Review of Plastic Surgery – Donal W. Buck II

Breast Cancer and Breast Reconstruction
89
9
9. Common preoperative considerations
• Smoking
■ Increased risk of mastectomy flap necrosis as well as
donor site skin necrosis and wound healing
complications, umbilical necrosis, hernia in autologous
reconstructions
• Antibiotics
■ Preoperative and intraoperative redosing as necessary
■ No evidence to support postoperative antibiotics
■ Oral antibiotics recommended as initial treatment for
early/minor infection of prosthetic reconstruction
• Anticoagulation
■ Preoperative anticoagulation with subcutaneous heparin
or low-molecular-weight heparin is effective in reducing
the risk of deep venous thrombosis and pulmonary
embolus
10. Common postoperative considerations
• Severe pain with expansion
■ Initial treatment recommendation is to remove fluid
from the expander because overfill can lead to ischemia.
• Mastectomy skin flap necrosis in setting of implant-based
reconstruction
■ Initial treatment recommendations depend on presence
or absence of expander exposure.
○ If necrosis occurs over area with no muscle coverage,
debridement and primary closure of skin, if possible,
is preferred.
○ If necrosis occurs over area with muscle coverage,
dressing changes and healing by secondary intent can
be performed.
• Secondary procedures
■ Reconstruction revision
○ Skin excision
○ Fat grafting for contour deformities (especially in the
upper pole)
○ Capsulectomy/capsuloraphy
■ Contralateral procedures for symmetry
○ Reduction mammoplasty
○ Mastopexy
○ Augmentation
■ Donor site revision
○ Scar revision
○ Dog-ear excision
○ Abdominal bulge/hernia repair
7. Anaplastic large cell lymphoma (ALCL)
• Women with breast implants may have a very small but
increased risk of developing ALCL in the scar capsule
adjacent to the prosthesis.
■ Generally more indolent, with a favorable prognosis
when compared to patients with systemic ALCL
• Diagnosis should be considered in patients who have
late-onset persistent seroma.
• Diagnosis made through histiologic examination of the
capsule for giant cells
• The Food and Drug Administration (FDA) does not
recommend removing implants in asymptomatic patients.
• Currently developing a registry of these patients to better
understand the disease and potential association
8. Phyllodes tumor (see Figure 9.4)
• Most commonly occurring nonepithelial neoplasm of the
breast
■ Accounts for 1% of all breast tumors
■ Approximately 85% of phyllodes tumors are benign.
• Characterized by a large (~5 cm), smooth, mobile, and
sharply demarcated mass
• Suggested treatment options
■ Wide local excision with 1-cm margins
■ Mastectomy (if mass size precludes breast-conserving
surgery)
Figure 9.4.  Benign phyllodes tumor of the breast with a diameter
of 30 cm in a 55-year-old patient. The visible vessels and thinned
skin are characteristics of large phyllodes tumors. (Reprinted from
Lenhard, M.S., Kahlert, S., Himsl, I., et al., 2008. Euro. J. Obstet. Gyn. Reprod.
Biol. 138 [2], 217–221.)

Breast Cancer and Breast Reconstruction
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Losken, A., 2013. Chapter 11: The oncoplastic approach to partial breast
reconstruction. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier,
pp. 296–313.
LoTempio, M.M., Allen, R.J., Blondeel, P.N., 2013. Chapter 19: Alternative
flaps for breast reconstruction. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed.
Elsevier, pp. 457–471.
Nahabedian, M.Y., Momen, B., Galdino, G., et al., 2002. Breast
reconstruction with the free TRAM or DIEP flap: patient selection, choice of
flap, and outcome. Plast. Reconstr. Surg. 110 (2), 466–475.
Narod, S.A., 2010. BRCA mutations in the management of breast cancer: the
state of the art. Nat. Rev. Clin. Oncol. 7 (12), 702–707.
Nava, M.B., Catanuto, G., Pennati, A., et al., 2013. Chapter 14: Expander-
implants breast reconstructions. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd
ed. Elsevier, pp. 336–369.
National Comprehensive Cancer Network, 2014. NCCN Guidelines for
Invasive Breast Cancer. Available at: <
physician_gls/f_guidelines.asp#breast/> Accessed on: August 6, 2014.
Neligan, P.C., Grotting, J.C., 2013. Chapter 17: Implant based breast
reconstruction. In: Neligan, P.C., Buck, D.W. (Eds.), Core Procedures in
Plastic Surgery. Elsevier, pp. 263–277.
Said, H.K., Javid, S.H., Colohan, S., et al., 2014. Chapter: Breast
reconstruction following mastectomy: indications, techniques, and results. In:
Cameron, J.L., Cameron, A.M. (Eds.), Current Surgical Therapy, 11th ed.
Saunders, pp. 621–624.
Spear, S.L., Clemens, M.W., 2013. Chapter 15: Latissimus dorsi flap breast
reconstruction. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier,
pp. 370–392.
Suggested Readings
American Cancer Society, 2010. Breast Cancer Facts and Figures. Available at:
<
cancer-facts-and-figures-2010/> Accessed on: January 8, 2015.
Beahm, E., Lang, J.E., 2013. Chapter 10: Breast cancer: Diagnosis, therapy,
and oncoplastic techniques. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed.
Elsevier, pp. 266.
Belz, J.M., Woo, A.S., Tung, T.H.H., 2014. Chapter 25: Breast cancer
reconstruction. In: Woo, A.S., Shahzad, F., Snyder-Warwick, A.K. (Eds.),
Plastic Surgery Case Review. Thieme, pp. 109–112.
Davidson, N., 2012. Chapter 204: Breast cancer and benign breast disorders.
In: Goldman, L., Schafer, A.I. (Eds.), Goldman’s Cecil Medicine, 24th ed.
Elsevier, pp. 1309–1317.
Fosnot, J., Serletti, J.M., 2013. Chapter 17: Free TRAM breast reconstruction.
In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 411–434.
Fosnot, J., Serletti, J.M., 2013. Chapter 18: Autologous breast reconstruction
using abdominal flaps. In: Neligan, P.C., Buck, D.W. (Eds.), Core Procedures
in Plastic Surgery. Elsevier, pp. 278–308.
Lenhard, M.S., Kahlert, S., Himsl, I., et al., 2008. Phyllodes tumor of the
breast: clinical follow-up of 33 cases of this rare disease. Euro. J. Obstet.
Gynecol. Reprod. Biol. 138 (2), 217–221.
Lipa, J.E., 2010. Chapter 9: DIEP flap breast reconstruction. In: Hall-Findlay,
E.J., Evans, G.R.D. (Eds.), Aesthetic and Reconstructive Surgery of the Breast.
Elsevier, pp. 117–146.

Noncancer Breast Surgery
Chapter
10 
General Information
1. Noncancer breast surgery includes all of the techniques aimed
at restoring an esthetic, more youthful appearance of the
breasts in the setting of various benign conditions.
2. Indications
• A motivated patient who desires improvement in the
appearance of her breasts with the presence of
macromastia, micromastia, and/or breast ptosis
3. Contraindications: Similar for all esthetic surgery
• Patient is being pushed into surgery by others or desires to
please others.
• Patient seeking esthetic breast surgery because of marital
problems or familial disapproval
• Patient with unrealistic expectations or with minimal
deformity and a distorted sense of their appearance (body
dysmorphic disorder)
• Patient who has been “doctor shopping” or has had
multiple prior surgeries but is still dissatisfied
Reduction Mammaplasty
1. Macromastia signs and symptoms
• Back pain, shoulder and neck pain, trapezius m.
hypertrophy, shoulder strap grooving, and inframammary
fold (IMF) intertrigo
2. Preoperative considerations
• Degree of ptosis and hypertrophy and desired
postoperative size will help determine the amount of
parenchymal reduction required and assist with selection
of skin incision pattern and pedicle location.
• Postoperative nipple-areolar complex (NAC) perfusion and
sensation
■ Most important determinant of postoperative sensation
is location of glandular resection and pedicle selection
(lateral pedicle, inferior pedicle, or medial pedicle are
best), not reduction volume, preoperative breast volume,
skin incision pattern, and/or sternal notch-to-nipple
distance.
• Postoperative lactation
■ Rates of breast-feeding in women after breast reduction
surgery are similar to those of child-bearing women who
have not had breast reduction surgery.
○ Approximately 30% of women after inferior pedicle
breast reduction breast-feed either exclusively or with
formula supplementation.
■ Most important determinant of ability to breast-feed
after breast reduction surgery is pedicle thickness
○ Pedicle type and reduction volume has no effect.
○ Impossible with free nipple grafting.
• Smoking cessation
• Breast measurements (see Figures 10.1 and 10.2)
■ Sternal notch-to-nipple distance
■ Nipple-to-IMF distance
■ Nipple-to-midline distance
■ Breast base width
Figure 10.1.  Preoperative measures (taken before breast
augmentation) include BH (breast height), BW (breast width),
N:IMF (nipple to inframammary fold), IMD (intermammary distance),
and SSN:N (suprasternal notch to nipple). (Reprinted from Neligan, P.C.,
Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 225.)
SSN:N
SSN:N
N:IMF
IMD
BH
BW

Noncancer Breast Surgery
92
■ Many advocate for preoperative mammography before
surgery with any breast masses, breast complaints,
or at-risk women (>35-40 years old [yo]) whose
mammogram is over 1 year old.
○ Risk of occult breast cancer occurrence in reduction
specimen is extremely rare (reportedly 0.2%).
○ When found, cancer is often early stage or in situ
carcinoma.
3. Techniques
• Suction lipectomy
■ Can be used alone in select patients
■ Contraindicated in patients with breast ptosis or who
will likely require skin reduction
■ Advantages
○ Minimal scars
○ Rapid recovery and return to work
○ Decreased operative time
○ Minimal risk to nipple sensation/perfusion
○ Minimal risk to postoperative lactation
■ Disadvantages
○ Unable to pathologically examine lipoaspirate
○ High risk of inadequate reduction
○ Skin contraction unpredictable, leading to excess skin
○ Unable to correct breast ptosis
• Traditional reduction mammaplasty
■ Combines a skin excision pattern with a pedicle to
maintain nipple perfusion
○ Skin patterns include Wise pattern, keyhole, vertical,
and no-vertical-scar techniques
○ Pedicle options include superior, medial,
superomedial, inferior, lateral, and central pedicle
◆ The inferior pedicle can achieve significant volume
reduction and reduce the vertical dimension of the
breast.
➔ Can be used for all reductions, including
moderate to severe reductions (>800 g)
Figure 10.2.  Statistical standards for the dimensions of the
breast. (Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core
Procedures in Plastic Surgery. Elsevier, 235.)
19 to 21 cm
19 to 21 cm
19 to 21 cm
5 to 6 cm
5 to
6 cm
9 to
11 cm
2cm
• Vertical mammaplasty
■ Uses a vertical-only skin excision that reduces scar
burden and narrows the breast, thereby increasing
projection
■ The initial breast shape is poor with a characteristic
flattened, lower pole and inferior dog ears; however, this
improves after 3 to 6 months.
■ This technique is generally used for moderate reductions
(<800 g) or smaller but is contraindicated with a long
pedicle length >9 cm because of concerns with nipple
perfusion.
4. Complications: Risk factors include obesity, reduction volume
>1000 g, and smoking.
• Infection
• Scarring
■ Long-term complication most associated with patient
dissatisfaction
• Seroma, hematoma
■ Greatest risk factor for hematoma is hypotensive
anesthesia
■ Drains have not reduced the incidence of hematoma.
• Fat necrosis
■ Characteristic finding: Development of delayed, firm,
and nontender masses
• Asymmetry
• Skin loss and wound development (especially at the
inferior T junction in Wise pattern reductions)
■ Most common complication in obese patients with large
reduction volume
• Under-resection
■ May require reoperation
• NAC complications
■ Incidence <5%
■ Risk factors: Smoking, elevated body mass index (BMI),
and long pedicle
■ Etiology
○ Intrinsic physiologic risk (obesity, smoking)
○ Excessive nipple-to-IMF distance/pedicle length and
excessive sternal notch-to-nipple distance
○ Torsion of the pedicle
○ Excessive tension on the closure
■ Management
○ If immediately after reduction, pedicle exploration
with release of tension
○ If pedicle release does not result in improvement,
convert to free nipple graft
◆ Be sure to graft to well-vascularized tissue and not
the compromised skin flap or pedicle.
○ If nipple compromise occurs after early postoperative
period, observation and conservative wound care
Mastopexy
1. Many similarities with reduction mammoplasty; however,
primary goal is to lift the breast and correct breast ptosis

Mastopexy
93
10
2. Breast ptosis: Relationship of the NAC to the IMF and lower
contour of the breast (see Figures 10.3 and 10.4)
• Regnault classification
■ Grade I: NAC within 1 cm of the IMF and above the
lower contour of the breast
■ Grade II: NAC is 1-3 cm below the IMF but above the
lower contour of the breast
■ Grade III: NAC >3 cm below the IMF and at the lower
contour of the breast
■ Grade IV (pseudoptosis): NAC at the level of the IMF,
but the majority of the breast volume has descended
below the IMF
○ Increased nipple-to-IMF distance in setting of stable
sternal notch-to-nipple distance
Figure 10.3.  Breast ptosis classification as described by Regnault.
(A) Minimal ptosis: Nipple is at the level of or just inferior to the
inframammary crease. (B) Moderate ptosis: Nipple is 1-3 cm below
the inframammary crease. (C) Severe ptosis: Nipple is >3 cm
below the inframammary crease. (Redrawn from Georgiade, G.S.,
Georgiade, N.G., Riefkohl, R., 1991. Esthetic breast surgery. In: McCarthy, J.G.
[Ed.], Plastic Surgery. WB Saunders, Philadelphia, 38–39.)
A
B
C
Figure 10.4.  Different types of breast ptosis. IMF, inframammary
fold. (Redrawn after Brink, R.R., 1993. Management of true ptosis of the
breast. Plast. Reconstr. Surg. 91, 657–662.)
A
B
C
D
Glandular ptosis
True ptosis
Parenchymal maldistribution
(high IMF)
Pseudoptosis
3. Preoperative considerations
• Degree of ptosis often correlates with particular surgical
plan.
■ Grade-I ptosis can often be treated with augmentation
alone or may sometimes require a crescentric or
periareolar mastopexy.
■ Grade-II ptosis often requires a vertical or infra-areolar
mastopexy.
■ Grade-III ptosis often requires a Wise pattern mastopexy
because of the amount of skin resection required.
• Massive weight loss patients
■ Presentation: Grade-III ptosis, deflated superior breast
pole, medicalization of the NAC with lateralization of
the breast mound, extension of the skin excess, and
ptosis to the lateral axilla and back
• Mastopexy after removal of implants
■ Degree of preoperative breast ptosis will determine
whether mastopexy is required after explantation.
■ If the amount of native breast parenchyma overlying the
implant is inadequate (<4 cm), or there is severe ptosis
requiring nipple elevation >4 cm, mastopexy should be
delayed for at least 3 months following explantation to
reduce the risk of NAC compromise.
4. Techniques
• Techniques are similar to those used in reduction
mammoplasty; however, the glandular resection is minimal
with a goal to lift the gland through excess skin removal
and parenchymal anchoring.

Noncancer Breast Surgery
94
◆ 3rd generation: Thicker shell with inner barrier
and increased cross linking of the silicone
elastomer, more viscous (cohesive) gel
➔ Designed to reduce silicone bleeding prostheses
◆ 4th generation: Cohesive gel (“gummy bear”)
implant
○ Moratorium in 1990s on use of silicone breast
prostheses because of fears over possible systemic
effect of silicone; lifted in early 2000s
◆ Multiple studies in Europe and North America
have failed to determine a causative association
between silicone breast prostheses and any
traditional or atypical connective tissue diseases or
autoimmune diseases.
• Texture
■ Textured implants have lower rates of capsular
contracture compared to smooth implants (particularly
with subglandular pocket placement).
○ Texturing alters the capsule response by making the
collagen pattern more disorganized.
■ Textured saline implants have higher rates of rippling
and deflation rates when compared to smooth saline
implants.
○ No difference in deflation rates between textured and
smooth silicone prostheses
• Implant size
■ Most important factor for determining prosthesis size is
the patient’s breast base width.
■ Large prostheses (>350 mL) are associated with
○ Long-term soft-tissue attenuation including thinning,
stretching, atrophy, rippling, and ptosis
○ Greater effect on vascularity, which increases
potential risk of NAC loss, skin flap loss, infection,
exposure, malposition, and deformity
• Implant position
■ Subglandular
○ Implant is placed in the subglandular/prepectoral
space.
○ Contraindicated in patients who have a pinch test
<2 cm, which signals inadequate soft-tissue coverage
of the implant
○ Higher rates of capsular contracture compared to
subpectoral placement
○ Preferred implant position for patients who are
weight lifters, athletes, or active and want to
minimize disruption of their pectoralis m.
■ Subpectoral
○ Implant is placed beneath the pectoralis major m.
○ Lower rates of capsular contracture
○ Lower rates of palpability/visibility
○ Contraction of pectoralis m. postoperative can lead to
distortion/animation deformity
5. Complications
• Similar complications to reduction mammoplasty
• See below for complications specific to augmentation-
mastopexy procedures.
Augmentation Mammaplasty
1. Preoperative consideration
• Age
■ Must be at least 22 yo to have silicone prostheses
■ Must be at least 18 yo to have augmentation
mammoplasty with saline implants (unless for
reconstructive purposes)
• Implant type
■ Saline: Silicone elastomer shell filled with sterile normal
saline
○ Advantages
◆ Can be inserted through smaller incisions
◆ Volume/fill can be adjusted or varied
◆ Less capsular contracture, particularly in the
subglandular pocket
◆ Ruptures are evident almost immediately
○ Disadvantages
◆ Higher rate of rippling, visibility
◆ Higher rate of deflation
◆ Less natural to touch
■ Silicone
○ Advantages
◆ Natural appearance and feel
◆ Lower rate of rippling, deflation
○ Disadvantages
◆ Requires larger incision for insertion
◆ Higher rates of capsular contracture, particularly
in the subglandular pocket
◆ Ruptures are often silent.
➔ The Food and Drug Administration (FDA)
recommends a magnetic resonance imaging
(MRI) scan at 3 years postoperatively, followed
by every 2 years after that to screen for rupture.
◆ Silicone can obscure some breast tissue on
mammogram.
➔ No increase in incidence or late diagnosis of
cancer
○ Silicone prosthesis generations
◆ 1st generation: Thick shell, viscous gel, and Dacron
patches
◆ Removed from market because of capsular
contracture and hardness
◆ 2nd generation (1973-1985): Thinner shell, lower
viscosity gel that resulted in softer, and more
natural-feeling prosthesis
➔ Removed from market because of rates of
rupture, bleed, and capsular contracture

Augmentation Mammaplasty
95
10
■ Double bubble deformity
○ Type A: Implant sits above the native breast
parenchyma.
○ Type B: Implant has fallen below the IMF and sits
below the native breast parenchyma.
• Infection
■ Frank infection denoted by gross purulence around the
implant
○ Treatment: Removal of the implant, irrigation of the
pocket, debridement of the capsule, and reinsertion
of an implant 6 months later
■ Mild infection
○ Treatment: Removal of the implant, irrigation of the
pocket, capsule debridement, and immediate
insertion of new implants
■ Triple-antibiotic solutions for irrigation
○ Improved broad-spectrum activity against bacteria
commonly cultured around breast implants
◆ 10% povidone iodine, gentamicin, and cefazolin
(for silicone implants)
◆ Bacitracin, gentamicin, and cefazolin (for saline
implants)
➔ Iodine contraindicated with saline implants
■ Nontuberculosis mycobacterium infection
○ Indolent infection that presents late
○ Symptoms: Erythema; swelling; turbid, odorless, and
clear fluid
○ Treatment: Long-term course of ciprofloxacin and
Bactrim
• Rupture
■ Mean age of implant rupture is 13.4 years.
■ MRI is most effective for assessing potential implant
rupture.
○ Reportedly, at 7 to 10 years, 50% of implants show
evidence of rupture on MRI.
○ “Linguine sign”: Fraying of the elastomer shell,
suggesting silicone rupture
■ Suggested management
○ Explantation and capsulectomy
○ Reinsertion of implants if desired. If not, follow
guidelines above for mastopexy after explantation.
• Capsular contracture
■ Development of scar around the implant
○ Foreign body response to surface-bound protein
fibrinogen
■ Baker classification of capsular contracture (see
Table 10.1)
■ Dual plane
○ Combination of subpectoral and subglandular
placement
○ Inferior attachments of pectoralis m. are released.
◆ Superior pole of implant covered by pectoralis m.
◆ Inferior pole of implant covered by breast
parenchyma
• Incision placement
■ Periareolar
■ IMF
■ Transaxillary
■ Umbilical
2. Special techniques
• Transaxillary augmentation
■ Pocket dissection and implant inserted through incision
along anterior axillary crease
■ Often used with endoscope for aid in visualization and
implant positioning
■ Disadvantages
○ High rate of malposition
◆ Minimized with endoscopic techniques
○ Potential injury to intercostobrachial n. and medical
brachial cutaneous n. during dissection within axilla,
leading to numbness and paresthesias of medial
upper arm
◆ Danger zone: Dissection deep into the axillary fat
posterior to the lateral border of the pectoralis m.
➔ Reduce risk by staying in the subdermal plane
until lateral border of pectoralis m. is reached.
• Augmentation/mastopexy
■ Balance of volume increase with implant placement and
excess skin reduction for ptosis correction
■ Implant should be inserted first, before the mastopexy is
performed.
■ Compared to mastopexy alone, the length of incisions
required to correct ptosis is reduced and the amount of
excess skin removed is often less because of the volume
by the implant.
■ Disadvantages
○ Higher rates of ptosis recurrence because of weight of
prosthesis on the incision
○ Increased risk of nipple malposition because the
nipple is moved at the same time as the implant
3. Complications
• Reoperation
■ 10-year risk for reoperation for any implant-related
indication: 25%
■ Often secondary to deflation of the implant, capsular
contracture, hematoma, wound infection, and seroma
• Malposition
■ Lateral displacement
○ Often a result of inadequate medial pocket dissection,
aggressive lateral pocket dissection, or activity of
pectoralis m.

Noncancer Breast Surgery
96
• Scarring
■ History of keloid scars
■ Incision placement related to complaints regarding
scarring
○ IMF incision is often well concealed within IMF
○ Transaxillary scar may be noticeable with arms raised.
○ Hypertrophy or widening of the periareolar scar is
the most common complaint with this incision.
• NAC sensory disturbance
■ Risk increases as implant volume increases.
■ Blunt dissection lateral to the lateral edge of the
pectoralis major m. reduces the risk for injury to the
lateral cutaneous branch of the 4th intercostal n.
• Skin or NAC vascular compromise
■ Increased risk with subglandular position (interruption
of perforators from thoracoacromial artery through
pectoralis m.)
■ In secondary augmentation-mastopexy procedures, a
superior or medially based pedicle is recommended due
to unreliability of the inferior pedicle because of atrophy
and thinning from the weight of the implants.
• Postoperative lactation and breast-feeding
■ Rates of breast-feeding in women after augmentation
mammaplasty is similar to that of child-bearing women
who have not had augmentation.
■ Silicone implants are safe with breast-feeding. The
silicone levels in breast milk are not higher than levels
found in women without silicone implants.
Suggested Readings
Brown, M.H., 2013. Chapter 3: Secondary breast augmentation. In: Neligan,
P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 39–66.
Cruz, N.I., Korchin, L., 2010. Breast feeding after augmentation mammoplasty
with saline implants. Ann. Plast. Surg. 64 (5), 530–533.
Fine, N.A., 2014. Chapter 14: Breast augmentation. In: Neligan, P.C., Buck,
D.W. (Eds.), Core Procedures in Plastic Surgery. Elsevier, pp. 222–232.
Fisher, J., Higdon, K.K., 2013. Chapter 8: Reduction mammaplasty. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 152–164.
Glaus, S.W., Tenenbaum, M., 2014. Chapter 27: Breast augmentation. In:
Woo, A.S., Shahzad, F., Snyder-Warwick, A.K. (Eds.), Plastic Surgery Case
Review. Thieme, pp. 115–118.
Glaus, S.W., Tenenbaum, M., 2014. Chapter 28: Mastopexy/augmentation. In:
Woo, A.S., Shahzad, F., Snyder-Warwick, A.K. (Eds.), Plastic Surgery Case
Review. Thieme, pp. 119–122.
Hall-Findlay, E.J., 2009. Chapter 119: Breast reduction. In: Guyuron, B.,
Eriksson, E., Persing, J.A., et al. (Eds.), Plastic Surgery: Indications and
Practice. Elsevier, pp. 1575–1590.
Higdon, K.K., Grotting, J.C., 2013. Chapter 7: Mastopexy. In: Neligan, P.C.
(Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 119–151.
Lorenz, P., Bari, A.S., 2013. Chapter 16: Breast reduction. In: Neligan, P.C.,
Buck, D.W. (Eds.), Core Procedures in Plastic Surgery. Elsevier, pp. 254–262.
Maxwell, G.P., Gabriel, A., 2013. Chapter 2: Breast augmentation. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 13–38.
Poppler, L.H., Tenenbaum, M., 2014. Chapter 29: Breast reduction. In: Woo,
A.S., Shahzad, F., Snyder-Warwick, A.K. (Eds.), Plastic Surgery Case Review.
Thieme, pp. 123–124.
Shestak, K.C., 2014. Chapter 15: Mastopexy. In: Neligan, P.C., Buck, D.W.
(Eds.), Core Procedures in Plastic Surgery. Elsevier, pp. 233–253.
Walden, J.L., 2009. Chapter 53: Breast augmentation. In: Aston, S.J.,
Steinbrech, D.S., Walden, J.L. (Eds.), Aesthetic Plastic Surgery. Elsevier,
pp. 661–673.
White, D.J., Maxwell, P.G., 2010. Chapter 67: Reduction mammaplasty.
In: Weinzweig, J. (Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby,
pp. 446–452.
Table 10.1  Grades of Capsular Contracture Divided
into the Following Four Types
GRADE
DESCRIPTION
I
Capsular contracture of the augmented breast feels as
soft as an unoperated breast.
II
Capsular contracture is minimal, breast is less soft than
an unoperated breast, implant can be palpated but is
not visible
III
Capsular contracture is moderate, breast is firmer,
implant can be palpated easily and may be distorted or
visible
IV
Capsular contracture is severe and breast is hard,
tender, and painful, with significant distortion present.
The capsule thickness is not directly proportional to
palpable firmness, although some relationship may
exist.
Reproduced with permission from Spear, S.L., Baker, J.L., Jr., 1995.
Classification of capsular contracture after prosthetic breast
reconstruction. Plast. Reconstr. Surg. 96 (5), 1119–1124.
■ If contracture persists after multiple revisions
(capsulectomies with implant replacement), next step is
latissimus flap.
■ Suggested management
○ Capsulectomy with implant replacement
○ Change of implant position (if original position is
subglandular)
○ Some have advocated for the use of acellular dermal
matrix.
○ If contracture recurs after multiple revisions, can
consider latissimus flap.
• Patient dissatisfaction with size
■ Risks of increasing implant size
○ Soft-tissue thinning
○ Atrophy of native breast parenchyma
○ Ptosis
○ Visibility and rippling
○ Less natural appearance
• Hematoma (reported in 1% to 3% of cases)
■ Can present late (14 days)
■ Can present after intense physical activity/trauma to the
chest
■ Suggested management
○ Surgical exploration and evacuation of hematoma
with replacement of implant if no evidence of
infection
○ If left untreated, even a small hematoma after
augmentation can lead to complications, including
capsular contracture, deformity, and infection.
○ Desire for explantation
■ See above for mastopexy after implant removal.

SECTION 3: Trunk and Lower Extremity
Trunk Reconstruction
and Pressure Sores
Chapter
11 
General Chest Wall Anatomy
1. The chest wall is composed of a bony shell that protects
critical structures (e.g., heart, lungs, liver, kidneys) with a
muscular component that assists with respiration as well
as stabilization and motion of the upper extremities (see
Figure 11.1).
to 10) or have no anterior articulation and are said to be
“floating ribs” (ribs 11 and 12).
3. The sternum contains three bony parts.
●
The manubrium articulates with the first ribs and
clavicles.
●
The body articulates with ribs 2 to 7.
●
The xiphoid process is insignificant.
4. Chest wall musculature
●
Intercostal muscles (external, internal, innermost m.) run
between ribs, contain neurovascular bundles, and
function to increase chest wall volume during inspiration.
■
The neurovascular bundles run between the internal
intercostal muscles and the innermost intercostal
muscles, just inferior to each rib (see Table 11.1).
Chest Wall Reconstruction
1. Chest wall defects are often the result of tumor resection,
deep sternal wound infections, chronic empyemas, and/or
trauma.
2. Chest wall defects following tumor extirpation often result in
large segmental composite defects.
●
In general, stabilization of the chest wall, in addition to
soft-tissue coverage, is required in defects >5 cm or more
than 2 to 3 contiguous ribs.
■
Options for skeletal support include mesh (e.g.,
polypropylene, polytetrafluoroethylene [PTFE]),
methylmethacrylate, and acellular dermal matrix.
■
Larger posterior rib defects may be tolerated because
of the scapula.
3. Mediastinitis following sternotomy is reported to occur in
0.25% to 5% of cases.
●
Risk factors include diabetes, bilateral internal mammary
artery (IMA) harvest, and obesity.
4. Pairolero and Arnold classified sternal wound infections into
three types (see Table 11.2).
5. Reconstruction of sternal wounds largely depends on the type
of infection, degree of purulence, and presence of bone and/
or cartilage infection or necrosis.
●
For type-1 sternal wounds, if the wound is not purulent
and the sternal bone is viable, sternal reconstruction with
plates and/or wires, followed by flap coverage or closure,
is possible.
Figure 11.1.  Anterior chest wall showing the sternum. Note where
the costal cartilages articulate with the sternum. In the intercostal
space lie different structures: Several kinds of intercostal muscles,
intercostal arteries, and associated veins, lymphatics, and nerves.
(Reprinted from Rendina, E.A., Ciccone, A.M., 2007. The intercostal space.
Thorac. Surg. Clin. 17 [4], e491–e501; with permission.)
Intercostal
nerve
External
intercostal
muscle
Internal
intercostal
muscle
(dissected)
Innermost
intercostal
muscle
Lateral
cutaneous
branch of
intercostal
nerves and
arteries
Anterior intercostal
branches of the
internal thoracic
(mammary) artery
External intercostal
membrane over the
internal intercostal muscles
1
2
3
4
5
6
7
8
9
10
2. There are 12 paired ribs that make up the bony framework of
the chest wall.
●
The first 7 ribs articulate posteriorly with the thoracic
vertebrae and anteriorly with the sternum via a true
sternocostal joint.
●
The last 5 ribs are often called “false ribs” because they
articulate anteriorly with the 7th rib costal cartilage (ribs 8

Trunk Reconstruction and Pressure Sores
98
Table 11.1  Extrathoracic Chest Wall Muscles
MUSCLE
ORIGIN
INSERTION
ARTERY
NERVE
ACTION
USE AND
CONSEQUENCE
Trapezius
Midline from the
external occipital
protuberance,
nuchal ligament,
medial part
superior nuchal
line, spinous
processes
vertebrae C7-T12
At the shoulders,
into the lateral
third of the
clavicle, the
acromion process,
into the spine of
the scapula
Transverse
cervical artery
Cranial nerve XI;
cervical nerves III
and IV receive
information about
pain
Retraction of
scapula
Used for upper chest
and neck defects
Latissimus
dorsi
Spinous processes
of thoracic T6-T12,
thoracolumbar
fascia, iliac crest,
inferior 3 or 4 ribs
Floor of
intertubercular
groove of the
humerus
Subscapular
artery, dorsal
scapular artery
Thoracodorsal
nerve
Pulls the forelimb
dorsally and
caudally
Lateral and anterior
chest wall defect;
excellent
musculocutaneous
collaterals allow
significant skin to
be taken
Pectoralis
major
Anterior surface
of medial half
of clavicle
sternocostal head,
anterior surface of
the sternum,
superior 6 costal
cartilages
Intertubercular
groove of the
humerus
Pectoral branch
thoracoacromial
trunk and internal
mammary, lateral
intercostal
arteries, lateral
thoracic
perforators
Lateral and
medial pectoral
nerve clavicular
head: C5/6;
sternocostal
head: C7/8 T1
Clavicular head;
flexes the humerus
sternocostal head;
extends the
humerus; as a
whole, adducts and
medially rotates
the humerus;
draws scapula
anterioinferiorly
Anterior and midline
(sternal defects); used
as a pedicle graft
based on the primary
blood supply or as a
turnover flap on
secondary supply,
possible displacement
of the breast and
abduction medial
rotation loss of arm
Serratus
anterior
Fleshy slips from
the outer surface
of upper 8 or 9
ribs
Costal aspect of
medial margin of
the scapula
Lateral thoracic
artery (upper
part),
thoracodorsal
artery (lower part)
Long thoracic
nerve from roots
of brachial plexus
C5-C7
Protracts and
stabilizes scapula,
assists in upward
rotation
Small muscle best
suited as an
intrathoracic flap
Rectus
abdominis
Pubis
Costal cartilages of
ribs 5-7, xiphoid
process of
sternum
Superior
epigastric artery
supply and deep
inferior epigastric
artery
Segmentally by
thoracoabdominal
nerves T7-T12
Flexion of trunk/
lumbar vertebrae
postural muscle;
assists with
breathing, helps to
create intra-
abdominal pressure
Lower anterior chest
wall; some muscle
atrophy occurs owing to
denervation; if based
on superior epigastric,
adequate blood flow by
way of the IMA required
External
oblique
Fleshy digitations
from lower 8
costae; broad,
thin, and irregularly
quadrilateral, its
muscular portion
occupying the side
Lower iliac crest,
inguinal ligament,
upper aponeurosis
anterior abdominal
wall, decussates at
the linea alba with
contralateral fibers
Lower thoracic
intercostal
vessels
Intercostal nerves
T5-T11, subcostal
nerve T12
Rotates torso
Upper abdomen and
lower thoracic defects
as far as the
inframammary fold
Reprinted from Naidu, B.V., Rajesh, P.B., 2010. Relevant surgical anatomy of the chest wall. Thorac. Surg. Clin. 20, 453–463.
IMA, Internal mammary artery.
●
In general, for type-2 and -3 sternal wound infections,
staged reconstruction is required with serial washouts,
debridement, and removal of hardware required to obtain
a clean wound before flap reconstruction.
●
Vacuum-assisted closure (VAC) therapy is often used
between serial debridement for assistance with wound
control.
6. Common flaps for reconstruction of sternal wounds
include
●
Pectoralis major
■
Vascular supply: Thoracoacromial artery (major),
IMA perforators (minor, segmental)
■
Can be used as an advancement flap or turnover flap
based off of the IMA perforators (requires intact IMA
system)
■
Limited coverage of inferior sternal wounds
■
Muscle can be disinserted to allow for additional
reach.
●
Rectus abdominis
■
Vascular supply: Superior and inferior epigastric a.
■
Useful for coverage of inferior sternal wounds
■
With ipsilateral IMA harvest sacrificing the superior
epigastric artery, the flap can survive off of the 8th
intercostal pedicle.

Abdominal Wall Anatomy
99
11
Abdominal Wall Anatomy
1. The abdominal wall is a hexagonal-shaped structure that
functions to
●
Protect critical intra-abdominal structures
●
Stabilize the pelvis during walking, running, and jumping
●
Flex the vertebral column
●
Increase intra-abdominal pressure (e.g., to assist with
expiration and defecation)
2. Vascular supply: Deep inferior epigastric a., superior
epigastric a., superficial inferior epigastric a., intercostal and
lumbar a.
3. Innervation: Nerves travel with the intercostal and lumbar
arteries in the plane between the internal oblique (IO) and
transversalis muscles.
●
Sensory: Anterior branches of the T7 to L1 intercostal and
subcostal nerves
●
Motor: T7 to L2 intercostal nerves, iliohypogastric n.,
ilioinguinal n.
4. Abdominal wall musculature
●
Rectus abdominis
■
Origin: Pubic symphysis and pubic crest
■
Insertion: Anterior surfaces of 5th to 7th costal
cartilages and xiphoid
■
Principle flexor of the abdomen, stabilizes pelvis,
protects abdominal organs
●
External oblique
■
Vascular supply: Segmental intercostal a., deep
circumflex iliac a., iliolumbar a.
■
Origin: Lower 8 ribs
●
Latissimus dorsi
■
Vascular supply: Thoracodorsal a. (major), lumbar
perforators (minor, segmental)
■
Useful for lateral chest wall defects
■
May require skin grafts
●
Omentum
■
Vascular supply: Gastroepiploic artery (major), short
gastrics (minor)
■
Useful for large sternal wounds
■
Requires laparotomy and tunneling of flap through
the diaphragm or extrathoracic
■
Requires skin graft (see Figure 11.2)
Table 11.2  Classification of Infected
Sternotomy Wounds
TYPE I
TYPE II
TYPE III
Occurs within first
few days
Serosanguineous
drainage
Cellulitis absent
Mediastinum soft
and pliable
Osteomyelitis and
costochondritis
absent
Cultures usually
negative
Occurs within first
few weeks
Purulent drainage
Cellulitis present
Mediastinal
suppuration
Osteomyelitis
frequent,
costochondritis
rare
Cultures positive
Occurs months to
years later
Chronic draining
sinus tract
Cellulitis localized
Mediastinitis rare
Osteomyelitis,
costochondritis, or
retained foreign
body always
present
Cultures positive
Reprinted from Pairolero, P.S., Arnold, P.G., 1985. Chest wall tumors.
Experience with 100 consecutive patients. J. Thorac. Cardiovasc.
Surg. 90, 367–372.
Figure 11.2.  Omentum anatomy. (Reprinted from Neligan, P.C., Song, D.H. [Eds.], 2013. Plastic Surgery, 3rd ed. Elsevier, 239–255.)
Original
incision
Incision
Omentum
Left gastroepiploic vessels divided
Omentum
B
C
A

Trunk Reconstruction and Pressure Sores
100
■
Insertion: Pubic crest; forms the inguinal ligament
■
Contributes to the anterior rectus sheath through
aponeurosis; most superficial of the lateral abdominal
wall muscles
●
IO
■
Vascular supply: Intercostal a., circumflex iliac a.,
iliolumbar a.
■
Origin: Thoracolumbar fascia, iliac crest, inguinal
ligament
■
Insertion: Inferior and posterior borders of ribs T10 to
T12; pubic crest via the conjoint tendon
■
Deep to the external oblique; above arcuate line, the
IO fascia splits to supply the anterior and posterior
rectus sheath.
●
Transversus abdominis
■
Vascular supply: Intercostal and subcostal a.
■
Origin: Iliac crest, inguinal ligament, inner surface of
T6 to T12 costal cartilages
■
Insertion: Posterior rectus sheath (above arcuate line);
pubic crest via the conjoint tendon
5. The rectus sheath is located in the midline of the abdominal
wall and is formed via the aponeuroses of the abdominal
musculature. The components of the anterior and posterior
rectus sheath change according to position with respect to
Figure 11.3.  Anatomy of the anterior abdominal wall. (Reprinted from Rosen, M. [Ed.], 2012. Atlas of Abdominal Wall Reconstruction. Saunders, 2–20.)
• External oblique fascia
Internal oblique muscle
External oblique muscle
• Internal oblique fascia
Transversus
abdominis muscle
Linea alba
Serratus anterior
muscles
Pectoralis major
muscle
Umbilicus
Arcuate line
Intercrural fibers
Femoral vessels
Linea semilunaris
Tendinous inscriptions
External oblique
muscle and
aponeurosis
Rectus
abdominis
muscles
Anterior superior iliac
spine (ASIS)
Symphysis pubis
Iliac crest
Parietal
peritoneum
Extraperitoneal
(subserosa) fascia
Posterior rectus sheath
(above arcuate line)
Anterior rectus sheath
(above arcuate line)
Transversalis fascia
• Transversalis fascia
• Internal oblique fascia
• Camper fascia
• Scarpa fascia
Superficial fascia
Fascia lata
Superficial epigastric and
circumflex iliac arteries
Xiphoid process
Midaxillary line
Costal margin
Inguinal ligament
Pubic tubercle
Pyramidalis muscle
5
6
7
8
10
9
the arcuate line (located midway between the umbilicus and
pubic symphysis).
●
Above the arcuate line, the anterior rectus sheath is
formed by external oblique fascia and part of the IO
fascia, whereas the posterior rectus sheath is formed by
the IO fascia and transversalis fascia.
●
Below the arcuate line, the anterior rectus sheath is
formed by the external and IO fascia and transversus
abdominis fascia, whereas the posterior rectus sheath is
formed solely by the transversalis fascia.
6. The linea semilunaris or semilunar line marks the junction
between the medial border of the external oblique muscle and
lateral border of the rectus muscle where the anterior rectus
fascia merges with the external oblique aponeurosis (see
Figures 11.3-11.5).
Abdominal Wall Reconstruction
1. Abdominal wall defects commonly result from ventral hernia
formation, oncologic tumor resection, and abdominal
catastrophes.
2. Goals of abdominal wall reconstruction
●
Soft-tissue coverage
●
Reestablish abdominal domain

Abdominal Wall Reconstruction
101
11
Figure 11.4.  Anatomy of the lateral trunk. (Reprinted from Rosen, M. [Ed.], 2012. Atlas of Abdominal Wall Reconstruction. Saunders, 2–20.)
External oblique
muscle
Linea alba
Serratus anterior
muscles
Latissimus dorsi muscle
Pectoralis major
muscle
Umbilicus
Arcuate line
Linea semilunaris
Tendinous inscriptions
External oblique aponeurosis
Rectus abdominis
muscles
Anterior superior iliac
spine (ASIS)
Iliac crest
Xiphoid process
Midaxillary line
Costal margin
Inguinal ligament
Pubic tubercle
5
6
7
8
10
11
12
9
●
Prevent hernia recurrence
●
Protect abdominal organs
3. To simplify the approach to abdominal wall reconstruction,
the fascia and soft-tissue envelope should be considered as
two distinct problems, each approached separately.
●
Common approach to fascia defects
■
Components separation
■
Mesh placement
 Synthetic (e.g., polypropylene)
 Biologic (e.g., acellular dermal matrix)
■
Autologous fascia/flaps
 Tensor fascia lata flap
 Anterolateral thigh flap
●
Common approaches to skin/soft-tissue deficits
■
Regional flaps (e.g., tensor fascia lata [TFL],
anterolateral thigh [ALT], rectus femoris)
 Difficult for epigastric coverage
■
Free flaps (e.g., TFL, ALT, latissimus)
 May require vein grafting
■
Tissue expansion
 Useful when a significant skin deficit exists, and
the abdominal defect can be approached in staged
fashion.
4. Staged reconstruction: Often performed for management of
the open abdomen or after abdominal catastrophe
●
Stage 1: Temporary fascia closure (e.g., Vicryl mesh) and
VAC therapy
●
Stage 2: Skin grafting of the granulating abdominal wound
■
Generally performed after 2 to 3 weeks of VAC
therapy, when the granulation scar is strong enough
to prevent evisceration
●
Stage 3: Formal hernia repair and abdominal wall
reconstruction after the wound has settled
■
Generally performed 6 to 12 months after skin graft
closure
5. Components separation (see Figures 11.6 and 11.7)
●
Mobilization of the rectus abdominis muscles bilaterally
by release of the external oblique aponeurosis from the
anterior rectus fascia at the linea semilunaris allows for
advancement of the rectus muscle component toward the
midline.
■
The external oblique is bluntly dissected off of
the underlying IO muscle to allow for greater
advancement.
■
The posterior rectus sheath can also be incised
internally (preferably at a site distant from the
location of the anterior release) to allow for an extra
2 to 3 cm of advancement.
■
The IO should not be dissected off of the transversus
abdominis muscle to avoid injury to neurovascular
bundles.
●
Components separation can allow for primary muscle
reapproximation of defects as large as 20 cm at the level
of the umbilicus.
●
Fascial repair should be supported by mesh to reduce
recurrence in all cases.

Trunk Reconstruction and Pressure Sores
102
Figure 11.5.  Anatomy of the anterior and posterior rectus sheath. DIEA, Deep inferior epigastric artery; DIEV, deep inferior epigastric vein.
(EO, External oblique muscle; IO, internal oblique muscle; TA, transversus abdominis muscle; TF, transversalis fascia; RA, rectus abdominis
muscle; DIEA, deep inferior epigastric artery; DIEV, deep inferior epigastric vein). (Reprinted from Rosen, M. [Ed.], 2012. Atlas of Abdominal Wall
Reconstruction. Saunders, 2–20.)
Level
above
costal
margin
Costal cartilage
5, 6, 7
EO = External oblique
RA = Rectus abdominis
IO = Internal oblique
TA = Transversus abdominis
TF = Transversalis fascia
Level
above
arcuate
line
Lateral and medial branch of
type-ll deep epigastric vessels
(DIEA and DIEV)
Inferior epigastric
vessels
Superior epigastric
vessels
Level
below
arcuate
line
Level
above
pubic
symphysis
Pubic
symphysis
Pyramidalis
muscle
Costal margin
Xiphoid
process
EO
EO
IO
IO
TA
TA
TF
TF
EO
IO
TA
TF
EO
RA
RA
RA
RA
Linea alba
(midline)
Linea alba
(midline)
Variations of anterior
and posterior
rectus sheath at
different levels
(right side)
Right
rectus
muscle
External
oblique
muscle
Arcuate
line
(behind
rectus
muscle)
Common branching patterns:
- Type-l DIEA continues as a single vessel (29%).
- Type-ll DIEA divides into two vessels (57%).
- Type-lll DIEA is a trifurcation (14%).

Vaginal Reconstruction
103
11
Figure 11.7.  Cross-sectional illustration showing external oblique
muscle release. (Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core
Procedures in Plastic Surgery. Elsevier, 211–221.)
Rectus abdominis
Bovie to identify
direction of twitch
Skin
Fat
External oblique
Internal oblique
Transversus
abdominis
●
Underlay with synthetic mesh has been reported to have
the lowest recurrence rates; however, synthetic mesh is
generally not recommended in contaminated fields. In
this case, a biologic mesh (e.g., acellular dermal matrix)
should be used because of its inherent ability to
incorporate and revascularize.
Reconstruction of the Perineum
1. Defects of the pelvis and perineum can pose challenges to the
reconstructive surgeon because of the close proximity to
genitalia.
2. Defects of the pelvis and perineum often result from
congenital defects, tumor extirpation, trauma, infection, or
pressure.
3. Fortunately, many expendable regional flaps are available for
use in perineal reconstruction (see Figure 11.8).
Vaginal Reconstruction
1. Acquired vaginal defects most commonly arise from resection
of tumors, including primary vaginal tumors, colorectal
tumors, and bladder carcinoma.
2. Cordeiro established a useful classification of acquired vaginal
defects along with an algorithm for reconstruction (see
Figures 11.9-11.11 and Table 11.3).
3. Singapore flaps
●
Vascular supply: Branches of the internal pudendal a. via
superficial perineal vessels and posterior labial a.
●
Good for anterior and lateral wall defects; bilateral flaps
can be used for total reconstruction
●
Can be sensate by sparing of the superficial perineal n.
●
Advantages: Ease of harvest, thin fasciocutaneous flaps
●
Disadvantages: Relatively small, may be in the field of
prior radiation
4. Rectus abdominis myocutaneous (RAM) flaps (vertical:
VRAM; oblique: ORAM)
●
Vascular supply: Deep inferior epigastric a.
●
Good for posterior and upper 2/3rds circumferential defects
5. Gracilis myocutaneous flaps
●
Vascular supply: Medial circumflex femoral a. branch off
of the profunda femoris a.
●
Bilateral flaps are good for total vaginal reconstruction.
●
Disadvantages: Can be bulky, vertical skin paddle can be
unreliable
6. Other flap options
●
Posterior thigh flaps
■
Vascular supply: Descending branch of the inferior
gluteal a.
■
Fasciocutaneous flap that can be used for anterior and
posterior defects
■
Can be sensate by sparing of the posterior femoral
cutaneous n.
●
Gluteal fold flap
■
Sensate flap based off of branches from the superficial
perineal vascular network
■
Useful for vulvar or perianal wounds
■
The flap is centered on the infragluteal crease
●
ALT flap
■
Useful for vaginal, vulvar, scrotal, or perineal defects
■
To increase the pedicle length and subsequent reach,
the flap can be tunneled underneath the rectus
femoris and sartorius muscles.
Figure 11.6.  Maximal unilateral rectus complex mobility in the
upper, middle, and lower abdominal levels, by means of component
separation of the external and IO muscles to the posterior axillary
line. The additional 2 cm of advancement is gained if the rectus
abdominis muscle is separated off of the posterior rectus fascia.
(Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in
Plastic Surgery. Elsevier, 211–221.)
4 cm + 2 cm
8 cm + 2 cm
3 cm + 2 cm

Trunk Reconstruction and Pressure Sores
104
Figure 11.9.  Vaginal vault. A, Anterior; P, posterior. (Reprinted from
Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 326–335.)
A
P
Genital Reconstruction
1. Penile reconstruction
●
In cases of sharp amputation, replantation should be
considered.
■
Care should be made to repair the dorsal nerves,
veins, and deep dorsal artery.
●
Free radial forearm flap
■
Incorporates an intraflap neourethra reconstruction
using the forearm skin paddle
■
Requires implantation of a penile prosthesis
●
Osteocutaneous free fibula flap
■
Presence of vascularized bone obviates the need for a
penile prosthesis.
■
A neourethra is formed via full-thickness skin
grafting.
2. Gender reassignment surgery
●
Preoperative considerations
■
Psychiatric evaluation to establish a true gender
identity disorder
Figure 11.8.  The pivot points of the vascular leash of all of the various musculocutaneous, fasciocutaneous, and perforator flaps in the
region are all located within a circle, with a radius of 10 cm centered over the perineum. A, V-Y flap, from medial thigh or inferior gluteal
area. B, Pudendal thigh flap. C, Rectus abdominis myocutaneous or DIEP (deep inferior epigastric artery) flap. D, SIEP (superficial inferior
epigastric perforator) flap (or extended SCIA [superficial circumflex iliac artery] flap). E, Rectus abdominis musculoperitoneal (RAMP) flap.
F, Gracilis myocutaneous flap. G, ALT (anterior lateral thigh) flap. H, Gluteal thigh flap. I, Gluteal fold flap. DCIA, Deep circumflex iliac artery;
DEPA, deep external pudendal artery; DIEA, deep inferior epigastric artery; LCFA, lateral femoral circumflex artery; MCFA, medial femoral
circumflex artery; OA, anterior branch of obturator artery; PLA, posterior labial artery (branch of pudendal artery); SCIA, superficial circumflex
iliac artery; SIEA, superficial inferior epigastric artery. (Reprinted from Guyuron, B., Eriksson, E., Persing, J.A., et al. [Eds.], 2009. Plastic Surgery: Indications
and Practice, 1st ed. Elsevier, 213–227.)
DIEA
PLA
MCFA
LCFA
OA
SCIA
DCIA
SIEA
DEPA
A
I
H
B
F
D
C
E
G

Back Reconstruction
105
11
■
Breast augmentation
■
Facial feminization procedures
●
Female-to-male surgical options
■
Penile reconstruction and scrotal reconstruction
■
Mastectomy
Back Reconstruction
1. Defects of the posterior trunk can occur in the setting of
congenital defects, following tumor extirpation, and as
consequence of spinal surgery and instrumentation.
2. A number of regional muscles can assist with reconstruction
of superior back wounds (e.g., trapezius, latissimus,
paraspinous/erector spinae, external oblique).
3. Wounds of the lumbosacral spine are more challenging and
may require use of gluteal-based flaps or large random-
pattern rotation flaps.
4. Midline defects associated with spinal surgery and spinal
instrumentation can often be closed using bilateral
paraspinous muscle flaps because these muscles are
expendable after the fusion.
5. General approach to back wounds
●
Debridement of nonviable tissue and local wound control
●
Determination of depth of defect, presence of
instrumentation, integrity of deep fascia, and exposure of
critical structures (e.g., hardware, spine, dura)
●
Reconstructive plan based on above factors (see
Figures 11.12 and 11.13)
■
Superficial wounds without instrumentation can
generally be closed with local wound care and/or VAC
therapy.
■
Deep wounds with exposed hardware or critical
structures require flap closure.
 Erector spinae muscle flap
 Latissimus flap (good for nonfused wounds of the
upper back)
 Trapezius flap
 Superior gluteal artery flap (good for deep
wounds of the lumbosacral region)
Figure 11.10.  A and B, Classification system of acquired vaginal
defects. A, Type I: Partial defect; B, type II: Circumferential defect.
A, Anterior; P, posterior. (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic
Surgery, 3rd ed. Elsevier, 326–335.)
TYPE I: PARTIAL DEFECT
A
P
A
P
A
P
A
P
TYPE II: CIRCUMFERENTIAL DEFECT
Upper two-thirds
Total
Anterior wall
Posterior wall
Lateral wall
B
A
A
P
Figure 11.11.  Algorithm for reconstruction of the vagina based on
defect type. (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed.
Elsevier, 326–335.)
Type I
Partial
Type IA
Anterior or
lateral wall
Vaginal defect
Singapore
Type IB
Posterior wall
Rectus
Type II
Circumferential
Type IIA
Upper 2/3
Rolled rectus
or colon
Type IIB
Total
Bilateral
gracilis
Table 11.3  Previously Described flap Options for
Vaginal Reconstruction
DEFECT TYPE
FLAP OPTION
IA
Singapore flap (also known as pudendal
fasciocutaneous flap)
IB
Pedicled rectus myocutaneous flap
Pedicled rectus musculoperitoneal flap
Muscle-sparing rectus myocutaneous flap
IIA/B
Vertical rectus abdominis myocutaneous
Gracilis
Singapore flap
Pedicled jejunum
Sigmoid colon
Reprinted from Neligan, P.C. (Ed.), 2013. Plastic Surgery, 3rd ed.
Elsevier, 326–335.
■
Confirmation of patient successfully living as the
opposite gender for prolonged period of time
■
Hormone therapy
●
Surgery is generally the final phase of transition.
●
Male-to-female surgical options
■
Penectomy and orchiectomy with vaginoplasty and
labioclitoroplasty

Trunk Reconstruction and Pressure Sores
106
6. Myelomeningocele
●
Most common neural tube defect worldwide
●
Often associated with motor and sensory defects
●
Characterized by herniation of meninges and cord
elements outside of the spinal column
●
Early closure is critical for survival and should be
performed within the first 24 to 48 hours of life.
 External oblique flap
 Omentum
 Tissue expansion
 Free flaps (often require vein loops because of
limited recipient vessels)
Figure 11.13.  The muscles are approximated in the midline. The
erector spinae muscles unfurl, changing shape from circular to
elliptical. (Reprinted from Dumanian, G.A., Neligan, P.C. [Eds.], 2013. Plastic
Surgery, 3rd ed. Elsevier, 256–278.)
Extend
flaps
Figure 11.12.  Cross section of lumbar spine area. Skin flaps are
elevated to expose the thoracolumbar fascia and reach the region
of the lateral pedicle entering the erector spinae muscles. The
thoracolumbar fascia is incised to allow a medial movement of the
muscles. (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed.
Elsevier, 256–278.)
Necrotic tissue
Fascia
Incise fascia
Lateral perforator
Medial perforator
Cutaneous
perforator
Exposed instrumentation
Longissimus
Iliocostalis
Spinalis
●
Requires neurosurgical assistance for dural repair
●
Many soft-tissue reconstructive options have been
described and generally involve fasciocutaneous or
myocutaneous rotation or advancement flaps.
■
One of the most common techniques is bilateral V-Y
advancement flaps from the flanks (see Figures 11.14
and 11.15).
Pressure Sores
1. Pressure sores result from prolonged pressure over a bony
prominence leading to irreversible tissue ischemia.
●
Muscle is most sensitive to pressure, followed by fat, and
finally skin.
●
Other contributing factors to development of these
wounds include friction, shear, moisture, and
malnutrition.
2. Pressure sores commonly occur in elderly, debilitated
patients, patients with spinal cord injury, and patients with
prolonged hospitalizations.
3. Pressure sore stages
●
Stage I: Intact, erythematous, nonblanchable skin
●
Stage II: Epidermolysis, blistering, dermal injury
●
Stage III: Destruction into subcutaneous tissue and
muscle
●
Stage IV: Destruction to underlying bone, joints, and/or
muscle fascia (see Figure 11.16)
4. Preoperative considerations
●
Wound status
■
Debridement of all necrotic debris, including the
wound bursa, is a critical first step in pressure sore
reconstruction.
■
Establish a clean wound before flap reconstruction.
●
Nutrition
■
Inadequate nutrition is a marker of poor capacity to
heal wounds and incisions.
■
Some advocate for albumin >3, prealbumin >15 to 30,
and transferrin >200 mg/dL before reconstruction.
●
Age, comorbidities, surgical history (e.g., diabetes,
cardiovascular disease, prior surgeries)
●
Smoking status
●
Incontinence
■
Consider bowel diversion through colostomy before
reconstruction for challenging perineal wounds.
●
Osteomyelitis
■
Presence of active osteomyelitis is a relative
contraindication to flap reconstruction.
■
Bone biopsy is the gold standard for the diagnosis of
osteomyelitis.
●
Social support
■
Lack of social support at home may affect patient’s
ability to care for wounds and/or incisions.
●
Compliance
■
Poor compliance is a contraindication to
reconstruction because compliance with postoperative

Pressure Sores
107
11
Fasciocutaneous crescentic V-Y advancement
Modified fasciocutaneous V-Y
Fasciocutaneous V-Y advancement
Fasciocutaneous transposition, one superior, one inferior
B
D
C
A
Figure 11.14.  Fasciocutaneous flaps in meningomyelocele repair. A, Bilateral crescentic V-Y advancement. B, Classic bilateral V-Y
advancement. C, Modified bipedicle V-Y advancement. D, Superior and inferior rotational transposition. E, Unequal Z plasty.
F, Z advancement. G, Bilobed transposition. H, Rhomboid transposition. (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier,
856–876.)
B’
Y
A
A
B
C
X
b
C’
45˚
60˚
Fasciocutaneous unequal Z plasty
Fasciocutaneous bilobed flap
Fasciocutaneous Z advancement flap
Fasciocutaneous rhomboid
H
E
F
G

Trunk Reconstruction and Pressure Sores
108
Distally based lat island musculocutaneous
Paraspinal muscle flap
Bilateral lat V-Y advancement
Muscle-only reverse lat transposition
B
D
C
A
Figure 11.15.  Muscle and musculocutaneous flaps in meningomyelocele repair. A, Distally based latissimus musculocutaneous
advancement. B, Bilateral latissimus V-Y musculocutaneous advancement. C, Paraspinous muscle advancement or turnover. D, Distally
based latissimus turnover muscle flap with split-thickness skin graft coverage over flap. E, Superior gluteal artery perforator (SGAP)
interposition. F, Bilateral latissimus musculocutaneous advancement. G, Bilateral latissimus musculocutaneous advancement with
lateral relaxing incisions covered with split-thickness skin grafts (STSG). H, Bilateral latissimus and gluteus maximus interconnected
musculocutaneous advancement. lat, Latissimus. (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 856–876.)
SGAP
Musculocutaneous lat with superior gluteal fascia in relaxing
incisions, STSG to the sides
Musculocutaneous lat without relaxing incisions
Musculocutaneous lat and gluteus advancement
G
E
F
H

Pressure Sores
109
11
A
B
C
D
Figure 11.16.  The National Pressure Ulcer Advisory Panel staging system. A,E, Stage I: Intact skin with nonblanchable redness of a
localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the
surrounding area. B,F, Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without
slough. May also present as an intact or open/ruptured serum-filled blister. This should not be used to describe skin tears, tape burns,
perineal dermatitis, maceration, or excoriation. C,G, Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon,
or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
D,H, Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Exposed bone is sufficient but not necessary to define a
stage-IV pressure sore. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling. May
extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis possible. Bone/tendon is
visible or directly palpable. I, Suspected deep-tissue injury: Purple or maroon localized area of discolored intact skin or blood-filled blister
due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy,
boggy, warmer, or cooler as compared to adjacent tissue. The wound may evolve and become covered by thin eschar. Evolution may be
rapid, exposing additional layers of tissue even with optimal treatment. J, Unstageable: Full-thickness tissue loss in which the base of the
ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until the base of the
wound is exposed, the true depth, and therefore stage, cannot be determined. (Reprinted from Kwon, R., Janis, J.E., 2013. Pressure sores. In: Neligan,
P.C. [Ed.], Plastic Surgery, 3rd ed. Elsevier, 352.)

Trunk Reconstruction and Pressure Sores
110
G
H
I
J
E
F
Figure 11.16, cont’d

Pressure Sores
111
11
Suggested Readings
Althubaiti, G., Butler, C.E., 2014. Abdominal wall and chest wall
reconstruction. Plast. Reconstr. Surg. 133 (5), 688e–701e.
Bauer, J.D., Mancoll, J.S., Phillips, L.G., 2007. Chapter 74: Pressure sores. In:
Thorne, C.H. (Ed.), Grabb & Smith, 6th ed. Lippincott Williams & Wilkins,
pp. 722–729.
Dumanian, G.A., 2013. Chapter 11: Reconstruction of the soft tissues
of the back. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier,
pp. 256–278.
Erdmann, D., Meade, R.A., Lins, R.E., et al., 2013. Chapter 12: Back
reconstruction. In: Neligan, P.C., Buck, D.W. (Eds.), Core Procedures in
Plastic Surgery. Elsevier, pp. 196–210.
Friedman, J.D., 2007. Chapter 72: Reconstruction of the perineum. In:
Thorne, C.H. (Ed.), Grabb & Smith, 6th ed. Lippincott Williams & Wilkins,
pp. 708–716.
Gottlieb, L.J., Aycock, J.K., 2009. Chapter 20: Reconstruction of the genitalia.
In: Guyuron, B., Eriksson, E., Persing, J.A., et al. (Eds.), Plastic Surgery:
Indications and Practice, 1st ed. Elsevier, pp. 213–227.
Gottlieb, L.J., Reid, R.R., Lee, J.C., 2013. Chapter 41: Pediatric chest and
trunk defects. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier,
pp. 856–876.
Kwon, R., Janis, J.E., 2013. Chapter 16: Pressure sores. In: Neligan, P.C. (Ed.),
Plastic Surgery, 3rd ed. Elsevier, p. 352.
Manahan, M., Silverman, R.P., 2009. Chapter 21: Chest and abdominal wall
reconstruction. In: Guyuron, B., Eriksson, E., Persing, J.A., et al. (Eds.), Plastic
Surgery: Indications and Practice, 1st ed. Elsevier, pp. 229–238.
Medalie, D.A., 2012. Chapter 13: Tissue and fascial expansion of the
abdominal wall. In: Rosen, M.J. (Ed.), Atlas of Abdominal Wall
Reconstruction. Saunders, pp. 224–243.
Naidu, B.V., Rajesh, P.B., 2010. Relevant surgical anatomy of the chest wall.
Thorac. Surg. Clin. 20, 453–463.
Netscher, D.T., Baumholtz, M.A., 2009. Chest reconstruction: I. Anterior and
anterolateral chest wall and wounds affecting respiratory function. Plast.
Reconstr. Surg. 124 (5), 240e–252e.
Netscher, D.T., Baumholtz, M.A., Bullocks, J., 2009. Chest reconstruction II:
Regional reconstruction of chest wall wounds that do not affect respiratory
function (axilla, posterolateral chest, and posterior trunk). Plast. Reconstr.
Surg. 124 (6), 427e–435e.
Rosen, M., 2012. Chapter 1: Clinical anatomy. In: Rosen, M. (Ed.), Atlas of
Abdominal Wall Reconstruction. Saunders, pp. 2–20.
Selvaggi, G., Bellringer, J., 2011. Gender reassignment surgery: an overview.
Nat. Rev. Urol. 8 (5), 274–282.
Shell, D.H., Vasconez, L.O., de la Torre, J., et al., 2010. Chapter 91:
Abdominal wall reconstruction. In: Weinzweig, J. (Ed.), Plastic Surgery
Secrets Plus, 2nd ed. Mosby, pp. 587–593.
Singh, N.K., Khalifeh, M.R., 2013. Chapter 13: Abdominal wall reconstruction.
In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 211–221.
Snell, L., Cordeiro, P.G., Pusic, A.L., 2013. Chapter 14: Reconstruction of
acquired vaginal defects. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed.
Elsevier, pp. 326–335.
Song, D.H., Roughton, M.C., 2013. Chapter 10: Reconstruction of the chest.
In: Neligan, P.C., Song, D.H. (Eds.), Plastic Surgery, 3rd ed. Elsevier, pp.
239–255.
Vargo, D., 2012. Chapter 16: Managing the open abdomen. In: Rosen, M.J.
(Ed.), Atlas of Abdominal Wall Reconstruction. Saunders, pp. 290–301.
Weinzweig, J., 2010. Chapter 90: Chest wall reconstruction. In: Weinzweig, J.
(Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby, pp. 587–593.
Zochowski, C.G., Soltanian, H., 2012. Chapter 15: Rotational and free flap
closure of the abdominal wall. In: Rosen, M.J. (Ed.), Atlas of Abdominal Wall
Reconstruction. Elsevier, Philadelphia, pp. 259–289.
restrictions and pressure–off-loading regimen is
critical to the likelihood of successful reconstruction.
●
Spasms
■
Treat spasms postoperatively to prevent undue
tension and shear on incisions and flaps (e.g., with
benzodiazepines, Baclofen).
●
Ambulatory status
■
Nonambulatory patients may be reconstructed with
sacrifice of muscle and advancement of myocutaneous
flaps.
5. Common flaps by location
●
Sacral pressure sores
■
Gluteal rotation flaps
■
Gluteal V-Y advancement flaps
●
Ischial pressure sores
■
Posterior thigh fasciocutaneous flap
■
Posterior thigh V-Y myocutaneous advancement flap
 Includes the hamstring muscles
 Hamstring muscle sacrifice is reserved for
nonambulatory patients.
■
Tensor fascia lata flap
●
Trochanteric pressure sores
■
Tensor fascia lata flap
■
Girdlestone procedure
 Removal of the femoral head with interposition of
vastus lateralis muscle
6. Postoperative considerations
●
Pressure relief: Pressure–off-loading mattresses, frequent
turning
●
Bed rest, with a limited progressive sitting protocol
(typically started after a period of 2 to 4 weeks)
●
Autonomic dysreflexia
■
Presents postoperatively with severe hypertension and
bradycardia
■
Often secondary to bladder distension
■
Can be treated with bladder catheterization
●
Recurrence
■
High reported recurrence even in ideal settings.
Patient education and careful operative planning is
important to allow for the possibility of reelevation
and readvancement of prior flaps in the setting of
recurrent wounds.

Peripheral Nerve Injuries,
Brachial Plexus, and
Compression Neuropathies
Chapter
12 
General Nerve Anatomy
1. The central nervous system (brain and spinal cord)
communicates with the rest of the body via the peripheral
nervous system (cranial nerves, spinal nerves with their roots
and rami, peripheral nerve trunks/branches, and the
autonomic system).
2. The anterior (ventral) and posterior (dorsal) nerve roots arise
from rootlets on the spinal cord and merge into the spinal
nerves (see Figure 12.1).
• The anterior primary rami of spinal nerves C5-T1 form the
brachial plexus of the upper extremity, whereas the
posterior primary rami of the spinal nerves travel to supply
the muscle and skin of the posterior neck and trunk.
3. The motor nerve cell body is located within the spinal cord,
and the sensory nerve cell body is located in the dorsal root
ganglia.
4. Peripheral nerves are surrounded by Schwann cells that create
the myelin sheath surrounding myelinated nerve axons.
5. Between each individual Schwann cell is the node of Ranvier
that allows for faster propagation of signals down an axon
through saltatory conduction.
6. Bundled axon nerve fibers are surrounded by endoneurium
and grouped with other neurons by a collagen layer called
perineurium. This group of neurons is termed a fascicle.
• Within a peripheral nerve, the fasicles are also imbedded in
loose connective tissue composed of collagen and
fibroblasts (the epineurium; see Figure 12.2).
7. The vascular supply of the nerve consists of segmental blood
vessels that branch into several vascular plexuses along the
epineurium and within the perineurium and endoneurium.
• This redundancy allows nerve mobilization over extended
lengths without disruption of blood supply.
Figure 12.1.  The anterior and posterior nerve roots, which emerge
from rootlets attached to the spinal cord. (Reprinted from Neligan, P.C.,
Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 694–718.)
Spinal cord
Dorsal root ganglion
Posterior primary
ramus
Anterior primary
ramus
Pia mater
Dura
Dura mater
Arachnoid
Spinal
nerve
Dorsal root
ganglion
Figure 12.2.  Schematic presentation of a peripheral nerve.
(Reprinted from Neligan, P.C., Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6,
3rd ed. Elsevier, 694–718.)
Epineurium
Fascicle group
Perineurium
Endoneurium
Basal lamina
Fascicle
Myelin sheath
Schwann cell
Axon

General Nerve Repair Principles
113
12
Classification of Nerve Injuries
1. Nerve injury can be classified generally into injuries that will
temporarily block nerve conduction without loss of axonal
architecture (neurapraxia) and those that will result in axonal
degeneration distal to the injury (axonotmesis or
neurotmesis).
2. Sunderland and Mackinnon modified the Seddon classification
to further describe the complexity of nerve injury.
Nerve Physiology
1. Myelinated nerve fibers have high conduction velocity
because the action potentials jump from node of Ranvier to
node of Ranvier.
• Unmyelinated nerve fibers have slower propagation of
impulses because they lack myelin and nodes of Ranvier.
2. After nerve injury, the axons and myelin sheath in the distal
segment degenerate (“Wallerian degeneration”), whereas the
Schwann cells coordinate nerve repair and regeneration by
up-regulating the production of neurotrophic factors and
their receptors (see Figure 12.3).
• Wallerian degeneration takes time after injury.
3. Regrowth of nerve occurs via multiple sprouts from the distal
part of each viable axon. Within these sprouts is a growth
cone that can sample the microenvironment and search for
guidance factors/structures to enable targeted growth.
Figure 12.3.  A, As the nerve is severed, activated macrophages
and Schwann cells will immediately start the removal of myelin
and remnants of the disintegrated axon, to allow for a conducive
environment for the regenerating axons (B). C, Within just a few
hours, numerous sprouts emerge from the distal part of each axon
and form the sprout growth cone that will guide the regeneration
process distally, until nerve regeneration is complete (D). (Reprinted
from Neligan, P.C., Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed.
Elsevier, 694–718.)
Sprouts with growth cones
Transection
Macrophages
activated
A
B
C
D
Diagnosis of Nerve Injury
1. Functional evaluation
• Motor and sensory function should be fully assessed.
2. Electrophysiology testing
• Must be interpreted with caution in first 3 to 4 weeks
because it may take 4-6 weeks for degeneration and
denervation to be detected by electrophysiologic studies.
• Electromyography (EMG) assesses the motor component
of a nerve only.
■ Measures resting electrical activity (e.g., abnormal
spontaneous activity such as fibrillations and/or positive
sharp waves), duration, amplitude, configuration, and
motor unit recruitment
■ Abnormal spontaneous activity (e.g., fibrillations) and
decreased motor unit recruitment occur with axonal
injury.
• Nerve conduction studies (NCSs) assess sensory (sensory
nerve action potentials [SNAPs]) and motor (compound
motor action potentials [CMAPs]) components.
■ Measures latency (the time from stimulus to recording),
amplitude (evoked response from stimulus), and
conduction velocity (calculated across a specific
segment)
■ Increased latency, decreased amplitude, and decreased
conduction velocity occur with nerve injury. In complete
conduction block, no distal response is obtained with
proximal stimulation.
■ Preganglionic injuries are associated with loss
of sensation but show intact SNAPs and absent
CMAPs.
General Nerve Repair Principles
1. Closed nerve injuries should be treated conservatively with
observation for signs of recovery.
• Consideration for electrophysiologic testing should be
deferred until at least 4-6 weeks after injury, and many can
wait until 3 months.
■ If at 3 months there is no sign of recovery, nerve
exploration is warranted.
■ If partial spontaneous recovery is identified within 3
months, regular reevaluation with electrophysiologic
testing can occur at 3-month intervals to observe
continued recovery.
2. Open nerve injuries should be explored immediately.
• If the nerve is found to be in continuity, treat as above as if
it were a closed injury.
• If the nerve is discontinuous, attempt immediate repair
(unless significant crush injury, wound, or gunshot
wound).
3. Nerve repair can occur either immediately or after delay.
• Direct immediate repair
■ Method of choice, especially if performed within 48 to 72
hours
■ Best outcomes

Peripheral Nerve Injuries, Brachial Plexus, and Compression Neuropathies
114
Table 12.1  Differing Treatments for Different Types of Nerve Injury
TYPE OF NERVE INJURY
NEUROGRAPHY/EMG
EXPLORATION
REVISION
REPAIR OR RECONSTRUCTION
Sharp transection
—
Immediate
Immediate
Immediate
Open wound: Nerve crush injury
4-6 weeks*
Immediate
Immediate
Immediate†
Delayed‡
Closed traction injury
4-6 weeks
Delayed
—
3-4 months§
Open wound: Gunshot wound
4-6 weeks*
Immediate
Immediate
Immediate†
Delayed‡
Reprinted from Neligan, P.C., Chang, J. (Eds.), 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 694–718.
EMG, Electromyogram.
*If the nerve is in continuity on exploration, can perform neurography/EMG in the same manner as that for closed injuries.
†If there is macroscopic nerve discontinuity on exploration, perform repair or reconstruction after repeated revision to ensure that the wound
is tidy.
‡If there is nerve continuity on exploration, treat the nerve injury as a closed injury so that repair or reconstruction is performed only when
there is no sign of nerve regeneration (Tinel’s sign), for example, for some injuries, exploration after 3-4 months.
§Repair or reconstruction is performed after 3-4 months if there are no clinical signs of nerve regeneration or reinnervation.
■ Technically easier than delayed repair
○ Less retraction of nerve ends
○ Less scarring
○ Identification of nerve ends is easier because the
nerve can often be stimulated for up to 72 hours after
transection.
• Delayed repair
■ Typically requires a nerve graft
■ Impaired functional outcomes (see Table 12.1)
4. Primary repair must occur without tension; otherwise,
consider a nerve graft.
• For nerve gaps <3 cm, nerve conduits (e.g., synthetic, vein)
can be used.
• For nerve gaps >3 cm, nerve grafts are recommended.
■ Common donor grafts: Sural n., posterior interosseous
n., lateral antebrachial cutaneous n.
■ Grafts are preferably reversed at the time of placement
to decrease the risk of nerve axon regeneration through
cut branches on the graft.
5. Nonviable tissue must be resected until healthy fasicles are
identified.
6. Alignment of the nerve ends according to their fasicular
pattern and topographical arrangement improves outcomes.
7. Nerve ends are commonly coapted with interrupted 9-0 or
10-0 nylon sutures.
• Repair can occur at the epineurial or fasicular level.
• Grouped fasicular repair is preferred for injuries to the
ulnar n. at the wrist.
8. If the proximal stump is absent, or if the nerve injury is
“high,” and end-to-side nerve repair can be performed in
which the distal stump end is coapted to the side of an
uninjured nerve.
9. Nerve transfer is a newer technique that has primarily been
used with proximal or brachial plexus injuries to provide a
source of regenerating axons in close proximity to the end
target and preserve motor end plates.
• In some cases, these transfers are performed as a
“babysitter” to maintain motor end plates while a proximal
injury is allowed to recover.
• Nerve transfers are associated with minimal to no
downgrade in donor function and provide better outcomes
(see Box 12.1 and Figure 12.4).
Reprinted from Neligan, P.C., Chang, J. (Eds.), 2013. Plastic Surgery,
vol. 6, 3rd ed. Elsevier, 719–744.
BOX 12.1  INDICATIONS FOR NERVE TRANSFER
• Proximal brachial plexus injuries where grafting is not
possible
• Proximal peripheral nerve injuries requiring long distance
for reinnervation of distal targets
• Severely scarred areas with risk of damage to critical
structures
• Segmental nerve loss
• Major upper extremity trauma
• Partial nerve injuries with functional loss
• Delayed presentation with inadequate time for
reinnervation of distal targets with grafting
• Sensory nerve deficits in critical regions
Brachial Plexus
1. Formed from the anterior primary rami of spinal nerves C5
to T1
2. Motor nerve cell bodies arise from the anterior horn of the
spinal cord, whereas the sensory nerve cell bodies are located
in the dorsal root ganglion within the intervertebral foramen,
immediately outside of the dura mater.
3. The brachial plexus is commonly divided into five anatomic
sections: Roots, trunks, divisions, cords, and branches
4. The mixed spinal nerves travel between the anterior scalene
m. and the middle scalene m. to form three trunks.
• Upper trunk: C5 and C6
• Middle trunk: C7
• Lower trunk: C8 and T1
5. Beneath the clavicle, each trunk divides into anterior and
posterior divisions.

Brachial Plexus
115
12
Figure 12.4.  Algorithm for open and closed nerve injuries. Flowchart showing timing of surgical exposure and nerve repair. (Reprinted from
Neligan, P.C., Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 694–718.)
>3 cm
<3 cm
Tidy wound
Nerve in continuity
End-to-end coaptation
Nerve graft
Tubular graft or nerve graft
Open injury
Closed injury
Sunderland class I
Recovery
Recovery
Partial recovery
No recovery
No recovery
No recovery
No recovery
Neurological examination
Neurological examination
Neurological examination
Irreversible denervation of target organs
Sunderland class I or II
Continued observation;
repeated neurophysiology
can be considered
Surgical exploration
Surgical exploration
Clinically unacceptable outcome
Sunderland class I or II
Secondary repair
Secondary repair
Surgical exploration,
end-to-end coaptation,
nerve graft
Nerve defect
Sunderland class V
Clear cut
Sunderland class V
Untidy wound
-unclear zone of injury
-wound contamination
>1 week
4-6 weeks
3 months
4 months
12 months
Clinical examination

Peripheral Nerve Injuries, Brachial Plexus, and Compression Neuropathies
116
6. Distal to the clavicle, the nerves exchange fibers to form cords.
• Lateral cord
■ Formed from the anterior divisions of the upper and
middle trunks
■ Passes anterior to the subclavian artery
■ Gives rise to the lateral cord contribution to the median
n. and the musculocutaneous n.
• Medial cords
■ Formed from the anterior division of the lower
trunk
■ Passes anterior to the subclavian artery
■ Gives rise to the medial cord contribution to the median
n. and the ulnar n.
• Posterior cord
■ Formed from the posterior divisions of all trunks
■ Passes posterior to the subclavian artery
■ Forms the axillary nerve and the radial nerve (see
Figures 12.5 and 12.6)
7. Types of brachial plexus injury
• Traction injury
■ Includes stretch, rupture, and/or avulsion (see Figure 12.7)
• Gunshot wound
■ Nerves are often in continuity, and in these patients,
spontaneous recovery is possible.
Figure 12.5.  Anatomy of the brachial plexus. Localization of brachial plexus lesions is dependent on detailed understanding of brachial
plexus anatomy. This illustration is reviewed with patients at the time of their initial evaluation. LSS, Lower subscapular nerve; MABC,
medial antebrachial cutaneous nerve; MBC, medial brachial cutaneous nerve; TD, thoracodorsal nerve; USS, upper subscapular nerve. (By
permission of Mayo Foundation for Medical Education and Research. All rights reserved. Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.],
2011. Green’s Operative Hand Surgery, 6th ed. Elsevier, 1235–1292.)
The Brachial Plexus
Nerves
Trunks
Divisions
Cords
Branches
Lateral
pectoral
Musculo-
cutaneous
Axillary
Radial
Median
Ulnar
MABC
MBC
USS
TD
LSS
Medial
pectoral
Subclavius
Suprascapular
Dorsal
scapular
Shoulder
Elbow
Wrist
Hand
Long
thoracic
T1
C8
C7
C6
C5
■ High-velocity injuries are less likely to recover
spontaneously.
• Laceration injury
■ Nerves are often in discontinuity, and thus, open
laceration injuries require operative exploration and
repair when possible.
8. Diagnosis of brachial plexus injury level
• Complete motor and sensory exam
• Presence of or progression of Tinel’s sign
• Presence or absence of Horner’s syndrome (miosis, ptosis,
anhidrosis) suggests avulsion of the C8 to T1 roots.
• Electrodiagnostic studies: NCSs and EMGs
■ NCSs: Amplitudes of SNAPs and CMAPs are most
important; absent CMAPs and absent SNAPs suggest
postganglionic lesion (absent motor and sensory),
whereas absent CMAPs and present/normal SNAPs
suggest preganglionic root avulsion (absent motor,
present sensory).
9. Treatment depends on etiology and level of injury and degree
of functional deficit.
• Treatment options can include nerve transfers, tendon
transfers, and free functioning muscle transfers.
• For most closed injuries, a period of observation can be
taken to look for spontaneous recovery before surgery.

Compression Neuropathies
117
12
Figure 12.6.  The origin of the nerves of the brachial plexus (C5-Th1, top) and their target muscles. (Reprinted from Neligan, P.C., Chang, J. [Eds.],
2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 694–718.)
Serratus anterior
Pronator
teres
Biceps
and
brachialis
Deltoid
Shoulder
rotators
Brachio-
radialis
Supinator
Palmaris longus,
flexor carpi radialis
Extensor
carpi
radialis
longus
Triceps
Abductor pollcis longus,
extensor pollicis brevis
Extensor pollicis longus
Extensor digitorum
Extensor carpi ulnaris
Flexor carpi ulnaris
Latissimus dorsi
Pectoralis major
Extensor
carpi
radialis
brevis
Extensor
indicis,
extensor
digiti
minimi
Flexor digitorum superficialis
Opponens pollicis,
abductor pollicis brevis,
flexor pollicis brevis
Adductor pollicis
Flexor pollicis longus
Flexor digitorum profundus
(index and long finger)
Flexor digitorum profundus
(ring and little finger)
Hypothenar
Interosseus
C6
C5
C7
TH1
C8
N. ulnaris
N. medianus
N. radialis
N. thoracicus longus
N. thoracodorsalis
Nn pectoralis med and lat
N. suprascapularis
N. musculocutaneous
N. axillaris
• In general, for neonates with traction injuries, if no
improvement is observed by 6 months of age, surgical
intervention is indicated.
Compression Neuropathies
1. Nerve entrapment occurs commonly, especially in the upper
extremity.
2. Double crush phenomenon: Peripheral nerve compression at
one site increases the susceptibility to compression at another
site along the same nerve (e.g., ulnar nerve compression at
the elbow and wrist).
• May require release of both sites of compression for
improvement in symptoms
• The distal site is often released first.
3. Pathologic changes within the nerve depend on the severity
and duration of compression.
• Progression of nerve entrapment
■ Endoneurial edema and thickening, followed by
increased endoneurial pressure and nerve ischemia
○ Results in paresthesias and sensory disturbances
■ Demyelination (localized progressing to diffuse with
increased compression) followed by remyelination
○ Results in muscle weakness and increased pressure
thresholds
■ Wallerian degeneration: Typically not observed until
advanced chronic nerve entrapment occurs
○ Results in anesthesia and muscle atrophy (see
Figure 12.8)

Peripheral Nerve Injuries, Brachial Plexus, and Compression Neuropathies
118
Figure 12.7.  A-D, Traction injury to the brachial plexus may cause nerve injuries of varying severity in the same patient. Such injuries
include avulsion (preganglionic injury) of nerve roots from the spinal cord (for practical purposes, cannot be repaired), stretch
(postganglionic injury) of different magnitudes (some spontaneous recovery possible), and extraforaminal rupture of the nerve or trunk (can
be repaired with surgery). (Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
1235–1292. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)
Dorsal root
ganglion
Stretch
Avulsion
Rupture
A
B
C
D
Figure 12.8.  The histopathology of chronic nerve
compression spans a spectrum of changes that
begins with breakdown of the blood-nerve barrier
and, with continued compression, progression to
axonal degeneration. The patient’s signs,
symptoms, and sensory testing will parallel the
histopathologic changes occurring in the nerve.
(Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson,
W.C., et al. [Eds.], 2011. Green’s Operative Hand Surgery,
6th ed. Elsevier, 977–1014.)
Intermittent
paresthesia
and/or aching
Blood-nerve
barrier
breakdown
Endoneurial edema
Axonal
degeneration
Numbness
and/or
atrophy
Sensory testing
Symptoms
Histopathology
Abnormal
two-point
discrimation
Diffuse fiber
demyelination
Localized fiber
demyelination
Constant
paresthesia
and/or weakness
Connective
tissue thickening
Positive
provocative
maneuvers
Abnormal
thresholds

Compression Neuropathies
119
12
5. Median nerve
• Sites of compression: Ligament of Struthers, lacertus
fibrosis (bicipital aponeurosis), two heads of the pronator
teres, transverse carpal ligament (see Figures 12.9 and 12.10)
Table 12.2  Provocative Tests for Nerve Entrapment
NERVE
ENTRAPMENT SITE
PROVOCATIVE TEST
CONSERVATIVE MANAGEMENT
Median
Carpal tunnel
Pressure proximal to the carpal tunnel, Phalen’s test,
reverse Phalen’s test (hyperextension of the wrist)
Splint the wrist in neutral position at night
Proximal forearm
Pressure over the proximal forearm in the region of
the pronator teres with the forearm in supination,
resisted elbow flexion, pronation, and finger flexion
Use stretching exercises for the pronator
teres
Ulnar
Guyon’s canal
Pressure proximal to Guyon’s canal, reverse Phalen’s
test
Splint the wrist in neutral position at night
Cubital tunnel
Elbow flexion and pressure proximal to the cubital
tunnel
Educate about the elbow pad, positioning
in elbow extension, and decreasing direct
pressure on the nerve
Radial (posterior
interosseous)
Arcade of Fröhse
Pressure over the supinator, resisted supination,
resisted long-finger, and wrist extension
Position in supination and avoid repetitive
pronation and supination activities
Radial (sensory)
Forearm
Pressure over the junction of the brachioradialis/
extensor carpi radialis tendon, forearm pronation with
wrist ulnar flexion
Avoid repetitive pronation and supination
activities
Brachial plexus
Supraclavicular
Elevation of arms above the head, pressure over the
brachial plexus in the interscalene region
Avoid provocative positions, stretch
shortened muscles, and strengthen
weakened scapular stabilizers
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier, 977–1014.
Figure 12.9.  The median nerve lies deep and the brachial artery
lies superficial to the ligament of Struthers, which forms an
accessory origin for the pronator teres. lig, Ligament. (Reprinted from
Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s
Operative Hand Surgery, 6th ed. Elsevier, 977–1014. Copyright Elizabeth
Martin.)
Brachial a.
Median n.
Lig. of Struthers
Humeral hd.,
pronator teres
Ulnar hd.,
pronator teres
Figure 12.10.  The palmar cutaneous branch (cut. br.) of the
median nerve lies radial to the median nerve and ulnar and to the
flexor carpi radialis (FCR) tendon. It may pierce either the volar
carpal or transverse (Trans.) carpal ligament or the antebrachial
fascia before it becomes subcutaneous. FCU, Flexor carpi ulnaris;
FDS, flexor digitorum superficialis; FPL, flexor pollicis longus; PL,
palmaris longus. (Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson,
W.C., et al. [Eds.], 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier,
977–1014. Copyright Elizabeth Martin.)
Deep br., ulnar n.
Trans. carpal lig.,
volar carpal lig.
Ulnar n.
Median n.
FCU
FDS
FPL
FCR
PL
Radial a.
Palmar cut. br.,
median n.
Motor br.,
median n.
Ulnar a.
4. Provocative tests: Useful in eliciting symptoms of nerve
compression and identifying potential sites of entrapment
(see Table 12.2)

Peripheral Nerve Injuries, Brachial Plexus, and Compression Neuropathies
120
• Carpal tunnel syndrome: Compression of the median nerve
at the wrist by the transverse carpal ligament
■ Symptoms: Nocturnal pain, numbness, paresthesias,
night awakenings
■ Signs: Tinel’s, weak abductor pollicis brevis, sensory
disturbance, thenar wasting, abnormal electrodiagnostic
studies, positive Phalen’s test (provocation of symptoms
with wrists flexed)
○ Can distinguish from pronator syndrome by
preservation of sensory in the palmar cutaneous
nerve distribution with carpal tunnel syndrome
■ Treatment
○ Conservative: Splinting, corticosteroid injection
○ Carpal tunnel release: Endoscopic or open
6. Ulnar nerve
• Sites of compression: Arcade of Struthers, medial
intermuscular septum, Osborne’s ligament/band, flexor
carpi ulnaris origin, anconeus epitrochlearis, Guyon’s canal
(see Figures 12.11 and 12.12)
• Cubital tunnel syndrome: Compression of the ulnar nerve
at the elbow
■ Symptoms: Pain, numbness, weak grip
■ Signs: Tinel’s at the medial elbow, weak first dorsal
interossei muscle, Froment’s sign (flexion of the thumb
interphalangeal [IP] joint with thumb/index pinch),
Wartenberg’s sign (abduction of the small finger),
provocation of symptoms with the elbow flexion/
pressure test, sensory disturbance of the ring and small
finger, intrinsic musculature wasting, abnormal
electrodiagnostic studies
■ Treatment
○ Conservative: Splinting, physical therapy
○ Surgical decompression: Can be performed alone or
with nerve transposition to subcutaneous,
intramuscular, or submuscular position
Figure 12.11.  The ulnar nerve lies on the medial head of the
triceps muscle, enters the cubital tunnel behind the medial (Med.)
epicondyle, and continues distally beneath the arcade of fascia,
where it joins the heads of the flexor carpi ulnaris (FCU). coll.,
Collateral. (Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
[Eds.], 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier, 977–1014.
Copyright Elizabeth Martin.)
Triceps
Ulnar coll.
lig.
FCU
FCU
Med.
epicondyle
Ulnar n.
Figure 12.12.  The ulnar nerve courses through Guyon’s canal
between the volar carpal ligament (lig.) and the transverse (Trans.)
carpal ligament. ADQ, Abductor digiti quinti; FCU, flexor carpi
ulnaris; FDQ, flexor digiti quinti; H, hamate; ODQ, opponens digiti
quinti; P, pisiform; superf. br., superficial branch. (Reprinted from Wolfe,
S.W., Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s Operative
Hand Surgery, 6th ed. Elsevier, 977–1014. Copyright Elizabeth Martin.)
ODQ
FDQ
ADQ
Fibrous arch
Piso-hamate lig., cut
Superf. br.,
deep br., ulnar n.
FCU
Ulnar a.
P
H
Trans.
carpal
lig.
Volar
carpal
lig., cut

Compression Neuropathies
121
12
• Ulnar tunnel syndrome: Compression of the ulnar nerve at
the wrist within Guyon’s canal; can occur secondary to a
mass (e.g., ganglion cyst) or ulnar a. aneurysm
(“hypothenar hammer syndrome”)
■ Symptoms: Paresthesias in the ring and small fingers,
ulnar-sided hand pain, decreased grip strength
■ Signs: Similar to cubital tunnel syndrome except with
possible Tinel’s at the wrist, abnormal electrodiagnostic
studies at the wrist level, and/or presence of palpable
mass, tumor, or fracture
■ Treatment
○ Release of the pisohamate ligament and volar carpal
ligament
7. Radial nerve
• Sites of compression: Fibrous bands to the radiocapitellar
joint, leash of Henry (recurrent radial vessels), proximal
edge of the extensor carpi radialis brevis (ECRB), arcade of
Fröhse (proximal edge of the supinator), distal edge of the
supinator, proximal to the radial styloid between the
brachioradialis and extensor carpi radialis longus (ECRL;
see Figure 12.13)
Figure 12.13.  Extension of the posterior Thompson approach
to the radial tunnel. ECRB, Extensor carpi radialis brevis;
ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris;
EDC, extensor digitorum communis. (Reprinted from Wolfe, S.W.,
Hotchkiss, R.N., Pederson, W.C., et al. [Eds.], 2011. Green’s Operative Hand
Surgery, 6th ed. Elsevier, 977–1014. Copyright Elizabeth Martin.)
Radial n.
Brachioradialis
ECRL
ECRB
EDC
ECU
Supinator
Arcade of Fröhse
• Radial tunnel syndrome: Compression of the radial nerve
(posterior interosseus nerve) in the forearm; distinguished
from posterior interosseous nerve (PIN) syndrome by lack
of motor weakness
■ Symptoms: Lateral proximal forearm pain
■ Signs: Pain along the lateral forearm, provocation of
symptoms with resisted elbow extension, forearm
pronation, wrist flexion
■ Treatment
○ Surgery is recommended for true PIN syndrome if
there is no improvement in muscle function after
3 months.
○ Conservative treatment with rest, physical therapy,
and NSAIDs is often successful
• Traumatic radial nerve injury often occurs in setting of
supracondylar fractures of the humerus.
■ Treatment
○ Observation because most are neurapraxia injuries
○ No recovery after 3 to 6 months warrants surgical
exploration.
8. Common peroneal nerve
• Sites of compression: Most commonly, the posterior crural
intermuscular septum, which compresses the nerve as it
courses around the fibular neck and deep to the peroneus
longus muscle
■ Can be caused by habitual leg crossing, external
compression against a hard object in debilitated or
paralyzed patients, trauma, intraneural or extraneural
tumors and masses
■ Can also occur in athletes with well-developed lower leg
muscles, individuals who spend significant time in a
crouched position (e.g., baseball catchers), and patients
after massive weight loss secondary to atrophy of the fat
pad overlying the fibular head, which predisposes the
nerve to external compressive forces
• Symptoms: Numbness and tingling in the posterior and
lateral lower leg and dorsal foot, foot drop
• Signs: Weak or absent dorsiflexion, abnormal gait, sensory
disturbance in the deep peroneal (first web space) and
superficial peroneal (dorsum of foot) distribution, Tinel’s
sign at the fibular neck, exacerbation of symptoms with
knee extension, abnormal electrodiagnostic studies

Peripheral Nerve Injuries, Brachial Plexus, and Compression Neuropathies
122
• Treatment
■ Ankle-foot orthotic (AFO) splint for protection and gait
assistance
■ Observation for 3 to 4 months in cases where
neurapraxia is the likely etiology
■ Surgical decompression is warranted when compression
does not improve, is caused by tumors/masses, or in
cases of severe compression with evidence of muscle
atrophy.
9. Posterior tibial nerve
• Sites of compression: Tarsal canal or “tarsal tunnel,” which
is located posterior to the medial malleolus and formed
primarily by the talus, calcaneus, and flexor retinaculum
■ Can be caused by external compression from masses,
muscle hypertrophy, tenosynovitis, rupture of the medial
tendons, and presence of anomalous muscles and/or
vasculature (e.g., varicosities, aberrant vascular leashes)
• Symptoms: Pain, numbness, tingling along the plantar foot;
often worse with weight bearing
• Signs: Sensory disturbance along the medial plantar or
lateral plantar nerve distribution, exacerbation of
symptoms with dorsiflexion, tenderness to palpation,
Tinel’s sign over the tarsal canal
• Treatment
■ Observation and conservative management
■ Trial of cast or walking boot immobilization
■ Surgical release for chronic cases that do not improve
and those caused by external compression from tumors
or masses
Neuroma
1. Formed after injury to a nerve with aberrant repair, in which
regenerating axons from the proximal stump are unable to
reenter the distal stump
• Results in a swelling of the distal end of the proximal
stump that contains Schwann cells, fibroblasts, vasculature,
and multiple axons
• Can occur as a “neuroma in continuity” in cases of partial
nerve injury with some intact nerve axons
2. Symptoms: Pain, hypersensitivity
3. Signs: Exquisite tenderness with palpation, Tinel’s sign,
hypersensitivity with history of injury/amputation
Table 12.3  Classification of Complex Regional
Pain Syndrome
Type 1
Reflex sympathetic dystrophy (pain, functional
impairment, autonomic dysfunction, dystrophic changes
without clinical peripheral nerve lesion/injury)
Type 2
Causalgia (pain, functional impairment, autonomic
dysfunction, dystrophic changes with a diagnosable
peripheral nerve injury)
Type 3*
Other pain dysfunction problems (e.g., myofascial pain)
Reprinted from Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al.
(Eds.), 2011. Green’s Operative Hand Surgery, 6th ed. Elsevier.
*Not discussed in this chapter.
4. Treatment options: Often, multimodal treatment with
assistance from hand therapists and pain management
specialists
• Range of motion exercises, stress loading, vibration,
massage, transcutaneous nerve stimulation
• Anticonvulsant and/or antidepressant medications
• Corticosteroids, gabapentin, lidocaine, and sodium channel
blockers have shown some benefit.
• Peripheral nerve block
• Nerve decompression
4. Treatment
• Conservative: Hand therapy with desensitization (vibration,
massage, and/or transcutaneous nerve stimulation)
• Resection with primary nerve grafting
• Resection with iatrogenic injury to proximal stump (crush,
cautery) and insertion into deep soft tissues
• Resection with transfer and coaptation to neighboring
nerve (“targeted re-innervation”) (see Figure 12.14)
Complex Regional Pain Syndrome (CRPS)
1. Syndrome of regional pain, autonomic dysfunction, atrophy,
and functional impairment that develops after trauma/injury
to the hand/digits
2. Symptoms: Pain that is out of proportion to the traumatic
insult, often with autonomic symptoms (e.g., a red, painful,
swollen finger), disuse of the affected extremity, neglect of the
extremity (see Figure 12.15)
3. Classification (see Table 12.3)

Complex Regional Pain Syndrome (CRPS)
123
12
Figure 12.14.  Model of neuroma and neuroma in continuity. A, Painful neuromas arise when normal neural repair/regeneration is
disrupted, such as by intervening scar tissue. B, The treatment for painful neuroma is resection of the neuroma with implantation of the
proximal nerve stump into a muscle. C, Neuroma in continuity is characterized by internal architectural derangement of an intact nerve. The
segment containing neuroma can be selectively or totally resected and then repaired using grafting or conduit. (Reprinted from Neligan, P.C.,
Chang, J. [Eds.], 2013. Plastic Surgery, vol. 6, 3rd ed. Elsevier, 486.)
Spinal cord
Peripheral nerves
or
Neuromatous segment excised
Autograft
Neuroma
Cut end of neuroma
(excised)
Injury to nerve
Muscle
Proximal nerve stump
Allograft
Conduit
Sensory neuroma is excised
Motor fibers are identified and spared
with intraoperative nerve conduction testing
Nerve is implanted
into muscle
Peripheral nerves
arise from spinal
nerve
Neuroma
Injury
Schwann cell
Nerve growth factor
Collateral sprouting
A
B
C
4
2
1
3

Peripheral Nerve Injuries, Brachial Plexus, and Compression Neuropathies
124
Suggested Readings
Bezuhly, M., O’Brien, J.P., Lalonde, D., 2013. Chapter 24: Nerve entrapment
syndromes. In: Neligan, P.C., Chang, J. (Eds.), Plastic Surgery, vol. 6, 3rd ed.
Elsevier, pp. 503–525.
Birch, R., 2011. Chapter 32: Nerve repair. In: Wolfe, S.W., Hotchkiss, R.N.,
Pederson, W.C., et al. (Eds.), Green’s Operative Hand Surgery, 6th ed.
Elsevier, p. 1036.
Boyd, K.U., Fox, I.K., Mackinnon, S.E., 2013. Chapter 33: Nerve transfers. In:
Neligan, P.C., Chang, J. (Eds.), Plastic Surgery, vol. 6, 3rd ed. Elsevier, pp.
719–744.
Chuang, D.C.C., 2013. Chapter 36: Brachial plexus injuries: adult and
pediatric. In: Neligan, P.C., Chang, J. (Eds.), Plastic Surgery, vol. 6, 3rd ed.
Elsevier, pp. 789–816.
Ducic, I., Felder, J.M., 2013. Chapter 23: Complex regional pain syndrome in
the upper extremity. In: Neligan, P.C., Chang, J. (Eds.), Plastic Surgery, vol. 6,
3rd ed. Elsevier, p. 486.
Farnebo, S., Thorfinn, J., Dahlin, L.B., 2013. Chapter 32: Peripheral nerve
injuries of the upper extremity. In: Neligan, P.C., Chang, J. (Eds.), Plastic
Surgery, vol. 6, 3rd ed. Elsevier, pp. 694–718.
Hollis, M.H., Calhoun, J.H., Nerve Entrapment Syndromes of the Lower
Extremity. Emedicine.com. Found at: <
article/1234809-overview#aw2aab6b4> Accessed on: October 16, 2014.
Koman, L.A., Poehling, G.G., Smith, B.P., et al., 2011. Chapter 69: Complex
regional pain syndrome. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C.,
et al. (Eds.), Green’s Operative Hand Surgery, 6th ed. Elsevier, p. 1959.
Mackinnon, S.E., Novak, C.B., 2011. Chapter 30: Compression neuropathies.
In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s
Operative Hand Surgery, 6th ed. Elsevier, pp. 977–1014.
Souza, J.M., Cheesborough, J.E., Ko, J.H., et al., 2014. Targeted muscle
reinnervation: a novel approach to postamputation neuroma pain. Clini.
Orthop. Relat. Res. 472 (10), 2984–2990.
Spinner, R.J., Shin, A.Y., Hebert-Blouin, M.N., et al., 2011. Chapter 38:
Traumatic brachial plexus injury. In: Wolfe, S.W., Hotchkiss, R.N., Pederson,
W.C., et al. (Eds.), Green’s Operative Hand Surgery, 6th ed. Elsevier, pp.
1235–1292.
Verndakis, A.J., Koch, H., Mackinnon, S.E., 2003. Management of neuromas.
Clin. Plast. Surg. 30 (2), 247–268.
Wheeler, A.H., Berman, S.A., Complex Regional Pain Syndromes Treatment &
Management. Emedicine.com. Found at: <
article/1145318-overview> Accessed on: October 16, 2014.
Figure 12.15.  Typical features of a patient with complex regional
pain syndrome. (Reprinted from Neligan, P.C., Chang, J. [Eds.], 2013. Plastic
Surgery, vol. 6, 3rd ed. Elsevier, 486.)
Pain
Hyper- or
hypohidrosis
Dystonia,
weakness,
atrophy
Parasthesias,
allodynia,
hyperpathia
Coldness,
color change
Dry, atrophic skin,
brittle nails
Swelling, warmth,
erythema
Vasomotor symptoms
Sudomotor symptoms
Neuropathic and motor/dystonic symptoms
Typical features of the
complex regional
pain syndrome

Lower Extremity
Reconstruction and
Lymphedema
Chapter
13 
1. General lower extremity (LE) anatomy
• Vascular supply (see Figures 13.1 and 13.2)
• Muscle compartments
■ Thigh
○ Anterior
♦ Sartorius m., rectus femoris m., vastus lateralis m.,
vastus intermedius m., vastus medialis m.
♦ Femoral n.
○ Posterior
♦ Biceps femoris m., semitendinosus m.,
semimembranosus m.
♦ Sciatic n.
○ Medial
♦ Gracilis m., adductor longus m., adductor brevis
m., adductor magnus m.
♦ Obturator n. (see Figure 13.3)
■ Lower leg
○ Anterior
♦ Tibialis anterior m., extensor hallucis longus m.,
extensor digitorum longus m., peroneus tertius m.
♦ Deep peroneal n.
♦ Anterior tibial a.
○ Lateral
♦ Peroneus longus m., peroneus brevis m.
♦ Superficial peroneal n.
Figure 13.1.  Major arterial supply to the lower extremities.
Medial circumflex femoral a.
Lateral circumflex femoral a.
Perforating branches to medial and posterior thigh
Profunda
femoris a.
Medial and Lateral sural a.
Anterior tibial a.
Dorsalis pedis a.
Superficial
femoral a.
Popliteal a.
Tibioperoneal trunk
Posterior tibial a.
Peroneal a.
Medial and Lateral
plantar a.
External lliac a.
Femoral a.
○ Deep posterior
♦ Tibialis posterior m., flexor hallucis longus m.,
flexor digitorum longus m., popliteus m.
♦ Tibial n.
♦ Posterior tibial a.
○ Superficial posterior
♦ Gastrocnemius m., plantaris m., soleus m.
♦ Sural n. (see Figure 13.4)
■ Foot
○ Medial
♦ Abductor hallucis m., flexor hallucis brevis m.
○ Lateral
♦ Abductor digiti minimi m., flexor digiti minimi
brevis m.
○ Interosseous (4)
○ Central (3)
♦ Flexor digitorum brevis m., quadratus plantae m.,
adductor hallucis m. (see Figure 13.5)
2. LE trauma
• Classification of injury
■ Gustillo classification
○ Description based on degree of soft-tissue injury and
presence of vascular injury
○ Major vascular injury requiring repair is
automatically a class IIIC.

Lower Extremity Reconstruction and Lymphedema
126
Femoral artery
Deep artery of thigh
First perforating artery
Second perforating artery
Third perforating artery
Descending branch of
lateral circumflex
femoral artery
Descending genicular artery
Articular branch of
descending genicular artery
Saphenous branch of
descending genicular artery
Superior medial genicular artery
Inferior medial genicular artery
Circumflex peroneal
branch of posterior
tibial artery
Anterior tibial artery
Anterior medial malleolar artery
Anterior lateral
malleolar artery
Lateral tarsal artery
Dorsal pedis artery
Medial tarsal artery
Arcuate artery
Posterior tibial artery
Superior lateral
genicular artery
Inferior lateral
genicular artery
Popliteal artery
Peroneal artery
Medial circumflex femoral artery
Ascending branch
of lateral circumflex
femoral artery
Transverse branch
of lateral circumflex
femoral artery
Figure 13.2.  Femoral and profunda arteries. (Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, 3rd ed. Elsevier, 1–62.)

Lower Extremity Reconstruction and Lymphedema
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13
Figure 13.3.  Thigh. A, Line drawing of the compartmental anatomy of the thigh. The three compartments comprise the medial (adductor),
posterior (hamstring flexor), and anterior (extensor). B, Transverse sonogram of the medial compartment of the thigh at the level of the
pubis. AL, Adductor longus; AB, adductor brevis; AM, adductor magnus. C, Transverse sonogram of the posterior compartment of the thigh.
AM, Adductor magnus; BF, biceps femoris; SM, semimembranosus; ST, semitendinosus. (A, Reprinted with permission from Standring, S. [Ed.],
Gray’s Anatomy, 40th ed. Edinburgh, Churchill Livingstone, 2008. B,C, From Allan, P.L., Baxter, G.M., Weston, M.J. [Eds.], 2011. Clinical Ultrasound, 3rd ed. Elsevier,
1137–1157.)
A
B
C
LOGIQ
E9
Common
origin
AL
AB
AM
Medial
SM
ST
BF
AM
Lateral
Sciatic nerve
Profunda femoris artery
Femur
Vastus lateralis
Vastus intermedius
Biceps femoris (long head)
Semitendinosus
Biceps femoris (short head)
Nerve to vastus medialis
Femoral artery in adductor canal
Long saphenous vein
Femoral vein
Rectus femoris
Adductor magnus
Semimembranosus
Vastus medialis
Gracilis
Adductor longus
Sartorius
Saphenous nerve
Posterior femoral cutaneous nerve
○ Classes I and II can generally be managed with local
wound care.
○ Class III generally requires flap coverage.
♦ Classes A, B, and C distinguished according to size
of wound and presence of vascular injury
➔ A: Wound <10 cm, soft-tissue coverage is
usually possible
➔ B: Wound >10 cm, regional or free flap
needed
➔ C: Presence of major vascular injury requiring
repair for limb salvage
♦ IIIB/C: Often requires initial stabilization with
external fixator (see Table 13.1)
■ Byrd classification
○ Established based on force of injury and degree of
bony comminution
♦ Type I: Low-energy, spiral, or oblique fracture
with clean wound <2 cm

Lower Extremity Reconstruction and Lymphedema
128
Figure 13.4.  Leg: Cross sections and fascial compartments. (Netter illustration from Copyright Elsevier Inc. All rights reserved.)
Interosseous membrane
Tibia
Deep posterior compartment
Deep flexor muscles
Flexor digitorum longus
Tibialis posterior
Flexor hallucis longus
Popliteus
Posterior tibial artery and veins
Tibial nerve
Fibular (peroneal) artery and veins
Transverse intermuscular septum
Superficial posterior compartment
Superficial flexor muscles
Soleus
Gastrocnemius
Plantaris (tendon)
Deep fascia of leg
(crural fascia)
Anterior compartment
Extensor muscles
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Fibularis (peroneus) tertius
Anterior tibial artery and veins
Deep fibular (peroneal) nerve
Anterior intermuscular septum
Lateral compartment
Fibularis (peroneus) longus muscle
Fibularis (peroneus) brevis muscle
Superficial fibular (peroneal) nerve
Posterior intermuscular septum
Fibula
Deep fascia of leg (crural fascia)
Cross section just above middle of leg
Anterior tibial artery and veins and
deep fibular (peroneal) nerve
Tibia
Interosseous membrane
Great saphenous vein
and saphenous nerve
Tibialis posterior muscle
Flexor digitorum longus
muscle
Fibular (peroneal) artery
and veins
Posterior tibial artery
and veins and tibial nerve
Flexor hallucis longus
muscle
Deep fascia of leg (crural fascia)
Plantaris tendon
Gastrocnemius muscle (medial head)
Medial sural cutaneous nerve
Small saphenous vein
Tibialis anterior muscle
Extensor hallucis longus muscle
Extensor digitorum longus muscle
Superficial fibular (peroneal) nerve
Anterior intermuscular septum
Deep fascia of leg
(crural fascia)
Fibularis (peroneus)
longus muscle
Fibularis (peroneus)
brevis muscle
Posterior intermuscular septum
Fibula
Lateral sural cutaneous nerve
Transverse intermuscular septum
Soleus muscle
Gastrocnemius muscle (lateral head)
Sural communicating branch
of lateral sural cutaneous nerve

Lower Extremity Reconstruction and Lymphedema
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13
Figure 13.5.  Muscles of the foot and ankle. (Netter illustration from Copyright Elsevier Inc. All rights reserved.)
Medial compartment
Superficial central compartment
(flexor digitorum brevis)
Deep central compartment (quadratus plantae)
Adductor compartment (adductor hallucis)
Lateral compartment
Four interosseus
compartments
(dorsal 4 plantar
interosseus muscles)
Flexor digiti
minimi brevis
Abductor digiti
minimi muscle
Flexor hallucis
brevis muscle
Abductor hallucis
muscle
Dorsal fasciotomy incisions
Medial fasciotomy
incisions
Table 13.1  Classification of Open Fractures
WOUND SIZE
CONTAMINATION
BONE INJURY
SOFT-TISSUE INJURY
1. 1 cm
Clean
Simple
Minimal
2. >1 cm
Moderate
Moderate, some comminution
Moderate, some muscle crushing
3. The following injuries are automatically graded as type-3 injuries:
• Segmental fracture
• Severely contaminated wounds (e.g., farmyard injuries)
• Shotgun wounds
• High-velocity gunshot wounds
3a. Usually >10 cm
High
Usually severe
Usually severe, but bone coverage possible
3b. Usually >10 cm
High
Usually severe
Bone coverage impossible, requires soft-tissue reconstruction
3c. Usually >10 cm
High
Usually severe
As 3b, with vascular injury requiring repair
Reprinted from McGrath, L., Royston, S., 2007. Fractures of the tibial shaft (including acute compartment syndrome). Surgery 2003. 21 (9),
231–235.
♦ Type II: Moderate-energy, comminuted, or
displaced fracture with >2 cm laceration and
moderate muscle contusion
♦ Type III: High-energy, severely displaced, and
comminuted fracture or bony defect with extensive
skin loss and devitalized muscle
♦ Type IV: Extreme energy, same as class C with
degloving or crush injury and/or vascular injury
(see Table 13.2)
• General management
■ Computed tomography (CT) angiography provides the
most rapid method for evaluating LE vasculature.
■ Preferred irrigation–low-pressure pulse lavage (14 PSI)
with 1% surgical soap resulted in a more significant
clearing of bone-adherent bacteria than other solutions.
Osteoclast and osteoblast function were also shown to be
preserved more significantly with the use of the 1% soap
or detergent solution.
■ Free flaps are often required for large defects because of
paucity of available local tissue (IIIB/C).
○ According to Godina, preferred timing of free-flap
reconstruction is within 72 hours; reports suggest
immediate reconstruction requires less dissection and
carries less thrombosis and infection risk.

Lower Extremity Reconstruction and Lymphedema
130
■ Free flaps are also preferred for early exposure of
hardware (before osseus union) rather than removal of
hardware with external fixator.
■ Adequate debridement is the key to successful
reconstruction in contaminated wounds as well as in the
treatment of posttraumatic osteomyelitis.
• Reconstruction versus amputation
■ Goal: Preserve a limb that will be more functional than
an amputation
○ If the extremity cannot be salvaged, the goal is to
maintain the maximum functional length.
♦ Minimum of 6 cm is required for adequate
prosthetic fitting of below-knee amputation.
➔ Can consider fillet of foot flap to preserve
length; otherwise, revision amputation is usually
indicated following traumatic LE amputation.
■ Absolute contraindications for reconstruction
○ Tibial nerve disruption
○ Warm ischemia time >8 hours
• Replantation
■ Contraindications for LE replantation include crush
mechanism of injury, warm ischemia time >8 hours,
multilevel injury, poor baseline health, and patient of
advanced age
• Vascularized bone flaps versus allogeneic bone grafts
■ Vascularized bone flaps
○ Shorten union time
○ Demonstrate increased osteocyte viability
○ Osteogenesis through osteoinduction versus
depending solely on creeping substitution (allogeneic)
○ Indicated for bony defects >6 cm
• Compartment syndrome
■ Increased pressure in a confined space
○ Requires clinical suspicion
♦ Symptoms/signs
➔ Pain out of proportion (often first sign)
➔ Paresthesias
➔ Poikilothermia
➔ Pallor
➔ Pulselessness (late sign)
➔ Paralysis (late sign)
➔ Tense compartment
 Compartment pressure >30 mm Hg
■ Management
○ Fasciotomy
3. Commonly used LE flaps (see Figure 13.6)
• Sartorius muscle flap
■ Origin: Anterior superior iliac spine
■ Insertion: Anteromedial surface of tibia
■ Function: Flex, laterally rotate, and abduct hip; weak
knee flexor
■ Arterial supply: Superficial femoral a. provides segmental
blood supply (type-IV muscle).
■ Nerve: Femoral n.
• Gracilis muscle flap
■ Origin: Ischiopubic ramus
■ Insertion: Medial tibia
■ Function: Flex, medially rotate, and adduct hip; weak
knee flexor
■ Arterial supply: Medial circumflex femoral a.
■ Nerve: Obturator n.
• Anterolateral thigh myocutaneous or perforator flap
■ Arterial supply: Descending branch of lateral circumflex
femoral a.
■ Nerve: Lateral femoral cutaneous n.
■ Underlying muscle: Vastus lateralis m.
• Gastrocnemius flap
■ Origin: Femoral condyles (medial and lateral)
■ Insertion: Calcaneus through achilles tendon
■ Function: Plantarflexion; knee flexion
■ Arterial supply: Sural arteries (medial and lateral)
■ Nerve: Tibial n.
■ Medial muscle: Indicated for medial upper leg 1/3
defects, longer than lateral gastrocnemius, and does not
risk damage to the peroneal nerve (see Figure 13.7)
• Soleus muscle flap
■ Origin: Fibula, medial border of tibia
■ Insertion: Calcaneus through achilles tendon
■ Function: Plantarflexion
■ Arterial supply: Popliteal artery (27.8%) superiorly
(anterograde flap), posterior tibial artery (38.8%), or
peroneal artery (33.3%) distally (retrograde flap)
■ Nerve: Tibial n.
• Sural artery flap
■ Arterial supply: Peroneal artery perforators, which
emerge 5 cm proximal to medial malleolus; tenous
drainage through small valveless comitant veins
■ Flap elevation landmarks: The lesser saphenous vein
and sural nerve, which should bisect the cutaneous
paddle
Table 13.2  Byrd Classification of Lower Extremity Fractures
TYPE
ENERGY
FRACTURE
SOFT TISSUE
I
Low
Spiral or oblique
Clean wound, <2 cm
II
Moderate
Comminuted of displaced
>2 cm laceration, moderate muscle contusion
III
High
Severely displaced and comminuted or bony defect
Extensive skin loss and devitalized muscle
IV
Extreme
Severely displaced and comminuted or bony defect
Extensive skin loss and devitalized muscle with
degloving, crush, and/or vascular injury

Lower Extremity Reconstruction and Lymphedema
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13
Figure 13.6.  Muscles of thigh: Anterior view. (Netter illustration from Copyright Elsevier Inc. All rights reserved.)
Anterior superior iliac spine
Iliacus muscle
Psoas major muscle
Gluteus medius muscle
Inguinal ligament
Pubic tubercle
Iliopsoas muscle
Tensor fasciae latae muscle
Pectineus muscle
Tensor fasciae latae muscle (origin)
Rectus femoris muscle (origin)
Greater trochanter
Iliopsoas muscle (cut)
Adductor longus muscle
Gracilis muscle
Sartorius muscle
Rectus femoris muscle*
Vastus lateralis muscle*
Vastus medialis muscle*
Vastus intermedius muscle*
Iliotibial tract
Patellar ligament
Sartorius tendon
Gracilis tendon
Tibial tuberosity
Semitendinosus tendon
Lateral patellar retinaculum
Medial patellar retinaculum
Patella
Pes anserinus
Iliotibial tract (cut)
Head of fibula
Patellar ligament
Tibial tuberosity
Rectus femoris tendon (cut)
Patella
Lateral patellar retinaculum
Quadriceps femoris tendon
Medial patellar retinaculum
Sartorius
tendon
Anterior superior iliac spine
Sartorius muscle (origin)
Anterior inferior
iliac spine
Ligaments
of hip joint
Pectineus
muscle
*Muscles of quadriceps femoris
Rectus femoris tendon (becoming part of
quadriceps femoris tendon)
Anteromedial
intermuscular
septum

Lower Extremity Reconstruction and Lymphedema
132
Figure 13.7.  Muscles of leg (deep dissection): Anterior view. (Netter illustration from Copyright Elsevier Inc. All rights reserved.)
Superior lateral genicular artery
Fibular collateral ligament
Lateral patellar retinaculum
Iliotibial tract (cut)
Biceps femoris tendon (cut)
Inferior lateral genicular artery
Common fibular (peroneal) nerve
Head of fibula
Fibularis (peroneus) longus muscle (cut)
Anterior tibial artery
Extensor digitorum longus muscle (cut)
Superficial fibular (peroneal) nerve
Deep fibular (peroneal) nerve
Fibularis (peroneus) longus muscle
Extensor digitorum longus muscle
Fibularis (peroneus) brevis
muscle and tendon
Superior medial genicular artery
Quadriceps femoris tendon
Tibial collateral ligament
Medial patellar retinaculum
Infrapatellar branch of saphenous nerve (cut)
Inferior medial genicular artery
Saphenous nerve (cut)
Patellar ligament
Insertion of sartorius tendon
Anterior tibial recurrent artery and recurrent
branch of deep peroneal nerve
Interosseous membrane
Tibialis anterior muscle (cut)
Gastrocnemius muscle
Soleus muscle
Tibia
Superficial fibular (peroneal) nerve (cut)
Extensor hallucis longus muscle and tendon (cut)
Interosseous membrane
Anterior medial malleolar artery
Medial malleolus and arterial network
Dorsalis pedis artery
Tibialis anterior tendon
Medial tarsal artery
Medial branch of deep fibular (peroneal) nerve
Arcuate artery
Deep plantar artery
Dorsal metatarsal arteries
Extensor hallucis longus tendon (cut)
Extensor hallucis brevis tendon (cut)
Dorsal digital branches of
deep fibular (peroneal) nerve
Fibularis (peroneus) longus tendon
Perforating branch of fibular
(peroneal) artery
Anterior lateral malleolar artery
Lateral malleolus and arterial network
Lateral tarsal artery and lateral
branch of deep fibular (peroneal) nerve
Extensor digitorum brevis and extensor
hallucis brevis muscles (cut)
Fibularis (peroneus) brevis tendon
Posterior perforating branches
from deep plantar arch
Extensor digitorum longus tendons (cut)
Extensor digitorum brevis tendons (cut)
Dorsal digital arteries
Branches of proper plantar
digital arteries and nerves

Lower Extremity Reconstruction and Lymphedema
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13
■ Can be transferred as a pedicle flap or free flap; partial
flap loss due to venous congestion is the most common
complication in a reverse sural artery flap.
• Fibula flap
■ Arterial supply: Peroneal artery
■ Often used for bony defect reconstruction
■ Can be taken with a skin paddle with
osteoseptocutaneous perforators from peroneal artery or
harvested with a segment of soleus muscle as an
osteomyocutaenous peroneal artery combined flap
• Medial plantar artery flap
■ Arterial supply: Medial plantar artery
■ Nerve: Medial plantar n. (L4 to 5)
■ Most reliable sensate flap with glabrous skin for coverage
of the plantar calcaneus
■ Flap elevation landmarks: Comes from the instep of the
foot between the head of the first metatarsal and the
midpoint of the heel
• First dorsal metatarsal artery (FDMA) flap
■ Arterial supply: FDMA from dorsalis pedis a.
■ FDMA is also the most common primary arterial blood
supply to the great toe or second toe flap, which is used
in toe-to-thumb transfer.
4. Diabetic ulcers
• Primary etiology: Peripheral neuropathy
• Not associated with large vessel atherosclerosis
5. Arterial insufficiency
• Symptoms: Claudication and rest pain
• Degree of insufficiency often correlates with the ankle–
brachial pressure index (ABI).
■ Normal ABI range 0.90 to 1.20
○ Patients with diabetes often have falsely elevated ABIs
because of arterial calcifications that make vessels
relatively noncompressible.
■ 0.50 to 0.80: Moderate disease, may develop ulcers
■ <0.50: Severe disease, often requires intervention
○ Ulcers associated with an ABI <0.45 generally do not
heal without revascularization.
• Arterial duplex scanning can also be used to evaluate
arterial flow.
■ Triphasic waveforms are considered normal flow.
■ Biphasic or triphasic arterial waveforms are usually
consistent with sufficient vascularity for wound
healing.
■ Monophasic waveforms are associated with extremity
ischemia.
○ If there is good amplitude and a narrow waveform
complex, monophasic waveforms are not necessarily
a contraindication for soft-tissue reconstruction.
• In patients with arterial calcifications, absolute toe
pressures are a better indicator of ischemia than ABIs
because digital vessels are frequently spared from
calcification.
■ A toe pressure <30 mm Hg indicates ischemia and
requires a vascular intervention before soft-tissue
reconstruction.
6. Venous stasis ulcers
• Pathophysiology: Venous valve incompetence → chronic
venous hypertension → elevated capillary hydrostatic
pressure → fluid and protein leakage into the extracellular
space → impaired oxygen transport to tissues → localized
cellular necrosis and ulceration
• Management: Compression of the edematous limb
■ Compression reduces interstitial edema and tissue
pressure, which improves oxygen delivery and enhances
wound healing.
■ Open wounds are best treated with an absorptive and
occlusive dressing.
○ For example, Unna boots
7. Nerve injury/compression (see Figure 13.8)
• Common peroneal n.
■ Origin: Sciatic n. (L4 to S3)
■ Innervates: Anterior and lateral leg compartments,
extensor digitorum brevis
■ Branches
○ Superficial peroneal n.
♦ Motor: Peroneus longus and peroneus
brevis m.
♦ Sensory: Anterolateral leg, skin of dorsum of foot
(1st dorsal web space spared)
♦ Injury/palsy: Inability to evert foot, numbness
along distal anterolateral leg with sparing of 1st
web space
○ Deep peroneal n.
♦ Motor: Extensor hallucis longus and brevis m.,
tibialis anterior, extensor digitorum longus and
brevis m., peroneus tertius m.
♦ Sensory: 1st dorsal web space
♦ Injury/palsy: Inability to dorsiflex/foot drop,
numbness in 1st dorsal web space
■ Etiology of neuropathy
○ Lateral gastrocnemius harvest
○ Bed rest
○ Hyperflexion of the knee
○ Habitual leg crossing
■ Injury/palsy leads to foot drop and numbness within the
1st web space.
○ Open injury: Urgent exploration with repair or
grafting
○ Closed injury: Evaluate with electromyography
(EMG) and nerve conduction studies (NCSs)
3 to 4 weeks postinjury, repeat studies in 4 weeks
if no improvement, explore for decompression
if no improvement in 2 to 3 months (see
Figure 13.9).
• Sural nerve
■ Origin: Comprised of tibial nerve (medial sural
cutaneous n.) and common peroneal nerve (lateral sural
cutaneous n.)
■ Innervates posterolateral leg, lateral foot, and 5th toe
■ Purely sensory
○ Often harvested as nerve graft

Lower Extremity Reconstruction and Lymphedema
134
Figure 13.8.  Sciatic nerve (L4, L5; S1, S2, S3) and posterior femoral cutaneous nerve (S1, S2, S3). (Netter illustration from
Copyright Elsevier Inc. All rights reserved.)
Posterior femoral
cutaneous nerve
(S1, 2, 3)
Inferior clunial nerves
Perineal branches
Tibial division
of sciatic nerve
Long head (cut) of
biceps femoris muscle
Adductor magnus muscle
(also partially supplied
by obturator nerve)
Semitendinosus muscle
Semimembranosus muscle
Tibial nerve
Articular branch
Plantaris muscle
Medial sural
cutaneous nerve
Gastrocnemius muscle
Sural nerve
Soleus muscle
Tibial nerve
Medial calcaneal
branches
Medial and lateral
plantar nerves
Greater sciatic foramen
Sciatic nerve (L4, 5, S1, 2, 3)
Common fibular (peroneal)
division of sciatic nerve
Short head of
biceps femoris muscle
Cutaneous innervation
Long head (cut)
of biceps femoris
muscle
Common fibular
(peroneal) nerve
Articular
branch
Lateral sural
cutaneous nerve
Sural
communicating
branch
Posterior femoral
cutaneous nerve
From sciatic
nerve
Lateral calcaneal
branches
Lateral dorsal
cutaneous nerve
Common fibular
(peroneal) nerve
via lateral sural
cutaneous nerve
Medial sural
cutaneous nerve
Superficial fibular
(peroneal) nerve
Sural nerve
Tibial nerve
via medial
calcaneal
branches

Lower Extremity Reconstruction and Lymphedema
135
13
Figure 13.9.  Common fibular (peroneal) nerve. (Netter illustration from Copyright Elsevier Inc. All rights reserved.)
Common fibular
(peroneal) nerve
(phantom)
Biceps femoris tendon
Common fibular (peroneal)
nerve (L4, 5, S1, 2)
Head of fibula
Fibularis (peroneus)
longus muscle (cut)
Superficial fibular
(peroneal) nerve
Branches of lateral
sural cutaneous nerve
Fibularis (peroneus)
longus muscle
Fibularis (peroneus)
brevis muscle
Medial dorsal cutaneous
nerve
Intermediate dorsal
cutaneous nerve
Inferior extensor
retinaculum (partially cut)
Lateral dorsal cutaneous nerve
(branch of sural nerve)
Dorsal digital nerves
Lateral sural cutaneous nerve (phantom)
Articular branches
Recurrent articular nerve
Extensor digitorum longus muscle (cut)
Deep fibular (peroneal) nerve
Tibialis anterior muscle
Cutaneous innervation
Extensor digitorum
longus muscle
Extensor hallucis
longus muscle
Lateral sural
cutaneous nerve
Superficial fibular
(peroneal) nerve
Lateral branch of
deep fibular
(peroneal) nerve
Extensor hallucis brevis
and
Extensor digitorum brevis
muscles
Medial branch of
deep fibular
(peroneal) nerve
Deep
fibular
(peroneal)
nerve
Sural nerve
via lateral dorsal
cutaneous branch

Lower Extremity Reconstruction and Lymphedema
136
• Tibial nerve
■ Origin: Sciatic n.
■ Innervates gastrocnemius, popliteus, soleus, plantaris,
tibialis posterior, flexor digitorum longus, flexor hallucis
longus
■ Branches
○ Medial plantar n.
♦ Motor: Abductor hallucis, flexor digitorum brevis,
flexor hallucis brevis, 1st lumbrical
♦ Sensory: Plantar surface of medial foot, plantar
surface of toes 1 to 3, and medial half of toe 4.
♦ Injury/palsy: Burning pain and numbness radiating
to toes 1 to 3, claw toes
○ Lateral plantar n.
♦ Motor: Quadratus plantae, flexor digiti minimi,
adductor hallucis, interossei, lumbricals, abductor
digiti minimi
♦ Sensory: Plantar surface of lateral foot, plantar
surface of 5th toe, and lateral half of toe 4
♦ Injury/palsy: Burning pain and numbness radiating
to toes 4 and 5, claw toes
■ Injury/palsy leads to tarsal tunnel syndrome.
○ Tarsal tunnel is found behind the medial malleolus.
♦ Contents include posterior tibial a., tibial n.,
tendons of the tibialis posterior m., flexor
digitorum longus ms., and flexor hallucis
longis m.
○ Symptoms: Burning pain and numbness radiating to
the toes and heel, claw toes (see Figures 13.10-13.12)
8. Lymphedema
• Etiology: Inadequate clearance of interstitial fluid →
pooling of fluid and protein within the interstitial space →
pitting edema (early stage) and nonpitting edema with
more fibrotic tissue and adipogenesis (late stage)
• Diagnosis: Lymphoscintigraphy and exclusion of other
causes of peripheral edema (e.g., renal failure, congestive
heart failure, venous stasis disease, deep venous
thrombosis, etc.)
■ Diagnosis is typically made by thorough history, physical
exam, and lymphoscintigraphy.
■ Classic signs
○ Pitting or nonpitting edema
○ Peau d’orange changes in skin
○ Inability to tent skin over toes (Stemmer sign)
○ Blunted appearance of the digits
■ Bilateral LE edema is more likely to be systemic, whereas
unilateral edema is more likely to be related to venous
insufficiency or lymphedema.
• Primary lymphedema (less than 1 year old), lymphedema
praecox (age of 1 to 35), and lymphedema tarda (older
than 35)
• Secondary lymphedema: Most common cause worldwide is
filariasis (Wucheria bancrofti); endemic in Africa. The most
common cause in western countries is breast-cancer-
related lymphedema, which is a sequela of mastectomy,
axillary lymph node dissection, and radiation. Radiation,
chemotherapy, and obesity are the major risk factors.
• Management
■ Compression and elevation: Mainstay of management
■ Physical therapy
○ Manual lymphatic drainage
○ Pneumatic pumps
○ Multilayer bandaging
■ Surgical options in carefully selected patients
○ Lymphaticovenous anastomosis
○ Vascularized lymph node flap transfer
○ Excisional surgery including suction lipectomy and
debulking procedure or Charles procedure
■ Diuretics are not effective in the treatment of
lymphedema.
■ Antibiotics are usually required for the control of
infection and cellulitis.

Lower Extremity Reconstruction and Lymphedema
137
13
Figure 13.10.  Tibial nerve. (Netter illustration from Copyright Elsevier Inc. All rights reserved.)
Tibial nerve
(L4, 5, S1, 2, 3)
Medial sural
cutaneous nerve (cut)
Articular branches
Plantaris muscle
Gastrocnemius
muscle (cut)
Nerve to popliteus muscle
Popliteus muscle
Interosseous nerve of leg
Soleus muscle (cut and
partly retracted )
Flexor digitorum
longus muscle
Tibialis posterior muscle
Flexor hallucis
longus muscle
Sural nerve (cut)
Lateral calcaneal branch
Medial
calcaneal branch
Flexor retinaculum (cut)
Lateral dorsal
cutaneous nerve
Common fibular (peroneal) nerve
Lateral sural cutaneous nerve (cut)
Medial calcaneal
branches
(S1, 2)
Medial
plantar nerve
(L4, 5)
Lateral
plantar nerve
(S1, 2)
From
tibial nerve
Saphenous nerve
(L3, 4)
Sural nerve
(S1, 2) via
lateral calcaneal
and lateral dorsal
cutaneous
branches
Cutaneous innervation of sole
Flexor
retinaculum
(cut)
Tibial
nerve
Medial
calcaneal
branch
Medial plantar
nerve
Flexor digitorum
brevis muscle
and nerve
Abductor hallucis
muscle and nerve
Flexor hallucis
brevis muscle
and nerve
1st lumbrical
muscle and
nerve
Common
plantar
digital
nerves
Proper
plantar
digital
nerves
Lateral calcaneal
branch of sural nerve
Lateral plantar
nerve
Quadratus plantae
muscle and nerve
Nerve to abductor
digiti minimi muscle
Abductor digiti
minimi muscle
Deep branch
to interosseous
muscles,
2nd, 3rd, and 4th
lumbrical muscles
and
adductor hallucis
muscle
Superficial
branch to
4th interosseous
muscle
and
flexor digiti minimi
brevis muscle
Common and
proper plantar
digital nerves
Note: Articular branches not shown
Articular branch