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

CHAPTER 20 — Upper Extremity Reconstruction
229
finger at level of the middle phalanx. It is based on the
dorsally migrating vessels that arise from the volar digital
arteries. The venae comitantes and other superficial veins
are left within the flap. Occasionally, sensory nerves can also
be incorporated in the flap to provide sensation. The flap
is elevated at the level of the paratenon which must be kept
intact for a skin graft to be utilized over the donor site once
the flap is inset. Just as in a page of a book, the flap is folded
over to cover the volar defect of the adjacent finger (Fig.
20.5). The flap will remain attached to the donor and the
recipient fingers for 2–3 weeks, when the flap is divided and
inset. The donor site is covered with a split thickness skin
graft and the bolster dressing applied for the first week to
provide adequate engraftment.
The reverse cross finger flap is used to cover dorsal defects
on the adjacent finger. The flap is outlined on the dorsum
of the donor finger but is de-epithelialized before it is trans­
posed to the adjacent finger. A split thickness skin graft is
used to cover the undersurface of the exposed flap as well
as the donor site. The flap is divided and inset at 2–3 weeks.
DISTAL FINGERTIP RECONSTRUCTION
The Thenar Crease Flap
The thenar crease flap employs the skin from the volar
aspect of the thumb at the level of the metacarpal phalan­
geal joint. The flap is based on the radial aspect of the
thumb and can measure 1.5 cm in width and up to 2 cm in
length (Fig. 20.6). The digit with the fingertip defect is
flexed down towards the elevated flap which is sutured in
place. The base of the flap is divided in 2–3 weeks. The
thenar crease flap is insensate and may result in flexion
contractures to the recipient finger if used in adults.
FINGERTIP AND DISTAL FINGER RECONSTRUCTION
Homodigital and Heterodigital Flaps
Homodigital and heterodigital flaps are usually axial flaps
that are elevated in and antegrade or retrograde fashion,
at least 2–3 mm from the nail folds dorsally, with a more
thorough dorsal dissection to release the fibrous septae,
while preserving the more volar neurovascular contribu­
tions. This again provides vascularized, sensate coverage but
is severely limited in advancement to about 0.5–0.75 cm.
DISTAL THUMB RECONSTRUCTION
The Volar Advancement (Moberg) Flap
This flap is most often used for the thumb. Radial and ulnar
midaxial incisions are made on either side of the thumb.
The flap is elevated in the plane above the tendon sheath
incorporating both the neurovascular bundles in the fascio­
cutaneous flap. The Moberg flap offers up to 2 cm of
advancement to cover distal thumb defects. Occasionally
the interphalangeal joint needs to be flexed to allow the flap
to be inset into the remaining nailbed. The interphalangeal
joint extends over time, stretching the flap as it does so. The
Moberg advancement flap provides well-vascularized, gla­
brous, sensate coverage (Fig. 20.4). There has been a
number of modifications of the Moberg that are employed
to provide a little more length to the advancement. The flap
can be advanced as a V-Y flap where the apex is at the volar,
proximal thumb crease. Alternatively, a transverse incision
can be made in the skin at the proximal thumb, the tissue
spread to release the tension from the more proximal
palmar skin. A skin graft is then used to close to proximal
donor defect as the flap advances distally. The Moberg, volar
advancement flap as described is not typically used for other
digits of the hand as it may cause flexion contractures of the
finger.
VOLAR AND DORSAL DIGIT RECONSTRUCTION
The Cross Finger Flap
The cross for your flap offers a two-stage approach to recon­
struction of the volar and dorsal aspect of digits including
the fingertip. The classic cross finger flap utilizes the skin
and subcutaneous tissue on the dorsum of the adjacent
Figure 20.4  (A–C) Tip of thumb defect reconstructed with a Moberg V-Y flap. The flap is elevated at the skeletal plane just above the flexor
pollicis longus tendon and sheath. The distal phalanx is flexed to accommodate greater advancement.
A
B
C

230
PART 3 — RECONSTRUCTION
allow the fingertips to be sutured to them (Fig. 20.9). The
patient must hold their arm in the position shown for 2–3
weeks until the flap is divided; these flaps are often bulky
and remain insensate.
The Free Toe Pulp Flap
The free toe pulp flap utilizes the lateral aspect of the great
toe but incorporates the glamorous skin, subcutaneous
based on the digital artery (Figs 20.7, 20.8). Care must be
taken to preserve the digital nerves so that sensation to the
distal aspect of the donor finger is not compromised.
The Thoraco-Epigastric Flap
It is very uncommon in current surgical practice to apply
the principles of the thoraco-epigastric flaps for closure
fingertip injuries. Small flaps are raised on the trunk to
Figure 20.5  (A–C) Mangled fingertip of the index finger closed with a cross finger flap from the dorsum of the adjacent finger.
A
B
C
Figure 20.6  (A,B) Third fingertip defect reconstructed with a thenar crease flap. The flap is based on the radial volar aspect of the metacar­
pophalangeal joint of the thumb.
A
B
Figure 20.7  (A–C) Dorsal defect over PIP joint reconstructed with a heterodigital flap. The flap is raised on the digital artery and moved as a
transposition or an island flap. The digital nerve is left in situ.
B
C
A

CHAPTER 20 — Upper Extremity Reconstruction
231
artery that lies within the fascia of the first dorsal interosse­
ous muscle (Fig. 20.11). The artery and superficial veins
provide the inflow and venous drainage of the fasciocutane­
ous portion of the flap which is taken from the dorsal aspect
of the proximal phalanx on the index finger. The pedicle is
dissected proximally to a point where the flap can be trans­
posed either through a tunnel or through open access to
the volar thumb. The arc of rotation of the flap makes it
extremely versatile to cover not only the volar thumb but
also dorsal aspect of the thumb and hand. Sensation is pro­
vided by branches of the superficial radial nerve.
The reverse dorsal metacarpal artery flap can also be uti­
lized to cover defects on the dorsal or volar aspect of the
digits and even fingertip. The flap is based at the level of the
metacarpal phalangeal joint in the web space, where perfo­
rating vessels from the Palmer vasculature communicate
with the dorsal metacarpal artery system. The flap is there­
fore a distally based flap (Fig. 20.12). The superficial veins
must be incorporated in the flap to provide adequate venous
outflow. The skin paddle is taken from the proximal aspect
of the dorsum of the hand in between the metacarpals. A
1 cm wide strip is fashioned that includes the dorsal metacar­
pal artery must be taken to prevent vascular compromise to
the flap. A Doppler must be used to identify the dorsal meta­
carpal artery prior to elevation of the flap. The more ulnar
the dorsal metacarpal artery the less reliable its presence is
within the fascia. The reverse dorsal metacarpal artery flap
may be prone to venous congestion because the venous
blood is forced to drain retrograde. Loose closure of the flap
may help the flap until it redirects the outflow. Alternatively,
a superficial dorsal vein could be anastomosed in the digit.
DORSAL AND PALMAR HAND DEFECT
RECONSTRUCTION
Soft tissue coverage of the hand can be challenging. The
Palmer side of the hand has glabrous skin that needs to be
extremely durable and able to tolerate significant shear
forces when grasping objects or holding items in the hand.
tissue, and neurovascular bundle. The flap is harvested as a
free tissue transfer (Fig. 20.10). Although this flap replaces
the defect in the finger with like tissue, it does involve
greater technical skills of fine microsurgery. Potential pit­
falls include complete loss of the flop due to thrombosis in
the anastomosed vessels, poor sensibility recovery, or
neuroma formation. Patients may also need to be hospital­
ized for 5–7 days until the fate of the flap is fully known.
VOLAR AND DORSAL FINGER RECONSTRUCTION
The Dorsal Metacarpal Artery Flap
The first dorsal metacarpal artery flap is used primarily to
provide durable sensate tissue to the volar aspect of the
thumb. The flap incorporates the first dorsal metacarpal
Figure 20.8  (A,B) Distal 2nd and 3rd finger defects reconstructed
with small heterodigital flaps.
B
A
B
Figure 20.9  (A–C) Thumb defect reconstructed with a pedicled thoracoepigastric flap. Debulking is performed to achieve a good contour.
A
B
C

232
PART 3 — RECONSTRUCTION
The dorsum of the hand is very thin and provides durable
coverage for the gliding extensor tendons. Soft tissue defects
therefore should be covered with flaps that are thin, durable
and provide glide for the underlying tendons. Box 20.3 lists
a variety of flaps that are locally and regionally available for
coverage of defects to the hand.
The regional tissue used for coverage of the hand are
distally-based fascial or fasciocutaneous flaps that rely on
flow from the radial or ulnar artery. If the arteries are
Figure 20.10  (A–C) Volar thumb defect reconstructed with a free toe pulp flap. The nerves and vessels are anastomosed in the anatomic
snuffbox. (Courtesy SIU photo archives.)
A
B
C
Figure 20.11  (A–D) A volar thumb defect reconstructed with a dorsal metacarpal artery flap.
A
B
C
D
Figure 20.12  (A–C) Distal dorsal 4th finger defect reconstructed with a reverse dorsal metacarpal artery flap. The other two defects were
reconstructed with skin grafts.
A
B
C
incorporated within the flap, the surgeon needs to be sure
that the patient has an intact palmar arch. This can be
assessed clinically with the Allen’s test. The reverse radial
forearm flap, for instance, is based on the radial artery and
its venae comitantes and the skin paddle is from the volar,
proximal forearm. The artery and veins are ligated and
transected at the proximal edge of the flap which means the
circulation of the flap is now reversed (Fig. 20.13). The
ulnar artery is the main blood supply communicating with

CHAPTER 20 — Upper Extremity Reconstruction
233
Box 20.3  Flaps that are Locally and Regionally Available for Coverage of Defects to the Hand
Fasciocutaneous
• Radial forearm
• Ulnar artery
• Lateral arm
• Deltoid
• Medial arm
• Scapular
• Parascapular
• Thoracodorsal artery perforator
• Deep inferior epigastric perforator
• Superior gluteal artery perforator
• Inferior gluteal artery perforator
• Anterolateral thigh
• Anteromedial thigh
• Medial plantar artery instep
• Supraclavicular
• First dorsal metacarpal artery
Muscle Flaps
• Rectus abdominis
• Rectus femoris
• Vastus lateralis
• Gracilis
• Latissimus
• Serratus
Myocutaneous
• Transverse rectus abdominis myocutaneous
• Vertical rectus abdominis myocutaneous
• Anterolateral thigh
• Vertical gracilis
• Transverse upper gracilis
• Latissimus
Fascia
• Anterolateral thigh
• Scapular
• Lateral arm
• Radial forearm
• Serratus anterior
• Temporal parietal
• Dorsalis pedis
Osteocutaneous
• Fibula
• Scapula
• Radial forearm
• Second metatarsal
• Iliac crest
• Lateral arm
• Anterolateral thigh
A
B
C
Figure 20.13  (A–C) Dorsal hand and finger defect reconstructed with a reverse radial forearm flap island. The flap in this patient required
further debulking in order to provide a good contour.

234
PART 3 — RECONSTRUCTION
the radial artery though the intact palmar arch. Venous
congestion could be a sequelae of employing the reverse
flaps because the valves in the forearm veins may inhibit
drainage. Congestion is rather uncommon, however, and
could be easily overcome with anastomosing superficial
veins in the skin paddle of the flap to those in the hand.
The posterior interosseous artery flap and ulnar artery flap
are other examples of regional flaps used to cover palmar
or dorsal hand wounds.
The posterior interosseous artery flap is a distally based
fasciocutaneous flap based on the watershed communica­
tions of the anterior interosseous artery on the volar wrist
with the posterior interosseous artery in the fifth dorsal
compartment of the dorsal wrist (Fig. 20.14). The pedicle
lies on the interosseous membrane between the extensor
digiti minimi and the extensor carpi ulnaris muscles. The
skin paddle is designed over the junction of the proximal
one-third and distal two-thirds of the dorsal forearm. The
perforator from the volar forearm that penetrates the inter­
osseous membrane is ligated at the distal end of the supina­
tor muscle. The perforator extends into the skin paddle and
is the start of the posterior interosseous artery flap. The skin
paddle is raised with the pedicle to roughly 2–5 cm from
the dorsal wrist crease. The flap is transposed carefully to
not kink the pedicle.
There are variations to harvesting these regional flaps.
The palmaris longus tendon can occasionally be harvested
with the radial artery flap to provide a vascularized tendon
graft if the recipient site is in need of simultaneous tendon
reconstruction (Fig. 20.15). Some fascial only flaps do not
need to incorporate the main arteries themselves but rather
only their perforators to the fascia at the level of the wrist.
Free tissue transfer offers a broad armamentarium for
closure of many defects of the hand, forearm, elbow, and
upper arm. Although regional or local flaps may be possible,
most wounds can be closed by bringing distant tissue with
its own vascular supply to the area. The wide array of flaps
that can be used is vast, given the advent of perforator flaps.
Figure 20.14  (A–C) A first web space defect reconstructed with a
posterior interosseous flap raised as a retrograde flap based on
watershed communications with the anterior artery at the distal
forearm and wrist. The skin paddle is positioned at the junction of the
middle third and proximal third of the extensor surface of the forearm.
(Courtesy of Prof. Gunter Germann.)
A
B
C
Figure 20.15  (A–D) The reverse radial forearm flap raised with the palmaris longus tendon to restore extensor function of the index finger
where both the extensor indices proprius and the extensor digitorum communis were absent from the original trauma.
B
D
C
A

CHAPTER 20 — Upper Extremity Reconstruction
235
Box 20.4  Considerations that Influence
Decisions on the Type of Flap
Needed in the Hand
• What are the characteristics of the missing tissue?
• Glabrous skin, crushed, location, function
• What is needed?
• Skin, bone, tendon, other soft tissue
• What tissue replacement provides the most “like with like”?
• Is skin better for that given wound?
• Is fascia better for that given wound?
• What is the body habitus of the patient?
• Will the flap be too bulky?
• Can you defat the flap if needed?
• What flap would provide the most return of function?
• Size, shape, sensibility, glide, range of motion, durability
• Do you anticipate secondary procedures will be needed?
• How would that affect your flap?
• Can you provide composite tissue in the flap if multiple
tissues are needed?
• Skin and bone loss
• Skin and tendon or nerve loss
• What are the consequences to the donor site?
• Close primarily
• Close with grafting
• Pain, seroma, wound complications
• Limb function
• What provides the best intraoperative positioning and surgi-
cal efficiency?
release of first web space contractures, a well contoured and
pliable flap is preferred to close the resulting defect. Muscle
flaps are often too bulky and should be avoided. Fascial or
fasciocutaneous flaps work very well to close first web space
defects. The lateral arm flap provides excellent coverage
and is usually the appropriate width, depth, and length. The
lateral arm flap can be harvested up to 6 cm in width while
still being able to close the donor site primarily (Fig. 20.16).
The flap should not be used if the donor site cannot be
closed primarily because of the significant morbidity associ­
ated with grafting this area where the radial nerve and
humerus may be exposed.
ELBOW AND PROXIMAL FOREARM SOFT TISSUE
DEFECT RECONSTRUCTION
The elbow is a unique area of the arm. To maintain func­
tion, the coverage of wounds to the elbow should be thin,
pliable, and permit extension and flexion. There are a
variety of local and regional flaps that are used around the
elbow. Box 20.5 lists various local/regional flaps for elbow
coverage. Local transposition flaps are either based on the
dorsal forearm skin for posterior elbow defects over the
olecranon or volar skin for anterior, medial, or lateral elbow
defects. The flaps are elevated at the level of the antebrach­
ial fascia where the resultant donor site defect is closed with
a split thickness skin graft.
The flexor carpi ulnaris flap (FCU) is a valuable tool to
close exposed olecranon, medial joint, or exposed hard­
ware. An incision is made along the entire FCU. The distal
FCU tendon is transected and the muscle is raised in a ret­
rograde fashion (Fig. 20.17). The muscle has multiple seg­
mental vascular pedicles from the ulnar artery as it course
radial to the muscle. Care is taken to preserve the most
proximal pedicles that can supply the entire flap. Through
epimysiotomy, the muscle can be unfurled to cover wider
defects over the elbow. The muscle is covered with a split
thickness skin graft unless there is enough local skin laxity
around the elbow to permit local coverage of the muscle.
The two regional axial flaps that provide stable coverage
for the elbow are the radial forearm flap and the reverse
lateral arm flap. The radial forearm flap is based on the
radial artery and its venae comitantes. The skin paddle is
designed in the distal volar forearm, elevated on its pedicle,
and inset to cover anterior, posterior, medial, or lateral
defects. In fact, the pedicled radial forearm flap can reach
up to 25 cm above the elbow. The donor site is closed with
a split thickness skin graft. Reefing the sublimis muscle over
the flexor carpi radialis tendon will prevent tendon expo­
sure if is skin engraftment is incomplete.
Box 20.5  Soft Tissue Coverage of the
Elbow and Proximal Forearm
• Local fasciocutaneous, random, transposition flaps
• Radial forearm axial fasciocutaneous flap
• Flexor carpi ulnaris muscle flap
• Pedicled latissimus muscle flap
• Distally based lateral arm flap
General principles, however, still apply. That is, the surgeon,
while deciding upon the flap of choice, should be respectful
of the needs of the recipient site while minimizing the
donor site morbidity. Muscle flaps offer stable coverage but
may be bulky if they are not stretched out prior to insetting.
Fasciocutaneous flaps may also be bulky in the obese patient.
Other important considerations in flap selection are listed
in Box 20.4. Many patients will need secondary procedures
such as tendon reconstruction, tenolysis, ligament recon­
struction, joint surgery, nerve grafting, neurolysis, nerve or
tendon transfers, or a functional muscle transfer. Fasciocu­
taneous flaps are often easier to elevate and inset again
compared with the fibrotic muscle or fascial flaps. If a fas­
ciocutaneous flap was used in an obese patient, the flap may
need to be debulked at a later date, either by direct fat exci­
sion or through liposuction. Typically the flap is not com­
promised with liposuction but may be with aggressive direct
excision. Therefore, a maximum of only half of the flap
should be elevated and thinned. The half thinned flap is
inset again and the patient can have the other half defatted
in 2–3 months once cutaneous vascularity is re-established
on the previously debulked half. These are all consider­
ations that need to be addressed prior to embarking upon
flap closure in the hand and upper extremity.
FIRST WEB SPACE SOFT TISSUE DEFECT
RECONSTRUCTION
The first web space is quite unique for hand function. The
thumb must be able to abduct and adduct in order to
provide prehensile grip. Contractures of the first web space
lead to a significant impairment of function. Following

236
PART 3 — RECONSTRUCTION
The latissimus muscle can also be used to cover defects
in the upper around the elbow. The muscle is elevated off
the back, transposed anteriorly, and draped over the exposed
vital structures of the upper arm or elbow (Fig. 20.18). The
latissimus muscle can extend beyond the elbow by up to
10 cm. Releasing the origin of the muscle can provide addi­
tional length but care must be taken not to stretch or avulse
the thoracodorsal vascular pedicle as it enters the muscle
towards its proximal end. The latissimus muscle can be tun­
neled under intact proximal skin to cover the more distal
wounds or inset along the entire length of the upper arm
after incising the proximal skin which occasionally is too
taught to permit tunneling. A modification of the latissimus
muscle flap incorporates a skin paddle over the muscle to
become a myocutaneous flap if durable skin coverage is
desired.
Before flap reconstruction proceeds, the surgeon needs
to be happy that the wound bed is rid of potential infection
and has fully demarcated with respect to viable and devital­
ized tissue. Second or third look surgeries are often required
at 24–72 h, to remove contaminates and to allow compro­
mised tissue to declare itself before the final closure. The
debridement is often performed by the more senior surgeon
as experience usually dictates an aggressive yet appropriate
removal of all that is compromised or devitalized. In fact,
we use the phrase “debride the wound like a pseudotumor
resection” to describe the process (Fig. 20.19).
The bone must be stabilized to provide a foundation for
the soft tissue healing. It is not always necessary to provide
complete boney continuity as external fixators or plate
osteosynthesis can maintain stability despite segmental
defects. The bone is reconstructed at a later date. Osteocu­
taneous flaps can, however, provide both bone reconstruc­
tion and soft tissue coverage in a single stage procedure.
Tendon and ligament reconstruction should be performed
before the definitive soft tissue closure.
The flap selection decision-making tree involves finding
the optimum tissue that replaces the contour and function
to that of the native tissue. The surgeon should compre­
hend the limitations that the patient’s body habitus offers.
For instance, an anterolateral thigh may be the optimal
donor site for wound coverage of the back of the hand in a
very thin patient, whereas the same flap may not be the first
choice in the severely obese patient. Alternative flaps will be
needed to provide the quality of coverage that provides
stable coverage and mimics native contour as much as pos­
sible. Similarly, a temporoparietal fascial flap leaves a rather
inconspicuous scar on the scalp of a young woman, but the
same donor site may be unacceptable in a bald man (Fig.
20.20). The serratus anterior fascia flap would be a better
Figure 20.16  (A–E) Defect in first web space after contracture release. The defect was reconstructed with a free lateral arm flap.
A
B
C
D
E

CHAPTER 20 — Upper Extremity Reconstruction
237
Figure 20.17  (A–C) The flexor carpi ulnaris muscle is transposed to
cover a small elbow defects. The muscle is divided distally and raised
in a retrograde fashion preserving proximal vascular supply from the
ulnar artery.
A
B
C
Figure 20.18  (A,B) Large elbow defects can de closed with a pedicled latissimus muscle and skin grafted. (Courtesy of Prof. Milan
Stevanovitch.)
B
A
choice for the patient in this case (Fig. 20.21). The thin skin
of the hand and fingers mandates the similar appraisal of
donor characteristics. Small defects may be best treated with
small fasciocutaneous flaps such as a free first dorsal meta­
carpal artery from the opposite hand or a medial plantar
flap from the foot. These small flaps were designed with the
intent of replacing like with like tissue. Larger fasciocutane­
ous and muscle flaps are often utilized for reconstruction
of forearm and upper arm defects for the obvious reason
that more volume is required.
Free tissue transfer offers a great advantage of being able
to close any size wound on the upper extremity. Free flaps
can be composed of skin, muscle, fascia, bone, or a combi­
nation of any of the above. Composite flaps are used to
provide soft tissue coverage and other tissue such as bone
in a one flap solution for a complex, composite defect of
the upper extremity. Box 20.6 define various tissue flaps
that are used to cover larger wounds in the upper extremity.
The latissimus and gracilis are the more commonly used
muscles because the donor site morbidity is low. The ser­
ratus anterior muscle provides a small thin muscle and can
be harvested with the latissimus and scapula flap to provide
Box 20.6  Flaps for Coverage of Elbow
Wounds
• Flexor carpi ulnaris muscle
• Local anterior or lateral fasciocutaneous transposition flap
• Radial forearm
• Distally based lateral arm
• Latissimus

238
PART 3 — RECONSTRUCTION
Figure 20.20  (A–D) Dorsal hand defect reconstructed with a tem­
poroparietal fascia flap providing thin coverage.
A
B
C
D
Figure 20.21  (A–C) A serratus anterior fascia flap is used to recon­
struct a dorsal hand defect. (Courtesy of Prof. Michael Sauerbier.)
A
B
C
Figure 20.19  (A,B) Mangled upper extremity. The wound is seen before and after debridement. The wound should be treated like a “pseudo-
tumor” in terms of performing an appropriate debridement.
A
B
larger soft tissue coverage. The rectus abdominis muscle is
easy to harvest and can cover long defects but can leave a
weakened abdominal wall and possible fat necrosis in obese
patients.
The more commonly used fasciocutaneous flaps include:
the scapula/parascapula flap (Fig. 20.22); the anterolateral
thigh flap (Fig. 20.23); the radial forearm (Fig. 20.24); the
deep inferior epigastric perforator (DIEP) flap (Fig. 20.25);
lateral arm flap. Although the anterolateral thigh flap is a
workhorse flap for many microsurgeons, the DIEP flap mini­
mizes donor site morbidity, especially when large defects
mandate skin grafting of the thigh if the thigh flap is used
(Fig. 20.25). Donor site to the thigh are minimized if the
flap is small enough to permit primary closure.
The scapular system offers reliable and large quantities
of tissue but has some drawbacks. Positioning can be prob­
lematic. The scars often stretch and look unappealing (Fig.
20.26). Seromas are also common.

CHAPTER 20 — Upper Extremity Reconstruction
239
Figure 20.23  (A–C) Volar hand, wrist, and distal forearm defect
reconstructed with a free anterolateral thigh perforator flap.
A
B
C
Figure 20.24  (A–C) Radial forearm free flap shown, with the donor
site seen before and after flap harvest.
A
B
C
Figure 20.22  (A–C) Dorsal hand and wrist defect reconstructed with a free scapula flap.
A
B
C

240
PART 3 — RECONSTRUCTION
Figure 20.25  (A–F) DIEP flap harvested and used for a large dorsal forearm defect.
A
B
C
D
E
F
A
A
B
C
Figure 20.26  (A–C) Coverage of a defect in the extensor surface of the forearm with a scapular flap. Immediate tendon transfer under the
flap optimize recovery and function. Note the widened scar at the donor site.

CHAPTER 20 — Upper Extremity Reconstruction
241
Expert Commentary
Francisco Del Piñal, MD, PhD
In trauma of the upper limb, the role of vacuum devices is, in
my view, minimal; not because they cannot achieve the goal of
coverage, but above all, because they will do so at the price of
delaying the actual wound closure. Time of wound closure in
the upper limb (particularly the hand) brings on stiffness and
poor function.
For these same reasons, I am a staunch advocate of using
the “reconstructive elevator” rather than the “reconstructive
ladder”: when a local flap is going to compromise in any way
the result (function or speed of recovery), I opt for a free flap.
The alternatives, as the authors pointed out, are enormous. In
my practice, moderate defects are solved with gracilis, iliac,
and lateral arm flaps. Such flaps have the advantage of either
being at the site, or causing minimal donor site morbidity. I do
not have any problem when using the gracilis in the dorsum
of the hand, as the result is aesthetically pleasing and the
tendons glide without difficulty. However, I do avoid coverage
with muscle flaps if I envisage the need for secondary surgery
under the flap. For large defects, I prefer the anterolateral
fascial flap or an expanded gracilis (achieved by removing the
outer epimysium). In my environment, the ALT flap is too thick
for the hand and the donor site is significant for large defects.
I do very rarely resort to very large flaps (such as latissimus
dorsi or DIEP flaps), mainly because most wounds can be
“itemized,” i.e., divided into complex and simple parts. A
complex wound is any defect where there is: bone devoid of
periosteum; tendon lacking peritenon; vessels without adventi-
tia; nerves without protection; or any defect located over a joint
or a skin fold. This division might seem naive. However, the
distinction bears enormous importance: only the complex part
of the wound needs flap coverage, while the rest can receive
a skin graft. In this manner, the size of the flap needed can be
reduced and the donor site morbidity can be kept to a minimum.
As an aside, much of the bulkiness created by the flap itself will
be avoided.
As a final thought, in combined defects, I have no hesitation
about using two different free flaps in the same sitting. I thus
avoid running into complex tridimensional reconstructions,
where a single flap performs acrobatics, which in turn risks
damaging the blood supply of the flap and increases the mor-
bidity of the donor site.
POSTOPERATIVE CONSIDERATIONS
Each flap used for reconstruction is unique. The postopera­
tive course will depend on the location, type of injury, type
of flap, the reconstruction performed under the flap, and
if a free flap was employed. Most of the fingertip flaps
require only a modest dressing consisting of Xeroform® or
adaptic non-stick gauze followed by some dry gauze and
wrap. Children may require casting to prevent the dressing
from being removed. The hand is elevated for comfort.
Larger flaps that cross the wrist creases require splinting
in the neutral position to prevent compromise to the flap.
Free tissue transfers require an open window in the dressing
to provide visual access for the clinical observation and pos­
sible Doppler monitoring of the flap for the first 5 days.
Flaps about the elbow also require splinting for the first 2–3
weeks, to prevent the flap from being put under tension.
COMPLICATIONS
Flap compromise is the most feared complication of any
tissue rearrangement surgery. Careful attention to preserv­
ing arterial inflow, prevent vein kinking or pedicle twisting,
and cautious use of reverse flow flaps will minimize risk of
vascular embarrassment. Other complications may include
bulky flaps that prevent function, joint contracture, complex
regional pain syndrome, and stiffness.
OUTCOMES
The outcomes of soft tissue coverage of the upper extremity
are dependent on the same considerations as for postopera­
tive care. Much is dependent on the mechanism of injury,
type of flap used, and the extent of the underlying recon­
struction of the bones, tendons, nerves, joints, and muscles.
CONCLUSION
Soft tissue reconstruction of the upper extremity is extremely
diverse, ranging from fingertip injuries to the mutilated
arm. The principles of reconstruction include patient resus­
citation, wound debridement, bone fixation, and restoring
native contour. Ultimately, the goals are to preserve or
restore function to the injured upper extremity.
Access further reading online at http://
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CHAPTER 20 — Upper Extremity Reconstruction 241.e1
FURTHER READING
Adani R, Marcoccio I, Tarallo L. Flap coverage of dorsum of hand
associated with extensor tendons injuries: A completely vascularized
single-stage reconstruction. Microsurgery 2003;23(1):32–9.
Adani R, Tarallo L, Marcoccio I, et al. Hand reconstruction using the
thin anterolateral thigh flap. Plast Reconstr Surg 2005;116(2):
467–73.
Akin S. Microvascular free on-top plasty in a mutilated hand. Ann Plast
Surg 2001;47(2):183–6.
Alagoz MS, Uysal AC, Sensoz O. Staged and late-period reconstruction
of the crushed hand: Prefabricated osseous flap. Ann Plast Surg
2007;58(1):84–90.
Baumeister S, Koller M, Dragu A, et al. Principles of microvascular
reconstruction in burn and electrical burn injuries. Burns 2005;
31(1):92–8.
Biswas G, Lohani I, Chari PS. The sandwich temporoparietal free fascial
flap for tendon gliding. Plast Reconstr Surg 2001;108(6):1639–45.
Brandt K, Khouri RK, Upton J. Free flap as flow-through vascular con­
duits for simultaneous coverage and revascularization of the hand or
digit. Plast Reconstr Surg 1996;2:321–7.
Brenner P, Lassner F, Becker M, et al. Timing of free microsurgical
tissue transfer for the acute phase of hand injuries. Scand J Plast
Reconstr Surg Hand Surg 1997;31(2):165–70.
Brent B, Upton J, Acland RD, et al. Experience with the temporopari­
etal fascial free flap. Plast Reconstr Surg 1985;76:177.
Brown DM, Upton J, Khouri RK. Free flap coverage of the hand. Clin
Plast Surg 1997;24(1):57–62.
Brown RE, Wu TY. Use of “spare parts” in mutilated upper extremity
injuries. Hand Clin 2003;19:73–87.
Buechler MJ, Pacelli L, Wilson KM. Serratus fascia “sandwich” free-
tissue transfer for complex dorsal hand and wrist avulsion injuries.
J Reconstr Microsurg 1999;15(5):315–20.
Bueno RA, Neumeister MW. Outcomes after mutilating hand injuries:
review of the literature and recommendations for assessments. Hand
Clin 2003;19:193–204.
Cavadas PC. Posterior interosseous free flap with extended pedicle for
hand reconstruction. Plast Reconstr Surg 2001;108(4):897–901.
Cavadas PC, Raimondi P. Free fillet flap of the hand for elbow preserva­
tion in nonreplantable forearm amputation. J Reconstr Microsurg
2004;20(5):363–6.
Chen HC, Buchman MT, Wei FC. Free flaps for soft tissue coverage in
the hand and fingers. Hand Clin 1999;15(4):541–54.
Chen SL, Chen TM, Lee CH. Free medial sural artery perforator flap
for resurfacing distal limb defects. J Trauma 2005;58(2):323–7.
Chen HC, El-Gammal TA. The lateral arm fascial free flap for resurfac­
ing of the hand and fingers. Plast Reconstr Surg 1997;99(2):454–9.
Chen HC, El-Gammal TA. The lateral fascial free flap for resurfacing
of the hand and fingers. Plast Reconstr Surg 1997;99:454.
Chen HC, Tang YB, Mardini S, et al. Reconstruction of the hand and
upper limb with free flaps based on musculocutaneous perforators.
Microsurgery 2004;24(4):270–80.
Chung KC, Cederna PS. Endoscopic harvest of temporoparietal fascial
free flaps for coverage of hand wounds. J Hand Surg [Am] 2002;
27(3):525–33.
Chung KC, Tong L. Use of three free flaps based on a single vascular
pedicle for complex hand reconstruction in an electrical burn injury:
a case report. J Hand Surg [Am] 2002;27(3):542.
Datiashvili RO, Shibaev EY, Chichkin CG, et al. Reconstruction of a
complex defect of the hand with two distinct segments of scapular
and a scapular fascial flap transferred as a single transplant. Plast
Reconstr Surg 1992;90:687–94.
De Lorenzi F, van der Hulst RR, den Dunnen WF, et al. Arterialized
venous free flaps for soft-tissue reconstruction of digits: a 40-case
series. J Reconstr Microsurg 2002;18(7):569–74.
Del Pinal F, Herrero F. Extensor digitorum brevis free flap: anatomic
study and further clinical applications. Plast Reconstr Surg 2000;
105(4):1347–56.
Del Pinal F, Herrero F, Jado E, et al. Salvage and functional rehabilita­
tion of a massively crushed hand with two sequential free flaps.
J Trauma 2002;53(5):980–3.
Del Pinal F, Pisani D, Garcia-Bernal FJ, et al. Massive hand crush: the
role of a free muscle flan to obliterate the dead space and to clear
deep infection. J Hand Surg [Br] 2006;31(6):588–92.
Fan CY, Jiang J, Zeng BF, et al. Reconstruction of thumb loss compli­
cated by skin defects in the thumb-index web space by combined
transplantation of free tissues. J Hand Surg [Am] 2006;31(2):
236–41.
Fassio E, Laulan J, Aboumoussa J, et al. Serratus anterior free fascial
flap for dorsal hand coverage. Ann Plast Surg 1999;43(1):77–82.
Flugel A, Kehrer A, Heitmann C, et al. Coverage of soft-tissue defects
of the hand with free fascial flaps. Microsurgery 2005;25(1):
47–53.
Fotopoulos P, Homer P, Leicht P, et al. Dorsal hand coverage with free
serratus fascia flap. J Reconstr Microsurg 2003;19(8):555–9.
Germann G, Bruener S. Free flap coverage of palmar hand wounds.
Tech Hand Up Extrem Surg 2000;4(4):272–81.
Hahn SB, Park JH, Kang JH, et al. Finger reconstruction with a free
neurovascular wrap-around flap from the big toe. J Reconstr Micro­
surg 2001;17(5):319–23.
Hallock GG. The utility of both muscle and fascia flaps in severe upper
extremity trauma. J Trauma 2002;53(1):61–5.
Hashmi PM. Free scapular flap for reconstruction of upper extremity
defects. J Coll Physicians Surg Pak 2004;14(8):485–8.
Hatoko M, Muramatsu T. The use of latissimus dorsi muscle flap in the
aesthetical reconstruction of heat-press injury of the hand. Burns
2001;27(1):75–80.
Ho T, Couch M, Carson K, et al. Radial forearm free flap donor site
outcomes comparison by closure methods. Otolaryngol Head Neck
Surg 2006;134(2):309–15.
Horch RE, Stark GB. The rectus abdominis free flap as an emergency
procedure in extensive upper extremity soft-tissue defects. Plast
Reconstr Surg 1999;103(5):1421–7.
Hough M, Fenn C, Kay SP. The use of free groin flaps in children. Plast
Reconstr Surg 2004;113(4):1161–6.
Hriscu M, Mojallal A, Breton P, et al. Limb salvage in proximal humerus
malignant tumors: the place of free vascularized fibular graft.
J Reconstr Microsurg 2006;22(6):415–21.
Hsieh CH, Yang CC, Kuo YR, et al. Free anterolateral thigh adipofascial
perforator flap. Plast Reconstr Surg 2004;112(4):976–82.
Hue KC, Zhang F, Lineaweaver WC, et al. Serratus anterior-rib compos­
ite flap: anatomic studies and clinical application to hand reconstruc­
tion. Ann Plast Surg 1999;42(2):132–6.
Hwang K, Han JY, et al. Topographical anatomy of the anconeus muscle
for use as a free flap. J Reconstr Microsurg 2004;20(8):631–6.
Hyza P, Vesely J, Stupka I, et al. The bilobed arterialized venous free
flap for simultaneous coverage of 2 separate defects of a digit. Ann
Plast Surg 2005;55(6):679–83.
Inada Y, Fukui A, Tamai S, et al. The arterialised venous flan: experi­
mental studies and a clinical case. Br J Plast Surg 1993;46(1):61–7.
Isik S, Sezgin M, Ozturk S, et al. Free musculofasciocutaneous medical
plantar flap for reconstruction of thenar defects. Br J Plast Surg
1997;50(2):116–20.
Javaid M, Cormack GC. Anterolateral thigh free flap for complex soft
tissue hand reconstruction. J Hand Surg [Br] 2003;28(1):21–7.
Jenkins NL, Lalikos JF, Wooden WA, et al. Innovative techniques in
bony reconstruction to facilitate hand salvage. Ann Plast Surg
2002;48(5):484–8.
Jim YT, Gao HP, Chang TS. Clinical application of the free scapular
fascial flap. Ann Plast Surg 1989;23:170.
Kantarci U, Cepel S, Gurbuz C. Venous free flaps for reconstruction of
skin defects of the hand. Microsurgery 1998;18(3):166–9.
Kaufman MR, Jones NF. The reverse radial forearm flap for soft tissue
reconstruction of the wrist and hand. Tech Hand Up Extrem Surg
2005;9(1):47–51.
Kawamura K, Yajima H, Kobata Y, et al. Clinical applications of free
soleus and peroneal perforator flaps. Plast Reconstr Surg
2005;115(1):114–19.
Kim PS, Gottlieb JR, Harris GD, et al. The dorsal thoracic fascia: Ana­
tomic significance with clinical applications in reconstructive surgery.
Plast Reconstr Surg 1987;79:72.
Kim HH, Jeong JH, Seul JH, et al. New design and identification of the
medial sural perforator flap: an anatomical study and its clinical
applications. Plast Reconstr Surg 2006;117(5):1609–18.
Kim JT, Kim SK. Hand resurfacing with the super thin latissimus dorsi
perforator-based free flap. Plast Reconstr Surg 2003;111(1):366–70.
Kim KS, Kim ES, Kim DY, et al. Resurfacing of a totally degloved hand
using thin perforator-based cutaneous free flaps. Ann Plast Surg
2003;50(1):77–81.
Kimura N, Satoh K, Hasumi T, et al. Clinical application of the free
thin anterolateral thigh flap in 31 consecutive patients. Plast Recon­
str Surg 2001;108(5):1197–208.

241.e2 PART 3 — RECONSTRUCTION
Koschnick M, Bruener S, Germann G. Free tissue transfer: an advanced
strategy for postinfection soft-tissue defects in the upper extremity.
Ann Plast Surg 2003;51(2):147–54.
Koshima I, Inagawa K, Jitsuika Y, et al. Scarpa’s adipofascial flan for
repair of Wide scalp defects. Ann Plast Surg 1996;36:88.
Koshima I, Nanba Y, Tsutsui T, et al. Vascularized femoral nerve graft
with anterolateral thigh true perforator flap for massive defects after
cancer ablation in the upper arm. J Reconstr Microsurg 2003;19(5):
299–302.
Kremer T, Bickert B, Germann G, et al. Outcome assessment after
reconstruction of complex defects of the forearm and hand with
osteocutaneous free flaps. Plast Reconstr Surg 2006;118(2):443–54.
Kuntscher MV, Erdmann D, Homann HH, et al. The concept of fillet
flaps: classification, indications, and analysis of their clinical value.
Plast Reconstr Surg 2001;108(4):885–96.
Lee HB, Tark KC, Kang SY, et al. Reconstruction of composite metacar­
pal defects using a fibula free flap. Plast Reconstr Surg 2000;105(4):
1448–52.
Lee HB, Tark KC, Rah DK, et al. Pulp reconstruction of fingers with
very small sensate medial plantar free flap. Plast Reconstr Surg
1998;10(4):999–1005.
Levin LS, Erdmann D. Primary and secondary microvascular recon­
struction of the upper extremity. Hand Clin 2001;17(3):447–55.
Li XJ, Tong J, Wang Y. Combined free toe and free deep inferior epi­
gastric perforator flap for reconstruction of the thumb and thumb
web space. J Reconstr Microsurg 2000;16(6):427–36.
Mardini S, Tsai FC, Wei FC. The thigh as a model for free style free
flaps. Clin Plast Surg 2003;30(3):473–80.
McGill D, Watson S. A novel use of the free gracilis muscle flap in hand
trauma. Plast Reconstr Surg 2005;115(6):1801–2.
Medalie DA. Perforator-based forearm and hand adipofascial flaps
for the coverage of difficult dorsi hand wounds. Ann Plast Surg
2002;48(5):477–83.
Meland NB, Weimar R. Microsurgical reconstruction: experience with
free fascia flaps. Ann Plast Surg 1991;27(1):1–8.
Millesi H. Free flap of gliding tissue (Discussion). J Reconstr Microsurg
1986;2:151.
Momeni A, Stark GB. The free fibular flap: a useful flap for reconstruc­
tion following composite hand injuries. J Hand Surg [Br] 2006;31(3):
304–5.
Muneuchi G, Suzuki S, Ito O, et al. Free anterolateral thigh fasciocu­
taneous flap with a fat/fascia extension for reconstruction of tendon
gliding surface in severe bursitis of the dorsal hand. Ann Plast Surg
2002;49(3):312–16.
Neumeister MW, Brown RE. Mutilating hand injuries, principles and
management. Hand Clin 2003;19:1–15.
Nichter LS, Jazayeri MA. The physiologic basis for nonconventional
vascular perfusion. Plast Reconstr Surg 1995;95(2):406–12.
Ninković MM, Schwabegger AH, Wechselberger G, et al. Reconstruc­
tion of large palmar defects of the hand using free flaps. J Hand Surg
[Br] 1997;22(5):623–30.
O’Neill PJ, Litts C. Hand and forearm reconstruction after skin cancer
ablation. Clin Plast Surg 2004;31(1):113–19.
Offer N, Baumeister S, Ohlbauer M, et al. Microsurgical reconstruction
of the burned upper extremity. Handchir Mikrochir Plast Chir
2005;37(4):245–55.
Okazaki M, Ueda K, Niu A, et al. Free lateral supramalleolar flap trans­
fer as a small, thin flap. Ann Plast Surg 2002;49(2):133–7.
Ozcelik D, Ugurlu K, Turan T. Reconstruction of the replanted hand
with latissimus dorsi muscle and serratus anterior fascia combined
flap. J Reconstr Microsurg 2003;19(3):153–6.
Pan CH, Chuang SS, Yang JY. Thirty-eight free fasciocutaneous flap
transfers in acute burned-hand injuries. Burns 2007;33(2):230–5.
Park JJ, Kim JS, Chung JI. Posterior interosseous free flap: various types.
Plast Reconstr Surg 1997;100(5):1186–97.
Pederson WC. Upper extremity microsurgery. Plast Reconstr Surg
2001;107(6):1524–37.
Pelzer M, Sauerbier M, Germann G, et al. Free “kite” flap: a new flap
for reconstruction of small hand defects. J Reconstr Microsurg
2004;20(5):367–72.
Rogachefsky RA, Ouellette EA, Mendietta CG, et al. Free temporopa­
rietal fascial flap for coverage of a large palmar forearm wound after
hand replantation. J Reconstr Microsurg 2001;17(6):421–3.
Rui Y, Shou K, Zhang Q, et al. Combined free-tissue transfer for primary
reconstruction of radial part of the hand. Microsurgery 2004;24(1):
59–62.
Sakai S. Free flap from the flexor aspect of the wrist for resurfacing
defects of the hand and fingers. Plast Reconstr Surg 2003;111(4):
1412–20.
Salgado CJ, Orlando GS, Serletti JM. Clinical application of the poste­
rior rectus sheath-peritoneal free flap. Plast Reconstr Surg 2000;
106(2):321–6.
Schwabegger AH, Hussl H, Rainer C, et al. Clinical experience and
indications of the free serratus fascia flap: a report of 21 cases. Plast
Reconstr Surg 1998;102(6):1939–46.
Shen YM, Shen ZY. Greater omentum in reconstruction of refractory
wounds. Chin J Traumatol 2003;6(2):81–5.
Summers AN, Sanger JR, et al. Lateral arm fascial flap: microarterial
anatomy and potential clinical applications. J Reconstr Microsurg
2000;16(4):279–86.
Takeiski M, Ishida K, Kurihara K. Free dorsal middle phalangeal finger
flap. J Reconstr Microsurg 2006;22(7):493–8.
Talbot SG, Athanasian EA, Cordeiro PG, et al. Soft tissue reconstruc­
tion following tumor resection in the hand. Hand Clin 2004;20(2):vi,
181–202.
Teran P, Araya E, Casado C. Reconstruction of a pulp defect using a
free finger-pulp flap from a non-replantable digit. Br J Plast Surg
2002;55(2):158–9.
Thatte MR, Thatte RL. Venous flaps. Plast Reconstr Surg 1993;91(4):
747–51.
Topalan M, Ozden BC, Aydin A, et al. Use of free serratus anterior
muscle slips for the reconstruction of dorsal-side defects of the hand
resulting from hot press injury. J Burn Care Rehabil 2004;25(4):
356–8.
Tsai FC, Yang JY, Mardini S, et al. Free split-cutaneous perforator flaps
procured using a three-dimensional harvest technique for the recon­
struction of post burn contracture defects. Plast Reconstr Surg
2004;113(1):185–93.
Turner A, Ragowannsi R, Hanna J, et al. Microvascular soft tissue recon­
struction of the digits. J Plast Reconstr Aesthet Surg 2006;59(5):
441–50.
Ulkur E, Uygur F, Karagoz H, et al. Use of free dorsoulnar perforator
flap in the treatment of postburn contractures of the fingers. Burns
2006;32(6):770–6.
Walton RL, Matory WE, Petry JJ. The posterior calf fascial free flap.
Plast Reconstr Surg 1985;75:914.
Wang HT, Fletcher JW, Erdmann D, et al. Use of the anterolateral thigh
flap for upper-extremity reconstruction. J Hand Surg [Am] 2005;
30(4):859–64.
Wintsch K, Helaly P. Free flap of gliding tissue. J Reconstr Microsurg
1986;2:143.
Woo SH, Seul JH. Optimizing the correction of severe postburn hand
deformities by using aggressive contracture releases and fasciocuta­
neous free-tissue transfers. Plast Reconstr Surg 2001;107(1):1–8.
Yang JW, Lee DC. Reconstruction of pulp defect using a free finger-
pulp flap from an excised extra digit. Br J Plast Surg 2000;53(8):
703–4.
Yano H, Fukui M, Yamada K, et al. Endoscopic harvest of free tempo­
roparietal fascial flap to improve done-site morbidity. Plast Reconstr
Surg 2001;107(4):1003–9.
Yano H, Nishimura G, Kaji S, et al. A clinical and histologic comparison
between free temporoparietal and scapular fascial flaps. Plast Recon­
str Surg 1995;95:452.
Yildirim S, Taylan G, Akoz T, et al. Use of fascia component of the
anterolateral thigh flap for different reconstructive purposes. Ann
Plast Surg 2005;55(5):479–84.
Yildirim S, Taylan G, Eker G, et al. Free flap choice for soft tissue
reconstruction of the severely damaged upper extremity. J Reconstr
Microsurg 2006;22(8):599–609.
Yousif NJ, Warren R, Matloub JHS, et al. The lateral arm fascial free
flap: Its anatomy and use in reconstruction. Plast Reconstr Surg
1990;86:1138.

242
Adult Brachial Plexus
Injury (A-BPI)
Reconstruction
David Chwei-Chin Chuang
21 
INTRODUCTION
The surgical management of adult brachial plexus injury
(A-BPI) reconstruction has evolved substantially over the
last century. The advancement of the operative microscope
and surgical loupe magnification, micro-instruments and
stitches, nerve stimulators, chemistry, molecular biology,
and pharmacology has enabled a far deeper understanding
of the internal anatomy of the nerves and pathophysiology
of nerve degeneration and regeneration. As a result of more
accurate preoperative diagnosis, microsurgical skills, more
nerve transfers, and functioning free muscle transplantation
(FFMT), significant improvements in the functional out­
comes of brachial plexus reconstruction have been achieved
consistently, since 1970.1–15 Nevertheless, there are still many
questions with few answers, and many debates with few con­
clusions. One of the major stumbling blocks to clarity is the
lack of general consensus, due to inadequate communica­
tion and collaboration.
Many reconstructive surgeons are interested in brachial
plexus reconstruction but they feel frustrated due to its
complexity (Box 21.1).15 This author has handled more
than 1800 cases of adult brachial plexus exploration and
reconstruction since 1985. The aim of this chapter is to give
a comprehensive overview of this experience and to make
the subject more accessible, with the further goal of obtain­
ing a more general consensus for A-BPI reconstruction.
CONSENSUS IN LEVELS OF ADULT
BRACHIAL PLEXUS INJURY
Different pioneers have had quite varied ways of describing
levels of A-BPI.15 Numerous classification systems have made
the anatomy of the brachial plexus more confusing than it
need be. A simple and easy classification system has been
developed by the author. This system simply uses numbers
(I–IV) for the levels of A-BPI (Fig. 21.1) based on key points
of the surgical approach:
• Level I injury: an injury inside the (vertebrae) bone, basi­
cally a preganglionic root injury involving cord, rootlets,
or roots. A laminectomy is required for nerve explora­
tion. The incidence of Level I injury is, unfortunately, the
highest, around 70%.14
• Level II injury: an injury inside the (scalene anterior and
middle) muscles, equal to a postganglionic spinal nerve
injury. Segmental resection of the anterior scalene muscle
is required for nerve exploration. The incidence of pure
Level II injury is about 8%.14
• Level III injury: an injury in the pre- and subclavicular
space, equal to a trunks and divisions injury. Osteotomy
of the clavicle is usually required for nerve exploration.
The incidence of pure Level III injury is about 5%.14
• Level IV injury: an injury in the infraclavicular space,
equals to a cords and terminal branches injury. It usually
requires tedious dissection and long nerve grafts. The
incidence of pure Level IV injury is about 17%,14 the
second highest.
The use of this “number” description for levels of BPI has
now been uniformly applied in the author’s center.
MANAGEMENT OF ADULT BRACHIAL
PLEXUS INJURY
Management of A-BPI, using the author’s modified classifi­
cation system follows. Avulsion and rupture are the two types
of lesion frequently seen in A-BPI. Both are traction injuries
Box 21.1  Complex Problems in Adult
Brachial Plexus Injury (A-BPI)
1. Complex and confusing anatomy
2. Complex pathophysiology (nerve de- and regeneration)
3. Complex evaluation (physical examination and diagnosis)
4. Complex surgical techniques: microneurovascular surgery
5. Long rehabilitation and long follow-up period
6. Different palliative surgeries for sequelae deformities
7. Unpredictable BPI reconstruction outcomes
PART 3  —  RECONSTRUCTION

CHAPTER 21 — Adult Brachial Plexus I njury (A-BPI) Reconstruction
243
Figure 21.1  Anatomy of the brachial plexus including Chuang’s classification system for adult brachial plexus injuries (Levels I–IV). (Reprinted
from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Musculocutaneous nerve (C5, C6, C7)
Axillary nerve (C5, C6)
Radial nerve (C5, C6, C7, C8, T1)
Median nerve (C5, C6, C7, C8, T1)
Ulnar nerve (C7, C8, T1)
Inconstant contribution
Contribution from T2
To longus colli and scalene muscles (C5, C6, C7, C8)
1st intercostal nerve
Long thoracic nerve (C5, C6, C7)
Medial pectoral nerve (C8, T1)
Medial cutaneous nerve of arm (T1)
Medial cutaneous nerve of forearm (C8, T1)
Upper subscapular nerve (C5, C6)
Thoracodorsal (middle subscapular) nerve (C6, C7, C8)
Lower subscapular nerve (C5, C6)
5 Roots
(Ventral Rami of
Spinal Nerves)
Lateral pectoral
nerve (C5, C6, C7)
Terminal
Branches
3 Cords
Lateral
Posterior
Lower
Middle
Upper
Medial
3 Anterior Divisions
3 Posterior Divisions
3 Trunks
1st rib
Suprascapular
nerve (C5, C6)
To subclavius
muscle (C5, C6)
Dorsal scapular
nerve (C5)
To phrenic
nerve
Contribution from C4
Dorsal ramus
C5
C6
C7
C8
T1
Anterior division
Posterior division
Pectoralis minor tendon (cut)
Coracoid process
Acromion
Cephalic vein
Musculocutaneous nerve
Anterior circumflex humeral artery
Axillary nerve and posterior
circumflex humeral artery
Pectoralis major muscle (cut)
Coracobrachialis muscle
Deltoid muscle
Biceps brachii muscle
Musculocuta-
neous nerve
Brachialis muscle
Thoracoacromial artery
Acromial branch
Deltoid branch
Clavicular branch
Pectoral branch
Axillary artery
Clavicle and subclavius muscle (cut)
Suprascapular artery and nerve
Dorsal scapular artery and nerve
Trapezius muscle
Transverse cervical artery
Anterior scalene muscle
Sternocleidomastoid muscle
Phrenic nerve
Omohyoid muscle
Subclavian artery and vein
1st rib
Brachial plexus
Superior thoracic artery
Lateral pectoral nerve
Medial pectoral nerve
Deep artery of arm
Radial nerve
Triceps brachii muscle
Brachial veins
Ulnar nerve
Median nerve
Brachial artery
Medial cutaneous nerve
of the forearm
Basilic vein
Ulnar nerve
Medial cutaneous
nerve of arm
Intercostobrachial
nerve
Circumflex
scapular artery
Lower sub-
scapular nerve
Teres major muscle
Subscapular artery
Latissimus dorsi muscle
Thoracodorsal artery and nerve
Upper subscapular nerve
Serratus anterior muscle
Lateral thoracic artery and long thoracic nerve
Pectoralis minor muscle (cut)
Comparison of Embryonic Limb Organization to the Plan of the Brachial Plexus
Axilla (Dissection): Anterior View

244
PART 3 — RECONSTRUCTION
CLINICAL PRESENTATION AND
EXAMINATION
PATIENT HISTORY
A-BPI may be caused by trauma sustained in motorcycle
accidents (the most common cause; about 80%), falling
from a height; traction injuries from rolling machines or
conveyer belts; compression injuries from heavy objects or
shoulder dislocation; penetrating injuries from sharp objects
or bullets; iatrogenic injuries; or even those from surgeons
during tumor resection. Other causes are tumors (primary
or secondary), infections (e.g., enterovirus, polio), or
inflammation (e.g., irradiation neuritis).
Patient history helps to classify the degree and extent of
injury. A history of shoulder dislocation or glenoid fracture
may show a high incidence of Level IV injury. A history of
C-spine fracture indicates that Level I root injury is more
likely. Artery rupture and repair can help determine the site
of nerve injury based on level. Segmental thrombosis of the
subclavian artery is usually associated with C8 T1 Level I root
injury. History of rib fracture and chest intubation warns
against intercostal nerve transfer because of higher failure
rate.19 Limping due to lower limb fracture with osteomyelitis
or non-union will also affect the intercostal nerve transfer
as the patient will not be able to perform appropriate reha­
bilitation.19 Extreme causalgia, often seen in cases with root
avulsion in aged patients, is also a major risk factor for poor
results due to poor rehabilitation.
PATIENT EXAMINATION
Patient examination is essential and is the most important
step in establishing the diagnosis of the site and degree of
injury. The patient is examined initially and again at 2
months post-injury, in order to get an accurate assessment
of the level and degree of injury.
MOTOR EXAMINATION
Motor examination should be completed, muscle by muscle,
in a disto-proximal fashion, and recorded using the British
MRC (Medical Research Council) scale (M0–M5), which
gives each muscle a level of strength, with M0 having no
movement and M5 having normal contraction against full
resistance.5
SENSORY EXAMINATION
Sensory evaluation should include a pinprick pain test and
Tinel sign. A pinprick test from areas of normal to abnormal
sensation will map out the area of sensory disturbance and
is sufficient for the patient’s sensory examination. Sensory
grading is based on the British MRC scale (S0–S4), modified
by adding a grade for sensory over-reaction (S2+).15 Such
sensory evaluations can give clues about the level and degree
of brachial plexus injury. Tinel’s sign is an important clinical
way to determine the location of neuroma or to judge the
regeneration of the injured nerves. Palpation or percussion
at the neck, at the supraclavicular Erb’s point (clavicular
insertion of the sternocleidomastoid muscle), at the infra­
clavicular coracoid process of the scapula, and at routes
of different nerves pathways may induce electric current
but with different characteristics (Table 21.1). Root avulsion
in BPI is usually accompanied with tearing of the dura and
a CSF leak with cyst formation, known as a “pseudomenin­
gocele.” In some cases, the root can be avulsed at its origin
with an intact dural cone and no cyst formation. This is
called “avulsion in situ,” which gives a grossly normal appear­
ance but with some loosening and/or curvature of the
involved spinal nerve at the time of surgical intervention,
despite established paralysis. Most often, the entire avulsed
roots, including the ventral and dorsal roots and the ganglia,
retract and migrate downward to the interscalene or precla­
vicular region. Clinically, C5 tends to be ruptured, C7 and
C8 avulsed, but T1 stretched in injury patterns.
CONSENSUS IN TIMING OF BRACHIAL
PLEXUS EXPLORATION
Early nerve surgery (immediate or within weeks); delayed
early nerve surgery (3 weeks to 6 months); and late nerve
surgery (>6 months after injury), are three generally
accepted time periods for nerve exploration. Timing of
nerve exploration is dependent on the degree of nerve
injury. Degree of peripheral nerve injury can be classified
into Sunderland grade 1–5 injury.1,16 In Sunderland 4° or 5°
injuries, only nerve repair can succeed in restoring continu­
ity. In Sunderland 1°, 2°, and 3° injuries, spontaneous recov­
ery may occur. In cases of penetrating injury by sharp objects
in A-BPI, it is clear that early nerve surgery is indicated. For
a closed traction injury, some surgeons advocate early nerve
surgery. This is much debated in Level IV injury17–18 because
of the desire to avoid tedious scar dissection and long nerve
grafts. However, most brachial plexus surgeons recommend
delayed early nerve surgery4–15 for closed type of A-BPI, no
matter which level of injury. The reason is that in closed BPI
with avulsed or ruptured stumps, it is often difficult to judge
the degree and extent of injury so soon after trauma. The
use of healthy stumps is more crucial for better outcomes.
In such cases, the benefits of waiting outweigh the advan­
tages of early nerve surgery.
Table 21.1  Nerve avulsion vs nerve rupture
Avulsion
Rupture
Nerve torn from its attachment
or at the bone margin
Nerve division + traction:
nerve deficit, nerve gap
or neuroma incontinuity
In the operated field, only one
disrupted end can be found
In the operative field,
two disrupted ends can
be found
It may be:
Level II, III, or IV lesions
  Proximal avulsion: Level I
nerve avulsion from the cord or
root
    or
  Distal avulsion: Level IV injury,
nerve avulsion from the muscle
or at the bone margin

CHAPTER 21 — Adult Brachial Plexus I njury (A-BPI) Reconstruction
245
relieved by psychological pathways such as the distraction
mechanism (concentrating on other tasks such as working,
exercise, gardening, change of posture, massage). This dis­
traction of pain is very helpful and should be well explained
with the patient and patients’ family. The best treatment for
root pain is distraction, rather than medicine or surgery.
PLAIN X-RAY AND IMAGING STUDIES
(MRI AND/OR CT)
Plain X-rays of the chest and cervical spine are routinely
required. Chest X-rays should include inspiration and expi­
ration views to exclude diaphragmatic palsy. C-spine X-rays
are evaluated for any fracture of the transverse or spinous
process as well as the vertebrae body. Cervical scoliosis or
neck spine rigidity is a possible sequel of Level I injury.
In recent years, invasive imaging studies (such as cervi­
cal myelography) are gradually being replaced by non-
invasive magnetic resonance imaging (CT-myelogram and
3D-MRI).20–23 An MRI study with various investigative tech­
niques is very helpful for diagnosis of root injury. Improved
techniques for diagnosis include C-spine MRI myelogram;
3D-FIESTA (Fast Imaging Employing Steady-state Acquisi­
tion) study provides rapidly obtained images of fluid-filled
structures with continuous slices from the antero-posterior
cutting plane (Fig. 21.2), different planes of ventral and
dorsal rootlets using curve planar reformat technique;
MRI, diffusion weighted imaging (DWI), and short tau
inversion recovery (STIR) techniques with views of the
Level II–IV nerve structures. Valuable and accurate data
provided by the various MRI techniques allow surgeons to
make more confident judgments on the level injury of
A-BPI.
ELECTRODIAGNOSIS
Electrodiagnostic studies, mainly consisting of nerve con­
duction velocity (NCV) and needle electromyography
(EMG), are used to localize the lesion and to assess its sever­
ity. Abnormal low sensory action potential (SNAP) ampli­
tude indicates a ganglionic or post-ganglionic lesion.
Conversely, the pick-up sensory action potentials taken from
a paralytic limb is evidence of a Level I lesion. The presence
sensation (like pins and needles) running down to the
shoulder or the hand. This is called “positive Tinel’s sign.”
Tinel’s sign should be localized at the point of maximal pain
elicited. If the Tinel’s sign remains at a fixed point, implying
retardation of nerve growth, surgical exploration is war­
ranted. If the Tinel’s sign advances from supraclavicular to
infraclavicular and further to arm or forearm at successive
examination, “wait and see” in this instance is recom­
mended. A weak or absent Tinel’s sign in the neck region
with a paralyzed limb usually indicates a total root avulsion.
Horner’s syndrome (miosis, ptosis, enophthalmos and anhi­
drosis) is a sign of sympathetic nervous system disturbance.
It indirectly implies avulsion of T1 and C8 roots. This syn­
drome usually persists in A-BPI.
VASCULAR INJURY EXAMINATION
Absence or weakness of pulsation of the radial artery at the
wrist indicates vascular injury of the axillary or subclavian
artery. Vascular injury should be taken into account when
considering the use of a vascularized ulnar nerve graft for
reconstruction. FFMT for reconstruction should also be very
carefully used in cases of absence of radial artery pulsation.
Splint immobilization that keeps the elbow in flexion at
more than 90° can easily compromise digital peripheral
circulation.
ROOT INJURY PAIN
Brachial plexus root pain is caused by avulsed nerve stump
wound (acute stage), or healed scars (chronic stage) with
pain. It is similar to a wound (acute stage) or healed scar
(chronic stage) on the skin. The skin wound scar may cause
itching and tingling pain on the skin, but regresses from
time to time. Brachial plexus root pain was similar, begin­
ning with severe and frequent nerve shooting pain, to the
intermittent but regressive pain. But sometimes it may
persist indefinitely if the nerve stump was healed by bad
scars. Typically the root pain will have no precise distribu­
tion and is described as an electric shooting pain continuing
for short duration (seconds), resolving spontaneously and
recurring. This characteristic pain is called “deafferentation
pain.” The pain can be induced by temperature change, but
Figure 21.2  (A,B) 3D-FIESTA (Fast Imaging Employing Steady-state Acquisition) study demonstrating root avulsion injury.
A
B

246
PART 3 — RECONSTRUCTION
Figure 21.3  Different incisions used for brachial plexus reconstruc­
tion: supraclavicular approach, infraclavicular approach, an upward
extension of the supraclavicular incision that allows for exposure of
the spinal accessory nerve. A chest semicircular incision for intercos­
tal nerve exposure; a submental incision for the hypoglossal nerve; a
medial arm incision for exposure of the biceps and brachialis muscle
nerve branches; and a contralateral neck C-curved incision for con­
tralateral C7 spinal nerve dissection.
of fibrillation potentials on needle EMG may suggest that
the lesion is at least axonotmesis. The significant reduction
of the amplitude of compound muscle action potentials
during motor nerve conduction studies indicates an axonal
loss (Sunderland 3–5° lesion), rather than a neurapraxia
(Sunderland 1°) lesion.24
SURGICAL TREATMENT
Nerve surgery is always the treatment of choice for A-BPI,
whether that be for closed or open injuries. For closed BPI,
management can be considered in the six stages:
• Stage 1: Stabilization stage (the 1st month), including sta­
bilization of vital signs, bone fracture, or joint dislocation
• Stage 2: Diagnostic stage (the 2nd month), including clini­
cal examination and ancillary investigations to establish
the diagnosis of the lesion condition; start of physiother­
apy to prevent soft tissue swelling, joint stiffness, slow
muscle atrophy by electric stimulation; and psychologic
education before surgery
• Stage 3: Nerve surgery (the 3rd to 5th month): if the patient
fails to show a return of function at 5 months, surgical
intervention is indicated. Nerve reconstruction with nerve
grafts or nerve transfers at 5 months seems to make no
big difference, with surgery in the 3rd month in results
of our series. However, results of nerve reconstruction
performed more than 6 months after injury are usually
significantly poorer than the denervation time of less than
6 months. Therefore, waiting until later than 6 months
after injury to perform nerve grafts or nerve transfers is
not recommended and often local or free muscle transfers
might become necessary to enhance the results
• Stage 4: postoperative care (3–4 weeks postoperatively)
and rehabilitation (3–4 years)
• Stage 5: late reconstruction for the sequelae deformities
or deficits (during 3rd or 4th year postoperatively)
• Stage 6: destination stage (5th or 6th year postoperatively)
including amputation and intolerable pain treatment.
In chronic cases (1 year after injury), the muscles have
undergone long-time denervation and atrophy, so late nerve
surgery in such circumstances is useless and usually leads to
poor results. FFMT, or banked nerve grafts from ipsilateral
or contralateral nerve transfer followed by secondary FFMT
is the option for such chronic cases.5,25
EXPLORATION OF THE SUPRACLAVICULAR
BRACHIAL PLEXUS
A C-curved incision – starting midway along the posterior
border of the sternocleidomastoid muscle down to 6–8 cm,
and curving laterally parallel to and above the clavicle to a
point to connect the line of deltoid-pectoral sulcus – is a
popular incision for supraclavicular approach (Fig. 21.3). A
platysma musculocutaneous flap is elevated. Dissection
beneath the sternocleidomastoid muscle is made to the inter­
nal jugular vein, a landmark of the uppermost medial dis­
section. The supraclavicular sensory nerves are the landmarks
of the uppermost cranial dissection. The omohyoid muscle
traverses just behind the sternocleidomastoid muscle and is
looped and spared, as it can serve as an important landmark
if a secondary surgery is necessary (deep to the plane of this
muscle are more critical structures including the brachial
plexus). Below the omohyoid muscle, there is an abundance
of adipofascial tissue containing rich lymphatic duct and
lymph nodes. The transverse cervical vessels also exist in this
space. A similar C-shaped incision along the internal jugular
vein medially and subclavian vein inferiorly is made and a
superiorly based adipofascial flap is elevated. The lymph
tissues, including the ducts coming from the deep plane of
the internal jugular vein, should be coagulated or ligated
before division to avoid postoperative lymph leakage and
chylous formation. The transverse cervical artery and vein
in the deeper plane of the adipofascial tissue are preserved
if possible, as they may potentially be required as recipient
vessels for a vascularized ulnar nerve graft. Following the
elevation of the adipofascial flap, the phrenic nerve is noted
over the scalene anterior muscle. The subclavian artery lies
just beneath the scalene anterior muscle and inferior to the
C7 spinal nerve and should be carefully protected. The
dominant transverse process of C5 at the top of the supra­
clavicular sensory nerves is palpable. If necessary, the fibrotic
scalene anterior muscle attached to the C5 transverse process
can be detached and segmentally excised to expose the C5
and C6 spinal nerves: the spinal nerve above the C5 trans­
verse process is C5, and below is the C6 spinal nerve. The
C7 spinal nerve is usually located a little farther away from
C6. C8 and T1 spinal nerves or of the inferior trunk are then
noted deep beneath the subclavian artery. Sometimes the
C8 is quite close or adherent to the C7.
EXPLORATION OF THE INFRACLAVICULAR
BRACHIAL PLEXUS
For the infraclavicular approach, an incision is made just
along the deltopectoral groove and extends upward to meet
the supraclavicular incision, or downward to the medial
sulcus of the biceps (Fig. 21.3). Chuang’s triangle14,15 is a

CHAPTER 21 — Adult Brachial Plexus I njury (A-BPI) Reconstruction
247
from the contralateral neck) to the avulsed brachial plexus
for neurotization of a paralytic nerve. These neurotizers
include the phrenic (Ph) nerve; the spinal accessory (XI)
nerve; the deep motor branches of the cervical plexus (cer­
vical motor branches, CMB); the hypoglossal (XII) nerve;
and the contralateral C7 (CC7) spinal nerve.25
Intraplexus Nerve Transfer
Intraplexus nerve transfers are applicable in cases of non-
global root avulsion, in which at least one of the spinal nerves
is a rupture injury, and still available for transfer, but not to
its original pathway but to other more important nerve of the
brachial plexus. For example, in a case of C5 and C6 Level II
ruptured injury in which the C5 stump is healthier than the
C6 stump, the C5 fibers are intentionally transferred to C6
(or anterior division of the upper trunk) for elbow. The distal
C5 (combined posterior division of the upper trunk and
suprascapular nerve) is then innervated by the partially
injured C6. This strategy acknowledges that elbow flexion
has priority over shoulder functions. In cases of a C5 and C6
two root avulsion injury, the ipsilateral C7 is then transected
and transferred to the upper trunk for reinnervation.
Extraplexus and intraplexus nerve transfers are both con­
sidered as proximal nerve neurotization.
Distal Nerve Transfer
Distal nerve transfer is a procedure that provides a direct
coaptation at a more distal site, closer to the neuromuscular
junction, thus achieving faster recovery of motor outcomes.
Distal nerve transfer is here defined as a procedure outside
of the supra- and infraclavicular fossa. Examples include
spinal accessory nerve transfer to the suprascapular nerve
via a posterior approach; partial ulnar nerve transfer to the
biceps nerve; part of median nerve transfer to the brachialis
nerve; long head of triceps branch transfer to the axillary
nerve; intercostal nerve transfer to the biceps nerve or the
entire musculocutaneous nerve; or to the nerve of the long
head of triceps, anterior interosseus nerve transfer to the
radial or posterior interosseus nerve, and branch of the
anterior interosseus nerve transfer to the deep motor
branch of the ulnar nerve in the forearm.11–13,25
Selecting proximal or distal nerve transfers is a subject of
debate (Table 21.2).
End-to-side neurorrhaphy (termino-lateral neurorrha­
phy) is a technique to transfer the distal end of a paralytic
and irreparable nerve to the side of an intact nerve with an
epineurotomy window for both motor and sensory recon­
struction. It might be one of either proximal or distal nerve
transfers. However, most of the brachial plexus surgeons are
reluctant to use this technique, or they may consider using
it as an adjuvant technique.
RECONSTRUCTIVE STRATEGIES WITH NERVE
TRANSFERS FOR DIFFERENT FUNCTIONS
Reconstructive strategies with nerve transfers for different
functions are individualized for each patient, depending on
the intraoperative findings, the surgeon’s philosophy, and
the patient’s condition and requirements.
Shoulder
Reconstruction for shoulder abduction in a Level I lesion
should take priority over shoulder adduction. If the
triangle bordered by the main branch of the cephalic vein,
the clavicle, and the deltoid muscle edge. Some of the deltoid
and clavicular parts of the pectoralis major muscle attach­
ments can be detached to increase the triangle exposure
area. Under the clavicle the subclavius muscle is noted.
Under the subclavius muscle, the lateral and posterior cords
as well as the suprascapular nerve can be seen. From this, the
suprascapular and infrascapular fossa is connected through
this avascular plane without the need for osteotomies of the
clavicle. The clavicle and the subclavius muscle are lifted
together by passing a rolling gauze. The “White line”14,15
identifies an intermuscular septum between the clavicular
and sternal parts of the pectoralis major muscle. Splitting the
septum, the underlying pectoralis minor muscle and infra­
clavicular brachial plexus can be seen and localized. The first
and most anterior cord encountered beneath the upmost
pectoralis minor muscle is the lateral cord. The Y-shaped
limbs from the lateral and medial cords will become the
median nerve. The subclavian artery can be easily found
between the Y-shaped limbs. The posterior cord lies posterior
to the subclavian artery and has two terminal branches: the
larger one is the radial nerve, and the smaller one is the axil­
lary nerve. In the upper arm, the musculocutaneous nerve
penetrates the coracobrachialis muscles and can be found
between the biceps and coracobrachialis muscles. Some­
times the musculocutaneous nerve has anatomical variation
and arises from the median nerve in the medial upper arm.
The axillary nerve in the axilla can be found at the humeral
neck, above the tendinous portion of the teres major, accom­
panied by the lateral circumflex humeral artery.
Other ancillary incisions (Fig. 21.3) may be required for
additional sources of nerve transfer: an upwardly extended
incision for spinal accessory nerve exposure; a chest semi­
circular incision for intercostal nerve exposure; a submental
incision for the hypoglossal nerve; a medial arm incision for
exposure of the biceps and brachialis muscle nerve branches;
and a contralateral neck C-curved incision for contralateral
C7 spinal nerve dissection.
SURGICAL STRATEGIES
Neurolysis, direct nerve repair, nerve grafts, nerve transfers,
and FFMT are the surgical options for brachial plexus
reconstruction. The decision of which procedure to pursue
is determined, based on the level of injury.
LEVEL I INJURY
Nerve transfer, pedicle muscle transfer and FFMT provide
the only possibilities for functional restoration.
NERVE TRANSFER
Nerve transfer is best done within 5 months of the injury
(referred to as the “golden time”) in order to reactivate the
paralyzed muscle(s) effectively (aiming for M4 restored
muscle strength).19,25 Nerve transfer can be broadly classified
into extraplexus, intraplexus, and distal nerve transfer.
Extraplexus Nerve Transfer
Extraplexus nerve transfer involves the transfer of a brachial
plexus neighboring nerve (either from the ipsilateral or

248
PART 3 — RECONSTRUCTION
supraspinatus, infraspinatus, and deltoid muscles are inner­
vated simultaneously, the results are predictably better.26
The Ph, XI, XII nerve, CMB, part of C5 or C6, long thoracic
nerve, branch to the long head of triceps, medial pectoral
nerve, IC nerves, and CC7 have all been reported as donor
nerves for shoulder abduction. The Ph and XI are the most
commonly used donor nerves for shoulder abduction. The
recipient nerves for shoulder abduction in order of priority
are the distal end of C5, suprascapular nerve, dorsal division
of the upper trunk, and axillary nerve.
Elbow
Reconstruction of elbow flexion is always the first priority.
Reported donor nerves for elbow flexion include IC nerves;
XI nerve with or without a nerve graft; Ph nerve with or
without a nerve graft; partial ulnar nerve; partial median
nerve; pectoral nerve; thoracodorsal nerve; and CC7. The
recipient nerve is the musculocutaneous nerve (mixed
nerve), biceps nerve, or brachialis nerve. Elbow extension
is a lesser priority for reconstruction. Ph nerve transfer to
the distal C5, to the posterior division of the upper trunk,
or to the radial nerve with a nerve graft can often yield
elbow extension. Some authors describe transferring two or
three IC nerves to the branch of the long head of triceps to
achieve elbow extension.9
Finger
In global (C5–T1) Level I injury, reconstructive priority for
finger function depends on the procedure used. In C5
rupture with C6–T1 four root avulsion, transfer of C5 to the
median nerve; or in a total root (C5–T1) avulsion, transfer
of the CC7 to the median nerve can achieve finger and wrist
flexion as well as finger sensation. Either one of these pro­
cedures requires a vascularized ulnar nerve graft. Results
from ipsilateral C5 transfer are usually better than contra­
lateral C7 transfer to the median nerve.
Another highly debated subject is whether total root avul­
sion or 4-root avulsion with C5 rupture, nerve transfers, or
FFMT should be the first choice of surgical treatment (Table
21.3). Multiple nerve transfers aim to achieve a one-stage
full reconstruction for shoulder, elbow, and hand functions,
while FFMT is used as an adjuvant reconstruction to enhance
results. FFMT as the first choice is an alternative approach.9
In the first stage, a long free muscle transfer (usually the
gracilis muscle) is set from the clavicle down to the extensor
digitorum communis (EDC) through an elbow pulley, and
Table 21.2  Comparison between “proximal nerve
transfers” vs “distal nerve transfer” in
reconstructive strategies for A-BPI
Proximal nerve
transfer
Distal nerve
transfer
Philosophy
Traditional
New strategy
Donor nerve
Extraplexus,
intraplexus nerves
Close to the
target
Advantages
Useful for diagnosis
and treatment
Strong donor nerves
exist
Less functional
deficits
For treatment (a
short cut)
Easy dissection
Stump: healthy,
no scars
Direct repair, no
nerve graft
Shorter operation
time
Shorter
rehabilitation,
faster recovery
Disadvantages
Difficult dissection
Stump: may not
healthy
May need long
nerve grafts
Long operation time
Long rehabilitation
period
Risk to cause
deficits
Risk to have
iatrogenic
injury
May need
multiple
incisions
Indication
Indicated in all kinds
of Avul/Rup injury
Only indicated in
non-global BPI
Table 21.3  Comparison between “Nerve transfers”
first vs “FFMT” first in reconstructive
priority for total root avulsion of BPI
Nerve transfer
first
FFMT first
Philosophy
Traditional strategy
New strategy
Reconstruction
priority
Shoulder, elbow
first, then finger
Finger and
elbow first,
then shoulder
Brachial plexus
exploration
Always
Not always
Nerve reconstruction
For shoulder
Yes
May or may
not need
For elbow
Yes
FFMT
For finger
Yes
FFMT
Stage requirement
One stage, full
reconstruction
Multiple stages
Rehabilitation
period
At least 4 years
2 years
Patient selection
High motivation,
intelligent patient
Less intelligent,
and impatient
patient
Predict outcomes
Shoulder elevation
Better (≥60°)
Shoulder
fusion (10–30°)
Elbow flexion
Usually better (M4)
M3–4
Finger flexion
M2–4
M3
Finger extension
(EDC)
M0
M2–3
Finger sensation
Yes
Bizarre

CHAPTER 21 — Adult Brachial Plexus I njury (A-BPI) Reconstruction
249
is innervated by the XI nerve. In a second stage, a second
long free muscle transfer is set from the second rib to the
flexor digitorum profundus (FDP), and the muscle is inner­
vated by IC nerves. With this strategy, nerve reconstruction
such as C5, contralateral C7, or IC transfer becomes an
adjuvant procedure for shoulder or elbow function.
FUNCTIONING FREE MUSCLE TRANSPLANTATION
FFMT is the transfer of a muscle utilizing microvascular
anastomoses for revascularization and microneural coapta­
tion to a recipient motor nerve for reinnervation. The use
of FFMT in brachial plexus reconstruction is one example
of the application of nerve transfer.25 It has been shown to
be effective and has become increasingly popular. The graci­
lis myocutaneous FFMT is the most common and best
choice of donor muscle. The commonly used donor nerves
include the XI, the IC, the Ph nerve, the CC7 nerve, part
of the ulnar nerve, part of the median nerve, or more proxi­
mally from the infra- or supraclavicular nerve, which requires
nerve elongation with a nerve graft followed by FFMT in a
two-stage procedure. The results from FFMT are more sat­
isfactory than those achieved with a local muscle transfer. It
is especially useful for elbow and hand function restoration
in global plexopathy. Indications for FFMT in A-BPI include
acute or chronic root avulsion, root injury with failed nerve
transfer (muscle strength less than M3), or BPI with associ­
ated Volkmann’s contracture of the forearm.
LEVEL II INJURY
The main findings with this type of injury are disruption at
the level of the spinal nerve, with neuroma formation and
dense scar tissue involving the scalene muscles. Nerve
rupture may occur at one or multiple spinal nerves. The
clinical differential diagnosis between Level I and Level II
injury is of great importance with regard to the surgical
approach and prognosis. Reconstruction for this level of
injury includes neurolysis, nerve repair, nerve grafts,
C-looped vascularized ulnar nerve graft, nerve transfers5,14
nerve surgeries, and other palliative reconstructions.
LEVEL III INJURY
Similar to Level II, neuroma and dense scars are the most
common findings. Bypass nerve grafting is required to
reestablish the connection between the supra- and infracla­
vicular brachial plexus. A clavicle osteotomy is often required
for wound exposure, especially for injuries involving the
lower trunk, to allow grafting or direct neurolysis. Multiple
nerve grafts are required. A C-loop vascularized ulnar nerve
graft is sometimes helpful to reduce the amount of nerve
grafts needed, especially in cases of extensive injury.
LEVEL IV INJURY
Level IV injury has its unique characteristics, including a
high incidence of scapular fractures, glenohumeral disloca­
tion, vascular injuries difficulties in surgical dissection, and
longer nerve grafts. The lesion is most commonly limited to
this zone and rarely has upward level involvement. Level IV
injuries are mostly encountered with nerve ruptures and
rarely with distal nerve avulsion, an avulsion at the bone
margin (such as suprascapular nerve avulsion at the scapu­
lar notch, or axillary nerve at the humeral neck, or radial
nerve at the spinal groove of the humerus), or at the muscle
attachment (such as the musculocutaneous nerve from the
biceps surface). In a closed injury with Level IV lesions, the
nerve damage is variable, ranging from simple isolated
nerve injuries (axillary, musculocutaneous, or radial nerve)
to lesions of all cords or all terminal branches. Nerve grafts
are more frequently utilized with less aberrant reinnerva­
tion and better prognosis. Long nerve grafts (>8 cm) are
usually required to bridge the nerve gap. Sometimes a
C-loop vascularized ulnar nerve graft is utilized. The results
are usually good. In nerve avulsion from the muscle, nerve
grafting of the proximal nerve stump and direct implanta­
tion into the muscle (nerve-to-muscle neurotization) yield
fair results (around M3). FFMT is a better option of recon­
struction for such particular cases to reach M4 result.
POSTOPERATIVE MANAGEMENT AND
REHABILITATION
Immediate postoperative neck splinting for 3 weeks is
required after nerve grafts or transfers. Thereafter, retrain­
ing and rehabilitation should start, including physiotherapy,
muscle stimulation, brain cognizance, biofeedback, and
occupational therapy. Patients should be followed up peri­
odically, every 3–4 months with the surgeon, and twice a
month with the physical therapist. Patients are encouraged
to have electrical muscle stimulation at home regularly
(twice a day). In cases of intercostal nerve transfer, passive
shoulder elevation remains restricted to <90° for 6 months.
Regular follow-up in the rehabilitation center and outpa­
tient clinics is tremendously important, and should be
explained to the patients before and emphasized again after
the surgery.
“Induction exercise” (or motivation exercise) is an impor­
tant muscle exercise for patients with nerve transfers. The
original function of the donor nerve must be practiced to
induce movement in the target muscles newly innervated by
the transfer. For example, deep breathing exercises by
running, long walks when phrenic or intercostal nerve trans­
fer is performed, tongue to palate push-up exercise in hypo­
glossal nerve transfer, shoulder adduction or grasp exercise
of the contralateral (or healthy) limb in contralateral C7
transfer (Fig. 21.4). Induction exercises begin when move­
ment of the innervated muscles is palpable (M1). The
action is comparable with an internal electrical stimulator.
PALLIATIVE RECONSTRUCTION FOR
SEQUELAE DEFORMITIES
Palliative reconstruction can be considered when sequelae
deformities persist after maximal recovery, either after spon­
taneous incomplete recovery or following nerve reconstruc­
tion. Palliative reconstruction procedures include tendon or
muscle transfer, FFMT, tenodesis, and arthrodesis. Alterna­
tively, orthotics and prostheses can be used for final assis­
tance. Patients in this stage should be encouraged to

250
PART 3 — RECONSTRUCTION
grafts, 62.5% in the combined C5 nerve grafts and nerve
transfers, and 54.8% in the nerve transfers. The conclusion
was that use of the C5 stump for reconstruction is critical.
It has also been demonstrated that triple nerve transfers
produce the best and most consistently reliable results for
shoulder elevation (an average of 160°), followed by double
nerve transfers (an average of 85°), and further followed by
single nerve transfer (an average of 65°).
ELBOW
We had made an investigation (not published yet) of total
of 188 patients with different methods of musculocutaneous
nerve neurotization for A-BPI were selected in the inclusion
criteria. The donor nerve was from C5, medial cord, C8,
contralateral C7, spinal accessory nerve, or phrenic nerve
groups of proximal nerve transfer, and from partial ulnar
nerve and/or partial median nerve groups of distal nerve
transfer. Intercostal nerve transfer to the musculocutaneous
nerve was categorized into a separate group. The results
showed that there were no significant differences in the
success rates (elbow flexion strength M>3) between the use
of proximal vs distal nerve transfers. Even though the speed
of recovery was faster in the distal group, 19 months vs 23.9
months, a number of patients had persistent grip strength
deficits resulting from the distal nerve transfers.
HAND
In successful cases after multiple nerve transfers for a total
root avulsion, 60° or more of shoulder abduction, M4 elbow
flexion, M2–M3 finger flexion can be achieved with the help
of contralateral C7 transfer and other nerve transfers. One
of most important achievements of the CC7 transfer is the
finger sensation achieved.
CONCLUSION
Timely referral to a center with expertise in brachial plexus
reconstruction is key, as is an informed patient who is moti­
vated and committed to the surgery and, even more impor­
tantly, to the demanding rehabilitation. These factors will
give the best chances of obtaining a favorable outcome in
A-BPI reconstruction.
recognize their disabilities and make use of the regained
but not completely recovered limb. In a failed reconstruc­
tion, or if the patient perceives the injured limb as a useless
dead weight, amputation might be considered.
RESULTS AND OUTCOMES
SHOULDER
The author reviewed the outcomes based on a focus
on shoulder abduction.26 Results showed shoulder abduc­
tion 108.57 ± 54.29° in the group of C5 nerve grafts,
107.50 ± 60.42° in the group of combined C5 nerve grafts
and extraplexus nerve transfer, and 84.05 ± 44.01° in the
group of extraplexus nerve transfers alone. Success rate of
shoulder abduction (≥90°) was 57.1% in the C5 nerve
Figure 21.4  Patient performing “induction exercises” (or motivation
exercise). Shoulder adduction or grasp exercise of the contralateral
(or healthy) limb is preformed after undergoing a contralateral C7
transfer.
A 35-year-old man had a motorcycle accident, resulting in a right
clavicle fracture and right BPI. Open reduction of the clavicle
was performed at another hospital. He was seen at our center 2
months after the injury. He was diagnosed as having a rupture
injury involving the musculocutaneous, radial, and axillary
nerves at Level IV. Intraoperatively, after the clavicle was refrac-
tured, the injury was at Level III; the anterior division of the
upper trunk to the lateral cord was still in continuity, but the
posterior divisions to the posterior cord were ruptured with
neuroma formation. Neurolysis of the musculocutaneous nerve
and nerve grafting were performed. Six nerve grafts, each mea-
suring 6 cm from anterior divisions of the upper and middle
trunks to the axillary (two cables) and radial nerve (four cables),
were performed. Good results of shoulder elevation and elbow
flexion and extension were shown (Fig. 21.5) 1 year after the
nerve surgery. His elbow flexion was actually obtained earlier,
with spontaneous recovery obtained 5 months after the surgery.
CASE 21.1  Level III Injury

CHAPTER 21 — Adult Brachial Plexus I njury (A-BPI) Reconstruction
251
CASE 21.1  Level III Injury—cont’d
Figure 21.5  (A,B) Postoperative results following good results of shoulder elevation and elbow flexion and extension are shown, 1 year
after nerve grafting for Level III brachial plexus injury. Six nerve grafts, each measuring 6 cm from anterior divisions of the upper and
middle trunks to the axillary (two cables) and radial nerve (four cables), were performed.
A
B
A 28-year-old man was a passenger in a car involved in a car
accident, resulting in paralysis of the right shoulder elevation
and elbow flexion. Head injury and craniotomy were performed
at another hospital. He was seen by our team 3 months after the
accident. Preoperative diagnosis was C5, C6 Level I root avulsion.
Exploration was performed 4 months after the injury, which
confirmed the diagnosis. Ipsilateral C7 was transected and trans-
ferred to the upper trunk directly, and XI nerve was transected
and transferred to the suprascapular nerve directly. Good results
of shoulder elevation and elbow flexion (Fig. 21.6) were achieved
3 years after the nerve surgery.
CASE 21.2  C5, C6 Level I Injury
Figure 21.6  (A,B) Good results of shoulder elevation and elbow flexion 3 years following C5, C6 Level I root avulsion and reconstruction
with ipsilateral C7 transection and transfer to the upper trunk, and XI nerve transection and transfer to the suprascapular nerve.
A
B

252
PART 3 — RECONSTRUCTION
An 18-year-old woman had a motorcycle accident, resulting in
fractures of the C5, C6 spine transverse process, positive Horn-
er’s syndrome, and severe root shooting pain. She was seen 1
month after the accident (Fig. 21.7A). Preoperative diagnosis
was ruptured C5 at Level II and C6–T1 Level I injury. Explora-
tion was performed 2 months after the injury. Injury levels were
confirmed. The operative procedures included:
1. Transfer of proximal C5 to the median nerve (level IV) with
a free vascularized ulnar nerve graft
2. Transfer of the Ph nerve and XI nerves to the suprascapular
and posterior division of the upper trunk
3. Transfer of T3–T5 three intercostal nerves to the musculocu-
taneous nerve. The results 5 years after nerve reconstruction
showed shoulder elevation ≥90° (Fig. 21.7B); elbow flexion
≥M4 (Fig. 21.7C); elbow extension and wrist extension ≥M3
(by Ph nerve effect); and finger flexion ≥M3 (Video 21.1).
CASE 21.3  C5 Level II, and C6–T1 Level I Injuries
Figure 21.7  (A) An 18-year-old woman had a motorcycle accident, resulting in fractures of the C5, C6 spine transverse process, positive
Horner’s syndrome, and severe root shooting pain. She was seen 1 month after the accident of C5 Level II, and C6–T1 Level I injuries.
(B,C) Postoperative result 5 years after nerve reconstruction showing shoulder elevation ≥90°; elbow flexion ≥M4; elbow extension and
wrist extension ≥M3 (by Ph nerve effect); and finger flexion ≥M3.
A
B
C

CHAPTER 21 — Adult Brachial Plexus I njury (A-BPI) Reconstruction
253
A 20-year-old man had a motorcycle accident, resulting in frac-
tures of the right clavicle, ruptured subclavian artery, and right
BPI. Open reduction of the clavicle and subclavian artery repair
with a vein graft were performed at another hospital. He was
seen 2 months after the accident (Fig. 21.8A). Preoperative diag-
nosis was total root avulsion C5–T1, Level I injury. An explora-
tion was performed 3 months after the injury. The suprascapular
nerve and posterior cord were not found due to dense scars in
Levels I–III. The operative procedures included:
1. Left contralateral C7 transfer to the median nerve with a
pedicled ulnar nerve graft
2. T3–T5 three intercostal nerves were transferred to the mus-
culocutaneous nerve.
A second operation was performed 8 years after the primary
nerve reconstruction, including wrist and thumb (carpometacar-
pal, metacarpophalangeal and interphalangeal joints) arthrod-
esis, and tendons of flexor carpi radialis and palmaris longus
transfer to the 3rd to 5th flexor digitorum profundus. The
results 12 years after the first nerve reconstruction showed stable
shoulder, good elbow flexion ≥M4 (Fig. 21.8B), finger flexion
≥M3, and finger sensation (Video 21.2).
CASE 21.4  Level I injury, total root avulsion
Figure 21.8  (A) A 20-year-old man, 2 months following an MVA with a diagnosis of total root avulsion C5–T1, Level I injury. An explora­
tion was performed 3 months after the injury. (B) The patient seen at 12 years following the initial reconstructive procedure and a secondary
procedure (see Case 21.4 for details), demonstrating stable shoulder, good elbow flexion ≥M4 and finger flexion ≥M3, and finger
sensation.
A
B

254
PART 3 — RECONSTRUCTION
3. Narakas A. Surgical treatment of traction injuries of the brachial
plexus. Clin Orthop 1978;133:71–90.
4. Leffert RD. Brachial plexus injuries. New York: Churchill Living­
stone; 1985. p. 1–38.
5. Terzis JK, Verkris MD, Soucacos P. Outcomes of brachial plexus
reconstruction in 204 patients with devastating paralysis. Plast
Reconstr Surg 1999;104:1221–40.
6. Millesi H. Brachial Plexus lesions: classification and operative tech­
nique. In: Tubiana R, editor. The hand. Philadelphia: WB Saun­
ders; 1988. p. 645–55.
7. Alnot JY. Traumatic paralysis of the brachial plexus: preoperative
problems and therapeutic indications. In: Terzis JK, editor. Micro­
reconstruction of nerve injuries. Philadelphia: WB Saunders; 1987.
p. 325–45.
8. Gu YD, Zhang GG, Chen DS, et al. Seventh cervical nerve root
transfer from contralateral healthy side for treatment of brachial
plexus root avulsion. J Hand Surg 1992;17B:518.
9. Doi K, Sakai K, Kuwata N, et al. Double-muscle technique for
reconstruction of prehension after complete avulsion of brachial
plexus. J Hand Surg 1995;20A:408–14.
10. Chuang DC. Management of traumatic brachial plexus injuries in
adults. Hand Clin 1999;15:737–55.
11. Oberlin C. Nerve transfer to biceps muscle using a part of ulnar
nerve for C5–C6 avulsion of the brachial plexus. Anatomical studies
and report of four cases. J Hand Surg 1994;19A:232–7.
12. Mackinnon SE, Novak CB, Myckatyn TM, et al. Results of reinner­
vation of the biceps and brachialis muscles with a double fascicular
transfer for elbow flexion. J Hand Surg 2005;30A:978–85.
13. Nagano A, Ochiai N, Okinaga S. Restoration of elbow flexion in
root lesions of brachial plexus injuries. J Hand Surg 1992;17A:815.
14. Chuang DC. Adult brachial plexus injuries. In: Mathes SJ, Hentz
VR, editors. Plastic surgery, vol. 7, 2nd ed. Philadelphia, PA: Saun­
ders Elsevier; 2006. p. 515–38.
15. Chuang DC. Adult brachial plexus injuries. In: Neligan P, editor.
Plastic surgery, vol. VI. 3rd ed. Philadelphia: Saunders Elsevier;
2011. p. 789–816.
16. Sunderland S. A classification of peripheral nerve injuries produc­
ing loss of function. Brain 1951;74:491–516.
17. Birch R. Infraclavicular lesions. In: Boome RE, editor. The brachial
plexus. New York: Churchill Livingstone; 1997. p. 79–88.
18. Burge P, Rushworth G, Watson N. Patterns of injury to the terminal
branches of the brachial plexus. The place for early exploration.
J Bone Joint Surgery (Br) 1985;67:630–4.
19. Chuang DC, Yeh MC, Wei FC. Intercostal nerve transfer of the
musculocutaneous nerve in avulsed brachial plexus injuries – eval­
uation of 66 patients. J Hand Surg 1992;17A:822–8.
20. Amarami K, Port J. Imaging the brachial plexus. Hand Clin
2005;21:25.
21. Baskaran V, Pereles S, Russell E, et al. Myelographic MR Imaging
of the cervical spine with a 3D true fast imaging with steady-stage
precession technique: initial experience. Radiology 2003;227:585.
22. Gasparotti R, Ferraresi S, Pinelli L, et al. Three-dimensional MR
myelography of traumatic injuries of the brachial plexus. Am J
Neuroradiol 1997;18:1733.
23. Yoshikawa T, Hayashi N, Yamamoto S, et al. Brachial plexus injury:
clinical manifestation, conventional imaging findings, and the
latest imaging techniques. Radiographics 2006;26:S133–4.
24. Aminoff MJ. Root and plexus lesions. Electromyography in clinical
practice. 3rd ed. New York: Churchill Livingstone; 1998. p. 337.
25. Chuang DC. Nerve transfer with functioning free muscle transplan­
tation. Hand Clin 2008;24:377–88.
26. Cardenas-Mejia A, O’Boyle CP, Chen KT, et al. Evaluation of
single-, double-, and triple-nerve transfers for shoulder abduction
in 90 patients with supraclavicular brachial plexus injury. Plast
Reconstr Surg 2008;122:1470–8.
Expert Commentary 
Wieslawa De Pawlikowski, MD, FACS
Obstetric brachial plexus palsy (OBP) is the result of a trac-
tion nerve injury during delivery. This injury could be a paresis
or paralysis, depending on the extent of the nerve damage.
This ranges from a partial and transitory compromise in sen-
sitivity and motility to a total and permanent nerve palsy. Any
area from the shoulder to the fingers could be involved,
depending on the affected nerves.
This highly variable lesion can be divided into two groups.
The most common is the upper plexus injury (C5, C6 or C5,
C6, C7), which is frequently a post-ganglionar lesion (roots
of the plexus rupture). Patients with this condition show
internal rotation and adduction of the arm, and flexion of the
wrist and fingers. A majority of these patients recover spon-
taneously. The second group, total/lower plexus injury (C5,
C6, C7, C8 and T1) is a more severe and often pre-ganglionar
lesion (rupture or avulsion of the spinal nerves). These
patients show flair arm, wrist, and fingers, and Horner’s syn-
drome. There is no spontaneous recovery, so surgery is
always required.
In an upper plexus palsy, optimizing the functionality is our
goal, while closely watching for the spontaneous return of
movement within the first 6 months, especially in active
elbow flexion. Because of this, the surgical decision is
delayed. Even though timing of the surgery is controversial,
the absence of recovery of the elbow function after 6 months
is an indication for surgery.
Surgical options are intraplexal nerve transfer with graft,
extraplexal nerve transfer close to the lesion, and distal nerve
transfer closer to the neuromuscular junction. It is important
to take into consideration the quality of the proximal stumps
(condition of the nerves, fibrosis, or unrecognized distal
damage) to choose the procedure.
Deciding when to use each method is more important than
the method used. We know that the outcomes are affected
more by the severity of the injury than by the method of
reconstruction.
The treatment of the OBP is complex and controversial,
involves multiple disciplines, and many times a secondary
surgery (tendon transfers or muscle free transplantation) is
necessary to improve the results.
Access videos online at
.inkling.com
REFERENCES
1. Sunderland S. Nerve and nerve injuries. 2nd ed. Edinburgh:
Churchill Livingstone; 1978.
2. Slingluff CL, Terzis JK, Edgerton MT. The quantitative microanat­
omy of the brachial plexus in man. Reconstructive relevance. In:
Terzis JK, editor. Microreconstruction of nerve injuries. Philadel­
phia: WB Saunders; 1987. p. 285–324.

CHAPTER 21 — Adult Brachial Plexus I njury (A-BPI) Reconstruction 254.e1
Video 21.1 An 18 year-old lady had C5 level II
ruptured injury, C6-T1 level I four root avulsion
injury. She received phrenic and spinal
accessory nerve both transfer to the distal C5
for shoulder; T3-5 three intercostal nerves
transfer to the musculocutaneous nerve as a
one stage procedure. 5 years after nerve
reconstruction, she showed improved shoulder
elevation (more than 90 degrees), good elbow
flexion (M4) and fair elbow and wrist extension
(M2), powerful wrist and finger flexion (M>3).

254.e2 PART 3 — RECONSTRUCTION
Video 21.2 A 20 year-old man had right
brachial plexus injury with total root avulsion
injury for 2 months. He received left
contralateral C7 transfer to the median nerve,
T3-5 three intercostal nerves transfer to the
musculocutaneous nerve at the first time
operation. 8 years later, he received wrist and
thumb fusion at the 2nd time operation. The
results 12 years after the first time operation,
he showed stable shoulder, good elbow flexion
and finger flexion and finger sensation.

255
Lower Extremity
Reconstruction
Frank Fang  |  Chih-Hung Lin
22 
INTRODUCTION
In this chapter we present the topic of reconstruction of
soft tissue and bone defects in the lower extremity. We
present the multiple indications for lower extremity recon­
struction and review the decision-making process for pro­
ceeding with limb amputation versus salvage for cases of
severe lower extremity trauma or major oncologic resec­
tion. We also discuss the likely postoperative sequelae and
secondary challenges that arise after major limb reconstruc­
tion and we discuss the importance of a multidisciplinary
approach for specific aspects of lower extremity patient
care. The ultimate goal of lower extremity reconstruction is
a functional restoration. The fundamental objectives for
reconstructing a functioning motor unit are achieving
durable weightbearing bony support, restoring stable
and durable soft tissue coverage, and achieving pain-free
mobility.
PREOPERATIVE CONSIDERATIONS
The etiology and level of defect must be considered during
lower extremity reconstruction because these two factors
will determine the surgical options available, probable time
course for reconstruction, adjunctive treatment measures,
possible complications, and rehabilitative expectations.
ETIOLOGY OF DEFECT
The etiologies of major soft tissue or bone defects in the
lower extremity are traumatic, infectious, oncologic, dia­
betic, vascular, or lymphatic. Traumatic injuries, necrotizing
soft tissue infections, and oncologic resections account for
most acute wounds. Diabetes, vascular disease, and lymph­
edema lead to chronic wounds (Table 22.1).1
TRAUMATIC
Trauma is the most common etiology for lower extremity
reconstruction. This is a well-studied topic with a wealth of
literature on indications for reconstruction, treatment
approaches, and outcomes. The mechanisms of these inju­
ries vary according to region but may include motorcycle,
motor vehicle, industrial, ballistic, and military trauma. In
the practice of the senior author, the trauma demographic
has an average age of 37 years, with a 2 : 1 male to female
preponderance, and the mechanism of injury being mostly
due to motorcycle or motor vehicle accidents. The severity
of these injuries threatens the functional viability of the
injured limb, and the surgical team must often decide
whether to attempt salvage or perform amputation.2
The trauma surgical team typically performs trauma
triage and stabilization of life-threatening injuries accord­
ing to advanced cardiac life support (ACLS) and advanced
trauma life support (ATLS) guidelines. When major limb
injury is apparent, specialties, including orthopedic sur­
gery and plastic surgery, will join in a multidisciplinary
effort. The trauma surgical team records the injury
severity score (ISS) for all trauma patients, and they
also apply the Mangled Extremity Severity Score (MESS)
and Nerve Injury/Ischemia/Soft Tissue/Skeletal Injury/
Shock/Age (NISSSA) scoring systems for extremity trauma
(Tables 22.2–22.4).1,3,4
Trauma management during the modern military con­
flicts, including the Persian Gulf theaters, has enhanced
our insight into management of the extremity trauma
patient. Frequently in combat settings, damage control
surgery becomes the essential strategy for catastrophic
trauma victims. Approximately 21.4% of combat extremity
trauma presents with life-threatening injury as compared
with 10–17% seen in civilian trauma.5 The mechanism of
injury is also different. Blast and penetrating missiles cause
79–90% of combat trauma, while blunt force accounts for
the majority of civilian trauma.6–8 The trauma surgical
team’s first priority in both military and civilian trauma is
life-saving resuscitation, while limb reconstructive surgery is
deferred until overall systemic stabilization is achieved. In
settings where there may be delayed presentation to a
medical facility, patients may begin to exhibit the “lethal
triad” (pH <7.2; coagulopathy of INR >1.6; hypothermia of
<34°C) as a consequence of the severity of their injuries.
Their clinical condition evolves into a vicious deteriorating
cycle if not properly managed. Without aggressive interven­
tion, these patients may progress to metabolic failure, mul­
tiple organ failure, and systemic shock, which may ultimately
prove lethal. In the scenario of impending development of
the lethal triad, the surgical objectives for the extremity
should be hemostasis and debridement. If there is a MESS
score of ≥10 in this type of critical setting, limb amputation
should generally be performed immediately. This type of
patient frequently requires major trauma surgical interven­
tion (such as thoracic or abdominal procedures), and the
goal from the extremity salvage surgeon’s perspective is to
participate productively with the trauma surgical team in a
manner that limits the overall surgical time to <6 h. The
PART 3  —  RECONSTRUCTION

CHAPTER 22 — Lower Extremity Reconstruction 255.e1
Table 22.1  Etiologies of lower extremity defects
requiring reconstruction
Acute
Chronic
Trauma
Diabetes
Oncologic resection
Peripheral vascular occlusive
disease
Necrotizing soft tissue
infection
Lymphedema
Table 22.2  Injury severity score1
The Injury Severity Score (ISS) is an anatomic scoring
system that provides an overall score for patients with
multiple injuries. Each injury is assigned an Abbreviated
Injury Scale (AIS) score (see below) for each of six body
regions (Head, Face, Chest, Abdomen, Extremities
(including Pelvis), External). The highest AIS score in each
body region is used. Each numeric score from the three
most severely injured body regions is squared. The 3
squared numbers are added to produce the ISS.
Region
Injury
description
AIS
(AIS)5
Head and
Neck
Face
Chest
Abdomen
Extremity
External
Injury Severity Score = Sum of 3 highest (AIS)5
numbers3:
Abbreviated Injury Scale (AIS), 1990 version3
AIS score
Injury
1
Minor
2
Moderate
3
Serious
4
Severe
5
Critical
6
Unsurvivable
Table 22.3  Mangled Extremity Severity Score
(MESS)
Variable
Points
Skeletal/soft tissue injury
Low energy (stab; simple fracture; civilian GSW)
1
Medium energy (open or multiple fracture,
dislocation)
2
High energy (close-range shotgun or military
GSW, crush injury)
3
Very high energy (above criteria + gross
contamination, soft tissue avulsion)
4
Limb ischemia
Pulse reduced or absent but normal perfusion
1*
Pulseless, paresthesias, diminished capillary refill
2*
Cool, paralyzed, insensate, numb
3*
Shock
Systolic BP always >90 mmHg
0
Transient hypotension
1
Persistent hypotension
2
Age
<30
0
30–50
1
>50
2
*Score doubled for ischemia time >6 h.
GSW, gunshot wound; BP, blood pressure.
(Reproduced from McNamara MG, Heckman JD, Corley FG.
Severe open fractures of the lower extremity: a retrospective
evaluation of the Mangled Extremity Severity Score (MESS).
J Orthop Trauma 1994; 8[2]:81–7.)

255.e2 PART 3 — RECONSTRUCTION
Table 22.4  The Nerve Injury/Ischemia/Soft Tissue/Skeletal Injury/Shock/Age (NISSSA) scoring system
Type of injury
Degree of
injury
Points
Description
Nerve Injury (N)
Sensate
0
No major nerve injury
Dorsal
1
Deep or superficial peroneal nerve, femoral nerve injury
Plantar partial
2
Tibial nerve injurya
Plantar
complete
3
Sciatic nerve injurya
Ischemia (I)
None
0
Good to fair pulses, no ischemia
Mild
1b
Reduced pulses, prolonged capillary refill, Doppler pulses present
Moderate
2b
No pulses, prolonged capillary refill, Doppler pulses present
Severe
3b
Pulseless, cool, ischemic, no Doppler pulses
Soft tissue/
contamination
(S)
Low
0
Minimal to no soft tissue contusion, no contamination (Gustilo type 1)
Medium
1
Moderate soft tissue injury, low-velocity gunshot wound, moderate contamination,
minimal crush (Gustilo type II)
High
2
Moderate crush, degloving, high-velocity gunshot wound, moderate soft tissue
injury, may require soft tissue flap, considerable contamination
Severe
3
Massive crush, farm injury, severe degloving, severe contamination, requires
soft tissue flap (Gustilo type IIIB)
Skeletal
Low energy
0
Spiral fracture, oblique fracture, no or minimal displacement
Medium
energy
1
Transverse fracture, minimal comminution, small-caliber gunshot wound
High energy
2
Moderate displacement, moderate comminution, high-velocity gunshot wound,
butterfly fragments
Shock (S)
Normotensive
0
Blood pressure normal, always >90 mmHg systolic
Transient
hypotension
1
Transient hypotension in field or emergency center
Persistent
hypotension
2
Persistent hypotension despite fluids
Age (A)
Young
0
<30 years
Middle
1
30–50 years
Old
2
>50 years
Total score = (N + I + S + S + S + A).
aNerve injury as assessed primarily in the emergency room. bScore doubles with ischemia >6 h.4

256
PART 3 — RECONSTRUCTION
eral vascular disease (ankle brachial index of <0.7, toe
blood pressure <40 mmHg, or transcutaneous oxygen ten­
sion [TcPO2] levels <30 mmHg), must have undergone
revascularization by the vascular surgery team prior to
undergoing any major soft tissue reconstruction.13 Patients
with lymphedema should receive inter­vention for the
primary problem such as aggressive edema management
measures, lymphatic reconstruction, or vascularized lymph
node transfer, prior to soft tissue reconstruction.14
INFECTIOUS POST-DEBRIDEMENT
Soft tissue defects resulting from debridement for infection
are often associated with one of the aforementioned sys­
temic conditions (diabetes, peripheral vascular occlusive
disease, or lymphedema). Necrotizing fasciitis or Fournier’s
gangrene will also lead to large skin defects that usually
require skin grafting. Occasionally, exposed vessels, tendon,
or bone will necessitate soft tissue reconstructions that are
based on the same basic reconstructive principles detailed
later. In the post-infection setting, attention to bacteriology
will optimize the chances for success. Skin grafting should
generally be delayed until bacterial quantities are <108
organisms/g of sampled tissue.15,16 Furthermore, the pres­
ence of beta-hemolytic streptococci and Pseudomonas in any
quantity has been observed to have a detrimental effect on
skin graft success.17 Involvement of an infectious disease
specialist for a well-directed antibiotic regimen is also
advisable.
LEVEL OF DEFECT
The level of defect dictates what reconstructive options are
available. The distal one-third level is traditionally held as
the critical boundary, beyond which local or regional flap
reconstructive options do not exist and microvascular free
tissue transfer becomes mandatory. However, with the
advent of perforator-based pedicled fasciocutaneous flaps,
relatively smaller distal one-third defects often no longer
require free tissue transfer. However, larger defects in the
distal one-third leg or foot still frequently need free flap
coverage.
INDICATIONS
TRAUMATIC INDICATIONS FOR SURGERY
SALVAGE VERSUS AMPUTATION
The context of reconstruction of the traumatized lower
limb should be understood by considering the approach to
the most severely injured patient. In this scenario, the deci­
sion for limb salvage versus amputation proceeds by first
classifying the patient according to the following three cat­
egories. One group of patients presents with severe limb
injury and concomitant life-threatening conditions, and
limb salvage is incompatible or significantly risky for life
preservation. These patients should undergo amputation. A
second group of patients presents with severe limb injury
and no imminent life-threatening injuries. In these patients,
sensation and distal mobility is preserved, and limb salvage
is attempted. However, the most challenging treatment cat­
egory of patients is the third group, who present with
acute care period will necessarily involve a critical care unit
for systemic stabilization and treatment of acidosis, coagu­
lopathy, and hypothermia. Subsequent wound debride­
ment and reconstruction are performed at a time point
determined by multidisciplinary discussion and agreement.
During the acute period, compartment syndrome may also
be evolving secondary to edema from the large area of mus­
cular crush, bleeding into a contained fascia compartment,
or from post-reperfusion edema in cases where muscle
ischemia has exceeded 2 hours. Treatment teams must also
be aware of the possibility of rhabdomyolysis whenever
there has been a large volume of muscular crush. The treat­
ing team should monitor for this condition by checking
blood levels of creatine kinase and potassium with specific
attention to ample intravenous resuscitation and possible
renal failure. Fat embolization is another potentially associ­
ated life-threatening condition, and any deterioration in
respiratory status should trigger consideration of this
possibility.
ONCOLOGIC
Major oncologic lower extremity reconstructions are mostly
musculoskeletal in origin, and they are relatively less
common.9,10 In some situations there needs to be a delay in
reconstruction from the time of resection until the final
histopathologic tumor margins are known. In such cases of
delayed reconstruction, the brief initial period of the inflam­
matory healing process will obscure the tissue planes and
potential recipient vessels to some degree, making recon­
struction more challenging. Extremity sarcoma cases will
frequently undergo preoperative neoadjuvant chemother­
apy or radiotherapy. Both of these treatment modalities
have a negative effect on healing capacity, and most sur­
geons wait 3–6 weeks from the last treatment before pro­
ceeding with definitive surgical resection and reconstruction
to allow for adequate recovery of the patient’s inflammatory/
wound healing capacity.10,11 Furthermore, the reconstructive
surgeon should bear in mind that any previously irradiated
field will have fibrotic tissue planes and friable recipient
vessels that will also make reconstruction more challenging.
The reconstructive measures taken for oncologic resections
must provide an expeditious recovery, as adjuvant radiation
or chemotherapy, which is critical to local control of the
cancer, is usually postponed until definitive healing has
occurred. This group of patients cannot afford to have a
delayed course to adjuvant therapy due to prolonged wound
healing.
DIABETIC, VASCULAR, OR LYMPHATIC ETIOLOGY
These patient groups are predisposed to ultimate recon­
structive failure because of the tendency of wound recur­
rence due to the ongoing process of the systemic condition.12
The surgeon must bear in mind that undertaking major
reconstruction within these clinical contexts without an
attempt to substantially improve the systemic condition that
is the root cause of the problem (e.g., major lifestyle altera­
tion for diabetics, successful vascular surgical intervention,
or successful vascularized lymph node transfer) is destined
for failure. The operative prerequisites for diabetics should
be stringent blood sugar control as measured by hemoglo­
bin A1C <7%, fitting for specialized orthotic diabetic shoes,
and frequent podiatric monitoring. Patients with periph­

CHAPTER 22 — Lower Extremity Reconstruction
257
integrity or if vascularized osseous tissue will be needed.
Assessment for nerve injury by meticulous sensory and
motor exam should determine the precise location of sus­
pected nerve injury at the sciatic, tibial, deep peroneal, or
superficial peroneal levels. With open injuries, nerve integ­
rity often will have to be definitively assessed intraopera­
tively by visualization. It should be noted that an insensate
foot upon initial presentation is no longer a criterion for
amputation given the frequency of recovery of function.24
The musculotendinous units that have been violated by
injury should be noted with particular attention to what
possible functional restoration may be attempted in a con­
comitant effort to provide the necessary soft tissue
reconstruction.
SURGICAL OBJECTIVES IN THE ACUTE SETTING
VASCULAR INTEGRITY
Attention should be first directed toward verifying vascular
integrity. Distal ischemia should always be first treated by a
trial of reduction of bony fracture, which often will restore
distal vascularity. Injury of at least one of the three vascular
trunks will frequently be present in the majority of Gustilo
IIIB or IIIC injuries,25 and CT angiography is a low morbid­
ity study that should be performed for both the purposes of
assessing a need for vascular repair and also choosing the
appropriate recipient site and technique (end-to-side vs
end-to-end) for microsurgical reconstruction.26 If distal isch­
emia has been ongoing, the plan for surgical intervention
should involve an immediate reestablishment of vascular
inflow by placement of a temporary vascular shunt.27 An
assessment of vessel defect should determine the potential
need for vein grafting. Our group’s preferred technique for
vein grafting of greater length involves the temporary cre­
ation of an AV fistula.28 Vessel defects requiring vein graft
reconstruction will require a concomitant overlying soft
tissue reconstruction.29,30 Recipient vessel selection should
be considered at this time. Our group’s preference is to
perform end-to-end anastomoses adjacent to the injured
area, choosing a vessel that shows no signs of injury (lack of
vigorous flow, thrombus, avulsed branches, intimal tearing,
“ribbon” sign).31 If a vessel is damaged, it still may be used
in an end-to-end fashion, but it must be trimmed back to a
healthy zone with a high degree of certainty and precision
in order to achieve a high rate of flap viability. However, if
all vessels are involved in the zone of injury and determined
unsuitable, one should utilize a vein graft to a site proximal
to the zone of injury in an end-to-side fashion.32,33 One may
also consider the possibility of using the contralateral leg in
a “cross-legged” free flap fashion.34 Our group’s preference
for venous drainage of the flap is to use the deep venous
systems whenever possible due to their proximity to the
recipient artery and their decreased likelihood to be
involved in a zone of injury.
DEBRIDEMENT AND TIMING OF SOFT
TISSUE RECONSTRUCTION
After salvage has been decided upon, attention to a thor­
ough surgical debridement is paramount. Our group’s
opinion echoes many other centers in that surgical debride­
ment is critical to the ultimate success of the recon­struction.
Inadequate debridement will ultimately result in infection,
severely damaged and de-functionalized limbs whose func­
tional prognosis is uncertain. For these patients falling into
the “gray zone,” a wealth of outcomes-oriented investiga­
tion over the last two decades has sought to provide reliable
guidance on the decision for amputation versus limb
salvage. Multiple scoring systems have been devised, includ­
ing the Predictive Salvage Index (PSI); Mangled Extremity
Severity Score (MESS); Limb Salvage Index (LSI); Han­
nover Fracture Scale; and the Nerve Injury/Ischemia/Soft
Tissue/Skeletal Injury/Shock/Age (NISSSA) score.18 Sub­
sequent studies including the Lower Extremity Assessment
Project (LEAP) series assessed these scoring systems and
tried to define the characteristics of the individuals who
sustained these injuries, the characteristics of their environ­
ment, the variables of the physical aspects of their injury,
the secondary medical and mental conditions that arose
from their injury and treatment, their ultimate functional
status, and their general health. Furthermore, these investi­
gations analyzed complications and instances of secondary
amputation, and none of the lower extremity injury severity
scoring systems could be consistently validated for deciding
on amputation versus salvage.19–21 The source of the dis­
agreement may be due to the highly variable patient popu­
lation of different regions, and the different personal
factors that substantially affect life outcome after such cata­
strophic injury. Our group has generally been able to
achieve worthwhile functional reconstructions and patient
satisfaction for MESS <10. If MESS is ≥10, we generally rec­
ommend amputation but ultimately allow the patient and
family to decide. Our reconstructive goals are to provide
functional restoration by combining a competent weight­
bearing bony support with a functional motor unit, to yield
a stable, durable, and pain-free limb. There is some evi­
dence that limb salvage is psychologically beneficial even
when functional outcome may not be better than prosthetic
replacement.22,23 Since very few limbs in the clinically stable
patient are not primarily salvageable with the current
arsenal of reconstructive modalities, our goal is to have the
patient arrive at an informed treatment decision after a
reasonable consideration of the relevant factors of overall
patient health, expected functional recovery of the salvaged
limb versus expected prosthetic functional level, and socio­
economic circumstances (ability to take time away from
work and available support network at home); it should be
noted that there is an association between favorable func­
tional outcome and adequate family help, as shown in the
LEAP study.19 Surgery should be pursued only after careful
consideration of these factors in the context of each indi­
vidual patient.
Traumatic indications for reconstruction generally
involve restoration of one or more of the following compo­
nents: bone, nerve, vasculature, muscle, tendon, and soft
tissue cover. After initial stabilization, the surgical team will
then make an accurate anatomic catalog of injury to allow
for a systematic decision-making process upon salvage
versus amputation. Vascular anatomy should also be noted
from the standpoint of whether tissues distal to the injury
are viable and which of the three branch vascular runoff is
preserved, as this will affect planning of potential micro­
surgical reconstruction. The extent of bony destruction
should be considered in regard to whether internal or
external fixation alone may be expected to provide bony

258
PART 3 — RECONSTRUCTION
abdominal hernia and pneumothorax, respectively. If using
the rib-serratus anterior composite flap in situations such as
with bilateral tibia-fibula fractures when the fibula is unavail­
able, we typically harvest a pair of non-consecutive ribs to
allow for a “double-barrel” design that provides better struc­
tural stability. The fibula osteocutaneous flap is the pre­
ferred technique for bone defects up to 18 cm and their
associated soft tissue requirements, as it has been shown to
provide the greatest amount of cortical bone and also to
have the lowest rate for surgical complications such as osteo­
myelitis, skin paddle partial loss, stress fracture, non-union,
and secondary amputation. At the upper limits of bone
requirement, it is occasionally necessary to rely on a single-
strut reconstruction, and our group has found these recon­
structions to evolve to excellent stability and durability with
the excellent potential for bony hypertrophy that is present
in vascularized bone. Of note, the fibula and rib donor sites
seem to have a more rapid rate of hypertrophy than the iliac
crest, but all three methods achieve comparable weightbear­
ing capacity at 2 years postoperatively (Figs 22.2–22.4).45–48
Some groups advocate a staged reconstructive process in
situations of substantial concomitant bony and soft tissue
defect. They recommend soft tissue coverage followed by
vascularized bone graft at a later stage. However, this
approach prolongs both the reconstructive timeline and the
period of disability for the patient. Furthermore, during the
surgery for the second free flap, the surgeon will encounter
a fibrotic soft tissue environment around the recipient
vessels that may render them unsuitable for use. Our group
has demonstrated the ability to reliably perform one-stage
composite soft tissue and bone reconstruction with similar
functional outcomes to the staged approach.49,50 The average
time to bony union in our series of osteocutaneous recon­
struction was 8.5 months.46
SOFT TISSUE COVERAGE
Traumatic lower extremity injury often creates a deficit of
soft tissue. Soft tissue defects requiring reconstructive flaps
will occur in the following areas: large vessels of the thigh,
knee, tibia, Achilles tendon, medial malleolus, lateral mal­
leolus, dorsal foot, hindfoot, and forefoot (Fig. 22.5). The
goals of reconstruction are to provide durable coverage of
critical structures (healing bone, tendons, or vessels).
Ideally, this initial reconstruction should be done in a
manner that eliminates the need for future procedures
whenever possible. Specifically, if an entire functional mus­
culotendinous unit is sacrificed by the initial trauma, our
group’s preference is to replace that musculotendinous unit
at the initial stage of reconstruction with a functioning free
muscle transplantation (FFMT). For instance, trauma that
has caused irrecoverable functional loss of any one of the
anterior compartments, posterior compartment, Achilles
tendon, or patellar tendon in the leg may be reconstructed
by an immediate single-stage composite rectus femoris
FFMT with anterolateral thigh (ALT) flap skin paddle if
necessary. Both flaps are based upon the lateral circumflex
femoral artery system (Fig. 22.6).49,51
Secondary reconstructive requirements frequently arise,
and thus the primary effort at soft tissue reconstruction
should always be performed in a manner that facilitates
possible second-stage procedures (e.g., flap re-contouring
or tendon transfer). The preference of our group is to use
which may manifest as a persistent wound, osteomyelitis,
bony non-union, or flap failure. Consideration of wound
debridement lends naturally to the topic of timing of recon­
struction. While previous studies have designated certain
timeframes and suggested the importance of adhering to
time restrictions in achieving wound coverage,35–40 more
recent literature has arisen to counter this argument.41 Our
feeling is that adequate surgical debridement should dictate
the time course of reconstruction. For instance, a blast
injury may necessitate repeated surgical debridement to
achieve a healthy and clean wound bed. While there is a
general effort to minimize the time to wound coverage, the
overriding objective is to continue with surgical debride­
ment until a healthy and viable wound bed is certain (Fig.
22.1). Our group agrees with the recommendations of the
EAST protocol with Gram-positive and Gram-negative cover­
age continuing for 72 h after injury and 24 h after soft
tissue coverage. In the patient population discussed in this
chapter (mutilating-type injuries often with extensive con­
tamination), we have an extremely low threshold for broad­
ening coverage to include anaerobic flora or extending
treatment to 7–10 days after flap reconstruction.
NERVE RECONSTRUCTION
In mutilating lower extremity trauma, one must screen for
concomitant nerve injury by an anatomic approach, as
described earlier. One must precisely locate any suspected
nerve lesion. Any vascular injury should automatically raise
concern for concomitant nerve injury given the usual prox­
imity of vessel location to nerves. Nerves should be explored
at the time of surgery whenever there is sensory or motor
deficit in the context of a large open injury and repaired
primarily by nerve graft at the initial reconstruction if the
mechanism is sharp. If the mechanism of injury is a crush
or blast, nerve reconstruction should proceed in a delayed
fashion. Sciatic lesions have the worst functional prognosis;
realistic hopes for reinnervation should be limited to recov­
ery of hamstring or calf muscle function and protective
sensation at best.42 Tibial nerve injuries below the knee have
a somewhat better prognosis with direct repairs and nerve
grafting, yielding 39–62% sensory recovery and 27–79%
motor restoration, as reported in previous literature.43
Common peroneal nerve transections have relatively the
best expectation of recovery with direct repair and nerve
grafting <6 cm yielding 84% and 75% rates of successful
recovery of motor and sensory function.44
BONY RESTORATION
Mutilating lower extremity injuries often test the limit of
orthopedic capability. Many of these injuries require either
external fixation or procurement of additional vascularized
bony tissue for reconstruction. Smaller bony defects up to
6 cm may be treated by conventional bone grafting at 6
weeks to minimize the risk of infection. Bony defects of the
tibia and femur exceeding 6 cm in length are best treated
by single-stage vascularized osseous flap transfers. Recon­
structions of ≤10–12 cm may be achieved with osteomuscu­
locutaneous flaps harvested from the fibula, rib-serratus
anterior, or iliac crest-groin flap donor sites. The potential
donor site morbidity with fibula harvest (great toe dysfunc­
tion, skin graft failure, ankle pain) is generally more minor
that that of iliac crest or rib harvest, which may incur

CHAPTER 22 — Lower Extremity Reconstruction 258.e1
Figure 22.1  Case illustration of thorough debridement – Gustilo IIIB open fracture of the right tibia and fibula after external fixation. (A,B) 3
days after trauma and initial debridement. (C) 8 days after trauma and second debridement.
A
B
C

258.e2 PART 3 — RECONSTRUCTION
Figure 22.2  Bone reconstruction options for the lower extremity. (A–C) Gustilo IIIB open fracture with >6 cm bone defect reconstructed by a
fibular osteomyocutaneous flap. (A) Preoperative defect. (B) Long-term stable osteosynthesis. (C) X-ray at 3-year postoperative time point,
showing stable osteosynthesis and evidence of bony hypertrophy.
A
B
C

CHAPTER 22 — Lower Extremity Reconstruction 258.e3
Figure 22.3  Bone reconstruction options for the lower extremity. A closed comminuted fracture of the ankle that evolved into an infected
non-union with a soft tissue defect over the ankle, reconstructed by an iliac osteocutaneous flap due to the contralateral fibula being unavail­
able because of recent injury. (A) Initial injury X-ray. (B) Exploration of the wound overlying the non-union finds necrotic bone and bone resorp­
tion. (C,D) The iliac osteocutaneous flap based on the deep circumflex iliac artery (DCIA). (E) Inset of the skin paddle. (F,G) A 1-year follow-up
X-ray with radiographic evidence of stable osteosynthesis and bony hypertrophy.
A
B
C
D
E
F
G

258.e4 PART 3 — RECONSTRUCTION
Figure 22.4  Bone reconstruction options for the lower extremity. Gustilo IIIB open fracture with 8 cm bone defect reconstructed by rib-serratus
anterior osteomusculocutaneous flap because fibula was unavailable due to bilateral leg injury. (A) Initial soft tissue and bone defect. (B) Initial
X-ray. (C,D) Rib-serratus anterior osteomusculocutaneous flap harvested with 5th and 7th ribs, based upon the serratus anterior branch of the
thoracodorsal artery. (E) Donor site closed primarily. (F) Skin paddle inset on leg. (G) X-ray at 41-month postoperative time point, showing
radiographic evidence of stable osteosynthesis and bony hypertrophy.
A
B
C
D
E
F
G

CHAPTER 22 — Lower Extremity Reconstruction
259
re-elevated because traumatic cases involving the joints will
frequently require secondary procedures such as joint con­
tracture release or tendon transfer. When there is a substan­
tial 3-D soft tissue defect such as around diaphyseal fractures
that require dead space obliteration, we use a myocutane­
ous flap.52
microvascular transfer of fasciocutaneous tissue for defects
around the metaphyseal regions of the knee and ankle
since these flaps have been shown to be equally effective as
free muscle flaps in preventing osteomyelitis and promoting
bony union. Furthermore, these flaps provide soft tissue
with a smooth, gliding undersurface that may be easily
Figure 22.5  The most common lower extremity defect locations leading to exposure of critical structures (blood vessels, tendon, or bone)
requiring reconstruction. The most standard reconstructive approaches are listed for each area.
Femoral vessels:
- Sartorius
- Gracilis
Knee:
- Medial/lateral
gastrocnemius
- Pedicled MSAP
- Reverse ALT
Upper 1/3 tibia:
- Medial/lateral
gastrocnemius
- Soleus
- Pedicled MSAP
Lower 1/3 tibia:
- Pedicled perforator flaps
(peroneal, posterior tibial,
or anterior tibial artery)
- Free flap
Middle 1/3 tibia:
- Soleus
- Pedicled perforator flaps
(peroneal or posterior
tibial artery)
- Free flap
Achilles tendon:
- Pedicled perforator flaps
(supramalleolar or
posterior tibial artery)
- Reverse sural
- Fasciocutaneous free flap
Hindfoot (heel):
- Medial plantar artery flap
- Lateral calcaneal artery flap
- Fasciocutaneous free flap
Plantar forefoot:
- V-Y medial plantar artery flap
- Fasciocutaneous free flap
Dorsal foot:
- Supramalleolar flap
- Fasciocutaneous free flap
Medial/lateral malleolus:
- Pedicled perforator flaps
(supramalleolar or posterior
tibial artery)
- Reverse sural
- Fasciocutaneous free flap

260
PART 3 — RECONSTRUCTION
are far more predictable, as preoperative imaging or tissue
biopsies allow for an approximate operative plan to be
established. Nerve defects should be reconstructed imme­
diately with nerve graft. Some oncologic cases necessitate
immediate bony reconstruction with cadaveric or vascular­
ized bone graft. There is a frequent need for postopera­
tive radiotherapy in these instances. In these cases, we
advocate the general approach of covering all hardware
or cadaveric bone with a layer of healthy vascularized
muscle to minimize the chance for major complications
such as non-union, fracture, or hardware exposure.57,58
Of note, the development of hardware or cadaveric
bone exposure in this setting is a limb-threatening con­
dition with amputation rates as high as 50%.57 If the soft
tissue deficit involves the entire muscle compartment
eliminating an entire functional unit, our group prefers
immediate reconstruction using functioning free muscle
transplantation.
DIABETIC, VASCULAR, OR
LYMPHATIC INDICATIONS
Defects in the lower extremity by these etiologies are usually
deficits of soft tissue cover. Similar to the trauma setting, the
chronic wound must be thoroughly debrided – all necrotic
tissue (including bone) must be removed in order to allow
for the possibility of successful reconstruction. Further­
more, wounds in these contexts may frequently necessitate
consideration of adjuvant antibiotic treatment to maximize
PROCEEDING WITH AMPUTATION BUT
PRESERVING LENGTH
Mutilating lower extremity trauma may result in a leg that
has no potential for salvage, or amputation is chosen due
to patient preference. In these situations it may become
necessary to devise measures to preserve length on the resid­
ual leg as the morbidity of proximal amputations is far
greater than of distal amputations.53–55 “Spare parts” from
the amputated part should always be considered first as a
source for tissue coverage, as with use of a fillet flap for
proximal tibial coverage to allow for preservation of ade­
quate proximal tibial length for pursuit of a below knee
rather than above knee amputation prosthesis and better
functional outcome.56
ONCOLOGIC INDICATIONS
Oncologic reconstruction for the purpose of limb preser­
vation was born from principles learned in trauma recon­
struction. Thus, oncologic indications for surgery can be
understood in an analogous framework, as with trauma.
Just as in the trauma setting, the plastic surgery team is
called upon to restore one or more of the following com­
ponents that has been resected with the tumor: bone,
tendon, nerve, vasculature, muscle, and soft tissue cover.
The same general principles apply for deciding upon the
reconstruction of each component. The great advantage
of oncologic reconstruction is that the conditions are rela­
tively more controlled. The defects of bone or soft tissue
Figure 22.6  Immediate functioning free muscle transplantation (FFMT). This patient sustained a Gustilo IIIB injury to the left leg that
rendered the anterior compartment non-functional; foot drop was present. (A) After debridement, a fracture is visible at the mid-tibia and sta­
bilized by external fixation. (B,C) Rectus femoris myocutaneous flap based upon the branch of the lateral circumflex femoral artery with
accompanying venae comitans and motor branch of the femoral nerve. (D) The flap inset at 1 week postoperatively.
A
B
C
D

CHAPTER 22 — Lower Extremity Reconstruction
261
deep surfaces) or releasing the muscle origin on the femur.
The division of either of the muscle origins must be under­
taken with caution given their proximity to the dominant
pedicle of the muscle. The medial gastrocnemius is ana­
tomically larger and thus capable of providing better defect
coverage. The lateral gastrocnemius has an inherent possi­
bility for greater morbidity, given the possibility of damaging
the common peroneal nerve that crosses over the muscle
the chance of healing after resection of necrotic bone asso­
ciated with osteomyelitis. Major defects involving musculo­
tendinous units or bone resulting from attritional destruction
by the chronic wound are rarely amenable to reconstruction
and usually require some form of amputation due to the
certain presence of extensive osteomyelitis.59
RECONSTRUCTION BY REGION
THIGH RECONSTRUCTION
BONE RECONSTRUCTION AT THE THIGH LEVEL
If vascularized bone reconstruction is necessary at this
level, the “double-barrel” technique of the free fibula flap
should be used to provide earliest possible restoration
of structural integrity of the reconstruction. In the less
common instances when the fibula is unavailable (e.g.,
orthopedic polytrauma), two nonconsecutive ribs of the
serratus anterior-rib flap are also able to provide adequate
weight-bearing reconstruction.47
SOFT TISSUE RECONSTRUCTION AT THE THIGH LEVEL
The ample quantity of local skin and muscle tissue in the
thigh makes this region the most favorable zone for recon­
struction. Indications for reconstruction in this region
are exposed femoral vessels (e.g., wounds associated with
infected vascular bypass graft or oncologic resection) and
large soft tissue defects from oncologic resection or debride­
ment of infection (e.g., necrotizing fasciitis). Defects associ­
ated with exposed femoral vessels in this region are usually
amenable to the use of local muscle (sartorius or gracilis).
Sometimes it is necessary to use the rectus abdominis if the
arterial inflow to the muscles of the thigh is questionable.
Skin grafting or fasciocutaneous local tissue rearrangement
(e.g., “keystone,” V-Y, or rotational flaps) can reconstruct a
skin defect if necessary. Occasionally, massive defects of the
anterior thigh require microvascular free tissue transfer. In
these instances, the contralateral anterolateral thigh (ALT)
flap or latissimus dorsi flap are suitable options. If the entire
extensor unit of the thigh has been sacrificed, our group
performs an immediate functioning free muscle transplan­
tation (FFMT) using the contralateral rectus femoris muscle,
based upon the lateral circumflex femoral artery system
with the ALT skin paddle if necessary (Fig. 22.7).
KNEE DEFECT RECONSTRUCTION
BONE RECONSTRUCTION AT THE KNEE
Bony reconstruction at this level is the domain of orthope­
dic surgery. Their use of knee arthroplasty implants and
cadaveric allograft such as during oncologic reconstruc­
tions, necessitates complete soft tissue coverage such by the
gastrocnemius muscle flap, which provides excellent soft
tissue reconstruction with obliteration of dead space.60
SOFT TISSUE RECONSTRUCTION AT THE KNEE
The traditional workhorse soft tissue reconstructive flaps for
knee defects are the medial and lateral gastrocnemius
muscles (Fig. 22.8). They each have enough reach to cover
up to the distal thigh level, with even greater reach attain­
able by scoring the muscle fascia (upon both superficial and
Figure 22.7  General algorithmic approach to soft tissue reconstruc­
tion of the thigh region. FFMT, functioning free muscle transplanta­
tion; VAC, vacuum-assisted closure.
Extensive defect
Critical
structures
exposed
Inadequate
local muscle
Adequate
local muscle
Local tissue
rearrangement
Adequate local
fasciocutaneous
tissue
FFMT free
flap
Free flap
± VAC, then
skin graft
Critical
structures
exposed
No critical
structures
exposed
Small to moderate
size defect
Thigh algorithm
Figure 22.8  General algorithmic approach to soft tissue reconstruc­
tion of the knee and upper-third leg region. VAC, vacuum-assisted
closure; MSAP, medial sural artery perforator; ALT, anterolateral
thigh.
Bone,
tendon, or
hardware
exposure
Bone or
tendon
exposure
Dead space,
prosthetic,
allograft
Free
flap
Skin graft
Consider VAC
or integra
Medial/lateral
gastrocnemius
or soleus
Pedicled MSAP,
distally based ALT,
or peroneal artery
perforator flap
Large defect >8 cm
Small to moderate
size defect <8 cm
Knee and upper 1/3 leg
algorithm

262
PART 3 — RECONSTRUCTION
SOFT TISSUE RECONSTRUCTION IN THE
MIDDLE-THIRD LEG
The most commonly encountered middle-third leg recon­
structive need is soft tissue coverage over an exposed tibia
(Fig. 22.10). The soleus muscle is the traditional workhorse
for soft tissue reconstruction in this area and is still the best
option for most moderate sized defects. It is usually possible
to recruit some portion of the tibialis anterior in bipedicled
fashion without division of the muscle to help achieve cover­
age without compromising the function of the muscle. It
should be noted that division of the tibialis anterior would
lead to debilitating foot drop. Large defects of the middle-
third leg may necessitate free tissue transfer involving either
the ALT or latissimus dorsi flaps. Pedicled “propeller” flaps
based upon the posterior tibial artery70,71 and peroneal
artery67–69 perforator flaps may also potentially be used for
reconstruction of smaller-sized defects in the mid-leg region.
The skin paddle of the posterior tibial artery perforator flap
has been reported up to 6 × 18 cm.72
SOFT TISSUE RECONSTRUCTION IN THE
LOWER-THIRD LEG (INCLUDING ANKLE)
The lower-third leg is traditionally a zone requiring micro­
vascular free tissue transfer to restore soft tissue coverage
(Fig. 22.11). The distal tibia and ankle joint, medial malleo­
lus, lateral malleolus, and Achilles tendons all frequently
present with soft tissue defects that require reconstruction.
Recent years have seen productive use of pedicled perfora­
tor flaps of the peroneal artery67–69 and posterior tibial
artery70–72 to cover smaller defects that previously required
microsurgical reconstruction. Also, the reverse-flow island
sural flap pivoting upon most distal perforator of the pero­
neal artery at the point 5 cm superior to the lateral malleo­
lus is a valuable option, although it is plagued by reports of
superficially. Mobilization of this muscle for reconstruction
must start with clearly visualizing the common peroneal
nerve prior to progressing with muscle harvest. The pedi­
cled medial sural artery perforator flap is a reliable option
more recently added to the reconstructive arsenal for the
knee region. The flap may be harvested up to 4–5 cm width
to allow for primary closure; greater widths require donor
site skin graft closure. Skin paddle lengths have been
reported up to 14 cm.61 A less popular but reliable method
for coverage in this region is the reversed ALT flap, based
upon the lateral circumflex femoral artery descending
branch’s communication with either the profunda femoris
artery or lateral superior genicular artery. This flap has been
reported to have success with skin paddles as large as
7 × 16 cm. The pedicle can potentially reach inferior to all
areas around the knee, but the pedicle reach is necessarily
dependent upon the variability in the vascular pedicle’s
pivot point in the distal thigh.62–64
LEG RECONSTRUCTION: UPPER-THIRD,
MIDDLE-THIRD, DISTAL-THIRD
BONE
For any substantial bony defect (>6 cm) of the proximal,
middle, or lower leg, our preferred approach is to recon­
struct with microvascular transfer of a double-barreled
fibula flap. As mentioned earlier, two nonconsecutive ribs
of the serratus anterior-rib flap may also be used. If only a
single strut reconstruction is possible (e.g., with either with
a fibula or free iliac crest flap), immediate structural integ­
rity will be more tenuous, but bone hypertrophy will eventu­
ally occur over 1–2 years and should be expected to provide
a structurally sound and weight-bearing reconstruction
(Fig. 22.9).65,66
SOFT TISSUE RECONSTRUCTION IN
THE UPPER-THIRD LEG
Generally, the exposed tibia bone is the main reconstructive
need. The upper-third of the leg is traditionally recon­
structed with similar options as the knee, using the medial
and lateral gastrocnemius muscles (Fig. 22.8). The soleus
muscle may also be necessary in the more distal portion of
the upper-third leg. However, the soleus muscle should be
harvested in a relatively more delicate manner than the
gastrocnemius, as it is a thinner and more fragile tissue that
is less tolerant of traction insult compared to the gastrocne­
mius. Smaller defects upon the upper-third leg are also
amenable to coverage with the aforementioned pedicled
medial sural artery perforator flap. The pedicled peroneal
artery perforator flap may also be used to cover relatively
small defects in this region. However, the areas that may be
reconstructed are dependent upon the perforator location,
which will vary somewhat from case to case. Furthermore,
the skin paddle should be harvested <7–8 cm to ensure
skin paddle viability (<4 cm if primary closure is expected).
Pedicle length is usually in the range of 4–5 cm, which only
allows for the skin paddle to be rotated in a propeller
fashion without any significant additional reach from the
original donor tissue position.67–69 The distally based ALT
flap also has some potential to cover defects on the proximal
part of the upper-third leg.62–64
Figure 22.9  A single strut fibula osteocutaneous flap reconstruction
of the distal 1/3 tibia; X-ray showing hypertrophy at the 2-year post­
operative time point.

CHAPTER 22 — Lower Extremity Reconstruction
263
are also amenable to reconstruction by the dorsalis pedis
pedicled fasciocutaneous flap. However, this flap is felt to
have an unfavorable degree of donor site morbidity with
some frequency of infection, wound breakdown, scar con­
tracture, reoperation, and permanent discomfort at the
site.78 The anterior tibial artery perforator flap can poten­
tially be used in a propeller fashion to cover some smaller
defects of the anterior ankle, but the surgeon should be
aware of its historically high complication rate.79–81
COMPARTMENTAL DEFECTS OF THE LEG:
IMMEDIATE FFMT
In situations where the entire functional unit of the anterior
or posterior leg has been sacrificed, our group favors an
immediate functioning free muscle transplantation (FFMT)
to reconstruct both the soft tissue and functional deficit.
The rectus femoris muscle with overlying ALT skin paddle
is the best donor flap to achieve this end. The gracilis also
may be used to restore dorsiflexion at the ankle. However,
even though it has greater excursion than the rectus femoris,
it is a substantially less powerful muscle.50,51
PROPELLER FLAPS
Propeller flaps add an element of uncertainty to the recon­
structive equation. They have been found to have a relatively
high rate of partial necrosis (>11%) and high overall com­
plication rate (>25%).81 The perforator locations are also
variable, so that the availability of a given propeller flap for
use in a particular area is not certain. After a period of
experience with propeller-type perforator flaps, we have
oftentimes found microvascular free tissue transfer to be
more straightforward than the unpredictability and risk
associated with a propeller flap. The decision regarding
which modality ultimately depends upon clinical context
and surgeon expertise, but it should be remembered that a
free flap will sometimes be the safest option.
FOOT RECONSTRUCTION
Foot reconstruction is a unique area (Fig. 22.12). The
expected weightbearing and friction-enduring role of the
foot makes careful sculpting of a durable and sensate soft
tissue coverage of the foot imperative. Trophic ulcers in
this area are certain to occur with any surface irregularity
or inadequate durability after reconstruction. It is the pref­
erence of our group to use fasciocutaneous rather than
muscle flap and skin graft for coverage. Our feeling is that
fasciocutaneous flaps have a great advantage in that they
provide durable coverage that does not become terminally
adherent to the underlying tendons and bone. Therefore
fasciocutaneous flaps allow easy flap re-elevation during
secondary procedures for fine re-contouring to optimize
conformation of the reconstructive flap tissue to the bony
foundation of the foot. Furthermore, in our experience,
foot and ankle defects reconstructed by muscle flap and
skin graft have a greater need for secondary re-contouring
procedures due to the bulky nature of the initial muscle
flap and a high frequency of evolution of trophic ulcers.82
Revisionary procedures for previous muscle flaps are
undertaken with a greater degree of difficulty due to the
dense fibrosis and adherence of the muscle flap to the
underlying structures.
partial necrosis rates up to 21%.73,74 The lateral supramalleo­
lar flap also based upon the distal perforating branch of the
peroneal artery 5 cm above the lateral malleolus, can
provide up to 8 × 6 cm coverage of the ankle.75,76 The lateral
calcaneal artery perforator flap is also useful for covering
small defects of the lateral ankle and hindfoot.77 Smaller
defects up to 10 cm on the anterior, medial, or lateral ankle
Figure 22.10  General algorithmic approach to soft tissue recon­
struction of the middle-third leg region. FFMT, functioning free muscle
transplantation; VAC, vacuum-assisted closure.
Bone,
tendon, or
hardware
exposure
Bone or
tendon
exposure
Dead space,
prosthetic,
allograft
Free
flap
FFMT
free
flap
Skin graft
Consider VAC
or integra
Soleus
Pedicled perforator
flap
Large defect >8 cm
Small to moderate
size defect <8 cm
Middle 1/3 leg algorithm
Figure 22.11  General algorithmic approach to soft tissue recon­
struction of the ankle and lower-third leg region. VAC, vacuum-
assisted closure.
Bone, tendon,
or hardware
exposure
Bone or
tendon
exposure
Dead space,
prosthetic,
allograft,
hardware
Free
flap
Skin graft
Consider
VAC or
integra
Reverse sural,
lateral
supramalleolar,
or pedicled
perforator flap
Large defect >8 cm
Small to moderate
size defect <8 cm
Ankle/lower 1/3 leg
algorithm

264
PART 3 — RECONSTRUCTION
donor site morbidity78 has made it a much less popular
choice with the many other tools now available in the recon­
structive arsenal.
BONE
Bones of the foot are often indicated for reconstruction due
to avascular necrosis or non-union. The talus and navicular
are the most frequently affected bones. Traumatic defects
or osteomyelitis of the metatarsals are also encountered with
some frequency. When the bone defect is <3.5 cm, suitable
options include the medial femoral condyle flap or iliac
crest flap if the overlying groin flap skin paddle is needed.
For bony gaps of >3.5 cm, reconstruction should be per­
formed with the fibula flap that may be taken with or without
a skin paddle.88–90 In cases of metatarsal bone defect, one
may also use conventional iliac bone grafting with free ALT
flap coverage.91
POSTOPERATIVE CONSIDERATIONS
POSTOPERATIVE PROTOCOL
Pedicled flap reconstruction without bony reconstruction
requires judicious resumption of activity to protect against
acute wound failure. Non weightbearing for an initial period
1–2 weeks followed by a total of 4 weeks of restricted weight­
bearing is a reasonable guideline. Free flaps should follow
a “dangle protocol” that usually begins 2–4 weeks postopera­
tively.92,93 For cases involving bone fracture or vascularized
bone graft reconstruction, the surgeon must ensure immo­
bilization until there is evidence of bony union. In our
series, the osseous flaps required an average of 8.5 months
for overall bony union. A supportive brace is continued for
24 months to guard against stress fracture for osseous flap
cases.46
ONCOLOGIC RECONSTRUCTION
POSTOPERATIVE CONSIDERATIONS
The detrimental effects of adjuvant therapy are well-known.
Postoperative irradiation should be delayed 3–4 weeks after
reconstructive operations to allow for significant wound
healing to occur. Postoperative chemotherapy is similarly
delayed until approximately 3 weeks after surgery.10 Of note,
there is clear evidence that adjuvant radiation therapy posi­
tively affects local control of the tumor for soft tissue sarcoma
patients94–96; therapy is generally implemented within 12
weeks after surgical resection. There is not yet strong evi­
dence of the effect of adjuvant chemotherapy for sarcoma,
even though it is still believed to have some absolute
benefit.97,98
TRAUMATIC RECONSTRUCTION
POSTOPERATIVE CONSIDERATIONS
EXPECTED SECONDARY CHALLENGES
The greatest proportion of postoperative challenges in trau­
matic reconstruction occurs in the timeframe after the
tissue transferred in the first reconstructive attempt has
stably incorporated and acute failure of the reconstructive
flap is no longer relevant. Bony non-union (15%); chronic
The two zones having the highest requirement for smooth
and durable cover are the plantar forefoot and plantar hind­
foot (heel) as these areas endure the highest weightbearing
of walking.83 Small defects up to 6 × 12 cm may be recon­
structed with the instep (medial plantar artery) flap in a
rotational fashion for defects on the plantar hindfoot (heel)
or in a V-Y advancement fashion for defects on the medial
aspect (first and second metatarsal area) of the plantar
forefoot.84 Defects up to 8 × 6 cm on the dorsal foot may be
reconstructed using the lateral supramalleolar flap.75,76
Small defects up to 3–5 cm on the lateral hindfoot may be
reconstructed by the lateral calcaneal artery perforator
flap.77 Larger defects will generally require microvascular
free tissue transfer. Our preferred donor site for the recon­
struction of plantar defects is the contralateral free instep
(medial plantar artery) flap because it has the ideal charac­
teristics for plantar foot reconstruction – sensibility, stability,
and durability (see Case 22.2).85 Just like the pedicled
version of the flap, the free instep flap option should be
used to resurface the plantar forefoot or hindfoot with first
priority. Provision of sensation is a debated topic,86 but our
feeling is that provision of sensation will reduce the proba­
bility of evolution of trophic ulcers. Smaller defects on
either the plantar or dorsal surface may be resurfaced with
the medial sural artery perforator flap. Larger defects of the
foot should be reconstructed with free ALT or similar fas­
ciocutaneous flap (e.g., free groin flap).87 The dorsalis pedis
flap may also be used in a reversed fashion to cover the distal
dorsal foot and toes, but the aforementioned significant
Figure 22.12  General algorithmic approach to soft tissue recon­
struction of the foot region.
Large defect >8 cm
Small to moderate
size defect <8 cm
Plantar
Dorsal
Free
fasciocutaneous
flap
Reverse sural
or lateral
supramalleolar
flap
Lateral
calcaneal
artery or
supramalleolar
perforator flap
Free
fasciocutaneous
perforator flap
Free
fasciocutaneous
perforator flap
Free
instep flap
Pedicled
instep flap
Forefoot
Hindfoot
Lateral
hindfoot,
Achilles
Plantar
other
surfaces
Foot algorithm

CHAPTER 22 — Lower Extremity Reconstruction
265
To restore dorsiflexion at the ankle and toes, we transfer the
tibialis posterior and flexor digitorum longus, respectively
(Fig. 22.13).102,103
Contracture Release and Functional Restoration.  The knee
and ankle are frequently affected by postoperative limita­
tion upon the range of motion. Inspection for and release
of fibrosis and contracture at the knee is done in a system­
atic fashion, starting on the superficial layer of skin and soft
tissue. The deeper quadriceps and patellar tendon are sub­
sequently inspected for points of restriction, which are
released if necessary. Finally, a joint capsulotomy may be
performed if there is ankylosis. Soft tissue coverage with an
anterolateral thigh flap or similar fasciocutaneous flap is
performed after the release to provide ample skin laxity to
allow maximum range of motion. If there is a deficit of
functional muscle unit in either the flexor or extensor units
of the thigh or leg, it becomes necessary to provide a func­
tioning free muscle transplantation in addition to excision
of fibrosis at the knee or ankle. Our group has shown the
effective restoration of knee extension by microvascular
transfer of a rectus femoris myocutaneous flap. We have also
restored ankle flexion and extension by using both rectus
femoris and gracilis myocutaneous flaps in the functioning
free muscle transplantation manner (Fig. 22.14).48,50
Non-union and Chronic Osteomyelitis.  Mutilating lower
limb trauma is associated with a high rate of bony non-union
(15%) or chronic osteomyelitis (9–12%). Non-union and
osteomyelitis are managed in conjunction with the orthope­
dic surgery team. An exploration and debridement of a
non-union or pseudoarthrosis of non-union is usually ame­
nable to conventional bone grafting and plate fixation.104
Non-union may also be managed with vascularized bone
grafting such as by the medial femoral condyle flap.89,105,106
Multiple failures of conventional bone grafting or a poor
recipient vascular bed may also influence the surgeon to
choose the vascularized tissue transfer option for treatment
osteomyelitis (9–12%); pain or dysfunction necessitating
secondary amputation (4%); and secondary fracture (2%)
are all encountered with frequency.99,100 Other common
sources of morbidity are persistent sensory or motor deficits,
ankylosis at the knee or ankle, or nonfunctional muscular
units from the initial soft tissue trauma. The surgeon and
patient must continually reevaluate whether the pain, dys­
function, and expected additional morbidity from the sal­
vaged limb and secondary procedures to optimize its
function are worth the psychologic and functional benefit
of keeping the limb.
Secondary Surgery after Traumatic Reconstruction
Nerve Dysfunction and Tendon Transfers.  Despite an
initial assessment of a nerve in continuity, the recovering
patient may still experience persistent functional denerva­
tion. In this setting, our group follows the protocol of Mack­
innon and colleagues for sharp trauma in performing
electrophysiologic studies at 3 weeks and then again at 3
months. If there is no recovery of nerve function, surgery
should be undertaken for exploration and subsequent neu­
rolysis and excision of any neuroma in continuity with
primary repair or nerve grafting. In those patients who had
undergone primary repair or nerve grafting at the first stage
of reconstruction, we follow the same monitoring schedule
of electrophysiological studies at 3 weeks and 3 months, with
surgical exploration for neurolysis and possible neuroma
excision if there is no functional recovery at that time point.
If there is subsequently no evidence of motor recovery at 1
year, we proceed with tendon transfers in an attempt to
maximize functional restoration.
Tibial nerve dysfunction is fairly amenable to orthotic use
if the patient is not appropriate for surgery, but common
peroneal palsy finds poor results with non-surgical adaptive
measures. Tendon transfer is the preferred intervention if
there is no functional nerve recovery. To achieve plantar-
flexion at the ankle, we transfer the tibialis anterior to the
calcaneus, passing through the interosseous membrane.101
Figure 22.13  Use of tibialis posterior tendon transfer to restore function in a case with common peroneal nerve palsy associated with trauma.
(A,B) Preoperative dorsiflexion and plantarflexion. (C,D) Postoperative dorsiflexion and plantarflexion.
A
B
C
D

266
PART 3 — RECONSTRUCTION
weeks) of negative pressure wound therapy followed by skin
grafting.109 The caveat of negative pressure wound therapy
use is that the suction should never be applied in close
proximity to large vessels due to the risk for vessel rupture
and life-threatening hemorrhage.110 Furthermore, conven­
tional debriding dressing changes should be continued
until the wound is clean and free of substantial necrotic
debris, due to the potential for wound deterioration and
acute infection in the setting of NPWT usage upon wounds
with excessive bacterial burden.111
Integra dermal regeneration template composed of
cross-linked bovine tendon collagen and glycosaminoglycan
(chondroitin-6-sulfate) has had a similar paradigm-changing
effect on lower extremity reconstruction as previous defects
of exposed bone or tendon that necessitated free tissue
transfer, can now be addressed with application of the
Integra, followed by skin grafting at a time point usually 3–4
weeks later.112–114 This strategy works well on the leg but is
less effective on the foot, where frequent friction on the
inherently less stable skin grafted surfaces may lead to
trophic ulcers.
COMPLICATIONS
TRAUMA
Limb salvage for catastrophic lower extremity trauma
encounters complications, with high frequency. Non-union
(31.5%) and postoperative infections (23.2%) are the most
frequent complications. Joint arthritis (9.4%), osteomyelitis
(8.6%), wound breakdown (6.5%), and painful hardware
(6.2%) are also encountered with frequency. Free flap
failure rates are also notably higher in the trauma popula­
tion (8.8%).115 Osseous flaps encounter stress fracture in up
of non-union. Significant bony gaps of >6 cm may occasion­
ally occur after debridement of osteomyelitis and should be
managed by transfer of an osseous flap such as the fibula,
iliac crest, or rib with serratus anterior based upon the same
principles discussed earlier. Ilizarov bone transportation is
another option for bony reconstruction of non-infected
bone deficits up to 12 cm, but vascularized bone transfer
requires a much shorter disability time for provision of bony
union and functional mobility.107,108
Vascular Challenges in Free Tissue Transfer.  Secondary
surgery in an area previously affected by major trauma can
be a daunting task due to the paucity of usable recipient
vessels. In undertaking secondary free flaps to the lower
extremity, it may become necessary to implement measures
such as formation of AV fistula or placement of long vein
grafts to support a free flap in an area remote to where
remaining recipient vessels reside.28 In situations where
there is a complete lack of usable vasculature in the area to
be reconstructed, one may use the technique of the cross-
legged free flap, in which one uses healthy vessels within the
contralateral leg to provide vascular support to the flap
reconstruction being performed. It is necessary to perform
a second-stage division of the pedicle after 3–4 weeks have
elapsed.34
OTHER TOOLS
NEGATIVE PRESSURE WOUND THERAPY
Negative pressure wound therapy (NPWT) has been a revo­
lutionary addition to the lower extremity reconstructive
arsenal. Soft tissue defects of the leg with exposed tendon
or bone that previously necessitated more invasive fasciocu­
taneous local tissue rearrangement or even microvascular
free tissue transfer are now treated with a short period (2–4
Figure 22.14  Secondary functioning free muscle transfer to achieve both functional muscle restoration and soft tissue coverage for a patient
with a history of Gustilo IIIB open tibia fibula fracture and extensive loss of the musculotendinous units of the anterior leg now presenting with
osteomyelitis. (A) Preoperative defect after scar excision and bony debridement with external fixation and conventional bone grafting. (B) Rectus
femoris and ALT skin paddle. (C,D) Plantarflexion and dorsiflexion at the long-term clinic follow-up.
A
B
C
D

CHAPTER 22 — Lower Extremity Reconstruction
267
Nevertheless, the development of outcomes metrics includ­
ing the LEAP and METALS7,19,125,126 studies have allowed us
to better understand the postoperative consequences from
the life quality standpoint and thus more effectively tackle
the postoperative challenges in this population with the
implementation of the following adjunctive therapeutic
efforts.
PSYCHIATRIC
As has been shown with the recent METALS study on out­
comes among military personnel injured in combat zones
in the Middle East, there is a high rate of post-traumatic
stress disorder within this population. Though it must still
be verified in literature, civilians injured in non-military–
related accidents could likely suffer from a similar post-
traumatic psychiatric ailment. As suggested by the METALS
study, the patient’s psychiatric health factors heavily into the
clinical outcome from the standpoint of life quality.7 The
surgical team should thus monitor for signs of declining
psychiatric health and arrange for evaluation by a psychiat­
ric team for appropriate psychotherapy and pharmacother­
apy if necessary.
NEUROLOGIC
Outcomes analysis from the LEAP study group found that
major lower extremity injuries have a high frequency of
chronic pain and allodynia even years after the trauma.127
Furthermore, patients with these types of injury frequently
develop chronic regional pain syndrome type II.128 Pharma­
cotherapies such as gabapentin and pregabalin have proven
effective, especially when used in conjunction with adjuvant
therapies such as mechanical desensitization or tempera­
ture therapies for chronic pain. Patients exhibiting signs of
chronic regional pain syndrome should be treated very
aggressively with multimodal analgesic therapy to halt the
downward spiral nature of the progression of the condition.
Nerve blocks and antidepressant pharmacologic therapy
(tricyclic antidepressants, serotonin reuptake inhibitors,
dopamine reuptake inhibitors) have also been suggested to
provide adjuvant benefit.129
PHYSICAL THERAPY AND
REHABILITATION SERVICES
Rehabilitation from major lower extremity trauma has typi­
cally involved the participation of adjuvant physical therapy.
However, the specific extent of participation has previously
been without stringent management. With the advent of
outcomes-focused studies, investigators have sought to verify
the specific effect and furthermore define the period and
manner of physical therapy that may benefit this particular
population. From the LEAP study group, 382 lower extrem­
ity salvage patients were observed in longitudinal fashion.
The investigators found that patients with an unfulfilled
need for therapy were significantly less likely to improve in
five selected domains of physical impairment when com­
pared to patients whose physical therapy needs were met.
Furthermore, the study suggests that physical therapists
were more likely than surgeons to identify patients who
could benefit from their services.130 Therefore, it is our
to 11.5% of cases, but the patients ultimately proceed to
union with an average of 10.5 months of immobilization.46
Flap donor sites may encounter difficulties such as infec­
tion, dehiscence, hematoma, seroma, and skin graft loss that
require additional procedures and present morbidity to the
recovering patient.
ONCOLOGIC
The most feared complication in the setting of reconstruc­
tive surgery after oncologic resection is the periprosthetic
infection, which happens with alarmingly high frequency
10–20%.11,116,117 Periprosthetic infection proceeds to ampu­
tation in >50% of cases.11,118,119 However, routine flap cover­
age of allograft and prostheses has decreased the number
of infections to as low as 3% in some studies.11
DIABETIC
Reconstructive flaps in diabetes-related wounds have a
generally higher rate of complication than reconstruction
in the non-diabetic population. Pedicled skin and fascio­
cutaneous flap have a 17.0% rate of partial flap loss and
10.9% rate of complete flap failure. Pedicled muscle and
myocutaneous flaps encounter a 9.1% rate of partial flap
loss and 2.3% rate of complete flap failure. Microsurgical
muscle flaps have a 3.1% rate of partial flap loss and 11%
rate of complete flap failure. Microsurgical fasciocutane­
ous flaps have a 4.8% rate of partial flap loss and 4.8%
rate of complete flap failure. These findings suggest that
microsurgical transfer of fasciocutaneous flaps can be a
relatively safe reconstructive modality for diabetic foot
defects.120
VASCULAR
Reconstruction in the patient with peripheral vascular
occlusive disease is a notably treacherous task. Even after
revascularization procedures, the reported complication
rates are still as high as 49% overall, with major bleeding
(24%), partial necrosis (9%), complete flap failure (6%),
fulminant infection (3%), and vascular steal phenomenon
(3%) being the most likely acute complications.121
LYMPHEDEMA
Operations in patients with concomitant lymphedema are
known to have an elevated rate of infection, seroma, and
hematoma (up to 19–33%).122,123
OUTCOMES
TRAUMA
Major lower extremity trauma is a physically and men­
tally disabling life event that requires a multidisciplinary
approach for effective acute and subacute care. Quality of
life after such an event is affected by multiple factors that
probably vary from one population to another. Measurable
functional outcomes after complex reconstruction may not
be significantly different than the amputation cohort.124