struction. TDAP is best for reconstructing partial mastectomy
defects. The chapter concludes with listing of potential com-
plications with various types of flaps that the surgeons need to
educate patients about prior to considering these various
options for autologous breast reconstruction. This is a useful
overview of autologous breast reconstruction for trainees as
well as seasoned reconstructive plastic surgeons. It provides a
clear and concise overview but also provides useful pearls and
hints that can aid a reconstructive surgeon in performing safe
and successful autologous breast reconstruction.
Venkat V. Ramakrishnan, MS, FRACS
Autologous breast reconstructions have grown in popularity
due to their durability, aesthetic outcomes, increase in use of
radiotherapy, and potential aesthetic enhancement at the donor
site. Increasing patient expectations for a predictable aesthetic
outcome and limited need for further procedures are being met
by refinements in use of flaps.
In our center, the deep inferior epigastric perforator (DIEP)
flaps form 85% and transverse upper gracilis (TUG) and pro-
funda artery perforator (PAP) flaps 10% of the autologous
reconstructions. Lumbar artery perforator (LAP) flaps are a new
addition to our armamentarium, and promising as a good
volume donor site, with softer fat compared with gluteal artery
perforator (GAP) flaps. Pedicled autologous latissimus dorsi
and transverse rectus abdominis myocutaneous (TRAM) flaps
and GAP flaps are used rarely.
The role of CTA in perforator choice has become integral to
our planning. In a DIEP flap, this not only provides the location
of a good-caliber perforator, but its arborization characteristics,
intramural course, and potential communications with SIEV
(superficial inferior epigastric vein). In medial thigh flaps, the
location of profunda artery perforator, decides if a PAP flap with
a high thigh scar can be designed, or a TUG is chosen.
We often extend the role of the DIEP flaps, while limiting
donor problems and fat necrosis with bipedicled or stacked
flaps, additional SIEV drainage, and combination of flaps, such
as DIEP and TUG. In cases with limited abdominal adiposity,
we add an implant to the DIEP to limit recruitment of distal
zones, or settle for smaller than required flap, providing a vas-
cular matrix and achieving symmetry at a second stage with
lipofilling. Primary lipofilling of the pectoralis or the gracilis
muscle is helpful in TUG flaps, if there is a small volume deficit.
Over 90% of our reconstructions are immediate. The quality
of the breast skin, ptosis, and quality of the mastectomy flaps
are the most important factors determining the aesthetic
outcome. Bench shaping of the flaps and accurate mastectomy
pocket control have become important steps in our practice.
With predictable anastomotic outcomes, our focus has shifted
to aesthetics, time efficiency, limitation of fat necrosis, and
ensuring adjuvant therapies are not delayed.

CHAPTER 16 — Breast Reconstruction
201
34. Ducic I, Spear SL, Cuoco F, et al. Safety and risk factors for breast
reconstruction with pedicled transverse rectus abdominis musculo­
cutaneous flaps: a ten year analysis. Ann Plast Surg 2005;55:
559–64.
35. Branford OA, Keleman N, Hartmann CEA, et al. Subfascial harvest
of the extended latissimus dorsi myocutaneous flap in breast recon­
struction: a comparative analysis of two techniques. Plast Reconstr
Surg 2013;132:737.
36. De Olivera RR, do Nascimento SL, Derechain SFM, et al. Immedi­
ate breast reconstruction with a latissimus dorsi flap has no detri­
mental effects on shoulder motion or postsurgical complications
up to 1 year after surgery. Plast Reconstr Surg 2013;131:673e.
37. Heitmann C, Guerra A, Metzinger SW, et al. The thoracodorsal
artery perforator flap: anatomic basis and clinical applications.
Ann Plast Surg 2003;51:23–9.
38. Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforator
flaps in breast reconstruction: a new concept. Br J Plast Surg
2004;57:531–9.
39. Hamdi M, Salgarello M, Barone-Adesi L, et al. Use of the thora­
codorsal artery perforator (TDAP) flap with implant in breast
reconstruction. Ann Plast Surg 2008;61:143–6.
40. Ahmadzadeh R, Bergeron L, Tang M, et al. The superior and infe­
rior gluteal artery perforator flaps. Plast Reconstr Surg 2007;120:
1551–6.
41. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal
artery perforator flap for breast reconstruction. Plast Reconstr Surg
2006;118:333–9.
42. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction
with gluteal artery perforator flaps: a critical analysis of 142 flaps.
Ann Plast Surg 2004;52:118–24.
43. Granzow JW, Levine JL, Chiu ES, et al. Breast reconstruction with
gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg
2006;59:614–21.
44. Schoeller T, Huemer GM, Wechselberger G. The transverse mus­
culocutaneous gracilis flap for breast reconstruction: guidelines
for flap and patient selection. Plast Reconstr Surg 2008;122:
29–38.
45. Vega SJ, Sandeen SN, Bossert RP, et al. Gracilis myocutaneous free
flap in autologous breast reconstruction. Plast Reconstr Surg
2009;124:1400–9.
46. Fansa H, Schirmer S, Warnecke IC, et al. The transverse myocuta­
neous gracilis muscle flap: a fast and reliable method for breast
reconstruction. Plast Reconstr Surg 2008;122:1326–33.
47. Dayan E, Smith ML, Sultan M, et al. The diagonal upper gracilis
(DUG) flap: a safe and improved alternative to the TUG flap. Plast
Reconstr Surg 2013;132:4s–1, 33–34.
48. Allen RJ, Haddock NT, Ahn CY, et al. Breast reconstruction with
the profunda artery perforator flap. Plast Reconstr Surg 2012;129:
16e.
49. Haddock NT, Greaney P, Otterburn D, et al. Predicting perforator
location on preoperative imaging for the profunda artery perfora­
tor flap. Microsurgery 2012;32:507–11.
50. Nahabedian MY. Secondary operations of the anterior abdominal
wall following microvascular breast reconstruction with the TRAM
and DIEP flaps. Plast Reconstr Surg 2007;120:365–72.
51. Nahabedian MY, Dooley W, Singh N, et al. Contour abnormalities
of the abdomen following breast reconstruction with abdominal
flaps: the role of muscle preservation. Plast Reconstr Surg 2002;
109:91–101.
52. Nahabedian MY, Manson PN. Contour abnormalities of the
abdomen following TRAM flap breast reconstruction: a multifacto­
rial analysis. Plast Reconstr Surg 2002;109:81–7.
53. Nahabedian MY, Momen B. Lower abdominal bulge after DIEP flap
breast reconstruction. Ann Plast Surg 2005;54:124–9.
54. Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing
the functional impact of SIEA, DIEP, and muscle-sparing free
TRAM flaps on the abdominal wall: part I. Unilateral reconstruc­
tion. Plast Reconstr Surg 2010;126:1142–53.
55. Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing
the functional impact of SIEA, DIEP, and muscle-sparing free
TRAM flaps on the abdominal wall: part II. Bilateral reconstruc­
tion. Plast Reconstr Surg 2010;126:1438–53.
56. Wu LC, Bajaj A, Chang DW, et al. Comparison of donor-site mor­
bidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast
reconstruction. Plast Reconstr Surg 2008;122:702–9.
11. Greenspun D, Vasile J, Levine JL, et al. Anatomic imaging of
abdominal perforator flaps without ionizing radiation: seeing is
believing with magnetic resonance imaging angiography. J Recon­
str Microsurg 2010;26(1):37–44.
12. Chernyak V, Rozenblit AM, Greenspun DT, et al. Breast reconstruc­
tion with deep inferior epigastric artery perforator flap: 3.0-t gado­
linium enhanced MR imaging for preoperative localization of
abdominal wall perforators. Radiology 2009;250(2):414–24.
13. Vasile JV, Newman T, Rusch DG, et al. Anatomic imaging of gluteal
perforator flaps without ionizing radiation: seeing is believing with
magnetic resonance angiography. J Reconstr Microsurg 2010;26(1):
45–57.
14. Jones GE, Garcia CA, Murray J, et al. Fluorescent intraoperative
tissue angiography for the evaluation of the viability of pedicled
TRAM flaps. Plast Reconstr Surg 2009;124:53.
15. Newman MI, Samson MC. The application of laser-assisted indocya­
nine green fluorescent dye angiography in microsurgical breast
reconstruction. J Reconstr Microsurg 2009;25:21–6.
16. Pestana IA, Coan B, Erdmann D, et al. Early experience with fluo­
rescent angiography in free-tissue transfer reconstruction. Plast
Reconstr Surg 2009;123:1239–44.
17. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion
mapping with laser-assisted indocyanine green imaging can predict
and prevent complications in immediate breast reconstruction.
Plast Reconstr Surg 2010;125:1065–73.
18. Nahabedian MY, Momen B, Galdino G, et al. Breast reconstruction
with the free tram or DIEP flap: patient selection, choice of flap,
and outcome. Plast Reconstr Surg 2002;110:466–75.
19. Nahabedian MY, Momen B, Tsangaris T. Breast reconstruction with
the muscle sparing (MS-2) free TRAM and the DIEP flap: is there
a difference? Plast Reconstr Surg 2005;115:436–44.
20. Nelson JA, Guo Y, Sonad SS, et al. A comparison between DIEP and
muscle sparing free TRAM flaps in breast reconstruction: a single
surgeon’s recent experience. Plast Reconstr Surg 2010;126:1428.
21. Wong C, Saint-Cyr M, Mojallal A, et al. Perfasomes of the DIEP flap:
vascular anatomy and the lateral versus medial row perforators and
clinical implications. Plast Reconstr Surg 2010;125:772.
22. Rozen WM, Dip PG, Ashton MW, et al. Avoiding denervation of the
recuts abdominis in DIEP flap harvest: the importance of the
medial row perforators. Plast Reconstr Surg 2008;122:710.
23. Healy C, Allen RJ. The evolution of perforator flap breast recon­
struction: twenty years after the first DIEP flap. J Reconstr Micro­
surg 2014;30:121–6.
24. Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion
and blood flow in free transverse rectus abdominis myocutaneous
and deep inferior epigastric perforator flaps. Plast Reconstr Surg
2000;106:1295–9.
25. Blondeel PN, Van Landuyt KHI, Monstrey SJM, et al. The “Gent”
consensus on perforator flap terminology: preliminary definitions.
Plast Reconstr Surg 2003;112:1378–83.
26. Nahabedian MY. The internal mammary artery and vein as recipi­
ent vessels for microvascular breast reconstruction: are we burning
a future bridge? Ann Plast Surg 2004;53:311–16.
27. Lorenzetti F, Kuokkanen H, von Smitten K, et al. Intraoperative
evaluation of blood flow in the internal mammary or thoracodorsal
artery as a recipient vessel for a free TRAM flap. Ann Plast Surg
2001;46:590–3.
28. Lorenzetti F, Souminen S, Tukiaanen E, et al. Evaluation of blood
flow in free microvascular flaps. J Reconstr Microsurg 2001;17:
163–7.
29. Chevray PM. Breast reconstruction with superficial inferior epigas­
tric artery flaps: a prospective comparison with TRAM and DIEP
flaps. Plast Reconstr Surg 2004;114:1077–83.
30. Holm C, Mayr M, Hofter E, et al. The versatility of the SIEA flap:
a clinical assessment of the vascular territory of the superficial
epigastric inferior artery. J Plast Reconstr Aesthet Surg 2007;60:
946–51.
31. Spiegel AJ, Kahn FN. An intraoperative algorithm for use of the
SIEA flap for breast reconstruction. Plast Reconstr Surg 2007;120(6):
1450–9.
32. Zenn MR. Insetting of the superficial inferior epigastric artery flap
in breast reconstruction. Plast Reconstr Surg 2006;117:1407–11.
33. Janiga TA, Atisha DM, Lytle IF, et al. Ipsilateral pedicle TRAM flaps
for breast reconstruction: are they safe as contralateral techniques.
J Plast Reconstr Aesthet Surg 2010;63:322–6.

202
PART 3 — RECONSTRUCTION
57. Nahabedian MY, Momen B, Manson PN. Factors associated with
anastomotic failure following microvascular reconstruction of the
breast. Plast Reconstr Surg 2004;114:74–82.
58. Rao SS, Parikh PM, Goldstein JA, et al. Unilateral failures in bilat­
eral microvascular breast reconstruction. Plast Reconstr Surg 2010;
126(1):17–25.
59. Selber JC, Samra F, Bristol M, et al. A head-to-head comparison
between the muscle-sparing free TRAM and the SIEA flaps: is the
rate of flap loss worth the gain in abdominal wall function? Plast
Reconstr Surg 2008;122:348–55.
60. Fischer JP, Nelson JA, Cleveland E, et al. Breast reconstruction
modality outcome study: a comparison of expander/implants and
free flaps in select patients. Plast Reconstr Surg 2013;131(5):
928–34.
61. Mointin LM, Smetona JT, Hanwright PJ, et al. Comparing thirty-
day outcomes in prosthetic and autologous breast reconstruction:
a multivariate analysis of 13,082 patients. J Plast Reconstr Aesthet
Surg 2013;66(7):917–25.

203
INTRODUCTION
The structure of the chest and back serves multiple func­
tions that are important to be aware of and maintain during
reconstruction. The chest and back protect the vital heart,
lungs, great vessels, and spine, and provide a pressure envi­
ronment for inspiration and expiration. This structure also
serves as the foundation for upper limb movement and
support of the head and trunk.
Chest and back defects have various causes and each
scenario requires careful thought about the etiology and
possible effects of the reconstructive process. Defects may
be caused by tumor resection infection, specifically, sternal
wound infections, chronic empyema, and bronchopleural
fistulas, osteoradionecrosis, trauma, congenital, and exposed
hardware.
PREOPERATIVE CONSIDERATIONS
As with any surgical patient, the surgeon should complete
a full history and physical exam and identify any medical
comorbidities that need to be optimized prior to recon­
struction. Certain comorbidities, such as end-stage renal
disease and chronic obstructive pulmonary disease, have
been associated with increased mortality in patients under­
going chest reconstruction.1 With back reconstruction, it is
important to assess whether the patient is ambulatory. While
indicated in both the ambulatory and the non-ambulatory
patient, perforator flap reconstruction is preferred over
muscle flap reconstruction in the ambulatory patient.
It is also important to understand all previous operations,
as this can affect which flap options are available. If the
patient has had a previous thoracotomy or axillary irradia­
tion, the latissimus dorsi may be affected and would not
be an ideal reconstructive option. Previous laparotomies
may have compromised the rectus abdominis or omentum.
Prior internal mammary artery harvest does not preclude a
superior-based rectus abdominis flap, as there is collateral
flow through the musculophrenic and lower intercostal
vessels, however there may be a need to supercharge the
outflow and/or inflow.2 In previous spine surgery, the
posterior intercostal perforators may have been divided
and their presence should be confirmed with Doppler
prior to performing a paraspinous or latissimus dorsi flap
reconstruction.
When approaching the defect, one should consider what
needs to be addressed prior to definitive reconstruction.
Prior irradiation may have rendered tissue rigid and scarred
and led to further healing complications if not adequately
debrided. Similarly, infected wounds should be precisely
debrided prior to definite reconstruction. Any exposed
prostheses or hardware need to be assessed and it needs to
be determined whether the hardware must be removed or
if it remains a critical structure to work around and properly
cover. If hardware is well fixed and the infection is early, the
area should be scrupulously debrided and the hardware can
be salvaged. Spinal hardware infection that has been present
for longer than 6 months typically requires removal, due to
prolonged microbial contamination.3 In back wounds, any
dural tears need to be identified and treated appropriately
with the involvement of neurosurgery.
Imaging may be helpful, but is not essential. Chest and
spine X-rays can give information on hardware and general
lung condition. One should consider obtaining a CT scan
if spinal hardware is present and there is concern for infec­
tion or fluid collections. In these cases, fluid collections
deep to the muscle are usually an indication of deep hard­
ware infection.
INDICATIONS
There are six main objectives of reconstruction:
1. Debride devitalized and/or infected tissues
2. Obliterate dead space
3. Cover exposed prostheses, hardware, and vital structures
4. Cover large surface area defects
5. Buttress organ repairs
6. Structural support.
The aims of providing structural support are to maintain
shoulder function and eliminate any discomfort from
resected structures. Skeletal reconstruction of the ribcage is
indicated if more than four consecutive ribs are resected, or
there is >5 cm of lateral chest wall resected. Otherwise, the
patient may experience flail chest and severe respiratory
compromise. This number can be increased to five consecu­
tive ribs if the patient had previous radiation due to increased
fibrosis of the chest wall. There are many options for skeletal
reconstruction, including synthetic or biologic meshes, tita­
nium ribs, bone grafts or vascularized osseous flaps.4 With
sternal wounds, one should also consider sternal plating as
this may reduce postoperative pain.5 Contraindications to
sternal plating are osteoporosis, infection, extreme obesity,
or significant bone loss.6
Chest and Back
Reconstruction
Amanda K. Silva  |  David H. Song
17 
PART 3  —  RECONSTRUCTION

204
PART 3 — RECONSTRUCTION
Free flap reconstruction should be considered if:
1. Prior reconstructions, ablations, or radiation have ren­
dered regional options useless
2. Large surface area defects are not adequately covered
with regional options
3. No locoregional flap options are available based on
location:
• Lower cervical back (large defects)
• Lower lumbar/sacral midline (large defects)
• Posterolateral iliac crest.
RECONSTRUCTION BY REGION
ANTEROLATERAL CHEST
PECTORALIS MAJOR
Coverage:
Advancement flap – upper two-third sternum
Island – complete sternum
Clavicle
Axilla
Turnover flap – lower two-third sternum
ADVANCEMENT/ISLAND FLAP
Details of pectoralis flap anatomy and dissection can be
found in Chapter 34. Briefly, the pectoralis major is accessed
via the midline sternotomy wound and the muscle edge is
identified by dissecting the skin approximately 1 cm (Fig.
17.1A).7–11 Dissection then proceeds on the undersurface
of the muscle superior, to the clavicle, inferior, with eleva­
tion of the rectus abdominis fascia, and lateral, until there
is enough advancement to midline (Fig. 17.1B). This usually
extends to between the midclavicular and anterior axillary
line. The thoracoacromial pedicle is encountered on the
deep surface of the muscle at the junction of middle and
lateral third of the clavicle. If more advancement is needed,
the muscle can be released from the origin on the clavicle
and the insertion on the humerus. When the pectoralis
major is being used to reconstruct an area on the anterolat­
eral chest, a similar dissection is performed with rotation
into the defect. For axillary defects, an island flap can be
used.12
TURNOVER FLAP
The pectoralis major muscle is exposed to the lateral extent
needed for coverage. Next, the muscle and thoracoacromial
pedicle are split laterally. The anterior axillary line may be
Figure 17.1  Pectoralis major advancement and island flap. (A) Pectoralis major vascular supply showing pectoral branch of thoracoacromial
artery and internal mammary perforators (left). Elevation of medial pectoralis major muscle for advancement (right). (B) Medial advancement of
bilateral pectoralis major muscles. May detach humeral insertion for further advancement.
Pectoralis major
Internal mammary
artery
Pectoral branch
of thoraco-acromial
artery
Pectoralis major
Pectoral branch
of thoraco-acromial
artery
A
B

CHAPTER 17 — Chest and Back Reconstruction
205
Details of rectus abdominis flap anatomy and dissection
can be found in Chapter 37. Briefly, the rectus abdominis
muscle is dissected out via a midline abdominal incision.
The deep inferior epigastric vessels and the inferior ten­
donous insertion to pubic symphysis are divided. The
muscle is then passed either subcutaneously or transdia­
phragmatically to fill the defect. As mentioned previously,
this flap may still be used despite prior internal mammary
harvest, but dissection should only extend up to the costal
margin, which according to some reports, will only allow
coverage of the inferior wound.14 If skin is needed, a vertical
rectus abdominis myocutaneous flap can be performed
which includes an ellipse of skin overlying the muscle
(Fig. 17.3).
A fasciocutaneous flap, sparing the underlying rectus
abdominis, is an alternative.15 Perforating vessels at the
costal margin should be preserved. If a greater arc of rota­
tion is needed, a cuff of rectus abdominis, including the
preserved13 by splitting the muscle vertically at the lateral
border of pectoralis minor and suturing the remaining
lateral pectoralis major to the underlying pectoralis minor
and rib periosteum or by making an L-shaped cut preserv­
ing the inferolateral pectoralis major. The undersurface of
pectoralis major is then dissected free and the origin at the
clavicle is divided. The internal mammary perforators pierce
the muscle in the intercostal space 1.5–2 cm from the
sternal border and dissection is stopped once these are
encountered. The muscle can be split horizontally to inter­
digitate with the contralateral pectoralis major flap if needed
for coverage (Fig. 17.2). This is helpful for small (<5 cm)
remaining inferior sternal defects.
RECTUS ABDOMINIS
Coverage:
Sternum up to sternal notch
Anterolateral chest
Figure 17.2  Pectoralis major turnover with modifications. The
pectoralis major is detached from the insertions on the humerus and
clavicle and the pectoral branch of the thoracoacromial artery is
divided. In order to preserve the anterior axillary line, the muscle can
be split more medial or in an L-shape. The muscle is turned over into
the defect. The muscle can be split horizontal to better fill the defect.
Pectoralis major
Pectoral branch
of thoraco-acromial
artery
Internal mammary
artery
Figure 17.3  Anterolateral chest defects covered by vertical
rectus abdominis myocutaneous flap. The rectus abdominis
muscle and overlying skin is rotated into the chest defect based on
the superior epigastric vessels. The inferior epigastric vessels are
divided inferiorly.
Rectus abdominis
Superior epigastric
artery
Inferior
epigastric
artery

206
PART 3 — RECONSTRUCTION
LATISSIMUS DORSI
Coverage:
Sternum
Anterolateral chest
Axilla
Details of latissimus dorsi anatomy and dissection can be
found in Chapter 41. Briefly, the flap is raised based on the
thoracodorsal vessels and a subcutaneous tunnel is created
in the axilla to the chest defect. If more reach is needed,
the flap can be tunneled under pectoralis major19 or
detached from the humeral insertion to gain approximately
5–10 cm. If a larger flap is needed, the latissimus dorsi can
be taken with the serratus anterior (Fig. 17.5). If a smaller
flap is needed, the muscle can be split by taking muscle
overlying only one of the thoracodorsal branches, thus pre­
serving the other portion. The latissimus dorsi can be com­
pletely spared by raising a thoracodorsal artery perforator
flap.19a
superior epigastric vessels can be included at the costal
margin.
OMENTUM
Coverage:
Sternum
Anterolateral chest up to root of neck
Axilla
Details of omentum anatomy and dissection can be found
in Chapter 36. Once the omentum is dissected free, the flap
is then passed into the chest defect via either a subcutane­
ous tunnel, which creates a hernia, or preferably via a right
transdiaphragmatic route with the liver buttressing the
defect.16 Use of the right gastroepiploic artery provides
5–10 cm greater arc of rotation and if the pedicle needs
to be lengthened, internal longitudinal dissection can be
performed due to the secondary arcade (Barkow’s arch)
(Fig. 17.4).17 Transdiaphragmatic harvest is also an option
to avoid laparotomy for harvest.18
Figure 17.4  Omentum flap. The omentum flap based on the right
gastroepiploic vessels. The short gastric vessels are divided along
the inferior stomach. Modification to increase reach of the flap is
shown with division of the internal arcades.
Gastroepiploic artery
Short
gastric
vessels
Greater omentum
Figure 17.5  Anterior chest defects covered by latissimus dorsi
and serratus anterior. Latissimus dorsi dissected free from origin
and rotated to anterior chest based on the thoracodorsal vessels.
Serratus anterior may be harvested with the latissimus dorsi based
off the serratus branch off the thoracodorsal vessel.
Serratus anterior
Latissimus dorsi
Thoracodorsal
artery
Serratus
branch off
thoracodorsal
vesse

CHAPTER 17 — Chest and Back Reconstruction
207
incision is made first and dissection proceeds subfascial
along the latissimus dorsi. As the dissection continues, the
perforator is identified. The 6th intercostal perforator is
located 3 cm anterior to the border of latissimus dorsi.
Once the vessel is identified, the intercostal muscle is freed
from the lower border of the rib and the anterior extension
of the posterior intercostal vessel is divided to allow up to
180° of rotation into the defect.25
For anterior intercostal perforator flaps, the largest ante­
rior intercostal pedicles are located in the 2nd–3rd intercos­
tal spaces 1–3 cm lateral to the sternum. The flap design is
usually longitudinal or oblique towards the ipsilateral shoul­
der. Dissection is performed in a latero-inferior to medio-
superior direction and may need to proceed through the
pectoralis major or rectus abdominis muscles.
SCAPULAR/PARASCAPULAR
Coverage:
Axilla
Details of scapular/parascapular perforator flap anatomy
and dissection can be found in Chapter 40. For axilla
SERRATUS ANTERIOR
Coverage:
Anterolateral chest
Axilla
Some detail on the serratus muscle flap can be found in
Chapter 41. An oblique incision over the lateral chest wall
is made and dissection proceeds between the anterior
border of latissimus dorsi and inferolateral border of pecto­
ralis major.20 The thoracodorsal vessels are identified and
followed proximal to identify the branch to serratus ante­
rior. Special care should be taken not to damage the pedicle,
which lies superficial to the muscle. The long thoracic nerve
is identified medial to the pedicle and preserved. The lower
3–4 segments of serratus anterior are harvested by dissecting
anterior to posterior in a supraperiosteal plane. The upper
segments of muscle are kept attached to the scapula to
prevent winging of the scapula.
EXTERNAL OBLIQUE
Coverage:
Superior extent – 3rd intercostal space, reports of up to
clavicle
Medial extent – 5 cm past midline
The incision is made extending inferior from the defect
with the inferior limb making a gentle horizontal curve
from just above the umbilicus to the anterior superior iliac
spine. Dissection proceeds in the subcutaneous plane to
linea semilunaris, where the anterior rectus sheath is incised.
Dissection then continues between the external oblique
and internal oblique to the midaxillary line, where the inter­
costal vessels enter. The external oblique is then divided
from the anterior iliac crest and costal margin.21 When
closing the abdomen, if a portion of the anterior sheath was
taken with the flap, the internal oblique is advanced and
sutured to linea alba to avoid potential weakness of the
abdominal wall. Larger flaps with greater arcs of rotation
can be created by making an oblique inferior backcut for
more cephalad movement and closing the donor site in a
V-Y fashion (Fig. 17.6).22 The external oblique muscle can
be spared and the flap raised on thoracoabdominal perfora­
tors as an island flap.23
INTERCOSTAL PERFORATOR FLAP
Coverage:
Anterolateral chest
Axilla
The flap can be based off either the lateral or anterior
intercostal perforator24 vessels depending on the coverage
needed (Fig. 17.7).
For lateral intercostal perforator flaps, the pedicle used
is usually from the 4th to 8th intercostal space, with the 6th
space being the largest. The skin paddle is usually oriented
parallel to the rib with the posterior border based at least
5 cm behind the posterior axillary line. Flaps as large as
25 × 20 cm may be raised, but in order to close the donor
site primarily the size taken is usually smaller. The posterior
Figure 17.6  External oblique flap. Elevation of external oblique
(left). Closure of donor site in V-Y fashion to allow further advance­
ment (right).
External
oblique
Intercostal
vessels
Internal
oblique
and rectus
abdominus

208
PART 3 — RECONSTRUCTION
anterior is thin and pliable, which is advantageous for but­
tressing bronchopleural fistula repairs. The muscles are dis­
sected free from their origins and insertions around the
pedicle and portions of the ribs near the pedicle are removed
to allow intrathoracic passage (Fig. 17.8). For buttressing
intrathoracic repairs, the muscle is draped over the repair
rather than being sewn to the potentially delicate, friable
repair.29
POSTERIOR TORSO
TRAPEZIUS
Coverage:
Lower cervical region and upper one-third thoracic
Details of trapezius flap anatomy and dissection can be
found in Chapter 39.30,31 The muscle can be used as a
rotation/advancement flap32 based on the transverse cer­
vical vessels, or a turnover flap33 based on the posterior
intercostal vessels (Fig. 17.9A). Additionally, a dorsal scapu­
lar artery perforator flap may be performed based off the
deeper branch of the transverse cervical vascular axis.33a
defects, a flap based on the parascapular axis is preferred.
This flap is especially useful in release of contractures from
axillary burns.26
TRAPEZIUS
Coverage:
Anterior superior chest
Axilla
Details of trapezius flap anatomy and dissection can be
found in Chapter 39. The dorsal scapular perforator flap
variation is the best option for defects of the anterior chest
and axilla (see Fig. 17.9B).27 This flap is based on a skin
paddle near the inferior portion of the muscle.
INTRATHORACIC
There are many regional flap options to cover exposed
vascular grafts or buttress intrathoracic repairs. The most
common used flaps are: pectoralis major, latissimus dorsi,
and serratus anterior.28 Each flap offers different advantages
depending on the defect characteristics. Latissimus dorsi
offers more bulk to fill large dead space, whereas serratus
Figure 17.8  Intrathoracic pectoralis major and serratus anterior.
The flap of choice is elevated on its pedicle and adjacent ribs are
removed to allow intrathoracic placement.
Pectoralis major
Serratus
anterior
Serratus
branch of
thoracodorsal
vessel
Pectoral branch
of thoraco-
acromial artery
Figure 17.7  Intercostal flaps. Lateral intercostal artery perforator
flap (left) and anterior intercostal artery perforator flap (right).
Internal
mammary
artery
Lateral
intercostal
artery
perforator
Intercostal
artery
Anterior
intercostal
artery
perforator

CHAPTER 17 — Chest and Back Reconstruction
209
thoracolumbar fascia for 6–8 cm laterally. In the cervical
and thoracic area, the trapezius and latissimus dorsi are
elevated with the skin flap. Dissection is easiest inferior,
where the muscle is round and large, and more difficult
superior, where it is thinner and attached to the undersur­
face of the trapezius. The thoracolumbar fascia is incised
5–6 cm from the midline and the erector spinae are mobi­
lized via dissection around the lateral edge and deep to the
muscle. The muscle is advanced medially, changing from a
round to an elliptical shape. If more medial advancement
is needed, the medial perforators can be divided, although
this is rare.35
INTERCOSTAL
Coverage:
Thoracic
For the dorsal intercostal perforator flap, the largest per­
forators lie beneath the 6th and 7th ribs, and if possible, it
is best to base the flap over these. Dissection is best per­
formed in a lateral to medial direction. The pedicle for this
flap is relatively short, but the length can be increased by
dissecting through the paraspinous muscles.36
LATISSIMUS DORSI
Coverage:
High- to mid-thoracic back
Thoracodorsal pedicle – superior extent top of scapula
Lumbar perforators pedicle – inferior, lower lumbar area
Details of latissimus dorsi anatomy and dissection can be
found in Chapter 41. For the posterior rotation/advancement
flap, the muscle is exposed and detached from the origins
on the vertebrae. Dissection on the undersurface of the
muscle proceeds until adequate midline advancement is
achieved (Fig. 17.10A). For the reverse turnover flap,34 the
latissimus dorsi muscle is disinserted from the humerus, and
the thoracodorsal vessels and nerve are divided. The muscle
is flipped over into the defect based on the posterior inter­
costals (Fig. 17.10B).
PARASPINOUS (ERECTOR SPINAE) MUSCLE
Coverage:
High cervical to low lumbar (best C6 to L3)
The muscle is exposed via a midline back incision longi­
tudinally. The skin is undermined superficial to the
Figure 17.9  Trapezius back coverage. (A) Trapezius turnover flap based on the posterior intercostal vessels. (B) Dorsal scapular artery
perforator flap with skin paddle. See Figure 39.1 for detailed anatomy of the trapezius flap and the region.
Trapezius
Dorsal scapular artery
Posterior intercostal arteries
A
Trapezius
Dorsal scapular artery
Posterior intercostal arteries
B

210
PART 3 — RECONSTRUCTION
fascia are mobilized medial and the omentum is placed on
top of the 12th rib. The patient is then repositioned, the
12th rib is excised, and the omentum is pulled through into
the defect.37
LUMBAR PERFORATOR
Coverage:
Lumbar
The 2nd and 4th lumbar perforators are the largest. The
flap can extend from the midline to the midaxillary line.
Dissection is usually performed starting lateral and deep to
the lumbar fascia.
POSTOPERATIVE CONSIDERATIONS
Postoperatively, it is important to ensure the flap pedicle is
protected. If necessary, the patient may have weightbearing
or movement restrictions in the immediate postoperative
period. It may also be beneficial to position the patient in
a way to avoid pedicle compression or opposing force on
EXTERNAL OBLIQUE
Coverage:
Lower lateral thoracic and lumbar
A midline abdominal incision is made and the external
oblique is divided at the anterior rectus sheath. Dissection
proceeds on the deep surface of the muscle to the posterior
axillary line where the vessels enter. The superior branches
at the anterior axillary line must be divided to allow reach
to the posterior torso. The muscle is then flipped and tun­
neled into the defect. Due to fascia at the distal edge of the
flap, it is not the best option to cover exposed hardware.
OMENTUM
Coverage:
Lumbosacral recess to mid-scapula
Details of omentum anatomy and dissection can be found
in Chapter 36. For inset for back defects, the line of lateral
peritoneal reflection (white line of Toldt) is incised to
expose the retroperitoneum. The right kidney and Gerota’s
Figure 17.10  Latissimus dorsi back coverage. (A) Rotation/advancement flap. The muscle is detached from the origins on the vertebrae
and advanced into the defect based on the thoracodorsal vessels. (B) Turnover flap. The muscle is disinserted from the humerus and the
thoracodorsal vessels and nerve are divided. The muscle is flipped over into the defect based on the posterior intercostal vessels.
Latissimus dorsi
Thoracodorsal artery
A
B
Latissimus dorsi
Posterior
intercostal
arteries

CHAPTER 17 — Chest and Back Reconstruction
211
the reconstruction. For example with latissimus dorsi flaps
used for anterior chest reconstruction, using a pillow to
hold the shoulder in abduction or for sternal reconstruction
wearing a chest binder. For posterior torso reconstructions
that overlie pressure points, the patient should recover on
a pressure relief bed for approximately 10–14 days. In the
great majority of cases, the donor site will require drains,
and if a large surface area was undermined, drains will need
to be in place for an extended period of time to decrease
risk of seroma formation. Special mention is given to
omental flaps, which given their intra-abdominal location,
have additional postoperative considerations. It is recom­
mended to decompress the stomach with a nasogastric tube
initially to avoid tension on vessel ligatures along the greater
curvature of the stomach.
COMPLICATIONS
RECIPIENT SITE COMPLICATIONS
Persistent infection at the recipient site may occur due to
many possibilities. Common nidi for infection are contami­
nated costal cartilages, persistent periprosthetic infection,
and retained sternal wires. Infection may also persist due to
failure to obliterate or adequately decontaminate dead
space or failure to control contaminating visceral fistulae.
Some have reported superior outcomes with omentum
versus other muscle flaps, which may be due to immune
properties of the omentum.38,39
The stability of the chest wall postoperatively, theoreti­
cally has an effect on respiratory mechanics. Midline ster­
notomy wounds that have been treated with muscle flaps,
but no rigid bony fixation tend to be tolerated well as long
as the chest wall is intact in one location. Patients have been
shown to have minimal change in pulmonary function tests
with a slight decrease in ability to maximally exhale.
Although well-tolerated in most patients, this may affect
patients with COPD.40 Up to 50% of patients undergoing
muscle flap closure for sternal wounds experience postop­
erative pain or discomfort, thought to be due to irritated
intercostal nerves from the sternal edges,41 and may be alle­
viated by sternal plating.
Any reconstructive surgery performed overlying the spine
carries the risk for dural tear and CSF leak. Neurosurgery
should be closely involved, and if the dura is violated, it
should be managed by neurosurgery with repair and place­
ment of a lumbar drain.
DONOR SITE COMPLICATIONS
Many flap options used for chest and back reconstruction
are associated with shoulder function. Therefore, functional
deficits of the shoulder are a concern. It has been shown
with latissimus dorsi flaps that there is no effect on daily
activities because other muscles compensate.42–44 If patients
do notice a difference, they are likely to note more rapid
fatigue than loss of power.45,46 This effect is minimal, but
should be considered if the patient is walker or wheelchair
dependent. Scapular winging is a potential complication
with serratus anterior harvest, although this usually can be
avoided if the muscle is harvested segmentally preserving
the superior 5–6 digitations. Injury to the spinal accessory
nerve and subsequent shoulder droop is a potential compli­
cation of trapezius harvest, especially if the dissection is
carried anteriorly, which usually is not necessary for chest
and back reconstruction.
Hernias and abdominal bulge are potential complica­
tions of using abdominal wall muscle flaps. Meticulous
closure ensuring all layers of the abdominal wall are included
and placement of mesh when necessary help to reduce this
complication. Obligatory hernias result from tunneling
omentum subcutaneous to recipient site defects on the
chest. This can be avoided by tunneling the omentum trans­
diaphragmatically. Use of the omentum flap additionally
holds the risk associated with any intra-abdominal surgery.
Seroma formation is a common complication resulting
from wide undermining necessary for raising pectoralis
major and latissimus dorsi flaps. The incidence can be
reduced with prolonged closed suction drainage.
OUTCOMES
Flap reconstruction in the chest and back has led to
improved outcomes. Sternal wound closure with muscle
flaps has been shown to decrease ventilator dependence,
hospital stays,47 morbidity, and mortality.48,49 Although
patients may experience some strength loss and chronic
pain postoperatively, the benefits of reconstruction out­
weigh the negatives.50 The use of intrathoracic muscle flaps
for empyema or bronchopleural fistula repair has a high
success rate of more than 70%.51–53 This has led some institu­
tions to use muscle flaps prophylactically in high-risk
patients.54 Muscle flaps have been used successfully to treat
and prevent CSF leaks in high-risk patients55 and increase
the rates of hardware salvage in spinal wound infections.56

212
PART 3 — RECONSTRUCTION
A 56-year-old woman with recurrent left chest osteosarcoma
after previous multiple resections and coverage who presented
with local recurrence. She had no distant metastatic disease and
thus remained a candidate for re-resection and coverage. She
underwent a radical chest wall resection, partial liver resection,
diaphragm resection, and lung resection. Skeletal replacement
along with abdominal replacement and diaphragm reconstruc­
tion was performed with porcine acellular dermal matrix. An
omental flap and skin graft were chosen for definitive chest wall
reconstruction (Fig. 17.11, Video 17.1
).
CASE 17.1  Chest Wall Defect Reconstructed with a Pedicled Omental Flap and Skin Graft
A
B
C
D
Figure 17.11  (A) Resected recurrent chest wall osteosarcoma specimen. (B) Resultant chest wall defect showing exposed lung, dia­
phragm, and liver. (C) Reconstructed chest wall and diaphragm with biologic mesh. (D) Reconstructed chest and abdominal wall with
biologic mesh, omentum flap in upper right corner.

CHAPTER 17 — Chest and Back Reconstruction
213
CASE 17.1  Chest Wall Defect Reconstructed with a Pedicled Omental Flap and Skin
Graft—cont’d
E
F
G
(E) Inset of omentum flap. (F) Skin graft overlying omentum. (G) Postoperative follow-up.
Figure 17.11, cont’d

214
PART 3 — RECONSTRUCTION
A 57-year-old man, who was diagnosed with metastatic adenocar­
cinoma after a work-up for chest pain, revealed a bony metastasis
of the manubrium. Further work-up demonstrated a distal
esophageal mass as the primary. He underwent radiation to the
manubrium followed by chemotherapy. He was then found to
have brain metastases and underwent further chemotherapy,
whole brain radiation therapy, and stereotactic radiosurgery,
with a good response. He continued to have pain and progres­
sion of his sternal lesion. Additional palliative radiation therapy
was given with relief of symptoms. He later developed osteora­
dionecrosis of the sternum. He underwent radical sternectomy
with thoracic surgery, then closure of defect with omental flap
and bilateral pectoralis major myocutaneous advancement flaps,
and placement of feeding jejunostomy tube. There were no
major intraoperative complications. He was extubated success­
fully postoperative day 1. He wore a chest binder at all times. He
began ambulating by day 5, and he was discharged to step-down
care on day 9. One month postoperatively, he was completely
healed with good respiratory function, despite the acquired
anterior flail chest. Unfortunately, his primary esophageal lesion
and metastatic brain lesions had progressed. He underwent one
additional stereotactic radiosurgery for a brain metastasis. His
dysphagia was significant and he refused further chemotherapy.
He was referred to a hospice (Fig. 17.12).
CASE 17.2  Sternectomy Defect Reconstructed with a Pedicled Omental and Bilateral
Pectoralis Major Flaps
Figure 17.12  (A) Preoperative sternal wound from metastatic adenocarcinoma. (B) Resected oncologic specimen. (C) Chest wall defect
remaining after oncologic resection and laparotomy incision for harvest of omentum flap. (D) Omentum available for harvest. (E) Inset
of omentum flap in sternal defect. (F) Postoperative follow-up.
A
D
E
F
B
C
(Case courtesy of Dr Aaron Pelletier from Cancer Treatment Centers of America in Zion, Illinois.)

CHAPTER 17 — Chest and Back Reconstruction
215
A
B
C
Figure 17.14  (A) Raised lateral intercostal artery perforator (LICAP) flap and anterior chest/breast defect. (B) LICAP flap pedicle.
(C) LICAP flap inset.
A 56-year-old woman with a history of breast conservation for a
lower pole 2 cm intraductal carcinoma removed at outside hos­
pital. She completed radiation therapy 13 months prior to the
operation to reconstruct the lower pole of her breast. An inter­
costal artery perforator (ICAP) flap was chosen for reconstruc­
tion (Fig. 17.14, Video 17.3
).
CASE 17.4  Lower Pole of Breast Defect Reconstructed with a Pedicled Intercostal Artery
Perforator Flap
A
C
B
D
Figure 17.13  (A) Resected chondrosarcoma specimen and chest wall defect with exposed lung. Resection included four ribs, including
a portion of the diaphragm. (B) Chest wall reconstruction with Gore-Tex mesh. (C) Markings for vertical rectus abdominis myocutaneous
(VRAM) flap depicting skin paddle, incision, and location of superior epigastric vessels. (D) VRAM flap inset and closed donor site.
A 48-year-old man with a chondrosarcoma of the chest wall.
Resection included four ribs, including a portion of the dia­
phragm. The patient underwent immediate reconstruction with
Gore-Tex mesh and a vertical rectus abdominis myocutaneous
(VRAM) flap (Fig. 17.13, Video 17.2
).
CASE 17.3  Lower Sternal Defect Reconstructed with a Pedicled Vertical Rectus Abdominis
Myocutaneous Flap

216
PART 3 — RECONSTRUCTION
Access videos online at
.inkling.com
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recalcitrant median sternotomy wound infections. Ann Plast Surg
1995;34:471–7.
17. Das SK. The size of the human omentum and methods of lengthen­
ing it for transplantation. Br J Plast Surg 1976;29:170–4.
18. Vyas RM, Prsic A, Orgill DP. Transdiaphragmatic omental harvest:
a simple, efficient method for sternal wound coverage. Plast Recon­
str Surg 2013;131(3):544–52.
19. Tizian C, Borst HG, Berger A. Treatment of total sternal necrosis
using the latissimus dorsi muscle flap. Plast Reconstr Surg 1985;
76:703.
19a.  Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in
pedicled thoracodorsal artery perforator flaps: a clinical experi­
ence with 99 patients. Plast Reconstr Surg 2008;121:1632–41.
20. Arnold PG, Pairolero PC, Waldorf JC. The serratus anterior muscle:
Intrathoracic and extrathoracic utilization. Plast Reconstr Surg
1984;73:240.
21. Bogossian N, Chaglassian T, Rosenberg PH, et al. External oblique
myocutaneous flap coverage of large chest-wall defects following
resection of breast tumors. Plast Reconstr Surg 1996;97:97–103.
22. Moschella F, Cordova A. A new extended external oblique muscu­
locutaneous flap for reconstruction of large chest-wall defects. Plast
Reconstr Surg 1999;103:1378–85.
23. Persichetti P, Brunetti B, Cagli B, et al. Chest wall reconstruction
with the perforator-plus thoracoabdominal flap. Plast Reconstr
Surg 2012;130(3):488e–490e.
24. Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the
intercostal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet
Surg 2006;59:644–52.
25. Hamdi M, Spano A, Van Landuyt K, et al. The lateral intercostal
artery perforators: anatomical study and clinical application in
breast surgery. Plast Reconstr Surg 2008;121:389–96.
26. Hallock GG. Okunski WJ. The parascapular fasciocutaneous flap
for release of the axillary burn contracture. J Burn Care Rehabil
1987;8(5):387–90.
27. Haas F, Weiglein A, Schwarzl F, et al. The lower trapezius musculo­
cutaneous flap from pedicled to free flap: anatomical basis and
clinical applications based on the dorsal scapular artery. Plast
Reconstr Surg 2004;113:1580e90.
28. Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An account
of their use in the management of 100 consecutive patients. Ann
Surg 1990;211(6):656–62.
29. Chen H, Lo SJ, Kim JH. Management of intrathoracic defects.
Semin Plast Surg 2011;25:70–7.
30. Mathes DW, Thornton JF, Rohrich RJ. Management of posterior
trunk defects. Plast Reconstr Surg 2006;118:73e.
31. Netscher DT, Baumholtz MA, Bullocks J. Chest reconstruction: II.
Regional reconstruction of chest wall wounds that do not affect
respiratory function (axilla, posterolateral chest, and posterior
trunk). Plast Reconstr Surg 2009;124(6):427e–35e.
Expert Commentary
Lawrence J. Gottlieb, MD, FACS
The most common circumstance in which free flap reconstruc-
tion for chest and back defects is required, is when previous
surgery or radiation therapy has compromised local-regional
tissue or its blood supply. In my experience, the most common
scenario in which this occurs is when the latissimus and or
pectoralis muscles or their pedicles have been divided or made
otherwise unusable for chest wall reconstruction or intratho-
racic transfer. The most frequent alternative free flaps used in
this situation are based on the lateral femoral circumflex system,
the deep inferior epigastric system, the omentum, or flaps
based on the contralateral subscapular system. Despite the
difficulties and inconvenience of having to reposition the patient,
contralateral free flaps based on the subscapular system is
indicated when vascularized autologous bone (rib and or
scapula) is preferred for thoracic skeletal support.
The choice of free flap is predicated on the 3-dimensional
size of defect, type of tissue component(s) needed, tissue avail-
ability, intraoperative positioning, the health and lifestyle of the
patient, potential donor site morbidity and quality of the recipi-
ent site. To maximize success, flaps with a robust blood supply
should be used in wound beds compromised by unresectable
scar and fibrosis from radiation or bacterial contamination.
These considerations may move one to convert a pedicled flap
to a free flap so that the most robust blood supply (the primary
angiosome) is used rather than the distal, and typically the less
vascularized portion of a pedicle flap. Another consideration
would be to dissect out a distal secondary pedicle to super-
charge (or super-drain) the distal part of a flap thereby improv-
ing its circulation or venous return.
The choice of recipient vessels is generally based on the
relative size and quality of available vessels in proximity to the
defect. Recipient vessels in the upper half of the chest are
usually abundant. The challenge is usually in the mid-torso and
lower back, where there is a paucity of large recipient vessels.
Frequently, long vein grafts are required in these locations.
Alternatively, our increased understanding of perforating
vessels throughout the trunk has opened the possibility of using
these perforators as recipient vessels.

CHAPTER 17 — Chest and Back Reconstruction 216.e1
Video 17.1 Chest wall and diaphragm mesh reconstruction
moving with respirations.
Video 17.2 Chest wall defect and expanding lung.
Video 17.3 Flap inset.

CHAPTER 17 — Chest and Back Reconstruction
217
32. Chun JK, Lynch MJ, Poultsides GA. Distal trapezius musculocutane­
ous flap for upper thoracic back wounds associated with spinal
instrumentation and radiation. Ann Plast Surg 2003;51:17–22.
33. Disa JJ, Smith AW, Bilsky MH. Management of radiated reoperative
wounds of the cervicothoracic spine: the role of the trapezius turn­
over flap. Ann Plast Surg 2001;47:394–7.
33a.  Sadigh PL, Chang LR, Hsieh CH, et al. The trapezius perforator
flap: an underused but versatile option in the reconstruction of
local and distant soft-tissue defects. Plast Reconstr Surg 2014;134:
449e–56e.
34. Liu Y, Yu S, Song B, et al. Reconstruction of posterior lumbar
defects in oncologic patients using two island flaps of the back in
series. Ann Plast Surg 2010;65:326–9.
35. Wilhelmi BJ, Snyder N, Colquhoun T, et al. Bipedicle paraspinous
muscle flaps for spinal wound closure: an anatomic and clinical
study. Plast Reconstr Surg 2000;106:1305–11.
36. Zenn MR, Jones G. Lateral intercostal artery perforator (LICAP)
flap. Reconstructive surgery anatomy, technique, and clinical
applications, vol. 1. St Louis, MO: Quality Medical Publishing;
2012. p. 474–91.
37. O’Shaughnessy BA, Dumanian GA, Liu JC, et al. Pedicled omental
flaps as an adjunct in complex spine surgery. Spine 2007;32:
3074–80.
38. Milano CA1, Georgiade G, Muhlbaier LH, et al. Comparison of
omental and pectoralis flaps for poststernotomy mediastinitis. Ann
Thorac Surg 1999;67(2):377–81.
39. Lopez-Monjardin H, de-la-Pena-Salcedo A, Mendoza-Munoz M,
et al. Omentum flap versus pectoralis major flap in the treatment
of mediastinitis. Plast Reconstr Surg 1998;101:1481–5.
40. Meadows JA III, Staats BA, Pairolero PC, et al. Effect of resection
of the sternum and manubrium in conjunction with muscle trans­
position on pulmonary function. Mayo Clin Proc 1985;60:604–9.
41. Ringelman PR, Vander Kolk CA, Cameron D, et al. Long-term
results of flap reconstruction in median sternotomy wound infec­
tions. Plast Reconstr Surg 1994;93(6):1208–14.
42. Brumback RJ, McBride MS, Ortolani NC. Functional evaluation of
the shoulder after transfer of the vascularized latissimus dorsi
muscle. J Bone Joint Surg Am 1992;74:377.
43. Laitung JK, Peck F. Shoulder function following the loss of the
latissimus dorsi muscle. Br J Plast Surg 1985;38:375.
44. Russell RC, Pribaz J, Zook EG, et al. Functional evaluation of latis­
simus dorsi donor site. Plast Reconstr Surg 1986;78:336.
45. Fraulin FO, Louie G, Zorrilla L, et al. Functional evaluation of the
shoulder following latissimus dorsi muscle transfer. Ann Plast Surg
1995;35:349.
46. Spear SL, Hess CL. A review of the biomechanical and functional
changes in the shoulder following transfer of the latissimus dorsi
muscles. Plast Reconstr Surg 2005;115:2070.
47. Kroll SS, Walsh G, Ryan B, et al. Risks and benefits of using Marlex
mesh in chest wall reconstruction. Ann Plast Surg 1993;31:303–6.
48. Jurkiewicz MJ, Bostwick J, Hester R, et al. Infected median ster­
notomy wound successful treatment by muscle flaps. Ann Surg
1980;191:738.
49. Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the
infected median sternotomy wound with muscle flaps: the Emory
20-year experience. Ann Surg 1997;225:766.
50. Daigeler A, Falkenstein A, Pennekamp W, et al. Sternal osteomy­
elitis: long term results after pectoralis muscle flap reconstruction.
Plast Reconstr Surg 2009;123(3):910–17.
51. Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An account
of their use in the management of 100 consecutive patients. Ann
Surg 1990;211(6):656–60.
52. Okumura Y, Takeda S, Asada H, et al. Surgical results for chronic
empyema using omental pedicled flap: long-term follow-up study.
Ann Thorac Surg 2005;79:1857–61.
53. Meyer AJ, Krueger T, Lepori D, et al. Closure of large intrathoracic
airway defects using extrathoracic muscle flaps. Ann Thorac Surg
2004;77:397–405.
54. Abolhoda A, Bui TD, Milliken JC, et al. Pedicled latissimus dorsi
muscle flap. Routine use in high-risk thoracic surgery. Tex Heart
Inst J 2009;36(4):298–302.
55. Saint-Cyr M, Nikolis A, Moumdijian R, et al. Paraspinous muscle
flaps for the treatment and prevention of cerebrospinal fluid fistu­
las in neurosurgery. Spine 2003;28:E86–92.
56. Mericli AF, Moore JH, Copit SE, et al. Technical changes in para­
spinous muscle flap surgery have increased salvage rates of infected
spinal wounds. Eplasty 2008;8:e50.

218
Abdominal Wall
Reconstruction
Donald P. Baumann  |  Charles E. Butler
18 
INTRODUCTION
The need for soft tissue coverage in abdominal wall recon­
struction implies a lack of tissue beyond the availability of
local tissue to be recruited to resurface the defect. As the
majority of abdominal wall defects can be reconstructed
with the redundant tissue from the torso, these defects rep­
resent a more complex subset of abdominal wall reconstruc­
tions. Indications for flap coverage vary by etiology of defect,
defect characteristics, and timeline for closure. Multiple
clinical scenarios can lead to a loss of abdominal wall soft
tissue requiring flap reconstruction, including oncologic
resection, traumatic injury, radiation-associated wounds,
skin necrosis, soft tissue infection, and septic evisceration.
The amount of soft tissue loss and amount of coverage
able to be performed with local skin advancement must be
factored into the reconstructive plan. Abdominal wall
defects requiring soft tissue coverage can be classified as
partial thickness defects, involving the skin and subcutane­
ous tissue only, or full thickness composite defects which
involve loss of the abdominal wall musculofascia in addition
to the overlying skin and subcutaneous tissue. The indica­
tions for soft tissue replacement in abdominal wall recon­
struction also depend on the chronicity of the wound/
defect with some defects benefiting from early flap cover­
age, others from delayed flap coverage, while some defects
might be better served with chronic wound care and healing
by secondary intention.
INDICATIONS
Historically, abdominal wounds were treated with wound
care and allowed to heal over time by secondary intention
or were reconstructed with a skin graft after the local wound
environment was optimized. This resulted in a prolonged
course of care and significant morbidity. In time, the concept
of delayed-primary closure gained popularity allowing
certain patients with favorable wound characteristics to
undergo closure after a short period of wound care, instead
of being committed to weeks or months of open wound
care. This enabled patients to achieve definitive wound
closure without a skin grafted surgical site and associated
donor site morbidity.
Soft tissue flap reconstruction offers significant advan­
tages over wound closure. Flap reconstruction is performed
in a single stage procedure obviating the need for chronic
wound management. Flap reconstruction offers immediate
and definitive wound closure mitigating the local milieu of
inflammatory response and local tissue injury. In recon­
structions involving musculofascial reinforcement with
bioprosthetic mesh, these two factors are critical. When
bioprosthetic mesh is interposed between two well vascular­
ized tissue planes (posterior abdominal wall/peritoneal
cavity and a soft tissue flap superficially) bidirectional vas­
cular ingrowth can be achieved accelerating the period of
bioprosthetic mesh revascularization and incorporation. In
addition, a closed wound environment diminishes the pro­
inflammatory state of an open wound, which limits the
degree of enzymatic degradation of the bioprosthetic mesh
during the incorporation phase.
Over recent years, the role of negative pressure wound
therapy (NPWT) has revolutionized the approach to wound
care particularly in the abdominal wall. NPWT allows pres­
ervation of the wound environment by managing fluid
losses, decreasing bacterial contamination, and accelerating
granulation tissue formation. In abdominal wall reconstruc­
tion, this translates in preserving the option for delayed
closure by flap reconstruction or delayed primary closure.
Composite full-thickness loss of the abdominal wall mus­
culofascia and overlying soft tissue represents the most
complicated abdominal wall reconstructions, sometimes
requiring multiple staged reconstructive procedures. Re-
establishment of myofascial continuity is paramount to
setting the stage for a durable abdominal wall reconstruc­
tion. Reconstituting the deficient myofascia with an inlay of
bioprosthetic mesh converts the open abdomen to a more
manageable abdominal wall wound. For midline defects,
early abdominal closure with primary rectus musculofascial
reapproximation over bioprosthetic mesh provides superior
outcomes to bridging the fascial defect with bioprosthetic
mesh. The risk of developing a hernia increases seven-fold
when bridging fascial repairs are performed instead of
reinforced mesh repairs.1 All attempts should be made to
achieve fascial coaptation as bridging repairs are far more
likely to develop hernias in the early postoperative period
<18 months. When early fascial closure is not an option
owing to ongoing debridement of the myofascia or the
need to perform a second-look laparotomy, a temporizing
abdominal wall closure can be utilized, such as the NPWT
system. A static bridging wound dressing protects and insu­
lates the viscera while controlling fluid loss in the wound
bed. NPWT also provides abdominal stability in the early
PART 3  —  RECONSTRUCTION

CHAPTER 18 — Abdominal Wall Reconstruction
219
Whenever feasible, a component separation should be
considered to either reduce the tension on a myofascial
repair to facilitate a second layer fascial closure over a bio­
logic mesh inlay or to advance myofascial flaps to reduce
the diameter of a bridging mesh repair. Minimally invasive
component separation (MICS) techniques can be utilized
to achieve myofascial release and closure under physiologic
tension while decreasing seroma formation and preserving
perfusion to the midline skin. Key technical aspects of mini­
mally invasive component separation include the creation
of 3 cm wide, subcutaneous access tunnels over the anterior
rectus sheath from the midline to the semilunar line at the
level of the costal margin. Through these access tunnels, the
external oblique aponeurosis is vertically incised 1.5 cm
lateral to the linea semilunaris. A narrow (2.5 cm wide)
subcutaneous tunnel is created with electrocautery superfi­
cial to the external oblique aponeurosis over the planned
release location using a narrow retractor and a headlight.
The external oblique aponeurosis is now released approxi­
mately 1.5 cm lateral to the lateral edge of the rectus sheath
from 12 cm above the costal margin superiorly to near the
pubis inferiorly. Next, lateral dissection between the inter­
nal and external oblique muscle is performed to the mid-
axillary line. Subcutaneous skin flaps are then elevated over
the anterior rectus sheath circumferentially to the medial
row of rectus abdominis perforator vessels. Next the muscu­
lofascial edges are advanced and reapproximated over the
mesh with sutures placed through the musculofascial layers
and mesh. A clinical controlled study demonstrated that the
minimally invasive technique patients had significantly
fewer wound healing complications (32% vs 14%, p = 0.026)
and skin dehiscence (28% vs 11%, p = 0.01) than the tradi­
tional open CS group.5 These improved wound healing out­
comes are likely due to preservation of the vascularity of the
overlying skin flaps and reduction of paramedian dead
space, which is the surgical principles highlighted in the
MICS procedure.
The reconstructive algorithm for skin coverage of full
thickness abdominal wall defects begins with local skin
advancement flaps and expands to local perforator flaps,
regional pedicled flaps, and ultimately free flap reconstruc­
tions. The overlapping angiosomes of the abdominal wall’s
cutaneous blood supply allow for wide undermining and
skin advancement. In addition, tissue expansion can be per­
formed in the trunk to increase the surface area and avail­
ability of local fasciocutaneous flaps as an alternative to a
pedicled or free flap donor site. In cases of prior radiation,
prior surgery, or excessive skin resection, a pedicled regional
or free flap may be required to provide adequate soft tissue
coverage. Composite abdominal wall defects can involve
significant loss of innervated myofascia and overlying skin in
a dimension that is greater than the surrounding tissue’s
ability to be recruited and mobilized for closure. In such
cases, regional or distant tissue flaps must be used for closure,
and the resultant repair will no longer be dynamic and coor­
dinated with the remaining abdominal wall musculature.
PREOPERATIVE CONSIDERATIONS
Preoperative planning for abdominal wall defects that
require flap reconstruction must factor defect type, defect
postoperative period for patients undergoing mechanical
ventilation and later when they ambulate and undergo phys­
ical therapy.
The goals of abdominal wall reconstruction of a full-
thickness composite defect are to re-establish the integrity
of the myofascial layer and provide cutaneous coverage. The
prevailing strategy in full-thickness composite reconstruc­
tion of the abdominal wall is to avoid patching the defect
and instead reinforce the entire surrounding section of
abdominal wall. This is accomplished through inlay (intra-
abdominal) mesh placement with the mesh sutured to
points of fixation: innervated myofascia, lamellar aponeu­
rotic tissue, or bone. Surgical planning in abdominal wall
reconstruction must address local wound conditions, includ­
ing bacterial contamination, previous operations, presence
of ostomies, and prior radiation therapy, all of which can
increase the risks of compromised wound healing and surgi­
cal site infections. Composite abdominal wall defects often
involve significant loss of innervated myofascia and overly­
ing skin in a dimension that is greater than the surrounding
tissue’s ability to be recruited and mobilized for closure. In
such cases, regional or distant tissue flaps must be used for
closure, and the resultant repair will no longer be dynamic
and coordinated with the remaining abdominal wall muscu­
lature, unless functional muscle transfers are performed.2,3
When both soft tissue and musculofascia require recon­
struction, such as a composite defect, it is preferred to
reconstruct these two components with different tech­
niques. Mesh and often component separation is used for
the musculofascial component and soft tissue flaps are used
for the soft tissue defect. The use of the fascial component
of a flap for musculofascial reconstructions can result in
increased bulge or hernia. In addition, insetting the fascial
component of a fasciocutaneous flap to reconstitute the
myofascial defect can potentially compromise the vascular­
ity of the overlying skin island by placing undue tension
across the myofascial repair. Thus, for composite midline
defects, myofascial reconstruction is generally performed
with component separation, with the use of mesh, to ensure
the structural integrity of the repair. Both synthetic and
bioprosthetic mesh materials have been used. Surgeon pref­
erence and the variables of any given clinical scenario will
determine whether bioprosthetic mesh or synthetic mesh is
implanted. Regardless of mesh type, the expectations are
that the mesh will maintain the abdominal wall contour,
without development of a hernia or bulge. In addition, the
mesh should be able to interface with the intra-abdominal
viscera without forming extensive adhesions or erosion that
can lead to fistulization. Bioprosthetic and synthetic meshes
can meet these expectations, and the decision to use either
is based on patient comorbidities, wound contamination,
prior radiation, availability of greater omentum, and the
quality of the overlying soft tissue.
Anchoring the mesh to stable fixation points in the
abdominal wall is a key element of a successful repair. The
abdominal wall pillars are stable fixation points; these
include the costal margin and rib superiorly, the linea semi­
lunaris and linea alba anteriorly, the inguinal ligament and
iliac crest inferiorly, and the investing lumbar and paraspi­
nal fascia posteriorly.4 To achieve a stable repair, it is impor­
tant to create an inlay mesh inset that links these anatomic
structures.

220
PART 3 — RECONSTRUCTION
function panel should be performed to evaluate any elec­
trolyte disturbances, anemia, infectious processes, or hepatic
disturbances. Electrolytes replacement is of particular
importance in patients with enterocutaneous fistulae or
open chronic abdominal wounds. Nutritional status should
be optimized preoperatively due to the fact that poor nutri­
tional status is associated with impaired wound healing and
impaired immune response. Nutritional status can be
assessed via measurements of albumin and prealbumin and
should be included with routine laboratory evaluations for
potential abdominal wall reconstruction candidates.
Abdominal CT scan is used to identify the extent of the
abdominal wall defect and the integrity of adjacent muscu­
lofascial structures and aid in preoperative planning. CT
angiography can be used to delineate the vascular anatomy
of the abdominal wall. CT angiography allows the surgeon
to refine plans for flap selection and make operative deci­
sions preoperatively. CT angiography is invaluable in accu­
rately identifying the abdominal wall vasculature to aid in
identifying recipient vessels when planning a free tissue
transfer. This is of particular importance in patients who
have undergone prior abdominal surgery where the vascu­
lar anatomy can be altered significantly and flap perforators
can be difficult to localize and recipient vessels may have
been injured at previous surgery.
OVERVIEW OF RECONSTRUCTION BY REGION
The anterior abdominal wall can be divided into three ana­
tomic regions: the epigastrium, the periumbilical region,
and the hypogastrium (Tables 18.1–18.3). The relationship
of defects to these anatomic regions guide decision-making
when regional pedicled flaps are planned for reconstruc­
tion. Options for pedicled flaps in the upper abdomen
include latissimus dorsi and omental flaps. Thigh-based
flaps such as anterolateral thigh, vastus lateralis, and tensor
location, availability of surrounding soft tissue and in certain
cases, planned intra-abdominal reoperation. As with any
reconstruction, there is plan A and an algorithm that plans
for all contingencies (i.e., plans B through Z). This plan
with multiple back-up plans is critical in abdominal wall flap
cases, as often the back-up plan becomes the plan and time
cannot be wasted deliberating each step in the reconstruc­
tive algorithm. Special consideration must be given to flap
type (muscle, myocutaneous or fasciocutaneous); donor site
(one that is harvested supine or requires a position change);
recipient vessels and the potential need for vein grafts. In
addition, flap reconstructions on the trunk merit discussion
of postoperative positioning and mobility restrictions. This
begins during flap inset to ensure postoperative positioning
or dependent pressure/swelling will not compromise flap
perfusion. As with any flap, a plan for postoperative moni­
toring must be established. Flap type and practice pattern
will determine the method of monitoring, clinical exam,
Doppler (handheld vs implantable), tissue oximetry, tissue
temperature, or vascular flow monitors.
PATIENT EVALUATION
When evaluating a patient for abdominal wall flap recon­
struction, history and physical examination, laboratory
assessment, as well as consultation from other services
including general surgery, internal medicine, pulmonology,
and nutrition are critical for successful operation. Features
within a history such as smoking status and alcohol abuse
are important due to the impaired wound healing effects
associated with vasoconstriction and immunocompromise.
In addition, aspects of a patient’s past medical history such
as peripheral vascular disease, diabetes mellitus, and auto­
immune disorders can be associated with impaired wound
healing. Prior abdominal surgery can alter perfusion to the
skin and musculofascia. Previous surgery also causes visceral
adhesions that when complex can lead to unplanned enter­
otomy which can complicate reconstruction efforts. Addi­
tionally, prior radiation exposure can decrease wound
healing capacity, which can lead to a higher complication
rate in radiated abdominal wall reconstructions.
Physical examination focuses on characteristics of the
abdominal wall defect, including chronicity; partial vs full-
thickness defects; size and location of the defect; wound
contamination; presence or absence of an ostomy; and the
presence or absence of enterocutaneous fistulae. Accord­
ingly, the size and location of the defect can help determine
future surgical management, as well as which type of flap will
be required, local, regional, or free flap. Preoperative evalu­
ation should focus on factors such as body mass index,
abdominal wall laxity, and evaluation of potential donor sites
for flap coverage. Weight reduction for obese patients and
tobacco cessation for active smokers are recommended to
decrease complication rates, whenever feasible. For elective
reconstructions smoking cessation for 8 weeks prior to sur­
gery and targeted weight loss to individual patient goals, will
reduce 30-day morbidity in abdominal wall reconstruction.6
Physical examination should focus on the potential donor
sites for flap harvest circumferentially around the defect.
As with any intra-abdominal procedure, the patient’s
metabolic and hematologic status should be evaluated prior
to surgical intervention. As such, a complete metabolic
panel, complete blood count with differential, and a hepatic
Table 18.1  Abdominal wall flap reconstruction
algorithm: epigastric defects
Local
Pedicled
Free
Epigastric
Transposition:
IM, IC, SE
Rectus
Thigh-
based:
ALT, AMT,
VL, TFL,
RF, STF
Keystone
Omentum
Back-
based: LD,
TAP, Scap/
Para
Bipedicled
fasciocutaneous
Thigh-
based
Transposition: IM, internal mammary artery perforator flap; IC,
intercostal artery perforator flap; SE, superior epigastric artery
perforator flap. Thigh-based: ALT, anterolateral thigh flap;
AMT, anteromedial thigh flap; VL, vastus lateralis flap; TFL,
tensor fascial lata flap; RF, rectus femoris flap; STF, subtotal
thigh flap. Back-based: LD, latissimus dorsi flap; TAP,
thoracodorsal artery perforator flap; Scap/Para, scapular/
parascapular flap.

CHAPTER 18 — Abdominal Wall Reconstruction
221
fascia lata flaps are generally able to reach the hypogastrium
and flank as pedicled flaps. If a pedicled flap is not available
or feasible, a thoracoepigastric bipedicled fasciocutaneous
flap may provide a local tissue alternative in patients who
are not candidates free tissue transfer.
However, when the volume of tissue loss or the arc of
rotation needed precludes a pedicled flap transfer, a free
flap is required for soft tissue coverage. The thigh can serve
as a source of fasciocutaneous flaps and myocutaneous flaps
that provide large skin paddles and significant muscle
volume.7 Recipient vessels in the lateral abdominal wall
include the deep inferior epigastric vessels, superior epigas­
tric vessels, internal mammary vessels, intercostal artery per­
forators, and thoracolumbar perforators. When no local
recipient vessels are available, vein grafts to the internal
mammary or femoral vessels may be required (see Figs 11.3
and 11.6).
LOCAL FLAP OPTIONS
Local flaps involve recruiting tissue adjacent to the wound
defect. Well-planned incisions are critical to preserve blood
supply to the local flap and avoid wound healing complica­
tions at the donor site used to resurface the wound/defect.
There are various flap transposition designs available includ­
ing advancement, rotation/advancement, interpolation, V-Y
advancement, and bipedicled flaps. These flaps can be ori­
ented in various dimensions: vertical, oblique, horizontal.
Given these flaps are perfused through random or axial
blood supplies, understanding the vascular anatomy in
terms of abdominal wall angiosomes and perforator loca­
tion is critical to designing robust local flaps.
It is also important to consider the impact of pre-existing
incisions in the abdominal wall when planning a flap design.
A midline laparotomy may preclude harvesting a local flap
from the contralateral abdominal wall. However, a midline
defect bisected by a laparotomy scar can be divided in half
and reconstructed by two local flaps, one from each hemi-
abdomen. Another key factor in performing a local flap
reconstruction is limiting tension across the wound closure
both at the defect site and the donor site. The flap perfu­
sion, especially at the most distal part of the flap can be
compromised if the flap is placed on high tension, either
by pushing the limits of the flap design or by creating exces­
sive biaxial tension across the flap when the donor site is
closed. One strategy that can be employed to mitigate exces­
sive tension is to transpose the flap to cover the defect site
and then skin graft the donor site. This concept is the main­
stay of the bipedicled flap in trunk reconstruction.
For midline defects, a bipedicled flap is generally used
for midline defects either unilaterally or bilaterally. The flap
is oriented vertically with a minimum of a 3 : 1 length/width
ratio and maintains a blood supply from both the superior
and inferior aspects of the flap. The flap is then directly
transposed to resurface the defect and by design the donor
site cannot be closed without an undue degree of tension.
To offload the tension a skin graft is placed on the donor
site preserving blood supply to the distal flap to maximize
wound healing.
Perforator flaps present multiple options for flap design
and rotation throughout the entire abdominal wall. Flaps
based on internal mammary, superior epigastric, deep infe­
rior epigastric, superficial inferior epigastric, and superficial
circumflex iliac perforators provide local flap options in all
zones of the abdominal wall. The keystone flap is one strat­
egy to reconstruct large trunk defects.8 Keystone flaps
enable one stage resurfacing of the both the defect and
donor site. The flap is designed as a large 3 : 1 ellipse parallel
to the long axis of the defect. The blood supply to the flap
is based on cutaneous perforators that shift towards the
Table 18.2  Abdominal wall flap reconstruction
algorithm: periumbilical defects
Local
Pedicled
Free
Periumbilical
Transposition:
DIEP, SIEA, TLP
Rectus
Thigh-
based:
ALT,
AMT, VL,
TFL, RF,
STF
Keystone
Omentum
Back-
based:
LD, TAP,
Scap/
Para
Bipedicled
fasciocutaneous
Thigh-
based
Transposition: DIEP, deep inferior artery perforator flap; SIEA,
superficial inferior epigastric artery flap; TLP, thoracolumbar
perforator flap. Thigh-based: ALT, anterolateral thigh flap; AMT,
anteromedial thigh flap; VL, Vastus lateralis flap; TFL, tensor
fascia lata flap; RF, rectus femoris flap; STF, subtotal thigh
flap. Back-based: LD, latissimus dorsi flap; TAP, thoracodorsal
artery perforator flap; Scap/Para, scapular/parascapular flap.
Table 18.3  Abdominal wall flap reconstruction
algorithm: hypogastric defects
Local
Pedicled
Free
Hypogastric
Transposition:
DIEP, SIEA, TLP
Rectus
Thigh-
based:
ALT,
AMT, VL,
TFL, RF,
STF
Keystone
Omentum
Back-
based:
LD, TAP,
Scap/
Para
Bipedicled
fasciocutaneous
Thigh-
based
Transposition: DIEP, deep inferior artery perforator flap; SIEA,
superficial inferior epigastric artery perforator flap; TLP,
thoracolumbar perforator flap. Thigh-based: ALT, anterolateral
thigh flap; AMT, anteromedial thigh flap; VL, vastus lateralis
flap; TFL, tensor fascia lata flap; RF, rectus femoris flap; STF,
subtotal thigh flap. Back-based: LD, latissimus dorsi flap; TAP,
thoracodorsal artery perforator flap; Scap/Para, scapular/
parascapular flap.

222
PART 3 — RECONSTRUCTION
harvested the functional donor site impact must be consid­
ered as it relates to the weakened abdominal wall. Patients
who have decreased core muscle strength will rely on upper
extremity strength and range of motion to complete activi­
ties of daily living. The impact of impaired shoulder and
upper extremity movement should be considered in these
patients. In addition, in terms of logistical planning, the
patient must undergo a position change to facilitate flap
dissection in the posterior chest wall. This adds complexity
and time to the procedure and extends ischemia time.
The thigh represents the mainstay for flap donor sites
for the abdominal wall. Both pedicled flaps for coverage
of the infraumbilical abdominal wall and free flaps can be
designed in several configurations: fasciocutaneous, myocu­
taneous, muscle and chimeric flaps. The descending branch
of the lateral circumflex femoral system provides blood
supply to the vastus lateralis and rectus femoris muscles. The
transverse branch of the lateral circumflex femoral system
provides blood supply to the tensor fascia lata muscle. These
flaps can be harvested as muscle only flaps or with overlying
skin paddles. The anterolateral thigh flap is designed by
including a skin paddle overlying vastus lateralis muscle and
can be designed as a myocutaneous or fasciocutaneous flap.
The tensor fascia lata flap can be designed to include the
distal fascia of the iliotibial tract and a smaller proximal
skin paddle if needed. The anteromedial thigh flap can
be designed on medial perforators from the descending
branch of the lateral circumflex femoral system. The rectus
femoris muscle is more commonly designed as a muscle flap
however a skin island can be included over the central
muscle when appropriate sized cutaneous perforators are
present.
These thigh-based flaps can be designed in any combina­
tion to form chimeric flaps, i.e.: ALT with AMT flaps, ALT
with TFL, vastus lateralis with TFL. For massive abdominal
wall defects the vastus lateralis, tensor fascia lata, and the
rectus femoris can be harvested with all overlying skin ter­
ritory as a subtotal thigh flap for increased volume and skin
coverage (Fig. 18.2).
RECIPIENT VESSELS
The success of any free tissue transfer relies on the avail­
ability of suitable recipient vessels providing arterial inflow
and venous outflow to the free flap. There are several recipi­
ent vessels available for abdominal wall reconstruction with
free flaps. The main vascular axis in the central abdominal
wall is the internal mammary-superior epigastric- inferior
epigastric system (see Figs 11.3, 11.6). The internal mammary
and deep inferior epigastric vessels provide large caliber
2–3 mm diameter recipient vessels for microanastomosis.
However, the vessels are present at the most cephalad and
caudal limits of the abdominal wall. The main challenge for
identifying recipient vessels is in the central aspect of the
abdominal wall. In situ options include intramuscular com­
ponents of the distal superior and inferior epigastric systems
or the terminal intercostal branches. However, these vessels
are much smaller in caliber 1–2 mm and present more tech­
nically challenging microanastomoses. In cases where the
internal mammary-epigastric axis is unavailable, the thora­
codorsal pedicle reach can be extended into the central
abdomen by way of vein grafts.
defect when the flap is advanced. Once the leading edge of
the keystone flap is inset the donor site is the closed on itself
from the poles of the long axis of the flap to the side of the
flap remote from the defect. The success of this flap is due
to the transposition tension from the advancement and
closure being distributed over the lengthy circumference of
the flap skin island.
REGIONAL FLAP OPTIONS
In cases where the defect size exceeds the availability of local
soft tissue for coverage the next line option is to consider a
regional pedicled flap. Use of regional flaps is often limited
when the defect is adjacent to the flap donor site, particu­
larly if the defect is a full thickness, or composite defect.
Regional pedicled flaps are harvested from adjacent ana­
tomic areas such as the chest, groin, thigh or back. Pedicled
flaps can be designed as either fasciocutaneous flaps, myo­
cutaneous flaps or muscle flaps resurfaced with a skin graft.
When selecting a pedicled flap it is important to factor the
donor morbidity incurred. As an example, a contralateral
vertical rectus abdominis myocutaneous flap can be used to
reconstruct a lower lateral abdominal wall defect, however
the donor site closure may compromise the flap inset
increasing the risk of postoperative complications. In addi­
tion, not only must the pedicled flaps ability to “reach” the
defect be considered but also how the transferred flap will
tolerate the rotational, flexion/extension forces placed on
it in the trunk. As an example, as the flap’s pedicle vessels
remain in their origin, the flap pedicle can pivot and tra­
verse the groin or flank and have its blood flow compro­
mised by compression or rotation at these areas.
FREE FLAP OPTIONS
Microsurgical free tissue transfer increases the capacity of
the reconstructive surgeon to provide soft tissue coverage
for abdominal wall defects that are not amenable to either
local or regional flap coverage. Flaps of essentially any size,
volume, dimension and composition can be transferred
from donor sites remote from the abdominal wall. While
much more technically demanding, the evolution of micro­
surgical techniques enables successful free flap transfer in
excess of 98% of cases.
There is a multitude of free flap donor site options avail­
able for abdominal wall reconstruction. The torso and thigh
are the main areas of flap harvest for defects in the upper
abdominal wall and epigastrium to the suprapubic region.
The posterior chest wall donor site yields the latissimus dorsi
myocutaneous flap, scapular/parascapular fasciocutaneous
flaps, thoracodorsal artery perforator flaps, and serratus
anterior muscle flaps. In addition, these flaps can be har­
vested together as a chimeric flap to increase the tissue
volume for flap transfer. These flaps can be transposed to
the upper epigastrium or subcostal region as a pedicled flap.
For defects beyond the reach of the thoracodorsal pedicle,
the flap can be converted to a free flap and be transposed
anywhere in the abdominal wall (Fig. 18.1).
In cases where a large skin paddle is required for the
abdominal wall defect, a free scapular or parascapular flap
can be designed on the circumflex scapular branch of the
subscapular arterial system. If a latissimus or serratus flap is

CHAPTER 18 — Abdominal Wall Reconstruction
223
judicious respiratory care and monitoring of pulmonary
function, as abdominal distention can compromise respira­
tory function. After discharge, patients should be instructed
to avoid strenuous activity that isolate the core truncal
muscle groups for at least 6 weeks, to optimize healing.
COMPLICATIONS
The most common complications after abdominal wall
reconstruction are surgical site infections, wound dehis­
cence, flap vascular compromise, seroma and mesh-related
infection. Surgical site infections are common after abdomi­
nal wall reconstruction, in addition to open ventral hernia
repair, although the exact incidence is difficult to deter­
mine, as most series poorly define this outcome variable.
Categorization of the intraoperative level of wound con­
tamination based on U.S. Centers for Disease Control and
Prevention (CDC) criteria into clean, clean-contaminated,
contaminated, and dirty wounds, is important to appropri­
ately stratify patients by risk of surgical site infection. In
patients
with
clean-contaminated
and
contaminated
wounds, a prospective multi-institutional study evaluating
the role of a porcine biologic mesh to repair abdominal wall
defects reported a 34% rate of superficial surgical site infec­
tions.9 In contrast, studies of clean wounds have reported
infection rates of 0–12%.10 All attempts possible should be
made to avoid surgical site infections, including aggressive
soft tissue debridement, evacuation and drainage of any
fluid collections, individualized prophylactic antibiotic use
and aggressive drain management.
Seroma formation can occur after open ventral hernia
repair or abdominal wall flap reconstruction. Subcutaneous
drains are placed in an attempt to obliterate the dead space
caused by the hernia and tissue dissection. To reduce the
risk of seroma formation, drains are often maintained for
up to 4 weeks. Intraoperative techniques, such as quilting
sutures or the progressive tension suture technique, may
help to prevent or reduce seroma formation. In general,
seroma treatment starts with serial percutaneous aspirations
and external garment compression therapy. If this is unsuc­
cessful, drains can be re-placed by direct open implantation
or radiographically guided percutaneous placement. The
use of sclerosing agents such as doxycycline or fibrin sealant
injection has also been described.11 The final option involves
operative exploration, pseudocapsule excision, quilting
suture placement, and drain placement.
Mesh infections are one of the most serious complica­
tions that can occur after an abdominal wall reconstruction.
Mesh infections are reported to occur in 6–10% of abdomi­
nal wall reconstructions employing mesh.12,13 The most
common organism infecting mesh is Staphylococcus aureus,
seen in up to 81% of cases; this suggests skin flora contami­
nation during mesh implantation. However, Gram-negative
organisms such as Klebsiella and Proteus spp. have been impli­
cated in up to 17% of mesh infections.13 Management of
mesh infections is complex and requires patient individual­
ization. In general, control of local sepsis is important, as is
preserving native tissue for eventual reconstructive proce­
dures. In some cases, macroporous polypropylene meshes
that become infected can be salvaged with local wound
measures and antibiotics and do not require removal.
Recipient vessels options exist beyond the abdominal wall
itself. There are a number of options in the groin based on
the superficial femoral system (see Figs 11.3, 11.6, 13.1,
13.2). The superficial inferior epigastric artery, the superfi­
cial circumflex iliac artery and the deep circumflex iliac
artery provide reasonable caliber vessels for free flap trans­
fer to the lower central and lateral abdominal wall. If
primary anastomosis is not feasible, then vein grafts or vein
loops are required. Vein grafts are often harvested from the
leg (greater or less saphenous vein) or arm (cephalic vein).
In addition, in abdominal wall reconstructions with concur­
rent laparotomy, intra-abdominal vessels can be used as
recipients if there are no local options in the abdominal wall
(see Figs 11.6, 38.2). The omental and gastroepiploic vessels
can be easily mobilized to reach the undersurface of the
abdominal wall. Care must be taken in insetting and sup­
porting the flap pedicle so that there is no tension on the
anastomoses when the visceral contents shift when the
patient transitions from supine to sitting/standing. In addi­
tion, the morbidity of re-entering the abdominal cavity must
be considered if there is a vascular thrombosis. Also, when
a mesh is used for the musculofascial reconstruction as an
adjunct to the fascia of the flap, the pedicle must traverse
an aperture in the mesh potentially increasing the risk of
pedicle kink and/or compromising the abdominal wall
integrity and potentially lead to a hernia defect. For these
reasons, local recipient options should be explored before
intra-abdominal vessels are selected.
Vein grafts and arterialized vein loops provide recipient
vessels in the central abdominal wall. Vein grafts can be
harvested from either the upper or lower extremity as a
cephalic vein (see Figs 12.22, 12.23) graft or saphenous vein
graft (see Fig. 13.19). For central and lower abdominal
defects, an arterialized saphenous vein loop can be designed.
The saphenous vein is dissected and transected distally and
then anastomosed to the superficial femoral artery or a side
branch. This allows delivery of the loop to the flaps recipient
site where the loop is divided providing an arterialized affer­
ent limb and a venous drainage efferent limb. This tech­
nique only requires three anastomoses instead of four as in
the case with direct arterial and venous vein grafts. Then
main recipient vessels sites for vein grafts or arterialized vein
loops are the thoracodorsal vessels, branches of the super­
ficial femoral system and the deep inferior epigastric vessels
can be used to extend the reach of vein grafts to the central
abdominal wall.
POSTOPERATIVE CONSIDERATIONS
Postoperative care of the patient undergoing abdominal
wall flap reconstruction is similar to that of any patient with
abdominal surgery; however, some points merit discussion.
Multiple subcutaneous drains should be placed in an effort
to prevent seroma formation, which may compromise flap
healing. An abdominal binder should be avoided postopera­
tively so as not to compress the flap pedicle or skin paddle
of the flap itself. Antiemetic prophylaxis should be given
postoperatively in an effort to prevent vomiting, which can
increase intra-abdominal pressures that can further strain
the musculofascial repair and/or flap perfusion. Addition­
ally, abdominal wall reconstruction patients should have

224
PART 3 — RECONSTRUCTION
However, microporous ePTFE mesh does not tolerate infec­
tion and almost always requires excision. An advantage of
biologic mesh materials is that they have the ability to toler­
ate a local wound infection if they are implanted in continu­
ity with well vascularized tissues. Once all infected fluid
collections have been drained and appropriate antibiotics
are administered, biologic mesh can be left in place even if
exposed and treated with NPWT. It is uncommon for bio­
logic mesh to require explanation in the presence of a local
soft tissue infection. Explantation would be reserved for
cases of abscess formation that prohibit the mesh for incor­
porating into the surrounding soft tissue. Abdominal wall
infection that degrades the integrity of a biologic mesh can
lead to an increase rate of bulge and potential hernia due
to the enzymatic degradation of the biologic mesh in a
chronic inflammatory wound milieu.
OUTCOMES
Abdominal wall reconstructions that require soft tissue flaps
represent the most formidable challenges in abdominal wall
reconstruction. Nevertheless, optimal outcomes can be
obtained with focus on patient selection, preoperative prep­
aration, operative technique and mitigation of postopera­
tive complications. With these tenets in mind, flap loss rates
should be as low as those encountered in other reconstruc­
tive areas. Similarly, when considering functional outcomes,
the incidence of recurrent hernia and bulge should
approach that of elective ventral hernia repair. Optimized
outcomes require a multidisciplinary approach, where the
synergistic actions of plastic surgeons and general surgeons
can reconstruct any abdominal wall defect.
CASE 18.1  Epigastric Defect Reconstructed with a Free Chimeric Latissimus Myocutaneous
Flap with Serratus Muscle Flap
Figure 18.1  (A) Preoperative view of planned composite full thickness resection of the abdominal wall including anterior reflection of
diaphragm. (B) Bioprosthetic mesh inlay bridging repair of the thoraco-abdominal defect. (C) Free chimeric latissimus myocutaneous flap
with serratus muscle flap. (D) Serratus muscle flap inset covering the bioprosthetic mesh with the latissimus myocutaneous flap providing
skin coverage. Right internal mammary vessels used as recipient vessels. (E) Patient at 6 months follow-up.
A
B
C
D
E
B

CHAPTER 18 — Abdominal Wall Reconstruction
225
CASE 18.2  Abdominal Wall Defect Reconstructed with a Free Anterolateral Thigh Flap
Figure 18.2  (A) Preoperative view of open abdomen treated with negative pressure wound therapy (NPWT). (B,C) A right-sided ALT flap
with vastus lateralis muscle was harvested on the descending branch of the lateral femoral circumflex system. (D) A sapheno-femoral A-V
loop was delivered into the lower abdominal defect to serve as recipient vessels. (E) Patient at 12 weeks follow-up.
A
B
C
D
E

226
PART 3 — RECONSTRUCTION
REFERENCES
1. Booth JH, Garvey PB, Baumann DP, et al. Primary fascial closure
with mesh reinforcement is superior to bridged mesh repair for
abdominal wall reconstruction. J Am Coll Surg 2013;217(6):
999–1009.
2. Lida T, Mihara M, Narushima M, et al. Dynamic reconstruction of
full-thickness abdominal wall defects using free innervated vastus
lateralis muscle flap combined with free anterolateral thigh flap.
Ann Plast Surg 2013;70(3):331–4.
3. Ninković M, Kronberger P, Harpf C, et al. Free innervated latissi­
mus dorsi muscle flap for reconstruction of full-thickness abdomi­
nal wall defects. Plast Reconstr Surg 1998;101(4):971–8.
4. Baumann DP, Butler CE. Lateral abdominal wall reconstruction.
Semin Plast Surg 2012;26(1):40–7.
5. Ghali S, Turza KC, Baumann DP, et al. Minimally invasive compo­
nent separation results in fewer wound-healing complications than
open component separation for large ventral hernia repairs. J Am
Coll Surg 2012;214(6):981–9.
6. Møller AM, Villebro N, Pedersen T, et al. Effect of preoperative
smoking intervention on postoperative complications: a ran­
domised clinical trial. Lancet 2002;359(9301):114–17.
7. Lin SJ, Butler CE. Subtotal thigh flap and bioprosthetic mesh
reconstruction for large, composite abdominal wall defects. Plast
Reconstr Surg 2010;125(4):1146–56.
8. Khouri JS, Egeland BM, Daily SD, et al. The keystone island flap:
use in large defects of the trunk and extremities in soft-tissue
reconstruction. Plast Reconstr Surg 2011;127(3):1212–21.
9. Itani KM, Rosen M, Vargo D, et al. Prospective study of single-stage
repair of contaminated hernias using a biologic porcine tissue
matrix: the RICH Study. Surgery 2012;152(3):498–505.
10. de Vries Reilingh TS, van Geldere D, Langenhorst B, et al. Repair
of large midline incisional hernias with polypropylene mesh: com­
parison of three operative techniques. Hernia 2004;8(1):56–9.
11. Butler CE. Treatment of refractory donor-site seromas with percu­
taneous instillation of fibrin sealant. Plast Reconstr Surg 2006;
117(3):976–85.
12. Baumann DP, Butler CE. Component separation improves out­
comes in VRAM flap donor sites with excessive fascial tension. Plast
Reconstr Surg 2010;126(5):1573–80.
13. Conze J, Kingsnorth AN, Flament JB, et al. Randomized clinical
trial comparing lightweight composite mesh with polyester or poly­
propylene mesh for incisional hernia repair. Br J Surg 2005;92(12):
1488–93.
Expert Commentary 
Jan Jeroen Vranckx, MD, PhD
Most full thickness abdominal wall defects can be recon-
structed by performing a perforator-saving component
release for soft tissue coverage and using a synthetic or
bioprosthetic mesh for abdominal wall strength. However,
complication rates are high in patients with two or more
comorbidities, especially when a primary closure is no longer
feasible. In a scarred and infected environment with pres-
ence of fistulas, after radiotherapy and in the presence of a
colostomy and urostomy, further component separation may
lead to more tissue hypoxia and spreading of infection. The
first goal is the treatment of infection and the coverage of
the bowels resulting in stable skin closure.
In an infected environment, only bioprosthetic meshes are
advocated to provide long-term structural support. Despite
their promise, several reports question the long-term durabil-
ity of bioprosthetic meshes, especially in a contaminated
milieu. Only a 50% recurrence-free survival over 3 years and
an overall wound complication rate of 48% or more were
reported. There is certainly a need for new-generation more
durable and less costly meshes that deliver long-term
strength when used in addition to pedicled or free flap
reconstructions.
In chronic complex bridged abdominal wall defects, vas-
cularized flaps generate the ideal milieu for a mesh that may
deliver extra strength. Free musculocutaneous flaps revas­
cularize the complex wound, supply coverage and add an
innervated dynamic muscular component. Due to temporary
denervation, free innervated flaps require a long recovery time
until the muscle is reinnervated. Pedicled innervated locore-
gional flaps may avoid this delay but are usually reported not
being able to reach the upper abdomen. When the pivot point
of the vascular pedicle is medialized from the sartorius
muscle, a thigh flap may reach to the xyphoid process. A
pedicled rectus femoris flap or an innervated vastus lateralis
muscle with a fasciocutaneous anterolateral thigh flap (PIVA
flap) can be used to restore the abdominal wall and create a
dynamic component that may improve the functional outcome
in those cases where a perforator-saving component release
and mesh reconstruction is not indicated.

e43
INTRODUCTION
Perineal and urogenital reconstruction has particular chal­
lenges due to the anatomic and functional complexity and
differences between the male and female genitalia. Further­
more, genital defects and abnormalities are associated with
psychological and social implications, which must be con­
sidered by the reconstructive surgeon. The complexity of
genital anomalies requires a multidisciplinary approach
with close cooperation between the reconstructive surgeon
and the urologist or gynecologist.
Pertinent functions to consider from a reconstructive
standpoint:
• General
• Micturition
• Urinary and fecal continence
• Intercourse
• Erogenous sensation
• Protective sensation
• Female
• Bidirectional vaginal/cervical patency (insemination,
menstruation, birth)
• Lubrication
• Male
• Erection
• Emission
• Ejaculation
• Extracorporal testicular location
• Upright micturition
ANATOMY
The perineum consists of a complex fibromuscular system,
which aids in actively supporting the abdominal and pelvic
viscera, and plays active roles in sexual function, micturi­
tion, and defecation. We focus on the recipient neurovascu­
lar structures located in the perineum.
GENDER-NONSPECIFIC ANATOMY
The perineum can be divided into an anterior, urogenital,
and a posterior anal triangle by a transverse line connecting
the ischial tuberosities (Fig. 19.1). In the urogenital triangle
we find the urogenital diaphragm, which spans between
both pubic rami and is perforated by the urethra and vagina.
Pelvic and Urogenital
Reconstruction
Jens U. Berli  |  Richard J. Redett III
19 
It also serves as the insertion point for the musculature of
the external genitalia (i.e., ischiocavernal and bulbospon­
giosal muscles). In the posterior lateral corner of the uro­
genital triangle, the neurovascular bundle enters the
perineal region from the pudendal canal (Alcock canal). It
consists of terminal branches of the pudendal nerve, the
internal pudendal artery and vein. The pudendal nerve is
split into the deep and superficial perineal nerve as well as
the dorsal nerve of the penis/clitoris. The artery too splits
into three branches: dorsal penile/clitoral artery, deep
dorsal penile/clitoral artery, and bulbous artery. The venous
drainage happens via the deep dorsal vein, the internal
pudendal system, as well as the earlier mentioned superficial
dorsal vein. The latter runs in the retropubic space and
drains into the vesical plexus. Branches of the internal
pudendal, obturator, and external pudendal vessels ensure
the blood supply to the vulva and scrotum.
The posterior anal triangle includes the ischioanal fossa,
the pudendal canal, and the anal sphincter system.
Pertinent neurovascular structures for the reconstructive
surgeon (see Chapter 11 for detailed discussion; also Figs
11.6 and 11.10):
• External pudendal artery and vein – superficial and deep
branch
• Medial circumflex femoral artery and vein
• Superficial circumflex iliac artery and vein
• Femoral artery and vein
• Saphenous vein
• Obturator artery and vein
• Obturator nerve
• Perineal branch of posterior femoral cutaneous nerve
• Iliohypogastric nerve
• Ilioinguinal nerve
• Genital branch of the genitofemoral nerve
PERTINENT MALE ANATOMY
Skin and fascial layers of the penis (Fig. 19.2):
• Skin
• Dartos fascia (continuation of Scarpa’s and Colles’ fascia)
• Areolar tissue and superficial dorsal venous system
• Buck’s fascia (continuum of suspensory ligament of penis
and perineal membrane)
• Unpaired deep dorsal vein, two dorsal arteries, two dorsal
penile nerves, spongy urethra
PART 3 — RECONSTRUCTION

e44
PART 3 — RECONSTRUCTION
Figure 19.1  Perineal region (urogenital and anal triangle). Note entrance of pudendal nerve and internal pudendal artery and vein via the
Alcock canal. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Pubic bone
Superior ramus of pubis
Symphysis pubis
Arcuate ligament of pubis
Deep dorsal vein of penis
Transverse ligament of pelvis
Inferior ramus of pubis
Dorsal artery and nerve of penis
Artery to urethral bulb
Urethra
Duct of Cowper’s (bulbourethral) gland
Deep artery of penis (profunda)
Inferior ramus of ischium
Superficial transverse perineal muscle (turned aside)
Central tendon of perineum
Fusion of superficial and deep fascia of
urogenital diaphragm
Cut edge of Colles’ fascia
Ischial tuberosity
Dorsal artery and nerve of penis
Cowper’s (bulbourethral) gland
Cut edge of inferior fascia
of urogenital diaphragm
Urethra
Regions (triangles) of the perineum
surface topography
Urogenital
triangle
Anal
triangle
Tip of coccyx
Ischial tuberosity
Ischio pubic
ramus
Symphysis
Deep transverse
perineal muscle
Sphincter urethrae
membranaceae

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e45
• Evaluate the defect and local anatomy
• Determine baseline fecal continence
• Assess the ejaculatory duct and amount of erectile tissue
(particularly important in congenital cases)
• Assess urinary tract and bladder function (i.e., presence
of perineal urethrostomy)
• Assess sensation and vascular supply to the region
INDICATIONS
For the purpose of this chapter, perineal and genital recon­
struction will be divided into acquired and congenital defor­
mities for both males and females:
• Penis/scrotum
• Acquired
• Phallic inadequacy
• Absent phallus
• Hidden penis
• Congenital
• Micropenis
• Aphallia
• Ambiguous genitalia
• Revision hypospadias repair
• Epispadia
• Bladder or cloacal exstrophy
• Vagina/vulva
• Acquired (trauma, oncologic resection)
• Vaginal defect
• Vulvar defect
• Congenital
• Vaginal agenesis
• Mayer–Rokitansky–Küster–Hauser
• Androgen insensitivity syndrome
• Ambiguous genitalia
• Bladder and cloacal exstrophy
• Pelvic floor
• Bladder and cloacal exstrophy
• Acquired from trauma or tumor extirpation
• Gender dysphoria
• Tunica albuginea
• Corpora cavernosa including deep penile arteries
PERTINENT FEMALE ANATOMY
The vagina is an elastic muscular tube that measures 5–10 cm
in length and 2 cm in width (Fig. 19.3). It enters the
perineum at an angle of inclination of around 30°. It is
bordered anteriorly by the bladder and urethra and poste­
riorly by the rectum and it is attached laterally to the pelvic
musculature. An abundance of autonomic innervation is
responsible for secretions and involuntary contractions.
Pain fibers are derived from the sacral plexus, and the
tactile and erogenous sensation is provided via the deep
perineal branch of the pudendal nerve. There is a rich
vascular supply consisting of multiple arcades that are
derived from the vaginal artery via the internal iliac
system.
PREOPERATIVE CONSIDERATIONS
Perineal and urogenital defects can have a varying degree
of functional, psychological, and aesthetic impairment. For
example, a short penile stump may be sufficient for upright
micturition but insufficient for sexual penetration. In the
pediatric population, emotional, cognitive, and body image
development may be affected by both the genital deformity
and the reconstructive surgery. In addition, donor site mor­
bidity and stigma can play a significant role in the choice of
reconstructive options.
The preoperative evaluation for the reconstructive surgeon
includes an assessment of the anatomic defect, evaluation of
the functional and aesthetic impairment and availability of
local or distant tissue used for the reconstruction. A thor­
ough sexual history should be obtained and realistic expecta­
tions defined. A multidisciplinary approach, including the
reconstructive surgeon, urologist, and gynecologist, can play
an important role. It is also important to consider the psy­
chological implications of a genital deformity prior to under­
taking any complex reconstruction.1
A preoperative urologic, gynecologic, and anorectal exam
should be performed to determine the following:
Figure 19.2  Cross-section through the body of the penis. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Superficial dorsal vein
Dorsal artery and nerve
Lateral superficial vein
Corpus cavernosum and its
tunica albuginea
Deep artery
Corpus spongiosum and its
tunica albuginea
Skin
Deep dorsal vein
Superficial (dartos) fascia of penis
Deep (Buck’s) fascia of penis
Intercavernous septum of deep fascia
Urethra

e46
PART 3 — RECONSTRUCTION
1. The procedure should be reproducible.
2. The penile reconstruction should result in a neourethra
that is capable of passing urine while standing in those
patients who are continent.
3. The neophallus should have both tactile and erogenous
sensation.
4. The reconstruction should provide enough bulk to
accept a prosthetic for erection and sexual penetration.
5. The neophallus should be aesthetically acceptable to the
patient.
Described Locoregional and Pedicled Flaps
• Groin flap
• Suprapubic flap
• Anteromedial thigh flap
• ALT2
• DIEP
RECONSTRUCTION BY REGION
Please see flap chapters for exact anatomy and harvest of
each respective flap. We focus on pertinent technical varia­
tions here.
PHALLOPLASTY
GENERAL PRINCIPLES OF
TOTAL PHALLOPLASTY
Phallic inadequacy that is not amenable to standard, local
penile lengthening procedures (i.e., penile stump ad­
vancement, suspensory ligament release, V-Y advancement,
penoscrotal web excision) can be treated with reconstruc­
tive phalloplasty using local or distant flaps. The goals for
penile reconstruction include:
Figure 19.3  Neurovascular supply to the female perineum. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Dorsal n. of clitoris
Posterior labial nn.
Superficial
Deep
Branches of perineal n.
Dorsal n. of clitoris passing superior to
perineal membrane
Gluteus maximus m. (cut away)
Pudendal n. in pudendal canal (Alcock) (dissected)
Perineal n.
Sacrotuberous lig.
Inferior anal (rectal) nn.
Posterior labial artery
Perineal artery
Internal pudendal artery
in pudendal canal (Alcock’s)
Inferior rectal artery
Internal pudendal artery
in pudendal canal (Alcock’s)
Dorsal artery of clitoris
Deep artery of clitoris
Artery to bulb of vestibule
Internal pudendal
(clitoral) artery
Perineal artery (cut)
Inferior rectal artery
Note: Deep perineal (investing or
Gallaudet’s) fascia removed from
muscles of superficial perineal space.

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e47
• Dorsal nerve of the clitoris (in Gender affirming surgery)
• Protective sensation: ilioinguinal, iliohypogastric, genito-
femoral, (L1–L4) saphenous, femoral nerve
LOCAL TISSUE USED FOR RECONSTRUCTION
There is a variable amount of native donor tissue that can
be used as part of the reconstruction. This is particularly
true for phalloplasty in gender affirming surgery and con­
genital conditions, where the remnant glans or clitoris can
be incorporated into the base of the neophallus. Similarly,
preserving the clitoral hood or parts of the labia is useful
for scrotal reconstruction. In the case of inadequate phallic
length in both congenital and acquired conditions, it is
prudent to preserve native corpora cavernosa that can be
used to proximally secure the IPP or fibula.
FLAP DESIGN
The overall size and design of the phalloplasty is similar,
regardless of the flap choice (Figs 19.5, 19.6). The surgeon
may decide to incorporate a urethral section in the flap if
immediate urethral reconstruction is desired.
URETHROPLASTY
There are four accepted methods of urethroplasty that can
be offered and discussed with the patient:
Described Free Tissue Flaps
• Radial forearm free flap phalloplasty (RFFFP)3
• Free fibula4
• Latissimus dorsi (± innervation)5
• ALT2
• Gracilis myocutaneous flap
• Chimeric ALT/sartorius flap
• SCIA
• Scapular
• LAF/ELAF
The Key Steps for Microvascular Phalloplasty
• Free tissue transfer with neurovascular coaptation to
create a sensate flap
• Glansplasty
• Delayed or immediate urethroplasty
• Glansplasty: no mention of timing.
• Tattooing of phalloplasty and laser hair removal (if
needed) before return of protective sensation (usually
performed between 3 and 6 months)
• Implantation of IPP after return of flap protective sensa­
tion – usually at 1 year
• Scrotal plasty using local tissue or pedicled medial thigh
flaps.6,7 The tissue can be augmented with scrotal silicone
implants.
These key steps can be performed in a single reconstruc­
tion or staged depending on the surgeon’s preference and
the patient’s needs. However, the safest and most predict­
able approaches that lead to the lowest rates of urethral
stricture or fistula formation seem to be the following:
1. Initial operation: Phalloplasty including vascularized
neourethra (either tube within a tube or a pedicled
SCIP), including glans
2. At 12 months: IPP, scrotal plasty
or
1. Initial operation: phalloplasty including glans
2. At 3 months: creation of neourethral plate (FTGS or
buccal graft)
3. At 6 months: 2nd stage of urethroplasty – tubularization
4. At 12 months: IPP; scrotal plasty
RECIPIENT NEUROVASCULAR STRUCTURES
The options for recipient neurovascular structures (Fig. 19.4,
see also Fig. 11.3, 11.6, and 11.8) for microvascular phallo­
plasty include:
• End-to-side: femoral artery (with or without reversed
saphenous interposition graft)
• End-to-end: femoral side branches, inferior epigastric
Recipient vein:
• End-to-end: saphenous vein or inferior epigastric
Recipient nerves:
• Erogenous (S4-Co): dorsal penile nerves (branch of
pudendal nerve)
Figure 19.4  Urogenital recipient vessel. Locoregional recipient
vessels in the example of a phalloplasty.
Ilioinguinal nerve
Dorsal penile nerve
Medial
antebrachial
cutaneous
nerve
Lateral antebrachial
cutaneous nerve
Saphenous
vein
Saphenous vein graft
Femoral
artery
Radial artery
and vein

e48
PART 3 — RECONSTRUCTION
IMMEDIATE RECONSTRUCTION WITH
A VASCULARIZED FLAP
A thin SCIP flap or a free ulnar forearm flap can be used
to create a vascularized neourethra in cases where a tube
within a tube is not feasible. Most often this is combined
with a pedicled ALT.
DELAYED RECONSTRUCTION
Tubed Skin Graft
A full-thickness skin graft (groin, expandable donor site,
labia minores) is wrapped around a Foley and inserted into
the phalloplasty. In order to prevent downstream fistula
formation, the tissue edges should overlap.
Creation of a Neourethral Plate and
Tubularization at a Subsequent Stage
At 3 months following phalloplasty, the ventral surface is
opened and a full-thickness skin graft or buccal mucosal
graft is placed to re-create the urethral plate. At 3–6 months
PRELAMINATION METHOD
(Fig. 19.7)
A full-thickness skin graft is wrapped around a Foley cath­
eter and placed under the proposed flap 3 months prior to
the phalloplasty. This method has been shown to provide a
viable continuous urethra of sufficient length, as well as a
trend to a lower incidence of urethral fistulas and better-
controlled girth.8
IMMEDIATE RECONSTRUCTION WITH
A TUBE-IN-TUBE DESIGN
This is the most commonly described method, where a
1.5 cm wide longitudinal strip is de-epithelialized 3 cm to
the lateral border of the flap. The lateral skin bridge is then
rolled over a Foley catheter and sutured to itself. The main
fasciocutaneous flap is rolled in the counter direction
around the neourethra (Fig. 19.5). For a radial forearm free
flap phalloplasty, the ulnar side of the flap is generally
chosen for the urethra, as it tends to contain less hair.
Figure 19.5  Tube-in-tube concept. Formation of the neophallus and immediate urethroplasty. A 1.5 cm wide longitudinal strip is de-epithelialized
3 cm to the lateral border of the flap. The lateral skin bridge is then rolled over a Foley catheter and sutured to itself. The main fasciocutaneous
flap is rolled in the counter direction around the neourethra. For a radial forearm free flap phalloplasty, the ulnar side of the flap is generally
chosen for the urethra, as it tends to contain less hair. Note the bottom right showing design without a tube-in-tube.
1.5cm
15x15cm
Coronaplasty
Urethroplasty/tube in tube
Design without tube in tube
Glansplasty
Coronaplasty
Glansplasty
3cm

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e49
placed coming out of the proximal, ventral surface of the
free flap in case of flap failure. At a subsequent stage, the
native urethra can be internalized for the urethroplasty and
the glans can be de-epithelialized and inserted into the
phallus. When reconstructing the urethra, a 12–14 French
catheter is used in pediatric and exstrophy patients and a
16–18F in the adult population.
GLANSPLASTY
For a glansplasty (Fig. 19.8), we prefer to create the neo­
coronal ridge before elevating the flap. To create a more
natural appearance of the glans, the neocoronal ridge can
be marked out in a boomerang shape but a plain circum­
ferential incision is also acceptable. The incision is made
about 3.5–4.0 cm from the distal tip of the neophallus. A
proximally based 1 cm skin flap is elevated in the deep
dermal plane circumferentially around the phallus. The
thin skin flap is folded onto itself and secured with inter­
rupted 5-0 polyglyconate suture to create the corona. The
palmaris longus tendon or a thin strip of acellular dermal
matrix can be inserted within the neocoronal ridge in an
attempt to reduce subsequent flattening. The exposed deep
dermal/subcutaneous donor site is then covered with a full-
thickness skin graft. The skin graft usually heals, appearing
like a scar, similar to that seen following circumcision. Over
time, the neocoronal ridge can flatten. Further reconstruc­
tion of the ridge can be accomplished by inserting acellular
dermal matrix or injectable fillers. The slightly darker color
of the glans can be achieved with tattoo techniques. Recon­
struction of foreskin is technically not feasible or has at least,
not been described.
IMPLANTABLE PENILE PROSTHESIS
To reduce the risk of implant erosion or extrusion, insertion
of the implantable penile prosthesis (IPP) is usually delayed
12 months for the return of sensation. For the same reason,
it is prudent to account for sufficient distal soft tissue cover­
age at the time of phalloplasty. Various techniques are
described to reduce the risk of erosion and extrusion, such
as reinforcing the most distal area of the IPP prosthesis with
fascia latae, acellular dermal matrix, or a polyethylene tere­
phthalate sleeve. In congenital cases, the IPP should only be
implanted in the late adolescence to early adulthood, as a
high degree of maturity is needed to avoid complications.
The main complications of IPP are:
• Mechanical dysfunction
• Leakage of reservoir
• Erosion and extrusion
• Infection
• Penile fibrosis/disfigurement
TIMING OF PHALLOPLASTY FOR CONGENITAL CASES
The normal male genitalia experiences exponential growth
during puberty secondary to increased testosterone recep­
tor density. A neophallus lacks these receptors and will only
grow longitudinally with the child. Therefore, reconstruc­
tion is usually delayed until after puberty to ensure adequate
size of the phalloplasty. This, however, has to be balanced
against the potential downside of delayed psychosexual
development.
later, the healed graft is tubularized over a Foley catheter
and the skin edges of the phallus are closed over the tubed
graft. A sheet of acellular dermal matrix can be inserted as
a layer of tissue that separates the two suture lines. This
repair is similar to certain methods used for hypospadia
repair.
Prelamination and delayed formation of a neourethral
plate and subsequent tubularization seem to offer the best
long-term result with the downside being multiple-staged
surgeries.
When not performing a prelaminated or immediate ure­
throplasty in congenital cases of micropenis or penile insuf­
ficiency, the native glans/urethra can be preserved and
Figure 19.6  Phalloplasty design. Outline of the phalloplasty design
on the volar forearm. Width of the flap should approximate 15 cm
and be centered over the radial artery. Depending on the size of the
forearm, the remaining skin bridge on the dorsum can be as narrow
as 2–3 cm.
Medial
antebrachial
cutaneous
nerve
Lateral antebrachial
cutaneous nerve
Radial artery
and vein
Cephalic vein
Basilic vein
Flap

e50
PART 3 — RECONSTRUCTION
RADIAL FOREARM FREE FLAP PHALLOPLASTY
Since its first description by Chang et al. in 1984, the radial
forearm free flap phalloplasty (RFFFP) has become the gold
standard due to the tissue pliability, limited donor site mor­
bidity, dual sensory innervation, and aesthetic outcome.3
Provided there is mixed radial–ulnar vascular supply, the
flap should be harvested from the nondominant hand (see
also Chapter 47).
FLAP CHARACTERISTICS
Neurovascular Structures
• Arterial: radial artery
• Venous: venae comitantes, cephalic vein
• Innervation: medial and lateral antebrachial cutaneous
nerves
Flap Size and Design
Approximately 15 × 15 cm (Fig. 19.6).9
Figure 19.7  (A–C) Prelamination method of urethral reconstruction. Placement of a Foley catheter with a full-thickness skin graft, at the loca­
tion of the future phalloplasty flap design. Example: free fibula phalloplasty.
Insertion
Urethral sound
16 French
Foley
6”
Full
thickness
skin graft
(neourethra)
Neourethral tunnel
B
A
C
Figure 19.8  Glansplasty. The neoglans is formed by elevating a
circumferential epidermal–dermal skin ridge that is folded on itself
with interrupted absorbable sutures. The donor site is skin grafted
with a small strip of full-thickness skin graft. This will give the appear­
ance of a circumcised glans.

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e51
ADVANTAGES
• Low donor site morbidity
• Large flap surface
• Almost hairless in some patients
• Pedicled option
• Stout TFL fascia (neotunica albuginea)
DISADVANTAGES
• Too bulky in many patients
• Moderate variability in perforator anatomy
• Unpredictable preoperative markings make a one-stage
reconstruction challenging
• Sensation inferior to RFFFP
FREE FIBULAR PHALLOPLASTY
The rigidity of a free osteocutaneous sensate fibular phal­
loplasty4 offers an alternative to the RFFFP (Fig. 19.9) (see
also Chapter 52).
NEUROVASCULAR STRUCTURES
• Arterial: peroneal artery
• Venous: venae comitantes
• Innervation: lateral sural cutaneous nerve
Figure 19.9  Inset of fibula free flap phalloplasty. If available, the
remaining dartos fascia surrounding the corpora cavernosa can be
sutured to the periosteum of the fibula (alternative: drill holes).
Fibular
bone
graft
Level of
reconstruction
Reconstructed
urethra
Corpus cavernosum
Pearls and Pitfalls
• Due to the absence of hair growth the ulnar sided
skin is preferred for the creation of the neourethra.
• A pneumatic pressure cuff can be applied to
facilitate bloodless dissection of the flap.
• The flap is elevated below the fascia to protect the
antebrachial cutaneous nerves and ensure adequate
flap thickness. The deep fascial layer may also help
protect the IPP.
• The choice of recipient neurovascular structures
depends on the surgeon’s preference.
• Care must be taken to expose both the dorsal
penile/clitoral nerve and a nerve of the
lumbosacral plexus (i.e. ilioinguinal).
• The palmaris longus tendon can be used to
secure the phalloplasty to the symphysis pubis
much like the penile suspensory ligament. It can
also be used to augment the neocorona.
Pearls and Pitfalls
• Flap design analogous to RFFFP except that
perforator anatomy can be variable and the
preoperative skin paddle markings may shift
depending on intraoperative findings.
• The TFL fascia can be used as neotunica albuginea
and/or to reinforce the distal part of the flap
(prevention of IPP extrusion).
• Pedicled: The ALT is raised and the vascular
pedicle is mobilized as far proximal as possible. In
order to decrease the distance to the defect and
tension on the pedicle, the flap can be tunneled
underneath the rectus femoris.
ADVANTAGES
• Consistent anatomy
• Thin and pliable
• One-stage reconstruction possible
• Two separate sets of sensory nerves (protective and erog­
enous sensation)
• Best sensory and aesthetic outcome of all phalloplasty
options10
• Long pedicle that can reach a variety of groin or lower
abdominal recipient vessels
DISADVANTAGES
• Donor site is difficult to hide
• Technically difficult
• Time consuming
• Hair-bearing
ANTEROLATERAL THIGH FLAP
The ALT2 can be used as a pedicled or free flap (see also
Chapter 59).
PEDICLE
• Descending branch of lateral femoral circumflex artery
and its venae comitantes
• Lateral femoral cutaneous nerve
Pearls and Pitfalls
• The vascular pedicle needs to be dissected all the
way to the tibioperoneal trunk in order to obtain
adequate length.
• A fibular bone length of approximately 10 cm is
adequate for sexual function.
• The periosteum or drill holes of the fibula are
sutured to remaining recipient tunica albuginea or
the pubic symphysis. This enhances rigidity and
structural continuity.
• In order to avoid tension on the neurovascular
pedicle a partial subperiosteal dissection releasing
the pedicle should be performed.

e52
PART 3 — RECONSTRUCTION
may be attributed to dissociated sensibility and the ability of
the brain to interpret tactile stimuli as erogenous in nature.
All these outcomes are based on the Belgium experience
with RFFFP reconstruction.10
VULVAR AND VAGINAL
RECONSTRUCTION
GENERAL PRINCIPLES
The ideal vaginal reconstruction or vaginoplasty forms a
lubricated, hairless, sensate, odorless, and distensible invagi­
nation in the urogenital triangle of the perineum with a
natural angle of inclination. For total vaginal reconstruction
in the setting of congenital agenesis, various techniques
have been developed from simple serial dilations, the Vec­
chietti balloon pull-through technique, surgical peritoneal
inlay, blunt dissection, and coverage with skin or skin-like
tissue (i.e., STGS, amnion homografts, vulvar flaps, buccal
mucosal grafts). Alternatively, there are two flap-based cat­
egories: locoregional pedicled flaps and intestinal pedicled
flaps. Reconstruction of acquired defects is often more
complex, as there can be involvement of adjacent structures.
A minimum of approximately 4–5 cm of pliable vaginal
stump is necessary for sexual function.
Described locoregional and pedicled flaps for vaginal
agenesis:
• Intestinal flaps
• Sigmoid
• Cecum
• Ileum
• Bilateral gracilis myocutaneous flaps
• Bilateral pudendal thigh flap11
Described locoregional and pedicled flaps for acquired
vaginal defects where more tissue is required:
• Pedicled VRAM
• Pedicled ALT
• Gracilis
• Pudendal thigh flap
• SGAP
• IGAP
Male-to-female gender affirming surgery with the inverted
penile technique is a complex local tissue rearrangement
that is not within the scope of this book.
NEUROVASCULAR PUDENDAL THIGH FLAP:
SINGAPORE FLAP11
The Singapore flap is shown in Figure 19.10.
INDICATIONS
• Vaginal agenesis
• Acquired defects
DESIGN/PEDICLE
• Bilateral horn-shaped skin islands 15 × 6 cm
• Arterial: based on the perfusion network of the posterior
labial artery (which anastomoses with external pudendal
ADVANTAGES
• Sensate
• Rigidity for penetration
• Autologous material
• Long vascular pedicle
• One less operative step as an IPP can be avoided
DISADVANTAGES
• Donor site morbidity
• Technically difficult
• Bone extrusion
• Bone resorption/warping leading to disfigurement
• Hair-bearing
• Single sensory innervation
• Cosmetic appearance of constant erection
POSTOPERATIVE CONSIDERATIONS AFTER
TOTAL PHALLOPLASTY
• Penile foam sleeve or other splint secured to suprapubic
skin to prevent kinking of pedicle
• Abduction pillow can help unload reconstruction and
keep area dry
• Removal of urethral catheter at day 10–14
• Bed rest for 5–7 days
• Long-term urologic follow-up
• Assessment of need for further psychological evaluation
and treatment
COMPLICATIONS
• Partial or total flap loss
• Early urethral fistula – conservative management
• Late urethral fistula – requiring revision
• Urethral stricture
• Delayed wound healing
• Neourethral stone formation
• Extrusion of penile implant
• Dysfunction of penile implant
• Inadequate length
• Incomplete skin graft take at donor site
OUTCOMES
The phalloplasty population is very heterogenous and there­
fore, general outcomes are hard to predict. About 40–80%
of patients will suffer urologic complications such as early
or late fistula formation and urethral stenosis (most of
which can be treated conservatively). Around 70% will com­
plain of post-voiding dribbling. If a neourethra is recon­
structed, close to 100% of patients will be able to void
standing. Long-term data as to durability of IPP are missing
but in the Belgium experience, 44% of patients needed
revision surgery or removal of the implant at a mean
follow-up of 22 months secondary to implant leakage,
mechanical dysfunction, or implant erosion. It can be
expected that 100% of patients will regain tactile sensation.
About two-thirds of patients will be able to perform penetra­
tive sexual intercourse for some period after their recon­
struction. Of the patients that participate in sexual activity,
a vast majority will be able to reach an orgasm. Part of this

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e53
perimysium of the adductor mass. This preserves the fascial
plain and ensures robust vascularity of the flap. The vascular
pedicle is not visualized during the dissection. The posterior
edge of the flap is undermined in a subdermal plane to give
the flap more mobility. Both flaps are then either tunneled
or laid into the defect. The flaps are sutured together along
all free skin edges and then inverted and inset. It is impor­
tant to secure the apex of the neovagina to the sacrum or
pelvic sidewall to prevent it from shortening or prolapsing
as it heals. In case of an intact vulva, there is the option
of tunneling the flaps, so as to not disrupt the intact
external genitalia. Drains are placed in both donor and
recipient site.
artery, medial femoral artery, and anterior branch of
obturator artery overlying the adductor mass)
• Venous drainage: analogous to arterial supply
• Innervation:
• Posterior labial branches of the perineal nerve from
the pudendal nerve
• Posterior cutaneous femoral nerve
TECHNIQUE
In order to capture the entire vascular network, the flap
is designed as a 15 × 6 horn-shaped skin paddle overlying
the adductor muscle mass in the groin crease adjacent to
the labia majores. The dissection is carried down to the
Figure 19.10  (A–C) Singapore and (D–F) bilateral gracilis flap for vaginal reconstruction. The basic principles behind both reconstructions are
the same. But note the location of the scars–groin crease (Singapore flap) versus medial thigh (gracilis-based reconstruction).
B
A
C
E
D
F

e54
PART 3 — RECONSTRUCTION
ADVANTAGES
• Easy dissection
• Low donor site morbidity
• Good vaginal length and natural angle of inclination
• Can be tunneled into the vaginal defect and hereby pre­
serve the external genitalia
• Moderately sensate
• Scar outside of actual perineal region (less stigmatizing)
DISADVANTAGES
• Unreliable vascularity of distal skin paddle. This is par­
ticularly important, as the distal pole is least amenable to
postoperative inspection
• Short pedicle (pertinent for perineal reconstruction)
• Scar visible in summer clothes
• Prolapse
PEDICLED ANTEROLATERAL THIGH FLAP
See also Chapter 59 for the anterolateral thigh flap (ALT).
INDICATIONS
• Low posterior defects
• Combined perineal and posterior vaginal defects
TECHNIQUE
See pedicled ALT for phalloplasty.
ADVANTAGES
• Low donor site morbidity
• Large bulk
DISADVANTAGE
• Medial and lateral scar
VERTICAL RECTUS ABDOMINUS MYOCUTANEOUS
See also Chapter 37 for the rectus abdominis flap (VRAM).
INDICATIONS
• Apical defects
• Posterior wall defects (s/p abdominoperineal resection,
pelvic exenteration)
• Perineal defects
• Coverage of hardware after sacrectomy
DESIGN/PEDICLE
• For partial defects the skin paddle is designed vertically.
In circumferential defects a transverse design will facili­
tate the formation of a tube.
• Arterial: deep inferior epigastric artery
• Venous: venae comitantes
ADVANTAGES
• Thin
• Sensate
• Ease of harvest
• Reliable vascularity
• Minimal donor site morbidity
• Natural angle of inclination
DISADVANTAGES
• Hair-bearing
• Limited vaginal length
• Unsightly scar
BILATERAL GRACILIS
See also Chapter 49 for the gracilis flap.12
INDICATIONS
• Total vaginal reconstruction
• Partial vaginal reconstruction
DESIGN/PEDICLE
Oval skin paddle, 6 × 20 cm
Artery: branch of the medial femoral circumflex artery
Venous: venae comitantes
Motor and sensory innervation: branch of obturator
nerve
TECHNIQUE
The skin paddle is oriented along the length of the muscle.
Perforators can be identified preoperatively with a Doppler.
Dissection can start distally to identify the tendinous inser­
tion of the gracilis. Once the muscle is identified, the mark­
ings for the skin paddle can be altered if needed. The flap
is dissected proximally where the pedicle is identified, usually
7 cm below the pubic symphysis. The muscle is disinserted
distally but not proximally. It is pivoted at the point of the
proximal pedicle and the flap is tunneled subcutaneously
through the medial thigh and medial groin and the labia.
The inset is performed analogous to the Singapore flap and
the free proximal skin edge is sutured to the introitus.
Pearls and Pitfalls
• The Woods modification of the Singapore flap
consists of releasing both labia majora and allowing
them to retract anteriorly, creating a space through
which the flaps can be passed. By doing this, the
flap does not need to be islandized and can be
inset easier, faster, and with less tension. This
modification comes with some degree of aesthetic
deformity that has to be weighed against fewer flap
complications.
• Laser hair removal can be considered preoperatively.
Pearls and Pitfalls
• Be aware to protect the saphenous nerve and vein
during the distal part of the dissection.
• The perfusion of the distal aspect of the skin flap
should be carefully evaluated. Intraoperative laser
angiography can be used to assess the skin paddle
if needed.
Pearls and Pitfalls
• Preservation of the symphyseal attachments can
protect the vascular pedicle from excess tension.
ADVANTAGES
• Reliable pedicle
• Ease of harvest
• Large bulk to fill pelvic dead space

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e55
• Return to the operating room on postoperative day 5 for
exam under anesthesia to rule out partial flap necrosis
and for proper washout
• Pressure-relief specialty mattress
• Early postoperative urinary retention can compress
vascular pedicle against pubic symphysis. Avoid early
de-catheterization by primary team
• Digital dilation and use of dilators at around 2–3 after
surgery if adequately healed
• Resume sexual activity at 6 weeks
COMPLICATIONS
• Hematoma
• Infection
• Partial or total flap loss
• Donor site morbidity
• Positive resection margins in setting of immediate
reconstruction
• No additional incisions necessary in case of an existing
laparotomy.
DISADVANTAGES
• Insensate
• Significant donor site morbidity (i.e., incisional hernia
formation, bulging)
• Potential need for mesh/acellular dermal matrix rein­
forcement of donor site
• May interfere with stoma placement
• Can be too bulky especially in obese patients (especially
if rectum still present)
INTESTINAL VAGINOPLASTY
The pedicled sigmoid pouch is the most commonly used,
flap-based reconstruction for vaginal agenesis due to its
vicinity to the perineum, ease of dissection, and vascular
reliability. It is less frequently used in oncologic cases, as the
sigmoid colon does not provide enough bulk for the sur­
rounding defect and is often part of the resection. Alterna­
tive intestinal sites reported are ileum and cecum. The
procedure can be performed laparoscopically (Fig. 19.11).
TECHNIQUE
The sigmoid is mobilized and a 10–12 cm segment is discon­
nected with the help of a linear surgical stapler. The free
sigmoid segment is dissected free on the left-sided pedicle
and brought into the perineal defect created to host the
neovagina. The distal portion is externalized and secured
with sutures to the surrounding introitus.
ADVANTAGES
• Most natural lining
• Lubrication
• Vaginal depth up to 12 cm
DISADVANTAGES
• Overall increased morbidity and mortality compared to
other options
• High incidence of excess discharge and malodor
• Insensate
VULVAR RECONSTRUCTION
In the setting of total vaginoplasty, there is usually a partly
intact vulvar component so local tissue rearrangement often
suffices. In the gender dysphoria population the remaining
scrotal tissue is used to reconstruct the vulva.13 Isolated
vulvar defects after ablative surgery or trauma are usually
reconstructed using either local tissue (i.e., lotus petal flaps)
for small defects or thigh or anterior abdominal wall–based
flaps in larger defects.14,15 Combined vulvar and vaginal
defects are usually treated with one flap (i.e., VRAM).
Overall, the goal of vulvar reconstruction is to re-create the
appearance and protective function of the labia majora.
POSTOPERATIVE CONSIDERATIONS AFTER
VAGINOPLASTY
• Abduction pillow can help unload reconstruction and
keep area dry
Figure 19.11  Intestinal vaginoplasty. Note the proximity of the vagi­
noplasty to the donor site and abundance of vascular supply via the
inferior epigastric system.
End-to-end
colo-colostomy
Introitus

e56
PART 3 — RECONSTRUCTION
• Pedicled SGAP
• Pedicled IGAP
The lotus petal flaps are based on the perineal and inner
thigh perforators that are supplied by the following
arteries:
• SCIA
• SIEA
• Superficial external pudendal artery
• Deep external pudendal artery
• Obturator artery
• Pudendal artery and its branches (perineal artery)
In larger defects or surgeon’s preference, the following
pedicled flaps are also suitable options.
Pedicled flaps:
• Gracilis
• Pedicled ALT
• Pudendal island flap
• Posterior thigh flap
• Gluteal rotational flaps
In case of communication with the intraperitoneal cavity,
flaps may need to fill dead space and, if the fasciocutaneous
defect cannot be closed tension free, provide fasciocutane­
ous lining. For this indication, the following three flap-
based options are widely accepted:
• Pedicled ALT
• Rectus abdominis pull-through
• Gracilis
By far the most frequently used is the VRAM flap. However,
in cases where there is no midline laparotomy, other skin
paddle orientations such as the transverse or oblique
(TRAM/ORAM) can be considered. The oblique pattern
has the main advantage of a greater arc of rotation. If both
inferior epigastric systems are patent, the tendency is to take
the right-sided rectus muscle in case of a future colostomy
placement. Previous radiation, ventral hernia formation,
fecal diversion, and multiple previous abdominal proce­
dures are relative contraindications to rectus abdominis
reconstruction, and a pedicled ALT or gracilis myocutane­
ous flap should be considered. In cases of large pelvic
defects, the use of an acellular dermal matrix can help
reconstruct the pelvic floor. If so, it is sutured to the remain­
der of the pelvic floor musculature/fascia.
A different entity that needs a mention are the large
pelvic exenterations that include sacrectomy and/or ischi­
ectomy, in which case a combination of flaps including
pedicled VRAM, pedicled TRAM, unilateral or bilateral
gluteal advancement flaps, pedicled omental flaps, and in
situations where bony reconstruction is required and non-
vascularized bone grafts are inadequate (previous radia­
tion), free tissue transfer with an osseous component may
be necessary.19,20,21
In ablative surgery, the benefit of flap-based reconstruc­
tion lies in decreased tissue tension, increased blood
flow with subsequent improved oxygenation, and delivery
of immune cells. Furthermore, it gives the ablative
• Pelvic prolapse
• Neovaginal stenosis
• Inadequate vaginal length
• Hair growth
• Poor lubrication
• Malignancy
• Dehiscence/ulceration
• Dyspareunia
• Vaginal prolapse
• Fistula (urethrovaginal, vesicovaginal, and rectovaginal)
• Malodor/drainage
OUTCOMES
There are multiple techniques used in vaginal reconstruc­
tion and comparative outcome studies are rare.16,17 The
gracilis has the highest rate of partial flap loss, primarily of
the skin paddle. The VRAM is robust and has proven to be
very reliable for vaginal reconstruction. However, it comes
with the risk for abdominal wall weakness and hernia forma­
tion. Sexual outcomes following vaginal reconstruction are
dependent on the patient’s preoperative sexual activity and
absence of complications such as fistula formation. If healing
is as uneventful, the vast majority can be expected to resume
penovaginal intercourse.
Serial dilation is the most commonly performed method
for reconstruction in vaginal agenesis. When serial dilation
is inadequate or contrary to patient preference, flap recon­
struction is a viable option. Intestinal vaginoplasty is the
preferred method as it gives the most natural result.
However, approximately 7% of these patients will suffer
from excess discharge and malodor and around 10% can
expect neovaginal prolapse. A majority of patients report
satisfactory sexual function.
PERINEAL AND PELVIC FLOOR
RECONSTRUCTION
GENERAL PRINCIPLES
Pelvic defects can be isolated or occur in combination with
vaginal defects. Conceptually, there are two different peri­
neal defects.
• With intraperitoneal communication (i.e., ablative sur­
gery)
• Without intraperitoneal communication (i.e., Fournier’s
gangrene, hidradenitis)
Wounds without intraperitoneal communication that are
not amenable to local wound care (i.e., negative pressure
dressing) and skin grafting may need to be reconstructed
using adjacent tissue transfer such as V-Y advancements.
Sometimes using tissue from both sides and the anterior
abdominal wall can help close a significant defect. If that
does not suffice locoregional perforator flaps are great and
aesthetically pleasant options.15,18
Perforator flaps:
• Lotus petal flaps (i.e., gluteal fold perforator)
• Profunda femoris artery perforator flap

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e57
infections, dehiscence, partial flap necrosis) rates.22 However,
when compared with ALT alone, the complication rates
are comparable and if performed as a true perforator fas­
ciocutaneous flap, then an ALT should not hinder early
mobilization of the patient.23 In a rectus abdominis–based
reconstruction, the oblique skin paddle has a similar com­
plication profile when compared with the vertical pattern
with the advantage of a greater arc of rotation and a thinner
more pliable skin paddle and less bulk.24
ACKNOWLEDGMENTS
We thank Dr. Jonathan Zelken for his help with the glans­
plasty design and Dr. Jessica Lynch for her help with the
animation.
surgeon more confidence to aggressively obtain an ade­
quate resection.
COMPLICATIONS
• Hematoma
• Seroma
• Infection
• Partial or total flap loss
• Donor site morbidity
• Positive resection margins in setting of immediate recon­
struction
• Pelvic prolapse
OUTCOMES
Compared with all thigh-based reconstructions VRAM has
been shown to have lower major complication (i.e.,
A 42-year-old woman underwent a vaginectomy procedure. Bilateral Singapore flaps were marked and rotated to close the defect.
CASE 19.1  Vaginectomy Defect Reconstructed with Bilateral Pedicled Singapore Flaps
Figure 19.12  (A) Singapore flaps are marked bilaterally overlying the groin crease. The borders are defined medially by the labia majores,
laterally by the flap width of approx. 6 cm, inferiorly by the gluteal fold, and superiorly by the mons and the inguinal crease. (B) Pathway
is made underneath the intact bilateral labia majores. Also note the depth of the donor site with the deep fascia and epimysium of the
adductor muscle included in the flap. The dissection is then carried down to a subfascial plane and the flaps left attached to an inferior
pedicle. The actual neurovascular bundle is not visualized. A tunnel for the flaps is created in the same plane underneath the labia majores.
Both flaps are sutured to each other to evert the flap edges into the neovagina, as illustrated in Fig. 19.10. The neovagina should be
anchored within the pelvis to prevent prolapse or sagging. (C) Final inset. The construct is secured in place with a soft vaginal form for 1
week. After 1 week, the patient is returned to the OR for removal of the form and an examination under anesthesia.
A
B
C

e58
PART 3 — RECONSTRUCTION
Figure 19.13  (A) The neophallus is created in situ on the forearm and usually measures 15 × 15 cm. The flap is marked out as shown in
Fig. 19.6. The neocoronal ridge is elevated and created without tourniquet and before the flap is harvested. The coronal ridge is turned
in on itself and secured with a 5-0 Maxon suture. The defect is covered with a full-thickness skin graft taken from the lower abdomen
and sutured into place with a 5-0 Biosyn. The arm is then exsanguinated with Esmarch and placed under tourniquet control. The neophal­
lus flap dissection is started distally at the proximal wrist crease. The radial neurovascular bundle is identified and ligated. The incision is
then carried ulnarly and the palmaris longus is identified and harvested with the flap. The PL will be used to anchor the neophallus to the
pubic bone. The dissection then proceeds ulnar to radial and distal to proximal. The flap is harvested in the subfascial layer to provide
additional tissue to protect the IPP, which is inserted a year after surgery. The cephalic vein is included with the flap. The peritenon and
radial sensory nerves are preserved. Both the medial and lateral antebrachial cutaneous nerves are included with the flap. The neophallus
and glans are created by tubularization. In this case, urethral reconstruction was performed with an ulnar-sided 1.5 × 15 cm strip of flap,
which will be tubed and inset into the main flap onto a de-epithelialized 1.5 cm measuring strip. (B) Ventral aspect of created neophallus.
Natural location of the meatoplasty and midline raphe. The flap is tubed and the free edges joined by interrupted resorbable sutures. The
glans is created by de-epithelializing the lateral distal corners and folding them inward to give the glans a conical appearance and allow
for meatoplasty. (C) Free tissue neophallus with vascular pedicle and medial and lateral antebrachial cutaneous nerves. (D) Final result.
Scrotum has been reconstructed using tissue expansion and implantation of silicone-based scrotal implants. Further improvement can
be achieved by the use of a 3-D tattoo that can give the illusion of a venous network as well as improve color match.
A 20-year-old wounded soldier with traumatic penile and scrotal amputation after by an explosive device. He was reconstructed with
a radial forearm free flap.
CASE 19.2  Penile Defect Reconstructed with a Free Radial Forearm Flap
A
B
C
D

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e59
A 34-year-old morbidly obese woman presented with recurrent
anal cancer with invasion of her posterior vaginal wall. The
tumor was resected, resulting in a defect of the posterior vaginal
wall, and the perineum. A dead space was present as a result of
the large resection. A VRAM was used to reconstruct the poste­
rior vaginal wall and the perineum and to fill the dead space in
the pelvis.
CASE 19.3  Perineum Defect Reconstructed with a Pedicled VRAM Flap
Figure 19.14  (A,B) Intraoperative view of the patient in the lithotomy position showing the lesion as well as the marking of the VRAM
flap. The VRAM skin paddle was marked on the abdomen, extending to the costal margin due to extent of proposed posterior sacral
defect. (C) Defect resulting after tumor extirpation, which included posterior vaginal wall, anorectum, perineum, and sacral skin. (D) Recon­
struction using vertical rectus abdominis myocutaneous flap, which has been tunneled from the abdomen to the pelvis and brought out
externally. The skin paddle was used to reconstruct the posterior vaginal wall, perineum, and sacrum. In order to extend the reach of the
flap, the inferior portion of the rectus muscle is divided with sparing of the inferior epigastric artery and vein. Preserving the attachment
of the rectus can be beneficial, in that it can help avoid traction on the pedicle during the inset. (E) At 8 months following flap transfer
and awaiting secondary reconstruction of the introitus. (Courtesy of Christopher J. Salgado, MD.)
A
B
C
D
E

e60
PART 3 — RECONSTRUCTION
REFERENCES
1. Salgado C, Chim H, Tang J, et al. Penile reconstruction. Semin
Plast Surg 2011;25(3):221–8.
2. Felici N, Felici A. A new phalloplasty technique: the free anterolat­
eral thigh flap phalloplasty. J Plast Reconstr Aesthet Surg 2006;
59(2):153–7.
3. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of
the penis. Plast Reconstr Surg 1984;74(2):251–8.
4. Sadove RC, Sengezer M, McRoberts JW, et al. One-stage total
penile reconstruction with a free sensate osteocutaneous fibula
flap. Plast Reconstr Surg 1993;92(7):1314–25.
5. Perovic SV, Djinovic R, Bumbasirevic M, et al. Total phalloplasty
using a musculocutaneous latissimus dorsi flap. BJU Int 2007;
100(4):899–905.
6. Alter GJ, Ehrlich RM. A new technique for correction of the hidden
penis in children and adults. J Urol 1999;161(2):455–9.
Expert Commentary 
Christopher J. Salgado, MD
Reconstruction and construction of the male and female urogeni-
tal region often require a multidisciplinary approach and remain
understudied, particularly by plastic and reconstructive surgeons.
This chapter by Dr. Rick Redett and colleagues highlights basic
principles in local, regional, and distant flap options for these
complex reconstructions.
With regard to reconstruction and construction of a natal or
transman phallus, respectively, there are additional consider-
ations that one should take when performing these operations.
The free radial forearm flap (with or without radius bone) remains
the most commonly performed free flap for phalloplasty to date.
It is because of the multiple donor nerves (medial and lateral
antebrachial cutaneous nerves) available for neural anastomosis
that allows for increased sensation compared with other alterna-
tive flaps. The radial forearm flap also has a reliable and long
vascular pedicle with minimal donor site morbidity and a very
acceptable donor scar with partial closure and staged skin graft-
ing over bovine collagen. Direct sensory comparisons to the
anterolateral thigh flap (only one donor nerve – lateral femoral
cutaneous nerve) and fibula free flap (one donor nerve – superfi-
cial peroneal nerve branch) have not been done; however, they
are under way. In our hands, prelamination of the radial forearm
flap with mucosa grafts 6–8 weeks prior to flap transfer has sig-
nificantly decreased our urethral complication rates and avoids
the need for electrolysis or laser hair removal preop, in addition
to allowing for the ability of a larger circumference in our radial
forearm flap since tissue is added for the neourethra and not
taken from the skin paddle itself as occurs in the tube-within-a-
tube radial forearm flap. Mucosal options are buccal (bilateral and
anterior vestibule), intestinal, and in transgender cases, vaginal
mucosa. Urethral lengthening using anterior vaginal wall and labia
minora tissue may be performed at the time of flap prelamination
in transgender operations and posterior and lateral vaginal
mucosa harvested at this time.
Common recipient vessels used for microvascular phalloplasty,
in addition to the femoral vessels, are the inferior epigastric artery,
which may be harvested via an extended Pfannenstiel incision
with circum-umbilical incision for added exposure if needed in
order to avoid a midline incision and avoid a vein graft for length.
Although dissected with the artery, the inferior epigastric vein is
often of very small caliber and often not usable; however, the
saphenous veins are excellent outflow veins for a microvascular
flap in this region.
A gynecoid mons, which is responsible for a buried or hidden
penis, if present during the time of reconstruction should be
resected to facilitate wound healing and in our practice, due to
the risk of urethral complications, we have performed a unilateral
gracilis flap prophylactically to augment the vascular supply at the
urethral anastomosis since this is an area in which there is often
dead space and relatively avascular. This gracilis flap transfer
eliminated urethral fistulas to date and has served to auto-
augment the neoscrotum in our transman phalloplasty patients.
Finally, a suprapubic (SP) tube is used in all phalloplasty patients
and we commonly perform a pericatheter retrograde cystoure-
throgram prior to discontinuing the penile Foley catheter followed
by discontinuation of the SP tube itself after adequate bladder
training. Urology follow-up is of utmost importance following phal-
loplasty as distal obstructions should be dilated to avoid a more
proximal fistula creation.
With respect to reconstruction of the vulvovaginal region, it
remains one of the most challenging in plastic surgery to date,
particularly from an often overlooked, cosmetic standpoint. Exter-
nally, when the clitoris is preserved then orgasmic function is
unhampered; however, following resection of this organ, free toe
web space flaps have been described for reconstruction. Fat
grafting has allowed for cosmetic enhancement of the soft tissues
in the female external genital region to augment existing labia
majora tissues or reconstructed neo-labia majora.
The vaginal canal reconstruction options are essentially divided
into skin flaps and intestinal flaps both with advantages and dis-
advantages. The vertical rectus abdominis pedicled flap offers
obliteration of pelvic dead space and sufficient skin for circumfer-
ential or partial defects and remains a workhorse for vaginal
reconstruction. After release of the inferior portion of the muscle
and isolation on the inferior epigastric pedicle, the skin portion
can readily reach the sacral region if needed. When using intes-
tinal flaps we have noticed that left colon flaps have been superior
to right colonic flaps due to more tissue redundancy and facility
of reaching the introitus for inset. These flaps may be harvested
laparoscopically or via a Pfannenstiel incision for scar conceal-
ment. Although there are concerns regarding secretions postop-
eratively, frequent douching and time (approximately 1 year),
there is a significant decrease in the secretions. These secretions,
however, facilitate penetrative vaginal intercourse without lubrica-
tion, which is necessary after reconstruction with a skin flap.
Finally, the postoperative course in vulvovaginal reconstruction
is critical to reconstructive success. Skin-grafted patients should
be immobilized for 4–5 days with adequate DVT prophylaxis and
return to the operating theatreer if possible for an adequate
assessment of one’s reconstruction regardless of the methods
used. This is an area that is often hard to evaluate at the bedside
and difficult for adequate hygiene and cleansing in the hospital
wards; however, it is critical to the success of the operation.
7. Bors E. Scrotal skin plasty to elongate the penis. J Urol 1962;87:
419–21.
8. Song C, Wong M, Wong CH, et al. Modifications of the radial
forearm flap phalloplasty for female-to-male gender reassignment.
J Reconstr Microsurg 2011;27(2):115–20.
9. Massanyi EZ, Gupta A, Goel S, et al. Radial forearm free flap phal­
loplasty for penile inadequacy in patients with exstrophy. J Urol
2013;190:1577–82.
10. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is
the radial forearm flap really the standard technique? Plast Recon­
str Surg 2009;124(2):510–18.
11. Wee JT, Joseph VT. A new technique of vaginal reconstruction
using neurovascular pudendal-thigh flaps: a preliminary report.
Plast Reconstr Surg 2006;83(4):701–9.
12. McCraw JB, Massey FM, Shanklin KD, et al. Vaginal reconstruction
with gracilis myocutaneous flaps. Plast Reconstr Surg 1976;58(2):
176–83.

CHAPTER 19 — Pelvic and Urogenital Reconstruction
e61
13. Selvaggi G, Ceulmans P, De Cuypere G, et al. Gender identity dis­
order: general overview and surgical treatment for vaginoplasty in
male to female transsexuals. Plast Reconstr Surg 2005;116(6):
135–45.
14. Hoeckerl M, Dornhofer N. Vulvovaginal reconstruction for neo­
plastic disease. Lancet Oncol 2008;9:559–68.
15. Yii NW, Niranjan NS. Lotus petal flaps for vulvo-vaginal reconstruc­
tion. Br J Plast Surg 1996;49(8):547–54.
16. McQuillan SK, Grover SR. Dilation and surgical management in
vaginal agenesis: a systematic review. Int Urogynecol J 2014;25(3):
299–311.
17. Crosby MA, Hanasono MM, Feng L, et al. Outcomes of partial
vaginal reconstruction with pedicled flaps following oncologic
resection. Plast Reconstr Surg 2011;127(2):663–9.
18. Niranjan NS. Perforator flaps for perineal reconstruction. Semin
Plast Surg 2006;20(2):133–44.
19. Grinsell DG, Morrison E, Tansley PD. The inferior gluteal artery
myocutaneous flap with vascularized fascia lata to reconstruct
extended abdominoperineal defects. Plast Reconstr Surg 2013;
132(5):836e–840e.
20. Maricevich M, Maricevich R, Chim H, et al. Reconstruction follow­
ing partial and total sacrectomy defects: an analysis of outcomes
and complications. J Plast Reconstr Aesthet Surg 2014;67(9):
1257–66.
21. Campbell CA, Chang DW. Vascularized femur flap for stabilization
after combined total sacrectomy and external hemipelvectomy.
Plast Reconstr Surg 2012;129(5):888e–9e.
22. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh
flaps for immediate reconstruction of pelvic and perineal cancer
resection defects. Plast Reconstr Surg 2009;123(1):175–83.
23. Pang J, Broyles JM, Berli JU, et al. Abdominal versus thigh based
reconstruction of perineal defects in cancer patients. Dis Colon
Rectum 2014;57(6):725–32.
24. Combs PD, Sousa JD, Louie O, et al. Comparison of vertical and
oblique rectus abdominis myocutaneous flaps for pelvic, perineal
and groin reconstruction. Plast Reconstr Surg 2014;134(2):315–23.

227
Upper Extremity
Reconstruction
Michael W. Neumeister
20 
INTRODUCTION
The many specialized structures of the hand and upper
extremity work in intimate synchrony to provide a harmoni­
ous interplay of precision motor biomechanics with fine
tactile senses. Our hands are subject to many common occu­
pational and domestic injuries, including fingertip trauma,
tendon lacerations, neurovascular compromise, fractures,
and soft tissue loss. Every extremity trauma has its own
unique characteristics that offer challenges for soft tissue
coverage. Although the principles of the reconstructive
ladder apply, this chapter focuses on soft tissue reconstruc­
tion of the upper extremity using local, regional, and free
flaps only.
PREOPERATIVE CONSIDERATIONS
All trauma surgeries start with patient stabilization, wound
irrigation and debridement, repair and reconstruction of
the skeleton and soft tissues, and culminates with definitive
closure. The closure decision should incorporate the goals
and priorities of reconstruction. Each area of the upper
extremity has its own set of unique soft tissue needs that
allow that area to function at an optimum level. Soft tissue
reconstruction of the upper extremity could be divided up
into six main areas (Box 20.1). A final category would add
catastrophic injuries such as the mangled or mutilated
upper extremity where the zone of injury transcends many
of the six zones in the limb.
While the goals include life preservation, limb preserva­
tion, function preservation, and then functional reconstruc­
tion, the priorities of function, contour, and stability, as well
as the anticipation of further reconstructive surgery is very
important in choosing the flap of choice. Currently used
flaps include fasciocutaneous, fascial, musculocutaneous,
muscle, and osteocutaneous flaps. Flap selection is based on
the characteristics of the defect, including size, shape, and
location, the availability of donor sites, and the goals of
reconstruction.
RECONSTRUCTION BY REGION
FINGER SOFT TISSUE RECONSTRUCTION
Finger reconstruction with flaps traditionally uses adjacent
tissue on the finger, tissue from the proximal digit, the
adjacent digits, the dorsal or palmar hand, or from distant
tissue such as the abdomen or toe pulp. The fingertip is an
area where local flaps is commonly used for reconstruction.
Box 20.2 illustrates the variety of flaps available for closure
of the fingertip injuries.
DISTAL FINGERTIP RECONSTRUCTION
The Volar V-Y Advancement (Atasoy or Kleinart) Flap
This flap is used for distal fingertip defects oriented in a
dorsal oblique or transverse fashion, measuring <1 cm,
usually with exposed bone. The volar triangular flap is ori­
ented with the apex at the distal interphalangeal crease (Fig.
20.1). The skin is incised full thickness. Blunt dissection with
spreading of the tissue in the direction of vascular inflow
into the flap is performed until the tissue advances to cover
the defect. The donor site is sutured to provide a V-Y, tension
Box 20.1  Soft Tissue Reconstruction of
the Upper Extremity is Divided
Into Six Main Areas
• Fingertips
• Digits
• Hand
• Forearm
• Elbow/antecubital fossa
• Upper arm
Box 20.2  Variety of Flaps Available for
Closure of the Fingertip Injuries
• Volar V-Y
• Lateral V-Y
• Cross finger
• Thenar crease
• Moberg volar advancement
• Homodigital
• Heterodigital
• Reverse dorsal metacarpal artery
• Thoraco-epigastric
• Free toe pulp/nail bed
PART 3  —  RECONSTRUCTION