Clinical Scenarios in Reconstructive Microsurgery: Andreas Gravvanis Despoina D. Kakagia Venkat Ramakrishnan

Andreas Gravvanis
Despoina D. Kakagia
Venkat Ramakrishnan
Editors
Clinical
Scenarios in
Reconstructive
Microsurgery
Strategy and Operative Techniques
Clinical Scenarios in Reconstructive
Microsurgery
Andreas Gravvanis • Despoina D. Kakagia •
Venkat Ramakrishnan
Editors
Clinical Scenarios in
Reconstructive
Microsurgery
Strategy and Operative Techniques
With 912 Figures and 10 Tables

Editors
Andreas Gravvanis Despoina D. Kakagia
Plastic, Reconstructive and Professor in Plastic Surgery
Aesthetic Surgery Medical School
Metropolitan Hospital of Athens Democritus University of Thrace
Athens, Greece Alexandroupolis, Greece
Venkat Ramakrishnan
St Andrews Centre for Plastic Surgery and Burns
Anglia Ruskin University
Essex, UK
ISBN 978-3-030-23705-9 ISBN 978-3-030-23706-6 (eBook)

https://doi.org/10.1007/978-3-030-23706-6
© Springer Nature Switzerland AG 2022

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Preface
The evolution of Plastic Reconstructive Surgery resulted in the “Reconstruc-

tion of the Reconstructive Ladder.” Microsurgical procedures became the first-
line reconstructive option for areas such as the head and neck, breast, and
upper and lower extremities. Yesteryear’s innovations guarantee clinical excel-
lence today. Restoration of form and function is not an optimistic goal but
frequently a realistic one. Better understanding of the anatomy of the blood
supply to flaps and the introduction of perforator flaps enabled us to better
match the missing components – color, texture, and function. The preservation
of form and function of the donor site of free flaps further simplified the
decision to bypass many of the preceding steps in the reconstructive ladder.
Flap prefabrication and prelamination are continuously evolving, aiming to get
the perfect tissue solution to match a given defect. Better understanding of
nerve regeneration and immunology popularized functional reconstructions
and composite tissue allotransplantation, respectively. Tissue engineering and
robotic microsurgery are new evolving fields that merit attention. The achieve-
ments by pioneers provide a glimpse into the future of the new generation of
microsurgeons.
Clinical Scenarios in Reconstructive Microsurgery: Strategy and Opera-
tive Techniques is a major reference book consisting of 100 cases covering the
whole spectrum of reconstructive surgery.
More than 200 pioneers and experts in reconstructive microsurgery from all
around the world have contributed to this project, generously offering their
knowledge and sharing their experience for the benefit of the readers.
Each full-color case begins with patient presentation and proceeds
through diagnosis, key decision, treatment plan, surgical procedures and
operative steps, postoperative management, outcome, and technical pearls.
Each chapter includes comments and summarizes the pros and cons of
management, learning points, and suggested literature. Hundreds of high-
quality illustrations and photographs render this book highly readable and
comprehensive.
This book is addressed to all surgeons actively involved in the field and
is ideal for senior residents and fellows in plastic surgery as well as head
and neck, breast, and hand surgeries, trauma, and orthopedics. We have no
v
vi Preface
doubt it will be an effective companion for board exams, but above all, a
valuable guide for keeping up with the cutting edge of reconstructive
microsurgery.
Athens, Greece Andreas Gravvanis, MD, PhD, FEBOPRAS

Alexandroupolis, Greece Despoina D. Kakagia, MD, PhD, FEBOPRAS
Essex, UK Venkat Ramakrishnan, MS, FRCS, FRACS
October 2022
Contents
Part I Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 Microvascular Reconstruction of Soft Tissue Defects of the

Scalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Despoina D. Kakagia and Andreas Gravvanis
2 Composite Defect of Scalp and Calvarial Bone Following

Oncological Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3 Reconstruction of Calvarial Bone Radionecrosis and

Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Andreas Gravvanis and Despoina D. Kakagia
4 Anterior Skull Base Reconstruction with Intracranial Free

Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Caroline Driessen and Andres Rodriguez-Lorenzo
5 Endoscopic Insetting of Free Flaps in Skull Base

Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Caroline Driessen, Erik J. Stigare, and
Andres Rodriguez-Lorenzo
6 Upper Lip Replantation with Arterialized Venous Flap,

Without Microsurgical Venous Outflow . . . . . . . . . . . . . . . . . 45
Daan De Cock and Assaf A. Zeltzer
7 Upper Lip Amputation: Microsurgical Replantation and

Postoperative Routine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Jonas Löfstrand
8 Salvaging a Failed Total Nasal Reconstruction Using Radial

Forearm and Forehead Flaps . . . . . . . . . . . . . . . . . . . . . . . . . 61
Sarah L. Versnel and Marc A. M. Mureau
9 SCIP Flap for Tongue Reconstruction . . . . . . . . . . . . . . . . . . 77

Jong-Woo Choi, Susana Heredero, Warangkana Tonaree, and
Joon Pio Hong
vii
viii Contents
10 Reconstruction of Partial Glossectomy with Innervated

Lateral Forearm Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Christopher M. K. L. Yao and Rene D. Largo
11 Tongue Reconstruction with Medial Sural Artery

Perforator Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Bhagwat S. Mathur and Marco Pappalardo
12 Total Lower Face Reconstruction with Double

Free Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Andres Rodriguez-Lorenzo and Holger Jan Klein
13 Total Lower Lip Reconstruction with Innervated Radial

Forearm Flap and Palmaris Longus Tendon . . . . . . . . . . . . . 119
Riccardo Schweizer and Andres Rodriguez-Lorenzo
14 Ear Replantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Pedro C. Cavadas
15 Ear Reconstruction Using Microvascular

Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Pedro C. Cavadas
16 Periauricular Reconstruction After Total

Parotidectomy with Facial Nerve Reconstruction
and Free Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Lara Cristóbal and Andres Rodriguez-Lorenzo
17 Reconstruction of a Massive Facial Defect

Following Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Andreas Gravvanis, Thomais Oikonomou, and
Despoina D. Kakagia
18 Mandible Reconstruction in Osteoradionecrosis . . . . . . . . . . 161

Martin Halle and Daniel Danielsson
19 Atrophic Maxilla with Fibula Flap and Implant-Supported

Prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Giorgio De Santis and Marta Starnoni
20 Reconstruction of Temporomandibular Joint with

a Fibula Free Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Andreas Gravvanis, George Lagogiannis, and
Despoina D. Kakagia
21 Orbital Reconstruction with Free Fibula Flap . . . . . . . . . . . . 197

Kalle Conneryd Lundgren and Martin Halle
22 Hypopharynx Reconstruction with a Chimeric

Musculocutaneous Anterolateral Thigh Free Flap . . . . . . . . 207
Holger Jan Klein and Andres Rodriguez-Lorenzo
Contents ix
23 TPFF Augmentation of Primary Pharyngeal Closure

Following Total Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . 215
Axel Sahovaler, Danny J. Enepekides, Kevin M. Higgins, and
Ralph W. Gilbert
24 Utility of Temporoparietal Adipofascial Free Flap in
Laryngotracheal Reconstruction . . . . . . . . . . . . . . . . . . . . . . 225
Ralph W. Gilbert
25 Complex Neck Allotransplantation . . . . . . . . . . . . . . . . . . . . 233
Maciej Grajek
26 Adult Facial Nerve Palsy Reconstruction Using
Gracilis Functional Muscle Innervated with
Cross-Face Nerve Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Kallirroi Tzafetta and Manaf Khatib
27 Adult Facial Palsy Reconstruction: Dual Innervation of
Gracilis Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Kallirroi Tzafetta and Stratos Sofos
28 Facial Reanimation in Congenital Facial Palsy
(Moebius Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
José E. Telich Tarriba and Alexander Cárdenas-Mejía
29 One-Stage Reconstruction of Facial Paralysis Using
Masseter Nerve-Innervated Gracilis . . . . . . . . . . . . . . . . . . . . 275
Pamela Villate-Escobar and Alexander Cárdenas-Mejía
30 Midface Reconstruction with Soft Tissue and
Bone Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Fares Samra, Joseph Disa, and Evan Matros
31 Free Fibula Flap Reconstruction of the
Cervical Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Alexander F. Mericli
32 Virtual Surgical Planning and CAD/CAM for Mandible and
Maxilla Reconstruction with Free Fibula Flap . . . . . . . . . . . 313
Richard Tee, Andres Rodriguez-Lorenzo, and Andreas Thor
33 Vascularized Vastus Lateralis Nerve Graft for Reconstruction
of Composite Facial Nerve Defect . . . . . . . . . . . . . . . . . . . . . . 331
Luís Vieira and Andres Rodriguez-Lorenzo
34 Aesthetic Subunit Microvascular Reconstruction
of the Cheek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
35 SCIP Flap for Simultaneous Management of Orocutaneous
Fistula and Facial Lymphedema . . . . . . . . . . . . . . . . . . . . . . . 349
Susana Heredero and Maria Isabel Falguera Uceda
x Contents
36 Reconstruction of Total Maxillectomy and Orbital Floor with a

Free Scapula Tip Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Luís Vieira, Riccardo Schweizer, and
37 Reconstruction of Mandible and Hemiglossectomy with a

Chimeric Scapula Tip and TDAP Flap . . . . . . . . . . . . . . . . . 369
38 Double Free Flap Reconstruction in the

Complex Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Cristina Gomez-Martinez de Lecea and
39 Management of Bone Nonunion in Mandible Free Flaps with a

Scapular Tip Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Richard Tee and Andres Rodriguez-Lorenzo
Part II Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
40 Complex Thumb Reconstruction Using Free

Chain-Linked “Mini Wraparound” Great Toe
and Dorsalis Pedis Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Roberto Adani and Giovanna Petrella
41 Free “Wrap-Around” Great Toe Flap for Thumb

Reconstruction After Avulsion Injuries . . . . . . . . . . . . . . . . . 413
42 Combined Osteodistraction and Free “Mini Wraparound”

Great Toe Flap for Thumb Reconstruction After Amputation
at the Metacarpophalangeal Level . . . . . . . . . . . . . . . . . . . . . 423
43 First Toe-to-Hand Transfer and the Forearm Radial Flap as

Chain-Linked Flaps for Thumb Reconstruction After
Amputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
Alexandru Valentin Georgescu
44 Serratus Anterior-Rib Flap for the Reconstruction of

Complex Defects Involving the First Metacarpal . . . . . . . . . 441
45 Free PIP Joint Transfer for Functional Finger

Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Paolo Sassu and Martina Åhlén
46 Treatment of Scaphoid Nonunion Using the

Free Corticocancellous Lateral Femoral Condyle
Bone Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Lucian P. Jiga and Katarzyna Skibinska
Contents xi
47 Treatment of the Avascular Necrosis of the Lunate

Using a Free Vascularized Corticocancellous Bone
Graft from the Lateral Femoral Condyle . . . . . . . . . . . . . . . . 477
Lucian P. Jiga and Zaher Jandali
48 Treatment of Kienböck’s Disease Using Free
Vascularized Cartilage Bone Flaps from the Lateral
Femoral Condyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Maria Anoshina, James P. Higgins, Lucian P. Jiga, and
Heinz Bürger
49 Augmentation of Bone Allograft with Vascularized
Medial Femoral Condyle Periosteal Flap in Radius
Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
Eugene Park, Steven T. Lanier, and Jason H. Ko
50 Free Medial Femoral Condyle Flap for Salvage Arthrodesis
of Carpal Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Steven T. Lanier, Eugene Park, and Jason H. Ko
51 Reconstruction of the Upper Extremity Using Free Proximal
Fibula Flap after Sarcoma Resection . . . . . . . . . . . . . . . . . . . 535
Gerardo Malzone and Marco Innocenti
52 Transverse Sensate Thoracodorsal Artery Perforator Flap
for Finger Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
Cheng-Ta Lin and Lee-Wei Chen
53 Extracutaneous Free Triple Split SCIP Flap for
Simultaneous Reconstruction of Multiple Soft Tissue
Defects of the Fingers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
Zaher Jandali, B. Merwart, and Lucian P. Jiga
54 Reconstruction of Palm Defects in Children Using
Microsurgical Free Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Luigino Santecchia
55 Thin Free Flap for Resurfacing of the
Arm and Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
Warangkana Tonaree, Hyunsuk Peter Suh, and Joon Pio Hong
56 Major Amputations at the Arm and Forearm Level:
Replantation Strategy and Technique . . . . . . . . . . . . . . . . . . 603
Pierluigi Tos, Alessandro Crosio, Francesco Giacalone, and
Bruno Battiston
57 Reconstruction of Complex Finger Defects Using the Free
Ulnar Artery Perforator Flap . . . . . . . . . . . . . . . . . . . . . . . . . 615
Mario Cherubino and Tommaso Baroni
58 Complete Brachial Plexus Lesion: Multistaged
Reconstruction of the Sensory-Motor Function . . . . . . . . . . . 625
Christian Heinen and Karthik Krishnan
xii Contents
59 Adult Immediate Brachial Plexus Reconstruction . . . . . . . . . 637

Lukas Pindur and Andrés A. Maldonado
60 Brachial Plexus Secondary Reconstruction with

Contralateral C7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651
Lisa Wen-Yu Chen, Annie Wang, Yu-Ching Lin, Cheyenne
Wei-Hsuan Sung, and Tommy Nai-Jen Chang
Part III Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
61 Combined Autologous Breast and Lymphedema

Reconstruction with a Predesigned DIEP and Lymph-Node
Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
Efterpi Demiri and Dimitrios Dionyssiou
62 Submental Lymph Node Transfer to the Lower

Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
Courtney Chen and Ming-Huei Cheng
63 LYMPHA Approach for Axillary Clearance

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683
Boccardo Francesco and Dessalvi Sara
64 Supermicrosurgical Lymphaticovenular Anastomosis

(LVA) for Early-Stage (Stage 1–2) Extremity
Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
Takumi Yamamoto
65 Lateral Thoracic Artery Lymph Nodes (LTLN) for Lower

Limb Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699
Ayush K. Kapila and Assaf A. Zeltzer
66 Free Transfer of Cervical Lymph Nodes to a Lower Limb

Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
Bien-Keem Tan, Michael Hsieh, and Fumio Onishi
Part IV Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721
67 Soft-Tissue Reconstruction in Exposed Total Knee

Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723
Rik Osinga, Ilario Fulco, and Dirk Johannes Schaefer
68 Tibial Tuberosity Coverage Using Venous Supercharged

Distally Based Pedicled ALT Flap . . . . . . . . . . . . . . . . . . . . . 735
Andreas Gravvanis, Jonathan A. Britto, and
Despoina D. Kakagia
69 Complete Peroneal Nerve Palsy: Functional Reconstruction

with Tendon Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
Giulia Colzani, Paolo Titolo, and Bruno Battiston
Contents xiii
70 Tibial Bone Defect Reconstruction with Ilizarov and

Free Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 751
Vasileios D. Polyzois, Dimitrios F. Georgiou, Aristeidis K.
Koutsopoulos, and Dimitrios V. Polyzois
71 Reconstruction of Plantar Heel Defect . . . . . . . . . . . . . . . . . . 761
Mohin A. Bhadkamkar and William C. Pederson
72 Plantar Weight-Bearing Area Defects Reconstructed with
Perforator Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
Andreas Gravvanis and George E. Papanikolaou
73 Plantar Weight-Bearing Area Defects Reconstructed with
Muscle Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
74 Lower Limb Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . 785
Pedro C. Cavadas
75 Thigh Sarcoma Reconstruction with Free
Functional Latissimus Dorsi Piggyback onto Rectus
Abdominis Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 795
Steven Lo
76 Diabetic Foot Reconstruction Using SCIP Flap . . . . . . . . . . . 807
77 Femur Reconstruction with a Modified Masquelet
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 819
Andreas Gravvanis and Efstathios Balitsaris
Part V Breast/Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
78 Composite Axillary Defect After Sarcoma Resection:

Reconstruction with Anterolateral Thigh Flap . . . . . . . . . . . 829
Shimpei Miyamoto
79 Anterolateral Thigh (ALT) Free Flap Reconstruction of a
Complex Chest Wall Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . 837
Christian M Asher, Mwango Bwalya, Navid Ahmadi, Aman S
Coonar, and Charles M. Malata
80 Anterolateral Thigh Flap for Poland’s Syndrome . . . . . . . . . 857
George E. Papanikolaou, Steven Lo, and Andreas Gravvanis
81 Abdominal Wall Reconstruction . . . . . . . . . . . . . . . . . . . . . . . 865
Roisin T. Dolan, Calum S. Honeyman, and Henk P. Giele
82 Abdominal Wall Reconstruction Postsarcoma Excision . . . . 875
Shameem Haque and Shadi Ghali
83 Total Vaginal Reconstruction After Total Pelvic
Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887
xiv Contents
84 Penile Reconstruction with a Free Radial Artery

Forearm Flap (FRAFF) for Bladder Exstrophy . . . . . . . . . . 895
Marlon E. Buncamper, Karel Claes, and Stan Monstrey
85 Areola-Sparing Mastectomy and Deep Inferior Epigastric
Perforator Flap Reconstruction . . . . . . . . . . . . . . . . . . . . . . . 907
Jack F. C. Woods, Lylas Aljohmani, and Philip Blondeel
86 DIEP Flap Reconstruction in a Slim Patient . . . . . . . . . . . . . 923
Efstathios Balitsaris, Vasilios Venizelos, and
Andreas Gravvanis
87 Breast Reconstruction with PAP Flap . . . . . . . . . . . . . . . . . . 935
Jian Farhadi and Barbara Pompei
88 Breast Reconstruction with Lumbar Artery
Perforator Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 943
Tasneem Belgaumwala, T. Roggio, and Venkat Ramakrishnan
89 Secondary Breast Reconstruction with Vertical Posteromedial
Thigh Flap (vPMT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 951
Mario F. Scaglioni and Vendela Grufman
90 SIEA Flap for Breast Reconstruction . . . . . . . . . . . . . . . . . . . 959
Gerald Duff and Colin Morrison
91 Superior Gluteal Artery Perforator Flap for Immediate
Breast Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 969
Tasneem Belgaumwala and P. Roblin
92 Superior Gluteal Artery Perforator (SGAP) Flap in Delayed
Autologous Breast Reconstruction . . . . . . . . . . . . . . . . . . . . . 977
Shine Singh, Laura Kearney, and Peter Ceulemans
93 Stacked Free Flaps for Breast Reconstruction . . . . . . . . . . . . 985
Warren M. Rozen, Harmeet K. Bhullar, Tasneem
Belgaumwala, and Venkat Ramakrishnan
94 Partial Mastectomy Reconstruction with Pedicled
Thoracodorsal Artery Perforator Flap . . . . . . . . . . . . . . . . . 995
Gabriele Giunta and Moustapha Hamdi
95 Bilateral Breast Reconstruction with the Free
Fasciocutaneous Infragluteal Flap (FCI) . . . . . . . . . . . . . . . . 1005
96 Breast Sarcoma Case: ALT and LTP Flaps in the
Management of Bilateral Asynchronous Breast
Angiosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013
Steven Lo
97 Intraoperative Perforator Avulsion in Free Flap Breast
Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1025
Randy De Baerdemaeker and Assaf A. Zeltzer
Contents xv
98 Deep Inferior Epigastric Artery Perforator (DIEaP) Flap

Harvest After Full Abdominoplasty . . . . . . . . . . . . . . . . . . . . 1035
Gabriele Giunta and Assaf A. Zeltzer
99 Perineal Reconstruction for a Complex

Perineal Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1045
Aileen Egan, Eamon Francis, and Colin Morrison
100 Breast Reconstruction Using a Transverse Upper

Gracilis Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1055
Tasneem Belgaumwala and N. Pantelides
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1065
About the Editors
Andreas Gravvanis currently serves as Head of

Plastic, Reconstructive and Aesthetic Surgery in
the Metropolitan Hospital of Athens. Following
his basic plastic surgery training at the General
State Hospital of Athens and at Chang Gung
Memorial Hospital, Taiwan, where he focused
on facial paralysis/head and neck reconstruction
(sponsored by MILLESI Award), he accom-
plished three microsurgical fellowships at St
Andrews Centre for Plastic Surgery, UK, focusing
on breast/microsurgery; Gent Plastic Surgery Uni-
versity Department, Belgium, focusing on breast
reconstruction (sponsored by EURAPS Scholar-
ship); and EURAPS/AAPS fellowship at MD
Anderson Cancer Centre focusing on head and
neck cancer reconstruction. Gravvanis was
appointed as a Consultant Plastic Surgeon with
special interest in Breast Reconstruction in Queen
Victoria Hospital, East Grinstead, UK, for the
period 2007–2008. He was subsequently appointed
as a Consultant in Plastic Surgery at General State
Hospital of Athens, 2009–2017. His interests
include all aspects of microsurgery dealing with
cancer and trauma reconstruction along with facial
palsy. He also focuses on facial and breast aesthetic
surgery. Three-dimensional (3D) photography and
3D virtual models are an integral part of his prac-
tice in both reconstructive and aesthetic surgery.
Gravvanis is the author and co-author of 62 publi-
cations in peer-reviewed journals with over a 1000
citations and 3 book chapters. He is the editor of the
reference book Clinical Scenarios in Reconstruc-
tive Microsurgery published by Springer. He is also
xvii
xviii About the Editors
an active member of EURAPS, a member of the

editorial board of Microsurgery, and a reviewer for
Aesthetic Plastic Surgery.
Despoina D. Kakagia is Professor of Plastic

Surgery at Democritus University in Thrace,
Greece, and has been practicing reconstructive
and cosmetic plastic surgery since 1998. Follow-
ing her comprehensive training in plastic surgery
at Metaxa Cancer Institute and Athens General
State Hospital in Greece, she underwent further
training in microsurgery of the hand and breast at
Canniesburn, Glasgow, Scotland; Chelsea and
Westminster Hospital, London, UK; and Aachen
University Hospital, Germany.
Professor Kakagia is a member of the Hellenic
Society of Plastic Reconstructive and Aesthetic
Surgery (HESPRAS), the Hellenic Society of
Reconstructive Microsurgery and Hand and
Upper Limb Surgery, and the Hellenic Society of
Wound Healing and is an active member of
EURAPS. Her special interests include oncologic
surgery and trauma, breast surgery, burns, and
wound healing.
Professor Kakagia has been teaching plastic
surgery at undergraduate and postgraduate level
since 2006 and has participated as an instructor in
many microsurgery training courses. She is the
author or co-author of more than 70 publications
in peer-reviewed international journals and has
authored 1 book as well as 15 book chapters.
She is an active reviewer in more than 30 interna-
tional medical journals.
Venkat Ramakrishnan is a Consultant Plastic

Surgeon at the St Andrew’s Centre for Plastic
Surgery and Burns, Chelmsford, United King-
dom, and Visiting Professor of Microsurgery at
the Anglia Ruskin University, Chelmsford,
United Kingdom. His main area of work is micro-
surgical reconstruction of the breast and aesthetic
surgery of the breast.
Ramakrishnan plays a major role as a trainer in
microsurgery and was the inaugural Tutor in Plas-
tic Surgery at the Royal College of Surgeons of
England, London. He was the Director of the
St Andrew’s Centre and has had roles in the
BAPRAS Council and the project board of the
About the Editors xix
National Mastectomy and Reconstruction audit.

He is a member of the editorial board of the
Journal of Plastic, Reconstructive and Aesthetic
Surgery and Archives of Plastic Surgery. He is a
fellow of the Royal College of Surgeons of
England and the Royal Australasian College of
Surgeons.
Ramakrishnan has numerous publications and
presentations at national and international meet-
ings. His main areas of research and audit are in
microsurgical techniques, service delivery, and
microcirculation in free flaps.
Section Editors
Shadi Ghali
Plastic Surgery Clinic
The Royal Free University Hospital
London, UK
Lucian P. Jiga
Evangelisches Krankenhaus
Medical Campus, Department of Plastic
Aesthetic, Reconstructive and Hand Surgery
University of Oldenburg
Oldenburg, Germany
Colin Morrison
Department of Plastic, Reconstructive and
Aesthetic Surgery
St. Vincent’s University Hospital
Dublin, Ireland
xxi
xxii Section Editors
Department of Plastic and Maxillofacial Surgery
Uppsala University Hospital and
Uppsala University
Uppsala, Sweden
Assaf A. Zeltzer
Rappaport Faculty of Medicine
Technion – Israel Institute of Technology
Haifa, Israel
Contributors
Roberto Adani Hand Surgery and Microsurgery, University of Modena,

Azienda Ospedaliero Universitaria Policlinico di Modena, Modena, Italy
Martina Åhlén Department of Hand Surgery, Sahlgrenska University Hos-
pital, Gothenburg, Sweden
Navid Ahmadi Royal Papworth Hospital, Royal Papworth Hospital NHS
Trust, Cambridge, UK
Lylas Aljohmani Department of Plastic & Reconstructive Surgery,
St Vincent’s University Hospital, Dublin, Ireland
Maria Anoshina Trauma Hospital, Graz, Austria
“Millesi Center” for Reconstructive Microsurgery, Peripheral Nerve Disease
and Plexus Brachialis, Vienna Privat Clinic, Vienna, Austria
Christian M Asher Department of Plastic & Reconstructive Surgery,
Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation
Efstathios Balitsaris Department of Plastic Reconstructive, Microsurgery
and Aesthetic Surgery, Metropolitan Hospital, Athens, Greece
Tommaso Baroni Hand and Microsurgery Unit, Division of Plastic and
Reconstructive Surgery, Microsurgery and Lymphatic Surgery Research Cen-
ter, Department of Biotechnology and Life Sciences, University of Insubria,
Varese, Italy
ASST Settelaghi, University of Insubria, Varese, Italy
Bruno Battiston U.O.C. Traumatology, Hand Surgery, Microsurgery, A.S.O.
Città della Salute e della Scienza, CTO - Hospital, Torino, Italy
Tasneem Belgaumwala St. Andrew’s Centre for Plastic Surgery and Burns,
Broomfield Hospital, Chelmsford, UK
Guy’s and St. Thomas’ NHS Trust, London, UK
Mohin A. Bhadkamkar Baylor College of Medicine, Houston, TX, USA
xxiii
xxiv Contributors
Harmeet K. Bhullar Department of Plastic and Reconstructive Surgery,

Peninsula Health, Frankston, VIC, Australia
Faculty of Medicine, Peninsula Clinical School, Central Clinical School,
Monash University, Frankston, VIC, Australia
Philip Blondeel Ghent University Hospital, Ghent, Belgium
Jonathan A. Britto Great Ormond Street, Hospital for Children, London, UK
Marlon E. Buncamper Department of Plastic Surgery, Ghent University

Hospital, Ghent, Belgium
Heinz Bürger Head of Hand- and Reconstructive Microsurgery Department,

Privat Clinic MariaHilf, Klagenfurt, Austria
Mwango Bwalya Department of Cardiovascular Science, UCL, London,

UK
Alexander Cárdenas-Mejía Plastic and Reconstructive Surgery Division,

Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico
Postgraduate Division of the Medical School, Universidad Nacional Auto-
noma de Mexico, Mexico City, Mexico
Pedro C. Cavadas Reconstructive Microsurgery, Clínica Cavadas, Valencia,

Spain
Peter Ceulemans Plastic Surgeon, Villa Medici, Mechelbaan, Belgium
Tommy Nai-Jen Chang Department of Plastic and Reconstructive Surgery,

Chang Gung Memorial Hospital, Linkou Medical Center and Chang-Gung
University, School of Medicine, Taoyuan, Taiwan
Courtney Chen UC San Diego School of Medicine, San Diego, CA, USA
Lee-Wei Chen Division of Plastic and Reconstructive Surgery, Kaohsiung

Veterans General Hospital, Kaohsiung City, Taiwan
Institute of Emergency and Critical Care Medicine, National Yang-Ming
University, Taipei City, Taiwan
Lisa Wen-Yu Chen Department of Plastic and Reconstructive Surgery,

Chang Gung Memorial Hospital, Linkou Medical Center and Chang-Gung
University, School of Medicine, Taoyuan, Taiwan
Ming-Huei Cheng Division of Reconstructive Microsurgery, Department of

Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College
of Medicine, Chang Gung University, Taoyuan, Taiwan
Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan,
Taiwan
Division of Plastic Surgery, Department of Surgery, University of Michigan,
Ann Arbor, MI, USA
Contributors xxv
Mario Cherubino ASST Settelaghi, Hospital, Department of Biotechnology

and Life Sciences (DBSV), Plastic Surgery, University of Insubria, Varese,
Italy
Hand and Microsurgery Unit, Division of Plastic and Reconstructive Surgery,
Microsurgery and Lymphatic Surgery Research Center, Department of Bio-
technology and Life Sciences, University of Insubria, Varese, Italy
Jong-Woo Choi Professor in Plastic Surgery, Department of Plastic Surgery,

Asan Medical Center, University of Ulsan, Seoul, Republic of South Korea
Karel Claes Department of Plastic Surgery, Ghent University Hospital,

Ghent, Belgium
Giulia Colzani Department of Orthopaedics and Traumatology, Division of

Hand Surgery and Microsurgery, CTO Hospital, University of Turin, Turin, Italy
Aman S Coonar Royal Papworth Hospital, Royal Papworth Hospital NHS

Lara Cristóbal Department of Plastic and Reconstructive Surgery and Burn

Unit, Getafe University Hospital, Madrid, Spain
Alessandro Crosio Hand Surgery and Reconstructive Microsurgery Depart-

ment, Orthopedic Institute ASST Gaetano Pini – CTO Hospital, Milan, Italy
Daniel Danielsson Craniomaxillofacial Surgery, Karolinska University Hos-

pital, Stockholm, Sweden
Department of Clinical Science, Intervention and Technology, Division of Ear,
Nose and Throat Diseases, Karolinska Institute, Stockholm, Sweden
Randy De Baerdemaeker Department of Plastic, Reconstructive & Aes-

thetic Surgery, Brussels University Hospital (VUB), Brussels, Belgium
Daan De Cock Department of Plastic, Reconstructive & Aesthetic Surgery,

Brussels University Hospital (VUB), Brussels, Belgium
Giorgio De Santis Division of Plastic Surgery, University of Modena and

Reggio Emilia, Modena, Italy
Efterpi Demiri Department of Plastic Surgery, School of Medicine, Aristotle

University of Thessaloniki, Thessaloniki, Greece
Dimitrios Dionyssiou Department of Plastic Surgery, School of Medicine,

Aristotle University of Thessaloniki, Thessaloniki, Greece
Joseph Disa Memorial Sloan Kettering Cancer Center, New York, NY, USA
Roisin T. Dolan Department of Plastic & Reconstructive Surgery,

Oxford Reconstructive, Plastic, Hand and Innovation Collaboration, Depart-
ment of Plastic, Reconstructive and Hand Surgery and Nuffield Department of
Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
xxvi Contributors
Caroline Driessen Department of Plastic and Maxillofacial Surgery, Uppsala

University Hospital, Uppsala, Sweden
Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
Gerald Duff Department of Plastic Surgery, St. Vincent’s University Hospi-
tal, Dublin, Ireland
Aileen Egan Department of Plastic, Reconstructive and Aesthetic Surgery,
St. Vincent’s University Hospital, Dublin, Ireland
Danny J. Enepekides Department of Otolaryngology–Head and Neck Sur-
gery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto,
ON, Canada
Maria Isabel Falguera Uceda Department of Maxillofacial Surgery, Hospi-
tal Universitario Reina Sofía, Córdoba, Spain
Jian Farhadi Plastic Surgery Group, Zürich, Switzerland
University of Basel, Basel, Switzerland
Boccardo Francesco Unit of Surgical Lymphology – Department of Cardio-
Thoracic, Vascular and Endovascular Surgery, S. Martino University Hospital,
Genoa, Italy
Department of Surgical Sciences and Integrated Diagnostics – DISC, Univer-
sity of Genoa, Genoa, Italy
Eamon Francis Department of Plastic, Reconstructive and Aesthetic Sur-
gery, St. Vincent’s University Hospital, Dublin, Ireland
Ilario Fulco Department of Plastic, Reconstructive, Aesthetic and Hand
Surgery, University Hospital Basel, Basel, Switzerland
Alexandru Valentin Georgescu Plastic Surgery, Aesthetic Surgery and
Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu, Reha-
bilitation Hospital, Cluj Napoca, Romania
Dimitrios F. Georgiou 4th Department of Orthopaedics & Traumatology,
KAT General Hospital, Athens, Greece
Shadi Ghali Plastic Surgery Clinic, The Royal Free University Hospital,
London, UK
Francesco Giacalone Orthopaedics and Traumatology 2 – Surgery of the
Hand and Upper Limb, AOU City of Health and Science – Trauma Hospital,
Turin, Italy
Henk P. Giele Oxford Reconstructive, Plastic, Hand and Innovation Collab-
oration, Department of Plastic, Reconstructive and Hand Surgery and Nuffield
Department of Surgery, Oxford University Hospitals NHS Foundation Trust,
Oxford, UK
Ralph W. Gilbert Department of Otolaryngology–Head and Neck Surgery,
Princess Margaret Hospital–University Health Network, University of
Toronto, Toronto, ON, Canada
Contributors xxvii
Gabriele Giunta Department of Plastic, Reconstructive & Aesthetic Surgery,

University Hospital Brussels, Vrije Universiteit Brussel (VUB), Brussels,
Belgium
Cristina Gomez-Martinez de Lecea Department of Plastic and Maxillofa-

cial Surgery, Uppsala University Hospital, Uppsala, Sweden
Maciej Grajek Oncological and Reconstructive Surgery, Cancer Center

IMSC, Gliwice, Poland
Andreas Gravvanis Plastic, Reconstructive and Aesthetic Surgery, Metro-

politan Hospital of Athens, Athens, Greece
Vendela Grufman Department of Hand- and Plastic Surgery, Luzerner

Kantonsspital, Lucerne, Switzerland
Martin Halle Reconstructive Plastic Surgery, Karolinska University Hospi-

tal, Stockholm, Sweden
Molecular Medicine and Surgery, Karolinska Institute, Stockholm,
Sweden
Moustapha Hamdi Department of Plastic and Reconstructive Surgery, Brus-

sels University Hospital, Brussels, Belgium
Shameem Haque The Royal Free University Hospital, London, UK
Christian Heinen Department of Neurosurgery, University of Oldenburg

Evangelisches Krankenhaus, Oldenburg, Germany
Susana Heredero Maxillofacial Surgeon, Department of Maxillofacial Sur-

gery, Hospital Universitario Reina Sofía, Córdoba, Spain
Kevin M. Higgins Department of Otolaryngology–Head and Neck Surgery,

Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON,
Canada
James P. Higgins The Curtis National Hand Center, Medstar Union Memo-
rial Hospital, Baltimore, MD, USA
Calum S. Honeyman Oxford Reconstructive, Plastic, Hand and Innovation

Collaboration, Department of Plastic, Reconstructive and Hand Surgery and
Nuffield Department of Surgery, Oxford University Hospitals NHS Founda-
tion Trust, Oxford, UK
Joon Pio Hong Department of Plastic Surgery, Asan Medical Center, Uni-
versity of Ulsan, Seoul, Republic of South Korea
Michael Hsieh Department of Plastic, Reconstructive, & Aesthetic Surgery,

Singapore General Hospital, Singapore, Singapore
Marco Innocenti Department of Health Sciences, Unit of Plastic and

Reconstructive Microsurgery, “Careggi” University Hospital, Florence,
Italy
xxviii Contributors
Zaher Jandali Department of Plastic, Aesthetic, Reconstructive and Hand

Surgery, Evangelisches Krankenhaus, Medical Campus, University of Olden-
burg, Oldenburg, Germany
Lucian P. Jiga Department of Plastic, Aesthetic, Reconstructive and Hand
Despoina D. Kakagia Professor in Plastic Surgery, Medical School, Democ-
ritus University of Thrace, Alexandroupolis, Greece
Ayush K. Kapila Department of Plastic, Reconstructive & Aesthetic Surgery
European Center for Lymphedema Surgery - Lymphedema Clinic, Brussels
University Hospital (VUB), Brussels, Belgium
Laura Kearney Specialist Registrar in Plastic Surgery, St. Vincent’s Univer-
sity Hospital, Dublin, Ireland
Manaf Khatib Plastic and Reconstructive Surgery Specialist Registrar,
St Andrew’s Centre of Plastic Surgery and Burns, Broomfield Hospital,
Essex, UK
Holger Jan Klein Department of Plastic and Hand Surgery, University
Hospital Zurich, Zurich, Switzerland
Jason H. Ko Division of Plastic and Reconstructive Surgery, Northwestern
University Feinberg School of Medicine, Chicago, IL, USA
Aristeidis K. Koutsopoulos 4th Department of Orthopaedics &
Traumatology, KAT General Hospital, Athens, Greece
Karthik Krishnan The Division of Neurosurgery, Frankfurt-Main-Taunus-
Hospital, Bad Soden, Frankfurt, Germany
George Lagogiannis Head and Neck Department, Metropolitan Hospital,
Athens, Greece
Steven T. Lanier Division of Plastic and Reconstructive Surgery, Northwest-
ern University Feinberg School of Medicine, Chicago, IL, USA
Rene D. Largo Department of Plastic Surgery, The University of Texas MD
Anderson Cancer Center, Houston, TX, USA
Cheng-Ta Lin Division of Plastic and Reconstructive Surgery, Kaohsiung
School of Medicine, National Yang-Ming University, Taipei City, Taiwan
Yu-Ching Lin Department of Medical Imaging and Intervention, Chang
Gung Memorial Hospital, Keelung and Chang Gung University, Taoyuan,
Taiwan
Steven Lo Canniesburn Plastic Surgery Unit, Glasgow, UK
University of Glasgow and The Glasgow School of Art, Glasgow, UK
Jonas Löfstrand Department of Plastic Surgery, Sahlgrenska University
Hospital, Gothenburg, Sweden
Contributors xxix
Kalle Conneryd Lundgren Senior Consultant, Craniomaxillofacial Surgery,

Karolinska University Hospital, Stockholm, Sweden
Associate Professor in Plastic Surgery, Molecular Medicine and Surgery,
Karolinska Institute, Stockholm, Sweden
Charles M. Malata Department of Plastic & Reconstructive Surgery,
Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation
School of Medicine, Anglia Ruskin University, Cambridge & Chelmsford, UK
Andrés A. Maldonado Department of Plastic, Hand and Reconstructive
Microsurgery, BG Trauma Center, Frankfurt am Main, Germany
Academic Hospital of the Goethe University, Frankfurt am Main, Frankfurt am
Main, Germany
Department of Plastic Surgery, University Hospital Getafe, Madrid, Spain
Gerardo Malzone Department of Health Sciences, Unit of Plastic and
Reconstructive Microsurgery, “Careggi” University Hospital, Florence, Italy
Bhagwat S. Mathur St Andrew’s Centre for Plastic Surgery, Broomfield
Hospital, Chelmsford, Essex, UK
Evan Matros Memorial Sloan Kettering Cancer Center, New York, NY, USA
Alexander F. Mericli Department of Plastic Surgery, The University of
Texas M.D. Anderson Cancer Center, Houston, TX, USA
B. Merwart Department of Plastic, Aesthetic, Reconstructive and Hand
Shimpei Miyamoto Department of Plastic and Reconstructive Surgery,
Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Stan Monstrey Department of Plastic Surgery, Ghent University Hospital,
Ghent, Belgium
Colin Morrison Department of Plastic, Reconstructive and Aesthetic Surgery,
Surgical Professional Unit, St. Vincent’s University Hospital, Dublin, Ireland
Marc A. M. Mureau Department of Plastic and Reconstructive Surgery and
Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotter-
dam, The Netherlands
Thomais Oikonomou Eugenideion Hospital, Athens, Greece
Fumio Onishi Department of Plastic Surgery, Saitama Medical Center,
Saitama Medical University, Saitama, Japan
Rik Osinga Centre for Musculoskeletal Infections, University Hospital
Basel, Basel, Switzerland
Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Univer-
sity Hospital Basel, Basel, Switzerland
Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK
xxx Contributors
N. Pantelides St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield
Hospital, Chelmsford, UK
George E. Papanikolaou Consultant Plastic Surgeon, Unit of Plastic,

Reconstructive Microsurgery and Aesthetic Surgery, Metropolitan Hospital,
Athens, Greece
Marco Pappalardo St Andrew’s Centre for Plastic Surgery, Broomfield

Division of Plastic and Reconstructive Surgery, Department of Medical and
Surgical Sciences, Policlinico University Hospital, University of Modena and
Eugene Park Division of Plastic and Reconstructive Surgery, Northwestern

University Feinberg School of Medicine, Chicago, IL, USA
William C. Pederson Baylor College of Medicine, Houston, TX, USA

Texas Children’s Hospital, Houston, TX, USA
Giovanna Petrella Hand Surgery Department, Policlinico of Modena,

Modena, Italy
Lukas Pindur Department of Plastic, Hand and Reconstructive Microsur-

gery, BG Trauma Center, Frankfurt am Main, Germany
Academic Hospital of the Goethe University, Frankfurt am Main, Frankfurt am
Main, Germany
Dimitrios V. Polyzois 4th Department of Orthopaedics & Traumatology,

KAT General Hospital, Athens, Greece
Vasileios D. Polyzois 4th Department of Orthopaedics & Traumatology, KAT

General Hospital, Athens, Greece
Barbara Pompei Plastic Reconstructive and Aesthetic Unit, Lugano,

Switzerland
Venkat Ramakrishnan St. Andrew’s Centre for Plastic Surgery and Burns,
P. Roblin Guy’s and St. Thomas’ NHS Trust, London, UK
Andres Rodriguez-Lorenzo Department of Plastic and Maxillofacial Sur-

gery, Uppsala University Hospital, Uppsala, Sweden
T. Roggio St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield
Hospital, Chelmsford, UK
Warren M. Rozen Department of Plastic and Reconstructive Surgery, Pen-

insula Health, Frankston, VIC, Australia
Faculty of Medicine, Peninsula Clinical School, Central Clinical School,
Monash University, Frankston, VIC, Australia
Contributors xxxi
Axel Sahovaler Department of Otolaryngology–Head and Neck Surgery,

Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON,
Canada
Department of Otolaryngology–Head and Neck Surgery, Princess Margaret
Hospital–University Health Network, University of Toronto, Toronto, ON,
Canada
Fares Samra Memorial Sloan Kettering Cancer Center, New York, NY, USA
Luigino Santecchia Department of Surgery – Orthopaedic Unit of Palidoro,
“Bambino Gesù” Children’s Hospital (Research Institute of Rome, Italy),
Rome, Italy
Dessalvi Sara Unit of Surgical Lymphology – Department of Cardio-
Thoracic, Vascular and Endovascular Surgery, S. Martino University Hos-
pital, Genoa, Italy
Department of Surgical Sciences and Integrated Diagnostics – DISC, Univer-
sity of Genoa, Genoa, Italy
Paolo Sassu Department of Hand Surgery, Sahlgrenska University Hospital,
Gothenburg, Sweden
Mario F. Scaglioni Department of Hand- and Plastic Surgery, Luzerner
Kantonsspital, Lucerne, Switzerland
Dirk Johannes Schaefer Centre for Musculoskeletal Infections, University
Hospital Basel, Basel, Switzerland
Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Univer-
sity Hospital Basel, Basel, Switzerland
Riccardo Schweizer Department of Plastic and Maxillofacial Surgery,
Uppsala University Hospital, Uppsala, Sweden
Department of Plastic Surgery and Hand Surgery, University Hospital Zurich,
Zurich, Switzerland
Shine Singh Registrar in Plastic Surgery, St. Vincent’s University Hospital,
Dublin, Ireland
Katarzyna Skibinska Department of Plastic, Aesthetic, Reconstructive and
Hand Surgery, Evangelisches Krankenhaus, Medical Campus, University of
Oldenburg, Oldenburg, Germany
Stratos Sofos St Andrew’s Centre of Plastic Surgery and Burns Broomfield
Marta Starnoni Division of Plastic Surgery, University of Modena and
Erik J. Stigare Department of Otorhinolaryngology, Uppsala University
Hospital, Uppsala, Sweden
Hyunsuk Peter Suh Department of Plastic Surgery, Asan Medical Center,
University of Ulsan, Seoul, Republic of South Korea
xxxii Contributors
Cheyenne Wei-Hsuan Sung Department of Plastic and Reconstructive Sur-

gery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang-
Gung University, School of Medicine, Taoyuan, Taiwan
Bien-Keem Tan Department of Plastic, Reconstructive, & Aesthetic Surgery,
Singapore General Hospital, Singapore, Singapore
Richard Tee Department of Plastic and Maxillofacial Surgery, Uppsala Uni-
versity Hospital, Uppsala, Sweden
José E. Telich Tarriba Plastic and Reconstructive Surgery Division, Hospi-
tal General “Dr. Manuel Gea González”, Mexico City, Mexico
Postgraduate Division of the Medical School, Universidad Nacional Auto-
Andreas Thor Department of Plastic and Maxillofacial Surgery, Uppsala
University Hospital and Department of Surgical Sciences, Uppsala University,
Uppsala, Sweden
Paolo Titolo Department of Orthopaedics and Traumatology, Division of
Hand Surgery and Microsurgery, CTO Hospital, University of Turin, Turin,
Italy
Warangkana Tonaree Division of Plastic and Reconstructive Surgery,
Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol Uni-
versity, Bangkok, Thailand
Department of Plastic Surgery, Asan Medical Center, University of Ulsan,
Seoul, Republic of South Korea
Pierluigi Tos Hand Surgery and Reconstructive Microsurgery Department,
Orthopedic Institute ASST Gaetano Pini – CTO Hospital, Milan, Italy
Kallirroi Tzafetta Consultant Plastic and Reconstructive Surgeon,
St Andrew’s Centre of Plastic Surgery and Burns, Broomfield Hospital,
Essex, UK
Vasilios Venizelos Department of Breast Surgery, Metropolitan Hospital,
Athens, Greece
Sarah L. Versnel Department of Plastic and Reconstructive Surgery and
Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotter-
dam, The Netherlands
Luís Vieira Microvascular Fellow, Department of Plastic and Maxillofacial
Surgery, Uppsala University Hospital and Department of Surgical Sciences,
Uppsala University, Uppsala, Sweden
Pamela Villate-Escobar Plastic and Reconstructive Surgery Division, Hos-
pital General “Dr. Manuel Gea González”, Mexico City, Mexico
Postgraduate Division of the Medical School, Universidad Nacional Autó-
Contributors xxxiii
Annie Wang Division of Plastic, Reconstructive & Aesthetic Surgery,

Department of Surgery, University of Toronto, Toronto, ON, Canada
Jack F. C. Woods Department of Plastic & Reconstructive Surgery,

Takumi Yamamoto Department of Plastic and Reconstructive Surgery,

National Center for Global Health and Medicine (NCGM), Tokyo, Japan
Christopher M. K. L. Yao Fox Chase Cancer Center, Philadelphia, PA, USA

Assaf A. Zeltzer Department of Plastic, Reconstructive & Aesthetic Surgery
European Center for Lymphedema Surgery - Lymphedema Clinic, Brussels
University Hospital (VUB), Brussels, Belgium
Part I
Head and Neck
Microvascular Reconstruction of Soft
Tissue Defects of the Scalp 1
Contents
The Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Preoperative Problem List: Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Alternative Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Preoperative Evaluation and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Preoperative Care and Patient Drawing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Technical Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Intraoperative Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Postoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Outcome: Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Avoiding and Managing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Abstract
Scalp soft tissue reconstruction aims to tension

free and durable coverage, especially in areas
where calvarium is exposed. Extensive soft
tissue defects of the scalp with exposed
D. D. Kakagia (*) calvarial bone require flap and often microsur-
Professor in Plastic Surgery, Medical School, Democritus gical reconstruction to reliably cover the bone
University of Thrace, Alexandroupolis, Greece
and prevent wound breakdown, osteomyelitis,
A. Gravvanis repeated operations, and patient distress.
Plastic, Reconstructive and Aesthetic Surgery,
Metropolitan Hospital of Athens, Athens, Greece
© Springer Nature Switzerland AG 2022 3

A. Gravvanis et al. (eds.), Clinical Scenarios in Reconstructive Microsurgery,
https://doi.org/10.1007/978-3-030-23706-6_1
4 D. D. Kakagia and A. Gravvanis
A sizeable soft issue defect, as a result of a

full thickness burn of the scalp, reconstructed
with anterolateral thigh free flap is presented.
The flap pedicle was anastomosed with the
superficial temporal vessels, which had preop-
eratively been evaluated to be appropriate as a
recipient system.
The anterolateral thigh flap provided rela-
tively thin skin to adequately and reliably
cover the extensive scalp soft tissue defect.
The flap can be harvested simultaneously
with wound debridement and the preparation
of the recipient vessels. Furthermore, it con-
tours nicely to the skull and is associated with
minimal donor site morbidity.
Recovery was uneventful and, despite
reconstruction with non-hair bearing skin, the
aesthetic outcome was satisfactory.
Keywords Fig. 1 The scalp soft tissue defect after escharectomy of

the burn wound
Free anterolateral thigh flap · Fasciocutaneous
free flap · Scalp soft tissue reconstruction ·
Scalp burns · Scalp reconstruction Treatment Plan
Due to the large size of the defect (572 cm2), a

The Clinical Scenario plan for free tissue coverage of the scalp full
thickness skin defect was developed (Leedy
A 74-year-old male sustained a full thickness burn et al. 2005; Ooi et al. 2015) and a single stage
to scalp and upper trunk following loss of con- procedure was set after three debridements of the
sciousness and fall into the fireplace. scalp burn wound and the management of trunk
Escharectomy and repeated thorough debride- burns with skin grafts.
ment of the scalp burn wound revealed a significant An extended free fasciocutaneous anterolateral
full thickness defect of the soft tissues measuring thigh (ALT) flap was planned to reconstruct the
26 cm by 22 cm and including the calvarial perios- large scalp soft tissue loss (Koshima et al. 1989;
teum of the underlying skull (Fig. 1). Wong and Wei 2010) and reliably cover the
Prior to the injury the patient had alopecia exposed calvarial bone (Ooi et al. 2015). Lateral
stage 7 according to Hamilton-Norwood classifi- thigh area presented with thin (pinch test <1 cm),
cation (Hamilton 1951; Norwood 1975). pliable skin, and despite the fact that it would not
provide the defect area with hair bearing skin, ALT
flap was chosen due to the previous advanced stage
alopecia of the aged patient (Yu 2004).
Preoperative Problem List:
Reconstructive Requirements
Alternative Reconstructive Options
1. Large full thickness soft tissue loss of the scalp
in a previously bald patient (Leedy et al. 2005; 1. Free latissimus dorsi musculocutaneous flap.
Mashkevich et al. 2008). The major disadvantage is the considerable
2. Calvarial bone exposure with periosteum loss donor site morbidity as compared to a perforator
(Lin et al. 2008; Beasley et al. 2004). flap. Another disadvantage, in the case of a large
1 Microvascular Reconstruction of Soft Tissue Defects of the Scalp 5
flap, is the necessity for change of patient posi- was not considered significant by the patient,
tion intraoperatively, that may significantly pro- due to his age and previous baldness. Most
long the operative time. The flap can be used as importantly, tissue expansion was excluded as
a muscle flap resurfaced with split thickness not a valid option due to the exposed bone and
skin graft. The muscle atrophies with time, scarred surrounding skin. Moreover, the
resulting in pliable soft tissue coverage and in necessity for repeated visits for gradual
good color and texture match with scalp skin expansion and a second operation were con-
(Pennington et al. 1989; Lin et al. 2008). ditions not accepted by the patient due to
2. Free thoracodorsal artery perforator flap social reasons.
(TDAP). Similarly, the necessity for position
change during surgery is the major disadvan-
tage of this challenging perforator flap Preoperative Evaluation and Imaging
(Heitmann et al. 2003). Skin grafting of the
donor site, in the case of a requirement for a The location and the size of the recipient vessels
large flap, is not aesthetically accepted. may influence the decision of the most appropriate
3. Free serratus anterior flap is also associated flap donor site. The superficial temporal vessels
with significant donor site morbidity and were in close proximity with the defect and could
requires turning the patient intraoperatively serve ideally as recipients. However, the superfi-
and a skin graft harvesting (Beasley et al. cial temporal artery and vein have historically not
2004; Lin et al. 2008). been considered adequate for microsurgical
4. Free DIEP flap would be probably another reconstruction and have rarely been described as
valid option. A bipedicle DIEP flap anasto- recipient vessels, mainly due to their size and their
mosed to the two superficial temporal vessels superficial location that makes them prone to
could reconstruct an extended scalp defect. compression and spasm (Hansen et al. 2007).
Nevertheless, it is more time consuming and The superficial temporal vessels were evalu-
certainly more bulky, providing less optimal ated for caliber size and patency with Duplex
contouring to the skull (Beasley et al. 2004; ultrasound (Fig. 2a) and were found appropriate
Leedy et al. 2005; Lin et al. 2008). as recipient vessels (Gravvanis et al. 2012). The
5. Staged reconstruction by tissue expansion suitability of temporal vessels smoothed the deci-
may provide hair bearing skin to a scalp defect sion for the lateral thigh as donor area, given that
(Radovan 1984; O’Reilly et al. 2012) but this there was no requirement for a very long pedicle
a b
Fig. 2 (a) Duplex ultrasound and (b) Color Doppler Ultrasonography of the superficial temporal vessels, assessed for
caliber size and patency and determined as recipient vessels
or a very long flap (e.g. latissimus dorsi flap) to

reach and cover the defect.
Both lateral thigh areas were evaluated to
determine the presence of a dominant perforator.
Although handheld Doppler is not highly specific
in identification of the dominant perforator, it is
useful to map the perforators and accordingly
design an exploration incision. On the other Fig. 3 Patient marking and location of perforators
hand, duplex ultrasonography has a 100% posi-
tive predictive value and a very low number of 2. The desired size of the flap was marked and
false-negative results. In this case, two intramus- centered over the perforators, located preop-
cular perforators were detected preoperatively eratively by the color Doppler.
by color Doppler ultrasonography (Fig. 2b) 3. The medial incision above the rectus femoris
and a large flap was designed (Gravvanis et al. muscle was then made and deepened down to
2010). the subfascial plane.
MRI or CT angiography can also be used in 4. The dissection was continued underneath the
many circumstances. deep fascia and extended laterally until the
perforators were encountered.
5. Two perforators were identified and the deci-
Preoperative Care and Patient sion to dissect both was made, in order to
Drawing ensure good vascularization of this large flap.
6. The intramuscular route of both perforators
The patient was placed in the supine position, was identified.
the leg internally rotated, and the ipsilateral hip 7. The dissection proceeded toward the intra-
elevated with a bump placed under the buttock muscular space between rectus femoris and
in order to facilitate flap harvesting. The area vastus lateralis muscle, to identify the main
proximally and distally to the thigh was pre- descending branch of the lateral circumflex
pped and draped so that the thigh was exposed femoris artery (LCFA). The lateral division of
from the inguinal ligament to just below the descending branch of the LCFA, which
the knee. enters the vastus lateralis muscle, was found.
A straight line was marked between the ante- 8. Then the intramuscular dissection of the
rior superior iliac spine and the lateral edge of the musculocutaneous perforators was performed
patella. The midpoint of this line was identified from distal (perforator entering the deep fas-
and a 3 cm radius circle was outlined (Fig. 3). The cia) to proximal (lateral division of the
perforators which are usually located within this descending branch of the LCFA) (Fig. 4).
area were detected by Color Doppler Ultrasonog- 9. The descending branch was dissected up to
raphy preoperatively (Fig. 2b). the origin of the LCFA and an adequate length
of 12 cm was obtained to facilitate microvas-
cular anastomoses.
Surgical Technique 10. The lateral incision of the skin flap was then
performed and completed the elevation of the
1. The superficial temporal vessels were first flap measuring 26 22 cm (Fig. 5).
dissected, through a preauricular incision. 11. The skin flap was inset to resurface the scalp
Good artery flow and good vein backflow, defect and then end-to-end microvascular
as well as good size vessels were recorded. anastomoses to the superficial temporal ves-
The above documented their suitability as sels were performed (Fig. 6).
recipient vessels and confirmed the preopera- 12. Special attention was paid for tension free
tive Doppler findings. anastomoses, as well as the edge of the skin
flap to cover the anastomotic area so as to

avoid any compression from the direct skin
closure over the anastomoses.
13. Following meticulous hemostasis, the donor
site closure was performed with split thick-
ness skin graft, due to the extended skin pad-
dle required for this reconstruction.
14. Light circumferential pressure was applied to
the thigh and light dressing to the head
postoperatively.
Technical Pearls
Fig. 4 Dissection toward the intramuscular space between
rectus femoris and vastus lateralis muscle revealed the
main descending branch of the LCFA which enters the 1. The key success of scalp reconstruction is the
vastus lateralis muscle. Intramuscular dissection of the selection of the recipient vessels. Superficial
musculocutaneous perforators from distal to proximal temporal vessels are in close proximity; how-
ever, they are not always of adequate size
and flow.
2. Duplex ultrasonography may provide both
anatomic and hemodynamic information for
the recipient vessels.
3. Alternatively, facial vessels may be used.
Nevertheless, the use of neck vessels may
require vein grafts or the use of a large flap
(e.g., latissimus dorsi muscle) to reach and
resurface the scalp defect.
4. Given that temporal vessels are superficially
located, avoid direct skin closure above the
anastomoses that may compress the vein.
Instead, design a large flap and inset the
Fig. 5 The ALT flap harvested with its pedicle
edge of the flap to cover the vessels and the
anastomoses.
5. The design of the ALT flap must not be
strictly committed to the handheld Doppler
perforator location. Instead, it can later be
modified depending on the location of perfo-
rators during surgery.
6. If the medial incision is placed too medial and
because the perforators may be situated more
laterally than expected, the final flap width
may not allow for direct skin closure. The
dissection must be beveled medially, to
avoid injury to the perforators if the flap is
placed too laterally.
Fig. 6 Flap inset on the scalp defect and microvascular
7. If robust perforators are visualized in the sep-
anastomoses of the flap vessels to the superficial temporal tum, then the anterior elevation can continue
pedicle until the septum is isolated both medially and
laterally. If the blood supply is entirely septal, main descending branch of the LCFA was identi-
the descending branch of the lateral femoral fied and followed by lateral division.
circumflex artery is found at the base of the The harvested flap with its pedicle is shown in
septum between the rectus femoris and vastus Fig. 5. Microanastomoses of the flap vessels to the
lateralis and traced proximally. superficial temporal vessels are presented in
8. In case no septocutaneous perforators are Fig. 6.
found, divide the thin fascia over vastus
lateralis and continue laterally over this mus-
cle, to identify the dominant intramuscular Postoperative Management
perforator.
9. Do not divide secondary perforators until the The patient was postoperatively closely moni-
major perforator has been successfully tored by physical examination and Doppler for
dissected. the first 5 days. Anticoagulant regimen included
10. It is advisable to include more than one per- low molecular heparin and oral aspirin.
forator in the case of a large flap. The patient was mobilized on Day 2. Skin graft
11. Follow the pedicle proximally until a satisfac- staples at the donor site and skin sutures at the
tory caliber artery and vein are identified. scalp were removed 2 weeks postoperatively.
There are many anatomic variations, more
frequent but certainly not confined to the
veins of the flap (Koshima et al. 1989). The Outcome: Clinical Photos and Imaging
two venae comitantes often merge into a sin-
gle vein before entering the deep femoral vein The patient experienced uneventful and fast recov-
12. In order to gain length, the pedicle can be ery and, immediately postoperatively, presented
dissected to its origin. with a satisfactory aesthetic result (Fig. 7a, b).
13. Separate gently the fascia lata from the vastus Free ALT flap provided expedient and durable
lateralis lateral to the perforators. coverage of the exposed calvarial bone and reli-
14. The flap design may need to be readjusted and able reconstruction of the soft tissue defect with a
this must be done before making the lateral thin skin paddle, nicely contouring to the scalp.
skin incision. The satisfactory cosmetic outcome contributed
15. Incise the fascia lata protecting the perforators to the return of the patient back to his social life.
and keep the dissection on the inner aspect of
the fascia.
16. Primary direct closure of the donor area is Avoiding and Managing Problems
attainable for flaps up to 9 cm in width. In
such a case, skin and subcutaneous tissue 1. The junction of the proximal and middle third
flaps are elevated medially and laterally at a of the long axis of the classically designed flap
level superficial to the fascia and closed in is often the site of a perforator that pierces the
layers with interrupted suture. A closed suc- tensor fascia lata. This point must be incorpo-
tion drain is usually used. rated in the flap to keep the TFL perforator as a
rescue vessel in the rare case the distal perfo-
rators are inadequate or injured during dissec-
Intraoperative Images tion. The junction of the middle and distal third
is marked and is also incorporated into the flap
In Fig. 3 the perforators are located, reconfirmed (Cormack 1992).
by Doppler, and marked on the skin. 2. Keep all robust perforators until the chosen
Flap elevation can be seen in Fig. 4. After perforator is successfully dissected. If the dom-
dissection of the intermuscular septum between inant perforator is injured during dissection,
the rectus femoris and the vastus lateralis, the use the next closer reliable perforator.
a b
Fig. 7 Immediate postoperative result. (a) Frontal and (b) Coronal view
3. Large flaps require more than one perforator. 3. Most of the flap is raised without committing to
Inflow dominance determines the adequacy of a final design, and the flap is intraoperatively
the chosen vessels. adjusted according to the location of the
4. The perforator pedicle must be transferred to the perforators.
donor vessel site very carefully to avoid its 4. In thin patients, ALT provides thin but durable
rotation which may cause vascular compromise coverage for scalp defects with good contouring.
and flap loss. On transfer to the head, it is
advisable that the flap be stabilized with staples
to the scalp to avoid traction during anastomosis Cross-References
or pedicle rotation (Wong and Wei 2010).
5. In the case of direct closure, seroma may occur ▶ Anterolateral Thigh (ALT) Free Flap Recon-
and it may be persistent. The use of closed struction of a Complex Chest Wall Defect
suction drain eliminates this possible compli- ▶ Anterolateral Thigh Flap for Poland’s
cation (Kimata et al. 2000). Syndrome
6. When the patient is mobilized, an increase in ▶ Composite Axillary Defect After Sarcoma
drainage is often observed, which is expected Resection: Reconstruction with Anterolateral
and subsides one or two days later. Closely Thigh Flap
monitor the patient (Kimata et al. 2000). ▶ Composite Defect of Scalp and Calvarial Bone
Following Oncological Resection
▶ Hypopharynx Reconstruction with a Chimeric
Learning Points Musculocutaneous Anterolateral Thigh Free
Flap
1. The ALT flap can provide large areas of
vascularized skin for soft tissue reconstruction
with minimal functional and cosmetic morbid- References
ity for the donor site.
2. Primary direct closure is achieved for flaps up Beasley NJ, Gilbert RW, Gullane PJ, Brown DH, Irish JC,
to 10 25 cm, a pinch test determines the Neligan PC. Scalp and forehead reconstruction using
free revascularised tissue transfer. Arch Facial Plast
maximum dimensions of the flap permitting
Surg. 2004;6:16–20.
direct skin closure. Larger skin paddle can be Cormack G. Anterolateral thigh flap: technical tip to facil-
harvested and the donor area be skin grafted. itate elevation. Br J Plast Surg. 1992;45:74.
Gravvanis A, Karakitsos D, Dimitriou V, Zogogiannis I, Lin SJ, Hanasono MM, Skoracki RJ. Scalp and
Katsikeris N, Karabinis A, Tsoutsos D. Portable duplex calvarial reconstruction. Semin Plast Surg. 2008;22:
ultrasonography: a diagnostic and decision-making tool 281–93.
in reconstructive microsurgery. Microsurgery. 2010;30: Mashkevich G, Patel AD, Urken ML. Aesthetic manage-
348–53. ment of external skin paddles following microvascular
Gravvanis A, Tsoutsos D, Delikonstantinou I, Dimitriou V, reconstruction of the head and neck. Facial Plast Surg.
Katsikeris N, Karakitsos D. Impact of portable duplex 2008;24:65–8.
ultrasonography in head and neck reconstruction. J Norwood OT. Male pattern baldness: classification and
Craniofac Surg. 2012;23:140–4. incidence. South Med J. 1975;68:1359–65.
Hamilton JB. Patterned loss of hair in man: types and O’Reilly AG, Schmitt WR, Roenigk RK, Moore EJ, Price
incidence. Ann N Y Acad Sci. 1951;53:708–28. DL. Closure of scalp and forehead defects using exter-
Hansen SL, Foster RD, Dosanjh AS, Mathes SJ, Hoffman nal tissue expander. Arch Facial Plast Surg. 2012;14:
WY, Leon P. Superficial temporal artery and vein as 419–22.
recipient vessels for facial and scalp microsurgical Ooi ASH, Kanapathy M, Ong YS, Tan KC, Tan
reconstruction. Plast Reconstr Surg. 2007;120:1879–84. BK. Optimising aesthetic reconstruction of scalp soft
Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. tissue by an algorithm based on defect size and loca-
The thoracodorsal artery perforator flap: anatomic basis tion. Ann Acad Med Singap. 2015;44:535–41.
and clinical application. Ann Plast Surg. 2003;51:23–9. Pennington DG, Stern HS, Lee KK. Free-flap reconstruc-
Kimata Y, Uchiyama K, Ebihara S, et al. Anterolateral tion of large defects of the scalp and calvarium. Plast
thigh flap donor-site complications and morbidity. Reconstr Surg. 1989;83:655–61.
Plast Reconstr Surg. 2000;106:584–8. Radovan C. Tissue expansion in soft-tissue reconstruction.
Koshima I, Fukuda H, Utunomiya R, Soeda S. The ante- Plast Reconstr Surg. 1984;74:482–92.
rolateral thigh flap; variations in its vascular pedicle. Br Wong CH, Wei FC. Anterolateral thigh flap. Head Neck.
J Plast Surg. 1989;42:260–3. 2010;32:529–640.
Leedy JE, Janis JE, Rohrich RJ. Reconstruction of Yu P. Characteristics of the anterolateral thigh flap in a
acquired scalp defects: an algorithmic approach. Plast Western population and its application in head and
Reconstr Surg. 2005;116:54e–72e. neck reconstruction. Head Neck. 2004;26:759–69.
Composite Defect of Scalp and Calvarial
Bone Following Oncological Resection 2
Contents
The Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Preoperative Problem List- Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Alternative Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Preoperative Evaluation and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Preoperative Care and Patient Drawing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Technical Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Intraoperative Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Postoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Outcome- Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Avoiding and Managing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Abstract
Squamous cell carcinomas developing on the

scalp are often aggressive and may invade to
the calvarium and through it to the dura mater.
D. D. Kakagia (*) Wide excision is necessary and reconstruction
Professor in Plastic Surgery, Medical School, Democritus may be challenging depending on the size and
University of Thrace, Alexandroupolis, Greece depth of the resulting defects.
e-mail: dkakagia@med.duth.gr
A 62-year-old man, presented with a deep
A. Gravvanis ulcerative neglected squamous cell carcinoma

https://doi.org/10.1007/978-3-030-23706-6_2
of the scalp extending to the underlying calvar-

ium without lymph node involvement.
Wide excision of the lesion resulted in a
composite soft tissue, bony, and dura mater
defect. The dura was reconstructed with lyoph-
ilized bovine pericardium, the osseous
calvarial defect with Medpor, while free ante-
rolateral thigh flap was used to provide soft
tissue cover.
The postoperative course was uneventful
and the patient underwent adjunct radiotherapy
two months postoperatively without any unto-
ward sequelae. During a 5 year follow up the
patient remains recurrence and metastasis free Fig. 1 The tumor of the scalp measuring 7 7 cm
with a good cosmetic outcome.
Scalp reconstruction of composite defects
resulting from oncologic resection with ALT
free flap is an option providing reliable and
durable coverage of the underlying
reconstructed structures especially in view of
future radiation therapy.
Keywords
Scalp squamous cell carcinoma · Composite

scalp reconstruction · Calvarial bone
reconstruction · Free anterolateral thigh flap ·
Dura mater reconstruction
The Clinical Scenario
A 62-year-old gardener presented with an ulcerat-

ing and partially crusted squamous cell carcinoma
(SCC) of his scalp that had been left untreated for
at least 1 year (Fig. 1). The patient, otherwise
healthy, had been advised by a dermatologist to
have the lesion excised, but he delayed and
instead attempted self-treatment by application
of “several creams” on the lesion. Fig. 2 CT scan showing invasion of the tumor to the
underlying calvarial bone
The tumor comprised a 7 7 cm full thickness
cutaneous lesion extending to the calvarium, but
caused no headache or any neurological symp- Computed tomography (CT) scan showed
toms to the patient. calvarial invasion at the cranial vertex (Fig. 2)
The cultures of the crusts showed normal and axial view of brain showed possible invasion
cutaneous bacterial flora without indication of to the dura mater. No distant or lymph node metas-
infection. tases were found at the tumor staging work out.
2 Composite Defect of Scalp and Calvarial Bone Following Oncological Resection 13
Preoperative Problem formation, which results in rapid, durable implant

List- Reconstructive Requirements fixation and makes it more resistant to bacterial
infection (Wellisz et al. 1992).
1. Necessity for wide tumor excision (LeBoeuf The patient was counseled regarding possible
and Schmults 2011) and requirement to cover sequelae of fasciocutaneous ALT flap harvest,
the calvarial reconstruction with well perfused including possible need to cover the flap donor
soft tissue, durable and reliable in view of site with a skin graft, visible scar, surgical wound
postoperative radiotherapy (Afifi et al. 2010; dehiscence and infection, variable lateral thigh
Van Tuyl and Gussack 1991). paresthesia, donor site pain, and possible limited
2. Requirement to reconstruct three tissue sub- range of motion of the hip and the knee (Kimata
units: the scalp subunit, the calvarial defect, et al. 2000).
and the dura defect after tumor resection (Afifi
et al. 2010; Earley et al. 1990; Pennington et al.
1989; Leedy et al. 2005; Lin et al. 2008). Alternative Reconstructive Options
3. Dura mater defect measuring 6X7cm after
debridement. 1. Cranioplasty with autologous osseous grafts,
4. Calvarial defect measuring 8X8 cm following such as split calvarial (Lin et al. 2008; Chang
removal of the invaded cranial part. et al. 2010; Pennington et al. 1989) or rib grafts
5. Full thickness cutaneous scalp defect measur- (Chang et al. 2010; Earley et al. 1990) was not
ing 10x10 cm after tumor wide resection a good option as the exact calvarial defect was
6. Lack of adequate and reliable soft tissue at the not known prior to the tumor excision and
remaining scalp more than one donor sites would be required,
7. No need to cover with hair bearing skin in this increasing the complexity and duration of the
particular patient as he had had advanced operation, and the risk for complications.
alopecia. 2. Local scalp flaps for soft tissue cover of the
cranioplasty were not considered as reliable
due to their relative inelasticity, not responding
Treatment Plan to the requirement of tension-free reconstruc-
tion (Lin et al. 2008).
A plan for all three subunits reconstruction at one 3. Staged soft tissue reconstruction by tissue
stage was set. expansion (Manders et al. 1984) would possi-
Reliable soft tissue coverage had to be ensured, bly result in critical delay in tumor excision.
so that, the cranioplasty would be effectively cov- 4. Microsurgical flap reconstruction is considered
ered. Free fasciocutaneous anterolateral thigh to be the most reliable option for large scalp
(ALT) flap was planned to reconstruct the soft defects, especially in view of future radiation
tissue defect of the skull (Koshima et al. 1989; therapy (Lin et al. 2008; Chang et al. 2010;
Wong and Wei 2010), following dura mater oblit- Pennington et al. 1989; Earley et al. 1990).
eration with lyophilized bovine pericardium and 5. Free serratus anterior (Ueda et al. 1993) or
calvarial reconstruction with Medpor at one stage. latissimus dorsi (Harii et al. 1982) or
Lyophilized bovine pericardium has long been thoracodorsal artery perforator (Heitmann
used for reconstruction of dura defects and in et al. 2003) flaps would, however, require
terms of durability, reliability, and flexibility is intraoperative change of patient position, thus
considered by far superior to human lyophilized increasing operative time.
dura mater (Laun et al. 1990). 6. Free radial forearm flap would possibly pro-
Medpor is a porous polymer with regularly long the patient’s absence from work
spaced pores that allow significant tissue ingrowth (Santamaria et al. 2000; Earley et al. 1990;
instead of surrounding fibrous tissue capsule Lin et al. 2008; Pennington et al. 1989).
7. Free greater omentum (Lin et al. 2008; Surgical Technique

Pennington et al. 1989; Chang et al. 2010)
would involve intra-abdominal surgery A two-team setup was organized to minimize
and skin grafting, providing dubious soft operative time.
tissue coverage of the polymer used for
cranioplasty. 1. Surgery began with the scalp lesion removal
8. Free rectus abdominus (Jones et al. 1986) with at least 1.5-cm margin (10 10 cm
would weaken the abdominal wall of this oth- diameter defect), followed by craniectomy
erwise physically active patient, while DIEP (8 8-cm diameter calvarial bone defect)
(Beasley et al. 2004; Leedy et al. 2005; Lin and debridement of the dura, resulting in a
et al. 2008; Ozkan et al. 2005) flap would be 6 7 cm dural defect (Fig. 3a).
more time consuming and bulky and would
provide suboptimal contouring (Chang et al.
a
2010; Lin et al. 2008).
Preoperative Evaluation and Imaging
Both lower extremities were evaluated to exclude

the presence of any disease and to ascertain the
pulse status of the patient.
Although Doppler is not highly specific in
identification of the dominant perforator, it is use-
ful to map the perforators and accordingly outline
the paddle. A pinch test was performed, to check b
for direct closure of the donor site.
Preoperative angiograms were obtained as a
guide.
The superficial temporal vessels were evalu-
ated for caliber size and patency with Doppler and
were found suitable as recipient vessels.
Preoperative Care and Patient

Drawing
The patient was placed in the supine position, the

ipsilateral hip elevated and the leg internally
rotated. A bump was placed under the buttock
to facilitate flap harvesting and the area proxi-
mally and distally to the thigh was prepped and
draped so that the entire anterior thigh from the
inguinal ligament to just below the knee was
exposed.
A straight line from the anterior iliac spine to
the lateral border of the patella was drawn and a
Fig. 3 (a) The extensive scalp soft tissue, calvarial bone
mark 2 cm lateral to the midpoint of this line was
and dura mater defect after wide tumor excision and (b).
made. The dominant perforator was located at The inset of lyophilized bovine pericardium to reconstruct
2 cm medial to this point. the dura defect
2. The dural defect was covered by a sheet of 8. The dominant vessel was chosen was of ade-
lyophilized bovine pericardium tailored to fit quate size, inflow dominance was assessed by
the defect (Fig. 3b) and was covered by temporary clamping, and was traced through
Medpor porous implant (Fig. 4). the muscle to the descending branch. The
3. The flap harvest commenced with the medial posterior flap was then dissected.
incision. The anterior flap was elevated first 9. The perforator and pedicle were dissected.
and the subcutaneous dissection was The distal aspect of the artery and veins
extended medially. were ligated and divided, and the flap was
4. Then the deep fascia was incised on the sur- raised on the vascular pedicle.
face of the rectus femoris and the incision was 10. The superficial temporal artery and vein were
extended longitudinally, checking for any selected as suitable recipient vessels and were
vessels perforating the rectus femoris muscle prepared for anastomoses to the ALT flap
and preserving vessels near the septum until pedicle.
the posterior flap was elevated and the perfo- 11. After microvascular anastomoses to the
rator vessels to the flap had been identified. superficial temporal vessels were completed,
5. The posterior flap was elevated toward the the skin paddle was placed and sutured on the
septum, checking for any major perforating scalp to resurface it.
vessels through the vastus lateralis muscle. 12. Following meticulous hemostasis, the donor
The lower perforator identified through the site was primarily closed. Skin and subcuta-
vastus lateralis was dissected to the neous tissue flaps were elevated superficially
descending branch of the lateral circumflex to the fascia and closed in layers with
femoral artery (LCFA). The septum was iden- interrupted suture. A closed suction drain
tified and any septal perforators were identi- was used.
fied and evaluated for adequacy to perfuse the 13. Light circumferential pressure was applied to
flap. After elevation of the posterior flap, the the thigh post-operatively.
perforators to the flap were surrounded.
6. The musculocutaneous perforators perfusing
the flap were dissected through the muscle Technical Pearls
until they met the pedicle and the muscular
perforators were dissected free. 1. The design of the flap must not be strictly
7. The anterior muscle was cut and “de-roofing” committed to the Doppler perforator location.
was performed with all the perforators that Instead, it can later be modified depending on
were skeletonized from distal to proximal. the location of perforators during surgery.
2. If the medial incision is placed too medial and
because the perforators may be situated more
laterally than expected, the final flap width
may not allow for direct skin closure. The
dissection must be beveled medially, to
avoid injury to the perforators if the flap is
placed too laterally.
3. Initial identification of the perforators is eas-
ier on the opposite side of the patient, so keep
the fascia elevated and observe from the
opposite side.
4. If robust perforators are visualized in the sep-
tum, then the anterior elevation can continue
until the septum is isolated both medially and
Fig. 4 Medpor fixed to reconstruct the calvarial bone laterally. If the blood supply is entirely septal,
defect the descending branch of the LCFA is found
at the base of the septum between the rectus Postoperative Management

femoris and vastus lateralis and traced
proximally. The patient was postoperatively closely moni-
5. In case no septocutaneous perforators are tored by physical examination and Doppler for
found, divide the thin fascia over vastus the first 5 days. Anticoagulant regimen included
lateralis and continue to skeletonize laterally low molecular heparin and oral aspirin.
over this muscle He was also monitored for development of
6. Do not divide secondary perforators until the thigh compartment syndrome, was mobilized on
major perforator has been successfully Day 2, and the drain at the thigh was removed on
dissected Day 4. Skin sutures at the donor site and the scalp
7. It is advisable to include more perforators were removed 2 weeks postoperatively.
even in small flaps if they are closely
located.
8. To open the fascia of the rectus femoris easily, Outcome- Clinical Photos and Imaging
make a small incision, slide your index
between the muscle and the thin fascia and The recovery period for this patient was fast and
then incise it. uneventful (Fig. 5a, b). Two months postopera-
9. Focus on the surface of the vessels and follow tively, the patient received radiation therapy and
their course carefully to avoid accidental 1 year postoperatively presented with a satisfac-
injury. Follow the pedicle proximally until a tory aesthetic result (Fig. 6), which contributed
satisfactory caliber artery and vein are identi- to the return of the patient back to his social life.
fied. There are many anatomic variations, After 5 years the patient remains recurrence
more frequent but certainly not confined to and metastases free.
the veins of the flap (Koshima et al. 1989). Free ALT flap provided expedient and durable
The two venae comitantes often merge into a coverage of the exposed calvarial bone and reli-
single vein before entering the deep able reconstruction of the soft tissue defect with a
femoral vein thin skin paddle, nicely contouring to the scalp.
10. In order to gain length, the pedicle can be
dissected to its origin.
11. Separate gently the fascia lata from the vastus Avoiding and Managing Problems
lateralis lateral to the perforators.
12. The flap design may need to be readjusted and 1. The junction of the proximal and middle third
this must be done before making the lateral of the long axis of the classically designed flap
skin incision. is often the site of a perforator that pierces the
13. Incise the fascia lata protecting the perforators tensor fascia lata. This point must be incorpo-
and keep the dissection on the inner aspect of rated in the flap to keep the TFL perforator as a
the fascia. rescue vessel, in the rare case the distal perfo-
14. Primary direct closure of the donor area is rators are inadequate or injured during dissec-
attainable for flaps up to 10 cm. tion. The junction of the middle and distal third
is marked and is also incorporated into the flap
(Cormack 1992).
Intraoperative Images 2. All robust perforators must be kept until the
chosen perforator is successfully dissected.
The composite scalp, calvarium, and dura mater 3. Large flaps require more than one perforator.
defect after debridement (Fig. 3a) and the inset of Inflow dominance determines the adequacy of
lyophilized bovine pericardium to reconstruct the the chosen vessels.
dura (Fig. 3b). 4. Avoid rotation of the perforator pedicle in
Medpor fixation at the calvarial bone is shown order to avoid vascular compromise and flap
in Fig. 4. loss. On transfer to the head, it is advisable that
a b
Fig. 5 (a) and (b). Immediate postoperative result with the thin ALT skin providing optimal contouring
5. When the patient is mobilized, an increase in

drainage is often observed, which is expected
and subsides one or two days later. Closely
monitor the patient. In the case of direct clo-
sure, seroma may occur and it may be persis-
tent (Kimata et al. 2000).
Learning Points
1. Cutaneous SCC of the scalp may invade to the

calvarial bone and through it to the dura mater
and the brain. The size and depth of the tumor
determines the prognosis.
2. Resection of invasive SCC is often followed by
postoperative radiation therapy.
3. Composite scalp defects following oncologic
resection require reliable soft tissue reconstruc-
tion to effectively cover the cranioplasty. Free
flaps ensure adequacy, durability, and reliabil-
ity of reconstruction with healthy and well
Fig. 6 Improved contour of the flap 1 year postoperatively vascularized tissue without tension.
and after radiation therapy 4. Free ALT flap is a versatile flap for head and neck
reconstruction, providing abundant and pliable
skin, for scalp soft tissue reconstruction. It has
the flap be stabilized with staples to the scalp to been found reliable in soft tissue reconstruction
avoid traction during anastomosis or pedicle of composite scalp and calvarial bone defects in
rotation (Wong and Wei 2010). view of postoperative radiation therapy.
5. Careful design and meticulous dissection dur- Jones NF, Sekhar LN, Schramm VL. Free rectus abdominis
ing elevation of the flap and closure of the muscle flap reconstruction of the middle and posterior
cranial base. Plast Reconstr Surg. 1986;78:471–7.
donor site without tension minimize possible Kimata Y, Uchiyama K, Ebihara S, et al. Anterolateral
complications. thigh flap donor-site complications and morbidity.
Plast Reconstr Surg. 2000;106:584–8.
Koshima I, Fukuda H, Utunomiya R, Soeda S. The ante-
rolateral thigh flap; variations in its vascular pedicle. Br
Cross-References J Plast Surg. 1989;42:260–3.
Laun A, Tonn JC, Jerusalem C. Comparative study of
▶ Microvascular Reconstruction of Soft Tissue lyophilized human dura mater and lyophilized bovine
Defects of the Scalp pericardium as dural substitutes in neurosurgery. Acta
Neurochir. 1990;107:16–21.
▶ Reconstruction of Calvarial Bone Radio- LeBoeuf NR, Schmults CD. Update on the management of
necrosis and Osteomyelitis high-risk squamous cell carcinoma. Semin Cutan Med
Surg. 2011;30:26–34.
Leedy JE, Janis JE, Rohrich RJ. Reconstruction of
acquired scalp defects: an algorithmic approach. Plast
References Reconstr Surg. 2005;116:54e–72e.
Lin SJ, Hanasono MM, Skoracki RJ. Scalp and calvarial
Afifi A, Djohan RS, Hammert W, Papay FA, Barnett AE, reconstruction. Semin Plast Surg. 2008;22:281–93.
Zins JE. Lessons learned reconstructing complex scalp Manders EK, Schenden MJ, Furrey JA, et al. Skin expan-
defects using free flaps and a cranioplasty in one stage. sion to eliminate large scalp defects. Plast Reconstr
J Craniofac Surg. 2010;21:1205–9. Surg. 1984;74:493–507.
Beasley NJ, Gilbert RW, Gullane PJ, Brown DH, Irish JC, Ozkan O, Coskunfirat OK, Ozgentas HE, et al. Rationale
Neligan PC. Scalp and forehead reconstruction using for reconstruction of large scalp defects using the ante-
free revascularized tissue transfer. Arch Facial Plast rolateral thigh flap: structural and aesthetic outcomes. J
Surg. 2004;6:16–20. Reconstr Microsurg. 2005;21:539–45.
Chang KP, Lai CH, Chang CH, Lin CL, Lai CS, Lin Pennington DG, Stern HS, Lee KK. Free-Flap Reconstruc-
SD. Free flap options for reconstruction of complicated tion of Large Defects of the Scalp and Calvarium. Plast
scalp and calvarial defects: report of a series of cases Reconstr Surg. 1989;83:655–61.
and literature review. Microsurgery. 2010;30:13–8. Santamaria E, Granados M, Barrera-Franco JL. Radial
Cormack G. Anterolateral thigh flap: technical tip to facil- forearm free tissue transfer for head and neck recon-
itate elevation. Br J Plast Surg. 1992;45:74. struction: versatility and reliability of a single donor
Earley MJ, Green MF, Millang MA. A critical appraisal of site. Microsurgery. 2000;20:195–201.
the use of free flaps in primary reconstruction of com- Ueda K, Harashina T, Inoue T, Tanaka I, Harada
bined scalp and calvarial cancer defects. Br J Plast T. Microsurgical scalp and skull reconstruction using
Surg. 1990;43:283–9. a serratus anterior myoosseous flap. Ann Plast Surg.
Harii K, Yamada A, Ishihara K, Miki Y, Itoh M. A free 1993;31:10–4.
transfer of both latissimus dorsi and serratus anterior Van Tuyl R, Gussack GS. Prognostic factors in craniofacial
flaps with thoracodorsal vessel anastomoses. Plast surgery. Laryngoscope. 1991;101:240–4.
Reconstr Surg. 1982;70:620–9. Wellisz T, Dougherty W, Gross J. Craniofacial applications
Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen for the Medpor porous polyethylene flexblock implant.
RJ. The Thoracodorsal Artery Perforator Flap: Ana- J Craniofac Surg. 1992;3:101–7.
tomic Basis and Clinical Application. Ann Plast Surg. Wong CH, Wei FC. Anterolateral thigh flap. Head Neck.
2003;51:23–9. 2010;32:529–640.
Reconstruction of Calvarial Bone
Radionecrosis and Osteomyelitis 3
Andreas Gravvanis and Despoina D. Kakagia
Contents
Preoperative Problem List: Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Preoperative Evaluation and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Outcome: Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Abstract
Osteoradionecrosis of the skull remains a com-

mon and life-threatening complication of radi-
ation therapy in cancer patients. This necrotic
process may develop in the skull after high-
A. Gravvanis (*) dose radiation therapy, is slowly progressing
Plastic, Reconstructive and Aesthetic Surgery, and is challenging to manage.
A 30-year-old woman, who had undergone
D. D. Kakagia brain surgery for temporal astrocytoma
Professor in Plastic Surgery, Medical School, Democritus
University of Thrace, Alexandroupolis, Greece followed by radiation therapy, presented

https://doi.org/10.1007/978-3-030-23706-6_3
20 A. Gravvanis and D. D. Kakagia
4 years later with extrusion of the cranioplasty

fixation clamp discs and signs of soft tissue
inflammation around them.
Thorough debridement of the necrotic bone
was followed by soft tissue reconstruction of
the temporoparietal area with a free radial fore-
arm fasciocutaneous flap.
The postoperative course was uneventful and
the calvarial bone reconstruction was performed
at a second stage with the use of methyl-
methacrylate plate, which was successfully cov-
ered by the previously reconstructed soft tissue.
Skull osteoradionecrosis management
requires meticulous debridement of the
necrotic tissue and cover with durable soft
tissue. Free radial forearm flap is a reconstruc-
tive option providing abundant and reliable
coverage for the cranioplasty.
Keywords
Scalp reconstruction · Calvarial

osteoradionecrosis · Radiation necrosis · Free
radial forearm flap · Brain astrocytoma
A 30-year-old female presented with extrusion of

Fig. 1 Exposed discs from previous cranioplasty after
cranioplasty fixation discs and a contour depres- astrocytoma extirpation, with mild skin inflammation.
sion at the right temporal area (Fig. 1). The patient (Note the temporoparietal area depression due to
had undergone excision of temporal astrocytoma osteoradionecrosis of the underlying calvarial bone flap)
and subsequent cranioplasty with the use of spin
soft. The cultures of the crusts around the extruded
down fixation clamps, followed by high-dose
discs showed Pseudomonas aeruginosa and Staph-
radiation therapy. Four years later, she noticed
ylococcus aureus. Axial computed tomography
the extrusion and exudate around the fixation
scan showed a bony sequestrum in the right tem-
discs. Osteoradionecrosis of the temporal bone
poral area. Axial view of magnetic resonance of
was impressed, and confirmed by study of osteo-
brain showed extensive deep white matter edema
myelitis including Galium-67 citrate scan (Ga-67)
involving the left fronto-parieto-temporal lobe with
and Technetium-99m methylene diphosphonate
mass effect indicating late temporal lobe necrosis
(Tc-99m-MDP) scans, while repeated biopsy did
following the radiation therapy (Fig. 2).
not show tumor recurrence. The patient received
serial management, including oral and intrave-
nous antibiotics, and local treatment for 1 year. Preoperative Problem List:
Consequently, the neurosurgeons referred the Reconstructive Requirements
patient to us. On examination, the patient had no
meningeal signs and symptoms and no neurologi- 1. Osteoradionecrosis of the calvarial flap previ-
cal motor deficit was revealed. The skin around the ously raised for brain tumor extirpation
extruded discs was erythematous and the hollow (Kveton 1988; Leonetti et al. 1997; Lin et al.
depression covering the right temporal area was 2008; Marx 1983; Ramsden et al. 1975).
3 Reconstruction of Calvarial Bone Radionecrosis and Osteomyelitis 21
temporoparietal area, (Chou et al. 2017; Earley

et al. 1990; Kveton 1988; Lin et al. 2008;
Pennington et al. 1989; Santamaria et al. 2000),
while calvarial reconstruction would follow at a
second stage. Reliable soft tissue coverage had to
be ensured so that, the methyl methacrylate
(MMA) implant to be used for cranioplasty
would be effectively covered (Lin et al. 2008;
Nguyen et al. 2011; Raggio and Winters 2018;
Robson et al. 1989).
So the first stage, which is presented herein,
involved the reconstruction of the temporoparietal
soft tissue defect with a free radial forearm flap.
The patient was properly counselled regarding
possible sequelae of flap harvest, including a vis-
ible scar, hypertrophic scarring necessitating the
use of a pressure garment, loss of a skin graft,
variable sensory loss over the radial thenar region,
the metacarpal region of the dorsum of the thumb
or the dorsal hand and claudication (Santamaria
et al. 2000).
Fig. 2 CT scan of the calvarial osteoradionecrosis

2. Inflamed soft tissue around the extruded
cranioplasty fixation clamp discs (Robson 1. Single-stage operation: cranioplasty covered
et al. 1989). with any flap was not a real option as the
3. Lack of adequate and reliable soft tissue at the exact calvarial defect was not known prior to
remaining previously raised the thorough debridement of the necrotic bone
temporoparietal flap. (Afifi et al. 2010; Chang et al. 2010; Fisher and
4. Requirement to debride all the necrotic bone Jackson 1989). Furthermore, the use of an
together with the skin surrounding the implant pre-requires an inflammation/infec-
extruded plates (Chang et al. 2010; Lin et al. tion-free environment. The long-standing
2008). extrusion of the infected fixation discs was far
5. Requirement to reconstruct two tissue sub- from an ideal condition (Nguyen et al. 2011;
units: the right temporoparietal scalp subunit Raggio and Winters 2018; Ramsden et al.
and the temporal calvarial defect after the thor- 1975; Robson et al. 1989).
ough debridement (Afifi et al. 2010; Nguyen 2. Single-stage reconstruction with split calvarial
et al. 2011; Raggio and Winters 2018; Chou (Lin et al. 2008; Chang et al. 2010; Pennington
et al. 2017). et al. 1989) or rib grafts (Chang et al. 2010;
Earley et al. 1990) and fasciocutaneous/
musculocutaneous flap coverage would
Treatment Plan require more than one donor sites, increasing
the complexity and duration of the operation,
A plan for individual unit temporoparietal area and the risk for complications. Local scalp
soft tissue reconstruction and calvarial reconstruc- flaps are not appropriate for this type of
tion at a two-stage procedure was set. reconstruction, due to the requirement for
Free fasciocutaneous radial forearm flap was tension-free reconstruction (Lin et al. 2008).
planned to reconstruct the soft tissue defect of the Microsurgical flap reconstruction is considered
to be the most reliable option for large scalp Preoperative Care and Patient
defects, especially those occurring in the set- Drawing
ting of compromised tissues (Chou et al. 2017;
Earley et al. 1990). A two-team setup was organized in order to min-
3. Staged soft tissue reconstruction by tissue imize the operative time.
expansion (Manders et al. 1984) would require With the patient placed in the supine position,
multiple visits for inflation of the expander and the arm placed on an arm board with the shoulder
possibly critical time loss. abducted at ninety degrees to the patient, without
4. Staged reconstruction with serratus anterior hyperextension or hyperabduction of the shoul-
(Ueda et al. 1993) or latissimus dorsi (Harii der. The radial artery was palpated and marked at
et al. 1982) would require intraoperative the wrist between the brachioradialis and flexor
change of patient position, thus increasing carpi radialis tendons. Then it was palpated prox-
operative time. imally and its course was marked on the skin up to
5. Staged reconstruction using greater omentum the medial cubital fossa.
(Lin et al. 2008; Pennington et al. 1989; The superficial veins were delineated by infla-
Chang et al. 2010; Raggio and Winters 2018) tion of the tourniquet just above the diastolic
would involve intra-abdominal surgery and pressure and were drawn in the middle and lateral
skin grafting, achieving a soft tissue recon- forearm.
struction of dubious reliability in covering The flap outline together with the pedicle exit
the calvarial MMA implant, while rectus side were drawn in the forearm. The flap was
abdominus (Jones et al. 1986) would weaken centered over the radial artery and extended later-
the abdominal wall of this otherwise physi- ally in order to include the lateral intermuscular
cally active patient. septum and the cephalic vein (Fig. 3).
6. Staged reconstruction with soft tissue provided
by DIEP or ALT (Ozkan et al. 2005) flaps
would provide bulky tissue and suboptimal
contouring, though it would have been consid-
ered if a requirement for a large skin paddle
had been anticipated (Chang et al. 2010; Lin
et al. 2008; Nguyen et al. 2011; Raggio and
Winters 2018).
The left arm was examined for scars, previous

injuries, and skin deformities. Modified Allen's
test was used to assess the adequacy of the
ulnar artery and cross-flow through the palmar
vascular arches of the left hand. One of the
advantages of the RFF for head and neck
reconstruction is the possibility for two surgical
teams to work simultaneously on the same side
of the patient. However, it is preferable to have
the operating arm board on the contralateral
side to the recipient site and furthermore, to
harvest the flap from the side of the non-
dominant hand. Fig. 3 Design of free radial forearm fasciocutaneous flap
The arm was elevated and without exsangui- 5. The ligation of the vessels distally just above
nations, the padded tourniquet was inflated at the deep fascia facilitates later on the plane of
225 mmHg and the exact time of inflation was suprafascial dissection.
recorded. 6. Then the dissection processes form the ulnar
and the radial borders of the flap at the sub-
cutaneous plane until the radial side of the
Surgical Technique flexor carpi radialis ulnar side of
brachioradialis are encountered.
1. Thorough debridement of the necrotic bone 7. At these points, the superficial layer of the
and compromised skin reveals a 10 cm two layers of deep forearm fascia is divided,
11 cm soft tissue defect to be reconstructed preserving the ensheathing septal perforators
by RFF (Fig. 4). and the dissection continues underneath the
2. The RFF flap is elevated under tourniquet and radial vessels.
with loupe magnification using the supra- 8. The conjoining of the two layers of the deep
fascial dissection technique (Gravvanis et al. forearm fascia and its deep layer are pre-
2007). served, and the flap elevation from this point
3. The flap dissection is commenced distally. proceeds mainly from distal to proximal.
4. The radial vessels are identified distally and 9. The superficial radial nerve and the lateral
freed from the underlying deep forearm fas- antecubital nerve are also preserved. The
cia, which is easily identified. proximal pedicle dissection is then completed
in the conventional manner and a superficial
vein may be included if required.
10. The entire donor site remains covered with the
well-vascularized deep fascia, preventing the
exposure and tending of the flexor tendons
11. The cephalic vein is selected as the draining
vessel, is dissected into the cubital fossa and
divided to the desired length.
12. The tourniquet is deflated. Any bleeding ves-
sels from the donor site and the flap are
coagulated.
13. A flap sized 10 cm 11 cm is harvested
(Fig. 5).
Fig. 4 Thorough debridement of the necrotic bone and

compromised skin. A 9 cm 7 cm calvarial defect expos-
ing the dura and a 10 cm 11 cm soft tissue defect to be
reconstructed by free RFF. Preparation of the facial artery
and vein as recipient vessels for the microvascular
anastomosis Fig. 5 The harvested free RFF with its vascular pedicle
14. The facial artery and vein are the selected Technical Pearls
recipient vessels, are prepared and anasto-
mosed with the flap pedicle. 1. If the Allen's test reveals an incomplete pal-
15. The donor site is covered primarily with mar arch, the RFF can still be harvested by
Integra artificial skin (Fig. 6). A dorsal sup- reconstructing the radial defect with a reverse
port splint is used. saphenous vein or cephalic vein grafting.
16. Fourteen days later, an ultrathin epidermal 2. Decide the exit side of the flap vascular ped-
autograft from the thigh area is applied over icle depending on the side of the head the
the newly formed neodermal tissue under anastomosis will be performed on. Design
local anesthesia (Fig. 7). Full range of hand the flap so that the pedicle exits on the edge
motion is allowed in 4 days. closest to the anastomosis site.
3. Decide the most favorable position for the
flap pedicle so to avoid kinking.
4. Determine the pedicle length required and
draw the flap as distal as necessary.
5. The flap may be placed more medially if an
osteocutaneous flap is to be used to provide
more skin and soft tissue to cover the area of
bone harvesting and protect probable plating.
6. Do not extend the flap too lateral, as the super-
ficial radial nerve may be inadequately covered
by skin and cause sensitivity. Also the aesthetic
outcome of the donor site may be compromised.
7. The lateral part of the skin flap does not need
Fig. 6 Integra artificial dermis was used to cover the deep to extend fully to the cephalic vein, as long as
forearm fascia the intervening subdermal tissue between the
skin flap and vein is preserved.
8. The dissection starts from distal to proximal
and from lateral to medial. The
brachioradialis tendon commonly covers the
artery either partially or completely. During
flap elevation and dissection, keep this in
mind to protect the perforators. Dissect the
brachioradialis like opening a book.
9. The distance between the recipient artery and
vein must allow the donor vessels to reach both
vessels comfortably, although this is not a prob-
lem when the cephalic vein is used as it is
totally separate from the main vascular pedicle.
10. Occasionally a very large dominant median
vein of the forearm can be used. Avoid using
venae comitantes for anastomoses, due to
their small size.
11. The recipient artery is selected according to
size, access, and position to avoid kinking or
excessive tension. The facial artery is most
Fig. 7 Complete take of the Integra artificial dermis over
commonly used, although the superior thy-
the deep forearm fascia by day 14 was followed by ultra-
thin split-thickness skin grafted that ensured excellent roid artery or even the transverse cervical
healing and cosmetic outcome artery may in some cases be a better choice.
Intraoperative Images The flap was postoperatively closely moni-

tored by physical examination and Doppler for
Figure 4 Thorough debridement of the necrotic the first 5 days.
bone and compromised skin. A 9 cm 7 cm Anticoagulant regimen included low molecu-
calvarial defect exposing the dura and a 10 cm lar heparin.
11 cm soft tissue defect to be reconstructed by RFF.
Preparation of the facial artery and vein as recipient
vessels for the microvascular anastomosis. Outcome: Clinical Photos and Imaging
Figure 5 The harvested free RFF with its vas-
cular pedicle. The patient experienced uneventful and fast recov-
Figure 6 Bilayer Integra artificial dermis is ery. Although the flap was hairless, the area could
used to cover the donor area. be effectively covered by the surrounding long hair
Figure 7 Ultrathin skin graft is used to cover (Fig. 9). The functional and cosmetic outcome allo-
the donor site after removal of the external sili- wed the patient to go home soon after the operation.
cone layer of Integra, 14 days after the RFF Two months postoperatively, the patient
harvest. underwent calvarial bone reconstruction with
Figure 8 Inset of the RFF. The remaining tem- methyl methacrylate implant under the
poral healthy skin was transposed. A subcutane- reconstructed soft tissue.
ous tunnel was created to pass the vascular pedicle Free radial forearm flap provided a reliable and
to the submandibular area close to the facial durable cover for the implant.
vessels. The patient was very satisfied with the overall
outcome.
Postoperative Management
The patient was splinted for 10 days, to immobi-

lize the wrist, with the fingers kept free. She was
allowed to use the donor hand as tolerated. Gentle
physiotherapy commenced the first postoperative
day. Elevation was strongly advised to minimize
edema and promote skin graft healing.
Fig. 8 Inset of the RFF. The remaining temporal healthy

skin was transposed. A subcutaneous tunnel was created to
pass the vascular pedicle to the submandibular area close to Fig. 9 Postoperative result after soft tissue reconstruction
the facial vessels with RFF and prior to calvarial bone reconstruction
Avoiding and Managing Problems 3. Free flaps ensure adequacy, durability, and reli-
ability of reconstruction with healthy, non-
1. Do not extend the flap too far over the lateral irradiated, and well vascularized tissue
aspect of the forearm, as the superficial radial without tension.
nerve may be inadequately covered by skin and 4. Free radial forearm flap is a versatile flap
cause sensitivity. Furthermore, the aesthetic out- with a long and reliable pedicle for head
come of the donor site may be compromised. and neck reconstruction, providing thin
2. If the flap is designed too medially, the cephalic and pliable, though relatively hairless
vein may be positioned too laterally to be skin for temporoparietal area soft tissue
safely used as the draining vein. reconstruction.
3. Identify the superficial branch of the radial 5. Careful flap design and meticulous dissection
nerve lateral to the brachioradialis and medial during elevation of the flap, preserving the
to the extensor pollicis brevis and abductor forearm fascia and identifying radial artery
pollicis longus and preserve it. perforators and the superficial radial nerve,
4. Preserve the epitenon of the muscles. It is cru- minimize possible complications.
cial to provide a well perfused bed for skin
grafting of the donor site if required.
5. Suprafascial dissection of the radial forearm Cross-References
flap creates a superior graft recipient site and
is an acknowledged method of enormous ▶ Microvascular Reconstruction of Soft Tissue
value. Defects of the Scalp
6. The use of Integra artificial skin is a valuable
advancement to further minimize the donor site
morbidity and results in excellent functional
and esthetic outcomes.
References
7. Dissect the brachioradialis like opening a book Afifi A, Djohan RS, Hammert W, Papay FA, Barnett AE,
from lateral to medial and from proximal to Zins JE. Lessons learned reconstructing complex scalp
distal. This will facilitate identification of all defects using free flaps and a cranioplasty in one stage.
perforators. J Craniofac Surg. 2010;21:1205–9.
Chang KP, Lai CH, Chang CH, Lin CL, Lai CS, Lin
8. Be cautious when using venae comitantes for SD. Free flap options for reconstruction of complicated
anastomoses. Although reliable, are occasion- scalp and calvarial defects: report of a series of cases
ally small size, presenting discrepancy with the and literature review. Microsurgery. 2010;30:13–8.
recipient vein at the micro-venous Chou PY, Lin CH, Hsu CC, Yang WH, Kane AA, Lin
CH. Salvage of postcranioplasty implant exposure
anastomoses. using free tissue transfer. Head Neck. 2017
9. Simultaneous skin/soft tissue defect and Aug;39(8):1655–61. https://doi.org/10.1002/hed.
calvarial bone reconstruction presents the risk 24813.
of infection of the foreign body. Earley MJ, Green MF, Millang MA. A critical appraisal of
the use of free flaps in primary reconstruction of com-
bined scalp and calvarial cancer defects. Br J Plast
Surg. 1990;43:283–9.
Learning Points Fisher J, Jackson IT. Microvascular surgery as an adjunct to
craniomaxillofacial reconstruction. Br J Plast Surg.
1989;42:146–54.
1. Osteoradionecrosis of the skull is a complica- Gravvanis A, Tsoutsos D, Iconomou T, Gremoutis G. The
tion of radiation therapy for brain tumors. use of Integra artificial dermis to minimize donor site
Necrotic bone needs thorough debridement morbidity after suprafascial dissection of the radial
and reliable soft tissue coverage to ensure pro- forearm flap. Microsurgery. 2007;27(7):583–7.
Harii K, Yamada A, Ishihara K, Miki Y, Itoh M. A free
tection of the calvarial bone reconstruction. transfer of both latissimus dorsi and serratus anterior
2. The reconstruction of composite scalp defects flaps with thoracodorsal vessel anastomoses. Plast
often requires more than one stages. Reconstr Surg. 1982;70:620–9.
Jones NF, Sekhar LN, Schramm VL. Free rectus abdominis Pennington DG, Stern HS, Lee KK. Free-flap reconstruc-
muscle flap reconstruction of the middle and posterior tion of large defects of the scalp and calvarium. Plast
cranial base. Plast Reconstr Surg. 1986;78:471–7. Reconstr Surg. 1989;83:655–61.
Kveton JF. Surgical management of osteoradionecrosis of Raggio BS, Winters R. Modern management of
the temporal bone. Otolaryngol Head Neck Surg. osteoradionecrosis. Curr Opin Otolaryngol Head
1988;98:231–4. Neck Surg. 2018;26:254–9. https://doi.org/10.1097/
Leonetti JP, Origitano T, Anderson D, et al. Intracranial MOO.0000000000000459.
complications of temporal bone osteoradionecrosis. Ramsden RT, Bulman CH, Lorigan BP. Osteoradionecrosis
Am J Otolaryngol. 1997;18:223–8. of the temporal bone. J Laryngol Otol. 1975;89:
Lin SJ, Hanasono MM, Skoracki RJ. Scalp and calvarial 941–55.
reconstruction. Semin Plast Surg. 2008;4:281–91. Robson MC, Zachary LS, Schmidt DR, Faibisoff B,
Manders EK, Schenden MJ, Furrey JA, et al. Skin expan- Hekmatpanah J. Reconstruction of large cranial defects
sion to eliminate large scalp defects. Plast Reconstr in the presence of heavy radiation damage and infection
Surg. 1984;74:493–507. utilizing tissue transferred by microvascular anastomo-
Marx RE. Osteoradionecrosis: a new concept of its patho- ses. Plast Reconstr Surg. 1989;83:438–42.
physiology. J Oral Maxillofac Surg. 1983;41:283–8. Santamaria E, Granados M, Barrera-Franco JL. Radial
Nguyen MT, Billington A, Habal MB. Osteoradionecrosis forearm free tissue transfer for head and neck recon-
of the skull after radiation therapy for invasive carci- struction: versatility and reliability of a single donor
noma. J Craniofac Surg. 2011;5:1677–81. site. Microsurgery. 2000;20:195–201.
Ozkan O, Coskunfirat OK, Ozgentas HE, et al. Rationale Ueda K, Harashina T, Inoue T, Tanaka I, Harada
for reconstruction of large scalp defects using the ante- T. Microsurgical scalp and skull reconstruction using
rolateral thigh flap: structural and aesthetic outcomes. a serratus anterior myoosseous flap. Ann Plast Surg.
J Reconstr Microsurg. 2005;21:539–45. 1993;31:10–4.
Anterior Skull Base Reconstruction with
Intracranial Free Flaps 4
Caroline Driessen and Andres Rodriguez-Lorenzo
Contents
Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Preoperative Problem List/Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Outcome, Clinical Photos, and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Abstract
Reconstruction of the skull base is of vital

importance to avoid life-threatening complica-
tions after surgery. A successful skull base
reconstruction results in a watertight repair of
C. Driessen (*) · A. Rodriguez-Lorenzo the dura defect, interposition of vascularized
Department of Plastic and Maxillofacial Surgery, Uppsala tissue between exposed dura and subjacent
spaces, filling of dead space, reconstruction of
Department of Surgical Sciences, Uppsala University, bony structures, and inner and outer lining and
Uppsala, Sweden
e-mail: andres.rodriguez.lorenzo@surgsci.uu.se cranial nerve reconstruction if required. This

https://doi.org/10.1007/978-3-030-23706-6_4
30 C. Driessen and A. Rodriguez-Lorenzo
chapter includes a case in which a chimeric

anterolateral thigh flap was used to reconstruct
a defect of the anterior skull base and enucle-
ation of the right eye after resection of an
aggressive meningioma. An adipofascial com-
ponent with intracranial insetting was used to
seal the dura defect, and a muscle component
was used to seal the central defect of the ante-
rior skull base. Additionally, a small cutaneous
skin island was left in the eye for flap monitor-
ing. Alternative free flaps include any combi-
nation of the thoracodorsal artery system or
flaps of the arm. In case of moderate to large
defects or if postoperative radiotherapy may Fig. 1 Bicoronal skin incision and the defect of the ante-
rior skull base
be needed, locoregional options should not
be considered as a feasible alternative for
microvascular reconstructions given the high 30 years, microvascular reconstructions have
complication rates. Generally speaking, early facilitated sealing the intracranial and extracranial
complications include intracranial complica- contents and covering of the defects. Before then,
tions such as cerebrospinal fluid (CSF) leakage reconstructions were mainly dependent on (loco)
and infectious complications and thrombotic, regional flaps and prosthesis with unpleasing
respiratory, or cardiac complications. functional and esthetic outcomes. Additionally,
titanium hardware, absorbable plate fixations,
Keywords and bone substitutes provide structural support
with long-lasting protection and maintenance of
Anterolateral thigh (ALT) flap · Anterior skull
the esthetic outcome (Imola et al. 2003).
base · Watertight repair
The skull base is divided among the anterior,
middle, and posterior fossa. The anterior skull
base is made up of the frontal, ethmoid, and sphe-
Clinical Scenario
noid bones. At the same time, the frontal bone is
the backside of the frontal sinus which has a
A 56-year-old woman with a medical history
mucosal lining, and the ethmoid bone forms the
of breast cancer presented with an aggressive
roof of the ethmoid sinus and is the origin of the
meningioma infiltrating the anterior skull base.
cribriform plate. The planum sphenoidale and
She was planned for tumor resection by means
anterior clinoid processes of the sphenoid bone
of a transcranial approach including resection
form the backside of the anterior skull base. Of
of the anterior skull base and enucleation of the
course, tumor resection may ignore these ana-
right eye (Fig. 1).
tomic boundaries (Kwon et al. 2017).
Several neurovascular structures arise from the
anterior skull base and transverse through these
Preoperative Problem List/ bones to reach their destination. There’s a venous
Reconstructive Requirements connection to facilitate outflow from the nose into
the superior sagittal sinus through the foramen
Reconstruction of the skull base is of vital impor- cecum which lies between the crista galli and fron-
tance to avoid life-threatening complications tal bone. The olfactory neurons (cranial nerve I)
after surgery. Improved reconstructive techniques traverse through the ethmoid roof to give rise to the
have contributed to improved outcomes after olfactory bulb, just above the cribriform plate.
these complex procedures. Since approximately Also, cranial nerves II, III, IV, and V1 and V2
4 Anterior Skull Base Reconstruction with Intracranial Free Flaps 31
traverse through the optic canal and superior and island was left in the eye for flap monitoring. Anas-
inferior orbital fissures. Intracranially these struc- tomoses were performed to the facial vessels.
tures divert medially towards the optic chiasm in
the middle cranial fossa (Kwon et al. 2017).
Generally speaking, individual factors should Alternative Reconstructive Options
first be considered when planning a reconstruction
of the skull base including general health, Before the microsurgical era, the reconstructive
prior surgery, prior radiotherapy, or the need of options consisted of nonvascularized tissue and
adjuvant radiotherapy. Preoperatively, it should small local flaps. In case of small dura defects,
be discussed how big the defect is expected to direct suturing or a dural patch may be considered.
be, including the dura defect specifically, as well To achieve a watertight sealing, high-quality run-
as the skin, mucosa, and soft tissue resection. ning locking or interrupted sutures are needed.
The necessity of reconstructing adjacent struc- Autografts, such as nonvascularized pericranium,
tures, such as after orbital exenteration, ear ampu- temporal fascia, or fascia lata are widely available.
tation, mandibulectomy, maxillectomy, or palatal Allogenic dura or skin substitutes may be an alter-
resection, and the need for cranial nerve recon- native. Fibrin glue is an excellent adjunct to those
struction should also be taken into consideration repairs. It is also advisable to suture the dura to drill
when choosing the best flap. holes through the cranium. In case of
A successful skull base reconstruction results pneumocephalus, this limits further pneumatic dis-
in (Imola et al. 2003; Kwon et al. 2017): section of the dura. Local options such as galea
frontalis pericranial flaps and temporalis muscle
• A watertight repair of the dura defect flaps are vascularized, but the available amount of
• Interposition of vascularized tissue between tissue is limited. Beware that when pushing a mod-
exposed dura and subjacent erate problem to a simple solution will inevitably
• Spaces (mainly in contaminated areas or large result in necrosis and infection which are associ-
defects) ated with high overall complication rates. In case of
• Filling of dead space moderate to large defects or if postoperative radio-
• Reconstruction of the outer lining therapy may be needed, nonvascularized or local
• Reconstruction of the inner lining options should not be considered as an alternative.
• Reconstruction of bony structures if resected Regional muscle flaps like the latissimus dorsi flap
• Cranial nerve reconstruction if required or pectoralis major flap have been suggested as
they were used for other head and neck reconstruc-
For this particular case, it was needed to seal tions, but the anterior skull base seemed to be too
the intracranial contents from subjacent struc- distant and complication rates were still high. Their
tures, obliterate the dead space, cover vital struc- volume most often does not reach further than
tures with vascularized tissue, and close the defect the zygomatic arch and infraorbital rim. In an
after enucleation. The orbit was involved, and older review by Neligan et al. (1996), the compli-
resection of the meningioma did extend beyond cation rate was much higher in regional muscle
the anterior skull base. flaps (75%) as compared to local (34%) or free
flaps (39%).
In our opinion, microvascular reconstruction
Treatment Plan is mandatory to facilitate the resection of bigger
tumors or tumors in unfavorable anatomic loca-
Reconstruction was planned using a chimeric ALT tions. Different flaps based on the lateral circumflex
flap with an adipofascial component with intracra- artery are useful because they are easy to reach, the
nial insetting to seal the dura defect and a muscle anatomy is consistent, and different components are
component to seal the central defect of the anterior available including the fascia, skin, muscle, and
skull base. Additionally, a small cutaneous skin nerve. Alternative free flaps could include any
combination of chimeric flaps of which the An ALT flap is drawn by using the well-known
thoracodorsal artery system is most interesting landmarks. A line is drawn from the anterior
because of its expandability and how big the flap superior iliac spine to the lateral border of the
is. Unfortunately, a patient should be turned to the patella. This line represents the axis of the surface
side or prone position to raise the flap. Other authors of the septum between the rectus femoris and the
have also described using flaps of the arm, including vastus lateralis. The skin incision is usually
fascial radial forearm flaps, lateral arm flaps, osse- planned in a curved line medial to the axis.
ous flaps including radial forearm flap, scapula flap
and fibula flap, and rectus abdominis myocutaneous
flaps (Teknos et al. 2002). Surgical Technique
Surgery was performed by a two-team approach.

Preoperative Evaluation and Imaging A head and neck surgeon in collaboration with
a neurosurgeon performed the tumor resection.
Preoperative imaging included CT and MRI show- Flap harvest by the plastic surgeon started at the
ing bone destruction and infiltration of the right same time. The flap was raised starting with the
orbita, ethmoidal sinus and eye (Figs. 2 and 3). medial incision to explore the lateral circumflex
femoral artery and veins and their branching.
The dissection of the flap was started, without a
Preoperative Care and Patient lateral incision and with the pedicle still attached
Drawing until the defect was completed. A chimeric ALT
flap was prepared including an adipofascial com-
Perioperative antibiotics are mandatory to avoid ponent (for a watertight repair of the dura defect)
meningitis and encephalitis. and a muscle component of vastus lateralis (to
obliterate the defect of the anterior skull base)
(Fig. 2). A template was made and placed on the
leg, and the shape was traced with marking pen.
Fig. 3 MRI showing infiltration of the right orbita, eth-

Fig. 2 CT scan showing bone destruction moidal sinus and eye
It was decided which tissue components were

needed, and their location as well as the position
and length of the pedicle were marked. The flap
was then completely raised and partially inset into
the head and neck defect. The vessels were anas-
tomosed to the facial vessels, and the remaining
flap inset was completed. At our institution, cou-
plers were used for the venous anastomosis only,
and postoperative monitoring is based on clinical
examination, internal venous Doppler and manual
external Doppler. It is beneficial to anastomose
two veins, and the internal jugular system is pre-
ferred over the external jugular system.
Technical Pearls Fig. 4 Chimeric ALT flap including an adipofascial com-

ponent and a muscle component of vastus lateralis
• With the anatomic considerations and recon-

structive goals in mind, prepare the case!
• A foam template is extremely worthy in those
complex cases, especially if a chimeric flap is
needed. The impression of the several compo-
nents and their interrelation becomes more
well-defined. For oncologic safety, wrap the
template in a transparent dressing before trans-
ferring it to the leg.
• Although the superficial temporal vessels seem
attractive due to their location, in our experi-
ence there is more flow in the facial vessels.
If you decide to use the superficial temporal
vessels instead, dissect them far out caudally
Fig. 5 Flap in place before closure of the skin. Note that
within the parotid gland. the vessels were tunneled through the cheek to reach the
facial vessels and the internal Doppler system
Intraoperative Images
internal Doppler system in place which is guided
externally through the wound.
The defect is presented in Fig. 1 including resection
of the anterior skull base and enucleation of the
right eye through a transcranial approach. The chi- Postoperative Management
meric ALT flap is presented in Fig. 4 with an
adipofascial component with intracranial insetting The overall complication rate in reconstruction
to achieve a watertight repair of the dura and a of anterior skull base defects is reported to be as
muscle component to obliterate the central defect high as 25–50% in 2003 (Imola et al. 2003).
of the anterior skull base. Figure 5 shows the result Early complications include intracranial
after the pieces of the cranium are repositioned to complications (23%) (Teknos et al. 2002) such
cover the flap and remaining intact dura and brain. as cerebrospinal fluid (CSF) leakage,
Also note that the vessels were tunneled through pneumocephalus, wound infection, and intracra-
the cheek to reach the facial vessels. Find the nial infections including meningitis, epidural
abscess, brain abscess, and even stroke. Dura

defects which have been directly sutured or
repaired with a patch are at risk for persistent
CSF leakage which is associated with meningitis.
Other short-term complications may be respira-
tory (16%) or cardiac (19%) or deep venous
thrombosis or pulmonary embolisms (Teknos et
al. 2002). Additionally, there may be microvascu-
lar complications including venous or arterial
thrombosis or donor site problems such as bleed-
ings or surgical site infection. Late complications
include globe malposition with resultant
diplopia, malocclusion, nasopharyngeal obstruc-
tion, trismus, chronic sinusitis, and facial defor-
mity. The mortality rate is reported to be
approximately 5% (Teknos et al. 2002).
It is hard to compare the outcome of local
reconstructive options to free tissue transfer
since there is an unavoidable selection bias in
Fig. 6 Long-term follow-up
the study population. The few available studies
include one by Neligan et al. (1996) which shows
a complication rate of 33.5% for free flaps,
whereas the pedicled flap group had a complica-
tion rate of 75%. A study by Heth et al. showed
that patients with local flap repair had more peri-
operative problems and late wound breakdowns
than the free flap group (Heth et al. 2002).
Outcome, Clinical Photos, and Imaging
Long-term follow-up is shown in Figs. 4 and 5,

showing the external prosthesis. Follow-up at 2
years and 9 months is shown in Figs. 6 and 7,
showing good esthetic outcome with external eye
prosthesis. The postoperative course was after-
wards uneventful. Unfortunately, due to tumor
recurrence, the patient passed away 3 years and Fig. 7 Long-term follow-up after fitting an external
6 months after the initial surgery. prosthesis
prophylactic intravenous administration of

Avoiding and Managing Problems cefuroxime (1.5 g, three doses per 24 h) and
metronidazole (400 mg, three doses per 24 h).
The most important risk factor for infection is Deep venous thrombosis and pulmonary embo-
a postoperative CSF leakage. Meningitis, sinusi- lism are an important burden in oncologic patients
tis, and even endophthalmitis may occur undergoing long operations. Therefore, pharmaco-
which may be caused by a bacterial or fungal logic prophylaxis or mechanical prophylaxis
pathogen. Our standard antibiotic regime includes is obligatory. Beware of the administration of
appropriate doses of prophylactic low molecular Cross-References

weight heparin. It may be needed to repeat the
dose during surgery in case of long-lasting surgery. ▶ Endoscopic Insetting of Free Flaps in Skull
Intermittent pneumatic compression devices may Base Reconstruction
be of attributive value in preventing venous throm-
bosis (Gould et al. 2012).
References
Learning Points Gould MK, Garcia DA, Wren SM, Karanicolas PJ,
Arcelus JI, Heit JA, Samama CM. Prevention of VTE
in nonorthopedic surgical patients: antithrombotic ther-
Reconstruction of the anterior skull base may apy and prevention of thrombosis, 9th ed: American
be difficult but is necessary to facilitate tumor College of Chest Physicians evidence-based clinical
resection without severe complications especially practice guidelines. Chest. 2012;141:e227S–77S.
Heth JA, Funk GF, Karnell LH, Mcculloch TM,
if postoperative radiotherapy is required. A good
Traynelis VC, Nerad JA, Smith RB, Graham SM,
collaboration is needed with the head and neck Hoffman HT. Free tissue transfer and local flap com-
surgeon and neurosurgeon to prepare for the plications in anterior and anterolateral skull base
defect and the required elements of your flap. surgery. Head Neck. 2002;24:901–11; discussion 912
Imola MJ, Sciarretta V, Schramm VL. Skull base recon-
In our opinion, a combination of flaps from the
struction. Curr Opin Otolaryngol Head Neck Surg.
lateral circumflex artery system includes all ele- 2003;11:282–90.
ments needed. Kwon D, Iloreta A, Miles B, Inman J. Open anterior skull
Use a foam template, especially if a chimeric base reconstruction: a contemporary review. Semin
Plast Surg. 2017;31:189–96.
flap is needed to plan the orientation of the flap
Neligan PC, Mulholland S, Irish J, Gullane PJ, Boyd JB,
before taking it from the leg. An adipofascial Gentili F, Brown D, Freeman J. Flap selection in cranial
component is an excellent substitute for a dura base reconstruction. Plast Reconstr Surg.
defect. Watertight repair of the dura by this fascia 1996;98:1159–66; discussion 1167–1168.
Teknos TN, Smith JC, Day TA, Netterville JL, Burkey BB.
is of great importance to avoid CSF leakage,
Microvascular free tissue transfer in reconstructing
which is an important risk factor for infectious skull base defects: lessons learned. Laryngoscope.
complications. Postoperatively, the patient should 2002;112:1871–6.
be admitted to a (neuro) intensive care unit to
monitor for cardiac and respiratory complications
including pulmonary embolisms.
Endoscopic Insetting of Free Flaps in Skull
Base Reconstruction 5
Caroline Driessen, Erik J. Stigare, and
Contents
Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Postoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Outcome, Clinical Photos, and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Avoiding and Managing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Abstract
In the era of endoscopic surgery, endoscopic

flap inset is the future for anterior skull base
C. Driessen (*) · A. Rodriguez-Lorenzo reconstructions. The main goal in the recon-
Department of Plastic and Maxillofacial Surgery, Uppsala struction of anterior skull base following onco-
University Hospital, Uppsala, Sweden logic surgery is to seal the brain from the
Department of Surgical Sciences, Uppsala University, nasopharyngeal cavity to avoid potentially lethal
Uppsala, Sweden intracranial infections. Free vascularized tissue
e-mail: andres.rodriguez.lorenzo@surgsci.uu.se
transfers may provide a robust reconstruction.
E. J. Stigare We describe a case in which a secondary
Department of Otorhinolaryngology, Uppsala University
reconstruction was achieved by means of endo-
Hospital, Uppsala, Sweden
e-mail: jerker.stigare@akademiska.se scopic flap inset. A transmaxillary approach

https://doi.org/10.1007/978-3-030-23706-6_5
38 C. Driessen et al.
was used through a mucosal incision inside the was designed in a chimeric fashion with an
upper sulcus and an anterior and medial adipofascial component to deal the dura and a
maxillectomy. The flaps were placed with the separate muscle component of vastus lateralis to
tip in the sphenoidal sinus. The flaps were obliterate the ethmoidal area in order to seal brain
inserted through the maxillary sinus, and the from the sinonasal cavity. An acellular dermis was
vessels were tunneled through the cheek to used for dural replacement. The microvascular
reach the facial vessels. The reconstruction anastomoses were performed to the right superfi-
was successful and the follow-up uneventful. cial temporal vessels. Postoperatively the patient
A multidisciplinary approach is mandatory for developed a progressive large pneumo-encephalus
innovative techniques in skull base surgery. with persistent CSF leakage due to distal necrosis
of the facial component of the flap toward the
sphenoidal sinus. It also resulted in persistent con-
Keywords
tinuity between intracranial and sinonasal cavities
Vastus lateralis muscle flap · Anterior skull (Fig. 2). A second reconstruction was planned.
base · Endoscopic flap inset
Preoperative Problem List/

Clinical Scenario Reconstructive Requirements
A 20-year-old man presented with signs of optic Endoscopic endonasal approaches have gained
nerve compression due to a large sinonasal carci- popularity worldwide to decrease the morbidity
noma infiltrating the frontal lobe (Fig. 1). The of an open tumor resection. The increased experi-
initial operation included a combined endonasal ence has expanded the indications for endoscopic
endoscopic and transcranial open approach to surgery which allows for resection of large tumors
resect the tumor. This resulted in a large defect of in the skull base and simultaneous endoscopic
dura over the frontal lobe, ethmoidal area, the reconstruction. Early results concerning quality of
posterior nasal septum, and mucosa. It was life following endoscopic approaches to the skull
reconstructed by an anterolateral thigh flap which base are promising. The morbidity of a craniotomy
Fig. 1 CT scan of the patient in the case report with a sinonasal carcinoma infiltrating the frontal lobe
5 Endoscopic Insetting of Free Flaps in Skull Base Reconstruction 39
Fig. 2 CT scan of the same patient after primary operation with intracranial ALT flap. Note the pneumo-encephalus with
persistent continuity between intracranial and sinonasal cavities
can be avoided, and functional complaints of alter- of the lateral femoral circumflex artery can per-
ations of the sinonasal anatomy seem to improve fuse the remaining muscle. If the muscle is
within a few months. harvested distal to the entry point of the motor
As in many reconstructive dilemmas, several nerve, there is hardly any donor site morbidity
considerations should be made when choosing (Cavadas and Sanz-Jimenez-Rico 2005).
what flap to use and by means of which surgical Specifically, for this case, the previous recon-
technique. Generally speaking for skull base struction had failed because separation of the
reconstructions, the brain should be sealed from intracranial content and the sinonasal cavities
the sinonasal cavities to avoid meningitis or wasn’t successful. This resulted in an extra chal-
encephalitis. Also, dead space should be lenge because the conventional intracranial
occluded, and sometimes a covering to replace approach failed in meeting the reconstructive
skin is required. Moreover, a robust reconstruc- requirements. Decreased morbidity is an extra
tion preferably with autologous tissue facilitates benefit of endoscopic flap inset in patients in
postoperative radiotherapy if needed. For smaller whom a transcranial approach is not needed.
defects, locoregional options are available, but
for bigger defects, free flaps are a superior
reconstruction. Treatment Plan
The vastus lateralis muscle flap has several
features that makes it ideal for this technique A second free flap, a contralateral vastus lateralis
with a long pedicle based on the descending muscle flap, was performed using endoscopic flap
branch of the lateral femoral circumflex artery. inset and microvascular anastomosis to the right
Usually a muscle length of 12 centimeters is facial vessels.
required plus a pedicle length of 10 centimeters Kang et al. was the first to publish on this
to reach the neck. The main branch runs along the technique in 2018 (Kang et al. 2018). Simulta-
medial side of the muscle, allowing the muscle to neously, we have executed this technique which
be trimmed and customized to the defect. Minor was published recently (Rodriguez-Lorenzo et al.
pedicles from the transverse and ascending branch 2019).
Alternative Reconstructive Options Surgical Technique
It could be considered to perform a second intracra- The procedure was performed by a two-team
nial free flap. The initial anterolateral thigh flap could approach (one oncologic and one reconstructive
be taken out which would be difficult due to tissue team). An ENT surgeon with experience in endo-
adherence in the postoperative period. Alternatively, scopic surgery resects the tumor though the nose
it could be left in place, and the contralateral super- or, as in this case, prepares the nasal cavity to
ficial temporal vessels could be used as the alterna- receive the second free flap. In case of tumor
tive recipient vessels. However, with inspiration, the resection, a neurosurgeon contributes to tumor
pressure of the airflow may press the flap away from resection by a transcranial approach. A trans-
the defect. In a complicated case like ours, this may maxillary approach is performed through a muco-
have contributed to a pneumo-encephalus. There- sal incision inside the upper sulcus as it has been
fore, an alternative position was considered to be described recently by Kang et al. (Kang et al.
the first choice. If a simultaneous eye enucleation or 2018; Rodriguez-Lorenzo et al. 2019). An ante-
maxillotomy is required, this may be an alternative rior maxillotomy, followed by a medial
route for the flap to enter the nasopharynx. maxillotomy, is performed preserving the piriform
Free flaps can be taken from the anterolateral aperture and the infraorbital nerve. This creates
thigh system, from the thoracodorsal system, or enough space to allow free flap introduction into
from the forearm based on the radial artery. The the nasal cavity toward the anterior skull base.
benefit of the first two is the availability of chime- The inset is performed by collaboration
ric flaps with a fasciocutaneous, adipofascial, or between ENT and plastic surgery and aided endo-
musculocutaneous component and a separate scopically (Figs. 3 and 4), with the main goal to
muscle component. Simultaneous harvesting of a pack the tip of the flap into the sphenoidal sinus in
latissimus dorsi flap however is impossible. The order to be able to seal the defect of the anterior
length of the vessels to the selected donor vessels, skull base. Fibrin glue sealant is used to attach the
as well as the donor site, should also be taken into muscle to the skull base.
consideration. The vastus lateralis muscle flap was anasto-
mosed to the facial vessels. They were dis-
sected in the neck just one cm inferior to the
Preoperative Evaluation and Imaging mandible, and the flap’s vessels were tunneled
subcutaneously from the anterior portion of the
Preoperative imaging includes the oncologic work- maxilla by using a Penrose drain. Alternatively,
up with CTscan and MR imaging. Avastus lateralis the facial vessels could be dissected at the
muscle flap does not need additional imaging. nasolabial fold or the superficial temporal ves-
sels could be used, although the diameter is
slightly smaller. Within the sinus and cavity,
Preoperative Care and Patient the vascular pedicle was covered by muscle or
Drawing fat in the nasal cavity to avoid infection leading
to thrombosis.
Perioperative antibiotics are mandatory to avoid
meningitis and encephalitis.
A vastus lateralis muscle flap is drawn by using Technical Pearls
the well-known landmarks. A line is drawn from
the anterior superior iliac spine to the lateral bor- – It is wise to trim the vastus lateralis muscle flap
der of the patella. This line represents the axis of on the leg. A too bulky flap will cause obstruc-
the surface of the septum between the rectus tion of the nasopharynx, loss of vision during
femoris and the vastus lateralis. The incision can inset, and compression at the level of the max-
be planned in a curved line medial to the axis, as if illary sinus. A 4 cm strip of muscle was suffi-
an ALT flap would be harvested. cient. The bigger the flap, the more difficult the
Fig. 3 Harvest of the

contralateral vastus lateralis
muscle flap
Fig. 4 Inset of the flap. Note in the left photo how a Penrose drain is temporarily positioned to link incision in the sulcus
with the facial vessels via the cheek
visualizing and insetting of the flap at the same

time using only endoscopy. Intraoperative Images
– It is easier to tunnel the vessels using a Penrose
drain instead of manually, to avoid trauma to Postoperative Management
the vessels.
– The flap can be sealed in the sphenoidal sinus At the end of surgery, the nose is packed with
with fibrin glue. surgical (Ethicon, USA) and gauzes draped in
– After anastomosing, traction on the flap may Terra-Cortril antibiotic ointment (Pfizer inc,
have occurred to assure a non-tensed anasto- USA). This tamponade is changed every other
mosis. Check again if the tip of the flap still week in theater under general anesthesia during
ends in the sphenoidal sinus. the first 6 weeks. During these changes, the
– Finally, during the nasal packing, evaluate if the wound healing and positioning of the flap may
flap’s circulation is still adequate by listening to be checked. Partial flap necrosis may be trimmed
changes of the venous cook during compression. during these operative sessions.
(Neuro)intensive care monitoring is mandatory, extensive oncologic resections and reconstruc-

and long-term admission to a neurosurgical depart- tions. Generally speaking, the risk of infections
ment may be needed to care for lumbar or ventric- of endoscopic surgery is reported to be as high,
ular drainage. A CT scan is performed 24 hours but not higher than open craniotomy approach.
postoperatively to rule out intracranial bleeding The most important risk factor for infection is
and correct positioning of the muscle flap. postoperative CSF leakage. Meningitis, sinusitis,
and even endophthalmitis may occur, which may
be caused by a bacterial or fungal pathogen.
Outcome, Clinical Photos, and Imaging Our standard antibiotic regime includes prophy-
lactic intravenous administration of cefuroxime
In case of the reported patient, the postoperative (1.5 gram, three doses per 24 hours) and metro-
course was uneventful. Endoscopic examination 3 nidazole (400 milligrams, three doses per
weeks postoperatively showed complete coverage 24 hours).
of the brain (Fig. 5). Computed tomography Airway patency is dependent on the size of the
showed that the pneumo-encephalus was resolv- flap. If the flap is too bulky, there may be difficulty
ing, that the muscle flap was accurately posi- in breathing after extubating the patient. Immedi-
tioned, and that there was a separation of ately after surgery, there may be some swelling of
intracranial and intranasal cavities (Fig. 6). Clini- the flap due to reperfusion. After the first week,
cally, there were no signs of CSF leakage or however, the first hypotrophic changes due to
infectious complications. muscle inactivity should be noted. If there is per-
The patient was discharged from the hospital 3 sistent difficulty in breathing, then it may be nec-
weeks after the second free flap and planned for essary to trim the flap, for example, during a
postoperative radiation 4 weeks after surgery. The change of the nasal packing.
patient is free of recurrence at 23 months follow-up.
Learning Points
Avoiding and Managing Problems
An endoscopic free flap to reconstruct the anterior
Meningitis and brain abscesses only occur in skull base is a good choice provided the surgical
1.8% of the cases that undergo endoscopic skull team is technically experienced to perform this
base procedures (Johans et al. 2018), but this approach. In some cases, it avoids craniotomy
may be a bit higher in the patients with the which is beneficial for the patients’ recovery.
Fig. 5 Endoscopic examination 3 weeks postoperatively. Note the complete coverage of the brain
Fig. 6 Postoperative CT scan shows resolving of the pneumo-encephalus, adequate location and obliteration of the cavity
with the muscle, and separation of the intracranial and sinonasal cavities
The learning points for our team so far are

listed in the technical pearls: References
It is wise to avoid a too bulky flap since it may
Cavadas PC, Sanz-Jimenez-Rico JR. Use of the
obstruct the airway. It is much easier to trim the extended-pedicle vastus lateralis free flap for lower
flap on the leg rather than during ischemia or after extremity reconstruction. Plast Reconstr Surg.
reperfusion. 2005;115:1070–6.
Johans SJ, Burkett DJ, Swong KN, Patel CR, Germanwala
The fibrin glue may facilitate attachment of the
AV. Antibiotic prophylaxis and infection prevention for
flap to the anterior skull base. endoscopic endonasal skull base surgery: our protocol,
Packing of the nose will support the recon- results, and review of the literature. J Clin Neurosci.
struction from caudally. 2018;47:249–53.
Kang SY, Eskander A, Hachem RA, Ozer E, Teknos TN,
Be aware that all these manipulations may
Old MO, Prevedello DM, Carrau RL. Salvage skull
influence the tension on the anastomosis and base reconstruction in the endoscopic era: vastus
pedicle. lateralis free tissue transfer. Head Neck. 2018;40:
E45–52.
Rodriguez-Lorenzo A, Driessen C, Mani M, Lidian A,
Cross-References Gudjonsson O, Stigare E. Endoscopic assisted insetting
of free flaps in anterior skull base reconstruction: a
preliminary report of five cases. Microsurgery. 2019.
▶ Anterior Skull Base Reconstruction with Intra- https://doi.org/10.1002/micr.30542. Epub ahead of
cranial Free Flaps print.
Upper Lip Replantation with Arterialized
Venous Flap, Without Microsurgical 6
Venous Outflow
Daan De Cock and Assaf A. Zeltzer
Contents
Preoperative Problem List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Treatment Plan and Alternative Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Prophylactic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Tetanus Prophylactics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Rabies Prophylactics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Replantation of the Amputate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Leech Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Alternative Reconstruction Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Abbe Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Estlander Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Karapandzic Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Surgical Technique, Patient Management, and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Abstract bite with a partial avulsion of the upper lip. The

A 52-year-old female presented at the emer- amputated part originated between the
gency department of our hospital after a dog philtrum and the left nasolabial fold. On explo-
ration of the fragment, a lateral vein of 1 mm
diameter was preoperatively identified, but no
artery was found in the amputate. An arterio-
D. De Cock
Department of Plastic, Reconstructive & Aesthetic
venous anastomosis with the left superior
Surgery, Brussels University Hospital (VUB), Brussels, labial artery was performed. Venous outflow
Belgium was achieved by using leeches and heparin
e-mail: mail@drdecock.be compresses. No necrosis or other complica-
A. A. Zeltzer (*) tions were seen at the replanted upper lip and
Department of Plastic, Reconstructive & Aesthetic Surgery achieved an aesthetically satisfactory result.
European Center for Lymphedema Surgery - Lymphedema
Clinic, Brussels University Hospital (VUB), Brussels,
Follow-up after 8.5 months showed good
Belgium healing of the upper lip. The satisfactory result
e-mail: assaf.zeltzer@uzbrussel.be; zeltzer@doctor.com

https://doi.org/10.1007/978-3-030-23706-6_6
46 D. De Cock and A. A. Zeltzer
in this case and literature research show that Preoperative Problem List
microsurgical replantation should always be
considered, which results in a better aesthetic Preoperatively, only a small lateral vein of 1 mm
and functional outcome. diameter was identified. No artery was found in
the amputate. This resulted in a challenging
replantation case.
Keywords
Microvascular · Anastomosis · Microsurgical ·

Replantation · Reimplantation · Lip Treatment Plan and Alternative
Reconstructive Options
The Clinical Scenario Prophylactic Antibiotics
Upper lip avulsions are common in facial dog Since infection is the most common complication of
bites. In Belgium, around 100.000 people get a dog bite, prophylactic antibiotics should be admin-
bitten by a dog every year with a high prevalence istrated. β-lactam antibiotics with a β-lactamase
in children of 22 out of 1000 per year. Children are inhibitor are preferred, such as amoxicillin +
bitten in the face more often because of their clavulanic acid (three times 500/125 mg per day),
smaller stature and relatively larger head. 20% of given the wide range of microorganisms that may be
all cases visit the emergency department, 40% the responsible for infection. In the case of allergy to β-
general practitioner, and 40% provides the wound lactam antibiotics, doxycycline (200 mg per day)
care at home (De Keuster et al. 2006; Kahn et al. can be given, or in children under 12 years of age
2003; Morgan and Palmer 2007). and pregnant women, erythromycin (BCFI 2003).
In this clinical scenario, a 52-year-old female Bite wounds are normally not sutured primar-
presented at the emergency department after being ily due to the risk of infection. However, when
attacked by a dog (Fig. 1). She sustained a lacer- aesthetic outcome prevails, this can still be con-
ated right cheek and an avulsion of the left upper sidered after thorough rinsing and disinfection of
lip. The amputated left upper lip originated the wound. In addition, as few subcutaneous
between the philtrum, the left nasal sill, and the stitches as possible should be used, as any foreign
left nasolabial fold. material in a contaminated wound increases the
Fig. 1 Pre-operative
photograph
6 Upper Lip Replantation with Arterialized Venous Flap, Without Microsurgical Venous Outflow 47
risk of infection. In this clinical case, since the Vaccination

lacerations are located on the face, it was decided status of the
to suture them. injured Severity of the injury
Superficial Wound with risk
and clean of tetanus
c) Last Toxoid (1 Toxoid (1 dose) and
Tetanus Prophylactics injection>10 dose) specific
years and < 20 immunoglobulins
There is a high risk of tetanus with bite injuries. years ago
Correct immunization against tetanus is therefore d) Last Toxoid (2 Toxoid (2 doses
of great importance. injection>20 doses with 6- with 6-month
years ago month interval) and
The primary vaccination of infants against tet- interval) specific
anus occurs with a combined hexavalent vaccine immunoglobulins
and starts at the age of 8 weeks (recommended
and at the earliest 6 weeks). It consists of three
doses with intervals of 4 weeks each (8, 12, and
16 weeks) and a repeat vaccination at the age of Rabies Prophylactics
15 months. A minimum period of 6 months
should be respected between the third dose of Dogs are important hosts and vector of the Rabies
the primo vaccination and the repeated vaccina- virus; therefore, dog bites have a high risk for
tion. A complete basic vaccination against tetanus Rabies infection. Cats can transmit the disease,
for an adult includes three injections: the second but do not seem to host the virus.
injection is given 4 to 6 weeks after the first and In case of known Rabies or when Rabies is not
the third about 6 months to 1 year after the second proven but (highly) suspected, the bitten patient
(BCFI 2003). needs to be vaccinated, and specific immunoglob-
The diagram below provides an overview for ulins against rabies are administered simulta-
prophylaxis. neously. If the animal can be observed for
10 days after a bite and there is no evidence of
Vaccination Rabies during that period, the immunization
status of the
injured Severity of the injury
schedule may be interrupted or immunization
Superficial Wound with risk
should no longer be initiated. If the animal
and clean of tetanus develops or dies any signs of rabies within
1. No or Complete Complete primo 10 days of the bite, it must be tested; if Rabies
uncertain primo vaccination and infection is diagnosed, the immunization must be
vaccination vaccination specific continued or started (BCFI 2003).
immunoglobulins
2. Incomplete Finish Finish vaccination
primary vaccination schedule and
vaccination schedule specific Replantation of the Amputate
immunoglobulins
3. Complete For the amputate, a microsurgical replantation
primo
should always be considered which results in a far
vaccination
a) Last 0 0
more satisfactory aesthetic and functional outcome.
vaccination However, if replantation is not possible, other
<5 years ago options such as primary closure, using the ampu-
b) Last 0 Toxoid (1 dose) tate as composite graft or reconstruction with a
vaccination>5 (local) flap, can be considered as an alternative
years
and < 10 years solution. These alternative options will be
ago discussed below. However, when opting for replan-
(continued) tation of the lip, this can be performed with one or
two arterial anastomoses. Although a venous anas- layer of gauze can be applied to keep the leech on
tomosis can be achieved in most cases, a sufficient the treatment area. The leeches normally start
venous outflow is the greatest obstacle to the suc- feeding immediately. If not, the skin can be punc-
cess of the replantation. Since functional veins are tured with a sterile needle to stimulate the leeches
created 4 to 6 days post-replantation via neo- with the released blood.
angiogenesis, this critical period must be bridged The treatment lasts for 30 to 90 min after which
by techniques to facilitate venous drainage such as the leech releases itself. During feeding, the
leech therapy (Hirudo medicinalis, with or without leeches can release a clear liquid: this is superflu-
topical heparin), mechanical pricking and the use ous water that they remove to concentrate the red
of topical heparin or intra-replant heparin or admin- blood cells in their digestive tract.
istering (additional) mono- or multi-anticoagulant/ After detachment of the leech, compresses
antiaggregant therapy such as heparin, aspirin, dex- soaked in isotonic sodium chloride solution or hep-
tran, and/or warfarin. Since these techniques main- arin solution (5.000 U/mL) can be applied to the
tain an active bleeding, hemoglobin (Hb) should be treatment area to maintain the active bleeding. The
closely monitored so that blood transfusions can be total treatment with leeches lasts for 2–6 days con-
made in time (Mumcuoglu 2014; James 1976). sidering the fact that functional veins are created 4
to 6 days post-replantation via neoangiogenesis.
Additional mono- or multi-anticoagulant/anti-
Leech Therapy aggregant therapy can be administered such as
heparin, aspirin, dextran, and/or warfarin,
The medicinal leech or Hirudo medicinalis has although the leech saliva also has some anti-
been used for over 50 years to remedy venous thrombotic activity. Patients may lose 5 to
congestion. And certainly today too, grateful use 15 mL of blood per leech treatment. But due to
is made of leech therapy as a lifebuoy in recon- the anticoagulant/antiaggregant therapy, a greater
structive microsurgery. The FDA approved leech blood loss must be assumed. Therefore, hemato-
therapy as a medical device in the field of plastic logic evaluations should be performed regularly
and reconstructive surgery in July 2004. (every 4 h), and hemoglobin (Hb) should be
Leech therapy is a relatively safe and well toler- closely monitored so that necessary blood trans-
ated. However, it is important to take the risk of fusions can be made in time (Mumcuoglu 2014;
infection into account caused by the Aeromonas James 1976).
bacteria, which are symbionts of leeches. These
bacteria are sensitive to second- and third-genera-
tion cephalosporins, fluoroquinolones, sulfameth- Alternative Reconstruction Techniques
oxazole-trimethoprim, tetracycline, and
aminoglycosides but are resistant to penicillin, If replantation is not possible, following the recon-
ampicillin, first-generation cephalosporins, and structive ladder, the first step in lip reconstruction is
erythromycin. Therefore, patients should be treated primary closure with or without wedge excision. It
each day of leech therapy with anti-Aeromonas is of utmost importance to correctly identify the
antibiotics such as 500 mg of ciprofloxacin. vermillion border and to respect this anatomical
One to ten leeches are used for each treatment. border during reconstruction. With lower lip
Different protocols have been described, ranging defects, especially in patients with high laxity of
from three leeches per hour to leeches applied the tissues (e.g., elderly), up to 60% can be closed
every few hours. Most protocols are established primary. If microstomia should occur, this can be
empirically and adjusted based on the degree of remedied with physiotherapy (stretching exercises)
congestion of the flap during the therapy. so that normal function can be regained. In contrast
Before application, leeches are thoroughly to the lower lip, reconstruction of the upper lip is
rinsed with deionized water. When the leech is somewhat more limited; only a defect of maximum
attached, a plastic adhesive membrane or a thick 40% can be primarily closed. This is mainly
because a possible lateral shift of the philtral col- Karapandzic Flap

umns immediately reveals an earlier reconstruction
and thus an aesthetic inferior result. The Karapandzic was reported in 1974 by
For larger defects, local rotation flaps should Miodrag Karapandzic, a Yugoslavian plastic sur-
be considered. In addition to various possible V- geon, as a “rotation advancement lip flap” which
to-Y advancement flaps, Abbe, Estlander, and is used as a one-stage flap for defects involving
Karapandzic flaps are the most used options in half of the upper lip or larger. A defect is restored
daily practice. If the defect is of that size that the by separating the orbicularis oris muscle while
aforementioned local flaps are insufficient, a free maintaining the nerve and blood supply intact
flap should be considered (Sanniec et al. 2018). and then rotating and advancing until closure of
the oral sphincter. Because the net circumference
becomes smaller, microstomia can occur. This can
Abbe Flap be remedied in most cases through physiotherapy
that results in a good recovery of the initial func-
The Abbe flap, also known as the “lip switch tion since the orbicularis muscle remains inner-
flap,” was published by the American surgeon vated (Karapandzic 1974).
Robert Abbe in 1898. Although the flap has
already been described by Pietro Sabattini
60 years earlier, in a book with a limited circula- Surgical Technique, Patient
tion which explains the unfamiliarity of this fact, it Management, and Outcome
remains known under the name Abbe flap.
The flap is a two-staged pedicled flap based on In this clinical case, only a small lateral vein of
the arteria labialis inferior or superior and can be 1 mm diameter was identified. No artery was
used, respectively, for both upper and lower lip found in the amputate. This resulted in a challeng-
reconstructions, although it is most commonly ing replantation case since not only the venous
used for upper lip reconstruction with central or outflow but also the arterial inflow was
lateral lower lip as donor site. The flap is designed compromised. The total ischemia time was
half as wide as the defect to obtain equal upper approximately 5 h, and the surgery time was 2 h
and lower lip lengths and with the same height as and 40 min.
that of the defect. The flap consists of the skin, It is largely assumed that facial veins, certainly
muscle, and mucosa. After harvesting, the flap is small caliber, are valveless. This assumption is
rotated and inset with respect to the anatomical based on the fact that infections can spread
landmarks, in particular the aligning of the ver- quickly from the face to the cavernous sinus.
milion border and the orbicularis oris muscle. The Although some studies contradict this and state
pedicle, a small amount of mucosa and also the that valves are nevertheless present (Zhang and
labial artery are divided after two to three Stringer 2010; Nishihara et al. 1995). In this clin-
weeks (Baumann and Robb 2008). ical case, after performing the arteriovenous anas-
tomosis using Ethilon® 10–0, the amputate
immediately regained color which indicated an
Estlander Flap efficient inflow through the vein (Fig. 2).
Since no microsurgical venous anastomosis
Jakob August Estlander was a Finnish surgeon could be provided, techniques to facilitate venous
who described the flap in 1872, which is used drainage were needed. In this clinical case, venous
for defects of the lower or upper lip involving outflow was achieved by using leeches, which
the oral commissure. The technique is similar to were changed every 3 h. Heparin compresses,
the Abbe flap, but a correcting second-stage soaked in a solution of 5000 UPS units/mL hepa-
commissuroplasty is often needed around rin with 30 mL NaCl, were applied locally on the
12 weeks after the first procedure (Quick 1946). flap. The leech therapy was extended to every 4
photograph
Fig. 3 The patient at 8.5

months postoperatively
photograph
hours at day 6 and stopped at day 9 postopera- the face by using a hot air blanket set at 43 C. The
tively. Due to the active venous bleeding, a total of systolic blood pressure was kept around 120 mil-
two units packed red blood cells were adminis- limeters of mercury.
tered at day 7 postoperatively. The patient was intubated for 9 days to accom-
Prophylactic antibiotics to prevent infections modate leech treatment. Due to respiratory com-
related to dog bites (amoxicillin/clavulanic acid) plications, intubation was prolonged for 4 days.
and infections associated with leech therapy (cip- No necrosis or other complications were seen
rofloxacin) were started (BCFI 2003). Prophylac- at the replanted upper lip and achieved an aesthet-
tic low-molecular-weight heparin (0.4 cc 1dd) for ically satisfactory result. Follow-up after
deep vein thrombosis prevention was also started. 8.5 months continued to show a good healing of
The patient was installed with the upper body in a the defect. Also a full recovery of sensory and
30 upright position. Warmth was applied over motor function was seen (Fig. 3).
Learning Points References
In this case, noninvasive heat was applied to the Baumann D, Robb G. Lip reconstruction. Semin Plast
Surg. 2008;13(2):269–80.
face using a hot air blanket at 43 C, which gave a
BCFI. Aanpak van bijtwonden door katten en honden
significant clearance of the cyanotic appearance of [Internet]. BCFI. 2003 [cited 2018Apr21]. Available
the replanted part. from: http://www.bcfi.be/nl/articles/1225?folia¼1217.
As demonstrated by this case, the inability to De Keuster T, Lamoureux J, Kahn A. Epidemiology of dog
bites: a Belgian experience of canine behaviour and
perform a venous anastomosis is not a contraindi-
public health concerns. Vet J. 2006;172:482–7.
cation for replantation. Also, performing an artery- James NJ. Survival of large replanted segment of upper lip
to-vein anastomosis appears to be a reliable alter- and nose. Case report Plast Reconstr Surg.
native when no artery can be found in the amputate. 1976;58:623–5.
Kahn A, Bauche P, Lamoureux J. Child victims of dog
Therefore, a microsurgical replantation should
bites treated in emergency departments: a prospective
always be considered which results in a far more survey. Eur J Pediatr. 2003;162:254–8.
satisfactory aesthetic and functional outcome. Karapandzic M. Reconstruction of lip defects by local
The continuous use of leeches near the mouth arterial flaps. Br J Plast Surg. 1974;27(01):93–7.
Morgan M, Palmer J. Dog bites. BMJ. 2007;334:413–7.
as well as noninvasive heating of the face, which
Mumcuoglu KY. Recommendations for the use of leeches
are both strongly recommended to avoid venous in reconstructive plastic surgery. Evid Based Comple-
congestion even with patent venous anastomosis, ment Alternat Med. 2014;2014:205929.
require postoperative intubation of the patient for Nishihara J, Takeuchi Y, Miki T, Itoh M, Nagahata S.
Anatomical study on valves of human facial veins. J
the duration of the therapy. To avoid any compli-
Craniomaxillofac Surg. 1995;23:182–6.
cations due to a longer period of intubation, this Quick B. The Estlander-Abbe operation. Aust N Z J Surg.
period should be kept as short as possible. Since 1946;16(02):142–8.
neoangiogenesis occurs in a period of 4 to 6 days, Sanniec K, Carboy J, Thornton J. Simplifying lip recon-
struction: an algorithmic approach. Semin Plast Surg.
a maximum duration of 7 days leech therapy
2018;32(2):69–74.
followed by extubation should be considered Zhang J, Stringer MD. Ophthalmic and facial veins are not
(Mumcuoglu 2014; James 1976). valveless. Clin Exp Ophthalmol. 2010;38(5):502–10.
Upper Lip Amputation: Microsurgical
Replantation and Postoperative Routine 7
Jonas Löfstrand
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Intraoperative Images (Figs. 3, 4, and 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Abstract is a young woman who was attacked by a dog

Lip amputations are rare and usually the result and suffered an amputation of more than half
of animal bites (dog, human), accidents, or of her upper lip, as well as a partial lower lip
sharp trauma (knife attack). The case presented avulsion.
The amputated lip was kept cool, and the
patient was immediately taken to operating
theater for replantation. The upper labial artery
J. Löfstrand (*) was identified both in the amputated segment
Department of Plastic Surgery, Sahlgrenska University and in the recipient area. Microvascular anas-
Hospital, Gothenburg, Sweden tomosis was performed and the segment was
e-mail: jonas.lofstrand@vgregion.se

https://doi.org/10.1007/978-3-030-23706-6_7
54 J. Löfstrand
reperfused. No vein suitable for venous anas-

tomosis was found; hence, leech therapy was
initiated to relieve the venous congestion.
The arterial anastomosis remained patent
and leeching continued for 11 days. The recov-
ery was uneventful and no further revision was
required.
The lips have unique anatomic properties
which are impossible to reconstruct in full
when a larger segment is lost. Thus, replanta-
tion is pivotal in order to maintain oral func-
tions and aesthetic appearance. Arterial
anastomosis is usually feasible using the labial
artery. However, veins large enough for anas-
tomosis are seldom found, and even in cases Fig. 1 Patient appearance at initial presentation in the
where venous anastomosis can be performed, emergency department
venous congestion is common. Hence, it is
important to be prepared to use additional
methods for relief of this congestion.
Keywords
Lip · Amputation · Replantation ·

Microsurgery · Leeching
A healthy, 28-year-old female attended a party on

a Friday night. At 8 p.m., she petted a dog with
visual impairment, which reacted by biting the
woman twice in the face, resulting in severe lip
injuries (Fig. 1). After first visiting the emergency
Fig. 2 The avulsed lip segment which was brought with
department at a rural hospital, she was referred to the patient
the Plastic Surgery Department at Sahlgrenska
University Hospital. bag, which was kept cool in a jar filled with cold
At initial examination, the woman had no other water and a few ice cubes. The size of the ampu-
injuries than those sustained to the lips. tated segment was 4.5 3 cm (Fig. 2).
The lower lip had a long laceration rendering it
partially avulsed, hanging by a lateral stalk at the
right commissure. The circulation to this avulsed Preoperative Problem List:
segment was adequate, suggesting that the inferior Reconstructive Requirements
labial artery from the right side was intact.
The upper lip had a significant defect, where 1. Loss of upper lip would impair several func-
more than half of the lip had been amputated. The tions, such as:
amputated upper lip segment had been found and • Mouth closing
brought with the patient to the hospital. It had • Oral competence
been draped in moist gauze and put in a plastic • Speech
7 Upper Lip Amputation: Microsurgical Replantation and Postoperative Routine 55
• Teeth and mucosa hygiene In order to do so, the amputated segment and
• Chewing the wound bed need to be thoroughly assessed.
• Cosmetic outcome The aims are to repair the skin, muscle, and
• Facial expressions mucosa, to restore function, and to enable healing
• Oral tactility of the replanted segment; the blood flow needs to
2. In case replantation of the upper lip segment is be restored by means of arterial and, if possible,
not possible, the simultaneous injury of the venous anastomosis. Sensation is addressed by
lower lip severely compromises attempts to repairing severed nerves.
use part of the lower lip as a flap for upper lip Thus, the patient is urgently taken to the oper-
repair, e.g., Abbé flap (Jamra 1980). ating theater in order to replant the segment and
3. The amputated segment is most likely too large revascularize the tissue. A common problem in lip
to be able to survive as a compound graft replantation is the inability to find sizeable veins
(Daraei et al. 2014; Walker and Sawhney for anastomosis, with resulting venous stasis.
1972). Hence, it is pivotal to have a plan for postopera-
4. Replantation and revascularization is the only tive relief of venous congestion. This can be
effective way to reconstruct all lip functions achieved by using leeches, mechanical
mentioned above, both functional, static, and pin-pricking with topical heparin, or by injecting
cosmetic (Duroure et al. 2004; Walton et al. heparin in the replanted segment.
1998).
5. Revascularization of the amputated lip seg-
ment requires microsurgical instruments and Alternative Reconstructive Options
experience, since the vessels in question are
small. 1. If microvascular replantation is not feasible,
6. Revascularization by means of arterial anasto- the amputated segment may be reattached as a
mosis is often feasible, usually the labial artery compound graft. The chance of success is
can be found and anastomosed. However, highly related to the size of the amputated
often it is difficult to find a vein suitable for segment. Smaller segments (<1.5 cm) can, in
anastomosis. The labial artery has no comitant an elective setting (cleft lip patients), survive
veins, and the venous drainage is mostly as composite grafts (Walker and Sawhney
through venous plexa. The injury mechanism 1972). However, in this case, where the seg-
in a majority of lip amputations is animal or ment is much larger and has been subjected
human bites, which furthermore traumatizes to biting and avulsion, success was highly
the small veins which reduce the chance for unlikely.
adequate venous repair. Even in cases where 2. As in other cases, with loss of significant
venous anastomosis is performed, more than amount of upper-lip tissue, e.g., due to tumor
half of the patients will need additional mea- excision, a flap from the lower lip could be
sures to relieve venous congestion (Gustafsson used to replace some of the missing tissue. A
et al. 2016). Hence, it is important to have a commonly used technique for this kind of large
plan to manage the possible postoperative volume loss is the Abbé flap (Jamra 1980). In
venous congestion. this case, however, the lower lip was trauma-
tized in a way that precluded an immediate
reconstruction with this method.
Treatment Plan 3. Free flaps have been used for lip reconstruction
and can provide volume, static support, and
The goal should be to restore normal anatomy to even sensation (Eguchi et al. 2005). However,
the largest possible extent. This provides the best there is no motor function, and no mucosal
possibility to maintain oral functions and reconstruction, and the aesthetic results are
aesthetics. uncertain.
56 J. Löfstrand
Preoperative Evaluation and Imaging the vascular anastomosis in order to decrease

the risk of movement/displacement of the lip
The appearance of these traumatic amputations is during and after vascular anastomosis, which
often quite dramatic, but it is important not to be could jeopardize the anastomotic patency.
distracted by this. It is important to perform an 4. Usually, nerves are found in the amputated
adequate assessment as of any other trauma segment, but in this case, none were found. If
patient, in accordance with the guidelines of nerve anastomosis is to be performed, it should
advanced trauma life support. If there are other be performed first. Since the bleeding after the
injuries with higher priority than the lip amputa- amputate has been revascularized, the visuali-
tion, these should be tended to first. zation and coaptation of these small nerves can
With regard to the lip amputation, no specific be impaired.
imaging is needed. 5. If decent-sized veins are identified, they are
now anastomosed, followed by arterial repair.
If no veins are found, the artery is anasto-
Preoperative Care and Patient mosed; after circulation is restored, it might
Drawing be possible to find a vein when the venous
blood is draining from the lip. The vessels are
The patient is put in a supine position. A sterile repaired under microscopic magnification,
back-table is prepared, where the amputated seg- usually with 10–0 or 11–0 sutures. In this
ment could be examined and prepared. case, 10–0 sutures were used since the arterial
The patient is thoroughly informed of the oper- diameter was barely 1 mm. The time from
ation plan and possible complications and risks. amputation to reperfusion was 4 h and 45 min.
Signed consent is needed if mandated. No preop- 6. Even after arterial anastomosis, no suitable
erative markings are needed. vein could be found. If no vein anastomosis
could be performed, it is important to activate
your preoperative plan of venous drainage.
Surgical Technique Meanwhile, the venous drainage through the
wound edges is adequate.
1. The amputated segment is thoroughly examined 7. Now perform layered repair of muscle
under loupes or microscope. This is performed (orbicularis oris) and skin. After this is fin-
on the back-table. The segment is irrigated with ished, you should immediately employ your
large amounts of saline and all obvious debris measures for venous drainage, in case you
and foreign material are removed. Structures have not performed a sufficient venous anasto-
that need to be identified are muscle, skin, mosis. In this case, leeches (Hirudo
mucosa, artery, vein, and nerves. The labial medicinalis) were used.
artery is not large, but usually easy to find. It
has no comitant veins, thus the search for veins
should be made elsewhere, preferably in the Technical Pearls
outskirts of the amputate toward the cheek
area where smaller veins are more abundant. 1. The use of a sterile back-table for examination
There are usually several sensory nerves in the of the replanted segment enables a two-team
area. For this case, a superior labial artery was approach, where the other team can examine
found, but no veins nor nerves. the wound bed simultaneously and thus
2. The wound bed is examined in a similar fash- shorten operative time.
ion, with meticulous cleaning and identifica- 2. By loosely attaching the lip segment before
tion of structures as mentioned above. doing microvascular anastomosis, the risk of
3. The lip is loosely attached with sutures starting anastomotic disruption due to displacement of
at the mucosal side. This is performed before the amputate is lessened.
3. In many cases, no obvious vein suitable for method was 6.6 days (Gustafsson et al. 2016).
anastomosis is found. In that case, the artery This duration is more in union with the fact that
is anastomosed; when the venous blood is neoangiogenesis creates functional venous out-
leaking out, it might be possible to find a vein. flow vessels 4–6 days after replantation (Smith
1960; Whalen and Zetter 1992). During the
leeching period, the patient was transfused with
Intraoperative Images (Figs. 3, 4, a total of 7 units of blood.
and 5) Peroperatively, this patient received a tracheos-
tomy to secure the airway when the oral soft tissues
got swollen and also to protect the airway from the
continuous blood leaking from the lip, which partly
went into the mouth and throat. The tracheostomy
Postoperative Management was removed at POD 8 as the swelling subsided and
The patient was kept sedated the first postopera-

tive night. The lip was monitored closely by a
dedicated nurse at the ICU and ward. Leeches
were applied frequently (every 45 min) the first
night, thereafter the interval was guided by the
color of the replanted segment. This resulted in
every 90 min postoperative day (POD) 1, every
2 h POD 2–4, every 3 h POD 5–9, and every 4 h
POD 10–11. After this, no more leeching was
required. This was longer leeching time than usu-
ally is required; in a literature review of lip replan-
tations without venous outflow, the average
duration for use of any venous congestion relief
Fig. 4 After replantation and arterial anastomosis, the lack

of venous outflow immediately makes the lip swollen and
turn blue
Fig. 3 Intraoperative exploration of the wound bed of the Fig. 5 A leech is applied to the replanted segment, which
upper lip and the injured lower lip turns pinkish, and the swelling decreases
58 J. Löfstrand
the blood leaking was less. The indication for tra-

cheostomy is not absolute and should be assessed
for each individual case, depending on the extent of
the injury and concomitant other injuries. At this
institution, there was an isolated lower lip replanta-
tion 2 years later with less soft tissue damage; that
patient did not need a tracheostomy.
In order not to interfere with the replanted lip,
the patient was prohibited from oral intake for the
first week, other than small sips of water. Enteral
nutrition was given by feeding tube for the first
3 days, but switched to total parenteral nutrition
for the following 4 days due to severe nausea and
vomiting.
Thrombotic prophylaxis was given in the form
of subcutaneous injections of 5000 U dalteparin
daily for 14 days. Fig. 6 Appearance 1 year after replantation
Broad-spectrum antibiotics in the form of
Meropenem 0,5 g 3 were given for 10 days to
cover both bacteria associated with dog bites and
commensal bacteria associated with leeches
(Aeromonas hydrophila) (Snower et al. 1989).
The patient was discharged on POD 14.
The follow-up was uneventful. The replanted seg-

ment survived without necrosis. The patient was
able to eat solid food after 4 weeks without prob-
lems. At 1-year follow-up, the lip still showed some
edema, which was continuously subsiding. The
oral continence and motor functions were good,
as well as articulation. The patient had sensitivity
for blunt touch but not for heat/cold or pin-prick. Fig. 7 The motor function of the lips is completely
This is in accordance with the fact that no nerves restored
were sutured in this patient (Figs. 6 and 7).
kind of replantation and the use of leeches are
not common at this institution, one dedicated
Avoiding and Managing Problems nurse was assigned for this patient at all times:
monitoring the flap, administrating the leeches,
1. Even though the microvascular anastomosis and performing general patient care.
seems like the largest challenge, one must still 3. Depending on the trauma, the labial artery
focus on the details. A meticulous repair of the stumps could be of varying quality. If there is
skin, mucosa, and especially the muscle is piv- a gap, it is better to use a short vein graft
otal for the functional and aesthetic outcome. instead of suturing the stumps under great ten-
2. The postoperative care of the patient should be sion, which increases the risk of anastomotic
kept on as few hands as possible. Since this failure.
4. Adequate debridement and empiric antibiotic found, nerve anastomosis should be performed
treatment are very important, since an infection if it is feasible.
in the replanted segment could have severe 4. Lower lip amputations are less common than
consequences. those of the upper lip. However, there is no
5. One must not forget that this kind of injury can difference regarding the technique and consid-
affect the patient’s mental state quite seriously. erations vis-à-vis upper-lip replantations.
Thorough information from the operating sur-
geon is important, and consultation by psy-
chologist/psychiatrist when indicated. Cross-References
▶ Upper Lip Replantation with Arterialized Venous

Learning Points Flap, Without Microsurgical Venous Outflow
1. Even though replantation should be performed

urgently, it is even more important to do it References
right. Successful replantation has been
Daraei P, Calligas JP, Katz E, et al. Reconstruction of upper
performed on a lip that had been ischemic for lip avulsion after dog bite: case report and review of
17 h (Jeng et al. 1992). Thus, if the patient literature. Am J Otolaryngol. 2014;35(2):219–25.
appears at a rural hospital with little or no Duroure F, Simon E, Fadhul S, et al. Microsurgical lip
microsurgical experience, there is likely time replantation: evaluation of functional and aesthetic
results of three cases. Microsurgery. 2004;24(4):
to consult and refer to a specialized center. If 265–9.
the amputated segment is kept cold, as in this Eguchi T, Nakatsuka T, Mori Y, et al. Total reconstruction
case, the ischemia-induced damages progress of the upper lip after resection of a malignant mela-
slower and the time frame for successful noma. Scand J Plast Reconstr Surg Hand Surg.
2005;39:45–7.
replantation is extended. Gustafsson J, Lidén M, Thorarinsson A. Microsurgically
2. The lips are unique in their anatomical consti- aided upper lip replantation – case report and literature
tution and very difficult to successfully recon- review. Case Reports Plast Surg Hand Surg.
struct if larger segments are lost. In case the 2016;3(1):66–9.
Jamra FA. Immediate repair of upper lip defect with a
replantation fails, most likely it will mean that cross-lip flap. Plast Reconstr Surg. 1980;66(2):288–9.
the patient will need several other surgeries Jeng SF, Wei FC, Noordhoff MS. Successful replantation of
with resulting worse outcome, more suffering, a bitten-off vermilion of the lower lip by microvascular
and higher costs. Thus, much effort must be anastomosis: case report. J Trauma. 1992;33:914–6.
Smith JW. The anatomical and physiologic acclimatization
invested pre- and postoperatively to succeed of tissue transplanted by the lip switch technique. Plast
with the replantation. Reconstr Surg Transplant Bull. 1960;26:40–56.
3. In this case, no nerve anastomosis was Snower DP, Ruef C, Kuritza AP, et al. Aeromonas
performed. The resulting sensibility did not hydrophila infection associated with the use of medic-
inal leeches. J Clin Microbiol. 1989;27:1421–2.
nearly regain normal function, which could Walker JC Jr, Sawhney OP. Free composite lip grafts. Plast
be disturbing in a body part that in many Reconstr Surg. 1972;50(2):142–6.
instances is depending on sensibility. Nerves Walton RL, Beahm EK, Brown RE, et al. Microsurgical
can regenerate through sprouting, and the replantation of the lip: a multi-institutional experience.
Plast Reconstr Surg. 1998;102(2):358–68.
amputated part can regain much sensibility Whalen GF, Zetter BR. Angiogenesis. Wound healing:
without nerve anastomosis, but this is highly biochemical and clinical aspects. Philadelphia:
unpredictable. Thus, if any nerves could be Saunders; 1992.
Salvaging a Failed Total Nasal
Reconstruction Using Radial Forearm and 8
Forehead Flaps
Sarah L. Versnel and Marc A. M. Mureau
Contents
Preoperative Problem List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
First Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Second Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Third Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Fourth Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Fifth Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Sixth Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Seventh Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Eighth Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Ninth Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Final Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Abstract
Reconstruction of a saddle nose deformity, as a

result of subtotal septum and hard palate necro-
sis due to cocaine abuse, requires a stepwise,
S. L. Versnel · M. A. M. Mureau (*) multistaged approach using a free flap for lin-
Department of Plastic and Reconstructive Surgery and
Hand Surgery, Erasmus MC, University Medical Center ing and a forehead flap for cover including
Rotterdam, Rotterdam, The Netherlands careful preparation and monitoring of the
e-mail: s.versnel@erasmusmc.nl; patient. The patient presented with a collapsed
m.mureau@erasmusmc.nl

https://doi.org/10.1007/978-3-030-23706-6_8
62 S. L. Versnel and M. A. M. Mureau
and contracted nose and scarred forehead and

cheeks after previously failed nasal reconstruc-
tion attempts with multiple rib and concha
cartilage grafts, local intranasal and
buccogingival transposition flaps, a para-
median forehead flap, nasolabial flaps, and a
facial artery musculomucosal (FAMM) flap.
A stepwise nasal reconstruction consisting
of nine stages was subsequently performed
with a folded radial forearm free flap, cartilage
rib grafts, and two forehead flaps for recon-
struction of the nasal inner lining, support,
and cover, respectively. The reconstruction
was complicated by partial flap necrosis of
the radial forearm free flap and extrusion of
the tissue expander due to breakdown of the
forehead skin. This case demonstrates that in
patients with substance abuse cessation is
essential, and that free flap surgery is a pre-
ferred choice for reconstruction of the inner
lining in this population. It shows that, despite
multiple previous operations and the occur-
rence of complications, still a satisfactory func-
tional and esthetic outcome may be achieved,
provided that the reconstructive plan and han-
Fig. 1 Saddle nose deformity, resulting from a subtotal
dling of complications are good. septum necrosis including hard palate due to cocaine abuse
Keywords
lining flaps, and rib and concha cartilage grafts.
Radial forearm free flap · Nasal Again, the procedure was complicated by necrosis
reconstruction · Forehead flap · Tissue of the intranasal lining with secondary infection of
expansion · Cocaine abuse · Tissue necrosis the cartilage grafts for which two salvage proce-
dures were performed to reconstruct the intranasal
lining and to cover the cartilage grafts using bilat-
The Clinical Scenario eral nasolabial flaps and a left-sided facial artery
musculomucosal (FAMM) flap 3 and 2 months
A 36-year-old female presented with a failed com- before presentation, respectively. Unfortunately,
plex nasal reconstruction of a saddle nose defor- the infection of the avascular cartilage grafts did
mity, resulting from a subtotal septum necrosis not resolve for which another two revision pro-
including hard palate due to cocaine abuse cedures were done without success. The patient
3 years earlier. Two prior attempts had been had been unsuccessfully operated on seven times
performed 2 and 1 year before presentation, and had been additionally treated with hyperbaric
using rib cartilage grafts complicated by expo- oxygen therapy, resulting in a scarred, deformed,
sure, infection, and resorption of the cartilage and failed nasal reconstruction and 5-kg weight
grafts due to necrosis of the intranasal mucosa loss for which she used supplemental nutrition
(Fig. 1). Six months before presentation, a total drinks. In addition, the patient was a heavy smoker.
nasal reconstruction had been performed using a On physical examination, there was evidence
left-sided paramedian forehead flap, local nasal of a subtotally collapsed and contracted nasal
8 Salvaging a Failed Total Nasal Reconstruction Using Radial Forearm and Forehead Flaps 63
reconstruction attempt using a left-sided para- The patient’s BMI was 18.2 kg/m2, and the
median forehead flap, bilateral nasolabial flaps, Allen test of both forearms was negative indicat-
left-sided FAMM flap, multiple rib and concha ing insufficient palmar arches.
cartilage grafts, and local intranasal and
buccogingival transposition flaps. The forehead
was scarred, the ears were deformed due to miss- Preoperative Problem List
ing conchal support, the intraoral cheek scar was
contracted, and the nasolabial scars were situated 1. Undernourishment and active smoking
too laterally on the cheeks (Fig. 2). In addition, 2. Insufficient and scarred nasal lining
there was a large oronasal fistula, which was cov- 3. Obstructed nasal airway
ered with a denture plate. 4. Insufficient nasal support and infected nasal
cartilage framework
5. Insufficient, scarred, and contracted nasal skin
cover
6. Scarred forehead and limited local donor sites
due to previous operations
7. Negative Allen test for both hands
Treatment Plan
The patient was advised to first gain weight until

her BMI was at least 20 kg/m2 and to stop
smoking. She was tested for MRSA carriership,
which turned out negative.
A multistaged operative plan was made
according to the reconstructive requirements.
Stage 1
1. To recreate the defect and to preserve as
much forehead skin as possible for future
use, the forehead flap needs to be trans-
ferred back to the forehead.
2. All scar tissue and infected cartilage grafts
at the nose have to be excised.
3. To reconstruct the missing nasal lining and
floor and to temporarily cover the nose, a
radial forearm free flap is used (Fig. 3).
4. To revascularize the hand, an interposition
cephalic vein graft is anastomosed to the
Fig. 2 Situation after a failed nasal reconstruction attempt
distal and proximal radial artery ends.
using a left-sided paramedian forehead flap, resulting in a
collapsed and contracted nose. In addition, bilateral 5. A cantilever rib graft is fixed to the nasal
nasolabial flaps, a left-sided FAMM flap, multiple rib and bone to create support of the nasal dorsum.
concha cartilage grafts, and local intranasal and 6. Scar revision of nasolabial scars.
buccogingival transposition flaps had been unsuccessfully
Stage 2 (about 4–6 weeks later)
used. Please note the forehead was scarred, the ears were
deformed due to missing conchal support, the intraoral 7. Tissue expander insertion under the right
cheek scar was contracted, and the nasolabial scars were forehead skin for pre-expansion of a para-
situated too laterally on the cheeks median forehead flap.
1. The chimeric paramedian-pericranial forehead

flap has been described for replacement of
nasal lining, and coverage with minimal
donor-site morbidity in a single surgery. The
pericranial flap is used for lining of the nasal
vestibule. The disadvantages are as follows:
exposed skull at donor-site, which may need
a free flap for closure; insufficient tissue for
reconstruction of the entire nasal inner lining,
as in the presented case. The advantages are as
follows: thin lining flap; the two vascularized
flaps on one single pedicle allow for placement
of support grafts at the time of initial surgery
(Harrison et al. 2019).
2. A nonfolded radial forearm free flap covered
with a full thickness skin graft may also be
used (Haack et al. 2014). A radial forearm
free flap with multiple skin paddles covered
with a skin graft has also been used to recon-
struct the lining of the nasal vestibule and
columella (Burget and Walton 2007). The dis-
advantages are as follows: more contraction
issues due to skin grafts, less flexibility at the
Fig. 3 Preoperative markings of previous forehead and
cheek scars, the esthetic subunits of the upper lip, and the
time of forehead flap insertion, shortage of
area of the right forehead where a tissue expander will be excess skin for salvage of possible complica-
placed during a subsequent reconstruction stage. Please tions, and torsion of the individual perforators
note the template for the radial forearm flap which will be in a multiple pedicled flap which may be more
used for nasal lining, columella, nasal floor, and temporary
nasal cover
complex and less adaptable (Menick 2009a).
The advantages are as follows: less donor-site
Stage 3 (4–5 months later) morbidity, possibly less vascularization issues
8. Excision of temporary radial forearm flap due to less tension during folding.
cover and thinning of lining parts. 3. A prelaminated radial forearm free flap with
9. Delayed primary rib cartilage grafts (strut, cartilage and skin grafts at the forearm is an
alar batten, and tip) for support. option if the forehead skin is too much scarred.
10. Transfer of pre-expanded right-sided para- The disadvantages are as follows: soft tissue
median forehead flap. contraction with limited revision options
Stage 4 (about 4 weeks later) due to minimal soft tissue excess, the initial
11. Elevation and thinning of forehead flap. design needs to be perfect, and donor-site
12. Sculpting and shaping of nasal skeleton. inconvenience/damage may occur (Sinha et
13. Resuturing of forehead flap for nasal cover. al. 2008).
Stage 5 (about 4 weeks later) 4. The ulnar forearm free flap is an alternative for
14. Transection of pedicle and inset of fore- the radial forearm free flap, when good hand
head flap. vascularization can be maintained (Allen test).
Stage 6 (about 6–9 months later) In the folded radial forearm flap design, the
15. Additional minor corrections to optimize skin of the ulnar side of the forearm is already
esthetic outcome. integrated. The disadvantages are as follows:
This flap has a shorter pedicle (4 cm) and defects in cocaine abusers with reliable long-
smaller concomitant veins. The advantages term results (Di Cosola et al. 2007). The dis-
are as follows: The ulnar forearm flap is less advantage of local flaps is the limited tissue
hirsute (advantage in male patients), and the that is available. The disadvantage of the
donor-site scar can be better concealed com- myomucosal buccal and FAMM flap is the
pared with the radial forearm donor-site. The limited reach to the anterior palate; in this
ulnar forearm free flap also shows less donor- case, there was already scarring of the inner
site morbidity, since more forearm muscles are and outer cheek. The tongue flap is a last resort
exposed instead of tendons (Kantar et al. with considerable donor-site discomfort and
2018). morbidity.
5. An osteocutaneous radial forearm free flap can
provide (limited) support. The disadvantages
are as follows: It is only for dorsal support; Preoperative Evaluation and Imaging
other parts still need grafts. It results in more
donor-site morbidity and flap drooping Donor-site:
(Kobayashi et al. 1995).
6. A 3D custom-made porous titanium prosthesis • For both arms, an Allen test was performed,
has been used as an alternative to replace the which in both cases was doubtful. A preopera-
cartilage support. The advantage is that it can tive arterial duplex ultrasound was obtained
be based on the original shape of the nose. It from the hand and wrist, which showed an
can be “prefabricated” by insertion of the insufficient arterial palmar arch on both sides.
implant in, for example, a thoracodorsal artery An MRA could also have provided the
perforator flap for a period of time to achieve required information.
primary integration, before free transfer of the • Only one paramedian forehead flap had been
complete structure is performed (Qassemyar et used; however, for a total nasal resurfacing,
al. 2018). The main disadvantages are the con- there was not enough unscarred forehead
sequences of possible infection. skin available (usually about 9 cm is
7. The free auricular helical flap, free fibula needed).
osteocutaneous flap, prelaminated temporo-
parietal fascial flap, first dorsal metacarpal Recipient-site:
flap, and dorsalis pedis flap are possible
alternative options for selected patients who • The “platform,” on which the nose is centered,
need a partial/subtotal nasal reconstruction was evaluated. Despite the palatal fistula, this
(Gasteratos et al. 2020). A thin anterolateral appeared stable. The upper lip was retracted
thigh flap has also been previously used to and the cheek scars were malpositioned.
replace lining, with an immediate rib graft • The dimensions of the nasal lining shortage
and forehead flap in one stage (Seth et al. were identified. The vault, vestibules, colu-
2013). However, experience with all these mella, and nostril floor all needed resurfacing.
alternatives has been limited compared to No additional imaging was done, but an MRI
the radial forearm free flap variations. could have given more details about the tissue
8. For closure of the remaining palatal defect, the conditions of the nasal remnants. In this case, it
following options could be considered, if the was not performed, since it had no clinical
patient wished a reconstruction: local flaps consequences for the operative plan. Recipient
from palate (von Langenbeck/Veau-Wardill- vessels (superficial temporal artery) did not
Kilner), regional flaps (myomucosal buccal require further imaging due to the nature of
flap, FAMM flap, tongue flap), and free flap the pathology. In case of inadequate superficial
(second radial forearm flap). Free flap recon- temporal arteries, the facial or external carotid
struction is the primary choice for large palatal artery may be an option.
Surgical Technique Using a template, a single paddle of forearm

skin (7 cm in width and 7 cm in height) was
First Stage outlined on the distal forearm, with a proximal
ulnar extension to resurface the nasal floor
The patient was positioned in a supine position according to the needs of the defect (Fig. 5). The
with her left arm on a hand table. The forehead radial forearm flap was raised in a standard fash-
flap was re-elevated off the nose, and after exci- ion with a 12 cm vascular pedicle including two
sion of the forehead scar and recreation of the concomitant veins. In addition, 30 cm of the
forehead defect, it was replaced to the forehead cephalic vein was dissected.
using 4.0 vicryl and 5.0 ethilon sutures. Subse- Using a previous subcostal scar, an osteocarti-
quently, all scar tissue and infected nasal cartilage laginous rib graft was harvested, which was
grafts were excised with the exception of healthy secured to the nasal and frontal bones using a
lining and cartilage grafts of the proximal part of six-hole miniplate and screws to provide dorsal
the upper vault of the nose (Fig. 4). Next, scar support. The bony part of the graft was oriented
tissue at the nasal floor and cranial upper lip was proximally and the cartilaginous part distally
excised to reposition the retracted upper lip cau- (Fig. 6). In addition, the cartilaginous part was
dally, creating a nasal floor defect. bilaterally secured to the old upper lateral carti-
lage grafts using 4.0 prolene. Closure of the donor
site was performed with 2.0 vicryl for the deep
fascia and 4.0 vicryl and monocryl for subcutis
and skin, respectively.
A subcutaneous tunnel under the right cheek
was made, and via a preauricular incision the
superficial temporal vessels were dissected prox-
imally until they had a sufficient caliber.
After ligation and transection of the vascular
pedicle, the thin, distal ulnar edge of the forearm
flap was pinched together in the midline to create a
neocolumella (similar to the Converse forehead
flap design), and the lateral distal tips of the fore-
arm flap were folded under and sutured to the
midline of the defect to line both nasal vaults
using 5.0 vicryl sutures. As a result of the folding,
the ulnar proximal skin extension rotated sponta-
neously medially to resurface the nasal floor
defect (Fig. 7). Now the cantilever graft appeared
too long. Therefore, it was shortened and a previ-
ously banked rib cartilage graft was harvested and
used as a strut graft which was fixed to the canti-
lever graft using a tongue-in-groove technique
and 5.0 prolene sutures (Fig. 8). The radial part
of the forearm flap could subsequently be used for
temporary cover of the nose and was inset using 5.0
Fig. 4 Intraoperative situation after re-elevation of the ethilon sutures. Next, the pedicle was pulled
forehead flap off the nose and replacement to the forehead. through the subcutaneous tunnel to the preauricular
Subsequently, all scar tissue and infected nasal cartilage
recipient vessels. The smallest of the two concom-
grafts were excised with the exception of healthy lining and
cartilage grafts of the proximal part of the upper vault of the itant veins was ligated, and using the operating
nose microscope two end-to-end anastomoses of the
Fig. 5 Using a template, a

single paddle of forearm
skin (7 cm in width and
7 cm in height) was outlined
on the distal forearm, with a
proximal ulnar extension to
resurface the nasal floor
(sill) according to the needs
of the defect. R.A.: radial
artery
radial artery to the superficial temporal artery and

other concomitant vein to the superficial temporal
vein were performed with 9.0 ethilon. Closure was
performed of the preauricular wound with 5.0
vicryl and 5.0 ethilon.
Meanwhile, the cephalic vein was harvested,
reversed, and anastomosed with 8.0 ethilon to the
distal and proximal radial artery ends as an inter-
position graft to re-vascularize the left hand. The
proximal forearm and the defect of the ulnar flap
extension were primarily closed after which the
distal part of the forearm defect was closed with a
split thickness skin graft from the left upper
medial thigh.
Finally, repositioning of the cheek scars to the
nasolabial folds was performed by excising skin
medial to the scars and medial transposition of
cheek skin after wide subcutaneous undermining.
Layered skin closure was performed with 4.0
vicryl and 5.0 ethilon (Fig. 9).
Postoperative Course
After an uneventful postoperative course during
the hospital admission, the patient presented
2 weeks postoperatively with a partial necrosis
of the left distal part of the radial forearm flap
with an exposed cartilage strut graft. A debride-
ment including removal of the exposed cartilage
Fig. 6 An osteocartilaginous rib graft was secured to the graft was performed at the outpatient clinic,
nasal and frontal bones using a six-hole miniplate and
screws to provide dorsal support. The bony part of the
followed by antibiotic therapy for 4 weeks. The
graft was oriented proximally and the cartilaginous part wound at the left alar base healed by secondary
distally intention causing an upward malposition of the
Fig. 7 Clarification of the

folding technique of the
radial forearm flap using a
template. The distal ulnar
edge of the flap is pinched
together to create the
columella, and the ulnar
extension of the flap forms
the nasal floor
Second Stage
To create sufficient forehead skin without scars

for a right-sided paramedian forehead flap,
3 months later, a tissue expander (4x8cm,
140 ml) was introduced in a subgaleal plane of
the right forehead using the healed medial scar of
the previous forehead flap. The wound was
closed in layers with 4.0 vicryl and 5.0 ethilon.
The tissue expander was pre-expanded with
20 ml of saline.
After 24 days, expansion of the forehead was
started with 15 ml saline per week. After 2 months,
the patient returned with an exposed tissue
expander, which was filled with 82 ml of saline,
due to skin breakdown of the previous forehead
flap, caudally as well as cranially. Antibiotic ther-
apy was started, and the patient was scheduled for
tissue expander removal (Fig. 10).
Third Stage
Fig. 8 Because the cantilever graft was too long, it was
shortened and a previously banked rib cartilage graft was Eleven weeks after the second operation, the
harvested and used as a strut graft, which was fixed to the exposed tissue expander was removed, includ-
cantilever graft using a tongue-in-groove technique ing most part of the contaminated scar capsule.
After excision of the wound edges, the forehead
alar base and shortage of the lining part of the was closed primarily with 3.0 vicryl and 5.0
radial forearm flap. The forehead and forearm ethilon. A passive drain was left in place for
donor-sites healed uneventfully. 4 days.
Fig. 9 The thin, distal ulnar edge of the forearm flap was skin extension rotated spontaneously medially to resurface
pinched together in the midline to create a neocolumella, the nasal floor defect. Repositioning of the cheek scars to
and the lateral distal tips of the forearm flap were folded the nasolabial folds was performed by excising skin medial
under and sutured to the midline of the defect to line both to the scars and medial transposition of cheek skin after
nasal vaults. As a result of the folding, the ulnar proximal wide subcutaneous undermining
The forehead healed uneventfully (Fig. 11).
Intermediate Analysis of Reconstruction

Requirements
Due to the partial necrosis of the radial forearm
flap with loss of the cartilage strut graft, there was
a shortage of lining of predominantly the left nasal
vestibule. In addition, the left alar base was
malpositioned cranially and there was insufficient
support of the nasal tip area with secondary con-
traction of the radial forearm flap. The forehead
was tight and scarred on the left side (Fig. 11).
To create sufficient nasal lining, a delay proce-
dure of the temporary cover part of the radial fore-
arm flap was planned to prepare for safely turning
over the external skin part. Bilateral paramedian
forehead flaps were planned to make sure the entire
external nose could be reconstructed with hairless
forehead skin. Additional rib cartilage grafts were
needed to make an L-strut for tip and columella
support and alar batten grafts for alae nasi support.
Fourth Stage
Fig. 10 Exposed tissue expander due to skin breakdown
of the previous forehead flap, caudally as well as cranially, Three months after the third operation, a delay
just prior to removal procedure of the temporary external part of the
radial forearm flap was performed by incising,

lifting, and suturing back this part of the flap.
There were no postoperative complications.
Fifth Stage
One week later, the external part of the radial fore-

arm flap was incised and turned over caudally after
carefully thinning the skin flap down to the level of
the subcutis. The flap was folded and sutured
together in the midline using 5.0 vicryl to create
the posterior part of the columella. At the left side,
the forearm flap was turned as much down until the
alar base was at the correct anatomical position.
Rib cartilage grafts were harvested through a
previous scar at the left subcostal area. An L-strut
graft was carved which was secured to the tip of
the old cantilever graft using 5.0 prolene sutures
(Fig. 12). The vertical part of the L-strut was fixed
to the nasal spine using a mini-Mitek anchor.
Next, alar batten cartilage grafts were carved and
forced into the correct shape using 5.0 prolene
Fig. 11 Due to the partial necrosis of the radial forearm spanning sutures. After correct positioning of the
flap with loss of the cartilage strut graft, there was a alar batten grafts, they were secured to the L-strut
shortage of lining of predominantly the left nasal vestibule. and alar base with 5.0 prolene sutures. Upper
In addition, the left alar base was malpositioned cranially
and there was insufficient support of the nasal tip area with
lateral cartilage grafts were carved and secured
secondary contraction of the radial forearm flap. The fore- between the caudal edges of the nasal bone and
head was tight and scarred on the left side the cranial edges of the alar batten grafts with 5.0
Fig. 12 The external part

of the radial forearm flap
was incised and turned over
caudally after carefully
thinning the skin flap down
to the level of the subcutis.
The flap was folded and
sutured together in the
midline to create the
posterior part of the
columella. A rib cartilage L-
strut graft was carved which
was secured to the tip of the
old cantilever graft
prolene sutures, functioning as buttress grafts to The forehead flaps were incised and raised as full
prevent the alar rims to rotate upward. Finally, a thickness flaps over the periosteum. The pivot
tip graft was fixed to the L-strut graft to optimize points were brought down below the level of the
nasal projection (Fig. 13). medial brows to enable tensionless transposition
Using a template for coverage of the entire of both forehead flaps to the alar bases and colu-
nose, a forehead flap design was outlined on the mella. The forehead flaps were sutured into place
right forehead which stopped at the level of the with 5.0 ethilon (Fig. 14). The forehead donor
medial scar of the previous left-sided forehead defects were covered with a paraffin gauze dress-
flap. Within the boundaries of this previous fore- ing to heal by secondary intention.
head flap, the rest of the nasal reconstruction
design (the right ala nasi) was outlined (Fig. 13).
The patient was put on antibiotic therapy for a
week, and she healed uneventfully.
Sixth Stage
Three and a half weeks later, both forehead flaps

were completely re-elevated in a 2–3 mm
Fig. 13 Alar batten cartilage grafts were carved and

forced into the correct shape using spanning sutures.
Upper lateral cartilage grafts were carved and secured
between the caudal edges of the nasal bone and the cranial
edges of the alar batten grafts, functioning as buttress grafts
to prevent the alar rims to rotate upward. Finally, a tip graft
was fixed to the L-strut graft to optimize nasal projection.
Using a template for coverage of the entire nose, a forehead
flap design was outlined on the right forehead which Fig. 14 The forehead flaps were incised and raised as full
stopped at the level of the medial scar of the previous thickness flaps, after which they were transposed and were
left-sided forehead flap. Within the boundaries of this sutured into place. The forehead donor defects were left to
previous forehead flap, the right ala nasi was outlined heal by secondary intention
subcutaneous plane, keeping their respective vas- Seventh Stage

cular pedicles intact. Subsequently, scar tissue at
the edges of the flaps was excised. All excess soft Twenty-seven days later, the left forehead flap was
tissues from the forehead flaps on the nose were re-elevated for the second time, exposing the ped-
excised, and the cartilage grafts of the nasal skel- icle of the right forehead flap. This latter pedicle
eton were carved into the ideal shape (Fig. 15). was severed after which the proximal and distal
An additional cartilage tip graft was sutured into parts were thinned and set in using ethilon 5.0
place using prolene 6.0. Subsequently, both quilting sutures. After infiltrating the left ear with
forehead flaps were resutured to the nose with a 1% lidocaine and 1:200.000 adrenaline solution,
ethilon 5.0. a rim of remaining concha cartilage was harvested
via an anterior approach. After hemostasis, the skin
Postoperative Course was closed using ethilon 5.0 and a paraffin gauze
There were no wound healing complications; tie-over dressing. The radial forearm flap lining at
however, the rim of the right ala nasi showed the rim of the right ala nasi was released from the
some retraction. old alar batten cartilage grafts. Next, the new con-
cha cartilage graft was sutured to the caudal edge of
the alar batten graft using prolene 6.0 sutures bring-
ing the rim of the ala nasi down to the level of the
contralateral side. After releasing the pedicle of the
left forehead flap bringing the pivot point further
down, the forehead flap was sutured back to the
alar defect with ethilon 5.0 (Fig. 16).
The quilting sutures of the right forehead flap
were removed after 2 days.
Eighth Stage
Four weeks later, the pedicle of the left forehead

flap was transected after which the proximal and
distal parts were thinned and set in using quilting
sutures. At the alar rim, there appeared to be a
small defect with connection to the alar batten
graft. A small part of the forehead flap was ele-
vated after which the wound was debrided and
closed primarily with ethilon 5.0.
The patient received oral antibiotics for 5 days.
There were no wound healing complications.
Fig. 15 Both forehead flaps were completely re-elevated
in a 2–3 mm subcutaneous plane, keeping their respective Analysis of Final Reconstruction
vascular pedicles intact. Subsequently, scar tissue at the Requirements
edges of the flaps was excised. All excess soft tissues from
The vestibular lining of both alae as well as the
the forehead flaps on the nose were excised, and the carti-
lage grafts of the nasal skeleton were carved into the ideal columella was too thick causing airway passage
shape problems. In addition, the alar crease at the left
Fig. 16 The left forehead flap was re-elevated for the Fig. 17 The vestibular lining of both alae as well as the
second time, after which the pedicle of the right forehead columella was too thick causing airway passage problems.
flap was severed and the proximal and distal parts were The alar crease at the left side was absent due to a too thick
thinned and set in. The radial forearm flap lining at the rim lateral side of the nose. The six-hole miniplate was
of the right ala nasi was released from the old alar batten removed improving the nasofrontal angle
cartilage grafts, and a new concha cartilage graft was
sutured to the caudal edge of the alar batten graft, bringing
the rim of the ala nasi down to the level of the contralateral 5.0 quilting sutures (Fig. 18). The columella was
side. Please note the release of the pedicle of the left elevated at the base, thinned, and sutured back
forehead flap, bringing the pivot point further down to correcting the nasolabial angle. Next, the left
resuture the flap back to the alar defect without tension
side of the nose was incised at the position of the
alar crease and at the transition with the paranasal
side was absent due to a too thick lateral side of cheek, after which the skin was elevated and the
the nose (Fig. 17). soft tissues were thinned. Using a piece of redun-
dant cartilage, the tip projection was improved by
introducing it via a subcutaneous tunnel at the left
Ninth Stage side. Finally, the skin at the left side of the nose
was sutured back using ethilon 5.0 quilting
Ten months after the last operation, the six-hole sutures (Fig. 19).
mini plate was removed improving the
nasofrontal angle (Fig. 17). The radial forearm
lining flaps of both vestibules were elevated and Final Result
aggressively thinned, and the cartilage grafts were
sculpted to enlarge the external valves, after Five months postoperatively, the patient had a
which the lining flaps were resutured using vicryl satisfactory outcome with a good contour of the
Fig. 18 The radial forearm

lining flaps of both
vestibules were elevated
and aggressively thinned,
and the cartilage grafts were
sculpted to enlarge the
external valves, after which
the lining flaps were
resutured using quilting
sutures
nose and only a minor retraction of the nasal tip.

Both nostrils were open with adequate airway
passage. The scars of the forehead, which had
healed secondarily, were inconspicuous (Fig. 20).
Technical Pearls
1. A good folded-flap design is key. The total

lining of the vault is about 7–8 cm (alar base
to alar base) in width and 4 cm in height. The
columella is reconstructed as a soft tissue
facade, 3 cm in height. The defect of nasal
floor lining is recreated by release of upper lip
contraction (Menick 2009a; Menick and
Salibian 2011).
2. The radial forearm flap is elevated from distal
to proximal with only fascia overlying the part
which includes the radial vessels and perfora-
tors. If possible, significant subcutaneous tis-
sue is immediately debulked after harvesting
under magnification, which is known as
“lipopluction” (Walton et al. 2005).
3. The ulnar distal part is pinched together in the
midline with sutures approximating its poste-
Fig. 19 The left side of the nose was incised at the rior raw surface to create a neocolumella. The
position of the alar crease and at the transition with the lateral distal tips of the forearm flap will auto-
paranasal cheek, after which the skin was elevated and the matically fold under. These are sutured to the
soft tissues were thinned. Using a piece of redundant car-
midline of the defect and toward each alar base,
tilage, the tip projection was improved by introducing it via
a subcutaneous tunnel at the left side. Finally, the skin at the from medial to lateral, completing the lining
left side of the nose was sutured back using quilting sutures inset. Tension, tight molding sutures, and
7. The long pedicle can be placed perpendicular to

the cover part, subcutaneously under the cheek
toward the superficial temporal vessels. Some
prefer an end-to-side anastomosis with the
external carotid artery and internal jugular vein
(Salibian et al. 2019). However, the advantage
of the superficial temporal vessels is that there is
no risk of kinking when turning the head.
8. The radial forearm flap folding technique is the
preferred method for microvascular recon-
struction of the nose, because a primary dorsal
cartilage graft can be placed in optimal vascu-
larization conditions, and dorsal skin excess
may be used to modify the lining inset and
the shape of the nostrils during forehead
resurfacing (Salibian et al. 2019).
1. Optimize the condition of the patient: Optimize

nutritional status and make sure the substance
abuse is under control. In this case, the nutritional
status was improved preoperatively; however,
the patient started smoking again after the first
Fig. 20 Final result 5 months postoperatively. The out-
come was satisfactory with a good contour of the nose and operation which had a negative impact on recon-
only a minor retraction of the nasal tip. Both nostrils were struction outcome. Good guidance by a psychol-
open with adequate airway passage. The scars of the fore- ogist/psychiatrist with regular checks is advised
head, which had healed secondarily, were inconspicuous during the entire treatment process, in order to
achieve optimal results. These patients tend to
aggressive thinning are avoided (Menick and have a noncompliant lifestyle and complete ces-
Salibian 2011). sation of cocaine use 6 months before surgical
4. If there is too much tension after folding, it may treatment is required. This can be checked with a
be helpful to apply a full thickness graft to the urine screening test (Di Cosola et al. 2007). Be
folded edges to avoid vascular problems aware of possible cocaine-induced local vasculi-
(Menick 2009a). tis which necessitates diagnosis and consultation
5. Always plan a staged reconstruction which by an internal autoimmune medicine specialist
allows further thinning to almost only forearm (Subesinghe et al. 2018).
skin, leaving the vascular pedicle intact (safe 2. Partial necrosis of the flap may sometimes
after 2 months). During the same stage, carti- occur due to too much tension after folding,
lage grafts are inserted and covered with a which compromises blood flow. Folding and
forehead flap (Menick 2009a). suturing under less tension, possibly with the
6. Always perform an Allen test. In case the test or use of full thickness skin grafts at the folded
additional imaging demonstrates absence of the edges, may avoid this. Intraoperative blanching
palmar arterial arch, the cephalic vein should be of flap parts should not be accepted. This means
harvested, and used in a reversed way as an release of tight sutures, repositioning of flaps,
interposition graft to revascularize the hand. and tensionless resuturing.
3. The use of a folded radial forearm flap leaves References

salvage options in case of partial flap necrosis
and/or contracture; the radial forearm skin on Burget GC, Walton RL. Optimal use of microvascular free
flaps, cartilage grafts, and a paramedian forehead flap
the external aspect may be turned over and
for aesthetic reconstruction of the nose and adjacent
used as additional inner lining (Salibian et al. facial units. Plast Reconstr Surg. 2007;120:1171–207.
2019). In the presented case, a delay procedure Di Cosola M, Turco M, Acero J, Navarro-Vila C, et al.
of the temporary external part of the folded Cocaine-related syndrome and palatal reconstruction:
report of a series of cases. Int J Oral Maxillofac Surg.
radial forearm flap was performed for correc-
2007;36:721–7.
tion of the contracture due to partial necrosis. Gasteratos K, Spyropoulou GA, Chaiyasate K. Microvas-
This was done by incising, lifting, and suturing cular reconstruction of complex nasal defects: case
back this part of the flap (Menick 2009b). One report and review of the literature. Plast Reconstr
Surg Glob Open. 2020;8:e3003.
week later, it was incised again and turned over
Haack S, Fischer H, Gubisch W. Lining in nasal recon-
caudally as additional nasal lining after care- struction. Facial Plast Surg. 2014;30:287–99.
fully thinning the skin flap. Harrison L, Sieffert M, Kadakia S, et al. Reconstruction of
4. If there is a shortage of forehead skin, a used a subtotal septorhinectomy defect with a chimeric para-
median-pericranial forehead flap. Am J Otolaryngol.
forehead flap should be transferred and sutured
2019;40:445–7.
back, if still pedicled. Tissue expansion of the Kantar RS, Rifkin WJ, Cammarata MJ, et al. Free ulnar
forehead skin was attempted with the goal of forearm flap: design, elevation, and utility in microvas-
resurfacing the total nose using one forehead cular nasal lining reconstruction. Plast Reconstr Surg.
2018;142:1594–9.
flap. Due to wound dehiscence of the scar of
Kobayashi S, Yoza S, Sakai Y, et al. Versatility of a micro-
the first forehead flap, the tissue expander had surgical free-tissue transfer from the forearm in treating
to be removed. This complication might have the dif cult nose. Plast Reconstr Surg. 1995;96:810–5.
been avoided if the tissue expander had been Menick FJ. The use of distant tissue for facial reconstruc-
tion – microvascular tissue transfer for nasal lining. In:
smaller and had been placed through a new
Nasal reconstruction: art and practice. Mosby Elsevier;
vertical incision above the hairline and not 2009a. p. 469–526.
through the old skin incision of the first fore- Menick FJ. Handling the forehead donor – the basics, old
head flap (Menick 2009b). scars, previous forehead flaps, delay and expansion. In:
Nasal reconstruction: art and practice. Mosby Elsevier;
5. In this patient, there still remained some tip
2009b. p. 239–69.
retraction possibly due to graft resorption, Menick FJ, Salibian A. Microvascular repair of heminasal,
resulting in suboptimal projection of the tip of subtotal, and total nasal defects with a folded radial
the nose. Future additional tip grafting could forearm flap and a full-thickness forehead flap. Plast
Reconstr Surg. 2011;127:637–51.
improve tip projection. However, the patient
Qassemyar Q, Assouly N, Madar Y, et al. Total nasal
did not wish further surgery at follow-up. reconstruction with 3D custom made porous titanium
prosthesis and free thoracodorsal artery perforator flap:
a case report. Microsurgery. 2018;38:567–71.
Salibian AH, Menick FJ, Talley J. Microvascular recon-
Learning Points struction of the nose with the radial forearm flap: a 17-
year experience in 47 patients. Plast Reconstr Surg.
1. Be aware of cocaine abuse-related (vasculari- 2019;144:199–210.
zation) problems! Try to avoid the use of local/ Seth R, Revenaugh PC, Scharpf J, et al. Free anterolateral
thigh fascia lata flap for complex nasal lining defects.
regional flaps for lining and make sure the
JAMA Facial Plast Surg. 2013;15:21–8.
patient is “clean.” Sinha M, Scott JR, Watson SB. Prelaminated free radial
2. Use a staged approach with options to manage forearm flap for a total nasal reconstruction. J Plast
complications. Reconstr Aesthet Surg. 2008;61:953–7.
Subesinghe S, van Leuven S, Yalakki L, et al. Cocaine and
3. Save as much forehead skin as possible for an
ANCA associated vasculitis-like syndromes – a case
esthetic cover of the nose. series. Autoimmun Rev. 2018;17:73–7.
4. Total nasal defects usually need a free flap Walton RL, Burget GC, Beahm EK. Microsurgical recon-
reconstruction for lining for optimal functional struction of the nasal lining. Plast Reconstr Surg.
2005;115:1813–29.
and esthetic outcomes.
SCIP Flap for Tongue Reconstruction
9
Jong-Woo Choi, Susana Heredero, Warangkana Tonaree, and
Joon Pio Hong
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
J.-W. Choi (*)

Professor in Plastic Surgery, Department of Plastic
Surgery, Asan Medical Center, University of Ulsan, Seoul,
Republic of South Korea
e-mail: pschoi@amc.seoul.kr
S. Heredero
Maxillofacial Surgeon, Department of Maxillofacial
Surgery, Hospital Universitario Reina Sofía, Córdoba, Spain
W. Tonaree
Division of Plastic and Reconstructive Surgery,
Department of Surgery, Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok, Thailand
Department of Plastic Surgery, Asan Medical Center,
J. P. Hong

https://doi.org/10.1007/978-3-030-23706-6_9
78 J.-W. Choi et al.

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Abstract dead spaces in the submandibular and carotid

Tongue reconstruction after carcinoma resection regions. A de-epithelialized SCIP perforator free
is essential to assure adequate deglutition, flap was considered for reconstruction of the
speech, and social interactions. Depending on hemiglossectomy defect.
the location of the carcinoma and the size of the Case 2 A 69-year-old man presented in the out-
defect, reconstructive options should be priori- patient clinic with a painful ulcer located in the
tized between providing mobility or bulkiness. left lateral border of the tongue (Fig. 1). A biopsy
Hemiglossectomy defects include resections of was positive for squamous cell carcinoma, and a
up to two-thirds of the tongue, and reconstruc- contrast computed tomography (CT) study
tion should be focused on using a thin and showed no signs of metastatic disease in the
pliable flap, which allows for adequate mobility neck. Diagnosis of a T2N0 squamous cell carci-
of the remaining tongue. noma of the mobile tongue was made, and the
Hemiglossectomy defects can be Head and Neck Cancer Committee approved sur-
reconstructed with regional flaps, as a sub- gery as the initial treatment. The patient
mental island flap, or with free flaps. The radial underwent hemiglossectomy and selective neck
forearm (RF) free flap and anterolateral (ALT) dissection of ipsilateral levels I–IV and contralat-
perforator flap are the most frequently used eral IB. Reconstruction with a superficial circum-
techniques worldwide. In recent years, the flex iliac artery perforator (SCIP) flap was planned
superficial circumflex iliac artery perforator to be done during the same surgical procedure.
(SCIP) flap has been proposed as a good alter- The SCIP flap was initially described (Koshima
native for intraoral reconstruction. et al. 2004) and developed from a groin flap, based
Two similar clinical scenarios of patients on the concept of perforator flaps. They reported a
with hemiglossectomy due to carcinoma resec- series of ten patients with different limb defects
tion, who were successfully reconstructed with reconstructed with this flap. It was not until 2013
thin SCIP flap, are presented in this chapter. when the use of a SCIP flap for intraoral
Keywords
Tongue · Hemiglossectomy · SCIP flap
Case 1 A 30-year-old man was referred with a firm

mass of the lateral tongue. The tumor was diag-
nosed as a T2N0 squamous cell carcinoma. Surgery
was performed under general anesthesia. Resection
of the primary tumor using a pull-through method
was performed simultaneously with left cervical
lymph node dissection. Tumor ablation resulted in Fig. 1 Clinical photograph showing the ulcer in the left
a defect of the mouth floor in the oral cavity and lateral border of the tongue
9 SCIP Flap for Tongue Reconstruction 79
reconstruction was first attempted (Green et al. Hemiglossectomy defects include resections
2013). Most of the articles describing the use of a of up to two-thirds of the tongue. In these
SCIP flap for intraoral reconstruction were specific patients, the main goal of reconstruc-
published in recent years, and they are primarily tion is to allow the residual tongue to move
from Asian countries (Altiparmak et al. 2020). and contact the premaxilla and palate for both
speech articulation and swallowing (Hanasono
et al. 2014).
For head and neck reconstruction, numerous
flaps have been used, such as the fasciocutaneous,
muscle, and musculocutaneous flaps, while the
In this specific clinical scenario, the main problem
fasciocutaneous flaps prevail in the modern era
was to reconstruct a defect of about 50% of the
because they could provide us with thin, pliable
mobile tongue. Reconstructive options should
tissues allowing for three dimensional reconstruc-
include a thin, pliable, and flexible flap to allow
tions. For successful microsurgical tongue recon-
for mobility of the remaining tongue.
structions, many things should be considered in
In the second case, the patient did not have an
advance, such as the defect size, location, charac-
adequate dual blood supply to the hand (bilateral
teristics of the donor tissue, length of the pedicle,
positive Allen tests), and so the radial forearm (RF)
and the recipient status. These case-specific fac-
free flap was not an adequate reconstructive option tors account for the numerous options for tongue
in this clinical scenario. Also, a thin profunda fem- reconstruction.
oral artery perforator (PAP) flap was not considered The inguinal flap was introduced in 1973 by Ian
in this patient because of the morphology of the Taylor and is used for many reasons. However, its
perforators seen in the CT angiography study pitfalls include providing thicker tissue with a short
(Fig. 2). In both thighs, perforators of the PAP pedicle length. In the early 2000s, Koshima
area were divided into smaller branches near the revisited and revolutionized the traditional inguinal
deep fascia (1.7 cm from the cutaneous surface). flap under the name “SCIP flap” based on the
This means that if these branches were included, perforators. He demonstrated that the superficial
the flap would have to be about 1.7 cm thick with circumflex iliac artery perforator (SCIP) flap
an area of about 2 3 cm, and it was too thick for could be an ideal donor perforator flap compared
the defect in the tongue in this clinical case. to the conventional inguinal flap (Koshima et al.
2004). It was JP Hong who popularized and mod-
Treatment Plan ernized SCIP flaps based on the superficial medial
branch. Since then, the SCIP free flap has become
The surgical treatment plan involved glosse- one of the workhorse flaps for reconstructive
ctomy, selective neck dissection, and reconstruc- microsurgeons (Goh et al. 2015).
tion with a suprafascial SCIP flap, harvested from However, for the head and neck reconstruction
the right groin area. surgeons who deal with intraoral defects, SCIP flaps
Fig. 2 Computed
tomography angiography
study showing the
morphology of the
perforators in the posterior-
medial thigh region. Both
perforators are divided into
branches near the deep
fascia. The close relation of
the perforator with the
cutaneous vein can be
appreciated in the right
thigh
present some difficulties, such as the short length of repaired with the tissue size of a SCIP free
the pedicle that may be overcome by using the de- flap, which allows us to make a primary clo-
epithelialization concept (Choi et al. 2017). sure on the donor inguinal area.
SCIP flap anatomy is different from the con- 2. The tongue is the most mobile organ in the
ventional inguinal flap, the modern SCIP free flap human body. It should be mobile even after
is based on the perforators being the superficial or reconstruction. For speech and swallowing,
deep branch of the superficial circumflex iliac the reconstructed tongue should be able to
artery. While Koshima mostly reported the use make diverse movements. According to our
of the deep branch of the SCIA, JP Hong has clinical experiences, SCIP free flaps allow
used the superficial branch. (Fig. 3). patients to move their tongues more freely
The superficial branch of the SCIA is known to compared to the other fasciocutaneous free
have two types. One is a direct anchoring type and flaps such as radial forearm free flaps, ante-
the other is the axial type. In the direct anchoring rolateral perforator free flaps, and
type, you can elevate the quite thin perforator skin thoracodorsal perforator free flaps, because
flap while in the axial type, you need to make a the inguinal area has the most elastic skin
tedious dissection along the axial SCIA in order to tissue.
get the thin perforator flap to the distal part (Suh
et al. 2017).
Peter Suh and JP Hong suggested the use of a Alternative Reconstructive Options
diagram for identifying the perforators of the
superficial branch of SCIP flaps. They reported For hemiglossectomy defects, a thin and pliable
that 95% of the perforators of the superficial flap is needed to preserve tongue mobility.
branch were found to penetrate the deep fascia Regional flaps such as submental island flaps
within an oval of 4.2 2 cm with a center point and supraclavicular flaps can provide an adequate
located at 4.5 cm lateral and 1.5 cm superior to the reconstruction. However, they can be
pelvic tubercle (Suh et al. 2017). contraindicated if there is extensive neck disease
The best advantages of the use of SCIP free that compromises the pedicle supplying the flap
flaps for tongue reconstructions include minimal (Vincent et al. 2019).
donor site morbidity and adequate mobility of the The most common free flaps used for defects of
tongue in terms of speech and swallowing function. up to two-thirds of the tongue are the RF free flap
and in thin patients, the anterolateral thigh perfo-
1. Most defects resulting from partial rator (ALT) flap (Engel et al. 2010). Recently, the
glossectomy and hemiglossectomy could be PAP flap has been proposed as a good choice for
Fig. 3 Two types of SCIP flap

tongue reconstruction (Fernandez-Riera et al. used to double-check the location of the vessels in
2017) (Scaglioni et al. 2015) (Wu et al. 2016). In the inguinal area and their locations were marked
Western populations, thigh flaps such as ALT and on the skin.
PAP flaps are less frequently used due to their
greater thickness and bulk as compared to those
from Asian patients. However, elevation of thin Preoperative Care and Patient
flaps in the plane of the superficial fascia layer, or Drawing
even thinner, have been described for both the
ALT (Hong et al. 2013) and the PAP (Heredero In the first case scenario, a skin flap was designed
et al. 2020) free flaps. The PAP flap is better than measuring 9 6 cm. A skin paddle was designed
the ALT flap in terms of pliability, which is an at the distal portion with a multilobed pattern and
important consideration for hemiglossectomy the proximal portion was allocated for the de-
reconstruction. epithelialization territory (the most prominent per-
The best advantages of thigh flaps and regional forator with a flow velocity of 40 cm/s was
flaps, such as the submental island flap, over the included in this territory). The extent of de-epi-
RF free flap is that they all have less donor site thelialization was determined depending on the
morbidity. necessary soft tissue volume that was assessed
The main disadvantage of the SCIP flap, as following the resection. Using a rubber sheet to
compared to the RF, the ALT, and the PAP flaps, simulate the oropharyngeal defect helps to reor-
is that the pedicle is shorter and smaller. However, ganize the actual defect three dimensionally.
the SCIP flap can be a good alternative for In the second case, morphologic analysis of the
hemiglossectomy reconstruction because it is flap was done using a preoperative CT angiogra-
also a very thin and pliable flap. phy and the open-source software HorosTM v
Cutaneous free flaps can be harvested as sen- 1.1.7 (GNU Lesser General Public License, ver-
sate flaps, and so can the SCIP flap, based on the sion 3). Three-dimensional images of the location
lateral cutaneous branch of the intercostal nerves of the superficial (medial) and deep (lateral)
(Iida et al. 2014). However, although neurotized branches of the superficial circumflex iliac artery
flaps have demonstrated improved flap sensation, were generated by identifying the course of the
there is insufficient evidence so far to demonstrate vessels. The flap was designed using augmented
functional improvement in speech or swallowing reality (Pereira et al. 2019). Three-dimensional
(Namin and Varvares 2016). images were imported to a smartphone, and a
free-share augmented reality app was used to
superimpose them and apply the markings in the
Preoperative Evaluation and Imaging operative field. The locations of the branches of
the superficial circumflex iliac artery were also
The patients underwent a complete pretreatment confirmed with duplex ultrasound. Drawings
clinical assessment, preoperative laboratory tests, were made according to the location of these
electrocardiogram, and nutritional assessment. A vessels (Fig. 4).
contrast CT scan was used for cancer staging.
Preoperative evaluation of the SCIP flap was
done with a CT angiography performed on a 64- Surgical Technique
slice multiple detector computed tomography
scanner (LightSpeed VCT; GE Healthcare, Mil- Tracheostomy was performed at the beginning of
waukee, WI, USA) using a standardized protocol. the operation. The patients were placed in a supine
Color Doppler ultrasound (NextGen Logiq-e position, and a two-team approach was used.
with 12L_RS probe, GE Healthcare, WI, USA., In the first case scenario, the SCIP flap sized
Philips Epiq 7, Royal Philips, Amsterdam, The 9 6 cm was harvested from the sub-superficial
Netherlands). Also, 8 MHz vascular setting was fascial layer. Dissection of the flap was carried out
Fig. 4 Sequence of virtual planning and marking of the flap using augmented reality. An anterolateral thigh perforator
flap was also designed as a backup plan. S ¼ superficial branch; D ¼ deep branch
as initially described by Hong et al. (Hong et al. jugular vein. The de-epithelialized skin flap was
2013). An incision was made in the lateral-inferior used to fill the dead space in the submandibular
border of the flap to the plane of the superficial and carotid region and to lengthen the pedicle.
fascia layer, which can be identified as a thin white The donor site was primarily closed.
film layer between the smaller superficial fat and In the second case scenario, the right SCIP flap
the deep large fat lobules. After identifying the was designed to be 13 7 cm. Dissection of the
dominant perforator, the position of the skin pad- flap was carried out in the same manner as the first
dle was adjusted. The distal to medial approach case except once the perforators were identified,
was used to identify the superficial medial perfo- elevation was proceeded from medial to lateral,
rator of the SCIP flaps. Then, dissection was made until they were completely isolated. Then, dissec-
towards the femoral vessels. tion was made towards the femoral vessels. The
A long axis of the flap was planned in order to final flap thickness ranged between 0.4 and
apply the de-epithelization concept (Choi et al. 0.6 cm. The pedicle length was 5.5 cm. Anasto-
2017). The proximal part of the flap was de- moses were done to the facial artery and a branch
epithelized and used to tunnel the space between of the internal jugular vein.
the oral cavity and the neck, whereas the skin
paddle in the distal part of the flap was used to
reconstruct the tongue. This technique also allo- Technical Pearls
wed for compensation for the pedicle shortness.
Insetting of the flap was adjusted by taking into 1. Preoperative virtual planning and/or duplex
account the length of the pedicle and the location ultrasound are useful to better understand the
of the defect and the recipient vessel. De-epithe- anatomy of the SCIP flap, making the
lialization of the proximal part was then harvesting of the flap easier.
performed, including thickness control of the dis- 2. To ensure direct closure of the donor site, a
tal part of the flaps. Microvascular anastomosis pinch test of the skin should be done while
was performed between the flap vessels and the designing the skin island of the SCIP flap.
superior thyroid artery and a branch of the internal The maximum width of the flap permitting
direct closure is about 8 cm, but it could be anastomosis could be possible, but it is some-
increased by 1 or 2 cm by flexing the hip during times difficult. In order to make the ensuing
closure and maintaining this position until the microanastomosis, you often need to find the
donor site is healed (Suh et al. 2018). known recipient vessels, such as the facial
3. The pedicle length of the SCIP flap is usually vessels or suprathyroid vessels. The problem
very short. Designing the flap with a long axis is the limitation of the pedicle length in SCIP
and using partial de-epithelization of the distal free flaps. In order to overcome this obstacle,
skin can help the pedicle reach the recipient the de-epithelization concept (Choi et al. 2017)
vessels. can be applied to the SCIP flap. This method
4. There are two ways to elevate the SCIP free provides us with many benefits, especially for
flap. One is medial to distal, and the other is head and neck reconstructions. It results in
distal to medial. Generally speaking, JP Hong increased length of the pedicle, elimination of
recommended the distal to medial method to the dead space after the neck dissection, vol-
identify the perforator of the superficial medial ume augmentation of the tongue base, and
branch of the SCIA, while Koshima suggested effectively protects the reconstructed area
the medial to lateral method to identify the from adjuvant radiation.
perforator of the deep lateral of the SCIA. (a) Lengthening of the pedicle. This is critical
Both methods can be used depending on the in microsurgical head and neck reconstruc-
situation. When in doubt whether the perfora- tion, where most microanastomosis proce-
tor would be the axial or direct anchoring dures involve the neck vessels, because
types, the medial to lateral approach could be neck dissection is the most common proce-
a safer way, while the lateral to medial dure in head and neck cancer management.
approach would be easier and faster when When not concerned about kinking of the
you are sure of the perforator types. When pedicle, the microanastomosis could be
harvesting the SCIP flaps care should be done on the neck with a de-epithelized
taken to avoid any injury of the inguinal SCIP flap (Fig. 5).
lymph nodes, which could lead to (b) Obliteration of the dead space. After neck
lymphorrhea. dissection, a dead space is formed. This
5. To easily identify the superficial fascia layer, dead space on the neck could be obliterated
one of the key techniques is to apply adequate with the de-epithelized part of the SCIP
traction to the flap (Suh et al. 2018). free flap.
6. It is recommended to select the perforator that (c) Fistula risk minimization. Fistula forma-
visually has the strongest pulse and is located tion is one of the major causes of infection
medial to the center of the flap (Hong et al. in intraoral head and neck reconstructions.
2013). It could be additionally protected with the
7. The medial or superficial branch of the super- de-epithelized part.
ficial circumflex iliac artery enters the deep (d) Protective effect against the radiation. Post-
fascia medially. By opening the deep fascia operative radiation should, in general, be
and extending the dissection towards the fem- applied to more than two-thirds of the
oral vessels, the pedicle length and the diame- tongue. A de-epithelized SCIP free flap
ter of the pedicle can be increased. could protect the major critical anatomic
8. The superficial cutaneous vein was not used in structures such as the carotid and internal
these clinical cases, but sometimes the flap jugular vessels.
venous drainage relies on this superficial 10. If you elevate the relatively thin SCIP free
system. flaps, the insetting is easy, similar to the
9. Microanastomosis of the SCIP free flaps for radial forearm free flaps. In a situation
head and neck reconstruction may be techni- where harvesting thin SCIP flaps is not pos-
cally demanding. Perforator to perforator sible, it is advisable to inset the lower parts
from the neck like the caudal insetting Postoperative Management

approach while the upper part is insetted
intraorally. This will allow you to make a The patients were positioned with their head ele-
water-tight closure in order to prevent fistula vated 30°. The tracheostomy cannula was
complications. removed on the seventh day. Nutrition was
maintained with a nasogastric feeding tube for
the first 10 days. Oral feeding started after the
Intraoperative Images tenth day of surgery.
Close monitoring of the flaps was performed
Case 1 (Figs. 6, 7 and 8) clinically for the first 6 days. The anticoagulant
regimen included low molecular heparin to pre-
Case 2 (Figs. 9 and 10) vent lower extremity deep venous thrombosis.
Fig. 5 Designed for de-epithelialized perforator free flap. paddle was designed at the distal portion. (Right) Flap
(Left) The proximal portion near the perforator was allo- designs with a multilobed pattern combined with the
cated for the de-epithelialization territory and the skin de-epithelialized flap
Fig. 6 Partial tongue defect was made after the resection of the squamous cell carcinoma
Fig. 7 SCIP free flap was elevated based on the sub-superficial fascia plane in order to get a thinner flap. Then de-
epithelization was done to lengthen the pedicle and obliterate the dead space on the neck
Fig. 8 Proximally de-epithelized SCIP free flap was insetted
Outcome, Clinical Photos, and Imaging patient undergoing adjuvant radiation 4 week post-
operatively, sufficient coverage of the defect could
be warranted in case of flap shrinkage. At the 1 year
No intraoperative nor postoperative major com-
follow-up, the patient showed an acceptable
plications occurred related to the surgical
appearance while sufficient volume of the flap
procedure.
could still be seen without shrinkage of the flap
The patients were able to return to oral feedings
tissue. Good contour restoration and mobility of
10 days after surgery. The contrast-enhanced CT
the tongue was achieved. (Figs. 11 and 12) The
scan on postoperative day 14 showed mild bulki-
donor site scar was acceptable. (Fig. 13).
ness but an acceptable appearance. Regarding the
Fig. 9 The SCIP flap in the donor site area. Partial de-epithelization was already done in the proximal region of the flap.
Additional de-epithelization was later done (yellow dotted line)
Fig. 10 Clinical photographs showing the reconstructed tongue after finishing the surgery (a and b) and 14 days later (c
and d)
Fig. 11 Postoperative view 1 year after the reconstruction (Case 1). The mobility seems much better than the other
fasciocutaneous free flaps. The patient has complete swallowing and speech function
Fig. 12 Postoperative view 1 year after the reconstruction (Case 2)

2. As with other cutaneous flaps, the thickness of

the SCIP flap can be customized and be spe-
cifically adapted to the defect.
3. Harvesting the SCIP flap above the superficial
fascia layer and leaving the deep fat with the
inguinal lymph nodes in the donor site
decrease the risk of postoperative
complications.
4. Since the SCIP flap has a short pedicle and
small vessels, special care must be taken
when selecting adequate recipient vessels
Fig. 13 Postoperative view of the donor site 1 year after designing the flap.
the reconstruction (Case 1). The inguinal donor scar looks
acceptable
Cross-References
Avoiding and Managing Problems ▶ Diabetic Foot Reconstruction Using SCIP Flap
▶ Reconstruction of Partial Glossectomy with
1. When reconstructing a hemiglossectomy Innervated Lateral Forearm Flap
defect, an adequate flap width is needed to ▶ SCIP Flap for Simultaneous Management of
prevent tethering of the tip of the tongue to Orocutaneous Fistula and Facial Lymphedema
the floor of the mouth, recreating the sulcus ▶ Thin Free Flap for Resurfacing of the Arm and
(Hanasono et al. 2014). Forearm
2. In glossectomies with an associated resection of ▶ Tongue Reconstruction with Medial Sural
part of the floor of the mouth, a certain amount of Artery Perforator Flap
bulk is necessary to obliterate the oral cavity and
to prevent fistulae formation to the neck. Flap
thickness can be customized by changing the References
plane of elevation of the flap in the desired areas.
3. The diameters of the SCIP flap vessels can be Altiparmak M, Cha HG, Hong JP, Suh HP. Superficial
very small. Hsu et al. found that the vessels circumflex iliac artery perforator flap as a workhorse
ranged from 0.5 to 1.8 mm in diameter (Hsu et flap: systematic review and meta-analysis. J Reconstr
Microsurg. 2020;36(8):600–5. https://doi.org/10.1055/
al. 2007). Hong et al. reported in their series of s-0040-1713666.
79 cases that the average diameter of the artery Choi JW, Kim YC, Oh TS, Koh KS, Jeong WS. The
was 0.7 mm, ranging from 0.4 to 1.2 mm. Thus, versatile use of revisited de-epithelialization concept
appropriate skills and instruments for super- in superficial circumflex iliac and anterolateral thigh
perforator free flap for head and neck reconstructions.
microsurgery must be assured before attempting J Craniomaxillofac Surg. 2017;45:872–80.
this kind of reconstruction (Hong et al. 2013). Engel H, Huang JJ, Lin CY, et al. A strategic approach for
4. The deep fat with lymph inguinal nodes should tongue reconstruction to achieve predictable and
not be included in the flap in order to prevent improved functional and aesthetic outcomes. Plast
Reconstr Surg. 2010;126:1967–77.
possible complications in the donor site. Fernandez-Riera R, Hung SY, Wu JC, Tsao CK. Free
profunda femoris artery perforator flap as a first-line
choice of reconstruction for partial glossectomy
Learning Points defects. Head Neck. 2017;39:737–43.
Goh TL, Park SW, Cho JY, Choi JW, Hong JP. The search
for the ideal thin skin flap: superficial circumflex iliac
1. The SCIP flap is a thin and very pliable flap artery perforator flap–a review of 210 cases. Plast
useful for hemiglossectomy reconstruction. Reconstr Surg. 2015;135:592–601.
Green R, Rahman KM, Owen S, et al. The superficial cir- oropharyngeal reconstruction: a systematic review.
cumflex iliac artery perforator flap in intra-oral recon- Head Neck. 2016;38:1717–21.
struction. J Plast Reconstr Aesthet Surg. 2013;66:1683–7. Pereira N, Kufeke M, Parada L, et al. Augmented reality
Hanasono MM, Matros E, Disa JJ. Important aspects of microsurgical planning with a smartphone (ARM-PS):
head and neck reconstruction. Plast Reconstr Surg. a dissection route map in your pocket. J Plast Reconstr
2014;134:968e–80e. Aesthet Surg. 2019;72:759–62.
Heredero S, Sanjuan A, Falguera MI, Dean A, Ogledzki M. Scaglioni MF, Kuo YR, Yang JC, Chen YC. The post-
The thin profunda femoral artery perforator flap for eromedial thigh flap for head and neck reconstruction:
tongue reconstruction. Microsurgery. 2020;40:117–24. anatomical basis, surgical technique, and clinical appli-
Hong JP, Sun SH, Ben-Nakhi M. Modified superficial cations. Plast Reconstr Surg. 2015;136:363–75.
circumflex iliac artery perforator flap and super- Suh HS, Jeong HH, Choi DH, Hong JP. Study of the medial
microsurgery technique for lower extremity reconstruc- superficial perforator of the superficial circumflex iliac
tion: a new approach for moderate-sized defects. Ann artery perforator flap using computed tomographic
Plast Surg. 2013;71:380–3. angiography and surgical anatomy in 142 patients.
Hsu WM, Chao WN, Yang C, et al. Evolution of the free Plast Reconstr Surg. 2017;139:738–48.
groin flap: the superficial circumflex iliac artery perfo- Suh YC, Hong JP, Suh HP. Elevation technique for medial
rator flap. Plast Reconstr Surg. 2007;119:1491–8. branch based superficial circumflex iliac artery perfo-
Iida T, Yoshimatsu H, Hara H, Mihara M, Koshima I. rator flap. Handchir Mikrochir Plast Chir. 2018;50:
Reconstruction of large facial defects using a sensate 256–8.
superficial circumflex iliac perforator flap based on the Vincent A, Kohlert S, Lee TS, Inman J, Ducic Y. Free-flap
lateral cutaneous branches of the intercostal nerves. reconstruction of the tongue. Semin Plast Surg.
Ann Plast Surg. 2014;72:328–31. 2019;33:38–45.
Koshima I, Nanba Y, Tsutsui T, et al. Superficial circumflex Wu JC, Huang JJ, Tsao CK, Abdelrahman M, Kolios G,
iliac artery perforator flap for reconstruction of limb Cheng MH. Comparison of posteromedial thigh Pro-
defects. Plast Reconstr Surg. 2004;113:233–40. funda artery perforator flap and anterolateral thigh per-
Namin AW, Varvares MA. Functional outcomes of sensate forator flap for head and neck reconstruction. Plast
versus insensate free flap reconstruction in oral and Reconstr Surg. 2016;137:257–66.
Reconstruction of Partial Glossectomy
with Innervated Lateral Forearm Flap 10
Christopher M. K. L. Yao and Rene D. Largo
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Alternative Reconstruction Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Intraoperative Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Outcome: Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Abstract
The reconstructive options for partial

glossectomy defects include doing nothing,
primary closure, using synthetic skin substi-
tute, skin grafting, regional pedicled flaps,
C. M. K. L. Yao
and free flap reconstruction. With the goal of
Fox Chase Cancer Center, Philadelphia, PA, USA minimizing scaring, optimizing tongue mobil-
e-mail: Christopher.yao@fccc.edu ity for articulation and swallowing, a thin, pli-
R. D. Largo (*) able free flap provides the best outcomes. This
Department of Plastic Surgery, The University of Texas case represents an early stage oral cavity
MD Anderson Cancer Center, Houston, TX, USA
e-mail: rdlargo@mdanderson.org

https://doi.org/10.1007/978-3-030-23706-6_123
92 C. M. K. L. Yao and R. D. Largo
tongue cancer requiring extirpation followed After extirpation including a partial glossectomy,
by free flap reconstruction. and neck dissection, the defect measured:
5 5 1.5 cm.
Keywords
Tongue cancer · Partial glossectomy

reconstruction · Lateral forearm free flap ·
Innervated free flap reconstruction
1. Innervation of free flap for glossectomy defects
(Baas et al. 2015; Chang et al. 2015; Yu 2004;
Loewen et al. 2010).
2. Thickness and pliability of free flap for tongue
A 58-year-old male with a history of a T2 squa-
mobility (Ahn 1997).
mous cell carcinoma of the tongue who underwent
3. Optimization of intelligibility (Bressmann
a partial glossectomy without reconstruction and
et al. 2004).
left neck dissection presented to the institution
4. Optimization of swallowing outcomes (Shin
with tumor recurrence. On examination, the ulcer-
et al. 2012).
ative tumor sat on the lateral border of the tongue
with involvement of the floor of mouth (Fig. 1).
The tongue mobility was slightly restricted due to
Treatment Plan
the prior glossectomy scar although with no evi-
dence of paresis. The depth of invasion of the
A plan for a thin, pliable flap with innervation was
tumor appeared to be close to 5 mm by palpation.
planned. The patient’s nondominant forearm was
There was no clinical evidence of involved lymph
assessed, with the thinnest skin on examination
nodes. The patient was evaluated by a multi-
identified to be the lateral forearm region, overly-
disciplinary team including a head and neck sur-
ing the lateral epicondyle. A lateral forearm flap
geon, the plastic reconstructive surgeon, and
was chosen in this patient (Shuck et al. 2020).
speech pathology. After completion of his
workup, he was presented to multidisciplinary
tumor conference, where the treatment plan was
Alternative Reconstruction Options
formulated. Surgical excision of the tongue cancer
was agreed upon and included performing a par-
1. Radial/ulnar forearm flap (Soutar and
tial glossectomy, selective neck dissection, trache-
McGregor 1986; Yu et al. 2012)
ostomy, and free flap reconstruction.
2. Medial sural artery perforator flap (Cavadas
Chemotherapy was proposed prior to surgery.
et al. 2001; Taufique et al. 2019)
3. Superficial circumflex iliac artery perforator
flap (Green et al. 2013)
4. Submental island flap (Martin et al. 1993;
Pistre et al. 2017)
While all the above reconstructive options may

also provide thin, pliable flap options, the donor
site for the lateral forearm is preferable to tradi-
tional forearm flaps given the ability to close the
donor site primarily, avoiding the need for a skin
graft and its associated morbidity. Compared with
Fig. 1 Preoperative picture with right tongue cancer with the medial sural artery perforator flap and super-
involvement of the floor of mouth ficial circumflex iliac artery perforator flap, the
10 Reconstruction of Partial Glossectomy with Innervated Lateral Forearm Flap 93
dissection is more reliably placed, and pedicle No preoperative imaging of the donor sites is
length longer. Finally, while there have been typically required; however, careful review of the
reports of using a submental island flap in the head and neck imaging allows for estimation of
setting of oral cavity cancer, it requires meticulous the size of the defect, and the health and location
skeletonizing of submental vessels while remov- of potential recipient vessels.
ing node-bearing tissue potentially making the
flap less reliably feasible.
Drawing
The patient is placed in a supine position, with a
In preparation for performing free flap surgery, it is shoulder roll. The upper extremity is sterilely
critical to examine and document the suitability of prepped from fingertip to clavicles, including the
your primary, secondary, and tertiary free flap axilla. The arm is positioned at the side of the
options. In the case of thin, pliable free flap donor body slightly abducted on a narrow arm board
sites, the focus begins with an upper extremity (Fig. 4).
exam, starting with the upper lateral arm, forearm, The deltoid insertion is marked, as well as the
inguinal region, and calf. Each site would be lateral epicondyle. The lateral intermuscular
assessed for the thinness, and pliability of the
skin, as well as for and presence of prior scars or
surgeries. For the lateral arm specifically, clinicians
should evaluate and document any radial nerve
weakness, ideally including the use of preoperative
grip strength testing with a hydraulic grip strength
tester. The lateral arm is chosen if a more bulky flap
is needed and the proximal forearm if a thin flap is
required (Figs. 2 and 3). For the forearm, the radial
and ulnar arteries should be palpated and the
Allen’s test used to ensure an intact arch with
adequate retrograde flow. Finally, with the calf,
ensuring there is adequate laxity with a pinch test
would help test the suitability of the medial sural
artery perforator as a donor site. Fig. 3 Thickness over the lateral epicondyle
Fig. 2 Thickness of the upper arm Fig. 4 Arm positioning during flap harvest
septum is palpated and drawn out. The skin paddle 7. The distal fascia in incised to the level of the
is outlined roughly centered at the lateral humeral periosteum, and the distal skin pad-
epicondyle. It can be extended up to 12–15 cm dle is elevated off the bone.
towards the forearm. The width should approxi- 8. The perforators are followed through the
mate 6 cm to allow for primary closure of the muscle towards the posterior radial collateral
donor defect, with elderly patients allowing for artery. This is exposed proximally until the
widths up to 8 cm. anterior radial collateral artery and radial
A tourniquet set at 120 mmHg for 60 min is nerve are exposed.
placed at the most proximal portion of the upper 9. Preservation of the posterior antebrachial and
arm, often overlapping with the deltoid insertion. brachial cutaneous nerves is possible. A
branch of the posterior antebrachial nerve
can be included to innervate the flap (Fig. 6).
Surgical Technique
1. The tongue cancer is resected, and margins

sent from the tumor bed to ensure adequate
extirpation. The mucosal defect of the tongue
measured roughly 5 5 cm. The neck dis-
section is performed in a standard fashion,
with a goal of preserving length on potential
recipient vessels. A tunnel was created
between the tongue and the neck, behind the
mylohyoid musculature. A 32 Fr chest tube
was inserted to maintain the tunnel while the
flap harvest proceeded.
2. Identification of branches of the lingual
nerves is mandatory and care must be taken
Fig. 5 Dissection begins along the posterior incision
to preserve intact lingual nerve branches. towards the septum. Perforators are clearly seen here
With partial thin glossectomies, it is often towards both the skin paddle and the triceps muscle
quite difficult to identify small distal branches
of the nerve.
3. Recipient vessels are assessed and prepared
by carefully freeing up the vessels from any
attachments, and ligating small branches. The
choice recipient vessels include the facial
artery or superior thyroid artery.
4. Flap harvest: The tourniquet is inflated.
5. An incision along the posterior marked skin
paddle is made and carried down to the level
of the muscles.
6. Staying in the subfascial plane, the dissection
is carried forward towards the intermuscular
septum, exposing the septocutaneous perfo-
rators. Once they are identified, completion
Fig. 6 The skin paddle is now isolated on the pedicle. A
of the skin paddle incision can be made branch of the posterior antebrachial cutaneous nerve is seen
(Fig. 5). (pointed by the pickups)
10. The pedicle is then followed up towards the 18. The neck is then closed, often with one drain
deltoid insertion, where the tourniquet must in place.
then be released, and if length is necessary, 19. The lateral forearm flap donor site is closed,
the dissection can carry further up towards the with a drain carefully placed away from the
humeral groove. The pedicle length is typi- radial nerve (Fig. 8). The arm including the
cally 12–14 cm long (Fig. 7). hand is wrapped with an elastic bandage
11. Once good hemostasis is obtained, the flap dressing from distal to proximal.
can be detached and brought up to the head
and neck.
12. The pedicle orientation is marked with a water- Technical Pearls
soluble marker, with dots along the pedicle.
13. The pedicle is then carefully placed through 1. The septum is approached by elevating the
the chest tube, as the chest tube is pulled fascia from posterior to anterior. The skin pad-
through the neck, gently carrying the pedicle dle is elevated from distal to proximal. The
into the neck. Light suction can be used to fascia often blends with the periosteum over
assist with keeping the pedicle in place. the lateral epicondyle, and careful dissection
14. Tacking sutures to partially inset the flap are using a microbipolar is required to release that
performed with interrupted 3-0 vicryl, portion of the flap.
starting from the posterior to anterior. 2. The flap can be raised without sacrifice of
15. The flap may be innervated at this time by the posterior antebrachial cutaneous nerve
anastomosing a branch of the posterior ante- (Ki 2016).
brachial cutaneous nerve to the proximal end 3. Respect and preserve radial nerve. The pedicle
of the lingual nerve branch. runs right along the nerve, and may have several
16. The flap is revascularized. The small diameter branches to the proximal triceps muscle, careful
of the extended lateral arm flap often matches use of clips and cold technique are essential to
the smaller caliber superior thyroid artery. minimize and postoperative paresis.
17. The rest of the flap inset is performed. If desired,
and if the resection approached the floor of
mouth, intraoperative testing for any leakage Intraoperative Photographs
could be performed using an irrigation bulb.
Fig. 7 The pedicle can be followed proximally towards Fig. 8 The lateral forearm flap can be closed primarily. A
the deltoid insertion, the length can be up to 14 cm subcuticular closure is preferred
Postoperative Management the same as baseline. There were no functional

limitations resulting from the flap harvest
The patient was monitored postoperatively in a (Fig. 10).
standard fashion. During the first 24 h, the flap is
monitored by dedicated, skilled nursing staff
every hour with clinical exam and Doppler Avoiding and Managing Problems
checks. During the next 48 h, the flap is monitored
every 2 h, and then every 4 h. The patient was Despite its many beneficial attributes, the lateral
monitored on a regular floor and ambulated on forearm flap does have shortcomings.
postoperative day 1.
The patient is kept on antibiotics for 24 h and 1. The lateral forearm flap has a relatively small
prophylactic enoxaparin. The patient is kept “noth- pedicle caliber compared to other thin
ing by mouth” for 7 days and discharged with a fasciocutaneous flaps commonly used for sim-
nasogastric tube. The patient undergoes a swallow ilar reconstructions, such as the RFF and the
study assessment prior to initiating swallowing, ulnar forearm flap. Indeed, the mean PRCA
guided by speech-language pathology care pro- diameter is 1.6 mm, a considerably smaller
viders. Patients may initiate salt and soda rinses caliber than the radial artery (Shuck et al.
after 48 h, and rinse every 3–4 h while awake. The 2020). This may potentiate an anastomotic
patient is discharged home on post-op day 7. size mismatch; however, there are often a
wealth of vessels to choose from in the neck
providing surgeons the opportunity to select a
Outcome: Clinical Photos and Imaging
The patient experienced an uneventful and fast

recovery, and had an adequate and satisfactory
function following surgery. The patient required
postoperative radiation and continued to work
with speech-language pathology, who provided
tongue mobility and swallowing exercises. After
6 months, the patient is now able to enjoy a
regular diet and articulate without any issues in
intelligibility (Fig. 9).
Innervation of the flap resulted in some tactile
sensation of the reconstruction. There was some
expected numbness around the donor site. How-
ever, the patient did not experience any radial
nerve weakness, and the grip strength remained
Fig. 9 Postoperative outcome of the recipient site Fig. 10 Postoperative outcome of the donor site
similarly sized recipient. Thereby, the superior patients with partial glossectomy. J Oral Maxillofac
thyroid artery seems to be the best match for Surg. 2004;62(3):298–303.
Cavadas PC, Sanz-Gimnez-Rico JR, la Camara AG, et al.
the lateral forearm flap pedicle artery in terms The medial sural artery perforator flap. Plast Reconstr
of vessel diameter in the neck. Surg. 2001;108(6):1609–15.
2. Another potential disadvantage is the proxim- Chang EI, Yu P, Skoracki RJ, Liu J, Hanasono MM. Com-
ity of the flap pedicle to the radial nerve, which prehensive analysis of functional outcomes and survival
after microvascular reconstruction of glossectomy
must be atraumatically dissected in order to defects. Ann Surg Oncol. 2015;22(9):3061–9.
avoid inadvertent injury. Green R, Rahman KM, Owen S, Paleri V, Adams J, Ahmed
3. In superficial glossectomy defects, there is the OA, Ragbir M. The superficial circumflex iliac artery
potential that the lateral forearm flap is too perforatory flap in intra-oral reconstruction. J Plast
Reconstr Aesthet Surg. 2013;66(12):1683–7.
bulky and requires debulking in the future. Ki SH. Lateral arm free flap with preservation of the
posterior antebrachial cutaneous nerve. Ann Plast
Surg. 2016;76(5):517–20.
Learning Points Klinkenberg M, Fischer S, Kremer T, Hernekamp F,
Lehnhardt M, Daigeler A. Comparison of anterolateral
thigh, lateral arm, and parascapular free flaps with regard
1. The lateral forearm flap is an excellent, reliable
to donor-site morbidity and aesthetic and functional out-
choice for thin, pliable soft tissue flaps that comes. Plast Reconstr Surg. 2013;131(2):293–30.
avoids the need for skin grafting, and patient Loewen IJ, Boliek CA, Harris J, Seikaly H, Rieger
satisfaction similar to that of an anterolateral JM. Oral sensation and function: a comparison of
patients with innervated radial forearm free flap recon-
thigh flap (Klinkenberg et al. 2013).
struction to healthy matched controls. Head Neck.
2. Patients undergoing small partial glossectomies 2010;32(1):85–95.
may still benefit from free flap reconstruction, Martin D, Pascal J, Baudet J, et al. The submental
owing to decrease in scarring and tethering of island flap: a new donor site. Anatomy and clinical
applications as a free or pedicled flap. Plast Reconstr
the tongue.
Surg. 1993;92:867–73.
3. Innervation of flaps for the oral cavity is pos- Pistre V, Pelissier P, Martin D, et al. Ten years of experience
sible, though in smaller defects, identification with the submental flap. Otolaryngol Head Neck Surg.
of distal sensory nerve branches may be 2017;157(2):201–9.
Shin YS, Koh YW, Kim SH, et al. Radiotherapy deterio-
challenging.
rates postoperative functional outcome after partial
4. Overcorrecting the tissue volume is typically glossectomy with free flap reconstruction. J Oral
recommended, as atrophy of the flap can be Maxillofac Surg. 2012;70(1):216–20.
anticipated. Care should be made to ensure the Shuck J, Chang EI, Mericli AF, Gross ND, Hanasono MM,
Garvey PB, Yu P, Largo RD. Free lateral forearm flap in
neo-tongue can reach the palate.
head and neck reconstruction: an attractive alternative
to the radial forearm flap. Plast Reconstr Surg.
2020;146(4):446e–50e.
References Soutar DS, McGregor IA. The radial forearm flap in
intraoral reconstruction: the experience of 60 consecu-
Ahn HC. Revision of lateral arm free flap; can it be a tive cases. Plast Reconstr Surg. 1986;78(1):1–8.
substitute for radial forearm free flap? Arch Reconstr Taufique ZM, Daar DA, Cohen LE, et al. The medial sural
Microsurg. 1997;6:80–6. artery perforator flap: a better option in complex head
Baas M, Duraku LS, Corten EML, Mureau MAM. A and neck reconstruction. Laryngoscope. 2019;129(6):
systematic review on the sensory reinnervation of free 1330–6.
flaps for tongue reconstruction: does improved sensi- Yu P. Reinnervated anterolateral thigh flap for tongue
bility imply functional benefits? J Plast Reconstr reconstruction. Head Neck. 2004;26(12):1038–44.
Aesthet Surg. 2015;68(8):1025–35. Yu P, Chang EI, Selber JC, Hanasono MM. Perforator
Bressmann T, Sader R, Whitehill TL, Samman patterns of the ulnar artery perforator flap. Plast
N. Consonant intelligibility and tongue motility in Reconstr Surg. 2012;129(1):213–20.
Tongue Reconstruction with Medial
Sural Artery Perforator Flap 11
Bhagwat S. Mathur and Marco Pappalardo
Contents
The Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Preoperative Problem List: Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 100
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Alternative Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Preoperative Evaluation and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Preoperative Care and Patient Drawing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Technical Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Intraoperative Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Postoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Outcome, Clinical Photos, and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Avoiding and Managing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Abstract
Reconstruction of tongue defects is a challeng-

ing task with regard to both functional and
B. S. Mathur (*)
St Andrew’s Centre for Plastic Surgery, Broomfield
aesthetic outcomes. The tongue function is of
Hospital, Chelmsford, Essex, UK paramount importance for a natural speech and
M. Pappalardo
swallowing, and the overall quality of life. In
St Andrew’s Centre for Plastic Surgery, Broomfield hemitongue reconstruction, thin and pliable
Hospital, Chelmsford, Essex, UK flaps are useful for appearance and mobility.
Division of Plastic and Reconstructive Surgery, This case illustrates an immediate reconstruc-
Department of Medical and Surgical Sciences, Policlinico tion of hemiglossectomy defect using a free
University Hospital, University of Modena and Reggio
Emilia, Modena, Italy

https://doi.org/10.1007/978-3-030-23706-6_12
100 B. S. Mathur and M. Pappalardo
medial sural artery perforator (MSAP) flap. The Both sides right and left of the tongue occur with
MSAP is a thin and pliable fasciocutaneous flap equal frequency. The majority of patients present
with adequate pedicle length. Donor-site mor- with unilateral cancer involvement on the lateral
bidity is minimal when it is closed primarily, border of anterior two-thirds of the tongue with-
and its location is more aesthetically pleasing. out crossing the midline (Lam and Samman
Following the lesion resection, a 5 8 cm 2013).
MSAP flap was transferred to reconstruct the Multidisciplinary treatment with radical resec-
defect. The recipient vessels for microvascular tion, stage-directed neck dissection, and radio-
anastomosis were superior thyroid artery and therapy is recommended to achieve successful
vein. Flap raising time was 40 min and flap curative treatment. The tongue is enveloped by
ischemia time 60 min. Donor-site was closed mucosa containing mucous and serous glands,
primarily. The flap healed uneventfully without special taste sensory receptors, and a complex
complications. Oral intake was started ten days set of muscles providing almost limitless range
after the operation, and the patient was of voluntary and involuntary movements. Tongue
discharged on day 14 after the operation. The deserves special attention as its multifunctional
functional and aesthetic result was satisfactory, role in speech, articulation, mastication,
and no secondary debulking procedures were swallowing, and airway protection makes it irre-
needed. The MSAP flap is a versatile, reliable, placeable. The posterior area of the tongue is more
and functionally aesthetically satisfactory involved in swallowing, whereas the anterior area
option for hemitongue reconstruction. is critical for speech and food manipulation.
Reconstruction attempts involve recreating
Keywords this complex anatomy, function, bulk, texture,
mobility, and sensation (Baas et al. 2015).
Tongue reconstruction · Hemiglossectomy ·
Reconstruction aims to restore mobility of the
Medial sural artery perforator flap · Radial
tongue after partial or hemiglossectomy and to
forearm flap · Anterolateral thigh flap
provide bulk when free tongue movements are
not possible after total glossectomy. The goals of
tongue reconstruction include restoring the abil-
ity for chewing, swallowing and intelligible
speech, uncomplicated airway support, unevent-
A 50-year-old gentleman presented with a
ful and fast wound healing avoiding postopera-
3-month history of a painful unhealed ulcerative
tive complications including oro-cutaneous
lesion on the left lateral tongue with a recent
fistula and infection and ensuring timely admin-
enlargement. The patient reported dysphagia, but
istration of radiotherapy if necessary. For tongue
no odynophagia, dyspnea, or hoarseness. Clinical
reconstruction, the speech intelligibility is
examination of the bilateral neck lymph nodes
strictly related to the mobilization of the residual
was negative. The patient’s past medical history
native tongue, and the deglutition function is
included hypertension for 10 years under medical
closely dependent on the volume of the
control. The patient was an ex-smoker, betel nut,
reconstructed tongue. Hence, the ideal flap for
and alcohol consumer. The patient had not under-
tongue reconstruction should provide both tissue
gone any previous radiotherapy or chemotherapy.
bulk and mobilization.
Nowadays, with advancement of microsurgical
Preoperative Problem List: techniques, many options are available for tongue
Reconstructive Requirements reconstruction. The challenge is more about opti-
mization of the functional and aesthetic outcome
Oral tongue cancer is the most common site of improving the postoperative quality of life of these
oral cancer in the US, with reports of incidence of patients (Zhang et al. 2018). Current concepts of
3.0 per 100,000 people (De Vicente et al. 2008). tongue reconstruction classify tongue defects after
11 Tongue Reconstruction with Medial Sural Artery Perforator Flap 101
tongue resection as partial, hemi, subtotal, and Cheng’s Class II includes defects up to 75% of
total glossectomy. Partial glossectomy includes the tongue, and it is further subclassified in IIa for
resection of less than one-third of the tongue; defects <66% and IIb up to 75% for flap selection.
hemiglossectomy consists of resection of For Cheng’s Class IIa defects, an ALT flap is
one-third to half tongue; subtotal glossectomy recommended over the RFF for the larger tissue
involves removal of half to three-fourths of available, especially when combined FOM or buc-
tongue; and total glossectomy is the resection of cal defects need to be reconstructed as well. An
the entire tongue. The resection may also include alternative option is represented by chimeric
other structures, including floor of the mouth MSAP flap, including partial gastrocnemius mus-
(FOM), soft palate, oropharynx, hypopharynx, or cle. For Cheng’s Class IIb defects, the remaining
mandible. A goal-directed tool to classify the 25% of the native tongue still plays a key role in
tongue defects should not just provide descriptions maintaining the anatomical integrity of the base of
but also simplify accurate judgment with therapeu- tongue, retromolar trigone, or pterygoid fossa. The
tic effects. Cheng’s classification divides tongue ALT myocutaneous flap is considered the flap of
defects into three main groups (I, IIa, IIb, III) choice in such defects as it is able to provide
(Engel et al. 2010) and is useful for preoperative adequate bulk for the tongue base. For Cheng’s
planning and selection of the optimal donor flap. Class III defects (total glossectomy), a
Flaps used to maintain mobility are thin, such as pentagonal-shaped ALT myocutaneous flap is
the radial forearm free (RFF) flap, ulnar forearm recommended for flap inset providing good vol-
flap, or medial sural artery perforator (MSAP) flap ume, and an aesthetically acceptable neo-tongue
(Hekner et al. 2013; Ives and Mathur 2015; Soutar tip. Alternative flap options for near-total or total
and Mcgregor 1986). On the other hand, flaps tongue defects are rectus abdominis myocutaneous
providing bulk include the anterolateral thigh flap and the latissimus dorsi flap.
(ALT), profunda femoris artery perforator (PAP), In case of a combined mandible defect, man-
latissimus dorsi myocutaneous, pectoralis major dible continuity can be restored at the same time
myocutaneous, trapezius, and rectus abdominis as tongue reconstruction using a bony free flap
myocutaneous flaps (Engel et al. 2010; such as fibular flap, iliac flap, or scapula flap
Fernández-Riera et al. 2017; Liu et al. 2017; (Engel et al. 2010; Pappalardo et al. 2018).
Pappalardo et al. 2016). However, based on the Hence, in case of concomitant oropharyngeal
different clinical scenarios, there is no optimal or hypopharyngeal defect, it is very important
flap, but only careful defect evaluation and to sealing off the oral cavity to avoid salivary
proper flap selection make a successful tongue exposure in the neck and minimize the risk of
reconstruction. serious complications such as carotid blowout
Based on Cheng’s classification, the clinical and fistula.
case proposed in this chapter is a Cheng’s Class
I hemitongue defect (50%). Preservation of
tongue mobility with a small amount of bulk Treatment Plan
and a thin, pliable flap to reproduce the native
mucosal characteristics, allowing adequate A two-team approach, including the ablative team
tongue movement for swallowing and speech is and the reconstructive team, is planned. Patients
considered the key to achieve success in such generally require tracheostomy as one can expect
defects. The RFF is suggested as it is a thin and significant flap and airway swelling immediately
pliable skin flap with a long pedicle. The MSAP after the surgery that may persist for several days.
flap can be used alternatively depending on the Hence, placement of a temporary nasogastric tube
microsurgical experience of the surgeon with feeding is also helpful to facilitate adequate post-
this perforator flap. Hence, ALT perforator flap operative nutrition. The ablative part includes left
for this defect is recommended only in thin side neck dissection level I to III and wide exci-
patients. sion of the tumor. Left side hemiglossectomy and
partial resection of FOM is planned with an esti- in lower extremity reconstruction, the MSAP flap
mated defect size of about 4 5 cm (Fig. 1a). is becoming increasingly popular due to its versa-
At St Andrew’s Centre, the preferred flap for tility, thinness, pliable nature, long pedicle, and
the reconstruction of hemiglossectomy defects is for its minimal donor-site morbidity (Daar et al.
the MSAP flap (Ives and Mathur 2015). The pre- 2019). Since then, several authors extended its
ferred choice of recipient vessels is left-sided clinical application for various indications,
superior thyroid artery and vein. including traumatic upper extremity and head
First described in 2001 by Hallock (Hallock and neck oncology defects (Ives and Mathur
2001), and then by Cavadas et al. (2001), for use 2015; Kao et al. 2009).
Fig. 1 (continued)
Fig. 1 (a) A 35-year-old male who underwent wide exci- dissection of the MSAP flap harvest demonstrating one
sion of ulcerated mass of the left tongue. (b) Preoperative perforator and its pedicle. (e) Intraoperative photograph
marking of the MSAP flap with the inferior border of demonstrating the extent of MSAP flap size harvested
medial gastrocnemius muscle and ultrasound hand-held and the pedicle length of 10.5 cm is shown. (f) Primary
Doppler marking of the perforators. A skin paddle of closure of the donor site. (g) Photograph demonstrating the
10 5 cm is marked. (c) Intraoperative MSAP flap harvest inset of the MSAP flap with good contouring and restora-
with one musculocutaneus perforator dissection with the tion of tongue form
posterior border of the flap still attached. (d) Complete
The ALT flap is nowadays a popular choice for

tongue and oral soft-tissue reconstruction for its
reliability and versatility with long vascular ped-
Table 1 shows advantages and disadvantages of
icle. It allows a large amount of soft tissue (skin
the most popular free flaps used for tongue
with or without muscle) to be transferred based on
reconstruction.
the perforators from the descending branch of the
The RFF flap has long been used as the work-
lateral circumflex femoral artery. Advantages of
horse flap for head and neck reconstruction in the
the ALT flap over the RFF flap include the avail-
UK and worldwide due to its relative ease of
ability of different tissues with large amounts of
harvest, very consistent anatomy, thin and pliable
skin and especially the low donor-site morbidity
nature, and generous pedicle length (Soutar and
due to its ability for primary closure. A drawback
Mcgregor 1986). The RFF flap allows for sensory
of the ALT flap is the lack of thin tissue needed for
reinnervation through the coaptation of the lateral
tongue and FOM reconstruction. The ALT flap is
antebrachial cutaneous nerve to the lingual or
very bulky, especially in the overweight Western
inferior alveolar nerves. However, this flap is
population. Attempt to defatting the ALT has been
associated with some notable drawbacks and sig-
associated with potential partial flap necrosis.
nificant donor-site morbidity due to regular need
Expert microsurgeons can adjust the flap thick-
for split-thickness skin grafting, potential tendon
ness raising it in suprafascial fashion or even up to
exposure, often-unsightly scarring, and, most of
the subdermal fat level as a thin or ultrathin flap
all, the sacrifice of the radial artery, one of the two
(Chen et al. 2016; Seth and Iorio 2017).
major feeding arteries that supply the hand.
Table 1 Comparison between different flaps for the reconstruction of tongue defect
Flap Advantages Disadvantages
RFF Ease of harvest Significant donor-site morbidity
Consistent anatomy Need for STSG, potential tendon exposure, unsightly
Thin and pliable scarring
Long pedicle Sacrifice of radial artery
Allows for sensory reinnervation Potential to cause distal limb ischemia
ALT Readily dissected Lack of the thin tissue needed for tongue and FOM
Reliable, versatile, and long pedicle reconstructions
Acceptable donor-site morbidity with a relatively Thicker subcutaneous tissue especially in overweight
concealed scar and obese patients
Allows for sensory reinnervation More hair-bearing skin on the lateral thigh ALT flaps
Sacrificing the lateral cutaneous nerve of the thigh
during harvest may result in discomfort to the patient
MSAP Thin and pliable Variation in perforator anatomy
Long vascular pedicle May require a tedious intramuscular dissection
Donor site located on the leg Limited size and volume of the flap suitable only for
Ideal for intraoral reconstruction regarding speech reconstruction of partial glossectomy defects
and swallowing recovery, and oral competence
It is a safe size for folding, if required
Versatile (fasciocutaneous, musculocutaneous, or
chimeric flap with bone)
Minimal donor-site morbidity
Less hair-bearing skin on the posterior leg
PAP Constant anatomy Flap size
Easy dissection
Reliable perforators and long pedicle
High pliability
Good donor-site cosmesis
RFF radial forearm free, ALT anterolateral thigh, MSAP medial sural artery perforator, PAP profunda femoris artery
perforator, FOM floor of the mouth
Compared with the thickness of the ALT subcuta- leave the ALT for more complex reconstruction in
neous fat, the calf region is uniformly thin, indi- case of recurrence in high-risk patients.
cating the MSAP flap as an optimal choice for The MSAP flap combines the advantageous
small to medium soft tissue defects in the head and features of the RFF flap (thin and pliable with a
neck region. The thin and pliable tissue of the long pedicle) and the ALT flap (low donor-site
MSAP flap is a further advantage in intraoral morbidity), making this flap a potential workhorse
reconstruction for its ability to fold safely and, option for the reconstruction of hemi or subtotal
regarding speech and swallowing, recovery and glossectomy defects.
oral competence.
The PAP flap is another valuable option for
tongue reconstruction. Fernandez-Riera and Tsao Preoperative Evaluation and Imaging
reported excellent results using the PAP flap for
partial glossectomy and FOM defects (Fernández- Preoperative examination showed an interincisal
Riera et al. 2017). The advantages of this flap distance of 40 mm and a lesion located in the
include its constant anatomy, easy dissection, reli- mobile left lateral tongue border. Preoperative
able perforators, and long pedicle, high pliability, Panorex did not show any bone involvement. A
and good donor-site cosmesis. The authors magnetic resonance imaging determined a left oral
recommended for hemiglossectomy defects to use tongue mucosal tumor without abnormal neck
the PAP flap over the ALT flap because of its better lymph node, T2N0. Chest X-ray did not show
concealed donor-site scar and the possibility to any pulmonary abnormality. Incision biopsy of
the right tongue lesion demonstrated squamous cell Surgical Technique

carcinoma. Hence, the clinical diagnosis was left
lateral tongue squamous cell carcinoma, T2N0M0. 1. The left lower limb is placed in semi frog-leg
Regarding the flap donor-site, skin thickness of position, and the skin paddle is designed
the right thigh and calf was evaluated. Ultrasound based on the location of the perforators and
or angiograms of lower limbs could provide quan- the recipient defect. The width of the flap is
titative confirmation of the reduced soft-tissue determined by skin pinch.
envelope thickness in the calf area compared to 2. Under tourniquet control, an exploratory incision
the thigh region. along the anterior margin of the flap is made.
The anatomy of the MSAP flap has been well 3. The flap is raised in subfascial plane until the
described (Cavadas et al. 2001). The medial sural perforators are found.
artery originates from the popliteal vessels and 4. The selected perforator is then traced in a
then enters the medial gastrocnemius muscle. retrograde fashion using the deroofing tech-
Preoperatively, hand-held Doppler (10 mHz) is nique splitting the medial gastrocnemius
routinely used to localize suitable perforators. muscle with Stevenson tenotomy scissors.
Typically, 1–3 perforators branching from the 5. Dissection is continued into the gastrocnemius
medial sural artery toward the subfascial plexus muscle until the medial sural artery is reached
are found. The most reliable perforators are gen- to achieve adequate pedicle length and com-
erally located within the upper one-third of the fortable vessel size for microsurgery anasto-
leg. It is possible to be misled by identifying the mosis (Fig. 1c). Ligaclips are used on all the
sural artery itself instead of the perforators. Com- muscular branches rather than cauterizing.
puted tomography angiography (CTA) is not rou- 6. After dissecting the pedicle, the anterior inci-
tinely utilized. This imaging modality may have a sion is stapled to avoid tension on the perfo-
role in evaluating the vascular status of the MSAP rator while the posterior part of the flap is
flap perforators, especially in patients with a pre- dissected.
vious history of trauma in the lower limbs or 7. The lesser saphenous vein, medial sural
diabetes mellitus. Other preoperative imaging nerve, and plantaris tendon can be integrated
modalities such as color Doppler or magnetic into the flap from the same wound if needed.
resonance angiography can add additional infor- 8. Before ligation of the main pedicle, the tour-
mation regarding perforators location. niquet is released to check the flap vasculari-
zation. Then the flap is transferred to the
recipient site.
Preoperative Care and Patient 9. The donor-site is closed quickly before signifi-
Drawing cant muscle swelling occurs following reperfu-
sion of the limb. The defect is primarily closed
With the patient in the supine position, the hip with absorbable Vicryl interrupted sutures
abducted and externally rotated, and the knee also followed by Monocryl subcuticular suture. In
flexed at 90°, a line is marked from the midpoint case the donor site is very tight to close, two or
of popliteal crease through the medial malleolus, three 0 nylon loop mattress sutures are inserted
and then the perforators are located by hand-held to facilitate skin approximation and avoid
Doppler ultrasound (Fig. 1b). The main perforator suture line dehiscence. These nylon sutures are
from the medial sural artery is usually identified removed 7–10 days after surgery.
about 8 cm from the midpoint of the popliteal 10. Inset starts at the most posterior part of the
fossa posteriorly (Ives and Mathur 2015). Other tongue defect and proceeds anteriorly, first on
authors reported differences in perforator anat- the dorsal side of the tongue to elevate the
omy among patients, with typically 2–3 perfora- posterior part of the flap and increasing the
tors located 8–12 cm distal to the popliteal crease volume of the posterior tongue to occlude
(Daar et al. 2019). dead space. Hence, extra tissue can be
recruited shortening the flap base by self- musculocutaneus perforator dissected with the
suturing a de-epithelialized inferiorly based posterior border of the flap still attached. After
triangle. careful dissection of the MSAP flap, this is how
11. Microanastomoses are performed between the flap appears right before ligation of the main
the pedicle medial sural artery and vein that pedicle (Fig. 1d). Figure 1e shows the extent of
is able to appropriately reach the recipient MSAP flap size harvested and the pedicle length
vessels superior thyroid artery and vein in of 10.5 cm. Primary closure of the donor-site is
the neck. If perfusion is adequate, the wounds performed without tension (Fig. 1f).
are closed.
Technical Pearls
The patient was allowed to mobilize normally and
1. The MSAP flap can be raised as a thin bear weight on the donor leg after 3–5 days. Post-
fasciocutaneous flap or including the underly- operatively, the patient continued receiving anti-
ing gastrocnemius muscle to increase bulk to biotic therapy to avoid problems at the primary
fill FOM dead space. It can also be harvested as site. Oral intake was started ten days after the
a chimeric flap. operation, and the patient was discharged on day
2. Endoscopic confirmation of the medial sural 14 after the operation.
artery perforators allows for close-up visuali-
zation of perforators and may help flap design
based on the perforator. It is used to visualize Outcome, Clinical Photos, and Imaging
the perforators before extending the incision
into the skin paddle design once the perforator Regarding the reconstruction, no surgical compli-
is considered reliable. cations occurred in the postoperative period. The
3. A long intramuscular dissection is often donor-site wound healed uneventfully. The clini-
needed for exposing the pedicle of the MSAP cal aspect of the left reconstructed tongue was
flap. The division of numerous small branches similar to the residual tongue, and its mobility
can make the dissection tedious and not was satisfactory (Fig. 1g). Good functional out-
suggested for not experienced microsurgeons. come using MSAP flaps was achieved with a
4. Due to the relatively superficial course of the relatively quick return to oral intake and good
vessel within the muscle using a self-retaining speech quality restoration. Finally, the patient
retractor allows good visualization of the per- was satisfied regarding the donor-site scar in the
forators during the whole dissection. left calf, and the altered sensation of the donor
5. Plastic surgeons should appropriately manage area improved with time.
the MSAP flap donor-site closure, trying to con- In a recent systematic review investigating the
tribute to minimal donor-site morbidity. The postoperative outcomes of MSAP flap, the
average flap width of nearly 6 cm is an important authors found a complication rate of 8.4%,
cutoff for achieving donor-site primary closure; which is lower than that reported for RFF or
otherwise, a split-thickness skin graft is required, ALT for head and neck reconstruction (Daar
which may not look good on calf. et al. 2019). Kao et al. comparing the RFF and
MSAP flaps in oral reconstruction did not find
significant differences in flap harvest time and
Intraoperative Images complications; however, the MSAP flap showed
better subjective function and low donor-site mor-
With the patient in a semi-frog leg position, a skin bidity compared with the RFF flap (Kao et al.
paddle of 10 5 cm is marked (Fig. 1b). Figure 1c 2009). Hung et al. (2017) evaluated functional
shows intraoperative MSAP flap harvest with one outcome, including speech and deglutition in
27 patients who underwent subtotal glossectomy who are generally concerned about the cos-
and reconstruction with MSAP flap. Speech metic result. Other minor donor-site compli-
assessment showed that 13 patients had a score cations that can be encountered include
of 5 (complete comprehension of speech). Deglu- dehiscence and infection. The use of loop
tition assessment evaluated that 16 patients mattress safety sutures allows to continue
achieved a full score of 4; it means that they early mobilization minimizing the risk of
were able to eat both solid and liquid diets. wound breakdown.
Donor-site complication rate, including dehis- 4. Finally, patient education in terms of post-
cence, delayed wound healing, and altered sensa- discharge care of the flap is also crucial to
tion, has been reported lower compared to control the overall survival of the flap.
alternative thin flaps such as RFF flap and an
overall complication rate of 1.9% (Daar et al.
2019). Learning Points
• The MSAP flap is a new workhorse flap for the

Avoiding and Managing Problems reconstruction of tongue defects allowing for
good speech, swallowing, and quality-of-life
1. During the flap harvesting, intramuscular dis- outcomes.
section can be tedious, and caution needs to be • The thin and pliable nature of the MSAP flap
posed for the detection of perforators. makes this flap ideal for hemi or subtotal
Although several studies reported expected tongue reconstructions providing comparable
perforators location using metrics location pliability for adequate tongue mobility and
from the midpoint of popliteal crease, the dif- volume replacement.
ferent locations of perforators are considered a • The MSAP can be used in a versatile fashion as
potential issue for the flap harvest. Hence, pre- a fasciocutaneus, musculocutaneus, and
operative hand-held Doppler or CTA is man- chimeric flap.
datory for a careful perforator location • Compared to alternative thin flaps, the donor-
assessment. However, although the number of site of MSAP is more inconspicuous with lim-
muscle branches may be higher compared to ited morbidity without aesthetic deformity.
other perforator flaps such as ALT or PAP, the Donor-site primary closure is possible for a
relatively superficial course of the perforators flap width up to 7 cm.
in the MSAP flap makes easier the exposure to • Distinct learning curve is necessary to harvest
visualize and deal with these small vessels in a the MSAP flap.
controlled way.
2. It has been reported a relatively high rate of
venous insufficiency for the MSAP flap, prob- References
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perforators. To increase the venous outflow, Baas M, Duraku LS, Corten EM, Mureau MA. A system-
the superficial saphenous vein can be added atic review on the sensory reinnervation of free flaps for
to the flap for supercharging. Vigilance to tongue reconstruction: does improved sensibility imply
functional benefits? J Plast Reconstr Aesthet Surg.
ensure adequate venous outflow can improve 2015;68(8):1025–35.
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produces an ugly donor-site scar. This should bidity after reconstruction of tongue defects with an
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Maxillofac Surg. 2016;54(10):1095–101. the medial sural artery perforator flap with the radial
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I. Microvascular free tissue transfer for tongue recon- Liu M, Liu W, Yang X, Guo H, Peng H. Pectoralis major
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Engel H, Huang JJ, Lin CY, et al. A strategic approach for Pappalardo M, Jeng SF, Sadigh PL, Shih HS. Versatility of
tongue reconstruction to achieve predictable and the free anterolateral thigh flap in the reconstruction of
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of reconstruction for partial glossectomy defects. Head Tsai CY. Long-term outcome of patients with or without
Neck. 2017;39(4):737–43. osseointegrated implants after resection of mandibular
Hallock GG. Anatomic basis of the gastrocnemius perfora- ameloblastoma and reconstruction with vascularized
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Total Lower Face Reconstruction with
Double Free Flaps 12
Andres Rodriguez-Lorenzo and Holger Jan Klein
Contents
Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Preoperative Problem List and Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . 110
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Abstract
A. Rodriguez-Lorenzo (*) The authors present a clinical scenario of an

Department of Plastic and Maxillofacial Surgery, Uppsala 81-year-old patient that presented with a large
University Hospital, Uppsala, Sweden squamous cell carcinoma in the chin. The
Department of Surgical Sciences, Uppsala University, oncological resection resulted in a massive
Uppsala, Sweden lower face defect including a through and
e-mail: andres.rodriguez.lorenzo@surgsci.uu.se though defect of the lower lip, neck skin,
H. J. Klein floor of the mouth, and a large bone defect in
Department of Plastic and Hand Surgery, University the mandible from angle to angle. The
e-mail: Kleinklein.holger@gmail.com

https://doi.org/10.1007/978-3-030-23706-6_14
110 A. Rodriguez-Lorenzo and H. J. Klein
reconstruction was successfully performed The patient was scheduled for surgery which
using a combination of two free flaps (fibula would include resection of the lower face leaving
osteocutaneous flap and anterolateral thigh a through and through defect below the oral com-
flap). Critical steps in this procedure include missures and bilateral neck lymphadenectomy.
virtual surgical planning of the mandible The resulting defect included the external skin
reconstruction, use of intraoperative templates extending from the lower lip to the neck skin at
to shape the ALT flap, planning of the surgical the hyoid bone level, the floor of the mouth, the
flow, and adequate selection of recipient mucosal lining of the lower lip, and a mandible
vessels. defect from angle to angle (Fig. 2).
Keywords
Total lower lip reconstruction · Virtual surgical Preoperative Problem List and
planning · Double free flap reconstruction · Reconstructive Requirements
Fibula free flap · ALT flap
The treatment plan included a large oncological
resection of the majority of the components of the
Clinical Scenario lower face including the lower lip and mandible
(Fig. 2). The reconstructive requirements in this
An 81-year-old active and otherwise healthy case were to achieve stable wound closure so the
woman presented with pain and a large ulcerated patient can receive postoperative radiotherapy in
mass in the chin. On clinical and radiological adequate timing, to restore oral competence to
exploration, the tumor macroscopically infiltrated retain food and liquids in the mouth, and to restore
the skin, the lip including the left oral commis- bone continuity and eventually dental rehabilita-
sure, and the gingiva over the mandible (Fig. 1a, tion and appearance of the lower lip. The main
b). A biopsy showed a high differentiated gingival problems that would be encountered after the
squamous cell carcinoma. Bilateral lymph node resection of the tumor along with the reconstruc-
neck metastases were detected in the CT and tive requirements are enlisted below:
the case was discussed in the head and neck
tumor board being staged as a T4N2M0. The 1. Mandible defect: the resulting defect will be a
treatment plan included surgery and postoperative long defect from angle to angle needing
radiotherapy. vascularized bone transfer
Fig. 1 (a) Image from CT showing the bone destruction of the mandible by the tumor (red arrow). (b) Clinical aspect of
the tumor
12 Total Lower Face Reconstruction with Double Free Flaps 111
Fig. 2 Intraoperative photo of the lower face resection after removal of the tumor
2. Through and through defect including total 6. Selection of recipient vessels: right side facial
resection of the lower lip needing: artery and vein for the free fibula flap and left
1. Inner lining side transverse cervical artery and vein for the
2. Large external skin defect reconstruction ALT
3. Restoration of lower lip suspension to be
able to have oral competence
3. Restoration of lip aesthetic subunits and Alternative Reconstructive Options
vermillion
As described in the section of the requirements of
the defect, any reconstruction attempted in a sim-
Treatment Plan ilar clinical scenario should include the transfer of
large vascularized tissues including bone and soft
1. Resection of lower face through and through tissue (Balasubramanian et al. 2012; Kuzon et al.
from oral commissures below to hyoid bone, 1998). There are other strategies that could be as
including the mandible from angle to angle as valid as described below:
shown in Fig. 2, bilateral neck dissection, and
tracheostomy 1. One-flap versus two-flap strategy: An alterna-
2. Reconstruction of the bone defect in the man- tive solution will be to do a chimeric flap from
dible and inner lining of the lip with a free the subscapular system (Jacobson et al. 2016)
fibula osteoseptocutaneous flap using the skin including two skin islands (TDAP plus Scapu-
island for inner lining. Preoperative virtual lar/parascapular flaps) plus Bone flaps (scapula
planning using CAD–CAM technology for or extended scapula tip). The use of a fibula
bone reconstruction with two skin islands alone will not be a good
3. Lip suspension using a fascial sling option due to the donor site defect. The authors
4. Reconstruction of external skin defect with a favor the strategy of using two free flaps as it
free anterolateral thigh (ALT) flap has less donor site morbidity, in comparison
5. Planning for second stage after radiotherapy with taking all necessary tissue from just one
for sculpting of flap to the recreated lower lip donor site, but also allows for more freedom
subunit and better insetting of each flap component. As
it was a primary case, plenty of recipient ves- An operation flow scheme is performed to
sels were available. allow better communication in the OR between
2. Alternative bone flaps: Other suitable options the surgical and anesthesiology teams with
for bone flaps would be the iliac bone and bone description of the surgical steps.
flaps from subscapular system (scapula and
scapula tip).
3. Combination of free bone flap plus pectoralis Surgical Technique
major myocutaneous flap for external skin cov-
erage: The downside is the donor site morbid- 1. Operation flow and surgical sequence: The
ity/deformity of using a large skin component surgical sequence is as follows:
from the chest in a female patient 1. Tracheostomy
4. Combination of using a reconstruction plate 2. Tumor resection and lymphadenectomy
for bone reconstruction and free ALT for both with parallel harvesting of free fibula flap
inner lining and external lining: It is a more from the right leg
simple option to avoid the use of a bone flap; 3. Intraflap osteotomies using cutting guides
however, the experience with reconstruction and osteosynthesis with 2.4 mm plates and
plate in central mandible defects is associated screws with the fibula still attached in the
often with complication in form of infection leg by its vascular pedicle
and plate extrusion. In our case, the patient will 4. Insetting of fibula flap with plating to the
also receive radiotherapy, therefore autologous mandible, anastomosis to the right facial
reconstruction will provide more robust wound vessels, and suturing of the skin island to
healing. the floor of the mouth and lateral buccal
mucosa. Parallel harvesting of the ALT
flap from the left thigh and harvesting of a
Preoperative Evaluation and Imaging fascia sling from rectus femoris muscle for
lower lip suspension
For the purposes of reconstruction, a Computed 5. Exposure of left transverse cervical artery
Tomography Angiography of the head and neck 6. Insetting of fascia sling from rectus femoris
area and lower leg was performed to enable pre- muscle
operative virtual planning using CAD-CAM tech- 7. Insetting of the ALT flap to the skin island
nology (Proplan CMF, Materialise-Depuy from the fibula intraoral and lateral to the
Synthes, Johnson & Johnson). A 3D model and neck skin; Anastomosis to the transverse
bone cutting guides are printed to assist with the cervical vessel from the left site; Parallelly,
conformation of the fibula (Figs. 3 and 4). closure of fibula and ALT donor sites, using
a skin graft to close the fibula donor site
2. Surgical team: The team consists of an onco-
Preoperative Care and Patient logical team and a reconstructive team includ-
Drawing ing ENT (two consultants and one resident),
plastic surgery (two consultant microsurgeons,
Drawing of the skin incision and skin island of two residents, and one microvascular fellow),
both the fibula osteocutaneous flaps is done and and maxillofacial surgery team (two special-
the perforators are marked in the skin island and ists). To maximize the intraoperative flow
located with hand-held Doppler. The patient when performing a two-flap reconstruction, it
receives antibiotic prophylaxis with combination is important to plan in advance the reconstruc-
of cephotaxime and metronidazole and tive team to consist of at least two micro-
thromboprophylaxis with subcutaneous injection surgeons able to work parallelly as much as
of low-dose heparin. possible in order to reduce the operative time.
Fig. 3 Computed imaging of the virtual surgical planning. Above, in red is marked the portion of the mandible that will
be resected and below the conformation of the fibula with the planned osteotomies
Fig. 4 Image of the virtual surgical planning showing the planned osteotomies in the fibula for further confirmation of the
mandible
3. Flap harvesting: The fibula osteocutaneous The ALT is dissected by performing the medial
flap is harvested in a standard fashion using subfascial approach to identify the perforator
an anterior approach to dissect first the in the septum between vastus lateralis and rec-
septocutaneous perforator followed by the lat- tus femoris followed by its intramuscular dis-
eral, anterior, posterior deep, and posterior section until the main pedicle at the descending
superficial leg compartments to harvest the branch of the lateral femoral circumflex artery.
peroneal vessels along with the bone flap. A template was made matching the soft tissue
defect and placed on the leg, and the shape was efficiently and to perform several steps simul-
traced with a marking pen. It was decided by taneously, therefore decreasing the operative
the template which tissue components were time which it is often related to the rate of
needed; the shape of the flap and their location complications.
as well as the position and length of the pedicle
were marked. The flap was then completely
raised and partially inset into the head and Intraoperative Images
neck defect.
See Figs. 5, 6, 7, and 8.
Technical Pearls
• Virtual surgical planning of the fibula bone
flap using CAD/CAM technology preoperative: After the operation, the patient is transferred
This allows for better visualization of the sur- under general anesthesia to an intensive care unit
gical plan; it increases the accuracy in the bone for the first 24 h postoperatively and then to the
reconstruction, shortens the flap ischemia time, ward.
as osteotomies are performed in the leg with
the flap still attached by its vascular pedicle, • Flap control: The flaps are closely monitored
and decreases the operative time (Levine et al. by the nursing staff by clinical inspection,
2012; Olsson et al. 2015). manual Doppler, and implantable Doppler
• Using templates intraoperative to customize the (Cook-Swartz) for 1 week. The frequency of
ALT flap to the soft tissue defect: At our institu- controls is as follows: once every 15 min dur-
tion, this is usually performed routinely in all ing the first 4 h, every 30 min during the next
head and neck reconstruction as it allows for 4 h and then once/hour of the first day, every
more accurate design of the flap to the defect. 2 h on day 2, every 3 h on day 3, every 4 h on
• Planning the surgical flow in advance with the day 4, every 5 h on day 5, and every 6 h on day
Oncological and Reconstruction Team includ- 6 according to the authors’ institutional
ing a setup of a checklist with the sequence of protocol.
the surgical steps: This allows for better com- • Nutrition: A nasogastric tube is placed under
munication between team, to work more the operation and enteral nutrition is usually
Fig. 5 Intraoperative image showing the conformation of the fibula to the shape of the mandible using cutting guides
when still attached to the leg by its vascular pedicle
Fig. 6 Image showing the insetting of the fibula in the mandible after reconstruction of the inner lining with the skin
island
• Mobilization: The patient needs to avoid

excessive mobilization of the neck for the first
week to avoid vascular spasm or compression/
kinking of the vascular pedicles. During the
first three days postoperatively, the patient
stays in bed but is instructed to do an active
mobilization of the extremities. At day 5
postop, a dressing change of the fibula donor
site is performed and the patient is instructed to
use an Aircast Boot that allows for painless
weight bearing of the fibula donor site.
• Antibiotics and thromboprophylaxis: Pre- and
perioperative antibiotic prophylaxis is given
using a combination of cefotaxime and metro-
nidazole antibiotics i.v. and thrombopro-
phylaxis by using daily subcutaneous injection
of low dose heparin (dalteparin) for 10 days. In
Fig. 7 Insetting of the fascial strip obtained from the addition, from day 1, the patient takes low-dose
Rectus Femoris tendon for lip suspension aspirin (75 mg) once a day for 1 month.
started on day 1 postoperatively. Oral intake is Outcome

not allowed for a week postoperatively to facil-
itate intraoral wound healing and avoid the risk The operation was uneventful. The patient stayed
of development of orocutaneous fistulas. in intensive care unit for 2 days postoperatively
• Tracheostomy: The process of decanulation and then was moved to the ward. Postoperatively,
starts from day 5 to 7 postoperatively. the patient developed a small wound dehiscence
Fig. 8 Image of the result at the end of the surgery after insetting of the ALT flap to replace the external skin
Fig. 9 Clinical outcomes at 6 months postoperatively

after radiotherapy
Fig. 10 CT showing excellent shape of the mandible at 6-

in the left of the oral commissure that resolved by months follow-up
secondary healing and was discharged from the
hospital 21 days postoperatively. She received At six-months follow-up, the patient was tumor-
postoperative radiation afterwards. The patient free and had a fairly good outcome (Fig. 9), with
developed a mucositis after radiotherapy and to adequate shape of the mandible (Fig. 10), however
enable the increase of her nutritional intake, she she had retraction of the oral commissures that
received a PEG. impaired her oral intake.
Fig. 11 Left, middle. Follow-up at 11 months postop before sculpture of the lower lip. Right: Intraoperative photo after
sculpture of the lower lip
A second stage was performed 11 months after 3. Selection of recipient vessels is critical
the first operation by doing a bilateral z-plasty in when planning two simultaneous free flaps
the oral commissures and sculpting the lower lip in the head and neck. Priority is given to the
by liposuction to create a mental sulcus and a scar bone flap, as it has less flexibility to reach
to recreate the lower lip aesthetic subunit, provid- different recipient sites, limited by its fixa-
ing a satisfactory functional and aesthetic out- tion. The transverse cervical artery is a very
come (Fig. 11). The patient was diagnosed with useful vessel to reach defects in the lower
a tumor recurrence with presence of distant metas- face and neck due to its caliber and is usu-
tasis and she died 1 year and 7 months later. ally uninjured.
4. Secondary procedures are often necessary to
achieve the goal of restoration function and
Avoiding and Managing Problems appearance in free flap surgery in head and
neck and should be part of the planned treat-
In large complex defects in head and neck area, ment from the beginning.
one of the critical factors is preoperative planning. 5. The main focus in the reconstruction should
This includes the previsualization of the defect be the customization of the flaps to achieve
that can be done with virtual surgical planning the best clinical outcomes, and steps such as
but also the planning of the surgical flow, espe- flap harvesting should be standard and
cially when performing two free flaps. It is impor- straightforward.
tant to have a check list of the surgical steps to be
discussed with all the surgical anesthesiology
Cross-References
team members in order to avoid extensive surgical
times that will lead to high rate of complications.
▶ Total Lower Lip Reconstruction with Inner-
vated Radial Forearm Flap and Palmaris
Longus Tendon
Learning Points
1. When using double free flap reconstruction in References

head and neck, it is critical to have a preoper-
Balasubramanian D, Thankappan K, Kuriakose MA,
ative planning of the surgical flow including Duraisamy S, Sharan R, Mathew J, Sharma M, Iyer S.
steps and “who is doing what” to avoid Reconstructive indications of simultaneous double free
mistakes. flaps in the head and neck: a case series and literature
2. Virtual Surgical Planning with CAD–CAM review. Microsurgery. 2012;32(6):423–30.
Jacobson L, Dedhia R, Kokot N, Chalian A. Scapular
technology allows in bone flaps to increase the osteocutaneous free flap for total lower lip and
accuracy of the reconstruction and decreases the mandible reconstruction. Microsurgery. 2016;36
ischemia time and the operative time (6):480–4.
Kuzon WM Jr, Jejurikar S, Wilkins EG, Swartz WM. surgery: the new state of the art. J Craniof Surg.
Double free-flap reconstruction of massive defects 2012;23(1):288–93.
involving the lip, chin, and mandible. Microsurgery. Olsson P, Nysjö F, Rodríguez-Lorenzo A, Thor A, Hirsch JM,
1998;18(6):372–8. Carlbom IB. Haptics-assisted virtual planning of bone,
Levine JP, Patel A, Saadeh PB, Hirsch DL. Computer- soft tissue, and vessels in fibula osteocutaneous free flaps.
aided design and manufacturing in craniomaxillofacial Plast Reconstr Surg Glob Open. 2015;3(8):e479.
Total Lower Lip Reconstruction
with Innervated Radial Forearm Flap 13
and Palmaris Longus Tendon
Riccardo Schweizer and Andres Rodriguez-Lorenzo
Contents
Preoperative Problem List/Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
First Stage: Innervated Composite Free Radial Forearm Flap . . . . . . . . . . . . . . . . . . . . . . . . . 122
Second Stage: Flap Sculpture and Creation of Aesthetic Lip Component . . . . . . . . . . . . . 124
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Abstract
R. Schweizer (*) Total lower lip defects often require free flaps
Department of Plastic and Maxillofacial Surgery, for reconstruction to achieve optimal outcome.
Here we present a case of a young woman
Department of Plastic Surgery and Hand Surgery, who developed a severe mucormycosis of the
University Hospital Zurich, Zurich, Switzerland
lower lip during immunosuppression due to
A. Rodriguez-Lorenzo hemophagocytic syndrome. After debride-
Department of Plastic and Maxillofacial Surgery,
ment, the resulting defect included the whole
lower lip and skin of the labiomental sulcus, in
Department of Surgical Sciences, Uppsala University,
addition to part of the right upper lip eventually
Uppsala, Sweden

https://doi.org/10.1007/978-3-030-23706-6_15
120 R. Schweizer and A. Rodriguez-Lorenzo
leading to drooling, altered speech, and a cos- by a contracted scar (Fig. 1). The young patient
metically severed lower face. Reconstruction was referred to our institution for secondary
was performed with a composite sensate free reconstruction. Her main complaints were inabil-
radial forearm flap for inner lining and skin ity to keep food in the mouth, an altered speech,
coverage, including the palmaris longus ten- and, clearly, the severely impaired aesthetics of
don for suspension and lateral antebrachial the lower face with complete gingival show.
cutaneous nerve coapted to the left mental
nerve for sensation. The right upper lip vermil-
ion was addressed using an advancement flap. Preoperative Problem List/
After an uneventful postoperative course, sec- Reconstructive Requirements
ondary procedures included sculpture of the
flap, scar correction, and tattooing for vermil- 1. Full-thickness defect of the lower lip involving
ion reconstruction achieving an excellent func- the vestibular mucosa (intraoral lining), muscle
tional and cosmetic outcome by restoring lip (orbicularis oris), and skin (vermilion, white
sensation, appearance, and oral continence. roll and labiomental sulcus)
2. Contracted right angulus oris and vermilion
Keywords defect right upper lip (partial thickness)
Total lower lip reconstruction · Sensate free 3. Inability of mouth closure with gingival show
radial forearm flap · Palmaris longus tendon · and consequent drooling (impaired sphincter
Free composite flap · Total lip reconstruction function)
4. Altered speech and articulation with impaired
social interaction
The Clinical Scenario 5. Young female patient with severely disfigured
lower face
A 20-year-old woman under immunosuppression
because of hemophagocytic syndrome developed
a severe mucormycosis of the lower lip extending Treatment Plan
to parts of the upper lip. Following multiple
debridements at an external hospital, the resulting The present tissue defect required thin, pliable,
defect was characterized by a full-thickness whole and hairless skin, and, to regain oral competence,
lower lip deficiency combined to missing vermil- some sort of suspension to reach the upper lip
ion on the right side of the upper lip, exacerbated would be advisable for an optimal outcome.
Fig. 1 Preoperative image

of the defect showing a full-
thickness total lower lip loss
with exposure of the lower
gingiva and dentition and
deficiency of part of the
right upper lip and angulus
oris. The scarring following
debridements reaches the
mentum, and the
labiomental sulcus is
completely missing
13 Total Lower Lip Reconstruction with Innervated Radial Forearm Flap and Palmaris Longus Tendon 121
In our opinion, local flaps were not an option in achieved good results, even though usually
this case because of the extent of lesion (complete reserved for older patients after cancer resections,
loss of lower lip) and young female patient, mean- with more skin laxity. Furthermore, neck flaps can
ing that the skin flaccidity was low and cosmetic be used as salvage procedure in very sick or old
expectations high, not accepting additional scars patients who do not qualify for free tissue transfer
in the face, in addition to the risk for microstomia or after failed free flap reconstruction (Yildirim
if using local flaps. et al. 2010). A bilobed platysma flap based on
We chose the free radial forearm flap (RFF) submandibular artery has been described and
because it meets abovementioned criteria and can might be suitable in older patients with sagging
be harvested in a composite fashion including the neck skin (Akdemir et al. 2014).
palmaris longus tendon (Jeng et al. 2004b), while Free flaps are usually the best choice to achieve
the vascular anatomy is very consistent and the optimal outcomes both functionally and aestheti-
pedicle long and of large caliber. The bilateral cally. Beside the free RFF, a handful of alternative
fixation of the palmaris longus tendon to the fasciocutaneous free flaps have been proposed for
modiolus allows to suspend the flap and achieve total lip reconstruction, such as the anterolateral
oral competence. In addition, the possibility to thigh perforator flap (ALT) with or without fascia
harvest a sensate flap makes the choice even lata for suspension (Yildirim et al. 2006), which
more appealing to foster regain of sensation to can be harvested sensate including the lateral
the lower lip. The defect of the upper right lip cutaneous femoral nerve but might be too bulky
could be addressed by a local vermilion advance- in the majority of patients (as it was in our case)
ment flap (Jeng et al. 2004a). even if harvested superthin in the suprafascial
For vermilion reconstruction of the lower lip, plane and is a perforator flap with less straightfor-
we planned tattooing after minor touch ups for ward harvesting requiring more technical exper-
scar correction, which is the less invasive way as tise. On the other hand, the restoration of
compared to tongue flaps or skin grafts. sensation with an ALT is not that predictable as
with a neurotized RFF. The ALT donor site, how-
ever, is better and less exposed than the RFF. The
Alternative Reconstructive Options ulnar forearm flap has been described with the
advantage of better donor site location and
While the free RFF has gained good acceptance improved aesthetic outcome as compared to the
over the last decades in particular for reconstruc- RFF (Hekner et al. 2013). The double-paddle
tion of head and neck defects, and especially of peroneal flap is an alternative when the RFF
the lower lip, disadvantages of such flap include would be too small and can better restore the
problematic donor site closure (requiring local vermilion-cutaneous junction (Lin et al. 2017),
advancement or rotation flaps, or skin grafts) and while the dorsalis pedis flap has been suggested
donor site appearance, color mismatch, potential as a salvage option in select patients (Stathas et al.
hair-bearing in men, and sacrifice of radial artery. 2014). If persistence of lower lip incompetence is
A multitude of local or pedicled flaps have an issue after reconstruction, the use of a double
been described to reconstruct total lip defects temporalis transfer with fascia lata sling may be an
where free flaps are not an option but usually option (Chan et al. 2012). If bony reconstruction is
lack functionality or provide insufficient soft tis- required for the mandible, the free osteocutaneous
sue, especially in younger patients with lack of fibula flap (Jeng et al. 2005) or scapula flap (Jacobson
skin laxity. The double mental neurovascular V-Y et al. 2016) can be integrated in the reconstructive
island advancement flap (Chen et al. 2012; Fang strategy.
et al. 2014), the extended Karapandzic flap To pursue the optimal functional reconstruction
(Dediol et al. 2018), the visor flap (Nthumba and in total lower lip defects, some authors advocate for
Carter 2009), and the modified bilateral cheek flap the use of free functional muscle flaps sutured to
(Chowchuen 2016) have been described and the remaining orbicularis oris muscle stumps and
coapted to buccal branches of the facial nerve, such and ulnar artery. Doppler can help to further eval-
as the free gracilis muscle flap (Gurunluoglu et al. uate the vascular status or an angiography in rare
2012; Lengele et al. 2004; Ninkovic et al. 2007), cases, when in doubt or previous operations at the
the free partial latissimus dorsi muscle flap (Ozkan donor site. Prior intravenous line or injuries on the
et al. 2019), or the combined free gracilis muscle forearm were excluded.
flap and RFF (Ueda et al. 2006). Recently, also the
free functional serratus anterior flap has been
reported, harvesting only the lower part, in order Preoperative Care and Patient
to leave the rest of the serratus anterior muscle Drawing
functional (Gundeslioglu et al. 2017).
Usually vermilion reconstruction is the last The patient was positioned supine with completely
step of total lip reconstruction and is not done at prepped right arm with tourniquet, and the arm
the time of initial reconstruction. Tattooing is an abducted at 90 in the shoulder.
easy option with low morbidity; other than that, The flap was pre-marked on the volar radial
additional options include the use of local flaps aspect of the forearm and the incision for pedicle
(Ninkovic et al. 2007), skin grafts, or even genital dissection marked over the grove between the
mucosal grafts (Muller-Richter et al. 2016), as brachioradialis and FCR muscle (Fig. 2). The
well as tongue flaps (Keskin et al. 2010), which palmaris longus tendon was identified and
all are more invasive and in the case of mucosal included into the design. The recipient site is
grafts tend to develop dryness. marked by defining the limits of the lip aesthetic
unit and scar resection and the level of planned
suspension in the commissures of the palmaris
Preoperative Evaluation and Imaging longus tendon (Fig. 3).
Definitive drawing was performed after exci-
An exact assessment of the involved, respectively sion of the scar and definitive intraoperative eval-
missing, structures is required to discriminate uation of defect size with the use of a template.
between partial or full thickness and the extent The flap was designed with two parts: one larger
of lower lip defect in order to establish a proper part for the inner lining and reconstruction of the
reconstructive plan. Patient tobacco abuse, condi- gingival sulcus and the lip and smaller part for the
tions impairing wound healing, or disturbed vas- external, labiomental skin coverage with inclusion
cular status (diabetes and peripheral arterial of the palmaris longus tendon and the lateral ante-
disease) need to be asked for. The age of the brachial cutaneous nerve (LACN) for a sensate
patient is important in terms of both skin elastic- flap. The latter usually runs next to the cephalic
ity/redundancy and expected aesthetic outcome. vein and is easily identified intraoperatively. Hair-
Functional impairment needs to be evaluated bearing areas should be avoided but was not an
in terms of oral competency, ability to speak, and issue in this young female patient.
facial expression. The patient’s expectations and
goals have to be discussed and determined.
The neck should be assessed for any previous Surgical Technique
procedures which might preclude proper recipient
vessel identification or dissection, usually the First Stage: Innervated Composite Free
facial or superior thyroid artery and veins, or the Radial Forearm Flap
jugular veins. Alternatively, the superficial tem-
poral vessels could be used but require a longer 1. First, the scar at the recipient site was excised;
pedicle. In this patient, no previous operations releasing the right angulus oris and the
were performed in the neck region. modiolus was exposed on both sides for
An Allen test is mandatory preoperatively and later attachment of the palmaris longus
was performed to assess patency of both radial tendon.
Fig. 2 Preoperative
drawing of the radial
forearm flap on the right
forearm including the
palmaris longus tendon
(PL) and the lateral
antebrachial cutaneous
nerve (LACN)
4. The recipient vessels (facial vessels) were

exposed and dissected on the left submandib-
ular region through a small skin incision.
5. The radial forearm flap was raised in a classi-
cal fashion starting from distal to proximal
including the fascia.
6. The palmaris longus including paratenon was
raised with the flap, and attention was taken to
leave the FCR paratenon uninjured.
7. An Allen test was performed intraoperatively
again after releasing the tourniquet and before
transection of the radial artery.
8. At the proximal border of the flap, the cephalic
vein was identified and was preserved.
9. Next to the vein, the LACN was identified
and followed proximally while dissecting the
pedicle.
Fig. 3 Preoperative drawing of recipient site marking the 10. After complete dissection of the pedicle, this
limits of the resection of the scar to replace the aesthetic was clipped off, and the flap harvested.
subunit of the lower lip and the level of suspension of the 11. After opening the tourniquet, precise hemo-
palmaris longus tendon at the level of the commissures
stasis was performed, and the defect covered
with a split skin graft from the right thigh. A
2. A labial advancement flap was performed to dorsal cast was applied to the forearm for
reconstruct the right-sided upper lip to the immobilization (fingers kept free).
angulus to restore symmetry to the upper lip. 12. The flap was the placed into the defect: first,
3. The final defect was measured taking in the gingival sulcus was reconstructed, and the
account the total size of inner lining (gingival flap inset with fast resorbable 4–0 braided
sulcus), lip, and labiomental sulcus paying sutures.
attention to the loss of length while folding 13. The palmaris longus tendon stumps on both
the flap. A template was used for that, and sides were trimmed in order to achieve ideal
the definitive flap design was corrected tension and sutured to the modiolus on both
accordingly. sides with a non-resorbable suture.
14. At this point, the pedicle was tunneled subcu- Second Stage: Flap Sculpture
taneously to the recipient vessels on the left and Creation of Aesthetic Lip
neck region. Attention was paid to have at Component
least two finger breadths of space subcutane-
ously to avoid pedicle compression and not to 1. Nine months postoperatively, the patient
twist it. underwent a second procedure.
15. Arterial end-to-end anastomosis was performed 2. Debulking occurred from a skin incision in the
under microscope magnification with interrupted labiomental sulcus by defatting the flap.
9–0 nylon sutures, and venous end-to-end anas- 3. Recreation of the labiomental sulcus with
tomosis was performed with a 2.5 mm coupler quilting sutures followed.
device. 4. Recreation of the skin vermilion line: A skin
16. The LACN was then sutured to the left mental incision was made on the flap at the site of the
nerve, and the remainder of the flap sutured new vermilion-cutaneous junction and
into the defect by folding it over the palmaris re-sutured with non-resorbable 4-0 single
longus tendon. stitches to emphasize the new white roll area.
5. Advancement of a local mucosal flap was used
to reconstruct the missing right upper lip
Technical Pearls (Fig. 4).
1. Not completely exsanguinating the arm before

tourniquet inflation helps recognizing the key Postoperative Management
blood vessels better during dissection.
2. Use a template of the defect (e.g., Mepilex foam After the first stage, the patient’s head was kept
sheet) to exactly plan flap size and design. elevated for the first 3 days, and the patient was
3. If a large flap is harvested, consider harvesting given peroral fluids for the first 3 days, escalating
the cephalic vein or another superficial vein food intake thereafter. Low molecular heparin
with the flap for a venous supercharge through (Fraxiparine 5000 IE/24 h) was given daily
the superficial system. together with 75 mg of ASS. No additional anti-
4. Suprafascial dissection can help to improve biotics were given to the perioperative single shot.
skin graft take and donor site appearance. Flap monitoring occurred clinically and by Dopp-
5. If a very thin flap is needed, the forearm fascia ler on an hourly basis for the first 3 days. The
doesn’t have to be harvested with the flap, but easyflow drain at the site of anastomosis was
it is recommended to take the fascia in the zone removed after 2 days. Postoperatively the patient
of the perforators to protect vascularity. had to wear a forearm cast for wrist immobiliza-
6. The donor site can be improved by transposition for about 1 week; after the first dressing
tion of a fascial flap based on ulnar perforators, change at the site of skin grafting, the patient
prior to skin grafting (Yii and Niranjan 1999). could move the arm again.
7. In case of need, the cephalic vein can be used to
reconstruct the radial artery.
8. To avoid unrecognized twisting of the pedicle Outcome, Clinical Photos, and Imaging
while tunneling subcutaneously to reach the
recipient vessels, it can be inserted into an The patient recovered well from the operation,
easy flow tube to keep the orientation prior to and the postoperative course was uneventful.
pull through. She was discharged after 1 week, and during the
9. Make sure the subcutaneous tunnel for the follow-up, she had proper wound healing with
pedicle is large enough not to compress (two no complications beside of development of scar
finger breadths). contracture in the right commissure, corrected
Fig. 4 Postoperative result 10 days after free tissue transfer showing good suspension of the flap and excess of volume
without labiomental sulcus (to be corrected in the second stage)
during secondary procedure. Figure 4 depicts the regrafting to avoid healing by secondary inten-
postoperative result at the first follow-up 1 week tion and improve the outcome.
after the first stage, and Fig. 5 shows the result 5. Bad donor sites can be improved by needling
directly after secondary touch-up procedure and micro/nano-fat grafting.
9 months later. The last step of the reconstructive 6. To avoid early sagging of the flap, slight over-
plan was reconstruction of the lower lip vermilion, correction of the palmaris longus tendon sus-
and the patient chose the tattooing option for that pension is advised.
(Fig. 6).
Learning Points
1. Total lower lip reconstruction usually needs a
1. It is imperative to leave the paratenon of the free flap for best results, even more so when
FCR tendon intact to avoid any adhesion and the defect includes the skin region to the
scar tethering and potential functional impair- mentum.
ment at the donor site. 2. The radial forearm flap with its variations as a
2. Delayed wound healing and bad donor site composite free flap including nerve and tendon
appearance are a frequent problem after free remains one of the most common performed
RFF; when direct closure is not possible, fas- choices for total lower lip reconstruction.
cial flaps can increase skin graft take rate and 3. To pursue a more functional reconstruction,
improve donor site outcome. free muscle flaps can be evaluated (gracilis,
3. Identify the dorsal branch of the radial nerve in partial serratus anterior, partial latissimus
the intermuscular septum and spare it to avoid dorsi).
loss of sensation or neuroma formation. 4. The age and sex of the patient, as well as their
4. If significant skin graft loss occurs at the donor expectations in terms of functional and aes-
site, consider an ulnar fascial flap and thetic outcome, must be taken in account.
Fig. 5 Postoperative result after secondary correction. Note the advancement flap on the right side of the upper lip and the
superficial skin incision at the boundary of the new lower lip, to accentuate the site of the new white roll
Fig. 6 Final result 3 years postoperatively. Left: good conventional make-up. Sensation to the lower lip recov-
result with complete mouth closure and oral competence ered in 1 year. Right: picture sent by the patient herself
and good lip symmetry. There is a very well reconstructed showing a satisfactory result after using conventional
labiomental sulcus and adequate lower lip suspension but a make-up masking the area of color mismatch
slight color mismatch that is solved by the patient with
Cross-References Jacobson L, Dedhia R, Kokot N, Chalian A. Scapular

osteocutaneous free flap for total lower lip and mandi-
ble reconstruction. Microsurgery. 2016;36:480–4.
▶ Upper Lip Replantation with Arterialized https://doi.org/10.1002/micr.30040.
Venous Flap, Without Microsurgical Venous Jeng SF, Kuo YR, Wei FC, Su CY, Chien
Outflow CY. Reconstruction of concomitant lip and cheek
through-and-through defects with combined free flap
and an advancement flap from the remaining lip. Plast
Reconstr Surg. 2004a;113:491–8. https://doi.org/
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Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Total lower
Akdemir O, Lineaweaver WC, Celik S, Cinar C, Zhang lip reconstruction with a composite radial forearm-
F. Submandibular artery: bilobed platysma palmaris longus tendon flap: a clinical series. Plast
myocutaneous flap for total lower lip reconstruction. Reconstr Surg. 2004b;113:19–23. https://doi.org/
J Craniomaxillofac Surg. 2014;42:1861–7. https://doi. 10.1097/01.Prs.0000090722.16689.9a.
org/10.1016/j.jcms.2014.07.004. Jeng SF, Kuo YR, Wei FC, Su CY, Chien
Chan RK, Bojovic B, Talbot SG, Weiss D, Pribaz JJ. Lower CY. Reconstruction of extensive composite mandibular
lip suspension using bilateral temporalis muscle flaps and defects with large lip involvement by using double free
fascia lata grafts. Plast Reconstr Surg. 2012;129:119–22. flaps and fascia lata grafts for oral sphincters. Plast
https://doi.org/10.1097/PRS.0b013e31823620b0. Reconstr Surg. 2005;115:1830–6.
Chen WL, Wang YY, Zhou M, Yang ZH, Zhang Keskin M, Sutcu M, Tosun Z, Savaci N. Reconstruction
DM. Double mental neurovascular V-Y island advance- of total lower lip defects using radial forearm free
ment flaps combined with tongue flaps for functionally flap with subsequent tongue flap. J Craniofac Surg.
reconstructing total lower-lip defects. J Craniofac 2010;21:349–51. https://doi.org/10.1097/SCS.0b013
Surg. 2012;23:181–3. https://doi.org/10.1097/SCS. e3181cf603a.
0b013e3182418ed5. Lengele BG, Testelin S, Bayet B, Devauchelle B. Total
Chowchuen B. Modified bilateral neurovascular cheek lower lip functional reconstruction with a prefabricated
flap: functional reconstruction of extensive lower lip gracilis muscle free flap. Int J Oral Maxillofac
defects. Plast Reconstr Surg Glob Open. 2016;4:e721. Surg. 2004;33:396–401. https://doi.org/10.1016/j.ijom.
https://doi.org/10.1097/gox.0000000000000680. 2003.11.004.
Dediol E, Cvrljevic I, Dobranic M, Uglesic V. Extended Lin YS, Liu WC, Lin YS, Chen LW, Hsueh JH, Yang
Karapandzic flap technique for reconstruction of KC. Double-paddle peroneal flap for extensive lip
lower lip and chin defect. J Oral Maxillofac defect reconstruction. Microsurgery. 2017;37:558–63.
Surg. 2018;76:213–20. https://doi.org/10.1016/j.joms. https://doi.org/10.1002/micr.30136.
2017.06.015. Muller-Richter UD, Weyandt GH, Woeckel A, Kubler
Fang QG, Shi S, Zhang X, Li ZN, Liu FY, Sun CF. Total AC. Vermilion reconstruction with genital mucosa.
lower lip reconstruction with a double mental Plast Reconstr Surg Glob Open. 2016;4:e701. https://
neurovascular V-Y island advancement flap. J Oral doi.org/10.1097/gox.0000000000000703.
Maxillofac Surg. 2014;72:834.e831–836. https://doi. Ninkovic M, Spanio di Spilimbergo S, Ninkovic M. Lower
org/10.1016/j.joms.2013.12.010. lip reconstruction: introduction of a new procedure
Gundeslioglu AO, et al. Lip reconstruction using a func- using a functioning gracilis muscle free flap. Plast
tioning serratus anterior free flap: preliminary study. Int Reconstr Surg. 2007;119:1472–80. https://doi.org/
J Oral Maxillofac Surg. 2017;46:1243–7. https://doi. 10.1097/01.prs.0000258527.99140.fe.
org/10.1016/j.ijom.2017.04.026. Nthumba P, Carter L. Visor flap for total upper and lower lip
Gurunluoglu R, Glasgow M, Williams SA, Gurunluoglu A, reconstruction: a case report. J Med Case Rep. 2009;3:
Antrobus J, Eusterman V. Functional reconstruction of 7312. https://doi.org/10.4076/1752-1947-3-7312.
total lower lip defects using innervated gracilis flap in Ozkan O, Ozkan O, Cinpolat A, Ubur MC, Bektas G,
the setting of high-energy ballistic injury to the lower Jumshudov A, Uysal H. Functional lower lip recon-
face: preliminary report. J Plast Reconstr Aesthet struction with the partial latissimus dorsi muscle free
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Van Cann EM. Donor-site morbidity of the radial fore- Goumas P. Dorsalis Pedis free flap: the salvage option
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Reconstr Surg. 2013;132:387–93. https://doi.org/ lip reconstruction. Case Rep Med. 2014;2014:458286.
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Ueda K, Oba S, Ohtani K, Amano N, Fumiyama Yildirim S, Gideroglu K, Aydogdu E, Avci G, Akan M,
Y. Functional lower lip reconstruction with a Akoz T. Composite anterolateral thigh-fascia lata flap:
forearm flap combined with a free gracilis muscle a good alternative to radial forearm-palmaris longus
transfer. J Plast Reconstr Aesthet Surg. 2006; flap for total lower lip reconstruction. Plast Reconstr
59:867–70. https://doi.org/10.1016/j.bjps.2005.10. Surg. 2006;117:2033–41. https://doi.org/10.1097/01.
014. prs.0000210663.59939.02.
Yii NW, Niranjan NS. Fascial flaps based on perforators Yildirim S, Karaca M, Bilgic IM, Akoz T. Lower lip
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10.1054/bjps.1999.3170. 10.1097/SCS.0b013e3181d87a12.
Ear Replantation
14
Pedro C. Cavadas
Contents
Preoperative Problem List-Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Abstract The case of a complete ear amputation in

Ear amputations are infrequent but extremely an adult patient treated with microvascular
challenging injuries. Ear replantation is the replantation is described. Identification of
only technique that may result in a near-normal suitable vessels in the stump and especially in
result, although it is technically difficult. the part requires high-power magnification
loupes or microscope. Veins can be difficult to
find in the amputated part. Temporary clamp
release after arterial repair greatly facilitates
P. C. Cavadas (*) vein identification. The skin edges are carefully
Reconstructive Microsurgery, Clínica Cavadas,
Valencia, Spain trimmed to healthy tissue to allow early
e-mail: pcavadas@telefonica.net; spontaneous cross-circulation should venous
pcavadas@clinicacavadas.es

https://doi.org/10.1007/978-3-030-23706-6_17
130 P. C. Cavadas
congestion develop. The conchal cartilage is diaphyseal femoral fracture (initially treated with
trimmed to allow anterior approach to posterior skeletal traction and definitively nailed 5 days
vessel anastomoses. Vessel size is in the 0.5 mm later), no tobacco smoking habits, and no signifi-
range and requires supermicrosurgical skills. cant medical comorbidities. The ear had not been
Vein grafts are taken from the foot and used cooled, and the warm ischemia time at presenta-
liberally. After stabilization with skin sutures, tion was 3 h.
the artery is repaired first, the clamp is tempo-
rarily released for 5 min and reapplied, and all
other microvascular anastomoses are performed Preoperative Problem List-
before definitive arterial clamp release. Reconstructive Requirements
Venous congestion is frequently cited in the
literature, and plans for leeching or mechanical 1. The loss of an ear is not a life-threatening
drainage should be made, although in the injury, but its importance for body image is
author’s series of four cases it has not been great. Replantation of the amputated ear is the
necessary. best treatment possible.
Ears are very important bodily parts, and 2. The avulsive mechanism of amputation pre-
every attempt should be made (by senior and dicts the need for vascular debridement and
fully trained microsurgeons) to replant an vein graft use. Small-caliber veins should be
amputated ear. located in the dorsum of the foot or the volar
wrist.
Keywords 3. The need for medicinal leeches or mechanical
venous drainage should be planned in case
Ear amputation · Ear replantation ·
there is postoperative congestion.
Supermicrosurgical anastomoses · Venous
congestion
Treatment Plan
Straightforward in this case and very similar to a
distal fingertip replantation, although the dramatic
A 56-year-old male patient presented with a
benefit to the patient is worth the complexity and
complete left ear amputation due to an avulsive
technical difficulty.
mechanism (Fig. 1). The patient also had a left
Thorough debridement of the skin edges to
facilitate spontaneous cross-circulation through
the scar should venous congestion develop.
Reciprocal vessel identification in the ampu-
tated part and the stump. As many vessels as
possible should be identified and repaired.
Nerves do not need repair as some sensation
returns spontaneously over time. Anticipate the
need for vein grafts.
Non-microvascular attachment techniques of

amputated ear segments have been described as
Fig. 1 The left ear completely amputated prior to vascular a composite graft, with several modifications to
identification and tagging. Avulsive mechanism enhance graft take (Baudet 1973; Pribaz et al.
14 Ear Replantation 131
1997). The results are unreliable and clearly infe- operating room, and one dose of prophylactic
rior to a successful microvascular replantation. antibiotic (first-generation cephalosporin).
These techniques should only be considered for Small-caliber subcutaneous veins are marked
small partial segments or if the patient cannot be in the dorsum of the foot or the volar wrist, and
referred to an experienced microvascular surgeon the course of the superficial temporal vessels is
with supermicrosurgical skills. palpated and marked.
The use of the cartilage after skin removal,
with coverage with a temporoparietal fascia
(TPF) flap, has been described with modest results Surgical Technique
(Cavadas 1997), not better than formal secondary
reconstruction. 1. The replantation is performed by a single
The artery-only ear replant has been described surgeon without simultaneous surgical fields.
due to the difficulty in repairing veins in ear The amputated ear is prepared in the side table,
replantation (Jung et al. 2013; Momeni et al. while the patient is transferred to the OR and
2016). The need for prolonged forced venous given general anesthesia. Once vessels are
drainage either using medicinal leeches or by tagged in the amputated part, it is easier for
mechanical means results in substantial blood the same surgeon to look for the corresponding
loss and the need for transfusion. Although it has vessels in the stump.
been suggested in a systematic review that results 2. The ear is cleaned, and all visible foreign bod-
are similar with or without venous repair ies are removed. The skin edges are trimmed to
(Momeni et al. 2016), the likely publication bias healthy tissue, and the conchal cartilage is
of the cases puts this statement in quarantine. removed liberally.
Not replanting the amputated ear and 3. Under high-power magnification loupes (4.5
proceeding with secondary formal ear reconstruc- or higher), or the operating microscope, the
tion has the disadvantages of additional donor vessels are identified and tagged with 7/0
sites, especially rib cartilages, and the need for black silk (black silk will be easily seen in the
an intact TPF. presence of blood). Enough length is dissected
out if possible. As many arteries and veins are
tagged as possible. Arteries tend to be at the
Preoperative Evaluation and Imaging root of the helix and the antitragus. Veins are
ubiquitous but harder to see. Manually squeez-
Straightforward. No specific imaging or evaluation ing the amputated ear will drive the remnants
is needed, apart from the obvious confirmation that of blood to the vessels on the cut surface and
the amputated ear has not been frozen. If freezing aids in identification. If no veins are found at
occurred at any point of the transport, replantation this stage, they can be identified later.
of the ear is still indicated, but blistering and pos- 4. Prepare the lateral face and scalp and the
sible partial skin necrosis will result. potential donor for vein grafts. Debride, clean,
Given the low incidence of hypercoagulability and identify vessels in the stump. Knowing
disorders, routine-specific tests are not performed. where the vessels were found in the amputated
part makes easier to find the corresponding ves-
sels. Tag them with black 7/0 silk. The superfi-
Preoperative Care and Patient cial temporal artery and vein are dissected.
Drawing 5. The ear is stabilized with carefully placed 5/0
nylon stitches. The need for vein grafts is
The usual care for any microsurgical replantation. evaluated. Vein grafts are harvested marking a
Supine position, adequate padding of the heels dot at the proximal end with the skin marker
and the occiput should the procedure get pro- (“purple proximal”) and kept in heparinized
longed unexpectedly, warm environment in the saline.
132 P. C. Cavadas
6. The skin is closed as much as possible while still part search in the posterior skin and in the
allowing access to the vessels. The posterior earlobe. Arterial clamp release helps if needed.
vessels can be approached from anterior if the In the stump rub gently with a gauze to identify
conchal cartilage is removed. The anastomoses corresponding veins. Pressure and irrigation
are usually difficult because of the small caliber allow for dissection and tagging of these veins.
and the deep and awkward positioning. An assis- 3. Close the skin as much as possible while still
tant separating the skin edges with strategically allowing access to the vessels. Close the skin
placed hooks can keep the vessels exposed, and progressively as vessels are repaired. It relieves
with some pressure, it also prevents bleeding tension and stabilizes the ear.
from veins. The artery is repaired first. In this 4. Because of the narrow spaces, back wall-first,
case direct end-to-end repair of 0.5 mm artery interrupted-stitches technique is preferred.
with interrupted 11/0 nylon was performed from Slight invagination of the proximal end into
anterior at the root of the helix. The clamp is the distal end of the vessels increases the
released for 3–5 min allowing reperfusion of the patency rate of anastomoses.
ear and facilitating vein identification 5. Working with the arterial clamp on allows for a
and tagging. The clamp was reapplied to the relatively bloodless field. Active bleeding
artery, and the rest of the vessels are repaired increases the difficulty and can turn a difficult
without active bleeding. As many vessels are anastomosis into an impossible one. Work
repaired as possible. In this case a second artery under ischemia.
was repaired using a vein graft, two vein anasto- 6. End-to-side vein grafts to the superficial tem-
moses were performed, and an arteriovenous poral vessels are sometimes useful.
draining anastomosis was also done. 7. In contrast to other replants, the skin sutures
7. The anastomoses of the veins are difficult and have to be placed precisely as in a normal facial
very similar to a subdermal vein repair in wound. Partial closure is not acceptable.
fingertip replants. There is not enough length
for clamp positioning, and the skin has to be
approximated with stitches to relieve tension. Intraoperative Images
The anastomosis has to be done under contin-
uous irrigation in a narrow space and requires See Fig. 2.
true supermicrosurgical skills.
8. If the posterior vessels are not accessible
from anterior, turn over the ear, and work from
posterior using vein grafts. Artery-to-vein
draining anastomoses are useful. After all ves-
sels have been repaired, the arterial clamp can be
removed and the skin closure finished.
9. No drains are needed, and a bulky dressing
with strict lateralization of the head is placed.
Technical Pearls
1. Expect a difficult replantation. This is not a 2-h

fingertip replant, but in sharp contrast to fin-
gertip replants, the benefit to the patient is
Fig. 2 The replanted ear after completion of two arteries,
worth the effort. two veins, and a draining arteriovenous anastomosis.
2. Veins are always present. It is a matter of Well-balanced circulation. Skin closed with cosmetic
persistence to find them. In the amputated suture technique
14 Ear Replantation 133
Postoperative Management dedicated to finding veins and achieving convinc-

ing venous repairs. Extensive experience in fin-
The usual postoperative management of a gertip replantation is a convenient background.
replantation. The patient is not allowed any intake If venous congestion develops during the first
per mouth for 24 h should surgical revision be 3 days, aggressive take back policy and revision
necessary. The head is turned and elevated 30 . of venous anastomoses or repair of an additional
The room is kept warm with an infrared lamp, and vein can save the replant. Expect a difficult revi-
the ear is exposed for continuous monitoring. sion because of the swelling, bleeding, and narrow
Avoid thermal burn of the replanted ear by placing exposure provided by limited suture removal.
the infrared lamp at a distance. Leeching if available or mechanical bleeding
Enough analgesia is administered. Antibiotics (frequent pinprick with 0.25 mm needle) can
are given prophylactically. Aspirin 100 mg/24 h save the congested replant if the skin edges were
and venous thromboembolism prophylaxis are properly debrided. Otherwise cross-circulation
given (low molecular weight heparin). will not develop, and the replant will eventually
Monitoring is clinical (color and capillary fail (Akyurek et al. 2001). Significant bleeding
refill) and performed by nurses and staff every can occur if congestion develops, requiring mul-
2 h for the first 4 days. No venous congestion tiple transfusion (de Chalain and Jones 1995).
developed.
Learning Points
1. Ear amputation is a strong indication for
The result was a near-normal ear with minimal replantation because the results are much better
scarring and good symmetry (Figs. 3 and 4). than any other reconstructive option.
2. Ear replantation is within the most
technically difficult microsurgical procedures
Avoiding and Managing Problems because of the small size of the vessels,
difficulty in finding adequate vessels, and the
The most frequent complication cited in the usually avulsive mechanism. Sound super-
literature is venous congestion either after microvascular skills are needed.
attempted venous repair or in artery-only replants. 3. Veins are by definition always present.
Avoidable if enough time and persistence are Identification and repair takes time and experi-
ence but is possible in most cases. Do not think
Fig. 3 Postoperative result at 1 year. Near-normal result Fig. 4 Good symmetry in the frontal view
134 P. C. Cavadas
of the questionable benefit of a fingertip Baudet J. Successful replantation of a large severed ear
replant. Think of the great benefit for the fragment. Plast Reconstr Surg. 1973;51:82.
Cavadas PC. Salvage of a failed auricle replant with
patient your effort will provide. a temporoparietal fascia and subgaleal fascia flaps.
4. Venous congestion is so frequent in the Eur J Plast Surg. 1997;20:92–4.
reported cases that plans to manage it should de Chalain T, Jones G. Replantation of the avulsed pinna:
be made from the beginning. 100 percent survival with a single arterial anastomosis
and substitution of leeches for a venous anastomosis.
Plast Reconstr Surg. 1995;95:1275.
Jung SW, Lee J, Oh SJ, et al. A review of microvascular ear
References replantation. J Reconstr Microsurg. 2013;29:181–8.
Momeni A, Liu X, Januszyk M, et al. Microsurgical
Akyurek M, Safak T, Kecik A. Microsurgical ear replanta- ear replantation-is venous repair necessary? A system-
tion without venous repair: failure of development of atic review. Microsurgery. 2016;36(4):345–50.
venous channels despite patency of the arterial anasto- Pribaz JJ, Crespo LD, Orgill DP, et al. Ear replantation with-
mosis for 14 days. Ann Plast Surg. 2001;46:439. out microsurgery. Plast Reconstr Surg. 1997;99:1868.
Ear Reconstruction Using
Microvascular Techniques 15
Pedro C. Cavadas
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Abstract A 49-year-old patient’s missing left ear and

Reconstruction of the ear in the absence of scarring on both sides of the scalp were
available retroauricular skin or ipsilateral reconstructed with a prefabricated free flap.
temporoparietal fascia (TPF) flap integrity The patient used an osseointegrated ear pros-
requires microvascular ear reconstruction. thesis and requested an autologous reconstruc-
tion. The cartilage framework was constructed
from rib cartilages and placed subcutaneously
in the left distal forearm. Eight weeks later the
P. C. Cavadas (*) prefabricated radial forearm flap with the ear
Reconstructive Microsurgery, Clínica Cavadas,
Valencia, Spain framework (flap prelamination) was micro-
e-mail: pcavadas@telefonica.net; vascularly transferred to the ear region. Two
pcavadas@clinicacavadas.es

https://doi.org/10.1007/978-3-030-23706-6_18
136 P. C. Cavadas
months later a revision surgery consisting of Preoperative Problem List/

skin removal with soft-tissue sculpturing and Reconstructive Requirements
grafting with split-thickness skin graft from the
scalp was performed to improve shape, contour, 1. The infected osseointegrated frame required
and color match. The end result was an autolo- removal before reconstruction.
gous structure with less-than-optimal definition 2. The autologous reconstruction needed a costal
and good color match. The overall results of cartilage framework. The costal cartilages in
microvascular ear reconstruction are inferior to adults tend to be calcified and are more difficult
classic reconstructions and should only be used to carve than in young microtia patients. There
in unfavorable anatomic situations. is no alternative to costal cartilage for autolo-
gous ear reconstruction (Brent 2002).
Keywords 3. The cartilage frame has to be covered with a
thin layer of skin that conforms to the convo-
Microvascular ear reconstruction ·
lutions of the cartilage skeleton and whose
Prefabricated free flap · Radial forearm flap ·
color matches that of the rest of the face. The
Flap prelamination
scarring in the periauricular skin prevented the
use of this skin as in microtia reconstruction.
The temporoparietal scarring, with injury to
superficial temporal vessels, prevented local
tissues from being used for cartilage coverage
A 49-year-old male patient presented with missing
and dictated the use of a free flap.
left ear due to traffic accident years before. He was
4. The color of the skin coverage of the recon-
using osseointegrated prosthesis but requested an
struction should match the overall pink face.
autologous reconstruction. There was extensive
scarring in the left periauricular region, with a
metallic framework with peri-implant infection
(Fig. 1). The patient was not satisfied with the Treatment Plan
anaplastic solution, in spite of good cosmetic
appearance. There was extensive scarring in the The ear reconstruction was planned as a pre-
temporoparietal region on both sides, no associated fabricated, staged procedure, including pre-
comorbidities, and no smoking habit. grafting (prelamination) of the left radial forearm

of the patient. The
osseointegrated metal frame
had peri-implant infection.
There was extensive
scarring in this area and in
bilateral temporoparietal
regions precluding classic
reconstructive techniques
15 Ear Reconstruction Using Microvascular Techniques 137
flap with the constructed cartilage frame. The The use of synthetic alloplastic frameworks for
distant prefabrication of the reconstructing flap ear reconstruction has been described, especially
was decided to allow simultaneous removal of porous polyethylene, which avoids the need for
the osseointegrated metal frame and infection costal cartilage harvest and carving (Ali et al.
clearance. The radial forearm flap was chosen 2017). This technique is straightforward but at
because it is distant from the infected recipient the expense of increased incidence of infection
area, thin-skinned, long-pedicled, and straightfor- and extrusion and the inherent lack of healing
ward to execute. potential after late trauma.
After initial placement of the carved cartilage Prelamination of the skeletal framework using
framework in a subcutaneous pocket over the porous polyethylene has been described (Simsek
radial vessels, once healed, the prelaminated flap and Eroglu 2012), with the same drawbacks cited
were to be free transferred to the already infection- above.
free auricular region. The color match of non-facial free flaps with
Because of edema and the relative bulk of the the rest of the face is poor, so secondary over-
radial flap, a debulking procedure was planned grafting with scalp split-thickness skin grafts is
afterwards, leaving a thin layer of vascularized advisable to improve color (Walton et al. 2008).
tissue over the cartilage frame to further delineate
the details and convolutions of the ear, and a pink-
colored skin graft was planned to improve color Preoperative Evaluation and Imaging
match with the rest of the face.
No specific imaging is usually needed for plan-
ning free flaps to the head and neck, especially in
Alternative Reconstructive Options non-radiated necks. There are plenty of possible
recipient vessels, branches of the external carotid
Single-stage reconstruction of the ear with thin artery and local veins.
microvascular flaps is possible, using either the Radiographic preoperative evaluation of the
contralateral TPF (Park and Roh 2001) or the degree of calcification of the costal cartilages is
greater omentum (Park et al. 2003). Local infec- impractical. Some intraoperative flexibility is
tion precluded immediate reconstruction after needed in selecting the less calcified areas.
metal frame removal. Delayed single-stage recon- No vascular imaging is needed for planning
struction would be an alternative, with increased the subcutaneous pocket for cartilage insertion in
risk of infection. the forearm. Direct intraoperative inspection
The contralateral TPF was unavailable. The allows perforator preservation around the
segmental free greater omentum can yield good framework.
results but requires a laparotomy with inherent
risk of major complications, disproportionate in
ear reconstruction. Other thin fascial free flaps, as Preoperative Care and Patient
the fascial lateral arm, or fascial radial forearm Drawing
flap would also be useful. Fascial ALT including
the fascia lata is probably too stiff for this purpose. Standard preoperative preparation in every stage.
In the absence of infection, a single-stage recon- Supine positioning, left upper arm tourniquet,
struction with a carefully carved cartilage frame- and marking of the radial artery. Relatively
work covered with a thin fascial free flap would be straightforward.
appropriate. Initial coverage with a non-specific The second stage was a free flap, so standard
STSG followed by later (months) removal, soft- care for free flap, plus precise marking of the
tissue sculpturing and definitive placement of a position of the reconstructed ear symmetric with
scalp STSG would be correct. the contralateral one.
138 P. C. Cavadas
Surgical Technique 1.3. Closure of the antebraquial wound over

suction drain (Fig. 3).
1. Stage one. Skeletal frame construction and flap 1.4. Once the forearm and the chest are
prelamination. closed and dressed, the infected metal
1.1. Harvesting the left sixth and seventh car- frame was removed to avoid cross
tilage ribs subperichondrally and carving contamination.
of the skeletal framework according to 2. Stage two. Transfer of the prefabricated flap.
the technique described by Brent (2002). Eight weeks after stage 1.
In this case the patient’s prosthesis served 2.1. The scarred area of the left auricular
as a template (Fig. 2). region was removed, except for a dorsally
1.2. Dissection of the subdermal pocket over based flap to cover the medial side of the
the radial vessels in the left distal forearm reconstructed ear.
under tourniquet control, parallel to the 2.2. Dissection of the recipient left facial
long axis of the forearm. The frame is artery and vein through a submandibular
placed in between perforating vessels. short incision.
Fig. 2 The patient’s

silicone prosthesis was used
as a template to construct
the cartilage framework.
Calcification of the costal
cartilages in adult patients
requires flexibility in
choosing the softer parts of
the cartilage block
harvested
Fig. 3 The radial forearm

8 weeks after cartilage
prelamination. Note the
placement of the incision to
allow 1 cm of extra skin for
helical coverage
Fig. 4 The prelaminated

radial free flap. The
cephalic vein is not
included
3. Stage three. Flap debulking, sculpturing, and

overgrafting. Eight weeks after stage 2.
3.1. The bulky and yellowish coverage of
the reconstructed ear (Fig. 5) was
resected carefully preserving a thin
layer of vascularized tissue over the
cartilage framework. The resection
was performed under loupe magnifica-
tion taking care not to leave any
exposed cartilage and to mark the con-
tours of the reconstructed ear as much
as possible. The vascular pedicle is
under the skeletal frame and away
from the dissection.
3.2. A STSG was taken with electric derma-
tome from the occipital scalp region and
used to cover the raw surface of the
reconstruction.
3.3. A bulky tie-over dressing was used to
secure and immobilize the graft for
1 week.
Fig. 5 Intermediate result before stage 3. There is lack of

detail and a poor color match with the rest of the face
Technical Pearls
2.3. Elevation of the prelaminated radial fore-
arm flap including 1 cm of extra skin 1. A high-profile cartilage frame is constructed
around the helix to allow for complete with a deep concave scapha to compensate
cartilage coverage (Fig. 4). for scar formation and retraction.
2.4. Vascular anastomoses between the facial 2. The frame should be placed as superficial as
and the radial artery end to end and one possible in the forearm (subdermal) and
radial vena comitante to the facial vein. respecting as many septocutaneous radial per-
2.5. STSG to the donor forearm area. forating branches as possible.
140 P. C. Cavadas
3. Avoid the dissection of the radial vessels dur- molecular weight heparin and 100 mg of aspi-
ing the first stage since it will result in scar rin for 1 month. The patient is not allowed to
formation around the pedicle and will make intake per mouth for 24 h should surgical revi-
later dissection and elevation more difficult. sion be necessary. The flap is clinically moni-
4. Leave a cuff of soft tissue around the cartilage tored every 2 h for the first 3 days. Bulky
frame and 1 cm of extra skin to cover the helix. dressing and avoid inadvertent pressure on
5. The cephalic vein is not included in the flap. the free flap.
The radial venae comitantes are large enough 3. Stage 3. Careful tie-over dressing avoiding
for the facial vein. undue pressure over prominent parts of the
6. During stage three, meticulous technique is reconstructed ear. Complete take of the STSG
required to avoid leaving exposed cartilage is important for the overall result.
that will not accept skin grafting. Aggressive
removal of soft tissue in the concave areas
improves the overall profile of the reconstruc- Outcome, Clinical Photos, and Imaging
tion. Loupe magnification is advisable.
The intermediate result after stage 2 before
debulking and overgrafting was very poor as
Intraoperative Images expected, with lack of detail and a yellowish
color (Fig. 5). After stage 3 the result improved
See Figs. 2, 3, and 4. markedly, although the final result was not excel-
lent. The quality of the details of the reconstructed
ear was less than desired because of scar
Postoperative Management contraction, but the size, contour, and color
match were acceptable (Fig. 6).
1. Stage 1. Single dose of first-generation cepha-
losporin. Standard analgesia. The dressing
over the inserted cartilage in the forearm Avoiding and Managing Problems
should be well conformed to the convolutions
of the ear, avoiding excessive pressure over the Throughout the stages every effort should be
protruding parts that can cause pressure necro- made to avoid exposure of the cartilage frame-
sis and exposure of the cartilage. work. Should it happen after stage 1, a small
2. Stage 2. Standard care of free flaps. Prophy- random, Lindberg-type flap can fix the problem
laxis of deep venous thrombosis with low if performed before the exposed cartilage
Fig. 6 Final result at

1 year. The result is not
excellent in terms of detail
of the convolutions,
although the overall shape,
size, position, and color
match were acceptable
becomes dry and necrotic. Excessive thinning of tissue sculpturing and overgrafting with
the skin pocket should be avoided. scalp STSG.
Precise insetting of the free flap during stage 2 3. Prelamination of the free flap is a multistaged
is important for symmetry. The use of a posterior- procedure, useful in the presence of infected
based flap of scarred local skin allows for cover- recipient areas.
age of the posteromedial surface of the ear and 4. Secondary soft-tissue sculpturing is critical to
obviates the need for an additional surgery for ear improve the quality of the details of the
separation. reconstructed ear regardless of the procedure
Stage 3 is critical for the quality of the result. being uni- or multistaged.
Aggressive subcutaneous sculpturing can result in
exposed cartilage and skin graft loss. Local
wound care can be effective if a very small area References
is denuded, but larger areas would require an
Ali K, Trost JG, Truong TA, et al. Total ear reconstruction
additional small free flap which would escalate using porous polyethylene. Semin Plast Surg.
the complexity of the case and compromises the 2017;31(3):161–72.
final result. Brent B. Microtia repair with rib cartilage grafts: a review
of personal experience with 1000 cases. Clin Plast
Surg. 2002;29(2):257–71.
Park C, Roh TS. Total ear reconstruction in the
devascularized temporoparietal region: I. use of the
Learning Points contralateral temporoparietal fascial free flap. Plast
Reconstr Surg. 2001;108(5):1145–53.
1. Compared to classic techniques (retroauricular Park C, Roh TS, Chi HS. Total ear reconstruction in the
skin pocket or pedicled TFP flap), microvascu- devascularized temporoparietal region: II. Use of the
omental free flap. Plast Reconstr Surg. 2003;111(4):
lar ear reconstruction has inferior results and 1391–7.
should only be considered in unfavorable ana- Simsek T, Eroglu L. Auricle reconstruction with a radial
tomical situations in patients willing to accept a forearm flap prelaminated with porous polyethylene
multistage procedure. (Medpor®) implant. Microsurgery. 2012;32(8):627–30.
Walton RL, Cohn AB, Beahm EK. Epidermal overgrafting
2. Local single-stage reconstruction can be improves coloration in remote flaps and grafts applied
appropriate in the absence of infection, to the face for reconstruction. Plast Reconstr Surg.
using a thin fascial free flap with later soft- 2008;121(5):1606–13.
Periauricular Reconstruction After
Total Parotidectomy with Facial Nerve 16
Reconstruction and Free Flaps
Lara Cristóbal and Andres Rodriguez-Lorenzo
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Soft Tissue Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Facial Nerve Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Abstract
L. Cristóbal (*)
Department of Plastic and Reconstructive Surgery and Surgical resection of tumors in the periauricular
Burn Unit, Getafe University Hospital, Madrid, Spain area often results in extensive and composite soft
A. Rodriguez-Lorenzo tissue defects involving facial nerve sacrifice.
Department of Plastic and Maxillofacial Surgery, Uppsala These composite defects lead to facial contour
University Hospital, Uppsala, Sweden deformities due to lack of volume and functional
Department of Surgical Sciences, Uppsala University, deficits. We present a clinical scenario that
Uppsala, Sweden illustrates a single-stage reconstruction of a

https://doi.org/10.1007/978-3-030-23706-6_19
144 L. Cristóbal and A. Rodriguez-Lorenzo
composite defect in this area including facial Preoperative Problem List/

nerve reconstruction. The patient is a 37-year- Reconstructive Requirements
old male diagnosed with metastasis in the
parotid gland after a teratocarcinoma in the eth- Surgical resection of tumors in the periauricular area
moidal sinus. Surgical treatment was planned can result in extensive composite defects, involving
involving total parotidectomy, mastoidectomy, several and different structures such as the skin, ear,
facial nerve sacrifice, and neck dissection with parotid gland, neck structures (lymph nodes,
preservation of internal jugular vein and spinal sternocleidomastoid muscle, etc.), bone, skull
accessory nerve. base, and facial nerve sacrifice. These composite
In order to restore the composite defect, a defects lead to facial contour deformities due to
free fasciocutaneous ALT flap was decided to soft tissue resections, and functional deficits related
resurface the external defect and to provide to sacrifice of the facial nerve (Rosenthal et al. 2008;
volume into the neck. Facial nerve reconstruc- Hanasono et al. 2012). The specific reconstructive
tion was planned at the same time of oncolog- requirements to be addressed in this case would be:
ical resection, with masseter nerve transfer to
buccal branch, and separated eye closure with 1. Deficit of skin and soft tissues: composite soft
interposition of lateral femoral cutaneous nerve tissue defects require providing skin and soft
from the facial nerve stump to zygomatic and tissues to achieve a stable wound closure and
frontalis branches. resistance to radiation therapy.
Postoperative recovery was uneventful. 13 2. Facial contour deformity and lack of volume:
months after surgery, the cosmetic and func- restoring three-dimensional appearance.
tional results were excellent, with restoration 3. Cervical structures (major blood vessels,
of contour in the neck and periauricular area nerves): coverage of neurovascular structures
and recovery of facial symmetry, smile, and of the neck.
blink functions. 4. Lateral temporal bone resection/middle skull
base: obliteration of the bone defect after mas-
toidectomy. If dura mater is exposed, isolating
Keywords
and protecting the dura and brain and pre-
Periauricular defects · Masseter nerve transfer · venting cerebrospinal fluid leakage are neces-
Free antelorateral thigh flap · Facial sary (not in the case presented here, as the dura
reanimation is not exposed).
5. Loss of facial nerve: restoring facial nerve
function.
The Clinical Scenario 6. Defects of the auricular framework: recon-
struction of the auricle or supporting auricular
A 37-year-old man with background of a terato- prostheses and facilitating restoration of hear-
carcinoma in the anterior skull base, treated pre- ing (not in the case presented here, as the ear is
viously with intracranial surgery and radiation not resected).
therapy, presents 3 years after initial surgery
with facial paralysis and a 4 centimeters metasta-
sis in the left parotid gland. After discussion in the Treatment Plan
tumor board, the patient is planned for combina-
tion therapy with surgery and postoperative radio- Combination therapy with surgery and postoper-
therapy. The oncological resection includes ative radiotherapy was planned. Surgical treat-
parotidectomy with facial nerve resection, mas- ment plan involved excision and reconstruction
toidectomy, and radical neck dissection with pres- in a single-stage procedure. Surgical resection
ervation of internal jugular vein and spinal included total parotidectomy, mastoidectomy,
accessory nerve (Figs. 1 and 2). facial nerve sacrifice, and radical neck dissection.
16 Periauricular Reconstruction After Total Parotidectomy with Facial Nerve Reconstruction and. . . 145
Fig. 1 Intraoperative
image of the resected tissue
including the parotid gland,
facial nerve, skin and
subcutaneous tissue,
sternocleidomastoid muscle
(SCM), great auricular
nerve (GAN), and lymph
nodes
In order to restore the composite defect, a free

fasciocutaneous anterolateral thigh (ALT) flap
was decided to resurface the external defect and
to provide volume in the neck. Facial nerve recon-
struction was planned at the same time of onco-
logical resection by performing masseter nerve
transfer to buccal and zygomatic branches to
restore midface animation and orbicularis oris
function, while separated eye closure would be
restored with interposition of lateral femoral cuta-
neous nerve graft (using the same donor site as the
ALT flap) from the facial nerve stump to zygo-
matic and frontalis branches (see Fig. 3).
Soft Tissue Reconstruction
The oncological resection resulted in a large soft

tissue defect; therefore locoregional pedicled flaps
such as cervicofacial, supraclavicular, or delto-
Fig. 2 Intraoperative image of the resulting defect. Yellow
vessel loops mark the distal facial nerve branches and the pectoral flaps might not provide enough volume
masseter nerve to obliterate the dead space. A pectoralis major
Fig. 3 Drawing of the planned surgical defect (a) and nerve grafts. (Reused with permission from Cristóbal
reconstruction (b) of soft tissues with ALT flap and facial et al. 2017)
nerve reconstruction with masseter nerve transfer and
flap could be an alternative; however, its donor flaps, can be an option (Pusic et al. 2007). How-
site and the final aesthetic result are worse in ever, they usually require changing position from
comparison with a perforator flap. Nevertheless, lateral or prone position to supine.
they are considered in poor free flap candidates or
as a secondary option if a free flap failure occurs
(Hanasono et al. 2012, 2014). Facial Nerve Reconstruction
The ALT flap has several advantages (Ali et al.
2009). It is a reliable flap; versatile in design and Simultaneous facial nerve repair after paroti-
providing volume with low donor site morbidity; dectomy is associated with a more favorable out-
it allows to work simultaneously with the onco- come compared to secondary surgeries (static
logical team using a two-team approach, and it is a procedures or muscle transfers), even if postoper-
source of donor nerves such as the lateral femoral ative radiation therapy is planned (Bascom et al.
cutaneous nerve or the vastus lateralis motor 2000; Gidley et al. 2010).
nerve in case of reconstruction of the facial Autologous nerve grafts from the proximal
nerve. Therefore, it is considered the first choice facial nerve stump to the distal branches are the
in reconstruction of large soft tissue defects after traditional approach to facial nerve reconstruction
parotidectomy. after parotidectomy. However, when long nerve
Other free flaps from the subscapular system, gaps are present, there are not enough axons
such as latissimus dorsi, thoracodorsal artery per- reaching the mimetic muscles, and there is a risk
forator flap (TDAP), and scapular or parascapular for synkinesis. A combination of masseter nerve
transfer targeting midface reanimation and ipsilat- Preoperative Care and Patient
eral facial nerve reconstruction with a nerve graft Drawing
targeting orbicularis oculi was performed in the
presented patient, in order to maximize the num- Flap markings are performed with the patient in
ber of axons reaching each target and the speed of supine position. A line connecting the anterior
nerve regeneration. superior iliac spine (ASIS) and the superior lat-
Other donor nerves for nerve transfers are the eral border of the patella is marked. Perforators
hypoglossal nerve, spinal accessory nerve, and the are located using a handheld Doppler. The skin
contralateral facial nerve. The masseter nerve has paddle is outlined centered over the location of
more functional similarities with the facial nerve the perforators, keeping in mind that the final
in terms of muscle co-activation for smile skin island will be designed after tumor excision,
reanimation and less donor site morbidity than to customize the flap to the final defect. In order
the hypoglossal and spinal accessory nerves to perform a two-team approach surgery, the
(Jensson et al. 2018). whole leg and the head and neck region are
The most commonly used donor nerve for nerve draped. Preoperative antibiotic prophylaxis and
grafts is the sural nerve. Another option includes thromboprophylaxis are administered.
branches from the cervical plexus. However, the
ALT flap donor site allows for harvesting several
nerves, both nonvascularized and vascularized Surgical Technique
nerve grafts, such as the vastus lateralis motor
nerve (Agrogiannis et al. 2015). 1. The patient is positioned in the supine position
on the operating table. Surgery is performed by
a two-team approach to minimize total opera-
Preoperative Evaluation and Imaging tive time: the ALT flap harvesting and the
tumor resection are performed simultaneously.
Careful general medical history and physical 2. The flap is raised starting with the medial inci-
examination should be performed. Related to the sion. Subfascial dissection proceeds to identify
donor site, both lower extremities should be eval- the perforator and the septum between rectus
uated. Thickness of the thigh, presence of previ- femoris and vastus lateralis. The lateral circum-
ous scars or injuries, and functional evaluation of flex femoral artery tree (LCFA) is explored, and
knee extension are assessed. Previous surgeries or a musculocutaneous perforator is dissected
vascular disease may require preoperative angiog- from distal to proximal until a convenient length
raphy (Mardini et al. 2017). Doppler examination of pedicle and vessel diameter is achieved.
of the thigh is routinely performed to look for the 3. Simultaneously, the oncological resection is
main perforator of the ALT flap. performed by the head and neck surgeon, includ-
Definition of the tumor location and extension ing total parotidectomy, facial nerve sacrifice,
and evaluation of the neck for previous surgeries mastoidectomy, and radical neck dissection.
or radiotherapy are fundamental. Imaging studies 4. Once the tumor is excised, a handmade tem-
such as PET–CT (positron-emission tomogra- plate (sterile foam) is shaped to match the
phy–computed tomography) and MRI (magnetic defect, and the superior thyroid vessels are
resonance imaging) play an important role in the prepared as recipient vessels.
evaluation of tumor extension. Another critical 5. The template is transferred to the thigh, and the
issue is the planification of the recipient vessels: skin paddle is redesigned and trimmed
in this case, without previous radiotherapy and according to it. The flap is completely raised.
considering the planned neck dissection, the 6. A nerve stimulator is used to identify the distal
superior thyroid, facial, or transverse cervical facial nerve branch of the zygomaticus major
vessels are the most commonly used recipient muscle and zygomatic and frontal branches.
vessels. Masseter nerve is located at the mandible
notch as previously described (Cheng et al. 4. Employ intraoperative handmade templates to

2013), transected distally, and transposed to design the flap properly. It allows to custom-
the surface of the muscle for neurorrhaphy to ize size, shape, tissue components, and pedi-
the facial nerve branch of the zygomaticus cle length of the flap. It should be done after
major muscle. Interposition of a nerve graft complete tumor excision. A foam dressing
(obtaining the lateral femoral cutaneous nerve can be used to make the template, since it is
from the same thigh as the ALT flap) from the pliable, and it can simulate the defect three
proximal facial nerve stump to the zygomatic dimensionally.
and frontalis branches is performed in order to 5. In order to reduce donor site morbidity by
isolate the action of blinking from smiling. avoiding excessive tissue resection, complete
7. Vascular anastomoses are performed after par- the lateral incision of the ALT flap only when
tial insetting of the flap. Implantable Doppler is the template is transferred to the leg, and it
placed on the vein for flap monitoring. matches the exact defect.
8. Finally, the distal part of the skin island is par- 6. Perform partial insetting of the flap previous to
tially de-epithelialized and buried into the neck vascular anastomosis.
to provide volume, while the skin paddle is used 7. Try to perform two vein anastomoses if possi-
to resurface the external periauricular defect. ble, preferably at least one of them to the inter-
9. The thigh donor site is closed primarily and a nal jugular system.
suction drain is placed. 8. Use a nerve stimulator to confirm the location
of the masseter nerve and to identify the func-
tion of the distal facial nerve branches to be
Technical Pearls reconstructed.
1. For ALT flap harvest, start with the medial

incision, and visualize the septum between Intraoperative Images
rectus femoris and vastus lateralis muscles.
2. Look for the descending branch of LCFA by The steps of ALT flap harvesting (including the
retracting the rectus muscle. lateral femoral cutaneous nerve), the facial
3. Visualize the selected perforator and the main nerve reconstruction, and the final outcome at
pedicle (LCFA) before proceeding with dissec- the end of the surgery are shown in Figs. 4, 5,
tion of the perforator. and 6.
image showing harvest of
the ALT flap with the
perforator running in the
septum between rectus
femoris (RF) and vastus
lateralis (VL) muscles. The
lateral femoral cutaneous
nerve (LFCN) is marked
with a yellow vessel loop
Fig. 5 Intraoperative image after nerve reconstruction Fig. 6 Final insetting of the ALT flap after partial
with the masseter nerve transfer to the buccal and zygo- desepidermization for wound closure and restoration of
matic branches and the facial nerve stump with a nerve volume in the neck. (Reused with permission from Cristó-
graft to the frontal and temporal branches. (Reused with bal et al. 2017)
permission from Cristóbal et al. 2017)
Postoperative Management Postoperative recovery was uneventful and both

the flap and the donor site healed well. The patient
Flap monitoring was performed clinically, with received postoperative radiotherapy 60 Gy, and
a handheld Doppler and an implantable Doppler no wound dehiscence or wound related problems
for 7 postoperative days. The head of the bed were observed posterior to radiation.
was elevated 30 during the first 72 h, and the At the final follow-up visit at 13 months after
patient was allowed for mobilization from day surgery, the patient had an excellent aesthetic
3. Care was taken to avoid compression of the result with restoration of the neck contour that
flap or pedicle. Regarding the donor site, drain remained stable after radiotherapy (Fig. 7). The
was removed when output was less than 30 ml/ functional result was graded as excellent
day. Deep venous thrombosis prophylaxis was according to Terzis’ Grading Scale and was eval-
administered with low-dose heparin for 10 days uated with photography and video recording.
and low-dose aspirin (75 mg) was administered Thirteen months postoperatively the patient
for 30 days after surgery according to the insti- showed good symmetry at rest as well as during
tutional protocol of free tissue transfer. Patient dynamic movements. The smile was comparable
was discharged from the hospital at 8 postoper- in both sides of the face and became effortless
ative day. without the need of biting (Fig. 8). Regarding
eye closure, satisfactory result with complete eye be tailored to the needs of the defect designed as
closure was obtained (Fig. 9). No secondary pro- fasciocutaneous, adipofascial, or chimeric flap
cedures were required. Unfortunately, the patient (Elliott et al. 2011; Cristóbal et al. 2017;
died of distant metastasis 27 months after surgery. Maldonado et al. 2017).
– Flap Design: To avoid poor flap designs, use
templates. Start with the medial incision during
Avoiding and Managing Problems the ALT harvest. Do not complete lateral inci-
sion of the skin paddle until the oncological
– Flap Selection: Composite defects in the peri- resection has finished and the template has
auricular area can be successfully reconstructed been designed. This allows to match the exact
with the ALT flap. It is a versatile flap that can defect and reduces donor site morbidity by
avoiding excessive tissue resection.
– Location of Masseter Nerve: Location of the
masseteric nerve could be difficult if not done
in a systematic way. Identify a triangular zone
delimited by zygomatic arch, condyle, and
coronoid process of the mandible, and start a
bloodless dissection in this triangle (Cheng et
al. 2013). Use always a nerve stimulator to
confirm the location of the nerve.
– Maximization of Nerve Regeneration: To
increase the number of axons in the distal
branches of the facial nerve, two donor
nerves are used, the masseter nerve and the
ipsilateral proximal facial nerve stump. For
facial nerve reconstruction, the buccal branch
Fig. 7 Postoperative image of the patient at 13 months and the zygomatic and frontal branches are
after surgery showing the restoration of the volume in the
neck by the ALT flap. (Reused with permission from Cris- reconstructed separately, in order to prevent
tóbal et al. 2017) synkinesis.
Fig. 8 Functional outcome 13 months after surgery. excursion with open bite (independence from masseter
Facial symmetry at rest (left image) and excellent smile nerve activation, right image)
Cross-References
▶ Adult Facial Nerve Palsy Reconstruction Using

Gracilis Functional Muscle Innervated with
Cross-Face Nerve Graft
▶ Ear Reconstruction Using Microvascular
Techniques
▶ Ear Replantation
▶ One-Stage Reconstruction of Facial Paralysis
Using Masseter Nerve-Innervated Gracilis
References
Agrogiannis N, Rozen S, Reddy G, Audolfsson T,
Rodriguez-Lorenzo A. Vastus lateralis vascularized
nerve graft in facial nerve reconstruction: an anatomical
cadaveric study and clinical implications. Microsur-
gery. 2015;35:135–9.
Ali RS, Bluebond-Langner R, Rodriguez ED, Cheng M-H.
The versatility of the anterolateral thigh flap. Plast
Reconstr Surg. 2009;124(6 Suppl):e395–407.
Fig. 9 Postoperative photograph at 13 months after sur- Bascom DA, Schaitkin BM, May M, Klein S. Facial nerve
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2000;16:309–13.
Cheng A, Audolfsson T, Rodriguez-Lorenzo A, Wong C,
– If eye closure is not successfully achieved, Rozen S. A reliable anatomic approach for identifica-
tion of the masseteric nerve. J Plast Reconstr Aesthet
placing a gold weight implant in a secondary Surg. 2013;66:1438–40.
procedure should be considered. Cristóbal L, Linder S, Lopez B, Mani M, Rodríguez-
Lorenzo A. Free anterolateral thigh flap and masseter
nerve transfer for reconstruction of extensive peri-
auricular defects: surgical technique and clinical out-
Learning Points comes. Microsurgery. 2017;37(6):479–86.
Elliott RM, Weinstein GS, Low DW, Wu LC. Reconstruc-
1. Composite defects in the periauricular area tion of complex total parotidectomy defects using the
following oncological resection can be suc- free anterolateral thigh flap. Ann Plast Surg.
2011;66:429–37.
cessfully reconstructed in a combined proce-
Gidley PW, Herrera SJ, Hanasono MM, Yu P, Skoracki R,
dure with an ALT flap and masseter nerve Roberts DB, Weber RS. The impact of radiotherapy on
transfer for smile restoration. facial nerve repair. Laryngoscope. 2010;120:1985–9.
2. Intraoperative handmade templates allow cus- Hanasono MM, Silva AK, Yu P, Skoracki RJ, Sturgis EM,
Gidley PW. Comprehensive management of temporal
tomize the flap and reconstruct the three-
bone defects after oncological resection. Laryngo-
dimensional components. scope. 2012;212:2663–9.
3. Reconstruction of the buccal branch and the Hanasono MM, Matros E, Disa JJ. Important Aspects of
zygomatic and frontal branches are performed Head and Neck Reconstruction. Plast Reconstr Surg.
2014;134(6):968e–980e.
separately, in order to prevent synkinesis.
Jensson D, Enghag S, Bylund N, Jonsson L, Grindlund
4. Simultaneous soft tissue and facial nerve repair M, Flink R, Rodríguez-Lorenzo A. Cranial nerve
are associated with a more favorable outcome. Coactivation and implication for nerve transfers to
Using nerve transfers maximize the speed of the facial nerve. Plast Reconstr Surg. 2018;141
(4):582e–5e.
nerve regeneration and therefore improve the
Maldonado A, Silva A, Humphries L, Gottlieb L. Complex
quality of life in the setting of advanced orofacial reconstruction with the intrinsic chimeric flap.
cancers. J Reconstr Microsurg. 2017;33(4):233–43.
Mardini S, Chim H, Wei FC. Anterolateral and ante- Pusic AL, Chen CM, Patel S, Cordeiro PG, Shah JP.
romedial thigh flaps. In: Wei FC, Mardini S, editors. Microvascular reconstruction of the skull base: a clin-
Flaps and reconstructive surgery. 2nd ed. Edinburgh: ical approach to surgical defect classification and flap
Elsevier; 2017. p. 700–16. selection. Skull Base. 2007;17:5–15.
Matthew M. Hanasono, Evan Matros, Joseph J. Disa, Rosenthal EL, King T, McGrew BM, Carroll W, Magnuson
Important Aspects of Head and Neck Reconstruc- JS, Wax MK. Evolution of a paradigm for free tissue
tion. Plastic and Reconstructive Surgery 134 transfer reconstruction of lateral temporal bone defects.
(6):968e-980e Head Neck. 2008;30:589–94.
Reconstruction of a Massive Facial
Defect Following Trauma 17
Andreas Gravvanis, Thomais Oikonomou, and
Despoina D. Kakagia
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Outcome: Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Abstract
Composite mandibular gunshot defects require

A. Gravvanis (*) double or chimeric flaps to reconstruct all ana-
Plastic, Reconstructive and Aesthetic Surgery, tomic subunits involved. This case illustrates a
Metropolitan Hospital of Athens, Athens, Greece three-stage reconstruction of a gunshot compos-
T. Oikonomou ite mandibular defect previously reconstructed
Eugenideion Hospital, Athens, Greece with plate and direct closure of soft tissues. The
e-mail: contact@thomaisoikonomou.gr
first stage involved the placement of a crescent-
D. D. Kakagia shaped tissue expander under the galea, and the

https://doi.org/10.1007/978-3-030-23706-6_20
154 A. Gravvanis et al.
skin at the left temporoparietal area that was

gradually expanded.
After 2 months of expansion the second
stage involved removal of the tissue expander,
reconstruction of the missing segment of the
mandible and the mucosa of the floor of the
mouth with a free osseocutaneous fibula
flap, and the use of pre-expanded temporal
artery–based scalp flap to reconstruct the
cheek in order to provide the defect area with
hair-bearing skin. Both flaps are associated with
minimal donor site morbidity. Three weeks later
the temporal artery skin pedicle was divided and
re-transposed to the temporal donor site area to
completely replace the donor site defect. Recov- Fig. 1 Patient’s appearance 2 months following the gun-
shot injury. Close-up view of left cheek: There is exposure
ery was uneventful at all three stages of recon- of the mandibular plate through the cheek skin that is
struction and the functional and aesthetic results heavily scarred and lacking of hair
were satisfactory.
area where significant tissue loss had taken place
Keywords (Williams et al. 1988; Vasconez et al. 1996).
Free fibula flap · Osseocutaneous free flap ·

Mandibular reconstruction, shotgun injuries Preoperative Problem List:
face · Cheek reconstruction Reconstructive Requirements
1. Exposure of previously inserted mandibular

The Clinical Scenario plate through the cheek skin (Wei et al. 1994;
Boyd et al. 1993; Williams et al. 1988)
A 35-year-old male sustained a close-range gun- 2. Cheek skin defect due to heavy scarring
shot injury to his face following a suicide (Menick 1987; Vasconez et al. 1996; Zide and
attempt. After thorough debridement of the Longaker 1998; Neligan et al. 2003)
wound, a defect of the left mandible 7 cm in 3. Lack of hair at the scarred area (Ozdemir et al.
length, as well as significant soft tissue loss 2002; Tsoutsos et al. 2005; Vitkus and Vitkus
both at the floor of the mouth and on the left 1990; Zide and Longaker 1998)
cheek had been evident. A reconstruction plate 4. Requirement to reconstruct three entire sub-
had been used to bridge the mandibular defect, units: the left hair-bearing buccomandibular
while the soft tissues had been primarily closed. facial subunit, the left lateral mandibular seg-
There were also comminuted fractures of his left ment, and the floor of the mouth (Menick 1987;
maxilla that had been reduced and fixated with Vasconez et al. 1996; Zide and Longaker.
mini plates. 1998; Neligan et al. 2003; Daya 2008)
Two months following his injury, the patient
presented to our institution with exposure of the
plate through the cheek skin that was heavily Treatment Plan
scarred and lacking of hair (Fig. 1). He also pre-
sented oral and cheek fistulas. The tongue was A plan for individual unit lining, mandibular bone
significantly tethered affecting his speech, due to reconstruction, and skin coverage was developed
the fact that a primary closure was done in this and a three-stage procedure was set.
17 Reconstruction of a Massive Facial Defect Following Trauma 155
Free osseocutaneous fibula flap was planned Alternative Reconstructive Options

to reconstruct the missing segment of the man-
dible and the mucosa of the floor of the mouth 1. Single-stage operation: chimeric fibular flap
(Wei et al. 1994; Daya 2008; Wein and Lewis with one skin paddle for the oral lining and a
2008), while pre-expanded temporal artery– second skin paddle for the cheek defect (Wei
based scalp flap was decided for cheek recon- et al. 1994).
struction in order to provide the defect area with 2. Single-stage operation: osseocutaneous fibular
hair-bearing skin (Tsoutsos et al. 2005; Ozdemir flap for the oral lining and a second free flap
et al. 2002). (i.e., ALT, radial forearm flap) for the cheek
Thus, the first stage involved the placement of defect (Huang et al. 2002; Zide and Longaker
a crescent-shaped tissue expander under the galea, 1998).
and the skin at the left temporoparietal area that The main disadvantage of both the above
was gradually expanded (Fig. 2a). options is the hairless skin for cheek
After 2 months of expansion (Fig. 2b), we reconstruction.
proceeded to the second surgical stage. The left 3. Other options for the osseocutaneous flap are
fibula osseocutaneous flap was planned to recon- scapular flap or iliac crest flap with the disad-
struct the mandible and the floor of the mouth vantages of donor site morbidity, flap bulki-
mucosa, while the pedicled pre-expanded tempo- ness, and lack of periosteal blood supply in
ral artery flap would restore the left cheek skin case of need for multiple osteotomies (Wil-
defect. liams et al. 1988; Vitkus and Vitkus 1990).
Fig. 2 (a) Drawing of the temporal flap to be expanded. tissue expander was placed under the galea, ipsilateral to
(b) Fully expanded temporal scalp flap: A crescent-shaped the composite mandible defect
Both lower extremities were evaluated to deter-

mine the presence or extent of any disease and to
ascertain the pulse status of the patient. The feet
were examined for signs of peripheral vascular
disease and the anterior and posterior tibial pulses
are palpated.
Because an intact arch can supply retrograde
flow to the major vessels of the foot, it can be
helpful to put pressure on the anterior tibial artery
when detecting the presence of a posterior tibial
pulse and vice versa. This modified Allen’s test
may detect proximal vessel obstruction masked Fig. 3 Drawing of the fibular flap with the marked
perforators
by an intact foot arch.
Preoperative angiograms were obtained as a
guide. MRI or CT angiography can also be used 2. The anterior fibula osseocutaneous flap was
in many circumstances. elevated just above the muscle and deep to the
muscular fascia. The septum was approached
by elevating the fascia from anterior to poste-
Preoperative Care and Patient rior. A septal perforator was seen and the
Drawing fibula’s skin paddle, measuring 4 6 cm,
was based on this single septocutaneous
The patient was placed in the supine position with perforator.
a bump under the ipsilateral hip to lessen the need 3. The skin paddle was raised from the posterior.
for excessive internal rotation of the lower leg. A Attention was then turned to the fibula bone.
well-padded tourniquet was placed on the thigh. 4. A 1 mm cuff of muscle was left attached to the
The leg from the knee down was prepped and fibular bone as proceeding medially from the
draped. anterior approach. Army-Navy retractors
The proximal and distal fibula was marked and were used as the muscle was peeled away
the axis of the bone was drawn. The axis of the leaving behind a cuff of muscle overlying
skin paddle was drawn at the posterior border of periosteum on bone. When the superior and
the fibula. The paddle was outlined a few centi- inferior locations of the planned osteotomy
meters below the neck of the fibula and 6 cm were marked, leaving an 8 cm long
above the medial malleolus (Fig. 3). vascularized fibula bone to be harvested, a
right angle retractor was used to gently encir-
cle the bone. Care was taken to hug the bone
so that the vessels were not captured. The soft
Surgical Technique tissue was protected by retractors when the
osteotomy was made with an oscillating saw.
1. The whole left buccomandibular subunit Bone clamps were then placed at the superior
involving the unstable facial scars was and inferior ends of the flap providing ante-
resected and the tongue tethering involving rior and posterior traction on the interosseous
the scarred mucosa of the floor of the mouth membrane which was then divided, revealing
was released. The resulting left cheek skin the peroneal artery and the accompanying
defect was estimated to be 5 5 cm wide, venae.
and the mucosal defect at the floor of the 5. The distal aspect of the artery and veins were
mouth 4 6 cm. The mandibular bone defect ligated and divided, and the flap was raised
was 8 cm long. superiorly on the vascular pedicle (Fig. 4).
Fig. 4 A vascularized
fibular bone and a skin
paddle based on a single
septocutaneous perforator
were harvested
9. The scalp donor site was temporarily resurfaced

with split thickness skin graft, while the fibula’s
donor site was closed primarily.
10. The third surgical stage took place 3 weeks
later, and involved the division of the tempo-
ral artery skin pedicle that was re-transposed
to the temporal donor site area and
completely replaced the donor site defect.
Technical Pearls
1. The septum is approached by elevating the

Fig. 5 The free fibula flap fixated with mini plates. No fascia from anterior to posterior.
osteotomies were required
2. The skin paddle is elevated from posterior.
3. Respect and preserve muscular perforators
The tourniquet was deflated to obtain hemo- posteriorly near the septum and dissect to the
stasis and ensure good blood flow to the foot. posterior tibial vessels through the anterior
6. Satisfactory contour was achieved with no aspect of soleus muscle, if no septal perforators
need for osteotomies. Mini plates were used are visible.
for the fixation of the fibula in place (Fig. 5), 4. The distal 6–7 cm of fibula must be preserved
while the facial vessels were used as recipient to ensure ankle mortise.
vessels. 5. Mark the proximal course of the peroneal
7. After flap revascularization, the skin paddle nerve at the fibula neck to avoid injury.
was placed intraorally to reconstruct the floor 6. Leave a cuff of 1 mm of muscle on the fibula
of the mouth. The perforator was freed from while proceeding medially from the anterior
the septum and further dissected from the approach.
peroneal vessels in order to permit the medial 7. Protect the vessels embracing the bone sub-
rotation and proper inset of the skin island in periosteally with retractors during osteotomy.
the mouth floor.
8. After the bone and the mucosal lining recon-
struction was accomplished, the pre-expanded Intraoperative Images
temporal artery scalp flap, 5 cm in width, was
elevated based on the superficial temporal In Fig. 2b the fully expanded temporal scalp flap
artery and transposed to cover the left cheek over a crescent-shaped tissue expander is shown.
defect (Fig. 6). The pedicle was temporarily The harvested osseocutaneous free fibula flap
left above the facial skin in order to shorten the based on a single septocutaneous perforator is
operative time and avoid further facial scaring. shown in Fig. 4. The fibula flap was fixed in
Fig. 7 Patient’s appearance 1 year following the recon-

struction. Anteroposterior X-ray view, demonstrating com-
plete bone healing
Fig. 6 The temporal artery scalp flap was transposed to

cover the left buccomandibular subunit and the pedicle was
temporarily left above the facial skin
place with microplates as shown in Fig. 5. The

expanded temporal artery flap transposed to
reconstruct the cheek is shown in Fig. 6.
The patient was postoperatively closely moni-

tored by physical examination and Doppler for
the first 5 days. Anticoagulant regimen included
low molecular heparin and oral aspirin.
A nasogastric feeding tube was placed till the
patient’s discharge.
The ankle was splinted in neutral position and
the patient was allowed to ambulate in a cast shoe
at about a week after surgery. At all other times the Fig. 8 Patient’s appearance 1 year following the recon-
foot was kept elevated. struction. Anteroposterior view showing good density of
hair and almost normal hair growth direction of the
reconstructed buccomandibular subunit
the area, producing a smooth and symmetrical jaw
Our patient experienced uneventful and fast contour (Figs. 7 and 8).
recovery at all three stages of reconstruction. Reconstruction of the floor of the mouth with
One year postoperatively, the patient presented the free fibula flap skin paddle successfully
with a satisfactory functional and aesthetic result. released the tongue tethering and 1 year postop-
The fibular bone was completely incorporated in eratively the patient showed normal speech and
posteriorly must be preserved and harvested in

a perforator flap fashion to the posterior tibial
vessels to preserve skin paddle viability. This
requires dissection through the anterior aspect
of the soleus muscle. If septal perforators were
present, the muscular perforators are ligated
and the septal vessels are preserved (Wei
et al. 1986, 1994; Wein and Lewis 2008).
2. The distal 6–7 cm of bone is preserved to spare
the ankle mortise and the proximal course of
the peroneal nerve is marked at the neck of the
fibula to spare the nerve. This usually still
leaves behind a significant length of bone that
varies in size with the patient height and build
(Wei et al. 1994).
3. Proximal and distal osteotomies are performed,
hugging the fibula subperiosteally for protec-
tion against injuring the vascular pedicle (Wei
et al. 1994; Anthony et al. 1995).
4. The donor site can heal slowly if closed under
tension or in the elderly patient (Anthony et al.
1995).
Fig. 9 Patient’s appearance 18 months following recon-

struction. Note the contour of the reconstructed
buccomandibular subunit Learning Points
1. Composite mandible gunshot defects are rarely

had no problems with bolus preparation, manipu- amenable to reconstruction with a single flap
lation, and deglutition anymore. transfer. Double flaps and chimeric flaps are indi-
Reconstruction of the entire buccomandibular cated in reconstruction of each subunit involved.
subunit by the temporal artery flap resulted in sym- 2. Successful reconstruction of breakdown of the
metric hair growth between right and left face. The defect into the facial aesthetic subunits and
reconstructed hair-bearing area of the cheek was intraoral anatomic subunits involved restoration
nicely integrated with the rest of his face (Figs. 7 of each subunit with similar replacement tissues.
and 9). Normal hair growth direction was achieved 3. Free osseocutaneous fibula flap can be used to
and the scars were well concealed at the interface of successfully reconstruct mandibular bone and
hair-bearing and non-hair-bearing facial skin (Fig. 8). floor of the mouth defects and restore bone conti-
The satisfactory functional and cosmetic out- nuity, facial contour, mastication, and deglutition.
come contributed to the return of the patient back 4. The free fibula may be safely combined with
to his social life and work. temporal artery flap for cheek reconstruction in
composite mandibular gunshot injuries.

Cross-References
1. Septal perforators can usually be seen from
the anterior approach. If no perforators are ▶ Aesthetic Subunit Microvascular Reconstruc-
visible, muscular perforators near the septum tion of the Cheek
References alternatives. Plast Reconstr Surg. 2002;109(5):

1528–35.
Anthony JP, Rawnsley JD, Benhaim P, et al. Donor leg Tsoutsos D, Gravvanis A, Ioannovich J. Prefabricated hair-
morbidity and function after fibula free flap mandible bearing temporal island flap for two different facial
reconstruction. Plast Reconstr Surg. 1995;96:146–52. aesthetic subunit reconstructions. Εur J Plast Surg.
Boyd JB, Gullane PJ, Rotstein LE, et al. Classification of 2005;27(8):394–6.
mandibular defects. Plast Reconstr Surg. 1993;92: Vasconez HC, Shokley ME, Luce EA. High energy gunshot
1266–75. wounds to the face. Ann Plast Surg. 1996;36:18–25.
Daya M. Peroneal artery perforator chimeric flap: changing Vitkus K, Vitkus M. Microsurgical reconstruction of shot-
the perspective in free fibula flap use in complex gun blast wounds to the face. J Reconstr Microsurg.
oromandibular reconstruction. J Reconstr Microsurg. 1990;6:279–86.
2008;24(6):413–8. Wei FC, Chen HC, Chuang CC, et al. Fibular osteosepto-
Huang WC, Chen HC, Jain V, et al. Reconstruction of cutaneous flap: anatomic study and clinical application.
through-and-through cheek defects involving the oral Plast Reconstr Surg. 1986;78:191–200.
commisure using chimeric flaps from the thigh femoral Wei FC, Seath CS, Tsai YC, et al. Fibular osteosepto-
lateral circumflex system. Plast Reconstr Surg. cutaneous flap for reconstruction of composite mandib-
2002;109:433–41. ular defects. Plast Reconstr Surg. 1994;93:294–304.
Menick FJ. Artistry in aesthetic surgery. Aesthetic percep- Wein R, Lewis AF. Synchronous reconstruction of the floor
tion and the subunit principle. Clin Plast Surg. 1987;14: of mouth and chin with a single skin island fibular free
723–35. flap. Microsurgery. 2008;28(4):223–6.
Neligan PC, Gullane PJ, Gilbert RW. Functional recon- Williams CN, Cohen M, Schultz RC. Immediate and long
struction of the oral cavity. World J Surg. 2003;27(7): term management of gunshot wounds to the lower face.
856–62. Plast Reconstr Surg. 1988;82:433–9.
Ozdemir R, Sungur N, Sensoz O, et al. Reconstruc- Zide B, Longaker M. Cheek surface reconstruction: best
tion of facial defects with superficial temporal choices according to zones. Oper Tech Plast Reconstr
artery island flaps: a donor site with various Surg. 1998;5:26.
Mandible Reconstruction in
Osteoradionecrosis 18
Martin Halle and Daniel Danielsson
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
M. Halle (*)
Reconstructive Plastic Surgery, Karolinska University
Hospital, Stockholm, Sweden
Molecular Medicine and Surgery, Karolinska Institute,
Stockholm, Sweden
e-mail: martin.halle@sll.se
D. Danielsson
Craniomaxillofacial Surgery, Karolinska University
Department of Clinical Science, Intervention and
Technology, Division of Ear, Nose and Throat Diseases,
Karolinska Institute, Stockholm, Sweden
e-mail: Daniel@mandibeln.se

https://doi.org/10.1007/978-3-030-23706-6_21
162 M. Halle and D. Danielsson

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Abstract is therefore important to address both the soft- and

Grade II–III osteoradionecrosis of the mandible hard tissue situation, often requiring a complex
often requires advanced and carefully planned composite reconstructive planning and surgery.
reconstructive strategy. Since irradiation does A 74-year-old female was referred for treatment
not only have an adverse effect on bone but of advanced grade III osteoradionecrosis (Fig. 1).
also adjacent soft tissue components, a compos- She had received full dose radiotherapy treatment
ite reconstruction is often needed. The current 5 years previously due to tongue cancer. A CT-
case illustrates a through and through composite angiogram of the jaw/neck area together with both
mandibular defect, where several aspects need to lower legs was performed in order to determine
be taken into account. First, the resection mar- margins of necrotic bone and recipient vessels, as
gins of necrotic bone need to be decided, after well as donor site anatomy. Regarding lower leg
which the osteotomies of the fibula can be anatomy, it is important to ensure that all three main
planned. In this case a three-piece fibula recon- vessels are patent, and also to identify the best leg
struction was used to bridge the mandibular regarding peroneal vessel perforators to the skin.
defect from angle to angle. In order to adequately
reconstruct the soft tissue components, a
de-epithelialized skin island was designed to Preoperative Problem List:
offer a combined inner and outer lining. Recov- Reconstructive Requirements
ery was uneventful and the functional and aes-
thetic results satisfactory given the conditions 1. Necrotic bone needs to be carefully evaluated
with preoperative severely impaired tissue qual- preoperatively in order to determine and
ity. We highly recommend an outer lining to be achieve adequate surgical margins and avoid
considered even without a preoperative external
defect. The impaired elasticity of the irradiated
neck usually hampers tension free closure over
the vascular anastomosis.
Keywords

Mandibular reconstruction ·
Osteoradionecrosis · Virtual surgical planning
Osteoradionecrosis (ORN) of the mandible has

recently been reported as a more common indica-
tion for composite head and neck free flap recon-
struction in a growing population of cancer
survivors (Zaghi et al. 2014; Danielsson et al.
2019). Radiation-induced fibrosis often includes
impaired vascularity and elasticity of the soft tis- Fig. 1 Preoperative view showing and orocutaneous fis-
sues surrounding the necrotic mandibular bone. It tula in her mental region
18 Mandible Reconstruction in Osteoradionecrosis 163
local recurrent ORN (Qaisi and Montague this case a three-piece segmented fibula recon-
2017). struction was deemed necessary in order to
2. Donor site anatomy need to be carefully eval- bridge the bony defect reaching from mandibu-
uated in order to exclude peripheral arterial lar angle to angle. In osteoradionecrosis cases,
disease and anomalies such as peronea arteria additional soft tissue components are often
magna (Abou-Foul and Borumandi 2016). needed for wound closure. In the current case,
3. Reconstruction of continuity defects in the this was necessary in order to close the exterior
mandible requires a plan for both future dental defect as well as intraorally to enable tension
reconstruction and the patient’s aesthetic free closure of the anterior floor of the mouth.
appearance. Today virtual planning with Since only one reliable perforator to the skin was
guides and patient-specific implants (PSIs) identified, a de-epithelialized skin-island was
are preferred and regularly used (Metzler designed to offer a combined inner and outer
et al. 2014; Deek and Wei 2016). lining (Fig. 2).
4. In addition to the bony reconstruction, soft tissue
planning is equally important, where impaired
soft tissue quality need to be taken into account Alternative Reconstructive Options
(Deek and Wei 2016; Garvey et al. 2012).
1. In less severe cases where only smaller unilat-
eral parts of the posterior mandible are affected
Treatment Plan by ORN, the symphyseal area of the mandible
can be kept and a straight fibula may be an
Once adequate margins for bony resection were option.
decided and donor site anatomy evaluated, a 2. A deep circumflex iliac artery (DCIA) flap or a
virtual surgical planning session took place. In scapular flap may also be used for ORN
Fig. 2 Virtual surgical plan of three-piece fibula

reconstruction, but not as a single solution for Preoperative Evaluation and Imaging
the described composite defect, since adequate
bony length in combination with inner and A CT-scan was used to evaluate the extent of
outer soft tissue lining cannot be achieved necrotic bone in order to plan for adequate surgi-
(Blumberg et al. 2019; Paré et al. 2019; Zaghi cal margins for the bony resection. This is often
et al. 2014). challenging and we recommend that a liberal
3. Alternative soft tissue options could further approach with regards to resection margins is
be considered for the described three-piece used to make sure that the risk of recurrent ORN
fibula flap such as adjacent muscle for inner in the residual bone is minimized. In rare cases the
lining with either flexor hallucis longus or necrotic bone may extend beyond the planned
soleus muscle. For outer lining, a pectoralis margins. Then the virtual plan need to be modified
major or deltopectoral flap may be consid- and the guides and PSIs cannot be used.
ered. In selected cases, a double free-flap for Both lower extremities were evaluated with CT-
one-stage reconstruction of massive mandib- angiogram in order to determine the presence or
ular defects is a justified procedure (with for extent of any disease or anomaly, but also to eval-
instance fibula+ ALT) to achieve adequate uate peroneal perforators to the skin. Digital imag-
inner and outer soft tissue bulk in combina- ing from both the mandible and the chosen fibula
tion with a long bony defect (Wei et al. were imported into the software for virtual surgical
1999). planning (Materialise, Leuven, Belgium) as previ-
4. For the described case, a transverse (instead of ously described (Metzler et al. 2014). In surgical
longitudinal) de-epithelialized skin island planning it is of importance to address both the
could be another option as described below width of the symphyseal area as well as the angu-
(Fig. 3). lation of the construct in cranio-caudal direction.
Fig. 3 Optional plan for the described composite defect (other patient)
Preoperative Care and Patient muscular fascia. The septum was approached
Drawing by elevating the fascia from anterior to poste-
rior. Only one sizable septocutaneous perfo-
The Patient was placed in supine position with a rator was seen and the fibula’s skin paddle,
bump under the ipsilateral hip to lessen the need for measuring 4 20 cm, was based on this
excessive internal rotation of the lower leg. The foot single septocutaneous perforator.
was put in a stirrup in order to have the knee slightly 4. The skin paddle was de-epithelialized in order
flexed. A padded tourniquet was placed on the to separate the exterior skin from the intraoral
thigh. The leg from the knee down was prepared part.
and draped. The palpable parts of the fibula were 5. A 1 mm cuff of muscle was left attached to the
marked and a line was drawn alongside the posterior fibular bone as proceeding medially from the
edge of the fibula. Osteotomies were marked with anterior approach. Retractors were used as
the most distal placed 8 cm above the distal end of the muscle was peeled away leaving behind
the fibula. A skin paddle was then designed to meet a cuff of muscle overlying periosteum on
soft tissue requirements with the CT-angiogram ver- bone. Proximal and distal osteotomies were
ified perforator marked after ultrasound confirma- first executed. The distal aspect of the artery
tion (Fig. 4).
Surgical Technique
1. The neck was incised from angle to angle

including excision of an orocutaneous fistula
and its surrounding skin with impaired tissue
quality in the right submandibular region.
Also, the intraoral part of the fistula was
excised including scarred alveolar mucosa as
well as mucosa from the floor of the mouth.
The resulting right chin skin defect was esti-
mated to be 3 5 cm (Fig. 5), and the muco-
sal defect at the floor of the mouth 3 5 cm.
Fig. 5 Marking of neck incisions for bony resection and
2. The necrotic mandibular bone was resected recipient vessel exposure. The fistula and the surrounding
from angle to angle according to the virtual damaged soft tissue parts are radically excised
surgical plan (VSP) as previously described
(Fig. 6).
3. The fibula osteocutaneous flap was elevated
just above the muscle and deep to the
Fig. 4 Preoperative marking of fibular bone and skin Fig. 6 Specimen of resected osteoaradionecrotic
island mandible
and veins were ligated and divided, and the

flap was raised in a distal to proximal manner
and isolated on the peroneal artery and the
accompanying venae comitantes.
6. Additional osteotomies were then performed
to achieve three segments according to the
VSP. A reconstruction plate was used to
Bridge all three segments before division of
the pedicle, in order to reduce ischemia time.
7. The facial artery and vein on the left side of
the neck were simultaneously prepared as
recipient vessels after resection of the sub-
mandibular gland by the second team.
8. The flap was detached and the bony construct
Fig. 8 Osteosynthesis to the remaining mandible under
fixed to the remaining mandible with ischemia time in order to achieve the exact position of the
osteosynthesis under ischemia time. This mandible before revascularization
sequence was preferred in order to get a
fixed position of the vascular pedicle before
revascularization (Fig. 7). Technical Pearls
9. The flap was then revascularized after anas-
tomosis to the left facial artery and vein, with 1. Always plan for additional soft tissue
the skin paddle naturally placed externally replacement in ORN cases, due to reduced
(Fig. 8). The segment proximal to the middle skin elasticity. Even neck skin overlying the
de-epithelialized part of the skin paddle was anastomosis may need to be replaced in order
then transposed intraorally to reconstruct the not to compress the pedicle with the fibrotic
anterior floor of the mouth (Fig. 9). Despite neck skin.
the absence of a preoperative intraoral defect, 2. If severe radiation fibrosis is observed on only
except the fistula, extra soft tissues were nec- one side of the neck, consider anastomosis to
essary to be added in order to allow tension the contralateral neck to reduce the risk of
free closure due to reduced elasticity. vascular complications (Tall et al. 2015).
10. In this case the donor site could be closed 3. With a vascular pedicle exiting posteriorly, we
primarily but due to skin elasticity, we gener- plan for a fibula harvested from ipsilateral side
ally have a low threshold for skin grafting. from the recipient vessels if the skin paddle
shall be oriented externally or vice versa for
an internal skin island.
4. For through and through defects with only one
sizable skin perforator, we de-epithelialize the
skin paddle. However, both a longitudinal skin
paddle (Fig. 9) or a transverse skin paddle (Fig. 3)
can be used.
5. We recommend that 8 cm of the fibula shall be
preserved to ensure ankle mortise.
6. An additional 1 cm of bone can preferably be
resected adjacent to the proximal osteotomy in
order to facilitate mobilization of the fibular
bone during harvest.
Fig. 7 Osteotomies and osteosynthesis performed on the 7. Perform osteosynthesis prior to revasculariza-
lower leg in order to reduce ischemia time tion in order to achieve the exact position of the
Fig. 9 De-epithelialized skin island for a combined inner and outer lining
pedicle, which will limit the risk of kinking the adequate soft-tissue replacement. The need for
vascular pedicle. additional soft tissue reconstruction shall not be
underestimated in ORN cases and the patient
shall be informed preoperatively about the neces-
Intraoperative Images sity of an external skin island if indicated. The
fibular bone was completely incorporated to the
remaining mandible (Fig. 10).
Postoperative Management Avoiding and Managing Problems
Patient is closely monitored clinically postopera- 1. Careful evaluation of CT-scan when determin-
tively, with the head elevated 30–45° to reduce ing the resection lines to avoid residual ORN in
swelling. The flap is monitored clinically for mandibular bone connecting to the transplant.
color, turgor and capillary refill in addition to 2. We perform preoperative CT-angiogram of
ultrasound Doppler on the skin perforator. We the donor site in order to identify peripheral
use only low molecular weight molecular heparin arterial disease and anomalies, but also to
as anticoagulant regimen (both pre- and postoper- map perforators to better plan soft tissue
atively) without any intraoperative additional components.
anticoagulant agent. The foot is slightly elevated 3. The need for extra soft tissue must be taken
and checked for peripheral pulses. Patient is allo- into account in ORN cases. We usually harvest
wed to ambulate already the day after surgery. the skin paddle a bit larger than calculated if
the level of fibrosis intraorally or in the neck is
severe.
Outcome: Clinical Photos and Imaging 4. Prevent compression of the pedicle, which may
be caused by primary closure of the fibrotic
The patient experienced uneventful and fast rec- neck skin, by adding an external skin paddle
overy after reconstruction. Patient was ambulat- in cases of reduced skin elasticity.
ing day one after surgery and both the donor and 5. Always consider anastomosis to the contralat-
reconstruction sites healed uneventfully. The eral neck if one side is severely damaged by
reconstruction had significant impact on pain previous radiotherapy and neck dissection.
reduction, as recently shown in a prospective 6. We use two 14 Fr active drains anchored with a
setting for ORN reconstructions (Danielsson et al. 2-0 nylon loop suture to prevent suction to the
2019). Salivary leakage was terminated due to pedicle.
Learning Points
1. Reconstruction of ORN defects often require

additional soft tissue replacement due to fibro-
sis, even if preoperative status shows adequate
soft tissue coverage.
2. Preoperative planning is mandatory for both
bony and soft tissue components. Detailed
imaging of the donor site and virtual surgical
planning can increase patient safety and
shorten operative time, respectively (Garvey
et al. 2012).
References
Abou-Foul AK, Borumandi F. Anatomical variants of
lower limb vasculature and implications for free fibula
flap: systematic review and critical analysis. Microsur-
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Blumberg JM, Walker P, Johnson S, Johnson B, Yu E,
Lacasse MC, Lam DK, Rittenberg B, Yao CMKL,
Chepeha D, de Almeida JR, Goldstein DP, Gilbert R.
Mandibular reconstruction with the scapula tip free
flap. Head Neck. 2019;41(7):2353–8.
Danielsson D, Munck-Wikland E, Hagel E, Halle M. Qual-
ity of life after microvascular mandibular reconstruc-
tion for osteoradionecrosis – a prospective study. Head
Neck. 2019;41(7):2225–30.
Deek NF, Wei FC. Computer-assisted surgery for segmen-
tal mandibular reconstruction with the osteosepto-
cutaneous fibula flap: can we instigate ideological and
technological reforms? Plast Reconstr Surg. 2016;137
(3):963–70.
Garvey PB, Chang EI, Selber JC, Skoracki RJ, Madewell
JE, Liu J, Yu P, Hanasono MM. A prospective study of
preoperative computed tomographic angiographic
mapping of free fibula osteocutaneous flaps for head
and neck reconstruction. Plast Reconstr Surg. 2012;130
(4):541e–9e.
Metzler P, Geiger EJ, Alcon A, Ma X, Steinbacher DM.
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fibula mandibular reconstruction: planned versus actual
results. J Oral Maxillofac Surg. 2014;72(12):2601–12.
Paré A, Bossard A, Laure B, Weiss P, Gauthier O, Corre P.
Reconstruction of segmental mandibular defects: cur-
rent procedures and perspectives. Laryngoscope
Investig Otolaryngol. 2019;4(6):587–96.
Qaisi M, Montague L. Bone margin analysis for
Fig. 10 Postoperative view showing well-healed inner osteonecrosis and osteomyelitis of the jaws. Oral
and outer lining together with bony integration Maxillofac Surg Clin North Am. 2017;29(3):301–13.
Tall J, Björklund TC, Skogh AC, Arnander C, Halle M. defects in head and neck cancer. Plast Reconstr Surg.
Vascular complications after radiotherapy in head 1999;103(1):39–47.
and neck free flap reconstruction: clinical outcome Zaghi S, Danesh J, Hendizadeh L, Nabili V, Blackwell KE.
related to vascular biology. Ann Plast Surg. 2015;75 Changing indications for maxillomandibular reconstruc-
(3):309–15. tion with osseous free flaps: a 17-year experience with 620
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in reconstruction of extensive composite mandibular necrosis. Laryngoscope. 2014;124(6):1329–35.
Atrophic Maxilla with Fibula Flap and
Implant-Supported Prosthesis 19
Giorgio De Santis and Marta Starnoni
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Intraoperative Images (Figs. 8, 9, 10, 11, 12, 13, 14, 15, and 16) . . . . . . . . . . . . . . . . . . . 176
Outcome Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Abstract prosthetic criteria, a vascularized fibula flap

A 48-year-old man came to plastic surgery was planned. Neither early nor late complica-
department because he suffered from extreme tions were detected at the donor site. Clinical
superior jaw atrophy. In order to restore both and radiologic signs of osteointegration were
the vertical and sagittal bone loss, according to found at all implant sites at the time of pros-
thetic loading. The success rate of loaded
implants was 100%. Patient was both function-
G. De Santis (*) · M. Starnoni ally and aesthetically satisfied with the results.
Division of Plastic Surgery, University of Modena and
e-mail: desantis.giorgio@unimore.it

https://doi.org/10.1007/978-3-030-23706-6_22
172 G. De Santis and M. Starnoni
Keywords In order to restore both the vertical and sagittal

bone loss, according to prosthetic criteria and not
Free fibula flap · Maxilla reconstruction · Jaw
only to anatomical ones, a great amount of dense
atrophy · Implant surgery
bone stock would have been necessary to restore
the superior dentoalveolar ridges. Limited bony
contact and vascular supply to the recipient site
would have adversely affected the integration of
non-vascularized bone grafts. For this reason, a
A 48-year-old diabetic man came to plastic sur-
vascularized fibula flap was planned for superior
gery department because of functional impair-
ment during mastication. He suffered from
extreme superior jaw atrophy and he was edentu-
lous (Figs. 1, 2, and 3). Food intake had been
limited to a soft diet for the last 10 years. The
patient complained that his social life was being
affected and so asked for a fixed prosthesis. At
clinical examination, severe resorption of superior
alveolar ridges was noted with complete oblitera-
tion of the vestibular fornix (Fig. 4). A class V
atrophy (according to Cawood) was diagnosed in
the maxilla. Three-dimensional jaw relationships
were completely altered, resulting in a marked
mandibular pseudo-prognathism.
Fig. 2 A 48-year-old male preoperative right lateral view
Fig. 1 A 48-year-old male preoperative frontal view Fig. 3 A 48-year-old male preoperative left lateral view
19 Atrophic Maxilla with Fibula Flap and Implant-Supported Prosthesis 173
– Conventional non-vascularized bone trans-

plant in combination with endosseous implant
placement is a traditional method for the treat-
ment of severe atrophy of alveolar bone
(Tolman 1995).
However, their use is not advisable in severe
conditions, when the residual basal bone is
poorly vascularized and/or mechanically
unstable (Fonseca 1986). Furthermore, implant
insertion into unstable bone tissue may pre-
Fig. 4 Preoperative intraoral view
clude long-term survival of prosthetic rehabil-
alveolar ridge augmentation. Systemic diseases itation (Van der Berg et al. 1998; Foster et al.
such as diabetes are not contraindications to sur- 1999).
gery if the patient’s conditions are stable. – Microsurgical reconstruction of jaw resections
is safe and reliable (Schusterman et al. 1994).
Resorption of vascularized bone flaps is mini-
Preoperative Problem List: mal especially when compared to non-
Reconstructive Requirements vascularized bone grafts.
Iliac crest, scapula, fibula, and radius are
– The aim of maxillary reconstruction must be considered to be the most suitable donor areas
not only to restore aesthetic but also to for the treatment of composite defects of the
complete oral function with correction of any facial skeleton (Taylor 1982).
possible alterations in relation to the maxilla- Among these, the fibula with its dimen-
mandible occlusion. sions, its unique morphology, and its accept-
– Three-dimensional bony reconstruction of the able donor site morbidity is an excellent source
alveolar crest represents the framework for of vascularized bone for mandibular or maxil-
implant rehabilitation. It is fundamental to cre- lary reconstruction (Nakayama et al. 1994).
ate necessary conditions for successful pros- The more vascularized bone is needed, the
thetic rehabilitation (Albrektsson et al. 1986): more the fibula is favored due to its length,
(i) Sufficient bone height and thickness which enabling a good bony reconstruction (Cordeiro
allows for the insertion of implants of a et al. 1999).
suitable size, both in length and diameter Cortical bone thickness, height, and
(ii) A correct relationship between the jaw’s bicortical structure of the fibula shaft are ideal
bone in both the sagittal and vertical planes for long-term implant-borne rehabilitation.
(iii) Sufficient quality and quantity of adher- Fibular cortical thickness is superior, in terms
ing gum tissue of primary stability, with respect to the iliac
crest or the scapular crest (Hayter and Cawood
1996).
Treatment Plan
– (1) Alveolar ridge augmentation with Preoperative Evaluation and Imaging

vascularized fibular flap
– (2) Osteosynthesis material removal and – Two closing wedge osteotomies of the straight
implant insertion at 6 months fibula bone are necessary to recreate the three-
– (3) Second-stage implant surgery and dimensional shape of the maxilla. These
vestibuloplasty at 9 months osteotomies have traditionally been
accomplished using templates based upon a flow Doppler. With its high positive predictive
preoperative CT scan and lateral cephalogram value and sensitivity, preoperative CT angiog-
of the patient, as in this case. Nowadays, using raphy can improve the chances of a successful
a virtual platform, computer-assisted design outcome. It provides the reconstructive surgeon
and modeling in combination with additive with a road map, revealing vasculature anoma-
printing have been used. Each technique has lies or diseases that could alter or contraindicate
pros and cons, so it is important for reconstruc- surgery. Morphometric computed tomographic
tive surgeons to be familiar with both methods. evaluation of the fibula is used to define pre-
Traditional templates are reliable and efficient cisely the length of the fibula and the axial
in most cases without the added cost or time dimensions of each portion and their cortical
necessary for virtual surgical planning (VSP). thickness (Pinelli et al. 2019).
In contrast, for cases where reliable measure- The lower extremities of our patient were
ment of the specimen cannot be performed investigated by color Doppler ultrasound of the
because of tumor distortion, or for delayed tibial and peroneal vessels as well as with a CT
reconstruction, VSP has inherent advantages scan of the fibula, aimed at assessing its bony
(Cordeiro and Matros 2019). volume and morphology.
Preoperatively the patient underwent a CT
scan of the head and neck and color Doppler
ultrasonography of both external carotid arteries Preoperative Care and Patient
and their branches. Radiographs, including Drawing
orthopantomography (Fig. 5) and anterior and
lateral cephalograms (Fig. 6), were also – Patient received 2 g intravenous of ceftriaxone
obtained. X-ray and CT scan (Fig. 7) allow to per day, starting at the time of general anesthe-
produce acrylic templates, necessary to establish sia induction and continued for 6 days after
the osteotomy angles and to facilitate bone flap
in-setting.
– The best method for preoperative evaluation of
the lower limb is controversial. Femoral angi-
ography has been considered as the gold stan-
dard; the current literature, however, advocates
less invasive methods of assessment such as
magnetic resonance angiography and color
Fig. 5 Orthopantomogram: extreme resorption of supe- Fig. 6 Lateral cephalogram showing severe pseudo-
rior alveolar ridge prognathism
Fig. 7 Preoperative
computed tomographic
dental scan showing severe
resorption of maxillary
bone
surgery, and nonsteroidal analgesics were fixated to the residual bone with titanium screws
given postoperatively. Antibiotics were admin- in association with titanium microplates. The
istered intravenously at the time of induction peroneal pedicle was anastomosed to the facial
and then continued intramuscularly. vessels. These vessels were identified and iso-
– The patient is positioned supine with the knee lated through a cervical incision. The closure of
flexed 90 . the oral surgical access was partially obtained,
– The course of the fibula was marked. It is after positioning of the fibula flap only, by sutur-
useful to draw the approximate course of the ing the two mucosal flaps (palatal and vestibu-
superficial peroneal nerve, which crosses the lar) against the two sides of the fibula and
fibula 2–3 cm below the fibula head. It is also covering the metal work. The central part of
useful to draw the approximate location of the the neo-ridge was left open with a muscle cuff
pedicle connection to the bone. exposed that will eventually mucosalize.
– Incomplete exsanguination of the leg was – Implant Placement
performed using an inflated tourniquet. The implant placement procedure was
performed under general anesthesia with
nasotracheal intubation 6 months after the
Surgical Technique reconstructive phase. The procedure started
with a full-thickness crestal incision and the
– Reconstructive Procedure elevation of the soft tissues overlying the
The reconstructive procedure was performed reconstructed jaw. The fixation screws and
under general anesthesia with nasotracheal intu- plates used for stabilization of the bone grafts
bation. The procedure started with a lateral inci- were removed, and six dental implants and
sion in the anterior compartment of the lateral their healing screws were placed according to
part of the leg, in order to harvest the free flap. At prefabricated resin template. Care was taken
the same time, the recipient bed was prepared by during incision, flap elevation, and implant
another surgical team through an intraoral site preparation to avoid damaging the vascular
approach consisting in a crestal incision and pedicle of the fibula flap.
elevation of two full-thickness mucosal flaps, – Second-Stage Implant Surgery and
to expose the residual maxillary bone. Once Vestibuloplasty
harvested, the fibular bone segment was Three months later, a vestibuloplasty was
modeled to match the defect morphology and performed using thin split-thickness skin grafts
taken from the buttocks. Once the graft was Postoperative Management
stabilized, the patient was sent to the dental
surgeon to complete the definitive denture – After reconstructive procedure, the patient was
with the standard procedures. closely monitored throughout physical exami-
nation and Doppler for the first 5 days together
with assessing the good perfusion, bleeding,
Technical Pearls
– A 3–5 mm muscle cuff from the flexor hallucis

longus and soleus muscles was harvested with
the fibular bone to obtain mucosalization of
adherent gingiva, and, at the same time, the
exposed muscle cuff of the inferior central
part of the fibula is an optimal way to
monitorize the flap.
– Fibular augmentation of an entire superior
alveolar crest calls for two wedge oste-
ctomies and three bone segments of pre-
defined lengths.
– Wedge ostectomies were made on the basis of
the surgical stent that reproduces the exact
ridge volume, showing the correct angles
between the bony segments.
– Ostectomies were performed at the level of the
canine region because it represents the point of
maximum rotation of the dentoalveolar arches.
– Semirigid fixation of the fibular segments
(intersegmental fixation) was obtained with
microplates and screws.
Fig. 9 The harvested fibula
Intraoperative Images (Figs. 8, 9, 10,

11, 12, 13, 14, 15, and 16)
See Figs. 8, 9, 10, 11, 12, 13, 14, 15, and 16.
Fig. 8 Superior alveolar ridge exposition Fig. 10 Side-table shaping

and color of the muscle cuff. Anticoagulant were removed 7–10 days postoperatively. The
regimen was obtained with low molecular hep- ankle was splinted in neutral position, and the
arin. Postoperative instructions included a soft patient was allowed to ambulate (with partial
diet for 2 weeks and appropriate oral hygiene load) about a week after surgery.
with 0.2% chlorhexidine mouthrinse. Sutures – After implant placement, postoperative
instructions included a soft diet for 2 weeks
and appropriate oral hygiene with 0.2% chlor-
hexidine mouthrinse. Patient received 2 g of
amoxicillin-clavulanate per day, starting at the
time of implant placement and continued for
6 days after surgery, and nonsteroidal analge-
sics were given postoperatively. Sutures were
removed 7–10 days postoperatively. Standard
oral hygiene maneuvers were restarted after
suture removal.
Outcome Clinical Photos and Imaging

Fig. 11 Flap in-setting: fixation of the three bone seg-
ments to the maxilla – The hospitalization of patient after the recon-
structive procedure was 8 days. Postoperative
recovery was uneventful with excellent inte-
gration of the bone transplant. Postoperative
recovery after implant placement was
uneventful.
– Neither early nor late complications were
detected at the donor site.
– Clinical and radiologic signs of
osteointegration were found at all implant
sites at the time of prosthetic loading.
– Radiologically there was no evidence of peri-
implant bone loss after 12 months of mastica-
tory load.
Fig. 12 Intraoral view with restored superior alveolar – The success rate of loaded implants was 100%
ridge (Figs. 17 and 18).
Fig. 13 Postoperative
radiograph (10th
postoperative day)
– Patient passed from a semiliquid diet to a solid – Facial rejuvenation was achieved (Figs. 19
diet without restrictions and was both func- and 20).
tionally and aesthetically satisfied with the
results.
– The donor-leg morbidity following harvest of

the fibular flap is favorable when compared
with other vascularized bone flaps. Donor-leg
function and morbidity are independent of the
length of the segment removed, provided that
4 cm proximally and 6 cm distally are pre-
served. Careful muscle dissection and donor
site closure may account for the absence of
functional impairment.
– Fibula flap can also be dissected without tour-
niquet by experienced surgeons. The use of a
Fig. 14 Intraoral fibula exposure before implant place- tourniquet can induce micro-thromboses and
ment (6 months after fibular transfer) muscle edema. There are risks correlated to
Fig. 15 Implants
placement 6 months after
fibular transfer
close-up view showing
implants coverage
Fig. 17 Orthopanto-
mogram after implantology
– Oral rehabilitation is limited by obliteration of

the vestibule that can lead to poor hygiene
around implants. Soft tissue infections and
recurrent abscesses that start as peri-implant
marginal bone loss may eventually lead to fail-
ure of the implant and of the dental rehabilita-
tion. For this reason, vestibuloplasties are often
required.
– Insertion of six osteointegrated implants (two
per fibular segment) allows a balanced distri-
bution of the prosthetic loading. The canine
regions of the new alveolar arch, where the
intersegmental ostectomies have been
performed, are the weakest areas at the time
of implant surgery. Therefore, it is better not to
insert fixtures into these sites. It is
recommended that 5 mm of bone space be
kept between adjacent fixtures, to avoid possi-
ble propagation of peri-implant inflammatory
diseases causing a “domino effect” implant
Fig. 18 Lateral cephalogram (end of rehabilitation) show-
ing improved maxillomandibular relationships
failure.
local compression such as nerve-related injury.

Moreover, no pulse of the perforators is visible. Learning Points
– Although intraoral connection of the peroneal
pedicle to the facial vessels is described in the – Fibular segmentation (not less than 3 cm per
literature, the use of an external approach is segment) does not impair the blood supply to
easier, it saves time, and the resulting cervical the bone and allows accurate dentoalveolar
scar is cosmetically acceptable. To reach the shaping.
facial vessels, the pedicle should be long – Despite the extreme thinness of the anterior
enough (at least 8 cm), and it should be pulled and lateral walls of the maxillary bone in
through a submucosal tunnel from the upper extreme atrophy, the fibular segments can be
vestibule to the neck. simply fixed to the zygomatic and paranasal
– The use of muscle coverage confers several

advantages: it protects the pedicle, covers the
bone, and allows safe monitoring of flap vital-
ity. The healing process of the muscle in the
oral cavity is well-known. It takes almost
3 months.
– The choice of facial vessels (e.g., superior thy-
roid or lingual artery; internal jugular vein,
external jugular vein, or facial vein) is dictated
by surgical needs and the diameter of the ves-
sels to be anastomosed.
– Fibular bone flaps develop good union 4–
8 weeks after transfer, but progressive struc-
tural bony change occurs between 6 and
12 months. This bone remodeling is dependent
from the masticatory loading and makes the
dentoalveolar ridge more regular and smooth.
This phenomenon is called “fibula bone
mimetism.”
– The length of dental implants is selected in
order to engage the cortical bone of the more
cranial part of the fibula to optimize the pri-
Fig. 19 Frontal view (end of rehabilitation) showing
improved aesthetic balance and facial rejuvenation
mary stability of the dental implants.
– Some authors have reported the possibility of
inserting implants into the free fibula flap
during the primary reconstruction, because
at that point there is better access to the
bone, interdental relationships are easier to
determine, and oral rehabilitation can be
attained in a shorter period of time. There
are several disadvantages, however, that
may result from this rehabilitative choice:
endosseous dental implant placement proce-
dure is time-consuming; the preoperative
planning becomes complicated; implants
can be entirely lost in the case of flap failure;
and there is a high possibility of mis-
alignment of the fixtures.
– Clinical criteria for implant survival
include absence of persistent pain or
dysesthesia; absence of peri-implant infec-
tion with suppuration; absence of mobility;
and absence of continuous peri-implant
Fig. 20 Lateral view (end of rehabilitation) showing radiolucency.
improved maxillomandibular relation – Peri-implant bone-level changes are recorded
comparing panoramic radiographs taken
buttresses. Fixation procedures can be greatly immediately after implant placement, at the
facilitated by orienting the peroneal pedicle on time of prosthetic loading, and annually
the palatal surface of the recipient bone. thereafter.
Cross-References Foster RD, Anthony JP, Sharma A, Pogrel MA.

Vascularised bone flaps versus nonvascularised bone
grafts in mandibular reconstruction: an outcome anal-
▶ Mandible Reconstruction in Osteoradionecrosis ysis of primary union and endosseous implant success.
▶ Reconstruction of Temporomandibular Joint Head Neck. 1999;21:66–71.
with a Fibula Free Flap Hayter JP, Cawood JI. Oral rehabilitation with endosteal
implants and free flap. Int J Oral Maxillofac Surg.
1996;25:3–12.
Nakayama B, Matsuura H, Hasegawa Y, Ishihara O,
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maxillectomy defect with a fibula osteocutaneous free
Albrektsson T, Zarb GA, Worthington P, Eriksson A. The flap. Br J Plast Surg. 1994;47:247–9.
long-term efficacy of currently used dental implants: a Pinelli M, Puglisi A, De Santis G. Evolution in preopera-
review and proposed criteria for success. Int J Oral tive imaging. In: De Santis G, Cordeiro P, Chiarini L,
Maxillofac Implants. 1986;1:11–25. editors. Atlas of mandibular and maxillary reconstruc-
Cordeiro PG, Matros E. Use of templates to perform tion with the fibula flap. Cham: Springer; 2019.
osteotomies of the fibula and to shape the neo-mandi- Schusterman MA, Miller MJ, Reece GP, Kroll SS, Marcji
ble or neomaxilla. In: De Santis G, Cordeiro P, M, Goepfert H. A single centre experience with 308
Chiarini L, editors. Atlas of mandibular and maxillary free flaps for repair of head and neck cancer defects.
reconstruction with the fibula flap. Cham: Springer; Plast Reconstr Surg. 1994;93:472–8.
2019. Taylor GI. Reconstruction of the mandible with free
Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction composite iliac bone grafts. Ann Plast Surg.
of the mandible with osseous free flap: a 10 year expe- 1982;9:361–76.
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Surg. 1999;104:1314–20. implants in grafted bone: a review of the literature. Int J
Fonseca RJ. Biologic aspects of transplantation of grafts. Oral Maxillofac Implants. 1995;10:275–94.
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1986. p. 23–31. Dent. 1998;80:175–83.
Reconstruction of
Temporomandibular Joint 20
with a Fibula Free Flap
Andreas Gravvanis, George Lagogiannis, and

Despoina D. Kakagia
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Abstract
Free fibula flap is an option for primary resto-

A. Gravvanis (*) ration after disarticulation mandibular resec-
Plastic, Reconstructive and Aesthetic Surgery, tion. Inset of the masseter, the key mandibular
Metropolitan Hospital of Athens, Athens, Greece elevator muscle, at the reconstructed mandible
G. Lagogiannis has been reported in literature to optimize func-
Head and Neck Department, Metropolitan Hospital, tional recovery.
Athens, Greece
A 54-year old male, diagnosed with mandib-
D. D. Kakagia ular ameloblastoma, underwent disarticulation

https://doi.org/10.1007/978-3-030-23706-6_23
mandibulectomy-condylectomy and reconstruc- Immediate reconstruction of the mandibular

tion of the defect by means of a fibular flap. defect by fibula free flap followed the tumor
The neocondyle was formed by the distal resection, and the new condyle was recons-
portion of the fibula and passively placed tructed by formation of the distal end of the fibula
directly into the glenoid fossa with preserva- in order to prevent the devastating impact of
tion of the temporomandibular disc. The deep mandibulactomy on the patients’ quality of life
portion of the masseter was inset at the angle of (Gravvanis et al. 2017; Guyot et al. 2004; Shenag
the reconstructed mandible. and Klebuc 1994; Hundepool et al. 2008,
Condylar position was postoperatively eval- Nicoletti et al. 2004; Zemann et al. 2007). This
uated by panoramic radiographs, and the patient single stage surgical approach prevented pain
was followed up for 36 months. The occlusion, and restored mastication, deglutition, articula-
mastication, speech, and cosmesis were evalu- tion, oral competence, and lower facial shape
ated as very satisfactory by the patient. and contour (Gravvanis et al. 2017; Zemann
The free fibula flap with direct seating of et al. 2007; Hidalgo 1994) and permitted early
the fibular formed neocondyle into the condy- return of this professionally active patient to his
lar fossa, followed by reinsertion of the deep work and normal life.
portion of the masseter muscle, provides
acceptable functional reconstruction of the
mandibulectomy-condylectomy defect. Preoperative Problem List:
Keywords
Free fibula flap · Osseocutaneous free flap · 1. Defect of the lateral and posterior segment of
Mandibular reconstruction, ameloblastoma the mandible, including the condyle (Gravvanis
mandible · Condylar reconstruction et al. 2017; Hidalgo 1994)
2. Mucosal defect necessitating reliable soft tis-
sue transfer to cover the neomandible
The Clinical Scenario (Anthony et al. 1997; Engroff 2005) (Fig. 3)
3. Requirement to reconstruct the right lateral
A 54-year-old male was diagnosed with mandibular segment and the floor of the mouth
ameloblastoma of the mandible involving the pos- (Anthony et al. 1997; Engroff 2005; Gravvanis
terior part of the mandible (Figs. 1 and 2). et al. 2017) in order to achieve oral competence
Segmental mandibulectomy with disarticula- (Gravvanis et al. 2017; Guyot et al. 2004;
tion of the temporomandibular joint was required Shenag and Klebuc 1994; Hundepool et al.
to resect this benign but rapidly evolving tumor 2008; Nicoletti et al. 2004), reliable prosthetic
with adequate margins (Gravvanis et al. 2015; rehabilitation (Foster et al. 1999), and normal
Zemann et al. 2007). lower facial shape and contour
Fig. 1 Panorex image of

the tumor
20 Reconstruction of Temporomandibular Joint with a Fibula Free Flap 185
Immediate reconstruction of the defect was

planned at the same stage with the harvest of a
free fibula osseocutaneous flap.
The distal end of the harvested bone would be
rounded to form a neocondyle (Gilliot et al. 2015;
Engroff 2005; Gravvanis et al. 2017). Free sliding
of the neocondyle into the glenoid fossa would
permit pain-free and early function of the TMJ,
while the neocondyle would be actively protected
and secured in position by partial transfer of the
masseter muscle to the angle of the reconstructed
mandible (Gravvanis et al. 2017).
Dental implants would complete the functional
Fig. 2 Clinical appearance of the patient. Note the lateral reconstruction (Hidalgo 1989; Hidalgo and Pusic
facial contour irregularity and asymmetry due to the tumor
2002; Hundepool et al. 2008; Foster et al. 1999).
The options for reconstruction of mandibular

resections that include condyle disarticulation
are limited.
1. A simple solution is provided by reconstruc-

tion plates with attached metallic condylar
prostheses. However, the metallic condylar
prostheses can erode the bone of the glenoid
fossa and are not approved for permanent
implantation (Wei et al. 2003; Shpitzer et al.
2000; Shenag and Klebuc 1994; Engroff 2005;
Maurer et al. 2010).
2. The excised condyle can also be replaced by the
Fig. 3 Buccal involvement responding to the mandibular well-established autogenous rib graft, but in this
tumor case the provided bone is insufficient for the
reconstruction of the ramus and body of the
4. Requirement to reconstruct the mandibular con- mandible (Hidalgo 1989, 1994; Engroff 2005;
dyle to ensure adequate painless movement and Shenag and Klebuc 1994; Cordeiro et al. 1999;
restoration of the ability to masticate and articu- Foster et al. 1999).
late intelligibly (Gilliot et al. 2015; Engroff 2005; 3. Other solutions as addition of iliac crest partic-
Hundepool et al. 2008; Nicoletti et al. 2004) ulate bone grafts are less favorable (Cordeiro
et al. 1999; Foster et al. 1999; Hidalgo and
Pusic 2002).
Treatment Plan
Tumor resection involving lateral disarticulation Preoperative Evaluation and Imaging

mandibulectomy and affected mucosa with 2 cm
margins was planned. The resection would Preoperative panoramic radiographs (Fig. 1) and
include disarticulation of the mandibular condyle computed tomography scanning were performed
with preservation of the articular plate (Engroff to assess the extent of tumor and required man-
2005; Gravvanis et al. 2017). dibular resection.
Normal vascular anatomy and arterial compe- the thigh, and the leg from the knee down was
tence were ensured by preoperative evaluation of prepped and draped.
the lower extremities. Both lower extremities The leg was elevated 60 and exsanguination
were evaluated to determine the presence or extent was performed. The tourniquet was inflated to at
of any disease and to ascertain the pulse status of least 100 mmHg above the patient’s systolic blood
the patient (Gravvanis et al. 2012). The feet were pressure, and a maximum ischemia time of
examined for signs of peripheral vascular disease, 90–120 min was respected.
and the anterior and posterior tibial pulses are The head of the fibula and the lateral malleolus
palpated. were marked, and the axis of the bone was drawn
Because an intact arch can supply retrograde along the posterior crural intermuscular septum,
flow to the major vessels of the foot, it can be which can be seen as the indentation between the
helpful to put pressure on the anterior tibial artery peroneus and soleus muscles (Fig. 4). The axis of
when detecting the presence of a posterior tibial the skin paddle was drawn at the posterior border of
pulse and vice versa. This modified Allen’s test the fibula. The paddle was outlined with the use of
may detect proximal vessel obstruction masked handheld Doppler to locate and mark the perfora-
by an intact foot arch. tors, which are usually found around the junction of
Preoperative angiograms were obtained as a the middle and distal thirds of the lateral leg, on
guide. MRI or CT angiography can also be used patient’s skin. Afterward, the distal and proximal
in many circumstances. osteotomy sites were marked, preserving 5–7 cm of
the distal fibula and 5 cm of the proximal fibula for
ankle and knee stability, respectively (Fig. 4).
Drawing
Surgical Technique
The ipsilateral fibula was chosen for mandible
reconstruction, and the vascular anastomosis was In this case of mandibular reconstruction, a
decided to be performed at the ipsilateral facial two-team approach was used as usual, one in the
vessels. This was mainly due to the fact that the mandible area and one in the lower extremity.
anterolateral surface of the fibula had to be the
anterior surface of the “neomandible” for secure 1. In order to access the mandible lesion, a sub-
fixation. Moreover, the flexibility of the septum mandibular incision was performed (Fig. 5).
allowed the use of the same donor leg when the 2. The mandibular osteotomy site was marked
contralateral neck vessels have to be used for the on the mandible with the saw.
vascular anastomosis. 3. A locking screw reconstruction plate was
The patient was placed in the supine position adapted to the outer surface and just above
with a bump under the ipsilateral hip to lessen the the lower border of the mandible and
need for excessive internal rotation of the lower contoured according to the shape of the resec-
leg. A well-padded tourniquet was placed around tion specimen (Fig. 6). Three screw holes
Fig. 4 Flap design. Note

the margins of fibular
osteotomies and the
location of perforators
Fig. 5 Submandibular
incision for mandibular
resection and preparation of
the recipient facial vessels
Fig. 6 Modeling of the

reconstruction plate on the
outer lateral mandible to be
resected, in order to serve as
a guide for formatting the
neomandible osteotomies
were drilled to either side of the planned the condyle and achieving 2 cm margins
mandibular osteotomy, and the plate was tem- (Fig. 7). The temporomandibular disc was
porarily fixed to the bone with bicortical preserved. The resulting mucosal defect at
locking screws. The position and angle of the floor of the mouth was 4 5 cm. The
the planned osteotomy were precisely drawn mandibular bone defect was 11 cm long.
on the external surface of the plate at the 6. At the leg site, an incision along the anterior
osteotomy site, and the angle was marked margin of the skin flap was made through
on it. deep dermis and fat, while the investing
4. The reconstruction plate and screws were deep fascia was carefully cut with monopolar
removed, and the plate was used as a template electrocautery (Gilbert 1979; Hidalgo 1989).
to plan and design the fibular osteotomies. 7. The peroneus longus and brevis muscles in
5. The left buccomandibular subunit affected by the lateral compartment were exposed and
the tumor was resected with disarticulation of pulled anteriorly with retractors.
8. The muscles were then separated from the 14. Small muscular branches to soleus and flexor
deep fascia up to the posterior crural hallucis longus branching from the perfora-
intermuscular septum with a scalpel. tors were ligated and divided.
9. Sharp dissection was continued posteriorly 15. Sharp dissection continued deep to soleus
along the septum, revealing two perforators until the flexor hallucis longus muscle was
curling around the posterior margin of the identified and the intermuscular septum was
fibula (Fig. 8). divided.
10. The position of the perforators was marked on 16. Continuing with the anterior dissection, the
the skin and deep fascia with ink. peroneal muscles in the lateral compartment
11. The flap was redesigned and centered over the were released from the fibula with electrocau-
perforators. tery, leaving a 5 mm cuff of muscle on
12. The posterior margin of the flap was dissected the bone.
taking care not to injure the sural nerve and 17. The dissection through the anterior crural
lesser saphenous vein. intermuscular septum continued with cautery
13. The posterior edge of the flap was retracted and extended proximally; the proximal part of
anterolaterally with skin hooks, and the deep the peronei and anterior crural intermuscular
fascia was elevated off the soleus muscle up septum were stripped off the bone by finger
to the posterior aspect of the posterior crural dissection.
intermuscular septum where the perforators 18. The peronei muscles are firmly retracted ante-
could be visible again. riorly and the extensor digitorum longus
medially with the use of deeper retractors.
19. The extensor digitorum longus and the deeper
extensor hallucis longus fibers are divided
with cautery, a few millimeters from the free
edge of the fibula.
20. The interosseous membrane was exposed
(Fig. 8) and divided. Proximal extension of
the dissection fully released the interosseous
membrane and permitted lateral retraction of
the fibula and exposure of the tibialis poste-
rior muscle and peroneal vessels (Fig. 9).
Fig. 7 The resected and disarticulated segment of the
mandible
Fig. 9 Retraction of the fibula after division of the

interosseous membrane and exposure of the tibialis poste-
Fig. 8 The interosseous membrane rior muscle and peroneal vessels
21. The proximal and distal osteotomies were were carefully dissected further toward the
performed. The length of fibula removed tibioperoneal vascular trunk.
included a length of bone proximally as deter- 33. The vein and artery were then separated from
mined by the length of the vascular pedicle each other for a few centimeters to facilitate
required. the vascular anastomoses.
22. The muscle and periosteum were divided 34. After the recipient facial vessels in the neck
transversely with a scalpel over the lateral had been prepared, the pedicle was ligated
surface of the fibula onto bone. using ligaclips and divided, paying attention
23. Gentle subperiosteal dissection around the not to injure the posterior tibial artery and
remainder of the fibula using a Mitchell’s tibial nerve.
trimmer was performed, taking care not to 35. The tourniquet was deflated following flap
excessively strip periosteum or injure the elevation, and bleeding in the surgical bed
peroneal vessels. was controlled with bipolar cautery, ligaclips,
24. A metal plate was used to protect the vessels and ties.
while performing the osteotomies with a 36. Finally, the fibula donor site was repaired by
high-speed electric oscillating microsaw. suturing the lateral compartment muscles to
25. The bone was retracted laterally by inserting a the soleus muscle over a suction drain. The
bone hook in the marrow cavity at the distal drain was placed with its free part distally in
osteotomy while the peroneal and anterior order to avoid injury of the ligated vessels
compartment muscles were retracted medially proximally.
in order to expose the tibialis posterior muscle. 37. The vascular pedicle was elongated by sub-
26. The anterior tibial vessels and deep peroneal periosteal dissection of the proximal fibula and
nerve were lying medially, lateral to the using the distal fibula for the reconstruction.
tibialis anterior muscle. 38. The reconstruction plate was placed vertically
27. The tibialis posterior muscle was divided on a stiff paper ruler, and looking from supe-
from distally to proximally with dissecting riorly, a line along the inner aspect of the plate
scissors, exposing the peroneal vessels cov- was drawn to outline the horizontal segment
ered by the intermuscular septum. of the mandible up to the angle of the mandi-
28. The peroneal vessels were ligated adjacent to ble. The lateral and vertical limbs of the plate,
the distal osteotomy. as viewed from anterolaterally, were drawn
29. The closed tips of the scissors were advanced on the paper, and the points of the mandibular
beneath the septum at the relatively avascular angle and the osteotomy angle between the
plane between the intermuscular septum and horizontal and vertical segments were
the peroneal vessels. The septum was divided marked. By positioning the segments in a
over the medial aspect of the vessels and straight line, a V-shaped template was drawn
proximally until the peroneal vessels were and used for V-shaped osteotomy.
fully exposed. 39. Three-dimensional shaping of the fibular
30. Side branches supplying the tibialis posterior osteotomy was performed according to the
found medially and larger branches supplying profile drawn on the paper ruler (Fig. 10).
the soleus muscle were ligated with ligaclips 40. The neocondyle was round shaped at the dis-
and divided. tal end of the fibula using the disarticulated
31. The flap was then detached from the flexor condyle as a guide (Fig. 11) (Gilliot et al.
hallucis longus, dividing the muscle from 2015; Engroff 2005; Shenag and Klebuc
distally to proximally, leaving a cuff of mus- 1994).
cle in the area of the perforating pedicle. 41. The flap (Fig. 12) was transposed to the bony
32. The peroneal vessels were inspected, and the mandibular defect, and the neocondyle was
most suitable vein was selected, and the slided to lie freely into the glenoid fossa
others were ligated. The selected vessels (Gravvanis et al. 2017).
Fig. 10 Modeling of the

paper ruler and marking of
the osteotomies on it, using
the premodeled
reconstruction plate as a
guide
Fig. 11 The fibula

formatted by osteotomies
according to the paper ruler
pattern
Fig. 12 The free fibular

flap formatted as
neomandible. The free end
is rounded to form the
neocondyle
42. The individual bony segments were fixed to exiting the anterior portion of the flap.
the plate with unicortical screws, while the The length of the vessels was adjusted
plate was fixed to the mandible with bicortical to allow a favorable geometry, and the
screws. Only two screws per segment were microvascular anastomosis was accom-
used, so as to facilitate placing dental implants plished with 9-0 nylon. End-to-end anas-
(Foster et al. 1999; Gravvanis et al. 2017). tomoses to the facial vessels were
43. The vascular pedicle was positioned on the performed. Arterial inflow and venous out-
medial aspect of the flap with the vessels flow were confirmed.
3. If no perforators are visible, the muscular per-

forators encountered must be preserved and
harvested.
4. Failure to have fully divided the interosseous
membrane will not permit the fibula to swing
laterally. Further mobilization can be achieved
by retracting the proximal segment of the fib-
ula laterally and carefully dividing the flexor
hallucis and the thick intermuscular fascia
between the peroneal vessels and the fibula.
5. Unnecessary osteotomies and bony segments
of <1.5 cm have to be avoided.
6. Beware of kinking of the vessels at the point
where they lie deep to the bone and are not
visible after bony fixation.
7. A palpable pulsating artery is not identical to
adequate flap perfusion. Bleeding from the
muscle or skin edges is the proof of adequate
Fig. 13 The transposition of the deep part of the masseter
muscle is outlined. The masseter muscle is sutured on the flap perfusion.
angle of the neomandible to actively secure the neocondyle 8. If the masseter muscle is of inadequate height
into the glenoid fossa to reach the reconstructed mandibular angle, a
tensor fascia lata graft can be used.
44. Then the deep part of the ipsilateral masseter

muscle was mobilized and partly rotated and Intraoperative Images
sutured to the angle of the reconstruction
plate to actively seat the fibula flap neo- The marking of the perforators along the axis of
condyle into the glenoid fossa (Fig. 13) the intermuscular crura is shown in Fig. 4.
(Gravvanis et al. 2017). The mandible lesion is assessed by a subman-
45. The skin paddle suture to the mucosa was dibular incision. The submandibular incision, as
completed. shown on Fig. 5, was used also for preparation of
the recipient facial vessels.
The mandibular osteotomy site was marked
Technical Pearls on the mandible with the saw, and the locking
screw reconstruction plate was adapted to the
1. Locking titanium (load-bearing) reconstruc- outer surface and just above the lower border of
tion plate systems are preferred so as to avoid the mandible and contoured according to the
compressing the plate against the bone and shape of the resection specimen as presented in
causing subcortical bone resorption and loos- Fig. 6.
ening of screws. In Fig. 8, the peroneus longus and brevis mus-
2. Preplating by contouring the plate on the cles in the lateral compartment were exposed and
exposed mandible prior to resection assures pulled anteriorly with retractors, while sharp dis-
good form and occlusion. If the tumor signifi- section continued posteriorly along the septum
cantly distorts the mandibular contour, it needs revealed two perforators curling around the pos-
to be elevated off the mandible to permit the terior margin of the fibula.
plate to be accurately placed on the bone. In The vascular pedicle was elongated by sub-
this case, the plate must be sterilized before use periosteal dissection of the proximal fibula and
at the final reconstruction. using the distal fibula as in Fig. 9.
The reconstruction plate was placed vertically One year postoperatively, the patient presented
on a stiff paper ruler, and osteotomy sites were with a satisfactory functional and esthetic result.
marked on the ruler (Fig. 10), which was then Reconstruction of the floor of the mouth with
transferred to the harvested fibula to three- the free fibula flap successfully restored oral com-
dimensionally format it with osteotomies as petence, mastication, deglutition, and articulation
shown in Fig. 11. (Figs. 15 and 16).
The repositioning of the deep part of the mas- Reconstruction of the entire buccomandibular
seter muscle to the neomandibular angle is unit, including the TMJ, ensured early rehabilitation
outlined in Fig. 13. and pain-free joint function, while it successfully
restored the facial height and contour (Fig. 16).
The composite flap facilitated and reliably
Postoperative Management supported the subsequent dental implantation.
The satisfactory functional and cosmetic out-
The patient was postoperatively monitored in the come contributed to the return of the patient back
ITU for the first 24 h and closely monitored by to his social life and work.
physical examination and Doppler for the first
5 days. Anticoagulant regimen included low
molecular heparin and oral aspirin. Avoiding and Managing Problems
A posterior lower limb foot splint was placed
for 1 week with the ankle at 90 degrees. Physio- 1. Mark the distal fibular osteotomy site at least
therapy to the lower limbs was commenced imme- 7 cm above the projection of the lateral
diately after splint removal. Also full weight malleolus to maintain ankle stability (Fig. 4).
bearing was commenced after 1 week. 2. Mark the width of the flap on the leg. When
The lower limb was kept elevated as much as harvesting a narrow skin island, it is critical
possible during the first month to avoid edema. to determine the position of the posterior
crural intermuscular septum as it carries
the perforators.
Outcome: Clinical Photos and Imaging 3. Beware of the superficial peroneal nerve
which is located 3–4 cm anterior to the longi-
Our patient experienced uneventful and fast tudinal line in the lower half of the leg, and
recovery. Panorex confirmed the correct position- the sural nerve which is 3–4 cm posterior to
ing of the condyle (Fig. 14). this line.
Panorex demonstrating the
correct positioning of the
neocondyle into the glenoid
fossa
4. The sural nerve that innervates the lateral leg more proximally and modify the flap to
is vulnerable during the elevation of the pos- include them. First incise the skin along
terior part of the skin flap as it courses in close the anterior margin of the flap in a gentle
proximity to the lesser saphenous vein. curve, so to extend the length of the skin
5. If a long flap is required, center it over the island if a perforator is situated outside the
junction of the proximal and medial third initial marking.
of the leg line drawn, where most perfora- 6. The common peroneal nerve winds from pos-
tors lie. If no perforators are seen, look teriorly around the lateral surface of the neck
of the fibula, and attention must be given
during the proximal dissection of the pedicle
at the head of the fibula.
7. At the time of final dissection and division of
the flap pedicle, pay attention not to injure the
posterior tibial artery and deep peroneal and
tibial nerves.
8. While attached to the leg, the fibula is usually
oriented with the pedicle on the wrong side
for intraoral reconstruction. To avoid confu-
sion, it is easier to place the fibula in the
correct orientation as it would lie in the
mouth by flipping it over in its longitudinal
axis while still attached by its vascular
pedicle.
9. A Valsalva maneuver is done to check for
bleeding and achieve meticulous hemostasis
before neck wound closure. A suction drain is
carefully inserted into the neck, which must
not cross over the microvascular repair or
over the internal jugular vein.
10. Skin suture of the tracheostomy helps avoid
ties around the neck, which may occlude the
Fig. 15 The buccal reconstruction with free fibula internal jugular vein and cause venous con-
osseocutaneous flap 6 months postoperatively gestion and flap failure.
Fig. 16 (a) Postoperative result with satisfactory occlusion and facial contour; (b) profile view of the reconstructed
mandible: the optimal esthetic outcome as shown by correction of the facial height
11. The leg donor site wound closure must be References

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Gravvanis A, Koumoullis HD, Anterriotis D, Tsoutsos D,
ous lower limb trauma can preclude the use of
Katsikeris N. Recurrent giant mandibular ameloblastoma
the fibular flap. in young adults. Head Neck. 2015;30. https://doi.org/10.
3. A major advantage of the fibular flap is the 1002/hed.24352. [Epub ahead of print].
possibility of modification by osteotomies in Gravvanis A, Anterriotis D, Kakagia D. Mandibular condyle
reconstruction with fibula free-tissue transfer: the role of
order to restore complex three-dimensional
the masseter muscle. J Craniofac Surg. 2017;28:1955–9.
bony architecture. https://doi.org/10.1097/SCS.0000000000003998.
4. The fibular bone is less affected by postopera- Guyot L, Oliver R, Layoun W, et al. Long term radiologic
tive radiotherapy due to its strength and findings following reconstruction of the condyle with
fibular free flaps. J Craniomaxillofac Surg. 2004;32:
thickness.
98–102.
5. The length of the pedicle is usually short but Hidalgo DA. Fibula free flap: a new method of mandible
can be increased significantly by subperiosteal reconstruction. Plast Reconstr Surg. 1989;84:71–2.
dissection from the proximal fibula. Hidalgo DA. Condyle transplantation in free flap mandible
reconstruction. Plast Reconstr Surg. 1994;93:770–81.
6. The periosteal blood supply is critical for the
Hidalgo DA, Pusic AL. Free-flap mandibular reconstruc-
bone viability when the fibula is shaped by tion: a10-year follow-up study. Plast Reconstr Surg.
performing the osteotomies. Therefore, as 2002;110:438–49; discussion 450–451
much periosteum as possible, as well as a cuff Hundepool AC, Dumans AG, Hofer SOP, et al. Rehabili-
tation after mandibular reconstruction with the fibula
of muscle, must be preserved around the fibula.
free-flap: clinical outcome and quality of life assess-
ment. Int J Oral Maxillofac Surg. 2008;37:1009–13.
Maurer P, Eckert AW, Kriwalsky MS, Schubert J. Scope
Cross-References and limitations of methods of mandibular reconstruc-
tion: a long-term follow-up. Br J Oral Maxillof Surg.
2010;48:100–4.
▶ Reconstruction of a Massive Facial Defect Fol- Nicoletti G, Soutar DS, Jackson MS, Wrench AA,
lowing Trauma Robertson G, Robertson C. Objective assessment of
speech after surgical treatment for oral cancer: experience Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen
from 196 selected cases. Plast Reconstr Surg. 2004;113: HC. Complications after reconstruction by plate and soft
114–25. tissue free flap in composite mandibular defects and
Shenag S, Klebuc M. TMJ reconstruction during secondary salvage reconstruction with osteocutaneous
vascularized bone graft transfer to the mandible. Micro- flap. Plast Reconstr Surg. 2003;112:37–42.
surgery. 1994;15:299–304. Zemann W, Feichtinger M, Kowatsch E, Kärcher
Shpitzer T, Gullane PJ, Neligan PC, et al. The free H. Extensive ameloblastoma of the jaws: surgical man-
vascularized flap and the flap plate options: compara- agement and immediate reconstruction using microvas-
tive results of reconstruction of lateral mandibular cular flaps. Oral Surg Oral Med Oral Pathol Oral Radiol
defects. Laryngoscope. 2000;110:2056–60. Endod. 2007;103:190–6.
Orbital Reconstruction with Free
Fibula Flap 21
Kalle Conneryd Lundgren and Martin Halle
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Primary Surgery (Figs. 3, 4, 5, 6 and 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Second Stage (Fig. 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
K. C. Lundgren
Senior Consultant, Craniomaxillofacial Surgery,
Karolinska University Hospital, Stockholm, Sweden
Associate Professor in Plastic Surgery, Molecular
Medicine and Surgery, Karolinska Institute, Stockholm,
Sweden
M. Halle (*)
Reconstructive Plastic Surgery, Karolinska University
Molecular Medicine and Surgery, Karolinska Institute,
Stockholm, Sweden
e-mail: martin.halle@sll.se

https://doi.org/10.1007/978-3-030-23706-6_25
198 K. C. Lundgren and M. Halle
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Abstract for exenteration and partial resection of the orbital

Extensive orbitomaxillary cancer resections rim and skull base, but due to a rapidly growing
in need for postoperative radiotherapy admin- cancer, a much larger resection was necessary to
istration often call for advanced autologous be performed. Based on preoperative MR imaging
composite reconstructions. The current case (Fig. 1), a resection was performed including the
illustrates a range of reconstructive require- anterior and medial maxillary walls; the infra-
ments that need to be addressed, from sealing orbital, lateral, and superior orbital margins; and
off the intracranial communication with the the anterior right bony skull base. An orbital
skull base to aesthetic considerations regard- extenteration was done. Given the rapidly grow-
ing the facial contour. The first stage involved ing nature of the tumor, the need for significant
extensive bony resection of the skull base, the margins, and a decision to avoid implants due to
inferior, superior, and lateral orbital rim planned postoperative radiation, a virtual surgical
together with orbital excenteration. An osteo- plan was deemed to be of limited value and was
cutaneous fibula flap with a large skin paddle not performed to create guiding tools. The patient
was used to address the requirements of the was instead planned for an immediate composite
defect in the first stage. Osteotomies were fasciocutaneous fibula reconstruction.
performed to achieve a three-segmented fib-
ula in order to reconstruct the orbital cavity, to
allow a future eye prothesis. The fibula flap Preoperative Problem List-
skin paddle was partly used to achieve a Reconstructive Requirements
water-tight closure toward the skull base
after de-epithelialization and partly for com- 1. Due to rapid tumor growth, the requirements
plimentary external coverage. At a second for the reconstruction could not be addressed
stage, a contralateral paramedian forehead until the final resection plan was set. A list of
flap was used to line the orbit before adjuvant
radiotherapy could be administered. There
was a final uneventful healing of both bony
and soft tissue components with an acceptable
cosmetic outcome allowing for orbital
rehabilitation.
Keywords

Orbital reconstruction · Maxillary
reconstruction · Skull base reconstruction
A 72-year-old male patient was referred for treat-

ment of advanced adenocystic carcinoma of the
lachrymal duct. The patient was initially planned Fig. 1 Preoperative MRI
21 Orbital Reconstruction with Free Fibula Flap 199
functional and aesthetic requirements is piece-segmented fibula reconstruction was

described below. deemed necessary in order to reconstruct the
2. A vascularized bony reconstruction was used, orbital rims. In addition, a large fasciocutaneous
due to extensive bony resection of the inferior, perforator-based skin paddle was planned, not
superior, and most importantly, the lateral only in order to achieve a water-tight closure
orbital rim. toward the skull base, but also for external cov-
3. One of the most significant cosmetic distur- erage. Since only one reliable perforator to the
bances among this patient group concerns the skin was identified, a de-epithelialized skin
eye. In order to achieve an orbit that allows an island was designed to offer a combined inner
eye prothesis, the reconstruction must have an and outer lining.
adequate orbital depth (Cevic et al. 2012),
intact marginal rims, and correctly positioned
walls to accommodate the eye in a natural
position (Perman and Baylis 1988; Li et al.
2008). Of note is that the inferior margin has
1. In less severe cases, a soft tissue flap may be
more flexibility in terms of aesthetic outcome
used, but with the limitation of adequate
than the medial (avoid a reconstruction that
contouring, especially with regard to the lateral
appears to broaden the nasal bridge) and the
orbital rim that will need a rigid support not to
lateral (avoid to broaden the facial contour) rims.
retract posteriorly and inferiorly.
4. The immediate reconstructive concern after
2. A osteocutaneous radial forearm flap has
skull base resection, in order to avoid any
been described as a single solution for com-
cerebrospinal fluid (CSF) leakage by securing
posite defects with osteotomies. However,
a sealed-off intracranial space, cannot be
the bone available in the forearm is less sta-
underestimated (Chang et al. 2001). A large
ble than the fibulae; the donor site when
peroneal perforator-based skin paddle was
using a large cutaneous flap is worse than
used to address this.
the lower leg.
5. Donor-site anatomy shall also be carefully eval-
3. Implant materials may be an excellent choice
uated in order to exclude peripheral arterial
in terms of the aesthetical outcome but have
disease and anomalies such as peronea arteria
severe limitations when only very thin soft
magna (Abou-Foul and Borumandi 2016).
tissue coverage is suitable, such as in the facial
6. In addition to the bony reconstruction, soft
area. When irradiation is planned, artificial
tissue planning is equally important, where
materials are an even less viable alternative
impaired soft tissue quality needs to be taken
for a sustainable reconstruction.
into account (Garvey et al. 2012).
7. Preoperative virtual planning (VSP) with cut-
ting guides and patient-specific implants (PSIs)
is today regularly used for fibula reconstruction Preoperative Evaluation and Imaging
(Metzler et al. 2014). However, a VSP was not
used due to time constraints in the described Both CT and MRI scans were used to identify
case and because in situ decisions on margins bony and soft tissue resection margins respec-
were to be inevitable. tively and evaluate the extent of affected bone in
order to plan for adequate surgical margins for the
bony resection.
Treatment Plan Both lower extremities were evaluated with
CT-angiogram not only to determine the pres-
Once adequate resection margins were set, a ence or extent of any disease or anomaly, but
bony reconstruction was planned and donor site also to evaluate peroneal perforators to the
anatomy was evaluated. In this case, a three- skin.
Preoperative Care and Patient muscular fascia. The septum was approached
Drawing by elevating the fascia from anterior to poste-
rior. Septocutaneous perforators were identi-
Patient was placed in supine position with a bump fied, and the fibula’s skin paddle, measuring 5
under the ipsilateral hip to lessen the need for x 20 cm, was based on this single
excessive internal rotation of the lower leg. The septocutaneous perforator.
foot was put in a stirrup in order to have the knee 3. The skin paddle was de-epithelialized in order
slightly flexed. A padded tourniquet was placed to serve as inner lining.
on the thigh. The leg from the knee down was 4. A 1 mm cuff of muscle was left attached to the
prepped and draped. The palpable parts of the fibular bone as proceeding medially from the
fibula were marked, and a line was drawn along- anterior approach. Retractors were used as the
side the posterior edge of the fibula. Osteotomies muscle was peeled away leaving behind a
were marked with the most distal placed 8 cm cuff of muscle overlying periosteum on
above the distal end of the fibula. A skin paddle bone. Proximal and distal osteotomies were
was then designed to meet soft tissue require- first executed. The distal aspect of the artery
ments with the CT-angiogram-verified perforator and veins was ligated and divided, and the
marked after ultrasound confirmation (Fig. 2). flap was raised in a distal to proximal manner
and isolated on the peroneal artery and the
accompanying venae comitantes.
Surgical Technique 5. Additional osteotomies were then performed to
achieve three segments designed intrao-
1. The resection was performed by a combined peratively at the resection site and transferred
neurosurgery and head and neck surgery by copying measurements on an identical dis-
team. First an orbital exenteration was posable ruler for the flap harvest team.
performed in a standard fashion. The bony 6. The facial artery and vein on the left side of
skull and skullbase were resected from the neck were simultaneously prepared as
above after a bicoronal flap had been dis- recipient vessels at the level of the mandible
sected to slightly above the superior orbital to ensure adequate length of the pedicle with-
rim. The orbital content, orbital rims, and the out vein grafting.
anterior skullbase were excised en bloc. With 7. A subcutaneous tunnel was dissected between
the dura mater exposed, a part of the dura was the defect and recipient vessels where a large
excised and a dural reconstruction performed. endotracheal tube (ET) was inserted.
2. The fibula osteocutaneous flap was elevated 8. A suction drain was then used to transpose the
just above the muscle and deep to the pedicle from the defect to the recipient vessels
Fig. 2 Preoperative
marking of fibular bone and
skin
as previously described (Lundgren et al. order to facilitate mobilization of the fibular

2016). bone during harvest.
9. A de-epithelialized part of the skin paddle 5. Perform osteosynthesis prior to revasculariza-
was first used to seal off intracranial space in tion in order to achieve the exact position of the
order to avoid any cerebrospinal fluid (CSF) pedicle, which will limit the risk of any
leakage. Microplates (Synthes) secured by kinking.
4 mm micro screws were then used to connect 6. Avoid placing the titanium plates at the most
all three segments and further anchor the protruding parts of the bone so as to reduce risk
whole construct to the facial skeleton. of late penetration and exposure through the
10. The flap was then revascularized after anas- skin. The bone is not bearing force or subject to
tomosis to the right facial artery and vein, movement, so thin microplates are sufficient
before the skin paddle was sutured externally. for stability.
The remaining part of the de-epithelialized 7. The bony parts shall be placed for optimal
skin paddle was then used to obliterate the facial contour keeping in mind that any mus-
maxillary sinus. The upper and lower eyelids cular remnants on the fibulae bone that may
were not resected and could be used as orbital give extra volume at the time of reconstruction
lining. will retract and shrink in a few weeks.
11. The donor site was closed with a split thick- 8. A running suture is optimal to create a water-
ness skin graft (STSG) harvested from the tight closure but should be secured by single
thigh and meshed at 1:1.5 ratio. sutures as well to reduce the risk for a suture
12. Due to wound dehiscence and instability of break that causes the whole reconstruction to
the eyelid skin lining the orbit, a second stage collapse.
of surgery was planned before adjuvant radio-
therapy was administered. Under general
anesthesia, a revision was performed and the Intraoperative Images
remaining defect covered with a paramedian
forehead flap. The flap was harvested from Primary Surgery (Figs. 3, 4, 5, 6 and 7)
the contralateral side and transposed after a
diagonal incision over the glabellar region in Second Stage (Fig. 8)
order to enable a one-stage solution.
Technical Pearls Postoperative Management
1. Use the most distal part of the harvested fibular The patient is closely monitored clinically post-
bone and the nearest recipient vessel option in operatively, with the head elevated 30–45
order to prevent vein grafting. degrees to reduce swelling. The flap was moni-
2. With a vascular pedicle exiting anteriorly, a tored with a Cook-Swartz implantable doppler
fibula harvested from ipsilateral side from the (Cook Medical), since no perforator could be
recipient vessels is planned for, if the skin monitored externally. Only low-molecular-
paddle shall be oriented internally in first weight heparin was used as anticoagulant regi-
place to address the intracranial defect. men (both pre- and postoperatively) without any
3. Preservation of 8 cm of the distal fibula is intraoperative additional anticoagulant agent.
recommended to ensure ankle mortise. The foot is slightly elevated and checked for
4. An additional 1 cm of bone can preferably be peripheral pulses. Patient was allowed to ambu-
resected adjacent to the proximal osteotomy in late the day after surgery.
Fig. 3 Three segments

were designed
intraoperatively at the
resection site
Fig. 4 The design was

further transferred by
copying the measurements
to an identical disposable
ruler for the flap harvest
team
bone was later completely incorporated into the

remaining facial skeleton (Fig. 9).
The patient experienced uneventful recovery with
watertight closure of the intracranial defect after
reconstruction. The patient was abulating postop Avoiding and Managing Problems
without pain, and both the donor and reconstruc-
tion sites healed uneventfully. The depth of the 1. Careful preoperative evaluation of both CT-
orbit was further improved with lining of forehead scan and MRI when determining the resection
skin after the second stage of surgery. The fibular lines, in order to ensure a safe surgical plan
Fig. 5 Osteotomies were

performed on the lower leg
to reduce the ischemia time
Fig. 6 Osteosynthesis of
the three segments anchored
to the facial skeleton
with a reconstruction that meets the require- 4. Always consider anastomosis in vicinity to the
ments of the defect. defect to avoid vein grafts.
2. Preoperative CT-angiogram of the donor site is 5. If postoperative radiation is used, it is
regularly used at our institution not only to likely that skin defects will occur espe-
identify peripheral arterial disease and anoma- cially at suture lines or at the orbital apex.
lies, but also to map perforators to better plan Do have a plan for later coverage already
soft tissue components. at the time of the initial reconstruction.
3. The need for extra soft tissue should to be taken Always try to protect the contralateral
into account to address both internal and external supratrochlear artery in order to have the
defects. The skin paddle is usually harvested a option to perform a forehead flap. The fore-
bit larger than calculated to ensure adequate head flap is very useful for smaller defects
coverage. in and around the orbit.
Fig. 7 Immediate postop

view following the first
stage
Fig. 8 A paramedian forehead flap was used for orbital lining, harvested from the contralateral side and transposed after a
diagonal incision over the glabellar region
2. Preoperative planning is mandatory for both

Learning Points
bony and soft tissue components. Detailed
1. Successful reconstruction of the orbitomaxillary imaging of the donor site and virtual surgical
region necessitates a breakdown of the defect planning can increase patient safety and shorten
into facial aesthetic subunits and mandates to operative time respectively (Garvey et al. 2012).
address any loss of integrity, such as maxillary 3. The eyelid skin proved to be an insufficient
sinus and/or intracranial exposure. lining; therefore, a forehead flap was used at a
Fig. 9 Immediate postop

CT
second stage, so that the orbital construct would mapping of free fibula osteocutaneous flaps for head
better withstand postoperative radiotherapy. and neck reconstruction. Plast Reconstr Surg. 2012
Oct;130(4):541e–9e.
Li D, Jie Y, Liu H, Liu J, Zhu Z, Mao C. Reconstruction of
anophthalmic orbits and contracted eye sockets with
References microvascular radial forearm free flaps. Ophthalmic
Plast Reconstr Surg. 2008;24(2):94e–7e.
Abou-Foul AK, Borumandi F. Anatomical variants of Lundgren TK, Pignatti M, Halle M, Boscaini G, Skogh
lower limb vasculature and implications for free fibula AC, Luigi C, De Santis G. Composite orbital recon-
flap: systematic review and critical analysis. Microsur- struction using the vascularized segmentalized osteo-
gery. 2016;36(2):165–72. fascio-cutaneous fibula flap. J Plast Reconstr Aesthet
Cevik P, Dilber E, Eraslan O. Different techniques in Surg. 2016;69(2):255–61.
fabrication of ocular prosthesis. J Craniofac Surg. Metzler P, Geiger EJ, Alcon A, Ma X, Steinbacher DM.
2012;23(6):1779e–81e. Three-dimensional virtual surgery accuracy for free
Chang DW, Langstein HN, Gupta A, et al. Reconstructive fibula mandibular reconstruction: planned versus
management of cranial base defects after tumor abla- actual results. J Oral Maxillofac Surg. 2014;72(12):2
tion. Plast Reconstr Surg. 2001;107:1346e–55e. 601–12.
Garvey PB, Chang EI, Selber JC, Skoracki RJ, Madewell Perman KI, Baylis HI. Evisceration, enucleation, and exen-
JE, Liu J, Yu P, Hanasono MM. A prospective study of teration. Otolaryngol Clin N Am 1988;21(1):171e-
preoperative computed tomographic angiographic 182e.
Hypopharynx Reconstruction with a
Chimeric Musculocutaneous 22
Anterolateral Thigh Free Flap
Holger Jan Klein and Andres Rodriguez-Lorenzo
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Electronic supplementary material: The online version

of this chapter (https://doi.org/10.1007/978-3-030-23706-
6_26) contains supplementary material, which is available
to authorized users.
H. J. Klein (*)
Department of Plastic and Hand Surgery, University
A. Rodriguez-Lorenzo
Department of Plastic and Maxillofacial Surgery, Uppsala
Uppsala, Sweden

https://doi.org/10.1007/978-3-030-23706-6_26
208 H. J. Klein and A. Rodriguez-Lorenzo
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Abstract
Pharyngolaryngectomy is a common procedure

for circumferential hypopharyngeal and
advanced laryngeal neoplasms. Reconstruction
of such defects is essential to improve function
assuring the patients’ quality of life. We herein-
after present an 82-year-old patient with a sec-
ondary hypopharyngeal carcinoma with severe
dysphagia while eating and drinking. The
patient had undergone combined radio/chemo-
therapy with neck dissection on her left side
10 years before. Total pharyngolaryngectomy
was performed with pharyngo-esophageal
reconstruction using a chimeric anterolateral
thigh and vastus lateralis flap aiming at restora-
tion of the continuation between pharynx and
esophagus as well as soft tissue coverage of the Fig. 1 Endoscopic (anterior) view showing the tumor
(white mass) at the left aryepiglottic transition
radiation-depleted neck. The patient recovered
well with successful swallow examination after
14 days. The advantage of chimeric flaps in
pretreated patients undergoing pharyngolar-
yngectomy is highlighted in this chapter.
Keywords
Hypopharynx reconstruction · Pharyngo-

esophageal reconstruction · Chimeric antero-
lateral thigh flap · Vastus lateralis
Clinical Scenario
An 82-year-old female patient presented with a

secondary hypopharyngeal carcinoma with severe
dysphagia while eating and drinking. Figures 1, 2,
and 3 depict the tumor located at the aryepiglottic
Fig. 2 Endoscopic (anterior) view showing the tumor
transition. The patient had undergone combined (white mass) at the left aryepiglottic transition
radio/chemo-therapy with neck dissection on her
left side 10 years before, when the first hypo- according to the head/neck tumor board decision.
pharyngeal carcinoma was found. The skin around Additionally, the patient presented with chronic kid-
her neck had become excessively firm and thin due ney disease, diabetes, and longstanding generalized
to prior radiation. Total pharyngolaryngectomy with arteriosclerosis with numerous percutaneous trans-
pharyngo-esophageal reconstruction was scheduled luminal angioplasties (PTA) and stentings.
22 Hypopharynx Reconstruction with a Chimeric Musculocutaneous Anterolateral Thigh Free Flap 209
4. Insetting of the ALT.

5. Anastomosis.
6. Insetting of the Vastus lateralis muscle to cover
the neck.
7. Split thickness skin graft for coverage of
Vastus lateralis muscle.
• Pedicled myocutaneous Pectoralis major flap

• Pedicled myocutaneous Latissimus dorsi flap
The patient is carefully examined for previous

scars on the thighs. The amount of redundant
tissue and its thickness on the anterolateral thigh
is roughly estimated by pinch test. ALT perfora-
Fig. 3 Schematic view from posterior on the larynx and tors are identified with a hand-held Doppler.
base of the tongue depicting the tumorous mass at the
aryepiglottic transition

Preoperative Problem List and Drawing
The patient is placed in supine position. The authors
1. Need for sufficient vascularized tissue for prefer ALT harvesting on the right thigh for right-
tubed pharyngo-esophageal reconstruction in handers and vice versa as the direction of perforator
a multimorbid patient (Yu et al. 2010; Lewis and pedicle dissection is more intuitive. A straight
et al. 2006) line is drawn from the anterior superior iliac spine to
2. Need for vital tissue to cover the neck with the lateral upper pole of the patella. The perforators
respect to the heavily radiated skin of the can be confirmed and marked on the skin again
neck (Lawson and Moreno 2016) within the middle third of the drawn line. A large
3. Problem of previous neck dissection with lim- medial crescent shaped line is drawn for the initial
ited recipient vessels and generalized arterio- incision guaranteeing optimal anatomical overview.
sclerotic affection Adjacent to this line, the design of a fasciocutaneous
skin paddle is placed around the most proximal
reliable perforator according to the length and diam-
Treatment Plan eter of the resected specimen. The diameter of the
remaining pharynx/esophagus multiplied by Pi (π)
1. Tumor resection is performed by Ear-Nose- equals the circumference of the required tubed skin
Throat (ENT) surgeons. paddle. Average circumference is about 9–10 cm in
2. Design and dissection of an antero-lateral a normal sized patient. A funnel-shaped/trapezoidal
thigh (ALT) flap according to the extent of design is recommended to account for a larger
the resection (length and diameter). diameter towards the pharyngeal side and a smaller
3. Partial Vastus lateralis muscle is included in the diameter towards the esophagus.
dissection supplied by the same pedicle for The head should be placed in a mold enabling
subsequent neck coverage. rotation to both sides. The anterior thorax should
be included in disinfection and draping to be and evert the inner lining into the lumen of the
prepared for pedicled reconstruction alternatives pharyngo-esophageal tube. A second suture
if free tissue transfer is impossible or fails for any line of the ALT fascia (outer lining) is
reason. recommended to sealing up the inner lining
avoiding salivary fistulas.
4. Anastomosis: The artery is now connected to
Surgical Technique the right facial artery end-to-end with a 9/
0 nylon under the microscope. Likewise, the
1. Tumor resection: Total laryngopharyngectomy venous anastomosis is performed to an ade-
with placement of a tracheostoma is performed quate branch of the internal jugular vein with
by ENT surgeons. a 3.0 mm coupler.
2. Flap raising: After the marking and design of 5. Neck coverage: The muscular portion of the
the flap is determined (funnel-shaped flap is now placed over the neopharynx and
11 9 7 cm), a large medial incision and fixed to the base of the tongue as well the
subfascial preparation is performed. The sep- sternocleidomastoid muscle in order to func-
tum between the rectus femoris and vastus tion as well vascularized tissue layer for the
lateralis muscle containing the descendent significantly compromised skin of the neck.
branch of the A. circumflexa femoris lateralis Where skin perfusion is vague, generous resec-
is performed. Then identification of the perfo- tion of the skin is advisable. A meshed split
rators and choosing a reliable proximal perfo- thickness skin graft placed on the vastus
rator supplying the planned skin paddle. lateralis muscle yields optimal esthetic results
Corresponding readjustment of the flap design and serves as monitor island simultaneously.
on the skin is sometimes necessary. Perforator 6. Wound closure: Ample irrigation and hemosta-
dissection is performed from distal to proximal sis is necessary in the neck. A 12 Charr. drain is
until the descendent branch is reached. Along placed through the sternocleidomastoid muscle
the descendent branch, the muscular compo- on both sides. The remaining skin of the neck is
nent of the chimeric flap is determined with fixed to muscle or closed primarily where
18 20 cm for later neck coverage. Then possible.
completion of the dissection of the descendent
branch up to the A. circumflexa femoris
lateralis and dividing it at its distal end. To Technical Pearls
easier raise the muscle component with the
flap, the lateral ALT incision is now performed. • Leaving the descendent branch fully attached
The vastus lateralis muscle is dissected with a to the vastus lateralis muscle component
thickness of approximately 2 cm. The raising of avoids meticulous perforator dissection and
the flap with its two components can now be saves time.
completed and checked for adequate perfusion – • Early lateral skin incision simplifies complete
ready to be transferred to the neck. After metic- vastus lateralis muscle raising along the
ulous hemostasis and placement of a 16 Charr. descendent branch.
drain, the donor site is closed primarily. • Skin grafts for the neck can be harvested from
3. Flap insetting: The flap is oriented with its the redundant ALT-tissue proximal and distal
larger end towards the remaining pharynx and to the planned skin paddle.
the pedicle is directed in the right neck, where • Meshed split thickness skin graft placed on the
adequate vessels have been identified. The flap vastus lateralis muscle yields optimal esthetic
is tubed and sutured to the pharynx and esoph- results and serves as monitor island
agus from posterior to anterior to reconstruct simultaneously.
the pharyngo-esophageal continuation. These • Drains placed through the sternoclei-
sutures should grab enough tissue (“big bite”) domastoid muscle optimally drain the deep
parapharyngeal space and have less tendency • Prophylactic anticoagulation with Heparin
to dislocated. 100 000 UI/24 h via perfusion
• Clinical flap monitoring and Doppler monitor-
ing every 2 h for 48 h, then every 4 for 72 h
Intraoperative Images • Drain removal after 48 h
• Bed rest for 12–24 h, then successive early
See Figs. 4, 5, 6, 7, 8, and 9. mobilization
Postoperative Management Outcome
• 40 upper body position The patient recovered well and demonstrated
• Broad-spectrum antibiotic prophylaxis for complete swallowing after 14 days without fistula
5 days (Video 1; Fig. 10). The skin of the neck showed
• Feeding via nasogastric tube complete healing without necrosis or develop-
• Swallow examination after 10–14 days ment of a frozen neck.
Fig. 4 Chimeric ALT flap

with a thin vastus lateralis
muscle layer for neck
coverage. Note the fully
attached descendent branch
onto the vastus lateralis
muscle without perforator
dissection saving precious
time
Fig. 5 Chimeric ALT flap

with a thin vastus lateralis
muscle layer ready for
insetting
Fig. 6 The tubed ALT skin

paddle has been inset with
anastomosis to the right
neck (facial artery and
branch of the internal
jugular vein). The muscle
component is folded back
temporarily
Fig. 7 The vastus lateralis

muscle component is placed
over the neopharynx and
big vessel sheath on both
sides serving as well
vascularized support for the
deteriorated skin of the neck
Fig. 8 Lateral view on the

left neck after closure
Fig. 9 Lateral view on the

left neck after closure and
split thickness skin grafting.
The grafted area serves as
monitor island
simultaneously
Fig. 10 Swallow
examination (left) and
postoperative PET-CT scan
(right) depicting the
reconstructed pharyngo-
esophageal transition in the
neck without leakage
• Clinical monitoring of the flap by inspec-

tion of the monitor island remains gold
• Physiotherapy with early mobilization at the standard as doppler signals can be mislead-
first postoperative day is recommended to ing due to the adjacent big vessels of the
avoid pneumonia and further complications in neck. If in doubt, scratching the monitor
multimorbid patients. The neck should not be island gives reliable information on in-
moved for 4 days. and outflow.
• Drains placed through the sternocleidomastoid • The nasogastric tube should remain at least for
muscle optimally drain the deep parapharyngeal 10 days to avoid aggressive reflux to the
space and have less tendency to dislocated sutures of the tubed ALT flap. Additional anti-
potentially endangering the anastomosis. reflux medication is recommended.
Learning Points Cross-References
• Chimeric flaps enable optimal functional ▶ Tongue Reconstruction with Medial Sural
reconstruction of the hypopharynx with Artery Perforator Flap
simultaneous tissue support of the radiated ▶ Utility of Temporoparietal Adipofascial Free
neck. Flap in Laryngotracheal Reconstruction
• The muscle tissue covering the neck might
serve as monitor island.
• The pedicle length of chimeric flaps for hypo- References
pharynx reconstruction might be moderate
long to short due to the directly adjacent ves- Lawson BR, Moreno MA. Head and neck reconstruction
sels of the neck for anastomosis. with chimeric anterolateral thigh free flap: indications,
• ALT flap for hypopharynx reconstruction outcomes, and technical considerations. Otolaryngol
Head Neck Surg. 2016;154(1):59–65.
should be avoided in obese patients. An alter- Lewin JS, Barringer DA, May AH, Gillenwater AM,
native is a myocutaneous pectoralis major flap Arnold KA, Roberts DB, et al. Functional outcomes
if two components are needed. after laryngopharyngectomy with anterolateral thigh
• Physiotherapy with early mobilization at the flap reconstruction. Head Neck. 2006;28(2):142–9.
Yu P, Hanasono MM, Skoracki RJ, Baumann DP, Lewin
first postoperative day is recommended to JS, Weber RS, et al. Pharyngoesophageal reconstruc-
avoid pneumonia and further complications in tion with the anterolateral thigh flap after total
multimorbid patients. laryngopharyngectomy. Cancer. 2010;116(7):1718–24.
TPFF Augmentation of Primary
Pharyngeal Closure Following Total 23
Laryngectomy

Ralph W. Gilbert
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Surgical Technique (Video 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Electronic Supplementary Material: The online version

A. Sahovaler
Department of Otolaryngology–Head and Neck Surgery,
Sunnybrook Health Sciences Centre, University of
Princess Margaret Hospital–University Health Network,
University of Toronto, Toronto, ON, Canada
D. J. Enepekides (*) · K. M. Higgins
e-mail: danny.enepekides@sunnybrook.ca; kevin.
higgins@sunnybrook.ca
R. W. Gilbert
e-mail: ralph.gilbert@uhn.ca

https://doi.org/10.1007/978-3-030-23706-6_27
216 A. Sahovaler et al.
Endoscopic-Assisted Harvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Abstract precluded future nonsurgical options mandating

Reports of pharyngocutaneous fistula rates in surgical rescue with a total laryngectomy.
total laryngectomies (TL) after radiation fail-
ure are as high as 57% Dirven et al. (2009),
Furuta et al. (2008), and primary closure of the
pharynx was associated with a statistically
higher overall fistula rate and fistula requiring
• Previously irradiated field in a smoker patient,
reoperation compared to reconstruction with
severely hampering the vascularity of local
vascularized tissue augmentation Microvascu-
tissues.
lar Committee of the American Academy of
• Tumor sparing of the piriform sinus mucosa
Otolaryngology-Head & Neck Surgery (2019).
allowing for a primary closure of the pharyn-
Therefore, the most employed surgical strategy
geal remnant.
to reduce these rates has been the recruitment
• A well-vascularized coverage in close proxim-
of non-irradiated tissue to overlay the pharyn-
ity to the pharyngeal closure would be required
geal closure, even in the context of TL, where
both to reinforce the suture line and promote
there is sufficient pharyngeal tissue to be
neo-vascularization.
closed primarily. The temporoparietal fascial
free flap (TPFF) represents an ideal option to
perform this task as it is a thin, pliable tissue
with robust vascularization and an insignificant
Treatment Plan
donor site morbidity Higgins et al. (2012).
After the ablative portion of the procedure, the
ultimate objective is to cover the pharyngeal clo-
Keywords
sure with vascularized tissue.
Temporoparietal free flap · Salvage The temporoparietal fascia free flap (TPFF)
laryngectomy was decided to be used for this reconstruction.
The temporoparietal fascia (TPF) is vascul-
arized by the superficial temporal artery (STA),
Clinical Scenario which courses over its outer surface and divides
2–3 cm superior to the zygomatic arch into an
A 65-year-old male, 40 pack-year smoker is pre- anterior and posterior branch with one or two
sented, who was initially treated with chemora- venae comitantes. An extensive prospective
diotherapy for a T4aN2a supraglottic squamous description of the vascular supply of the TPF
cell carcinoma. A year later he developed a recur- (Park et al. 1999) has shown that in 63% of cases
rence located in the aryepligottic fold extending to the pattern of vascularization consists of an STA
the thyroid cartilage. Primary radiation treatment and one vein. The remaining vascular anatomical
23 TPFF Augmentation of Primary Pharyngeal Closure Following Total Laryngectomy 217
variants included an STA and a posterior auricular muscle. However, its location makes it difficult
vein (18%) and a posterior auricular artery and a for a two-team approach. In addition, shoulder
vein (6.5%) among others. Measurements of the dysfunction, especially when performed in com-
dominant vessel sizes in the preauricular or post- bination with an ipsilateral neck dissection,
auricular area demonstrated mean diameters of decreased chest wall compliance, difficulty with
1.7 mm for the artery and 2.2 mm for the vein. speech rehabilitation, and excessive bulk leading
The auriculotemporal nerve, a sensory branch to wound breakdown have been widely reported
of the trigeminal nerve, is invariably present when (Moukarbel et al. 2010).
harvesting the flap, usually running superficial to Fascial radial forearm free-flaps (FRFFF) have
the STA. This raises the possibility of harvesting been also explored as a reconstructive option in this
the TPFF as a sensate flap. setting. Feasibility of a two-team approach and a
There are some disadvantages to the TPFF free longer pedicle with larger vessels are among its
flap. Although vessel caliber is more than adequate attributes. A reduction in major wound complica-
in most cases, small vessel caliber may occasion- tions but similar rates of pharyngocutaneous fistula
ally be encountered. Pedicle length can also be have been observed in the literature compared to
problem in the vessel depleted neck. However, simple pharyngeal closure (Fung et al. 2007). The
when used in the clinical scenario herein described anterolateral Thigh free-flap (ALT) has been tradi-
this is compensated by proximity of the flap to the tionally employed mostly for partial or total
recipient vessels (usually thyroid artery and vein). pharyngectomy defects. Likewise, it can also
Whereas the anatomy of the STA is relatively cover the pharyngeal closure sharing some of the
constant, venous anatomy is variable. This some- advantages with FRFFFs, with the addition of pro-
times necessitates capturing the posterior auricu- viding larger dimensions of vascularized tissue. The
lar vein when adequate venae comitants cannot be main disadvantage is the thickness of the flap, even
found. In cases where a good venous signal can- if harvested as a perforator-based flap or supra-
not be found preoperatively, the contralateral vas- fascially.
cular anatomy should be assessed. In rare cases Recent reports have proposed the infraclavicular
where a superior temporal vein cannot be identi- flap (IFF) as a preferred option to bolster the neo-
fied on either side by doppler, we advocate mak- pharyngeal closure. The benefits include a relative
ing the preauricular incision and exploring the easy of harvest, it pedicled nature, and low mor-
pedicle as an initial step in the harvest. bidity (Yoo and Belzile 2015). Even though the
The TPFF is not recommended in patients with quality of tissue is comparable to the TPFF, the
previous history of parotidectomy, bicoronal infraclavicular flap can be excessively thin and
approaches, trauma, and temporal arteritis. If the vascularization is less robust.
being considered in such patients an intact vascu- The TPFF combines reduced donor site mor-
lar pedicle should be confirmed preoperatively. bidity compared to the pectoralis major and RFFF,
As with any laryngeal cancer salvage case, it is and thickness compared to the FRFFF, providing
paramount to corroborate the status of the hypo- a more robust tissue vascularized tissue than the
pharynx. If partial or total pharyngeal reconstruc- IFF.
tion is required, a different donor site must be used.

Imaging studies are not routinely performed pre-
The Pectoralis Major muscle flap has represented operatively. A flow Doppler was employed to map
the classic option for coverage of the pharyngeal the vascular anatomy of the temporoparietal area
closure after total laryngectomy (Righini et al. after induction of anesthesia in the operating
2005). Its advantages include ease of harvest, room. The main consideration is to determine
pedicled nature, and volume of well vascularized the venous anatomy which is less consistent, as
previously stated the vein can follow a divergent • As dissection proceeds to the vertex of the
course from the arterial pedicle. skull, separation becomes increasingly difficult
secondary to the fibrous connections and the
perforating vessels from the superficial tempo-
Preoperative Care and Patient ral artery to the overlying scalp. Meticulous
Drawing hemostasis is required. Countertraction of the
scalp by an assistant significantly facilitates
When utilized for defects located in the neck, the dissection.
TPFF allows for a two-team approach. The patient • The anterior dissection is limited by the frontal
is positioned supine and the head is supported on a branch of the facial nerve which lies deep to the
horseshoe surgical head rest in a lateral position. TPF. As a general rule, anterior dissection
This allows to easily turn the head to the contra- should not be carried below the level of the
lateral side if the flap artery or vein are insufficient anterior branch of the superficial temporal
for free tissue transfer. artery.
A chevron-style or hemi-coronal incision is • The complete vascular anatomy of the flap can
marked. If local infiltration with dilute epineph- be identified at this point, with the anterior and
rine is employed, care should be taken to avoid the posterior branches of the STA. Bleeding from
main pedicle throughout the injection process and the sharp dissection is usually controlled taking
applied superficially. An additional line between a extreme care in not cauterizing the main
point 5 mm below the tragus and 15 mm above the vessels.
lateral eyebrow (Pitanguy’s line) can be marked to • Dissection is continued to the required size,
identify the presumed course of the frontal branch which can reach dimensions up to 14 17 cm.
of the facial nerve. Moreover, a facial nerve mon- • When the adequate size is reached, the TPF is
itor can be utilized as an extra measure to protect incised until the plane of the superficial layer of
the nerve. The entire head and neck region the deep temporal fascia. The deep aspect of
(including the scalp) is prepared and draped in the flap can be easily dissected from the deep
the customary fashion and prophylactic antibi- fascia as it is represented by a loose areolar
otics are administered. tissue.
• The attention is then turned to the final vascular
pedicle dissection, in case an STA and a vein
Surgical Technique (Video 1) are present, they are carefully followed until
their entrance to the parotid gland or until the
• An incision is made following the preoperative base of the tragus and circumferentially dis-
markings, preferably using scalpel. sected. If there is a posterior auricular vein as
• Dissection begins in the preauricular area to an anatomical variant, then it is dissected and
identify the vascular pedicle. The planes are incorporated to the flap. Pedicle length can be
more easily identified in this area, and the sepa- up to 7 cm long.
ration between the TPF and the dermis is looser. • After division of the pedicle the skin is closed
The artery and vein can be distant from each in layers over a closed-suction drain.
other.
• Flap elevation is carried cephalad in a sub-
follicular supra-superficial musculoaponeurotic Endoscopic-Assisted Harvesting
system plane exposing the TPF. This is
performed using with scalpel or jeweled micro- In order to avoid large scars, a minimally invasive
bipolar forceps. Needle point coagulator in low harvesting method was described for TPFF
setting can also be employed. This is to both harvesting (Yano et al. 2001). This entails a 4 cm
protect the fascial vessels as well as prevent preauricular incision to identify the main pedicle
thermal injury to the hair follicles in this area, and then completing the cephalad anterior and
which may result in postoperative alopecia. posterior dissection using a 30° endoscope and
endoscopic cauterization devices. An additional constrictor muscle whenever possible, the

upper scalp incision can be used to facilitate the TPFF is then applied directly over the pharyn-
flap elevation, and the two incisions are connected geal closure.
through the plane between the scalp and TPF • Absorbable sutures are placed to anchor the
(Helling et al. 2008). Noteworthy, there is a sig- TPFF preferably to the prevertebral fascia or
nificant learning curve with this technique and constrictor fascia laterally and to the subman-
should be reserved for those who master the dibular gland or the digastric muscle superiorly.
open harvest technique. • With respect to the microvascular anastomosis,
the superior thyroid artery and vein and the
middle thyroid vein possess adequate size
Technical Pearls match with the vessels of the TPFF. The short
nature of the pedicle is typically not an issue
• Initiate the harvest on the pre-auricular area to given the proximity of the pharyngeal closure
identify the arterial and venous pedicle. The to the carotid sheath.
vein can run away from the STA, usually pos- • This is a very straight forward procedure. It has
terior to it. Consider the existence of a posterior been our experience that the venous drainage
auricular vein. If both vessels are not identified, of this flap is most reliable on the right.
then it is advisable to explore the contralateral • As most fistulae occur at the base of tongue or at
side. Be mindful that the flap can be based and the most dependent distal end of the pharyngeal
harvested on the posterior auricular vessels as closure, it is essential that the length of the
well. closure be known prior to flap harvest. The flap
• Take special care to not harm the vein during should completely cover these two critical areas.
the first portion of the harvest as it lies in a
more superficial plane than the artery.
• Keep in mind the frontal branch of the facial Intraoperative Images
nerve, coursing over the Pintanguy’s line. Dis-
section anterior to the anterior branch of the See Figs. 1, 2, 3, 4, 5, 6, 7, and 8.
STA should be carefully executed.
• As a general rule, dimensions of 15 8 cm are
sufficient to cover the entire pharyngeal Postoperative Management
closure.
• Once the tracheostomy is performed and a two- The patient left the operating room with a naso-
layer primary closure of the pharynx com- gastric tube. Nasogastric tubes are needed for feed-
pleted with incorporation of the inferior ing unless a gastrostomy tube is in place.
Fig. 1 Preoperative
marking of the patient with
a chevron-style incision
Fig. 2 Initial dissection to

identify venous anatomy of
the flap
Fig. 3 The flap is elevated

after the desired dimensions
are obtained
Fig. 4 The deep aspect of

the flap is easily dissected
from the deep fascia
Fig. 5 Primary pharyngeal

closure in a “T” fashion,
incorporating some of the
inferior constrictor
musculature
Fig. 6 TPFF inset over the

pharyngeal closure
Fig. 7 Close up image

showing adequate coverage
in critical areas (base of
tongue and distal end of the
pharyngeal closure)
Fig. 8 In this case the right

superior thyroid artery and
the internal jugular vein
(end to side) were used as
donor vessels. Note the
appropriate size match
between the thyroid artery
and the STA
Antithrombotic measures consist in early mobiliza- • Keep in mind the frontal branch of the facial
tion and heparin prophylaxis, while antibiotic treat- nerve (nerve monitoring/Pitanguy’s line), and
ment should cover intraoral and skin flora. Drain is avoid excessive anteroinferior dissection to the
usually removed on postoperative day 2–3. anterior branch of the STA.
On postoperative day 7 a barium swallow was • The pedicle length is limited but compensated
performed and no leak was detected. Oral diet was by the proximity to the donor vessels (superior
started in a stepwise fashion (fluids, semisolids, thyroid artery and vein). It is recommended to
full diet). follow the pedicle until its entrance to the
parotid gland.
Outcome
References
A primary tracheoesophageal puncture (TEP) was
placed during the operation and eventual success- Dirven R, Swinson BD, Gao K, Clark JR. The assessment
of pharyngocutaneous fistula rate in patients treated
ful voicing with a TEP prosthesis was achieved.
primarily with definitive radiotherapy followed by sal-
vage surgery of the larynx and hypopharynx. Laryngo-
scope [Internet]. 2009;119(9):1691–5. Available from
Avoiding and Managing Problems http://www.ncbi.nlm.nih.gov/pubmed/19544379
Fung K, Teknos TN, Vandenberg CD, Lyden TH, Bradford
CR, Hogikyan ND, et al. Prevention of wound compli-
The deleterious impact of radiotherapy on wound cations following salvage laryngectomy using free
healing is well-known. If dehiscence of the neck vascularized tissue. Head Neck [Internet]. 2007;29
incision occurs with flap exposure, the inherent (5):425–30. Available from: http://doi.wiley.com/10.
rich vascular network of the flap will allow gran- 1002/hed.20492
Furuta Y, Homma A, Oridate N, Suzuki F, Hatakeyama H,
ulation and secondary intention healing. Suzuki K, et al. Surgical complications of salvage total
laryngectomy following concurrent chemoradiotherapy.
Int J Clin Oncol. [Internet]. 2008;13(6):521–7. Available
Learning Points from: http://www.ncbi.nlm.nih.gov/pubmed/19093180
Helling ER, Okoro S, Kim G, Wang PTH. Endoscope-
assisted temporoparietal fascia harvest for auricular
• Determining the vascular anatomy of the TPF reconstruction. Plast Reconstr Surg [Internet].
with a handheld or color doppler before 2008;121(5):1598–605. Available from: http://con
harvesting the flap is paramount. tent.wkhealth.com/linkback/openurl?sid¼WKPTLP:
landingpage&an¼00006534200805000-00011
• The flap vein can follow an anomalous/diverg- Higgins KM, Ashford B, Erovic BM, Yoo J, Enepekides
ing course from the artery. In our experience, DJ. Temporoparietal fascia free flap for pharyngeal
venous anatomy is most reliable on the right. coverage after salvage total laryngectomy.
Laryngoscope [Internet]. 2012;122(3):523–7. Avail- Microvascular Committee of the American Academy

able from: https://doi.org/10.1002/lary.22477 of Otolaryngology-Head & Neck Surgery. Salvage
Moukarbel R V., Fung K, Franklin JH, Leung A, Rastogi R, laryngectomy and laryngopharyngectomy: Multi-
Anderson CM, et al. Neck and shoulder disability fol- center review of outcomes associated with a recon-
lowing reconstruction with the pectoralis major pedi- structive approach. Head Neck [Internet]. 2019;41
cled flap. Laryngoscope. [Internet]. 2010;n/a-n/a. (1):16–29. Available from: https://doi.org/10.1002/
Available from: https://doi.org/10.1002/lary.20900 hed.25192
Park C, Lew DH, Yoo WM. An analysis of 123 tempo- Yano H, Fukui M, Yamada K, Nishimura G. Endoscopic
roparietal fascial flaps: anatomic and clinical consider- harvest of free temporoparietal fascial flap to improve
ations in total auricular reconstruction. Plast Reconstr donor-site morbidity. Plast Reconstr Surg [Internet].
Surg [Internet]. 1999;104(5):1295–306. Available from: 2001;107(4):1003–9. Available from: http://www.
http://www.ncbi.nlm.nih.gov/pubmed/10513909 ncbi.nlm.nih.gov/pubmed/11252096
Righini C, Lequeux T, Cuisnier O, Morel N, Reyt E. The Yoo J, Belzile M. Infraclavicular free flap for head and
pectoralis myofascial flap in pharyngolaryngeal sur- neck reconstruction: Surgical description and early out-
gery after radiotherapy. Eur Arch Oto-Rhino-Laryngol- comes in 7 consecutive patients. Head Neck [Internet].
ogy [Internet]. 2005;262(5):357–61. Available from: 2015;37(3):309–16. Available from: https://doi.org/10.
https://doi.org/10.1007/s00405-004-0827-8 1002/hed.23597
Utility of Temporoparietal
Adipofascial Free Flap 24
in Laryngotracheal Reconstruction

Ralph W. Gilbert
Contents
Clinical Scenario: Temporoparietal Fascial Free Flap for Recurrent T1-T2
Glottic Cancers Treated with Primary Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Preoperative Problem List/Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Preoperative Evaluation and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Preoperative Care and Patient Drawing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Supplementary Information: The online version of this

chapter (https://doi.org/10.1007/978-3-030-23706-6_122)
contains supplementary material, which is available to
authorized users.
A. Sahovaler
D. J. Enepekides (*) · K. M. Higgins
e-mail: danny.enepekides@sunnybrook.ca;
kevin.higgins@sunnybrook.ca
R. W. Gilbert
e-mail: ralph.gilbert@uhn.ca

https://doi.org/10.1007/978-3-030-23706-6_122
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Abstract disease and no pulmonary comorbidities preclud-

Early stage glottic cancers (T1-T2) are treated ing open surgery.
with primary radiotherapy or minimally inva- The approach consisted in a vertical partial
sive surgical approaches (transoral laser micro- laryngectomy (VPL). This included the resection
surgery -TLM). Both treatments have similar of the ipsilateral thyroid cartilage, the anterior
oncologic control rates and voice outcomes. In commissure and one vocal cord. A functioning
case of recurrence after radiotherapy, the trans- ipsilateral arytenoid cartilage was partially pre-
oral approaches are usually reserved for small served. This would result in a defect extending
recurrences. In more advanced diseases with- from upper border of the ipsilateral cricoid to the
out cartilage invasion, open approaches can be aryepiglottic fold and extend posteriorly to the
performed in the form of vertical partial laryn- vocal process of the preserved arytenoid.
gectomy or TL. The main disadvantages of the
partial procedures are poor voice outcomes and
wound complications. Moreover, the effects of Preoperative Problem List/
ionizing radiation preclude the utilization of Reconstructive Requirements
adjacent laryngeal structures or local transpo-
sitions of the extralaryngeal musculature to • Patient has failed prior radiation treatment.
reconstruct these complex defects. Consequently traditional partial laryngectomy
Therefore, employing free tissue transfer to is not possible. A laryngeal preservation
reconstruct small laryngeal defects became the approach requires free tissue transfer due to
essential when considering salvage partial lar- the impact of radiotherapy on local tissues
yngectomy. The Temporoparietal fascial free (Ouyang et al. 2013 #34; Burgess 1993 #35).
flap (TPFF) is an excellent and versatile option • The reconstruction will aim to provide volume
to perform airway reconstruction due its out- to recreate an opposing surface for the
standing pliability and thin nature. remaining vocal cord while being thin and
pliable enough to be moved by the remaining
cricoarytenoid unit.
Keywords
• Structural support and new mucosal lining for
Temporoparietal free flap · Laryngeal the neo-hemilarynx will be required. The con-
reconstruction cept of a “vascular carrier” for airway recon-
struction has been developed by Delaere et al.
(1997 #36) and consists in employing free
Clinical Scenario: Temporoparietal tissue transfers to provide a nurturing environ-
Fascial Free Flap for Recurrent T1-T2 ment to a fabricated cartilaginous structure and
Glottic Cancers Treated with Primary a mucosal graft, with the final goal to ensure
Radiotherapy structural support to the airway.
A 45-year-old male was presented in the multi-

disciplinary head and neck tumor board for a Treatment Plan
recurrence of a right T2 glottic squamous cell
carcinoma treated with primary radiotherapy. A It is important to confirm that the recurrence is
surgical rescue with an organ preservation amenable to be treated with an organ preservation
approach was decided, due to the volume of the approach. This procedure should be limited to T1
24 Utility of Temporoparietal Adipofascial Free Flap in Laryngotracheal Reconstruction 227
or T2 (low volume) glottic recurrences. Disease epinephrine is employed, care should be taken to
that extends to the subglottis and /or supraglottis avoid the main pedicle throughout the injection
are best treated with total laryngectomy. process and applied superficially. An additional
The final goal of the intervention will be to line between a point 5 mm below the tragus and
create an opposing structure to the remnant vocal 15 mm above the lateral eyebrow (Pitanguy’s line)
cord preserving phonation and deglutition in the can be marked to identify the presumed course of
context of an organ preservation approach (pres- the frontal branch of the facial nerve. Moreover, a
ervation of the larynx and no permanent tracheos- facial nerve monitor can be utilized as an extra
tomy). The TPFF flap was decided for its measure to protect the nerve. The entire head and
pliability and thin nature (Gilbert et al. 2012 #20). neck region (including the scalp) is prepared and
draped in the customary fashion and prophylactic
antibiotics are administered.
The radial forearm free flap (RFFF) has been

Surgical Technique
employed for laryngeal reconstruction. Extended
hemilaryngectomy defects (which include a por-
• A tracheostomy is performed above the first
tion of the pharynx) were reconstructed with a
and second tracheal ring.
RFFF using the palmaris major tendon to recreate
• Steps for TPFF harvesting are identical as the
a vocal fold. The skin on the flap acted as a lining
ones described in the chapter “Temporoparietal
for the airway (Mihara et al. 2012 #15; Chantrain
fascial free flap for augmenting the primary
et al. 1991 #18). The main issue with this tech-
closure of total laryngectomies in the salvage
nique is the excessive bulk which is created often
setting.” Briefly:
requiring permanent tracheostomy.
• An incision is made following the preoperative
markings.
Preoperative Evaluation and Imaging • Dissection in the preauricular area to identify
the vascular pedicle.
Imaging studies are not routinely performed pre- • Flap elevation is carried cephalad in a sub-
operatively. A handheld Doppler was employed to follicular supra-superficial musculoaponeurotic
map the vascular anatomy of the temporoparietal system plane exposing the temporoparietal fas-
area after induction of anesthesia in the operating cia (TPF).
room. The main consideration is to determine the • As dissection proceeds to the vertex of the skull.
venous anatomy which is less consistent, as pre- • The anterior dissection is limited by the frontal
viously stated the vein can follow a divergent branch of the facial nerve which lies deep to the
course from the arterial pedicle. TPF. As a general rule, anterior dissection
should not be carried below the level of the
anterior branch of the superficial temporal artery.
Preoperative Care and Patient Drawing • The anterior and posterior branches of the
superficial temporal artery can be identified at
In patients where partial laryngeal procedures are this point.
planned but there is high clinical suspicion of • Dissection is continued to the required size. A
impaired pulmonary reserve, we advocate to pre- slightly bigger flap than the partial laryngec-
operatively perform pulmonary function testing tomy defect is elevated (10x5 cm).
(PFT). The FEV1/FVC ratio is used to diagnose • A buccal mucosal graft and a cartilaginous rib
obstructive lung disease, and rates lower to 59% graft (or from the contralateral thyroid ala) are
have been associated to pulmonary complications harvested as well.
after partial laryngectomies (Joo et al. 2009 #37). • The mucosal graft is thinned and sutured to what
A chevron-style or hemi-coronal incision is will constitute the luminal surface of the TPFF
marked. If local infiltration with dilute (Fig. 4).
Fig. 1 Picture (taken from

the left) showing the right
glottis after the anterior
fissure approach with the
mucosal cuts performed.
• The flap is inset. First, the mucosal graft is

sutured to the mucosa of the larynx posteriorly.
The next step is to adequately locate the carti-
lage graft. The TPFF is unfolded and the carti-
lage graft is positioned at the level of
the contralateral cord, on the dorsal aspect of
the TPFF. The flap is then folded surrounding
the cartilage graft (Fig. 5 and Fig. 6). The edge
of the TPFF is sutured anteriorly to the contra-
lateral thyroid cartilage (Video 1).
• After the microvascular anastomosis, a pre-
fabricated Montgomery laryngeal luminal
stent is inserted and held in position
with transcutaneous sutures (Fig. 7). This is
to keep the reconstructed elements in position.
Technical Pearls
The vascular pedicle should be placed between

the ipsilateral sternohyoid and sternothyroid to
maintain the anteroposterior position of the flap. Fig. 2 Explanatory diagram of the resection
Intraoperative Images early mobilization and heparin prophylaxis, while

antibiotic treatment should cover intraoral and
skin flora. Drain is usually removed on postoper-
ative day 2–3.
Postoperative Management The stent was removed 14 days after the surgi-
cal procedure via direct laryngoscopy. The patient
The patient was transferred to a step-down unit initiated oral diet that met nutritional criteria at
and a hand held doppler was utilized for flap postoperative day 20 and was decannulated
monitoring. Antithrombotic measures consist in one-month postoperatively.
Fig. 3 Right partial

vertical laryngectomy
defect (taken from the right
side)
Fig. 4 Buccal mucosa

graft sutured to the
TPFF flap
Outcome of the ipsilateral arytenoid cartilage, prolonged and

occasionally permanent tracheostomy may be
Functionally the patient exhibited a good recov- required. Delayed complications such as granula-
ery, with satisfactory voice and swallowing out- tion tissue requiring debridement, subglottic steno-
comes. Decannulation was achieved a month sis requiring dilation and cartilage graft resorption
postoperatively. (confirmed by postoperative CT scan) may occur.
Avoiding and Managing Problems Learning Points
Most patients can be successfully decannulated • Eligibility of patients to receive partial laryn-
within the first month. In cases requiring resection gectomy reconstruction with TPFF has to be
highly selective, as individuals with impaired

pulmonary function are non-ideal candidates.
• Fitting of the cartilage graft strut and thin-
ning of the mucosal graft should not be
underestimated as they represent a critical
step of the operation.
• Expect revision procedures (granuloma resec-
tion and dilation procedures) and counsel
patients preoperatively about the possibility
of permanent tracheostomy, especially when
the arytenoid cartilage requires resection.
• Recurrence is possible and careful follow-
up is essential. This procedure should only
be considered in reliable patients. Salvage,
when possible, requires total laryngectomy.
• The TPFF is a thin versatile flap with excel-
lent pliability, a rich vascular supply, and
almost no donor site morbidity. In situations
where all of the above characteristics are
Fig. 5 Drawing depicting the inset of the TPFF, the buccal
mucosa and cartilage graft required, it represents an extremely valuable
Fig. 6 The buccal mucosa

graft is sutured to the native
mucosa
Fig. 7 Final picture of the

insertion of the
montgomery laryngeal stent
to secure the reconstruction.
Transcutaneous stitches will
hold the stent in place. The
anterior fissure approach is
then closed placing sutures
to the anterior portion of the
TPFF. The stent will be
removed in a period of
2–3 weeks
option that lends itself to very elegant laryngectomy with temporoparietal free flap recon-
reconstructions of the laryngopharynx and struction for recurrent laryngeal squamous cell carci-
noma: technique and long-term outcomes. Arch
trachea. Otolaryngol Head Neck Surg [Internet]. 2012;138(5):
484–491. Available from: http://www.ncbi.nlm.nih.
gov/pubmed/22652947
References Joo Y-H, Sun D-I, Cho J-H, Cho K-J, Kim M-S. Factors
that predict postoperative pulmonary complications
Burgess LP. Laryngeal reconstruction following vertical after supracricoid partial laryngectomy. Arch
partial laryngectomy. Laryngoscope [Internet]. Otolaryngol Head Neck Surg [Internet]. 2009;135
1993;103(2):109–132. Available from: http://www. (11):1154–1157. Available from: http://www.ncbi.
ncbi.nlm.nih.gov/pubmed/8426502 nlm.nih.gov/pubmed/19917930
Chantrain G, Deraemaecker R, Andry G, Dor P. Wide Mihara M, Iida T, Hara H, Hayashi Y, Yamamoto T,
vertical hemipharyngolaryngectomy with immediate Mitsunaga N, et al. Reconstruction of the larynx and
glottic and pharyngeal reconstruction using a radial aryepiglottic fold using a free radial forearm
forearm free flap. Laryngoscope [Internet]. 1991;101 tendocutaneous flap after partial laryngophar-
(8):869???875. Available from: http://doi.wiley.com/ yngectomy: a case report. Microsurgery [Internet].
10.1288/00005537-199108000-00011 2012;32(1):50–54. Available from: http://www.ncbi.
Delaere PR, Blondeel PN, Hermans R, Guelinckx PJ, nlm.nih.gov/pubmed/22121068
Feenstra L. Use of a composite fascial carrier for Ouyang D, Liu T-R, Liu X-W, Chen Y-F, Wang J, Su X,
laryngotracheal reconstruction. Ann Otol Rhinol et al. Combined hyoid bone flap in laryngeal recon-
Laryngol [Internet]. 1997;106(3):175–181. Available struction after extensive partial laryngectomy for laryn-
from: http://www.ncbi.nlm.nih.gov/pubmed/9078928 geal cancer. Eur Arch Otorhinolaryngol [Internet].
Gilbert RW, Goldstein DP, Guillemaud JP, Patel RS, 2013;270(4):1455–1462. Available from: http://www.
Higgins KM, Enepekides DJ. Vertical partial ncbi.nlm.nih.gov/pubmed/22983297
Complex Neck Allotransplantation
25
Maciej Grajek
Contents
Preoperative Problem List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Abstract
Larynx transplantation idea is known for over

50 years. There are some more or less success-
ful studies based mostly on animal models. In
April 2015 a multiorgan neck transplantation
Electronic supplementary material: The online version including larynx and other organs was
of this chapter (https://doi.org/10.1007/978-3-030-23706- performed. The patient was 34-years-old male
6_28) contains supplementary material, which is available with dramatic medical history. The allograft
to authorized users. included larynx and 8 cm of trachea, pharynx
M. Grajek (*) with esophagus, thyroid and 4 parathyroid
Oncological and Reconstructive Surgery, Cancer Center glands, hyoid bone with the anterior bellies of
IMSC, Gliwice, Poland digastric muscles, all in one block with
e-mail: mgrajek@poczta.onet.pl

https://doi.org/10.1007/978-3-030-23706-6_28
234 M. Grajek
sternohyoid muscles, and anterior cervical Preoperative Problem List

wall skin paddle corresponding with the size
of the recipient’s defect. Currently, over In a typical manner for total laryngectomy
4 years after the procedure, the patient’s patients, he was able to only breathe through
vocal cords are functioning, and he is able to the tracheostomy and could not speak. Even his
understandably communicate, he has non- throat speaking was barely hearable. Addition-
compromised swallowing and is breathing ally there already was a stenosis of upper diges-
easily through his mouth and nose without tive tract (reconstructed previously with free
tracheostomy. Fully healed skin paddle on jejunum). His neck was heavily scarred after
his neck provides satisfactory aesthetic effect. multiple surgical procedures, and some ana-
The transplanted thyroid and parathyroid tomic disorders that may not have been revealed
glands became fully functional within about by preoperative diagnostics were expected
3 weeks after the procedure and remained so intraoperatively. There was no thyroid or para-
till present day. Within next 4 years another thyroid glands, so these must have been taken
three, very anatomically similar procedures into account.
have been successfully performed.
Treatment Plan
Keywords
Laryngeal transplantation · Neck The plan was to operate on donor and recipient
transplantation · Complex tissue allotransfer simultaneously in two adjacent operating rooms.
Preparation of the recipient should include:
The Clinical Scenario 1. Resection of all the scar tissues including ante-
rior cervical wall
The patient was 34-years-old male with long 2. Finding any veins and arteries that would be
and dramatic medical history. In 2001 he potentially good donor vessels for further
underwent left kidney transplantation due to microanastomoses
IgA nephropathy with lifelong immunosup- 3. Finding and identify remaining nerves in the
pression. Four years later he developed acute area
myeloid leukemia successfully treated with 4. Exposing and preparing distal trachea stump
chemotherapy. In 2009 the patient was diag- 5. Exposing and preparing remains of the phar-
nosed with squamous cell cancer of the larynx ynx and esophagus
(T3N1), and underwent radiotherapy followed
by a total laryngectomy, with severe postoper- Preparation of the donor should include:
ative complications – a large pharyngeal fistula
due to pharynx necrosis. Overall three recon- 1. Dissection of large en block complex
struction attempts were unsuccessful, and consisting of trachea, pharynx with esophagus,
finally he completed the therapy with perma- thyroid and parathyroid glands, hyoid bone
nent tracheostomy, gastrostomy, and heavily with anterior belly of digastric muscles,
scarred neck. A few years later he underwent sternohyoid muscles, skin island
pharyngoesophageal reconstruction with the 2. Finding, identity, and dissection of as many
use of free jejunal flap. The patient had been blood vessels feasible for further micro-
disease free from leukemia for 12 years, and anastomoses as possible
6 years from laryngeal cancer, which was 3. Finding, identity, and dissection of upper
enough from the oncological point of view laryngeal nerve bilaterally, and laryngeal
(based on prognosis and cure rates). recurrent nerve bilaterally
25 Complex Neck Allotransplantation 235
The next step after the simultaneous prepara- performed imaging procedure was ultrasonogra-
tion should be detaching the transplant, short phy, which showed no deviations from standard.
(2 min) ex vivo perfusion in preservation fluid Recipient site: heavily scarified neck, lack of
(Celsior in this case) via any visible larger larynx, upper trachea, thyroid and parathyroid
artery/arteries, and finally transferring it to the glands. Free jejunal flap acting as upper part of
recipient’s operating room. esophagus with major grade stenosis at the base of
The order of next actions depends mainly on the neck (upper chest opening). AngioCT scans
anatomical relations in a newly created operating revealed that the right external carotid artery was
field, but the preferred schedule should go as amputated very early on its course, left upper
follows: thyroid was already used for free jejunal flap,
and left facial artery seemed intact. Even though
1. Performing any possible vascular micro- right external carotid artery did not exist, the right
anastomoses in a typical manner lingual artery was functional, probably due to
2. Reconstruction of digestive tract (lower part, anastomoses or a backflow.
deep layer)
3. Reconstruction of airways (lower part, superfi-
cial layer) Preoperative Care and Patient
4. Reconstruction of aerodigestive tract (upper Drawing
part)
5. Performing nerve anastomoses preferably end There were some special preoperative consider-
to end to corresponding stumps ations regarding mainly the recipient. The
6. Coverage with transplant’s skin island tailored transplantologists had to induct the immunosup-
to defect pression starting from the day 0. In this particu-
lar case the induction immunosuppression
In the postoperative period, the transplant consisted of 1.25 mg/kg per day antithymocyte
(flap) is monitored in a typical manner. Skin island globulin (Thymoglobulin, Genzyme, Lyon,
acts as viability monitor for the rest of the flap. France) for 10 days, tacrolimus to maintain the
plasma concentration between 12 and 15 ng/mL,
mycophenolate mofetil at a dose of 2 g per day,
and methylprednisolone at a dose of 10 mg/kg
on the day of transplantation, 5 mg/kg on days
There are not known any reconstructive options in
+1 and + 2, 3 mg/kg on days +3 and + 4, with
this area that could ensure functional effect close
subsequent taper. In the maintenance phase
to complex allotransplantation. It is possible to
tacrolimus was administered to maintain the
reconstruct digestive tract solely (free jejunum or
plasma concentration between 7 and 10 ng/mL,
tubular anterolateral thigh flap), and it is also
mycophenolate mofetil was continued at
possible to reconstruct trachea solely (tubular
reduced dose (1.5 g per day), while the dose of
radial forearm free flap). The same but purely
methylprednisolone was reduced to 4 mg per
aesthetic effect is easy to obtain with any larger
day.
free soft tissue flap (which harvesting should be
No special positioning was used, except for a
always left possible, in a case like this, as a backup
little bending backwards in a typical way for
plan in case of rejection).
performing cervical lymph nodes dissection.
There was just an intuitive drawing around
Preoperative Evaluation and Imaging recipient defect indicating how much to resect
(Fig. 1).
Donor site: the donor’s neck was intact during the Similar rhomboidal shaped drawing but a little
accident that finally led to his demise. The only larger was made on donor’s skin.
236 M. Grajek
Fig. 2 Harvested VCA
Fig. 1 Preoperative planning
Surgical Technique
In the recipient the neck was explored, scar tissues

were resected with the anterior cervical wall
(15x12 cm), blood vessels, as well as bilateral
sublingual, phrenic, and vagus nerves were pre-
pared. The distal stump of trachea was exposed,
and further previously reconstructed pharynx and
esophagus.
Fig. 3 Inserted VCA
Simultaneously, in the donor, a tissue complex
of the neck was designed and harvested. The
allograft included larynx and 8 cm of trachea,
pharynx with esophagus, thyroid and 4 parathy-
roid glands, hyoid bone with anterior bellies of
digastric muscles, all in one block with
sternohyoid muscles, and anterior cervical wall
skin paddle corresponding with the size of recip-
ient’s defect (Figs. 2 and 3). The allotransplant
vascularity was based on two superior and two
inferior thyroid arteries, and 4 veins (bilateral
jugular internal with 4 thyroid branches, and two
anterior cervical veins) and 4 nerves were recog-
nized and harvested – bilateral superior laryngeal
and bilateral recurrent laryngeal. The transplant
was detached and after short perfusion (Fig. 4)
with preservation fluid (Celsior) was transferred
to the recipient’s defect. Fig. 4 VCA in place
The insetting started with vascular micro-

anastomoses – arterial (end to end 10.0 nylon
sutures) between thyroid superior and recipient’s
left facial and right lingual arteries, venous – bilat-
erally internal jugular with recipient’s internal jug-
ular end to side (10.0 nylon sutures), additionally
donor’s anterior cervical veins were anastomosed
with recipient’s external jugular veins (coupler).
After that, the nerves were connected – superior
laryngeal of the donor were bilaterally sutured end
to side to sublingual recipient’s nerves, and the
ends of recurrent laryngeal nerves were anasto-
Fig. 5 Visible skin monitor
mosed to side of left phrenic and right vagus recip-
ient’s nerves (10.0 nylon sutures). The next step
was to restore the aerodigestive tract continuity – problems. Theoretically, planning of the skin
donor’s and recipient’s tracheal ends were island is similar to the infrahyoid flap.
connected and sutured with superior repositioning 3. The thyroid gland acts as a vascular distribu-
of neotracheostomy, then the upper part of jejunal tor, and a complex flap can be “built” around
flap was resected creating a space between tongue it according to the reconstructive needs. That
base and 5 cm below for donor’s pharynx and also means the parathyroids are always some-
esophagus replacement. The transplant insetting where there. Parathyroid glands were never
ended up with hyoid bone suspension, suturing seen or purposely looked for intraoperatively,
donor’s digastric muscles to their stumps in the yet they were always visible in a postopera-
recipient, and finally subcutaneous tissue and skin tive scintigraphy.
suturing (Grajek et al. 2017). 4. Begin the preparation from the lateral, find
carotid arteries and internal carotid vein, find
and identify arterial branches (upper and lower
Technical Pearls thyroid arteries). The veins are easy to find but
sometimes harder to identify – it does not
Since the surgery herein described, three more, really matter, they just have to be large enough.
successful neck allotransplantations have been Anterior jugular veins were always addition-
performed. Each case was of more or less of ally prepared as a backup, besides these
similar complexity, and all the comments written become visible at the very early stage. Repeat
below will relate to the knowledge gained during the same on the other side. Find the nerves.
all these operations. Make sure the superior laryngeal nerve is
harvested and not ansa cervicalis. Laryngeal
1. It is good to have a skin flap as a monitor even recurrent is easier as the only one there.
if it is not needed as a part of a reconstruction. 5. To keep the operating field sterile, start with
Later it will act as an excellent place for the trachea first and help the anesthesiologists
biopsies (Fig. 5). with their tubes. Since the patient is bent
2. If point 1 is applied, then the sternohyoid slightly backwards, even more trachea length
muscles will be in the flap. The skin island can be included in the flap, as long as the
was everytime harvested without looking for endotracheal tube is safely inserted and
any perforator, just taking care not to tear it secured into the trachea stump inside the chest.
off. It is easier faster, and each of harvested 6. Try to open the pharynx at the very end, only
four islands in total survived without any when safe detachment of the flap is ensured.
238 M. Grajek
The incision 1 cm above the front of hyoid

bone is optimal and then goes down towards
the spine. Watch out for lingual arteries bilat-
erally. In case an esophagus is also harvested,
its incision can be made right after completion
of the pharynx harvest.
7. Now some optimistic observation. Performing
one arterial anastomosis on any side (so one in
total) seems to be enough to adequately perfuse
the whole transplant. In every case a proper
venous outflow was observed from every
open vein, after anastomosing just one thyroid
Fig. 6 Prefusing the VCA
artery (superior or inferior). Naturally is always
desirable to try to perform as many anastomoses
as possible as a backup (up to 4 in a last case). and steroids. Additionally he had a whole spectrum
8. Try to anastomose as many veins as possible, of antibiotics, antifungal and antiviral drugs, which
including anterior jugular – these can be of in his case were meropenem, acyclovir, and flucon-
larger diameter than the rest and can be azole. Furthermore, he had a typical for a free flap
harvested very long. The AP dimension of a reconstruction management that is considered a
typical flap is the same or even larger than the standard in author’s center, that is, Clexane 40 mg
side/lateral dimension, hence anastomosing daily subcutaneous and Pentoxifyllinum 300 mg
anterior jugular makes sense. It can be done to daily intravenous. Flap monitoring was performed
recipient’s interior or exterior jugular vein. just by visual observation of skin island every hour
Venous couplers were used anytime it was in the first 3 days, later this period was extended to 2
possible. and then 3 hours. He had two drains symmetrically,
9. Typical intestinal couplers were used for and these were removed on fourth postoperative
esophagus twice and hand sutures twice. day. The patient was fed through previously
Both methods work. performed gastrostomy, and was breathing through
10. In each case the nerve length was more than tracheostomy tube size 8.
satisfactory, and these were shorten to just
comfortably perform the anastomosis. Nerve
anastomoses were done in a typical manner Outcome: Clinical Photos and Imaging
with 10.0 sutures, and using venous muffs
taken from donor every time. Satisfactory aesthetic outcome has been achieved,
and the skin island is well healed. In terms of
functional effects, the patient can easily breathe
Intraoperative Images the physiological way, and at any moment there
was no need for retracheostomy, after it was
Figure 6 removed about 2 weeks after the procedure. His
vocal cords are moving voluntarily, but the voice
quality (mostly the volume) could be better. Yet he
Postoperative Management can easily communicate, he’s back to his work, he’s
able to speak through the phone. In terms of pure
There was no special patient positioning except for quality of life this was a huge step forward. A
avoiding excessive neck flexion. The patient was movie attached to this book with a second patient
kept under full sedation for the first 2 days, mainly whose voice quality and loudness after very similar
for safety reasons. He was receiving all the immu- procedure is impressive (mov. 1). The first patient
nosuppressive drugs typical for complex tissue allo- described here is currently having a nonrestricted
transfer, that is, tacrolimus, mycophenolate mofetil, oral diet (Fig. 7), yet during the first 3 years he had
4. Have a trusted histopathology laboratory

working 24 h. A few early acute rejections
have been healed just by modifying the dose
of steroids. This all was possible due to early
recognition and reaction.
5. In case the patient has developed any problems
with swallowing (most common issue from the
experience), a good endoscopy can recognize
and deal with the problem.
Learning Points
1. One arterial anastomosis seems to be adequate

Fig. 7 Epiglottis movement
to perfuse a whole flap. For obvious reasons,
it’s important to perform more if possible.
2. In each of four patients, the endoscopical exam-
ination performed within 2 weeks after the pro-
cedure revealed that the vocal cords were in
lateral position. The first two are easily commu-
nicating right now, the second two were made
during writing of this chapter, so it’s too early to
judge.
3. In each of the cases, the endocrine glands were
back to normal function within a few days.
4. A swollen epiglottis at the early stage (happened
twice) can help prevent flooding the lungs with
saliva or liquid diet. Later, when the epiglottis is
back to normal size (Fig. 9) but the superior
Fig. 8 Thyroid function scinigraphy
laryngeal nerves are still not functioning, there
may be a problem with aspiration pneumonia.
Consider performing a gastrostomy, or leaving
a few endoscopical procedures to manage the ali-
previously performed gastrostomy for at least a
mentary tract constricture. The transplanted thyroid
few months.
and parathyroid glands became fully functional
within about 3 weeks after the procedure and
remained so till the present day (Fig. 8).
1. Whenever you can, harvest a skin island.

2. Perform as many anastomoses as possible.
This is one of the few things can be really
controlled when performing such a procedure.
3. Later, if there’s any doubt, make a skin biopsy
(see point 1). Mucosal biopsies are possible but
technically demanding, and thus extremely
psychologically aggravating to the patient. Fig. 9 Swallowing a few month postop
240 M. Grajek
References Poltorak S. First complex allotransplantation of neck

organs: larynx, trachea, pharynx, esophagus, thyroid,
Grajek M, Maciejewski A, Giebel S, Krakowczyk Ł, Ulczok parathyroid glands, and anterior cervical wall: a case
R, Szymczyk C, Wierzgon J, Szumniak R, Dobrut M, report. Ann Surg. 2017;266(2):e19–24. https://doi.org/
Oleś K, Drozdowski P, Walczak D, Szpak-Ulczok S, 10.1097/SLA.0000000000002262. PMID: 28463895
Adult Facial Nerve Palsy
Reconstruction Using Gracilis 26
Functional Muscle Innervated
with Cross-Face Nerve Graft
Kallirroi Tzafetta and Manaf Khatib
Contents
Preoperative Problem List /Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 244
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
First Stage: Cross-Face Nerve Grafting (CFNG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Second Stage: Facial Reanimation with Gracilis Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
Outcome, Clinical Photos, and Imaging (Figs. 10, 11, 12, 13, 14,
15 and 16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Abstract
K. Tzafetta (*) The two-stage reanimation, with cross-face
Consultant Plastic and Reconstructive Surgeon, nerve grafting followed by free gracilis muscle
St Andrew’s Centre of Plastic Surgery and Burns,
Broomfield Hospital, Essex, UK
transfer, has been considered to be the gold
standard treatment for long-standing severe or
M. Khatib
Plastic and Reconstructive Surgery Specialist Registrar,
total facial paralysis in adults. There have been
St Andrew’s Centre of Plastic Surgery and Burns, refinements over the years with regard to mus-
Broomfield Hospital, Essex, UK cle volume harvested, positioning of it, and
https://doi.org/10.1007/978-3-030-23706-6_29
242 K. Tzafetta and M. Khatib
other nuances important for a satisfactory func- • Upper and lower eyelid avulsion.
tional and esthetic outcome. • Left retro-mandibular vein transection.
• Damage to left lateral nasal wall.
• Avulsion of left auditory canal.
Keywords
• Hemorrhage from skull base requiring
Facial functional muscle transfer · Cross-face tamponade with Foley catheter.
nerve grafting · Free gracilis flap · Facial nerve
reconstruction · Facial palsy After her initial resuscitation and hemorrhage
control surgery at the original hospital, she had
multiple reconstructions by a surgical team
The Clinical Scenario consisting of neurosurgeons, ENT surgeons, and
maxillofacial surgeons. She required a cranioplasty
A 41-year-old female was referred with post- plate to her left temporal area followed by two
traumatic left-sided facial nerve paralysis. She initial reconstructions of her orbital floor, zygoma,
was involved in a high-energy hit-and-run acci- and replantation of her eyelids.
dent and was run over by a van in 2007 and left for Intraoperatively, it was found that her masse-
dead. She arrived to the emergency department in teric nerve was also severed as a result of the
the early hours of the morning in severe hemor- zygomatic arch injury. She subsequently required
rhagic shock with a hemoglobin of 5 g/dL and in surgery to correct her external auditory canal ste-
metabolic acidosis with a pH of 6.7. She had nosis, scar revision, and a medial canthopexy. She
suffered extensive craniofacial trauma involving also underwent correction of her left facial soft
the left side of her face, and skull base (Fig. 1). tissue deficit with a Medpor (Medpor Biomaterial;
Her main injuries were: Porex Surgical, Newnan, GA, USA) implant and
static fascial slings to improve the resting symme-
• Extensive left-sided soft tissue injuries to try of her lips.
the face. She recovered well from her initial reconstruc-
• Left zygomatic arch fracture. tions and went back to work. However, around
• Left orbital floor fracture. 6 years from the injury she noticed that she was
• Left temporalis muscle avulsion. increasingly developing a hearing deficit from her
Fig. 1 The patient on her

initial presentation
demonstrating extensive
damage to left side of face at
initial presentation in
accident and emergency
26 Adult Facial Nerve Palsy Reconstruction Using Gracilis Functional Muscle Innervated with. . . 243
left auditory canal. After being referred to ENT and further hollowing of her left temporal fossa
and maxillofacial surgery in a different hospital, and a skeletal appearance.
she had her Medpor (Medpor Biomaterial; Porex She was then referred to the facial palsy ser-
Surgical, Newnan, GA, USA) implant removed vices nearly 7 years after the original incident. Her
and a custom-made zygomatic arch reconstruc- main concerns were to address the temporal
tion. Unfortunately, she then developed near hollowing and to reanimate the left side of her
total stenosis of her left external auditory canal face (Figs. 2 and 3).
Fig. 2 Frontal, oblique, and lateral photos of the patient 7 years after the original incident showing her left sided facial
paralysis and significant left temporal hollowing
Fig. 3 Left – photo showing pronounced left-sided facial asymmetry when smiling. Right – photo showing incomplete
left eye closure
Preoperative Problem List / • Single-stage dynamic facial reanimation with

Reconstructive Requirements gracilis flap to nerve to masseter was not pos-
sible due to damage to left-sided masseteric
1. Left incomplete eye closure: Patient has positive nerve.
Bell’s phenomenon and corneal protection. • Static reanimation with fascial slings. The
– Clinical evaluation showed that the patient had them previously and wants
incomplete eye closure was most likely a improvement in dynamic facial symmetry.
result of her left lower eyelid malposition • Single-stage reanimation with latissimus dorsi
due to the descent of her left facial bony muscle with coaptation of the thoracodorsal
framework. nerve branch to a buccal branch from the con-
– It was not a priority for the patient to be tralateral facial nerve (Wei et al. 1999). The
addressed and had no long-term problems patient wanted to avoid the donor site compli-
from the incomplete eye closure. cations and weakness attributed to a latissimus
2. Left temporal hollowing: Avulsion of dorsi flap.
temporalis muscle and temporal fat pad contrib-
uted to contour defect. Cranioplasty plate
inserted by neurosurgeons complicates matters, Preoperative Evaluation and Imaging
as fat grafting may not be possible for contour
augmentation. To address the contour defect, it • Comprehensive facial medical photography
would require a buried fasciocutaneous free flap and videos demonstrated dynamic asymmetry
– patient did not want to undergo complex of face.
procedure to address this. • Preoperative CT angiography of facial vessels
3. Left facial asymmetry: Facial nerve paralysis was performed. This is done only in selective
with significant smile asymmetry and func- cases especially and was performed in the
tional problems with eating and dribbling herein presented patient due to her history of
which would require both static and dynamic significant facial trauma.
facial reanimation to address asymmetries and
functional problems.
Drawing
Treatment Plan
The patient was admitted the night before surgery
A plan for a two-stage facial reanimation with a and given prophylactic low molecular weight hep-
first-stage cross facial nerve graft (CFNG) and arin (LMWH) the evening before.
second-stage free gracilis muscle was made Patient marking was done intraoperatively for
(Harii et al. 1976). sural nerve and gracilis muscle harvest. This is
discussed in detail in the surgical technique section.

Surgical Technique
• Temporalis muscle transfer either as turnover
(Gilles 1934) or as a sliding temporalis First Stage: Cross-Face Nerve Grafting
myoplasty (Labbe 1997) was not possible due (CFNG)
to avulsion of muscle in the original injury.
• Nerve transfers were not possible due to dam- Sural Nerve Harvest
age to masseteric nerve in the original injury The sural nerve is harvested via small step inci-
and motor end-plate fibrosis of facial muscles sions along the course of the nerve on the lateral
due to long-term facial muscles denervation of aspect of the lower leg (Fig. 4). This can be done
more than 7 years. using thigh tourniquet control, but this is often
Fig. 4 Markings of step

incisions for sural nerve
harvest as demonstrated on
a different patient to the one
discussed in this chapter
Fig. 5 Left sural nerve

harvest through multiple
small step incisions
unnecessary. The most distal incision posterior handheld nerve stimulator set at 2 mA (Vari-
to the lateral malleolus is made initially to iden- Stim ® III nerve stimulator, Medtronic Xomed
tify the sural nerve. The nerve is closely associ- Inc., Jacksonville, FL, USA) was used to identify
ated to the lesser saphenous vein, and care must all facial nerve branches at the anterior border of
be taken not to damage the vein. Once the nerve the parotid gland. A distal buccal branch was
is identified and dissected, gentle tugging of the selected as donor motor branch and divided. It is
nerve is done to identify the exact position of the imperative to ensure that there are other buccal
nerve at the more proximally marked incision. branches with similar function in order to avoid
This is done until a sufficient length of nerve is compromising the unaffected side.
dissected (Fig. 5). It is essential to handle the The nerve graft is reversed with its distal part
nerve with care to avoid traction injury. destined to coapt to the donor facial branch and
Of note, frequently, branches need to be divided the proximal end of the sural nerve to reach the
to allow harvest of the nerve. It is advised to ligaclip affected side of the face. The nerve is tunneled
the divided branch and cauterize it with bipolar subcutaneously to the pretragal area with the use
diathermy to reduce the risk of neuroma formation. of a nerve passer (Fig. 6) through the superior part
of the upper lip. It is initially brought out with a
Facial Nerve Branch Identification 2 mm incision at the base of the columella and
and Preparation of Pockets passed again through the same incision and
Using a modified facelift incision, the right-side brought out to the left preauricular area with a
unaffected facial nerve was explored and a 1 cm incision. The distal end is tagged with a 6/0
Fig. 6 Nerve passer is used

to tunnel sural nerve graft
through the subcutaneous
tissue. The nerve graft is
passed over and over
through the loop and
sutured to itself prior to
passing it through the
subcutaneous tissue
Ethilon™ (Ethicon: Johnson & Johnson, New free end of the CFNG is serially incised with a
Brunswick, NJ, USA) suture for easy identifica- diamond knife until healthy fascicles are seen
tion at the second stage. The nerve graft is fixed at under the microscope.
the preauricular area on the paralyzed side of the A sub-SMAS dissection of the pocket is
face. performed; this is to ensure the thickness of
The stump of the donor branch was coapted in the composite flap and to prevent tethering of the
an end-to-end manner with a reversed sural nerve transferred muscle to the overlying skin. The
graft using 9/0 Ethilon™ (Ethicon: Johnson & pocket is created up to the nasolabial fold,
Johnson, New Brunswick, NJ, USA) sutures in philtrum of the upper lip, midline of the lower
an epineural fashion. On average, 8–10 sutures are lip, and inferiorly at the submandibular area.
used, and meticulous care is taken to not have any This pocket will accommodate the transferred
gaps in the epineurium to avoid nerve fiber muscle. A pattern is drawn on the affected cheek
splaying. and is transferred on a piece of paper representing
The second stage took place 11 months later the shape and size of the gracilis muscle that will
after monitoring the advancing Tinel’s sign, and fit in each individual patient. Meticulous hemo-
the results from the electrophysiological studies. stasis is performed.
The facial artery and vein are the donor vessels
in the majority of the cases. They are identified
Second Stage: Facial Reanimation with with a Doppler probe and are prepared and
Gracilis Flap encircled with small vessel loops at the level of
the mandible, before they separate from each
Face: Preparing the Recipient Site other. The artery runs more antero-medially
Attention is drawn to the affected side of the face. toward the nasolabial area, and the vein passes
The previously modified facelift skin incision is up more vertically. In those circumstances, where
used (Fig. 7). The skin flap is lifted with extra one or both of the vessels were considered to be
caution being given to identify and mobilize the nonsubstantial to support the supply to and from
cross facial nerve graft that was previously fixed the free neuromuscular unit, either branches of
and tagged. Tissue specimens from the end of the the external carotid artery / external jugular vein
nerve graft are sent for histology, in order to at the neck is used with interposition vein grafts,
establish the presence and number of nerve or the superficial temporal vessels.
axons. Of note, specimens for histology are also The nerve graft destined to innervate the free
taken from the obturator nerve of the free gracilis gracilis is prepared and placed close to the vascu-
muscle after the flap is raised. Furthermore, the lar pedicle.
Fig. 7 Left-sided facial dissection showing the previously placed cross facial sural nerve graft identified and prepared for
coaptation
Right Medial Thigh: Harvesting pedicle is dissected under the adductor longus
the Gracilis Muscle muscle and traced up the profunda femoris ves-
It starts with the patient being supine on the oper- sels. Thorazine soaked cottonoids are placed
ating table, the donor’s thigh being abducted, and around the vessels until the final harvest of the
the knee partially flexed and supported on a rolled muscle takes place.
blanket. A medial thigh incision is drawn about In order to ensure that the muscle is going to be
3 cm posterior to an imaginary line that connects positioned on the cheek with its normal resting
the pubic tubercle and the medial condyle of the tone, marker sutures (Fig. 8) are placed at 1 cm
femur, along the proximal two-thirds of the thigh. intervals along the anterior border with the muscle
A much smaller incision is performed at the in situ and will be measured again when it is
medial aspect of the knee close to the subcutane- placed in the new position at the face to ensure
ous insertion of the gracilis on the medial tibial correct tensioning of muscle (Fig. 8).
condyle. The muscle takes origin from the pubic Following this, the muscle is sculpted in situ.
symphysis and is located posterior to adductor The pattern/mold that was designed on the cheek,
longus and anteriorly to semimembranosus. It is as previously mentioned, outlines the width and
a Type II muscle according to the Mathes and length of the gracilis muscle and its strip projec-
Nahai classification, with a dominant pedicle tions that are going to fit in the recipient area. The
being the ascending branch of the medial circum- sculpture always involves the proximal part of the
flex femoral artery and venae commitantes arising muscle. The fibrous origin of the gracilis, at the
from the profunda femoris artery and vein. The pubic symphysis, is split up into four strips which
dominant pedicle enters the muscle from the deep will correspond to the ones that will be inserted at
surface approximately 10 cm inferior to the pubic the philtrum, upper lip, commissure, and lower
tubercle. The minor pedicles are one or two lip. The longest one is for the lower lip, and the
branches of the superficial femoral artery and shortest for the commissure. Quite frequently,
venae commitantes. Incision of the fascia over about half of the width of the proximal muscle,
the gracilis and adductor longus takes place. The on the pedicle side, is utilized.
dominant vascular pedicle and the motor nerve Subsequently, the obturator nerve is divided,
(obturator) to the muscle are identified and pre- and the tendinous insertion strips are prepared
served. The gracilis muscle subsequently is with application of 5/0 Prolene ™ (Ethicon: John-
completely freed to its origin and distally toward son & Johnson, New Brunswick, NJ, USA)
its insertion. Attention is then focused again on sutures, where the anchoring is determined to
the neurovascular pedicle (Fig. 8), the nerve is be. The pedicle is then divided from the profunda
traced as proximally as possible, and the vascular vessels. Immediately after, the muscle is
Fig. 8 Top left – gracilis muscle dissected in the right medial thigh. Top right – vascular pedicle and obturator nerve
dissected. Bottom – 6/0 silk sutures placed at 1 cm intervals to aid tensioning of muscle when transferred to the face
completely detached from its origin and is divided while the rest are 4/0 Prolene ™ (Ethicon: John-
distally with a GIA bowel stapler-cutter and trans- son & Johnson, New Brunswick, NJ, USA)
ferred to the face. The distal part of the muscle is sutures. After the correct tension is applied, mon-
removed from the insertion at the tibial medial itored by the marker silk sutures being apart at
condyle before closing the wounds in the thigh 1 cm, the muscle is anchored along a preauricular
over Jackson Pratt drains. line with Prolene ™ 3/0 (Ethicon: Johnson &
Johnson, New Brunswick, NJ, USA) sutures.
Positioning of the Gracilis Muscle at The microscope is then brought into the place.
Recipient Site The artery is flushed with heparinized normal
The gracilis muscle is transferred to the pocket, saline and anastomosed using 8/0 Ethilon™
and the insertion begins with fixation of the ten- sutures, followed by the venous anastomosis
dinous strips starting at the philtrum of upper lip, a using a venous coupler and the nerve coaptation
second one at halfway between cupid’s bow and with 9/0 Ethilon™ sutures.
commissure, followed by a third one inserted at In the completion of the vascular and nerve
the modiolus, and a final one at the lower lip half repairs, the area is thoroughly irrigated and closed
way between the modiolus and midline of the lip. over drains. The exact position of the pedicle and
The anchoring sutures at the lower lip, philtrum, the anastomotic site is marked with a temporary
and infraorbital area are bolstered with 3/0 Pro- suture on the skin to facilitate subsequent Doppler
lene ™ (Ethicon: Johnson & Johnson, New monitoring. Implantable Dopplers can be used for
Brunswick, NJ, USA) sutures on a tapered needle, monitoring if required.
Technical Pearls • The patient is prescribed the following

medications:
• Isometric placement of the muscle within the 1. Prophylactic intravenous antibiotics for
facial pocket is very important. If the muscle is 48 h, and orally for 5 days (due to contact
slack, it will lose some of the excursion as dic- with the mouth during placement of the
tated by Starling’s principle – the contraction of perioral sutures).
a muscle unit is proportional to the fiber length at 2. Prophylactic LMWH and thromboembolic
rest. On the other hand, if it is too tight it will be deterrent (TED) stockings during the course
constantly contracted and will get fatigued. of her admission.
• Debulking of the muscle in situ is important, 3. Topical chloramphenicol ointment is
although it is also important to avoid applied to all exposed facial incision sites
devascularizing or denervating the portion of three times a day for a week.
functional muscle to be transferred. Having a • The thigh drain is removed once the patient is
bulky muscle flap may not be cosmetically freely mobilizing, and the drainage is less than
acceptable to some patients. 30 ml in 24 h.
• The position of the new nasolabial fold is very • The patient was discharged 5 days postopera-
important and should be symmetrical with the tively with no acute complications.
contralateral side. A more lateralized position
of the muscle can be unsightly, and attention
must be paid so the muscle is attached more Outcome, Clinical Photos, and Imaging
medially to the new nasolabial fold. (Figs. 10, 11, 12, 13, 14, 15 and 16)
• In regards to selection and subsequent division
of the buccal branch of the facial nerve on the
unaffected side, it is imperative to ensure that
other branches with similar function have been Avoiding and Managing Problems
identified and preserved in order to avoid
downgrading and functional compromise on 1. Poor tensioning: Too tight of gracilis flap inset-
the donor side of the face. ting will lead to chronic contractions and sub-
sequent fatigue. In contrast, a loose inset will
not generate sufficient contraction for a
Intraoperative Images dynamic smile. It is imperative to inset the
gracilis in an isometric manner. This can be
ensured by marking 1 cm intervals using a
suture or staple on the muscle in situ prior to
Postoperative Management division. When insetting the flap in the cheek,
the interval area is measured and ensured to be
• A pressure dressing is placed as seen in Fig. 9. 1 cm.
A splint is applied to the left oral commissure 2. The use of a high-quality nerve stimulator
to support the tensioning of the gracilis muscle. helps identify the correct nerve branch for sac-
The splint is designed using a thermoplastic rifice. More than one buccal branch of the
splint that is wrapped with jelonet dressings. facial nerve is identified, and using a nerve
It functions to lift the oral commissure and stimulator, its muscle action is checked to
reduce the tension on the inset gracilis flap. ensure similar function. Once two nerves of
• The patient is transferred from theater recovery similar function are identified, then it can be
to a specialist plastic surgery ward with nurses safe to sacrifice one. The use of a buccal branch
familiar with flap monitoring and care. that innervates the zygomaticus major is
Fig. 9 Series of immediate postoperative photos showing the pressure dressing and the bespoke thermoplastic splint
recommended as the muscle’s action has been zygomatic area with a more acute vector, and
shown to produce the most naturally perceived another part to the preauricular area at a more
smile (Penn et al. 2013). neutral vector.
3. Bulkiness of the gracilis flap can lead to a poor
cosmetic outcome and need for debulking revi-
sion surgery. Partial gracilis flap harvest avoids Learning Points
future problems. A template of the muscle is
designed prior to flap pedicle division. The • The method of facial reanimation must con-
template allows us to then sculpt the muscle sider the desires of the patient and their phys-
flap in situ prior to division. ical state. Furthermore, the anatomical
4. It is important to use two different vectors of constraints must be delineated such as in this
pull when insetting the gracilis flap –one part patient with damage to the temporalis muscle
of the gracilis is inset in the temporal/ and nerve to masseter. The appropriate method
photos at 3 weeks
photos at 5 months
of reconstruction will vary depending on those (Hontanilla et al. 2013; Manktelow et al.
multiple factors. 2006). Moreover, a combination of both can
• A two-staged technique for facial reanimation be used to dual innervate a transferred muscle
can achieve excellent results with a relatively for facial reanimation (Watanabe et al. 2009). It
predictable outcome (Terzis and Olivares 2009). is important to understand the principles of
Some surgeons prefer the use of a one-stage those different procedures and to offer the
reconstruction using the nerve to masseter as a most appropriate method of reconstruction
donor nerve to the transferred muscle, and this based on the reconstructive requirements, and
has shown excellent and comparable results anatomical and patient-related constraints.
photos at 1 year
photos at 2 years
photos at 32 months
Photos at 39 months
section of laryngology). Proc R Soc Med.

1934;27:1372–82.
Harii K, Ohmori K, Torii S. Free gracilis muscle transplan-
tation, with microneurovascular anastomoses for the
treatment of facial paralysis: a preliminary report.
Hontanilla B, Marre D, Cabello A. Facial reanimation with
gracilis muscle transfer neurotized to cross-facial nerve
graft versus masseteric nerve: a comparative study
using the FACIAL CLIMA evaluating system. Plast
Reconstr Surg. 2013;131(6):1241–52.
Labbe D. Lengthening of temporalis myoplasty and
reanimation of lips. Technical notes. Ann Chir Plast
Esthet 1997;42:44–4.
Manktelow RT, Tomat LR, Zuker RM, Chang M. Smile
reconstruction in adults with free muscle transfer
innervated by the masseter motor nerve: effective-
ness and cerebral adaptation. Plast Reconstr Surg.
2006;118(4):885–99.
Penn JW, James A, Khatib M, Ahmed U, Bella H,
Clarke A, Butler PE. Development and validation of a
computerized model of smiling. Modelling the percent-
age movement required for perception of smiling in
unilateral facial nerve palsy. J Plast Reconstr Aeshtet
Surg. 2013;66(3):345–51. https://doi.org/10.1016/j.
Fig. 16 Right gracilis flap donor site at 11 months
bjps.2012.10.016. Epub 2012 Nov 29
postoperatively
Terzis JK, Olivares FS. Long-term outcomes of free-
muscle transfer for smile restoration in adults. Plast
Reconstr Surg. 2009;123(3):877–88.
Cross-References Watanabe Y, Akizuki T, Ozawa T, Yoshimura K, Agawa K,
Ota T. Dual innervation method using one-stage recon-
struction with free latissimus dorsi muscle transfer for
▶ Adult Facial Nerve Palsy Reconstruction Using re-animation of established facial paralysis: simulta-
Gracilis Functional Muscle Innervated with neous reinnervation of the ipsilateral masseter motor
Cross-Face Nerve Graft nerve and the contralateral facial nerve to improve the
quality of smile and emotional facial expressions.
J Plast Reconstr Aesthet Surg. 2009;62(12):1589–97.
Wei W, Zuoliang Q, Xiaoxi L, Jiasheng D, Chuan Y,
References Hussain K, Hongtai H, Gontur S, Li Z, Hua M, Tisheng
C. Free split and segmental latissimus dorsi muscle
Gilles H. Experiences with fascia lata grafts in the opera- transfer in one stage for facial reanimation. Plast
tive treatment of facial paralysis (section of otology and Reconstr Surg. 1999;103(2):473–80.
Adult Facial Palsy Reconstruction:
Dual Innervation of Gracilis Muscle 27
Kallirroi Tzafetta and Stratos Sofos
Contents
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Preoperative Problem List- Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 256
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
First Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Second Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Intraoperative Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Post-Operative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Outcomes-Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Abstract
Restoration of spontaneous, synchronous and

powerful facial movement is the main aim of
K. Tzafetta (*) facial reanimation surgery. The gold standard
Consultant Plastic and Reconstructive Surgeon, surgical treatment for long-standing unilateral
St Andrew’s Centre of Plastic Surgery and Burns, facial paralysis is a 2-stage reconstruction with
Broomfield Hospital, Essex, UK
cross-facial nerve graft (CFNG) followed by
S. Sofos free muscle transfer. Although spontaneity and
St Andrew’s Centre of Plastic Surgery and Burns
Broomfield Hospital, Chelmsford, Essex, UK synchronicity is achieved with this technique,

https://doi.org/10.1007/978-3-030-23706-6_31
256 K. Tzafetta and S. Sofos
the power of contraction may be weaker than were noticeable at rest and during dynamic exam-
desired. The dual innervation of free gracilis ination. The patient’s Bell’s palsy occurred in
muscle transfer aims to examine the effect of 2006 and his first of a two-stage procedure to
the simultaneous use of CFNG (to provide coor- reanimate the affected face was in 2011 with a
dination) and masseteric nerve (to provide pow- cross facial nerve graft and finally a dually inner-
erful contraction). The senior author has been vated free gracilis muscle transfer in 2012 as a
performing the dual innervation since August second stage procedure (Fig. 1).
2012 on a selected number of patients and
believes it is a useful method of reanimation
on patients who have had other failed proce- Preoperative Problem List-
dures, “heavy” faces and when an expedited Reconstructive Requirements
re-animation is required or expected.
1. Inability to fully close right upper eyelid.
Keywords 2. Right lower eyelid ectropion with resultant
Dual muscle innervation · Masseteric nerve · epiphora.
Cross face nerve graft 3. Drooping of right-sided corner of mouth
resulting in drooling and difficulty eating and
drinking.
The Clinical Scenario 4. Need to reconstruct a symmetrical spontaneous
smile.
History
A 53-year-old gentleman presented with right- Treatment Plan

sided Bell’s Palsy with the expected sequelae
involving hemifacial (right sided) weakness and The dual innervation of free gracilis muscle trans-
more specifically difficulty raising his right eye- fer aims to examine the effect of the simultaneous
brow, and difficulty closing his right upper eyelid; use of CFNG (to provide coordination) and mas-
lower eyelid ectropion with resulting epiphora, seteric nerve (Borschel et al. 2012) (to provide
droopy right side of mouth with difficulty in eat- powerful contraction).
ing and drinking, and finally, the inability to smile A plan was made to perform a dual innervation
spontaneously and symmetrically. His symptoms of the free muscle (Biglioli et al. 2012) in two-
Fig. 1 From left to right: Left-Dynamic asymmetric smile; Middle-Inability to raise right eyebrow; Right-Inability to
adequately close right eye
27 Adult Facial Palsy Reconstruction: Dual Innervation of Gracilis Muscle 257
stage reconstruction with free gracilis muscle Preoperative Care and Patient
(Tzafetta et al. 2021). Drawing
The goal being to reanimate the right side of
the face by providing a more symmetrical and First Stage
spontaneous smile (Terzis and Tzafetta 2009).
The first stage involved the coaptation of a The patient was placed in the supine position,
cross facial nerve graft (sural nerve) onto the a supported by a head ring. The head and neck
buccal branch of the unaffected facial nerve, and region was prepped and draped. A facelift incision
the second stage, the microvascular transfer of a was drawn on the unaffected (left) side of the face
gracilis muscle with coaptation of the CFNG and where the CFNG was to be coapted to donor
masseteric nerve to the obturator nerve of the buccal branch of the facial nerve.
gracilis. In addition, a tarsal strip advancement A well-padded tourniquet was placed on the
of the lower eyelid as well as a platinum chain thigh where the sural nerve was to be harvested
weight was planned in order to facilitate ade- and the leg from the knee down was prepped
quate closure, and therefore protection, of the and draped. The sural nerve donor site was
right eye. marked mid-way between the lateral malleolus
and the achilles tendon. Vertical incisions
were drawn proximally for harvest of the sural
Alternative Reconstructive Options nerve.
1. Reanimation with free functional muscle

(Gracilis or Pectoralis Minor) transfer with Second Stage
cross face nerve graft in a two-stage procedure
(Terzis and Olivares 2009). Patient again placed supine, this time with the
2. Free latissimus flap in a single stage donor leg in a “frog leg” position, i.e., the thigh
reanimation (Watanabe et al. 2009). being abducted and the knee partially flexed and
3. Right temporalis muscle transfer. supported on a rolled blanket. A medial thigh
4. Static procedure using Tensor Fascia lata sling incision is drawn about 3 cm posterior to a line
to oral commissure for symmetrization. drawn from the pubic tubercle to the medial con-
dyle of the femur, along the proximal two thirds of
the thigh.
Pre-operative examination was performed to Surgical Technique

assess the function of both facial nerve function.
Clinical photographs and videos were performed First Stage:
for medical records and for baseline objective 1. This consists of a CFNG (sural nerve graft)
function. Donor nerves were examined including harvested via small step incisions along the
the mandibular branch of the trigeminal nerve by course of the sural nerve on the lower leg (see
asking the patient to clench his teeth. Fig. 2).
Both the masseter and temporalis muscle were 2. The reversed nerve graft is coapted end-to-
examined. Other nerves examined were the hypo- end to a buccal branch of the facial nerve on
glossal (Conley 1977) by examination of the tongue the unaffected side and tunneled subcutane-
and the phrenic nerve by use of a chest x-ray to ously to the pre-tragal area through the supe-
examine the hemidiaphragms (Faria et al. 2007). rior part of the upper lip. The distal end is
Nerve conduction studies were performed to tagged with a 6/0 Ethilon™ (Ethicon: John-
assess any residual function of the facial nerve on son & Johnson, New Brunswick, NJ, USA)
the affected side, and finally, the patient was suture for easy identification at the second
assessed by the physiotherapists. stage.
Fig. 2 Markings of sural

nerve harvest demonstrated
*this image is not from the
patient discussed in this
chapter
Second Stage:
1. The second stage takes place at approxi-
mately 12 months after eliciting positive
Tinel’s sign in all cases.
2. Through a modified facelift incision (Fig. 3)
previously banked CFNG is identified and
dissected and a sub-SMAS pocket is created
to accommodate the free muscle.
3. The free end of the CFNG is serially incised
with a diamond knife until healthy fascicles
are seen under the microscope.
4. The Masseteric Nerve (MN) is then identified
at an average distance of 1 cm below the
zygomatic arch and 3 cm anterior to the tragus
within the deep substance of the masseter
muscle. In cases of House-Brackmann Scale
grades IV/V, special attention is paid to care-
fully preserve the buccal and zygomatic
branches of the facial nerve during the loca- Fig. 3 Modified face lift incision (post operatively) show-
tion of the MN. By detaching about 3 cm of ing where the extent of the incision and its anatomical
the origin of the masseter muscle from the location
zygomatic arch, the nerve is identified close
to the deep surface of the muscle as it courses gracilis muscle has been examined under the
inferiorly and anteriorly (Hwang et al. 2005). microscope.
A hand-held nerve stimulator set at 2 mA 7. Simultaneously, a segment of gracilis muscle
®
(Vari-Stim III nerve stimulator, Medtronic is harvested and transferred to the face. The
Xomed Inc., Jacksonville, FL, USA) facili- procedure for harvesting is thus:
tates the its identification. 8. The patient is positioned supine on the oper-
5. The descending branch is preferentially ating table, the donor thigh in the “frog leg”
divided at its most distal point, leaving the position and supported on a rolled blanket.
more proximal branch-(es) intact. 9. A medial thigh incision is drawn about 3 cm
6. The divided distal end is transposed superfi- posterior from the pubic tubercle to the
cially for nerve coaptation after the anterior medial condyle of the femur, along the prox-
branch of the obturator nerve (ON) from the imal two thirds of the thigh.
10. A smaller incision is placed at the medial

aspect of the knee where the gracilis inserts
to the medial tibial condyle. The muscle has a
dominant pedicle and minor pedicles. This is
crucial to know for the process of debulking.
The dominant pedicle is the ascending branch
of the medial circumflex femoral artery and
venae commitantes, and stems from the pro-
funda femoris artery and vein. The dominant
pedicle enters the muscle from the deep sur-
face approximately 10 cm inferior to the
pubic tubercle. The minor pedicles are one
or two branches of the superficial femoral
artery and venae commitantes.
11. The dominant pedicle is identified through an
incision of the fascia over the gracilis and
adductor longus. This will also reveal the
motor nerve (obturator) to the muscle. Fig. 4 Diagram showing the muscle positioning and nerve
coaptations on a female model
12. The gracilis muscle subsequently is then
detached from its origin and distally towards fascicles). The half containing the large fasci-
its insertion simultaneously protecting the cle is then shortened to 1 cm from the hilum
precious neurovascular bundle. and end-to-end epineural coaptation is
13. The gracilis then is inset into the cheek, where performed with the CFNG using 9/0
a pocket has been created, taking care to Ethilon™ suture. The remaining half 4 cm
achieve the appropriate width and length and from the hilum is coapted to the previously
its strip projections that are going to fit in the divided descending branch of the masseteric
recipient area. The sculpting/debulking always nerve with 9/0 Ethilon™ suture in end-to-end
involves the proximal part of the muscle which fashion (Fig. 5) (Tzafetta et al. 2021).
is the fibrous origin of the muscle, and is split 17. The muscle is then secured posteriorly at the
up into four strips, as discussed below. deep temporal fascia and along the pre-auricular
14. The tendinous part of the gracilis muscle is ®
area with 3/0 PDS suture passing through
split into 4 strips. The first strip was placed at the heat-sealed muscle fibers as a result of the
the midline of the upper lip and second strip linear stapler (Linear Cutter 75, Ethicon: John-
are placed and secured half-way between the son & Johnson, New Brunswick, NJ, USA)
commissure and the midline of the upper lip. which allows better suture purchase.
The third one was placed on the modiolus at 18. Finally, and critically, at the end of the case a
the commissure, and the final strip was placed thermoplastic custom-made splint is placed at
at the lower lip, half-way between the com- the corner of the mouth to prevent avulsion of
missure and midline of lower lip (Fig. 4). the muscle from its attachments (Terzis and
15. The obturator nerve is then prepared. This Tzafetta 2009).
nerve commonly has 2–4 fascicles, one larger
one that supplies the anterior portion of the
gracilis muscle and the remaining fascicles Technical Pearls
supplying the rest of the muscle (Fattah
et al. 2013, Morris and Yang 1999). 1. Heat sealing the gracilis muscle allows better
16. The nerve is split longitudinally under the purchase of the muscle during inset and there-
microscope into two halves 4 cm from the fore better accuracy and function.
hilum (one half containing the large fascicle, 2. The appropriate tension of the gracilis muscle
and the second half containing the remaining must be gauged to provide the maximum
Fig. 5 Photo taken from

microscope screen showing
the longitudinal splitting of
the obturator nerve that was
coapted with the CFNG
close to the hilum of the
muscle (*) and with the
masseteric branch 4 cm
more distal (**) in order to
give advantage to the
innervation of the CFNG
CFNG Gracilis muscle
Obturator Nerve split (*)

Masseteric nerve (**)
excursion. Too slack, and it loses excursion; The patient was nursed head up at 45 degrees
too taught and it will be constantly contracted and a warm environment was provided to accom-
and will get fatigued, but also providing an modate good perfusion to the flap.
“unnatural” look. Standard free flap monitoring was thereafter
3. The gracilis muscle can be bulky and there- performed, hourly for the first 24 h, and then
fore care must be taken to debulk it enough more intermittently as per unit protocol. Intrave-
so that it fits better in the soft tissue pocket, nous antibiotics were administered for 48 h post-
but not too much so that it becomes op and chloramphenicol ointment applied to
devascularized. exposed surgical incisions.
4. The muscle strips of the gracilis at its oral The patient’s results are shown at Figures 6–9.
insertion point must be carefully placed Crucially, analgesia was prescribed to keep the
so as to achieve symmetry with the contralat- patient comfortable during this recovery period.
eral side. Drains were monitored in both the head region
5. Selection of buccal branches in stage one, for and the gracilis donor site for any collection. A
coaptation to the CFNG must allow for good urinary catheter was used until the patient was
function of the unaffected side, supplied by the safe to mobilize to the toilet independently. Finally,
remaining buccal branches. mechanical and pharmacological anti-thrombotic
prophylaxis was provided to the patient.
Intraoperative Photographs
Outcomes-Clinical Photos and Imaging
Post-Operative Management
The patient had an implantable doppler to mon-
itor the flap the first five postoperative days, 1. High quality nerve stimulator is imperative to
and a splint at the corner of the mouth to identify the appropriate donor side nerves for
prevent the functioning side distorting the oper- the CFNG. It is the senior author’s practice
ated site. to use a buccal branch that innervates the
photos
Fig. 7 Photos at 1 year

post op
zygomaticus major as the muscle’s action has 4. Secure there is no kinking of the vessels during
been shown to produce the most naturally per- inset of gracilis flap.
ceived smile. 5. Vigilant flap monitoring can be vital in the
2. Appropriate inset, bulkiness and tautness of the salvage of a potentially struggling flap.
gracilis muscle is vital for best outcomes. 6. Post-operative physiotherapy is crucial to the
3. Meticulous hemostasis is crucial to avoid prob- patient’s surgical outcomes.
lems both in the donor site and the inset of the 7. Massaging the flap will reduce oedema and
gracilis flap. therefore expedite healing and function.
Fig. 8 Photos at 2 years

post gracilis muscle transfer
and 6 weeks after the patient
had platinum chain to the
right upper eyelid, tarsal
strip advancement of the
lower eyelid and the
anterior belly of digastric
muscle transfer to correct
the lower lip depression
Fig. 9 Photos at 5 years

post surgery
2. The addition of masseteric nerve coaptation to

Learning Points
the obturator nerve provides power to the
excursion of the muscle, whereas the CFNG
1. It is important to ascertain from the patient their
provides synchronicity, it is thus felt the com-
wishes for reconstruction. The plethora of static
bination of dual innervation provides better
and dynamic procedures allows for choice,
function (Tzafetta et al. 2021).
depending on patient and psychosocial factors.
Cross-References neurovascular architecture of the gracilis muscle: appli-

cation to functional muscle transfer. J Plast Reconstr
Aesthet Surg. 2013;66(9):1230–7.
▶ Adult Facial Nerve Palsy Reconstruction Using Hwang K, Kim YJ, Chung IH, Song YB. Course of the
Gracilis Functional Muscle Innervated with masseteric nerve in masseter muscle. J Craniofac Surg.
Cross-Face Nerve Graft 2005;16(2):197–200.
Morris SF, Yang D. Gracilis muscle: arterial and neural
basis for subdivision. Ann Plast Surg.
1999;42(6):630–3.
References Terzis JK, Olivares FS. Long-term outcomes of free-
muscle transfer for smile restoration in adults. Plast
Biglioli F, Colombo V, Tarabbia F, Pedrazzoli M, Reconstr Surg. 2009;123(3):877–88.
Battista V, Giovanditto F, Dalla Toffola E, Lozza A, Terzis JKT, Tzafetta K. Facial Reanimation. In: Plastic
Frigerio A. Double innervation in free-flap surgery for surgery: indications and practice, Bahman Guyuron
long-standing facial paralysis. J Plast Reconstr Aesthet EE, John Persing, Kevin Chung, Joseph Disa, Arun
Surg. 2012;65(10):1343–9. Gosain, Brian Kinney, J Peter Rubin (ed), vol. 1. Edin-
Borschel GH, Kawamura DH, Kasukurthi R, Hunter DA, burgh: Saunders Elsevier; 2009. p. 907.
Zuker RM, Woo AS. The motor nerve to the masseter Tzafetta K, Al-Hassani F, Pinto-Lopez R, Wade RG,
muscle: an anatomic and histomorphometric study to Ahmad Z. Long term outcomes of dual innervation in
facilitate its use in facial reanimation. J Plast Reconstr functional muscle transfers for facial palsy. J Plast
Aesthet Surg. 2012;65(3):363–6. Reconstr Aesthet Surg (accepted March 2021).
Conley J. Hypoglossal crossover–122 cases. Trans Sect Watanabe Y, Akizuki T, Ozawa T, Yoshimura K,
Otolaryngol Am Acad Ophthalmol Otolaryngol. Agawa K, Ota T. Dual innervation method using
1977;84(4 Pt 1):ORL-763–8. one-stage reconstruction with free latissimus dorsi
Faria JC, Scopel GP, Busnardo FF, Ferreira MC. Nerve muscle transfer for re-animation of established facial
sources for facial reanimation with muscle transplant in paralysis: simultaneous reinnervation of the ipsilateral
patients with unilateral facial palsy: clinical analysis of masseter motor nerve and the contralateral facial nerve
3 techniques. Ann Plast Surg. 2007;59(1):87–91. to improve the quality of smile and emotional facial
Fattah AY, Ravichandiran K, Zuker RM, Agur AM. A expressions. J Plast Reconstr Aesthet Surg.
three-dimensional study of the musculotendinous and 2009;62(12):1589–97.
Facial Reanimation in Congenital
Facial Palsy (Moebius Syndrome) 28
José E. Telich Tarriba and Alexander Cárdenas-Mejía
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
First Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Second Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Abstract Free functional gracilis muscle transfer is the

Moebius syndrome is a developmental neuro- gold standard treatment for long-standing facial
logical disorder characterized by unilateral or paralysis; innervation of the muscle with extra-
bilateral facial and abducens nerve paralysis. facial donor motor nerves is performed when
the contralateral facial nerve is not available,
such as in patients with classic Moebius syn-
drome; however, in the case of incomplete
J. E. Telich Tarriba · A. Cárdenas-Mejía (*) Moebius syndrome, the contralateral facial
Plastic and Reconstructive Surgery Division, Hospital nerve is functional, but its power is severely
General “Dr. Manuel Gea González”, Mexico City, Mexico
diminished. In order to achieve symmetry and
Postgraduate Division of the Medical School, Universidad adequate oral commissure excursion, a dually
Nacional Autonoma de Mexico, Mexico City, Mexico

https://doi.org/10.1007/978-3-030-23706-6_33
266 J. E. Telich Tarriba and A. Cárdenas-Mejía
innervated gracilis muscle flap is performed, Preoperative Problem List

combining stimulus from the contralateral facial
and ipsilateral masseter nerves: Use of the con- Moebius syndrome is a developmental neurolog-
tralateral facial nerve connected to a cross-facial ical disorder characterized by unilateral or bilat-
nerve graft (CFNG) allows synchronic and eral facial and abducens nerve paralysis, and
spontaneous movement, while the masseter patients typically present with congenital
nerve’s high axonal count allows for quick esotropia and a mask-like expressionless face.
reinnervation and strong muscle contraction. The syndrome is often associated with paraly-
The objective of this chapter is to present an sis of other cranial nerves such as the hypo-
approach developed for the evaluation and glossal or glossopharyngeal, as well as a wide
management of patients afflicted with Moebius range of craniofacial, cardiac, and musculo-
syndrome. skeletal malformations (Arrieta-Joffe et al.
2017).
Patients with Moebius syndrome are classified
Keywords
into three large groups depending on their clinical
Facial paralysis · Moebius syndrome · presentation: Classic Moebius syndrome presents
Masseter nerve · Gracilis muscle · Cross-face with bilateral paralysis of the sixth and seventh
nerve graft cranial nerves, while patients with incomplete
Moebius syndrome have bilateral paralysis of the
sixth cranial nerve and unilateral residual function
Clinical Scenario of the facial nerve, finally, patients with Moebius-
like syndrome show facial paralysis accompanied
A 13-year-old female diagnosed with Moebius by dysfunction of other cranial nerves, excluding
syndrome was referred to the clinic for dynamic the sixth (Terzis and Noah 2003).
facial reanimation; she had no relevant family The clinical manifestations found in the patient
history, her mother denied complications during from the clinical scenario are consistent with
pregnancy and delivery, as well as exposure to incomplete Moebius syndrome: complete unilat-
drugs or other known teratogens. eral facial paralysis with residual activity on the
Her parents reported that the patient had labial contralateral side. Therefore, she will require
incompetence that hindered speech and no facial dynamic reconstruction of the left hemiface.
expressions since birth. Medical history was rele-
vant for club foot and strabismus, both of which
had been surgically corrected previously. Treatment Plan
Physical examination showed complete left
facial paralysis and right hemiface paresis, with Decision-making in the surgical management of
moderate excursion of the right oral commissure; developmental facial paralysis remains challeng-
the patient also presented bilateral lagophthalmos ing due to the variety of procedures available.
with adequate Bell’s sign, as well as dysfunction Nevertheless, reconstructive goals remain con-
of lateral movement in both eyes. Adequate func- stant: restoration of facial symmetry at rest and
tion of the masseter, spinal, and hypoglossal achievement of a spontaneous and symmetric
nerves was found (Fig. 1). No other craniofacial, smile (Tate and Tollefson 2006).
limb, or cardiac malformations was identified. Free functional muscle transfer (FFMT) is cur-
Electromyography showed complete absence rently the gold standard treatment for long-
of activity on the left face, and residual activity standing unilateral facial paralysis (Razfar et al.
on the right face; the masseter, hypoglossal, and 2016). The gracilis muscle has become the most
spinal nerves all had normal function. Imaging commonly used flap owing to its constant
studies demonstrated presence and adequate per- neurovascular anatomy, acceptable donor-site
meability of the facial artery and vein. morbidity, and adequate excursion.
28 Facial Reanimation in Congenital Facial Palsy (Moebius Syndrome) 267
Fig. 1 Preoperative clinical photographs of the patient showing mild facial asymmetry at rest, lagophthalmos, and left
facial paralysis with residual activity of the depressor muscles on the paralyzed side
Management of patients with Moebius syn- of incomplete Moebius syndrome, the contralat-
drome should follow an algorithmic approach eral facial nerve is partially functional and can be
based upon whether the facial paralysis is unilat- used as a donor (Cardenas-Mejia and Palafox
eral or bilateral and by the available donor motor 2018).
nerves. Innervation of the muscle with extrafacial Several research groups have proposed the use
donors such as the masseter or accessory-spinal of a dually innervated or supercharged gracilis
nerves is required when the contralateral facial muscle flap in order to achieve symmetry and
nerve is not available, such as in patients with adequate oral commissure excursion in patients
classic Moebius syndrome; however, in the case with unilateral facial paralysis (Watanabe et al.
results. Surgical options can be broadly classi-

fied into microsurgical and nonmicrosurgical
procedures.
Microsurgical procedures take advantage of
free muscle transfer to achieve good commissure
excursion and adequate smile vectors; even
though the gracilis is currently the most com-
monly used muscular flap in facial reanimation,
multiple options have been described, including
the latissimus dorsi, pectoralis minor, rectus
abdominis, and serratus anterior; each flap
has advantages and disadvantages, and often
selection rests on surgeon and patient preference
(Domeshek et al. 2018).
Nonmicrosurgical options take advantage of
regional muscles and may be appropriate options
in patients who are not candidates for or wish to
avoid free muscle transfer. These techniques
involve the transfer of either the temporalis or
Fig. 2 Diagram of a dually innervated gracilis FFMT with
neurotization of the obturator nerve to the masseteric masseter muscles. Regional muscle transposition
branch of the trigeminal nerve and the contralateral facial will not recreate spontaneous, symmetrical
nerve mimetic function, instead, each movement
requires a specific volitional action (Harris and
2009; Biglioli et al. 2012; Cardenas-Mejia et al. Tollefson 2015).
2015). The technique seeks to combine stimulus
from the contralateral facial and ipsilateral masse-
ter nerves, taking advantage of the strengths of Preoperative Care and Patient
both neural sources: Use of the contralateral facial Drawing
nerve connected to a cross-facial nerve graft
(CFNG) allows synchronic and spontaneous Every patient is evaluated at the peripheral nerve
movement, while the masseter nerve’s high axo- clinic by a multidisciplinary team. A detailed neu-
nal count allows for quick reinnervation and rological exam is performed, including every can-
strong muscle contraction (Cardenas-Mejia et al. didate donor nerve: masseter, spinal, hypoglossal,
2015) (Fig. 2). and contralateral facial nerve.
In the present clinical scenario, the patient is Photography and video recordings are manda-
afflicted with incomplete Moebius syndrome and tory, and they should document the face at rest and
has residual activity on the right hemiface. There- during movement; these images are helpful
fore, a double innervated functional gracilis mus- intraoperatively to guide the final position of the
cle transfer is proposed. smile vector and identify the nasolabial fold’s
position.
Bilateral electromyography of the facial mus-
Alternative Reconstructive Options culature and all extrafacial donor motor nerves
complements physical exam findings and allows
Numerous protocols for dynamic facial recon- the team to define the surgical plan. Doppler ultra-
struction have been described, with differing sound imaging of the facial and superficial tem-
opinions as to the ideal procedure and number poral vessels is useful, although not mandatory for
of stages required to achieve satisfactory preoperative evaluation.
The first stage of the procedure requires required; however, care should be taken to avoid
performing a CFNG connected to the zygomatic the inguinal crease (Sharma et al. 2016).
branch of the facial nerve. Surgical markings are
limited to a preauricular incision and Zuker’s
point, a site midway from the root of the helix to Surgical Technique
the commissure that indicates the position of the
facial nerve’s zygomatic branch (Cardenas-Mejia First Stage
et al. 2015).
The second stage of the procedure is the The goal of the first stage of the procedure is to
gracilis muscle transfer. A preauricular incision perform a CFNG using the contralateral buccal
with submandibular extension should be drawn branch of the facial nerve.
on the paralyzed side, as well as the position of A preauricular incision is made on the healthy
the zygomatic arch, the planned nasolabial crease, side of the face, and a cheek flap is dissected
and the vector of intended pull. Both facial and anteriorly until the buccal branch of the facial
superficial temporal vessels are identified using a nerve is identified with the help of an electro-
doppler ultrasound probe, and their position is stimulator. Simultaneously, a 20–25 cm sural
marked (Fig. 3). The gracilis flap is raised from nerve graft is harvested by a second team and
the leg ipsilateral to the paralyzed hemiface, and transferred to the face, placing it in an orthodromic
the incision line is marked posterior to the adduc- fashion. An end-to-side anastomosis to the previ-
tor longus by two or three finger breadths; the ously identified buccal branch is performed, then
dominant pedicle of the muscle should be identi- the distal end of the graft is tied to a blunt tendon
fied with the ultrasound probe and marked as well; passer and is passed to the contralateral side
it lies around 10 cm distal to the pubis; the length through the upper lip, where it is banked beneath
of the incision depends on the amount of muscle the tragus (Cardenas-Mejia and Palafox 2018).
Fig. 3 Preoperative markings: (a) Preoperative markings paralyzed side should include a preauricular incision, the
on the nonparalyzed side include a preauricular incision position of the zygomatic arch and nasolabial fold, and the
and Zuker’s point. (b) Preoperative markings on the desired smile vector
Second Stage for traction. The obturator nerve is identified and

stimulated to verify adequate contraction of the
The second stage of the operation is carried out muscle, and it is followed until its emergence at
once reinnervation of the CFNG has been con- the foramen obturatum; afterward, the adductor
firmed by Tinnel sign and neuroconduction stud- longus muscle is rejected and the gracilis’ vascu-
ies 3–4 months later. lar pedicle is identified, dissecting it carefully
Two surgical teams work simultaneously. The until its origin at the femoral vessels.
head team begins the operation by making a pre- Once the neurovascular pedicle has been ade-
auricular incision on the paralyzed side; the cheek quately identified and isolated, the muscle is tri-
flap is dissected in a subcutaneous plane above the mmed into a trapezoid shape based on the
parotid fascia. Dissection is carried anteriorly measurements made by the face team, adding an
until the anterior border of the masseter muscle extra centimeter to its length to allow suturing at
is found; the zygoma corresponds to the superior the edges. The muscle is transected with a GIA
limit of dissection, while the mandibular border is 80 mm intestinal stapler (MEDTRONIC, Minne-
the lower limit. At the anterior border of the mas- apolis, USA). Once dissection on the face has
seter, the facial vein is identified, and directly been completed, the vascular pedicle is divided
anterior to it the facial artery. Both vessels are using surgical clips and the nerve is transected.
dissected toward the oral commissure, divided The muscle is transferred to the face, and its
and pulled toward the incision. (If the facial ves- proximal tendon is lowered and anchored to the
sels are absent or small, the superficial temporalis nasolabial fold using the vicryl sutures applied
artery and vein are dissected.) The buccal fat pad previously. An end-to-end anastomosis is
is extracted carefully using blunt dissection in an performed between the distal end of the CFNG
attempt to decrease tissue bulk. and the obturator nerve, then an end-to-side coap-
The surgeon then identifies the orbicularis oris, tation from the masseteric nerve to the obturator
the modiolus, and zygomatic muscles and applies nerve about 1 cm proximal to the gracilis muscle
0 vicryl stay sutures to each landmark, using hilum. Finally, the vascular anastomoses are made
figure-of-eight stitches as anchoring technique. in an end-to-end fashion.
Once the sutures have been positioned, the After the neurovascular repairs, the distal end
nasolabial fold should be recreated when traction of the muscle is anchored to the preauricular fascia
is applied. with mattress sutures, and any redundant muscle
The next step is to identify and dissect the tissue is removed until adequate tension is
banked CFNG and the masseteric nerve. The achieved, which is seen as a slight pull of the
CFNG should be harvested from the location commissure (Cardenas-Mejia and Palafox 2018).
where it was banked; the masseteric nerve is iden-
tified by performing blunt dissection at the man-
dibular notch, rejecting the parotid gland and the Technical Pearls
masseter muscle fibers; once the nerve has been
isolated, it is transected at its most distal portion • A layer of fat should be kept on the
and directed outward. rhitydectomy flap to avoid dermal adhesions
While the first team works on the face, the to the muscle transfer.
second surgical team harvests the gracilis muscle. • Buccal fat pad resection is a good technique to
A short 7 cm skin incision over the posterior reduce cheek volume, while avoiding the need
border of the adductor longus muscle is made, to debulk the gracilis muscle.
approximately 3 cm below the inguinal crease. • The surgical plane required to dissect the facial
Blunt dissection is performed until the gracilis artery near the oral commissure is where the
muscle belly is identified. Circumferential dissec- anchoring stitches should be placed.
tion of the muscle begins by surrounding its prox- • Anchoring sutures should be performed using
imal and distal edges using a penrose drain to use a row of mattress sutures, as described by
Dr. Zuker; this avoids muscle fiber tearing and Postoperative Management
secures the muscle in its planned position, lim-
iting posterior migration of the nasolabial fold After the procedure, the patients remain in the recov-
(Zuker 2018). ery room for 1–2 h and are transferred to the plastic
• The arterial anastomosis if done first, and the surgery ward. They remain hospitalized for 5 days
venous anastomosis, is performed using the and are evaluated hourly with a manual Doppler
commitant vein that ingurgitates the most. probe to verify the permeability of the vascular
• End-to-side neurorrhaphies require performing anastomosis. Prophylactic antibiotics, analgesia,
a perineural window on the side of the motor and thromboprophylaxis are administered.
nerves to allow for axonal sprouting, as Follow-up is performed at the outpatient
described by Dr. Viterbo (Viterbo et al. 2017). peripheral nerve clinic. Rehabilitation is started
3 weeks after the procedure by making mastica-
tory exercises. Once the gracilis shows signs of
Intraoperative Images contraction, a smile rehabilitation protocol is
started in front of a mirror, so the patient identifies
See Figs. 4, 5, 6, 7, and 8. the triggers for symmetric and independent com-
missure contraction.
Comparative pre- and postoperative photographs

show adequate gracilis muscle contraction, with
good oral commissure excursion and smile sym-
metry (Fig. 9).
Hematomas are the most common early compli-

cations, and careful and thorough hemostasis
Fig. 4 Cheek flap elevation on the paralyzed side. Note
that a layer of fat is preserved beneath the skin should be performed throughout the procedure in
Fig. 5 Buccal fat pad resection decreases cheek volume Fig. 6 Anchoring sutures placed and pulled to recreate the
and allows better exposure of the facial artery and vein nasolabial fold on the paralyzed hemiface
photograph showing the
gracilis muscle belly,
vascular pedicle, and
obturator nerves in situ
Dr. Viterbo’s technique can be done (Viterbo and

de Paula Faleiros 2005).
Learning Points
1. Moebius syndrome is a rare and complex cause

of developmental facial paralysis characterized
by lack of facial expression and dysfunction of
lateral movements in both eyes.
2. Segmental gracilis free functional muscle
transfer is the procedure of choice for
dynamic facial reanimation in patients with
Fig. 8 Use of a gastrointestinal stapler to ease resection of long-standing facial paralysis.
the gracilis muscle segment
3. Preoperative electromyography of the facial
muscles and extrafacial nerve donors is
order to avoid them. If a hematoma is identified, paramount for the elaboration of the
early evacuation and surgical exploration should surgical plan.
be performed. 4. The dual innervation technique takes advan-
Surgical site infections are rare but potentially tage of the symmetry and spontaneity derived
devastating complications, and these should be from the use of the CFNG and the strong con-
treated aggressively with intravenous antibiotics traction and quick reinnervation from the mas-
and surgical lavage if any localized collections are seter nerve.
identified. 5. Dynamic facial reanimation in patients with
In cases of flap failure or flap loss, a contralat- Moebius syndrome should follow an algorith-
eral gracilis flap transfer can be performed; if a mic approach based on whether the paralysis is
second gracilis muscle is unavailable, an ortho- unilateral or bilateral, and the availability of
dromic transfer of the temporalis muscle using donor motor nerves.
Fig. 9 Comparative pre- and postoperative photographs show adequate gracilis muscle contraction, with good oral
commissure excursion and smile symmetry
Frigerio A. Double innervation in free-flap surgery for

References long-standing facial paralysis. J Plast Reconstr Aesthet
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molecular y de imagen de los pacientes con Síndrome tertiary referral hospital in Latin America. Ann Chir
de Moebius del Hospital General “Dr. Manuel Gea Plast Esthet. 2018;63(4):338–42.
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2017;43(4):395–400. Margolis A, Rozen S. Double innervated free func-
Biglioli F, Colombo V, Tarabbia F, Pedrazzoli M, tional muscle transfer for facial reanimation. J Plast
Battista V, Giovanditto F, Dalla Toffola E, Lozza A, Surg Hand Surg. 2015;49(3):183–8.
Domeshek LF, Zuker RM, Borschel GH. Management of made easy and better. J Craniofac Surg. 2005;16
bilateral facial palsy. Otolaryngol Clin North (2):306–9.
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Harris BN, Tollefson TT. Facial reanimation: evolving Rodrigues CP. End-to-side versus end-to-end
from static procedures to free tissue transfer in head neurorrhaphy at the peroneal nerve in rats. Acta Cir
and neck surgery. Curr Opin Otolaryngol Head Neck Bras. 2017;32(9):697–705.
Surg. 2015;23(5):399–406. Watanabe Y, Akizuki T, Ozawa T, Yoshimura K,
Razfar A, Lee MK, Massry GG, Azizzadeh B. Facial paral- Agawa K, Ota T. Dual innervation method using
ysis reconstruction. Otolaryngol Clin North one-stage reconstruction with free latissimus dorsi
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Sharma PR, Zuker RM, Borschel GH. Gracilis free muscle paralysis: simultaneous reinnervation of the ipsilateral
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Tate JR, Tollefson TT. Advances in facial reanimation. expressions. J Plast Reconstr Aesthet Surg. 2009;62
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(4):242–8. Zuker RM. Improving the results of muscle transplanta-
Terzis JK, Noah EM. Dynamic restoration in Möbius and tion for facial reanimation. In: Bumbasirevic M,
Möbius-like patients. Plast Reconstr Surg. 2003;111 Georgescu A, Soucacos PN, editors. Technical tips
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Viterbo F, de Paula Faleiros HR. Orthodromic transpo- it. 2018. p. 165–7. Zavod za udžbenike, Belgrade,
sition of the temporal muscle for facial paralysis: Serbia.
One-Stage Reconstruction of Facial
Paralysis Using Masseter 29
Nerve-Innervated Gracilis
Pamela Villate-Escobar and Alexander Cárdenas-Mejía
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Learning Points (5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Abstract communication. Furthermore, the facial nerve

Facial paralysis is a deeply disabling condition. is also responsible for providing other functions
Adequate function of the mimetic musculature such as ocular protection, adequate nasal air-
is essential for both verbal and nonverbal flow, articulation of speech, and oral continence.
Etiology of facial paralysis can be heteroge-
neous, ranging from developmental defects to
traumatic, idiopathic, infectious, iatrogenic, or
P. Villate-Escobar · A. Cárdenas-Mejía (*) neoplastic causes. Facial reanimation surgery
Plastic and Reconstructive Surgery Division, Hospital has been thoroughly proven to improve quality
General “Dr. Manuel Gea González”, Mexico City, Mexico of life. However, decision-making in the surgi-
Postgraduate Division of the Medical School, Universidad cal management of facial paralysis remains
Nacional Autonoma de Mexico, Mexico City, Mexico

https://doi.org/10.1007/978-3-030-23706-6_112
276 P. Villate-Escobar and A. Cárdenas-Mejía
challenging due to the multiple reanimation pro- confirmed complete right facial paralysis, no excur-
cedures currently available. In order to achieve sion of the right oral commissure, and speech artic-
symmetry and adequate oral commissure excur- ulation difficulties. The patient also presented right
sion, a one-stage masseter nerve-innervated lagophthalmos with adequate Bell’s sign, right side
gracilis muscle flap is performed for patients in ectropion, and right soft tissue laxity (Fig. 1). Sat-
which a dual innervation is not feasible. This isfactory clinical function of the masseter, spinal,
approach allows satisfactory results with low and hypoglossal nerves was found.
donor nerve morbidity in elderly individuals, Electromyography showed complete absence
patients with comorbidities that cannot tolerate of activity on the right side of the face, with total
two procedures, or when a contralateral facial muscle denervation on the mid and lower thirds.
nerve is not available. In these cases, the mas- The masseter, hypoglossal, and spinal nerves all
seter nerve’s high axonal load allows for quick had normal function. Imaging studies demon-
reinnervation and strong muscle contraction. strated presence and adequate permeability of
The objective of this chapter is to present an the facial artery and vein.
approach for the evaluation, and management
of patients afflicted with long-standing facial
paralysis, by means of a one-stage reconstruc- Preoperative Problem List
tion using masseter nerve-innervated gracilis.
Differential diagnosis on facial paralysis can be
broad. Etiology among adult and pediatric popula-
Keywords
tion differs. Most cases of facial paralysis in adult
Facial paralysis · One-stage reanimation · patients are acquired, being Bell’s palsy reported as
Masseter nerve · Gracilis muscle flap the most common cause, followed by infection,
trauma, iatrogenic, and tumors (Mackinnon 2015).
While in children the most frequent cause of
Clinical Scenario acquired facial palsy is Bell’s paralysis, followed
by infection, trauma, birth trauma, and Leukemia
A 65-year-old female was referred to the peripheral (Cha et al. 2008). These vary among different
nerve clinic after being diagnosed with facial paral- authors and centers (Mackinnon 2015).
ysis secondary to schwannoma resection 2 years At the senior author’s center, the first cause of
prior to consultation. She stated that the symptoms surgical treatment for facial reanimation is
before surgery started with progressive unilateral Moebius syndrome, followed by patients with
hearing loss and right hemifacial paresis. However, facial paralysis secondary to resection of head
it was only until she developed complete unilateral tumors close to or involving the facial nerve,
facial palsy that the tumor diagnosis was made. The especially schwannomas. In the pediatric popula-
patient was referred to the peripheral nerve clinic tion, especially in classic Moebius syndrome,
for dynamic facial reanimation once the oncology alterations of facial mobility may not be initially
team ruled out the presence of additional tumor evident. Late diagnosis may delay treatment of
lesions or recurrences. She had no relevant family facial paralysis among these patients, causing
history, denied other complications during the other alterations in facial growth development
tumor resection surgery, and had no other previous and triggering additional functional problems. In
reanimation procedures. contrast, even though facial paralysis in the adult
After schwannoma resection, along with the population also develops functional alterations
right side facial palsy, she presented total hearing such as lagophthalmos, oral incontinence, and
loss. The patient referred oral incompetence and speech difficulty, there is a greater psychological
speech difficulties as the most undesired functional impact due to better self-awareness of the social
symptoms, but she also referred social isolation due stigma this implies. Therefore, surgical treatment
to aesthetic appearance. Physical examination with facial reanimation becomes key to improve
29 One-Stage Reconstruction of Facial Paralysis Using Masseter Nerve-Innervated Gracilis 277
Fig. 1 Preoperative clinical photographs of the patient showing facial asymmetry at rest, lagophthalmos, and right
complete facial paralysis
not only functional aspects but also recover pre- to consider neoplastic involvement of this nerve in
vious social interaction. every patient with facial nerve-related symptoms
On the other hand, tumors of the facial nerve are (Wilkinson et al. 2011). Schwannomas are the most
rare. Still, head, neck, and skull base tumors may common benign lesions seen to involve the facial
lie in close proximity or invade the facial nerve nerve, being acoustic schwannomas located in the
throughout its anatomic trajectory, hence the need cerebellopontine angle or auditory canal frequent
in presentation (May 1986). In the present clinical Free functional muscle transfer (FFMT) is cur-
scenario, resection surgery to treat an acoustic rently the gold standard treatment for long-
schwannoma in the cerebellopontine angle was standing unilateral facial paralysis (Razfar et al.
mandatory. 2016). The gracilis muscle has become the most
Latter clinical manifestations in the patient were commonly used flap, due to its constant
consistent with acoustic and facial nerve involve- neurovascular anatomy, acceptable donor-site
ment: hearing loss with complete unilateral facial morbidity, and adequate excursion. Innervation
paralysis. Facial nerve involvement caused lago- of the muscle with extra-facial donor nerves is
phthalmos, ectropion, oral incontinence, and diffi- required when the contralateral facial nerve is
culties for speech articulation, as well as social not available, such as in some developmental
isolation. Therefore, both functional and aesthetic paralysis, when patients cannot undergo more
issues benefited from treatment. Due to clinical and than one procedure due to multiple comorbidities
electrodiagnostic findings in the patient, she bene- or simply when the patient does not want more
fited from dynamic reanimation of the right hemi than one surgical staged procedure.
face. Concerning the FFMT innervation, the masseter
nerve has become the standard source of donor
nerve in patients who are not candidates for cross-
Treatment Plan facial nerve grafts. The first description of its use in
facial reanimation was made in 1925 by Escat and
The patient presented with long-standing facial Viela. However, this procedure remained largely
paralysis that led to several functional, aesthetic, forgotten until Spira’s preliminary reports in 1978
and psychological symptoms, all of which required (Brenner and Schoeller 1998). The masseter nerve
a multidisciplinary approach. Decision-making in has several advantages that make it well suited for
the surgical management of facial paralysis facial reanimation surgery, such as its proximity to
remains challenging due to the variety of options the facial nerve, consistent location, limited donor-
available. However, dynamic reanimation is the site morbidity, high-density axonal load, and sub-
ideal treatment in long-standing facial palsy. sequent ease for rehabilitation (Klebuc 2015).
Concerning the lower third of the face, achieving In the present clinical scenario, a 65-year-old
a spontaneous and synchronic smile while restor- patient was afflicted with long-standing complete
ing facial symmetry is still the main reconstructive right facial paralysis, and total denervation of the
goal (Tate and Tollefson 2006). mid and lower thirds of the right hemiface. She
When treating a patient with long-standing facial presented with different functional symptoms, all
paralysis, the patient’s desires and needs must be of which benefited from treatment to improve both
considered. In order to address a patient with facial appearance and restore function. Due to late con-
paralysis due to tumor resection, it is useful to sultation, and electrodiagnostic findings, dynamic
follow an algorithmic approach based on time of reanimation methods of the upper face were not
palsy onset and electrodiagnostic findings regarding feasible in the patient, and they lie beyond the
muscle reinnervation (Terzis and Konofaos 2008): scope of this chapter. Still, after the initial assess-
ment, it was determined lagophthalmos and
• Patients with facial paralysis with less than ectropion benefited from static procedures, thus a
6 months of denervation: cross-facial nerve Kuhnt-Szymanowski procedure was planned. On
grafts (CFNG’s) the other hand, the patient referred oral inconti-
• Patients with facial paralysis with denervation nence and speech difficulties as the most undesired
time between 6 months to 2 years: “Baby-sitter”- symptoms, and specifically asked for no more than
procedure (minihypoglossal + CFNG) muscle one staged surgery as treatment. Therefore, and
transfers taking into account both clinical and electro-
• Patients with facial paralysis with denervation diagnostic findings, a one-stage reconstruction
time greater than 2 years and 3 months: with masseter nerve-innervated gracilis muscle
CFNG’s procedure + muscle transfers transfer was proposed.
Alternative Reconstructive Options protective function (Terzis and Olivares 2009).

Pedicled or free-muscle transfers for orbicularis
Numerous protocols for dynamic facial recon- substitution are reported as methods on dynamic
struction have been described, with different opin- facial reanimation of the upper face. Upper face
ions as to the ideal procedure and number of static procedures include brow-lift include brow
stages required to achieve satisfactory results. lift, botox to contralateral frontalis muscle, gold
Surgical reanimation options can be broadly clas- weight placement, lateral canthoplasty, and bleph-
sified into static and dynamic procedures. Further- aroplasty, among others.
more, dynamic reanimation procedures include Mid-face secondary surgery often may result
microsurgical and non-microsurgical techniques. from free-muscle transfer deficiencies. Elderly
Microsurgical procedures take advantage of patients require more revision procedures due to
free muscle transfer to achieve good commissure their tissue laxity. Nasolabial fold compensatory
excursion and adequate smile vectors. Even procedures are frequently used in order to achieve
though the gracilis is currently the most com- better symmetry, as well as complementary pro-
monly used muscular flap in facial reanimation, cedures for inadequate direction of pull, lateral
multiple options have been described, including fixation of the oral commissure, and skin tighten-
other donor muscles such as the latissimus dorsi, ing. On the other hand, lower face deficiencies
pectoralis minor, rectus abdominis, and serratus most often include inadequate function of the
anterior (May 1986). Each flap has pros and cons, depressor mechanism (Terzis and Olivares 2009).
and often selection lies on surgeon and patient In the senior author’s experience, patients most
preference (Domeshek et al. 2018). often require contralateral depressor labii inferioris
Several research groups have proposed the use myomectomy, but other interventions include, fat
of a dually innervated or supercharged gracilis grafts, neck lift, and scar revision, among others.
muscle flap in order to achieve symmetry and Addressing each patient’s needs prior to sur-
adequate oral commissure excursion in patients gery allows a more accurate treatment plan and
with unilateral facial paralysis (Watanabe et al. may decrease the need for further interventions.
2009; Biglioli et al. 2012; Cardenas-Mejia et al. Still, it is helpful to discuss the probable need of
2015). The use of the contralateral facial nerve secondary surgery during the surgical assessment
connected to a cross-facial nerve graft (CFNG) and planning, in order to ground the patient’s
allows synchronic and spontaneous movement, expectations.
while the masseter nerve’s high axonal count
allows for quick reinnervation and strong muscle
contraction (Cardenas-Mejia et al. 2015). Preoperative Care and Patient
Non-microsurgical options take advantage of Drawing
regional muscles and may be appropriate options
in patients who are not candidates for or wish to Every patient is evaluated at the peripheral nerve
avoid free muscle transfer. These techniques clinic by a multidisciplinary team. A detailed neu-
involve the transfer of either the temporalis or mas- rological exam is performed, including electro-
seter muscles. Regional muscle transposition will diagnostic studies of every potential donor
not recreate spontaneous, symmetrical mimetic nerve: masseter, spinal, hypoglossal, and contra-
function. Instead, each movement requires a spe- lateral facial nerve.
cific volitional action (Harris and Tollefson 2015) Photography and video recordings are manda-
and frequently creates undesired bulk. tory; they should document the face at rest and
It is important to keep in mind that both static during movement. These images are also helpful
and dynamic facial reanimation methods may intraoperatively to guide the final position of the
require secondary procedures in order to achieve smile vector and identify the nasolabial fold’s
the desired result. Restoration of an adequate eye position.
closure and blink are treatment priorities in the Bilateral electromyography of the facial mus-
upper face in order to restore the eye sphincter culature and all extra-facial donor motor nerves
complements physical exam findings and allows

the team to define the surgical plan. Doppler ultra-
sound imaging of the facial and superficial tem-
poral vessels is useful, although not mandatory for
preoperative evaluation.
Surgical markings are limited to a preauricular
incision and the anatomic landmarks that allow
the location of the masseter nerve for its dissec-
tion. The masseter nerve should be easily located
3 cm anterior to the tragus and 1 cm caudal to the
zygomatic arch, approximately 1.5 cm deep to the
submuscular aponeurotic system (SMAS)
(Borschel et al. 2012). Not all patients fit these
measures, so we find it easier to use constant bone
anatomical references in order to dissect the mas-
seter nerve. Therefore, markings corresponding to
the zygomatic arch and the mandibular notch are
drawn, to ease the masseter nerve identification
(Fig. 2).
During the gracilis muscle transfer, a pre-
auricular incision with submandibular extension
should be drawn on the paralyzed side, as well as
the position of the zygomatic arch, the planned
Fig. 3 Preoperative markings on the paralyzed side: pre-
auricular incision, position of the zygomatic arch, and
nasolabial fold
nasolabial crease, and the vector of intended pull

(Fig. 3). Both facial and superficial temporal ves-
sels are identified using a manual Doppler ultra-
sound probe and their position is marked.
The gracilis flap is raised from the leg ipsilat-
eral to the paralyzed hemiface. The incision line is
marked posterior to the adductor longus by two or
three finger-breadths. The dominant pedicle of the
muscle should be identified with the ultrasound
probe and marked as well; it lies around 10 cm
distal to the pubis. The length of the incision
depends on the amount of muscle required; how-
ever, care should be taken to avoid the inguinal
crease (Sharma et al. 2016) (Fig. 4).
Surgical Technique
Two surgical teams work simultaneously. The

head team begins the operation by making a pre-
Fig. 2 Topographic localization of the masseteric branch auricular incision on the paralyzed side. A cheek
of the trigeminal nerve flap is dissected in a subcutaneous plane above the
Fig. 4 Thigh preoperative markings
parotid fascia. Dissection is carried anteriorly gracilis muscle. A short 7 cm skin incision over
until the anterior border of the masseter muscle the posterior border of the adductor longus muscle
is identified. The zygoma corresponds to the supe- is made, approximately 3 cm below the inguinal
rior limit of dissection, while the mandibular bor- crease. Blunt dissection is performed until the
der is the lower limit. At the anterior border of the gracilis muscle belly is identified. Circumferential
masseter, the facial vein is identified, and directly dissection of the muscle begins by surrounding its
anterior to it the facial artery. Both vessels are proximal and distal edges using a penrose drain
dissected toward the oral commissure, divided for traction. The obturator nerve is identified and
and pulled toward the incision. If the facial vessels stimulated to verify adequate contraction of the
are absent or small, the superficial temporalis muscle. The dissection should be followed until
artery and vein are dissected and used as recipient its emergence at the foramen obturatum in order to
vessels. Once the parotid duct is identified and gain the longest possible length. Afterward, the
preserved, the buccal fat pad is carefully extracted adductor longus muscle is rejected and the
using blunt dissection in an attempt to decrease gracilis’ vascular pedicle is identified. Careful
tissue bulk. dissection is made until the pedicle’s origin is
The surgeon then identifies the orbicularis oris, identified at the femoral vessels.
the modiolus, and zygomatic muscles, and applies Once the neurovascular pedicle has been ade-
0 vicryl stay sutures to each landmark, using figure- quately identified and isolated, the muscle is tri-
of-eight stitches as anchoring technique. Once the mmed into a trapezoid shape based on the
sutures have been positioned, the nasolabial fold measurements made by the face team, adding an
should be recreated when traction is applied. extra centimeter to its length on every side, to
The next step is to identify and dissect the donor allow suturing at the edges. The muscle is trans-
nerve. The masseteric nerve is localized at the man- ected with a GIA 80 mm intestinal stapler
dibular notch below de zygomatic arch. Blunt dis- (MEDTRONIC, Minneapolis, US). Once dissec-
section is used, carefully rejecting the parotid gland tion on the face has been completed the vascular
and the masseter muscle fibers. Once the nerve has pedicle is divided using surgical clips and the
been identified and isolated, it is transected at its nerve is transected.
most distal portion and directed outward. The muscle is transferred to the face, and its
While the first team works on the face, the proximal tendon is lowered and anchored to the
second surgical team simultaneously harvests the nasolabial fold using the vicryl sutures previously
positioned. Once the muscle is firmly attached, the • Thorough hemostasis is mandatory. Bipolar
vascular anastomoses are made in an end-to-end cautery is used to decrease surrounding tissue
fashion. Finally, an end-to-end neurorrhaphy is damage. During masseter nerve dissection, it is
performed between the distal end of the masseter helpful to leave a small absorbable gelatin
nerve and the obturator nerve. sponge after the distal transection in order to
After the neurovascular anastomosis, the distal prevent further bleeding.
end of the muscle is sutured to the preauricular • In elderly patients, hemostasis should be veri-
fascia with mattress sutures. Any redundant mus- fied while having a mean arterial pressure over
cle tissue is removed until adequate tension is 70 mmHg, prior to skin closure.
achieved, which is seen as a slight pull of the
commissure (Cardenas-Mejia and Palafox 2018).
Technical Pearls see Figs. 5, 6, 7, 8, and 9
• A useful method to reduce cheek volume during

this reanimation technique is to remove the buc- Postoperative Management
cal fat pad. This will prevent the need to debulk
the gracilis muscle in a secondary procedure. After the procedure the patients remain in the
• Anchoring sutures should be performed using recovery room for 1–2 h and are transferred to
a row of mattress sutures. This avoids muscle the plastic surgery ward once they have recovered
fiber tearing and secures the flap in its planned from anesthesia. They remain hospitalized for
position, voiding posterior migration of the 5 days and are evaluated hourly with a manual
nasolabial fold (Zuker 2018). Doppler probe to verify the permeability of the
• Identification of constant bony structures such as vascular anastomosis. Prophylactic antibiotics
the zygomatic arch, and the mandibular notch, and analgesia are administered, as well as
simplifies the masseteric nerve localization. thromboprophylaxis with a low molecular weight
• When transecting the gracilis, the additional heparin (enoxaparin). In patients who have multi-
centimeter used in other patients for the ple comorbidities, it is necessary to restore their
anchoring of the muscle might be reconsidered usual pharmacological management in the imme-
in elderly patients, given the hyperlaxity of diate postoperative period in order to avoid com-
their tissues. This will allow a more accurate plications associated with the therapeutic
oral commissure position. abandonment of such comorbidities.
Fig. 5 Buccal fat pad

identification and resection
to decrease cheek volume
and allow better exposure of
the facial artery and vein
Fig. 6 Intraoperative in
situ topographic bony
landmarks for masseteric
nerve identification:
zygomatic arch and
mandibular notch
Fig. 7 Anchoring sutures

placed on the gracilis
muscle ready to be
anchored and pulled to
recreate the nasolabial fold
Follow-up is performed at the outpatient

peripheral nerve clinic. Rehabilitation starts
3 weeks after surgery with oral closing and open-
ing exercises, followed by masticatory exercises,
which initiate 6 weeks after surgery. Once the
gracilis shows signs of contraction, the smile reha-
bilitation protocol is started in front of a mirror, so
the patient identifies the movement that triggers
commissure contraction.
Comparative pre- and postoperative photographs

show adequate gracilis muscle contraction, with
Fig. 8 Intraoperative photograph showing the gracilis
muscle belly (GM), vascular pedicle (Vp), and obturator
good oral commissure excursion and smile sym-
nerves (ObN) in situ metry (Fig. 9).
Fig. 9 Comparative pre- and postoperative photographs show adequate gracilis muscle contraction, with good oral
commissure excursion and smile symmetry
exploration. Changes in volume or consistency

of the surgical site should be noted. If there is
Hematomas are the most common early compli- clinical suspicion of any volume occupying pro-
cations. Close observation of the patient’s postop cess, the use of Doppler ultrasonography helps to
helps to identify the need of early hematoma determine the need of further reintervention.
evacuation, as well as the need of surgical Careful and thorough hemostasis should be
performed throughout the procedure in order to • Dynamic facial reanimation in patients with
avoid these complications. long-standing facial paralysis should follow
Acute venus or arterial thrombosis might pre- an algorithmic approach based on time of
sent. Early detection is key to assess the need of palsy onset, electrodiagnostic findings regard-
immediate surgical intervention. If necessary, the ing muscle reinnervation viability, and ade-
vascular anastomoses must be redone to ensure quate donor nerve function.
flap viability and avoid additional complications.
No thrombolytic agents are applied.
Surgical site infections are rare but potentially Cross-References
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eral gracilis flap transfer can be performed. If a (Moebius Syndrome)
second gracilis muscle is unavailable, an ortho-
dromic transfer of the temporalis muscle, using
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to elaborate an appropriate surgical plan. in Möbius syndrome: experience from 76 cases from a
3. One-stage reconstruction of facial paralysis tertiary referral hospital in Latin America. Ann Chir
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a two-stage procedure. alyzed face. Ann Chir Plast Esthet. 2015;60
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Viterbo F, de Paula Faleiros HR. Orthodromic transpo- Soucacos PN, editors. Technical tips & tricks for recon-
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Midface Reconstruction with Soft
Tissue and Bone Flaps 30
Fares Samra, Joseph Disa, and Evan Matros
Contents
Soft Tissue Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Outcome, Clinical Photos, and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Osteocutaneous Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
F. Samra · J. Disa · E. Matros (*)

Memorial Sloan Kettering Cancer Center, New York, NY,
USA
e-mail: disaj@mskcc.org; matrose@mskcc.org

https://doi.org/10.1007/978-3-030-23706-6_113
288 F. Samra et al.

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Abstract Soft Tissue Reconstruction

Midface, or maxillary, reconstruction remains
one of the most challenging domains within The Clinical Scenario
head and neck reconstruction. The maxilla,
often visualized as a box with important func- A 60-year-old female with no significant past
tions on nearly every surface, is a geometri- medical history was diagnosed with sarcoma of
cally and functionally complex structure. the left maxillary sinus. The patient had noticed
Superiorly, it supports the globe and orbital some left cheek numbness. The patient’s com-
contents, and inferiorly, the palate and maxil- plaints included numbness of the left cheek and
lary alveolus are critical for speech and oral left upper lip which had progressed over a few
intake. Medially lies the nasal vault and poste- months. She denied any visual disturbances. She
riorly the skull base. Ablation of this structure had no prior chemotherapy or radiation (Fig. 1).
often leaves the reconstructive surgeon with mul- Past medical history is unremarkable. Of note,
tiple surgical problems to solve. The initial recon- she had a remote history of a biopsy of the left
structive consideration is if the defect is best upper dental alveolus 15 years prior which was
served with a soft-tissue-only reconstruction, or reported to be benign. Her surgical history is sig-
if it necessitates an osseous reconstruction. nificant for the above-mentioned biopsy, as well as
Two different cases are presented in this chap- bilateral breast augmentation, hemorrhoidectomy,
ter. The first is a patient who had a free vertical and transverse Cesarean section. The ablative sur-
rectus myocutaneous flap with iliac bone grafting geon is planning for a left maxillectomy, orbital
for left maxillary and orbital floor resection. The floor excision, and preservation of the globe
second is a patient who had a virtual-surgical- through a Weber-Ferguson approach.
planned multiple segment free fibula flap as well Her preoperative examination is notable for
as iliac bone grafting for an extended left maxil- mild proptosis and absent sensation in the V2
lary and orbital floor resection. The specific distribution. She has an equivocal Allen’s test
nature of each patient’s surgical defect is bilaterally, with right hand dominance. She has
discussed with relevance to the different type of thin thighs. Her abdomen is noted to have some
reconstruction. Both patients did well postopera- redundant tissue with a mild to moderate rectus
tively with excellent functional and aesthetic diastasis and a well healed low transverse scar.
outcomes.
Keywords Preoperative Problem List/

Midface reconstruction · Maxillary
reconstruction · Free tissue transfer · 1. Support for the globe following resection of
Osteocutaneous free flap · Soft tissue free flap · the orbital floor (Cordeiro and Santamaria
Iliac crest bone graft 2000)
30 Midface Reconstruction with Soft Tissue and Bone Flaps 289
Fig. 1 Patients preoperative appearance and CT scan showing malignancy
2. Obliteration of the dead space previously occu- used for the ablation. The microvascular anas-
pied by the maxilla (Cordeiro and Santamaria tomosis would be performed to the vessels in
2000) the ipsilateral neck.
3. Closure of the acquired palatal defect along The soft tissue flap of choice in this case would
with separation of the oropharynx from nasal be a free vertical rectus abdominus myocutaneous
cavity (Cordeiro and Santamaria 2000) (VRAM) flap. This was the preferred soft tissue
donor site because of its bulk, large number of
perforators supplying the skin enabling multiple
Treatment Plan skin paddles if necessary, as well as a long pedicle
length (Cordeiro and Santamaria 1997). Com-
An operative plan was devised to include the pared to muscle-only flaps, the volume of
transfer of vascularized soft tissue and an fasciocutaneous flaps is more stable over time. If
autogenous bone graft. The bone graft would desired, the VRAM could be separated into more
be harvested from the iliac wing to provide than one skin island to provide skin for lining of
support for the globe and orbital contents the nasal cavity as well as for the palate.
(Cordeiro and Santamaria 2000). As an alter-
native, a piece of titanium mesh can be used
for the orbital floor reconstruction; however, it Alternative Reconstructive Options
introduces an additional foreign body which
could become exposed following radiation. In 1. Radial Forearm Flap and bone graft – This
a soft tissue only free flap would be transferred would provide supple soft tissue for lining, but
for obliteration of dead space, support for lacks the bulk necessary to obliterate the large
revascularization of the bone graft, improved maxillary dead space and properly contour the
contour, and closure of the palatal defect. This cheek. Furthermore, the patients preoperative
would all be performed in a single stage pro- Allen’s test was concerning (Cordeiro et al.
cedure through the Weber-Ferguson approach 1998).
290 F. Samra et al.
2. Anterolateral Thigh Flap – This would be an significant comorbidities (Rogers et al. 2003,
acceptable option, particularly if harvested as a Moreno et al. 2010).
chimeric flap with a piece of vastus lateralis
muscle. The muscular portion of the flap would
be placed beneath the orbital floor reconstruction Preoperative Evaluation and Imaging
to revascularize the bone graft. The principle
limitation of the ALT is its unpredictable pedicle The preoperative exam was critical in determining
length. Often the dominant perforator comes off the presence of the soft tissue necessary for a VRAM
the transverse branch of the circumflex femoral flap. If the patient has an obese abdomen or other
system effectively shortening the pedicle. reasons why it cannot be used as a donor site, the
Approximately 12 cm of pedicle is needed to ALT becomes a second-line option. Given this
reach the neck from the maxilla, likely requiring patient’s prior C-section, some authors may prefer
a vein graft in the setting of an ALT. Alterna- to obtain preoperative imaging to ensure the conti-
tively, if an ALT was the preferred option, it nuity of the deep inferior epigastric vessels, although
would likely require anastomosis to the superfi- this is usually not essential. This can be performed
cial temporal vessels which are smaller in caliber using CT or MR angiography. Imaging of the recip-
than those in the neck. This particular patient ient vessels is typically not necessary in a patient like
also had thin thighs that likely would have this who has not had prior neck dissection.
required a folded flap, complicating the position
of the pedicle to prevent any twisting or com-
Preoperative Care and Patient Drawing
pression (Cordeiro and Chen 2012b).
3. Scapula flap – Similar to the ALT flap, the
The patient was placed on the operating room
subscapular system allows for a chimeric flap
table in the supine position. Standard sterile prep
to be designed; however, with the opportunity
and draping was performed including the head
to harvest bone with the flap. The scapula tip
and neck as well as the abdomen. The VRAM
harvested off of the angular branch could be
flap was marked on the left abdomen (Fig. 2).
used to support the orbital contents. Negative
aspects of this flap are the short pedicle to the
fasciocutaneous parascapular/scapular skin
island which is based on the proximal circum-
flex scapular branch. This would likely require
a vein graft perhaps even to the superficial
temporal vessels. This flap would also require
repositioning of the patient.
4. Nonmicrosurgical reconstruction – The wound
could theoretically be resurfaced with a
temporalis flap with skin graft and palatal clo-
sure by an obturator. The temporalis flap would
be used to cover the orbital floor reconstruction
whether it be with a bone graft or titanium
hardware. Usually the zygomatic arch will
need to be removed and replaced to allow
adequate flap transposition. The obturator
would need to be in place for adequate speech
and oral intake. Following radiation, trismus
could preclude easy removal of such a large
obturator. This reconstructive option is gener-
ally reserved for elderly patients or those with Fig. 2 Preoperative markings for a left-sided VRAM
The incision for harvesting the iliac bone graft 6. A left VRAM was harvested to ensure ade-
was marked on the contralateral side. quate skin and soft tissue to close the palatal
defect. At least 1 cm of anterior rectus sheath
was preserved medially and laterally to allow
Surgical Technique for primary closure of the abdominal wall. The
flap is elevated from cephalad to caudal using a
1. Measurement of the surgical defect is performed combination of electrocautery and bipolar
following the oncologic ablation. The entire left down to the junction of the iliac vessels.
maxillary sinus was removed including the 7. Drill holes were placed through the remaining
entire hard palate from the midline to the buccal portions of the hard palate and Mitek suture
mucosa on the left side. The intraoral palate anchors were used for securing the flap upon
defect measured 6 cm 3.5 cm. The soft palate transfer. The flap was divided and transferred up
was spared posteriorly. The orbital floor defect to the head and neck and inset accordingly. The
measured approximately 4 cm 3.5 cm. For- flap was contoured and tailored to the dimen-
mation of a template for the orbital floor is sions of the palatal defect and the pedicle was
performed using a piece of sterile X-ray film passed down to the neck using a Penrose drain.
or the side of a sterile plastic specimen cup. 8. Microvascular anastomosis was performed and
2. Dissection of recipient vessels in the left neck, appropriate perfusion ensured. The flap was inset
including the external and internal jugular so that the rectus abdominus muscle was abutting
veins and the superior thyroid artery and lin- the orbital floor reconstruction and the abdomi-
gual/facial trunk. nal subcutaneous fat filled the maxillectomy
3. The iliac bone graft was harvested first by defect. The skin of the flap is used to replace
making a 6 cm incision medial and superior the palatal mucosa and ensures an immediate
to the anterior superior iliac spine. Dissection water-tight closure. All surgical sites were then
is carried down to the abdominal wall and the closed in layers.
musculature is released from the iliac spine. A
periosteal elevator is used to dissect the sub-
periosteal space off of the internal table of the Technical Pearls
ilium. Using both an oscillating saw and
osteotomes, a 5 cm 5 cm square of cortical 1. A template of the orbital floor can be created
cancellous graft was taken from the medial using a piece of sterile X-ray film or the side of
portion of the ilium. a sterile plastic specimen cup. Position of the
4. The bone graft is then contoured and fixated orbital floor reconstruction can be confirmed
using multiple titanium miniplates. It is some- with use of intraoperative navigation, if available.
times necessary to bisect the graft to obtain the 2. A forced duction test is performed on comple-
ideal curvature of the orbital floor. The graft is tion of the bone graft inset to ensure appropri-
anchored to the zygoma laterally and the nasal ate and free movement of the globe.
process of the maxillary bone medially. A 3. A Penrose drain is placed in the tunnel for the
forced duction test is performed on completion pedicle to allow for accurate measurements of
of the bone graft inset to ensure appropriate and the required amount of pedicle length as well
free movement of the globe. as facilitate pedicle transfer through the tunnel.
5. A tunnel is created between the maxillary 4. At least 1 cm of anterior rectus sheath can be
defect and the ipsilateral neck using blunt dis- preserved medially and laterally to allow for
section for placement of the pedicle. The tun- primary closure of the abdominal wall follow-
nel is created medial to the mandibular ramus ing harvest of the VRAM.
and angle. A Penrose drain is placed in this 5. VRAM pedicle is elevated all the way down to
space and measurements are performed to con- the junction of the iliac vessels to maximize
firm the required amount of pedicle length. pedicle length. Anterograde dissection of the
292 F. Samra et al.
vessels into the muscular component of the flap and these are maintained to bulb suction until
can also be performed to add additional length output is low enough for removal. Anticoagulant
to the pedicle (Cordeiro and Santamaria 1997). regiment included low molecular weight heparin
6. A DIEP flap could be performed as an alterna- and aspirin. Nasogastric tube was used for feed-
tive to minimize donor site hernia risk; how- ing until postoperative day 7.
ever, the perforator portion of the pedicle can The head is maintained in a neutral position
be inadvertently injured when brought through until postoperative day 14. There are no pil-
the long tunnel down to the neck. lows allowed behind the head during this time
7. The orbital volume should be overcorrected at to prevent any neck flexion which could result
the time of surgery to account for soft tissue in kinking of the pedicle. A nasal trumpet can
deflation following radiation. be placed in the ipsilateral nasal aperture to
8. Drill holes and Mitek suture anchors can be allow for adequate nasal breathing and to pre-
used to inset the flap to the existing bony vent chronic airway stenosis in the nasal
landmarks. cavity.
Intraoperative Images Outcome, Clinical Photos, and Imaging
See Figs. 3, 4, 5, 6, and 7. Our patient experienced a fairly uneventful post-

operative course with only some minor complica-
tions related to medications for adjuvant therapy
Postoperative Management that warranted admission. At 1-year follow-up,
she has an excellent aesthetic and functional out-
The patient was closely monitored in the inpa- come. She tolerates a regular diet and her speech
tient setting. Regular Doppler flap checks were is normal. She is very pleased with her appear-
performed for several days. Drains were placed ance. She denies any diplopia. There is no evi-
in the abdominal donor site as well as the neck dence of morbidity at the donor site. She does
Fig. 3 Specimen following

resection of the entire left
maxillary sinus
appear to have mild hollowing at the lid cheek the morbidity on any particular side. Further-
junction (Fig. 8) and the patient was offered fat more, steps should be taken to minimize the
grafting to this area for contour improvement, but risk of morbidity with closure. For example,
was not interested. leaving an appropriate amount of anterior rec-
tus sheath medially and laterally at the time of
VRAM harvest assists with primary closure of
Avoiding and Managing Problems the abdominal wall afterwards without the
need for mesh. Moreover, meticulous closure
1. Harvesting the iliac bone graft and the VRAM of the different layers of the abdominal wall
flap from opposite sides of the abdomen limits after harvest of the iliac bone graft decreases
the risk of abdominal wall weakness/hernia at
that operative site (Patel et al. 2012).
2. Anchoring the soft tissue flap to bony land-
marks prevents descent of the soft tissue flap
into the oropharynx. This is accomplished via
drill holes with sutures passed through as well
as Mitek suture anchors.
3. Abutting the muscular component of the
VRAM against the iliac bone graft used for
orbital floor reconstruction facilitates revas-
cularization and decreases the risk of resorp-
tion. Although titanium mesh is a quick
alternative option to a bone graft, there is a
risk of plate exposure especially in the setting
of radiation.
Learning Points
1. It is essential to appropriately support the

globe and periocular contents in the setting
Fig. 4 Defect following resection of the entire left maxil- of orbital floor resection as a component of a
lary sinus maxillectomy defect. This can be performed
Fig. 5 Reconstruction of
the orbital floor using iliac
bone graft and titanium
miniplates
294 F. Samra et al.
Fig. 6 Inset of free VRAM

flap to reconstruct the
palatal and maxillary defect
Fig. 7 On table result with

layered closure of all
surgical sites
Fig. 8 One-year
postoperative outcome
following left maxillary and
orbital floor reconstruction
with off-the-shelf devices or preferentially Weber-Ferguson approach. He has no visual dis-

with autologous bone grafts. turbances, enophthalmos, or vertical dystopia.
2. Complete obliteration of the dead space created The left cheek is symmetric with the contralateral
following oncologic resection of the midface side. He has intact facial nerve function and sen-
needs to be managed with well vascularized sation (Fig. 9).
soft tissue to improve the aesthetic contours of Past medical and surgical history are unre-
the face as well as separate anatomic areas such markable. His preoperative examination is nota-
as the nasal vault from the oropharynx. ble for an appreciable mass in the midline of the
3. Flap selection needs to provide the appropriate hard palate. He has palpable facial arteries. He
soft tissue bulk and pedicle length with regard to also has thin lower extremities with palpable dorsalis
a patient’s particular body habitus and anatomy. pedis and posterior tibialis pulses bilaterally.
4. Supporting the soft tissue flap with bone
anchored sutures can prevent ptosis and decent
of the flap into the oropharynx which can inter- Preoperative Problem List/
fere with function. Reconstructive Requirements
1. Support for the globe following resection of

Osteocutaneous Reconstruction the orbital floor (Cordeiro and Santamaria
1997)
The Clinical Scenario 2. Obliteration of the dead space previously occu-
pied by the maxilla (Cordeiro and Santamaria
A 35-year-old male with no significant past med- 1997)
ical history was diagnosed with low-grade 3. Closure of the palate and separation of the
chondrosarcoma of the nasal septum, palate, and oropharynx and nasal vault (Cordeiro and
left maxillary sinus. The ablative surgeon is plan- Santamaria 1997)
ning for a left maxillectomy, orbital floor resection 4. Upper lip support given the resection of pre-
with preservation of the globe, and removal of the maxillary alveolus, warranting bony recon-
central and left maxillary alveolus through a struction (Okay et al. 2001)
Fig. 9 Patient’s
preoperative appearance
and CT scan showing
malignancy
296 F. Samra et al.
Treatment Plan flaps typically have a short pedicle compared

to the fibula flap, likely requiring a vein graft
An operative plan was devised to include the (Brown et al. 2002; McCarthy and Cordeiro.
transfer of vascularized bone and soft tissue, as 2010).
well as an autogenous bone graft. The bone graft 3. Two free flaps: A combination of a soft tissue
would be harvested from the iliac wing to provide free flap and a bony free flap is an acceptable
support for the globe and orbital contents. A bone alternative. This would be an option if the
and soft tissue free flap would be transferred for patient did not have the appropriate soft tissue
obliteration of dead space, support for and revas- volume overlying the fibula bone. For exam-
cularization of the bone graft, dental rehabilitation ple, if the patient was very thin, the fibula skin
with alveolar reconstruction, improved aesthetic island would be inadequate to properly fill the
contour, closure of the palatal, and nasal defect. maxillary dead space. In this instance, a second
This would all be performed in a single stage fasciocutaneous free flap of appropriate vol-
procedure through the Weber-Ferguson approach ume could be selected.
used for the ablation. The microvascular anasto- 4. Nonmicrosurgical reconstruction: While theo-
mosis would be performed to the ipsilateral facial retically an option, such a young patient with a
vessels at the mandible, obviating the need for a defect of this nature would have a severely
neck incision or vein graft. compromised outcome with prosthetic recon-
The flap of choice in this case was a free fibular struction alone (Rogers et al. 2003; Kornblith
flap with multiple skin paddles. This clinical scenario et al. 1996; Hanasono et al. 2013).
warrants an osteocutaneous flap, given the extensive
resection to the maxillary alveolus. Providing well
vascularized bone with good corticocancellous Preoperative Evaluation and Imaging
strength such as a fibula flap will enable future dental
rehabilitation with osteointegrated dental implants. The preoperative exam allows the surgeon to
assess the patient’s lower extremities for vascular
status as well as soft tissue availability. This
Alternative Reconstructive Options patient had good soft tissue overlying his fibula,
as well as palpable DP and PT pulses bilaterally.
1. Soft-tissue-only reconstruction: While this The vascular exam is critical in allowing the sur-
would allow us to manage this patient in a geon to feel comfortable with distal perfusion in
similar fashion to the prior case, absence of the setting of harvesting the peroneal vessels.
bone in the central segment of the maxillary In addition to the preoperative exam, it is pre-
arch would lead to poor upper lip support and ferred to obtain CT imaging of the patient’s lower
midface projection. In addition, the more extremities. CT angiography can be performed
extensive alveolar resection in the current preoperatively to allow for careful analysis of the
case would result in poor dental rehabilitation patient’s vascular status as well as assessment of
options postoperatively. Loss of the central perforators to the overlying soft tissue of the
premaxilla in addition to the left maxillary fasciocutaneous portion of flap, particularly
alveolus would result in inadequate remaining when more than one skin paddle is needed. In
teeth to support either an obturator or dental combination with the head and neck surgeon, a
bridge (Patel et al. 2012; Okay et al. 2001). preoperative plan can be made via virtual surgical
2. Alternative bone flap options: While there are planning. This allows for the creation of precise
other options for obtaining a vascularized bone 3-D printed cutting guides for both the ablative
flap, such as the iliac wing or scapula, neither and reconstructive surgeons, and this has been
of these would provide a similar quantity and found to be extremely helpful intraoperatively
quality of corticocancellous bone needed for (Fig. 10). Depending on surgeon preference, cus-
this large defect. Furthermore, both of these tom plates can also be prefabricated.
Fig. 10 Cutting guides for the oncologic resection
Preoperative Care and Patient Drawing determined to be 4 4 cm2. An iliac bone

graft was then harvested from the right abdo-
The patient was placed on the operating room men in an identical nature to the prior case.
table in the supine position. Standard sterile prep This was inset to reconstruct the orbital floor
and draping was performed including the head using miniplates, again as described in the
and neck as well as the abdomen and the entire prior case.
right lower extremity circumferentially. The fibula 4. A 3 cm incision was then made on the face
flap was marked on the right lower extremity overlying the facial vessels at the level of the
(Fig. 11). The incision for harvesting the iliac mandible. Dissection was carried down to the
bone graft was marked on the ipsilateral side. level of the facial vessels and these were iso-
lated and prepared for microvascular anasto-
mosis. Care was taken to preserve any
Surgical Technique crossing branches of the marginal mandibular
nerve.
1. Simultaneous to the tumor ablation, the right 5. A tunnel is created between the maxillary
fibula flap is harvested under tourniquet con- defect and the ipsilateral facial vessels using
trol. This flap was harvested in the standard blunt dissection for placement of the pedicle.
fashion. Multiple cutaneous perforators were A Penrose drain is placed in this space and
identified and preserved, allowing for separate measurements are performed to confirm the
skin paddles to be used independently from required amount of pedicle length.
one another. If only one perforator to the skin 6. The rigid flap construct is then harvested from
was present, a strip of skin could be the lower extremity and transferred up to the
de-epithelialized, but with the less degrees of maxillary defect. The lateral aspect of the flap
freedom for skin paddle positioning. was inset to the remaining zygoma, and the
2. A prefabricated cutting guide for the fibula medial flap fixated to the contralateral maxilla.
from the virtual surgical planning session was The pedicle to the flap was then transferred
then used to make precise osteotomies for the through the tunnel.
shaping of the fibula into the necessary maxil- 7. Microvascular anastomosis was then
lary construct. This construct was then rigidly performed to the ipsilateral facial vessels with
fixated using titanium miniplates while the flap hand-sewn arterial anastomosis and a venous
remained perfused on the lower extremity. coupler device.
3. Following tumor resection, the defect in the 8. The skin paddle on the osteocutaneous flap
orbital floor was carefully measured and was then split into two different segments on
298 F. Samra et al.
Fig. 11 Preoperative
markings for
osteocutaneous free fibula
flap
the multiple perforators that were available. other can be de-epithelialized for obliteration
One segment measured 5 cm 7 cm was of dead space.
used for reconstruction of the palatal defect, 3. The facial vessels can be dissected out using a
and the other was de-epithelialized and used small, discrete incision without necessitating a
for obliteration of the dead space created by complete neck dissection. This decreases the
maxillary resection. need for a longer pedicle, avoids vein grafting,
9. Closure was then performed in an anatomical and limits the morbidity to the patient. Care
way, with multilayer closure of the Weber- must be taken to preserve branches of the mar-
Ferguson incision on the face. The iliac bone ginal mandibular nerve that will be crossing
graft donor site was similarly closed, as over the facial vessels.
described in the previous case. The fibula flap 4. Fixation of the flap against the reconstructed
donor site necessitated a split thickness skin bony orbital floor construct can allow for
graft from the ipsilateral thigh for closure. improved suspension of the soft tissue recon-
struction as well as increased vascularity of the
autogenous bone graft. Alternatively, a muscle
Technical Pearls component to the flap, such as the flexor hallucis
longus, can be used to abut the orbital floor
1. Preoperative virtual surgical planning (VSP) is reconstruction to maximize revascularization.
incredibly helpful. Prefabricated cutting guides
and prebent titanium plates facilitate operative
execution and significantly decrease operative Intraoperative Images
time. The geometry of the maxilla is much
more complicated than the mandible so VSP See Figs. 12, 13, and 14.
is strongly recommended for any osseous max-
illary reconstruction.
2. The presence of multiple cutaneous perforators Postoperative Management
allows for independent skin paddles on the
same flap. This can be advantageous in a case The patient was closely monitored in the inpa-
such as ours where one skin paddle can be used tient setting. Regular Doppler flap checks were
for resurfacing of the palatal defect, and the performed for several days. A drain was placed
Fig. 12 Multiple
cutaneous perforators
within the posterior septum
of the fibular flap
Fig. 13 Inset of osseous construct to ipsilateral zygoma and contralateral maxilla for bony reconstruction
in the lower extremity donor site and maintained complications related to edema of his left eye
to bulb suction until output was low enough for that required some Tobradex eye drops. Postop-
removal. Anticoagulant regiment included low erative CT scan demonstrated an excellent osse-
molecular weight heparin and aspirin. Nasogas- ous reconstruction (Fig. 15). At approximately
tric tube was used for feeding until postoperative 1 year after surgery, he was taken for a revision of
day 7. his flap, including fat grafting to the left cheek,
aesthetic improvement of the left nasal alar sub-
unit, and debulking of the flap both intranasally
Outcome, Clinical Photos, and Imaging and intraorally. At 2-year follow-up, he was
taken to the OR again for placement of perma-
Our patient experienced a fairly uneventful post- nent dental implants and repeat fat grafting to the
operative course with only some minor left lid cheek junction. He tolerates a regular diet
300 F. Samra et al.
Fig. 14 Inset of multiple skin paddles on separate perforators for reconstruction of the palatal defect and obliteration of
dead space
virtual surgical plan and
postoperative CT scan
showing excellent osseous
reconstruction of the
maxilla and orbital floor
and his speech is normal. He is very pleased with Avoiding and Managing Problems
his appearance and has excellent symmetry to the
contralateral side. He denies any diplopia. There 1. Excess intraoral flap can result in difficulty
is no evidence of morbidity at the donor sites with speech or oral intake and be very both-
(Figs. 16 and 17). ersome to patients. Efforts can be made to
Fig. 16 Follow-up at 2.5

years after surgery with
excellent symmetry to the
contralateral side
Fig. 17 Follow-up at 2.5

years with dental
rehabilitation utilizing
osteointegrated implants
tailor the amount of flap precisely, and some 2. Contour abnormalities can occur, particularly
authors have advocated for even in-setting the at the lid cheek junction as seen in both of the
intraoral flap under some tension. In the case patients in this chapter. This can be effectively
presented, tension on the closure was mini- managed using small volume fat grafting. As is
mized for fear of breakdown or fistula and often the case with fat grafting, this will some-
address minor excess at a later time if neces- times need to be done in multiple stages.
sary. As was the case in the patient, elective 3. Ensuring well vascularized tissue is abutting
debulking can be combined with other pro- the autogenous bone graft used for reconstruc-
cedures such as vestibuloplasty or osteo- tion of the orbital floor is paramount to improv-
integrated implant placement in an outpatient ing the viability of that graft. This can either be
setting. This is safe and effective, while min- accomplished through de-epithelialized dermis
imizing complications to the patient (Cordeiro or with muscle. In the previous case, the mus-
and Chen 2012a). cle of the VRAM was used, and in this case the
302 F. Samra et al.
de-epithelialized dermis of the second skin part I. Algorithm and outcomes. Plast Reconstr Surg.
paddle was used. Alternatively, some flexor 2012a;129:124–36.
Cordeiro PG, Chen CM. A 15-year review of midface
hallucis longus could have been transferred reconstruction after total and subtotal maxillectomy:
with the fibula flap and used as vascularized part II. Technical modifications to maximize aesthetic
muscle to cover the autogenous bone graft and functional outcomes. Plast Reconstr Surg.
(Hanasono et al. 2013). 2012b;129:139–47.
Cordeiro PG, Santamaria E. The extended, pedicle rectus
abdominus free tissue transfer for head and neck recon-
struction. Ann Plast Surg. 1997;39:53–9.
Learning Points Cordeiro PG, Santamaria E. A classification system and
algorithm for reconstruction of maxillectomy and mid-
facial defects. Plast Reconstr Surg. 2000;105:2331.
1. Resection of greater than half of the alveolus Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial
results in an arch that is often unstable for forearm Osteocutaneous “sandwich” free flap for
prosthetic reconstruction. As a result, this reconstruction of the bilateral subtotal Maxillectomy
patient’s resection warranted an osseous recon- defect. Ann Plast Surg. 1998;40:397–402.
Hanasono MM, Jacob RF, Bidaut L, Robb GL, Skoracki
struction with a free fibula flap to reconstruct RJ. Midfacial reconstruction using virtual planning,
the maxilla and upper alveolus. rapid prototype modeling, and stereotactic navigation.
2. Virtual surgical planning has been invaluable for Plast Reconstr Surg. 2010;126(6):2002–6.
head and neck reconstruction, particularly for Hanasono MM, Silva AK, Yu P, Skoracki RJ. A compre-
hensive algorithm for oncologic maxillary reconstruc-
maxillary and delayed reconstructions, allowing tion. Plast Reconstr Surg. 2013;131:147.
for precise and efficient tumor resection and Kornblith AB, Zlotolow IM, Gooen J, Huryn JM, Lerner T,
reconstruction. Multiple segment osteocutaneous Strong EW, Shah JP, Spiro RH, Holland JC. Quality of
flaps can be crafted in complicated three-di- life of maxillectomy patients using an obturator pros-
thesis. Head Neck. 1996;18:323–34.
mensional patterns with precision, allowing for McCarthy CM, Cordeiro PG. Microvascular reconstruc-
improvements in the outcomes and the ability to tion of oncologic defects of the Midface. Plast Reconstr
tackle more challenging problems (Hanasono Surg. 2010;126:1947.
et al. 2010, Stranix et al. 2019, Shenaq and Moreno MM, Skoracki RJ, Hanna EY, Hanasono
MM. Microvascular free flap reconstruction versus pal-
Matros 2018). atal obturation for maxillectomy defects. Head Neck.
2010;32:860–8.
Okay DJ, Genden E, Buchbinder D, Urken
Cross-References M. Prosthodontic guidelines for surgical reconstruction
of the maxilla: a classification system of defects.
J Prosthet Dent. 2001;86:352–63.
▶ Atrophic Maxilla with Fibula Flap and Implant-
Patel NP, Matros E, Cordeiro PG. The use of the multi-island
Supported Prosthesis vertical rectus abdominis myocutaneous flap in head and
▶ Orbital Reconstruction with Free Fibula Flap neck reconstruction. Ann Plast Surg. 2012;69:403–7.
Rogers SN, Lowe D, McNally D, Brown JS, Vaughan
ED. Health-related quality of life after maxillectomy:
a comparison between prosthetic obturation and free
References flap. J Oral Maxillofac Surg. 2003;61:174–81.
Shenaq DS, Matros E. Virtual planning and navigational
Brown JS, Jones DC, Summerwill A, Rogers SN, Howell technology in reconstructive surgery. J Surg Oncol.
RA, Cawood JI, Vaughan ED. Vascularized iliac crest 2018;118(5):845–52.
with internal oblique muscle for immediate reconstruc- Stranix JT, Stern CS, Rensberger M, Ganly I, Boyle JO,
tion after maxillectomy. Br J Oral Maxillofac Surg. Allen RJ Jr, Disa JJ, Mehrara BJ, Garfein ES, Matros
2002;40:183–90. E. A virtual surgical planning algorithm for delayed
Cordeiro PG, Chen CM. A 15-year review of midface maxillomandibular reconstruction. Plast Reconstr
reconstruction after total and subtotal maxillectomy: Surg. 2019;143(4):1197–206.
Free Fibula Flap Reconstruction
of the Cervical Spine 31
Alexander F. Mericli
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Abstract on creeping substitution for incorporation,

Reconstruction of the cervical spine with resulting in faster union and a stronger con-
vascularized bone may be indicated after struct in a shorter period of time. The free
multilevel oncologic vertebrectomy, osteomy- fibula flap is the most common source of
elitis, or failed fusion with nonvascularized vascularized bone for the cervical spine,
bone graft. Vascularized bone does not rely favored due to its strength, available length,
and potential for chimeric design.
This case illustrates posterior, after failed
anterior, corpectomy and fusion in a patient
A. F. Mericli (*)
Department of Plastic Surgery, The University of Texas with a history of spinal radiation for medullo-
M.D. Anderson Cancer Center, Houston, TX, USA blastoma. The peroneal vessels from the fibula
e-mail: AFMericli@mdanderson.org

https://doi.org/10.1007/978-3-030-23706-6_114
304 A. F. Mericli
flap were anastomosed to the facial vessels,

and the fibula was fixated with plates and
screws as a posterior onlay. Union was
achieved 6 months after surgery, resulting in
a stable, well-aligned cervical spine.
Keywords
Free fibula flap · Cervical spine ·

Vertebrectomy · Corpectomy · Non-union
A 34-year-old male developed cervical spine

instability 20 years after surgical resection
and radiation therapy for medulloblastoma.
The surgical resection consisted of an occipital
craniectomy, partial cerebellar resection, and
C1–C4 laminectomies. Twenty years postopera-
tively, he developed cervical subluxation, which
was initially treated with a C3 corpectomy and
Fig. 1 A 34-year-old male with history of spinal radiation
stabilization with an expandable interbody cage, presents with cervical non-union associated with failed
nonvascular bone graft, anterior instrumentation, anterior fixation and nonvascularized bone graft. Symp-
and halo fixation. He failed to achieve bony union toms include neck pain and bilateral upper extremity mye-
with this construct (Fig. 1), and so a posterior lopathy. Note the exaggerated kyphosis on this lateral view
occipito-cervical instrumentation and fusion was
planned; plastic surgery was consulted for a et al. 2017; Lee et al. 2005), after vertebral
vascularized bone flap. debridement for osteoradionecrosis (Ng et al.
The indications for cervical spine reconstruc- 2002; Tanaka et al. 2017; Lee et al. 2005; Powell
tion using a vascularized bone flap are related to et al. 2013), or after failed cervical fusion with
either defect etiology or recipient site factors. nonvascularized bone graft (Lee et al. 2005).
In general, vascularized bone, compared to non- Cervical recipient site features indicative for
vascular allo- or autograft, results in accelerated a vascularized bone flap include defect length, radi-
healing, earlier fusion, and increased strength. ation, ongoing infection, or a need to expedite bony
Cell viability is maintained in the bone, and pri- fusion. The more spinal levels involved in the resec-
mary bone healing occurs at the fusion sites. tion and instrumentation, the more difficult it is to
This is opposed to the manner in which non- obtain durable stabilization (MacDonald et al. 1997;
vascularized bone grafts heal via creeping substi- Singh et al. 2003). Fusion rates range from 90% to
tution, which requires extensive bone remodeling, 96% for uncomplicated two- and three-level cervi-
revascularization, resorption, and production of cal fusions using bone graft; however the fusion rate
new bone – a process that can take up to 2 years plummets to 47–84% for fusions >3 levels or bony
(Burchardt et al. 1975). Regarding defect etiology, defects >4 cm (Vaccaro et al. 1998; Doi et al. 1988;
a vascularized bone flap can be useful in the Gore 2001; Saraph et al. 2005). As such, many
setting of chronic osteomyelitis (Ng et al. 2002; surgeons consider vascularized bone flaps for lon-
Moche et al. 2011; Powell et al. 2013; Lee et al. ger and more extensive fusions. Radiation signifi-
2005), after oncologic resection (Rodriguez- cantly impairs nonvascular bone graft healing by
Lorenzo et al., 2014; Ng et al. 2002; Tanaka impairing both angiogenesis and osteocyte viability.
31 Free Fibula Flap Reconstruction of the Cervical Spine 305
Bone remodeling is suppressed by inhibiting oste- radiographic evidence of union (Jandali et al.
oblast turnover and osteocyte differentiation. This is 2011; Kaltoft et al. 2012; Lee et al. 2005). The
in contradistinction to bone flaps, which are consid- patient had failed several previous attempts at
ered radioresistant; the vascular pedicle reduces the anterior fixation and fusion; therefore a posterior
dependence upon angiogenesis to establish and approach was planned. This would also allow
maintain bone viability. maintenance of his anterior hardware while
adding posterior fixation; anterior and posterior
fixation has demonstrated superior fusion rates in
Preoperative Problem List complicated cervical cases (Capen et al. 1985).
and Reconstructive Requirements Because of his significant radiation-related cuta-
neous scarring and soft tissue fibrosis along the
1. Failed anterior-only multilevel cervical fusion posterior neck, primary closure of his incision
using nonvascular bone graft (Lee et al. 2005) would not be reliable, risking posterior instrumen-
2. Previous spinal radiation contributing to cervi- tation exposure. Therefore, a soft tissue flap would
cal non-union (Mericli et al. 2019; Ng et al. be required for a durable and reliable closure. The
2002; Tanaka et al. 2017; Powell et al. 2013) first-line flap options for a wound along the poste-
3. Significant soft tissue and cutaneous radiation rior cervical spine include the paraspinous muscles,
fibrosis – anticipate being unable to primarily trapezius muscles, and possibly the latissimus mus-
close the skin without risking instrumentation cles. Unfortunately, due to his multiple previous
exposure (Mericli et al. 2019) surgeries and muscle atrophy attributed to his cor-
4. Malnutrition – prealbumin ¼ 9 g/dL tical brain injury, all local and regional muscle flaps
5. Cervical dystonia – involuntary muscle spasms were either absent or insufficient. Therefore, a free
that expose the surgical site and bony construct flap would be needed for the soft tissue component
to sheer stress, potentially impairing soft tissue of the defect. Considering his extensive surgical
and bony healing history and past non-union, additional bone allo-
or autograft would likely fail; therefore a vascular
bone flap was also indicated. The free fibula flap
Treatment Plan was chosen due to its length; strength; ease of
chimeric design – therefore providing both bone
Although there was no radiographic evidence of and soft tissue; and its reported use in the literature
bony fusion at the time of initial consultation, an for this clinical scenario.
urgent or emergent operation was not necessary,
as his cervical spine was well-aligned and stabi-
lized with the external halo device. This provided Alternative Reconstructive Options
time to optimize the patient preoperatively. He
had a number of wound healing risk factors, 1. Nonvascularized bone graft
including malnutrition, previous radiation therapy • Allograft or autograft
to the spine, cervical dystonia, and a history of – Nonvascularized bone grafts from a
multiple surgeries in the same location. Each of homologous or cadaveric source have
these was carefully considered and ameliorated to been successfully used for reconstruc-
the extent possible while developing the surgical tion of the cervical spine with union
plan. His nutritional status was improved after rates of 97–100% in uncomplicated
placement of a percutaneous gastrostomy tube degenerative cases (Moche et al. 2011,
and initiation of protein-enriched enteral feeds. Park et al. 2010; Lewandrowski et al.
Cervical dystonia was improved after titrating 2004; Fernyhough et al. 1991).
his muscle relaxant dosing; furthermore, the – Bone allograft and autograft are most
reconstructive plan included maintaining his commonly obtained from either the
halo external fixator postoperatively until iliac crest or fibula.
306 A. F. Mericli
– Nonvascular bone grafts do poorly Preoperative Evaluation and Imaging

when the recipient site is compromised
by ongoing infection or radiation expo- • A full medical history was obtained and
sure (Lukash et al. 1984; Bouchard physical exam performed. The surgeon should
et al. 1994). note previous surgeries, previous radiation or
• Graft components plan for postoperative radiation, medical
– Grafts can contain cortical bone, cancel- comorbidities, and a history of venous throm-
lous bone, or both. boembolism or hypercoagulability.
– Segmental grafts containing cortical • The back and posterior trunk were exam-
bone initially provide strength and struc- ined, noting the location of scars, muscle
ture to the construct. However, they take bulk, and function. For this particular
up to 2 years for remodeling and creep- patient, he had severe ataxia and required
ing substitution to take place, during assistance for ambulation. He had a well-
which they are mechanically weak and healed midline incision extending from the
prone to fracture. occiput to interscapular space. The bilateral
– Particulate and cancellous grafts may paraspinous muscles could be palpated but
revascularize faster, but do not were somewhat atrophied. Additionally, the
offer immediate biomechanical support bilateral trapezius and latissimus muscles
(Wittenberg et al. 1990). were present and innervated, however
2. Other vascularized bone flaps atrophied on the left. The bilateral lower
• Vascularized bone flaps for cervical spine extremities were similarly examined, noting
reconstruction include the rib, iliac crest, muscle bulk, scars, and vascularity; he had 2
osteocutaneous radial forearm, and scapula. + dorsalis pedis and tibial posterialis pulses
• Pedicled rib flaps are limited to the thoracic bilaterally.
spine; free rib flaps are possible for the • Regarding imaging, the patient had CT scans
cervical spine, but the curved shape and of the neck and chest which were examined.
brittle structure are not mechanically favor- The trapezius muscles were visualized on both
able (Metaizeau et al. 1989; Aydinli et al. scans but were thin and atrophic, consistent
2006). with the physical exam (Fig. 2).
• The iliac crest is significantly weaker than • Because of his complex surgical history and
the fibula, and the donor site is plagued by a radiation therapy, a CT angiogram of the neck
number of complications including chronic was obtained to assist with recipient vessel
pain and hernia (Wittenberg et al. 1990). identification. Large transverse cervical vessels
• The radial forearm provides a small seg- were noted as possible recipients (Fig. 3).
ment of unicortical bone, which would • Preoperative imaging of the lower extremities
have little use in the cervical spine. is not routinely needed when planning a
• The scapula flap has not been described for free fibula flap. The vascular anatomy of the
spinal reconstruction; however it is com- lower leg is highly conserved and with little
monly used for craniofacial applications. variation; therefore routine preoperative angi-
Theoretically, it could provide a segment ography is not necessary nor cost-effective.
of cortical bone 14–16 cm in length with Preoperative CT angiography is prudent in cer-
the possibility for a skin or muscle compo- tain select circumstances, such as in patients
nent. The flap could be harvested in the with previous lower extremity surgeries or
prone or decubitus positions, avoiding a injuries or with an abnormal preoperative
position change. peripheral vascular exam.
Fig. 2 Axial cut of

scan of the chest and neck
demonstrating the thin,
atrophic trapezius muscles
Fig. 3 Three-dimensional
reconstruction of a
angiogram of the neck,
demonstrating numerous
potential recipient sites for
microvascular anastomosis
two points, centered over the axis of the fibula.

Drawing Osteotomy sites are marked on the patient’s
skin, 7 cm superior to the lateral malleolus and
• The donor leg is marked in the standard fashion 4–5 cm inferior to the fibular head.
for a free fibula flap, noting the location of the • For many oncologic resections and extensive
most prominent point of the fibular head and debridements of the cervical spine, the vertebra
lateral malleolus. A line is drawn connecting the will be approached anteriorly and posteriorly
308 A. F. Mericli
during the same surgical episode. Considering Surgical Technique

the duration of such a complex surgery as well
as the physiologic demand for the patient, divid- • A tracheostomy was first performed in the
ing the surgery into two stages, separated by supine position. The patient was placed
2–5 days, should be considered. The fibula can prone, and neurosurgery placed posterior
reliably be harvested in virtually any position – instrumentation from occiput to T2. A left sub-
supine, prone, or lateral – during the first stage, trapezius dissection was performed in order to
identify the transverse cervical and dorsal
allowing for a two-team approach and reducing
scapular vessels. On the preoperative CTA of
time under anesthesia. During this first stage,
the neck, these vessels had appeared suitable
the fibula is elevated, osteotomized, and banked
for microvascular anastomosis, however were
in the leg without dividing the pedicle (Fig. 4). rather diminutive in actuality.
In order to prevent inadvertent soft tissue trauma • The patient’s posterior spine incision was
or pedicle injury between the two stages caused provisionally closed, and he was carefully
by the mobilized fibula segment, the flap is repositioned laterally. He was reprepped and
temporarily fixated to the proximal and distal redraped, including his left leg. A left subman-
fibular remnants with miniplates and screws dibular incision was made, and the facial ves-
(Fig. 4). During the second stage, the fibula is sels were dissected, taking care to protect the
rendered ischemic, inset to the spine in conjunc- marginal mandibular nerve.
tion with neurosurgery, and revascularized. • A 30 cm segment of saphenous vein was
harvested from the leg. The vein was reversed
and anastomosed to the facial artery and vein,
creating a large arteriovenous loop. The loop
was carefully tunneled subcutaneously into the
posterior spine incision and allowed to dilate and
perfuse, while the free fibula flap was elevated.
• When used for cervical spine applications, the
free fibula flap may or may not be designed
with a skin paddle. If there is any possibility of
needing a skin paddle, then the flap should be
elevated while maintaining any peroneal sys-
tem perforators traveling through the posterior
septum.
• If the fibula flap is to be placed anteriorly,
replacing resected vertebral bodies, then the
flap is typically harvested as a bone-only free
flap (Fig. 5). However, occasionally a portion of
the posterior pharyngeal wall is also resected –
such as in cases of locally advanced laryngeal
cancer – and in this situation the fibula skin
paddle or adipofascial tissue can be used to
reconstruct the pharynx and/or cervical esopha-
gus (Rodriguez-Lorenzo et al. 2014; Ng et al.
Fig. 4 After completing the fibula flap dissection during
the first stage, the bone is temporarily fixated in situ to 2002; Kaltoft et al. 2012).
avoid inadvertent soft tissue or vascular injury between • The fibula flap was harvested with the patient
stages in the lateral position, using the standard
technique. A skin paddle was designed based • The arteriovenous loop was divided, creating
on a single peroneal perforator. The bone seg- one venous vein graft and one arterial vein
ment was 13 cm in length (Fig. 6). The flap was graft, which were anastomosed to the peroneal
rendered ischemic and transferred to the cervi- vein and artery, respectively.
cal spine. • The soleus muscle flap was inset over the
• The flap was positioned as a posterior onlay and C1–C3 hardware, and the skin paddle was
fixated to the C3 and C7 lamina with miniplates inset in the midline along the length of the
and screws, bridging the corpectomy defect. incision.
The fixation was performed in conjunction • The free fibula flap donor site was closed using
with the spine surgeons. a split thickness skin graft.
Technical Pearls
1. The nonvascular piece of proximal fibula can

be used as a template to plan the exact length of
flap needed to span the gap between the
remaining vertebrae. This minimizes flap
trauma and reduces ischemia time, compared
to burring and tailoring the flap itself to exactly
fit the defect (Lee et al. 2005).
2. If anterior and posterior approaches are
planned for the same surgical episode, dividing
the surgery into two stages can be beneficial to
the patient and the surgeon. Staging eliminates
the need for an intraoperative position change,
reduces continuous time under anesthesia,
reduces the physiologic demand on the patient,
and decreases surgeon fatigue. If possible, the
anterior approach should be performed first to
take advantage of the increased neck range of
motion.
Fig. 5 Sagittal radiograph after cervical spine reconstruc-
tion with an anteriorly placed free fibula flap. (From Moche 3. If the fibula flap is needed due to vertebral
et al. 2011, with permission) osteomyelitis, stage the reconstruction with a
Fig. 6 Single-strut free

fibula flap with skin paddle,
to be used for posterior
cervical spine
reconstruction
310 A. F. Mericli
temporary interbody cage and antibiotics until • Postoperative imaging is obtained at monthly
the infection is controlled, before doing the intervals until radiographic evidence of
fibula flap (Moche et al. 2011). fusion is appreciated. The halo vest can then
4. If there is a coexistent pharyngeal defect requir- be removed.
ing reconstruction, a skin paddle can be included
to complete the pharyngoplasty. If the patient
has a thick fibula skin paddle, this can contribute Outcome
to postoperative dysphagia. One option is to thin
the flap by removing the skin, thereby creating The patient did well in the immediate postopera-
an adipofascial paddle to reconstruct the phar- tive period. There were no flap complications,
ynx (Rodriguez-Lorenzo et al. 2014). and he was discharged to a rehabilitation unit.
5. If the skin paddle is needed posteriorly, Radiographic evidence of fusion was identified
the bone must be used as a posterior onlay, after 6 months, and the halo was removed
as in the case described. If a pharyngoplasty (Fig. 7). Unfortunately, the patient passed away
is needed, the bone must be placed in the 2 years later due to sepsis and multi-system organ
interbody space in order to position the failure related to chronic aspiration pneumonia.
skin paddle anteriorly. If no soft tissue is
needed, the bone flap can be placed anteriorly
or posteriorly. Biomechanically, anterior flap Avoiding and Managing Problems
placement creates a stronger, more anatomi-
cally correct cervical construct. • These patients require a significant amount of
6. The posterior trunk is notorious for its relative planning and cooperation between a number of
paucity of recipient vessels. Common different surgical disciplines. Communication
choices include the transverse cervical and is key to a successfully executed operation.
thoracodorsal vessels. If pedicle length is insuf- • Identify recipient vessels prior to rendering the
ficient, an arteriovenous loop can be used to flap ischemic. If none are readily available,
reach a more distant target along the external vein graft to a distant source.
carotid system (Jandali et al. 2011).
7. The fibula can be osteotomized to create a
multi-strut design for high-cervical-occipital
fusions. The multiple struts increase the bony
surface area available for fusion (Jandali et al.
2011; Kaltoft et al. 2012).
• The patient was placed in a halo vest postop-

eratively in order to ensure spinal stability.
• The patient was positioned in order to offload
his posterior trunk so that no pressure would be
imparted to his flap or pedicle.
• The flap was examined using Doppler ultra-
sound every hour for the first 3 days, every 2 h
for days 4–6, and every 4 h thereafter.
Fig. 7 Three-dimensional reconstruction of computed
• If a bone-only flap is used, an implantable tomographic scan, 6 months postoperatively. Note the fib-
Doppler probe should be placed intraoperatively ula flap fixated in position as a posterior onlay, with evi-
in order to monitor flap perfusion. dence of bony union
• Considering the significant mobility of the cer- Capen DA, Garland DE, Waters RL. Surgical stabilization
vical spine, a halo should be used until there is of the cervical spine. A comparative analysis of anterior
and posterior spine fusions. Clin Orthop Relat Res.
radiographic evidence of fusion. 1985:229.
• Special care should be taken to position the Doi K, Kawai S, Sumiura S, Sakai K. Anterior cervical
patient postoperatively in order to minimize fusion using the free vascularized fibular graft. Spine.
pressure to the flap and pedicle. 1988;13:1239.
Fernyhough JC, White JI, LaRocca H. Fusion rates in multi-
• If the flap is complicated by a thrombosis and level cervical spondylosis comparing allograft fibula with
salvage is not possible, any soft tissue associ- autograft fibula in 126 patients. Spine. 1991;16:5561.
ated with the flap should be removed, and the Gore DR. The arthrodesis rate in multilevel anterior cervical
fibular strut should be left in place as a non- fusions using autogenous fibula. Spine. 2001;26:1259.
Jandali S, Diluna ML, Storm PB, Low DW. Use of the
vascular bone autograft. vascularized free fibula graft with an arteriovenous
loop for fusion of cervical and thoracic spinal defects
in previously irradiated pediatric patients. Plast
Reconstr Surg. 2011;127:1932.
Learning Points Kaltoft B, Kruse A, Jensen LT, Elberg JJ. Reconstruction of
the cervical spine with two osteocutaneous fibular flap
1. Cervical fusions requiring anterior and poste- after radiotherapy and resection of osteoclastoma: a case
rior approaches should be staged. report. J Plast Reconstr Aesthet Surg. 2012;65:1262.
Lee MJ, Ondra SL, Mindea SA, et al. Indications and ratio-
2. The fibular strut should be placed anteriorly for nale for use of vascularized fibula bone flaps in cervical
the most biomechanically favorable construct. spine arthrodesis. Plast Reconstr Surg. 2005;116:1.
If the fibula flap skin paddle is needed for the Lewandrowski KU, Hecht AC, DeLaney TF, Chapman PA,
Hornicek FJ, Pedlow FX. Anterior spinal arthrodesis
posterior neck, the bone can be inset as a pos-
with structural cortical allografts and instrumentation
terior onlay. for spine tumor surgery. Spine (Phila Pa 1976).
3. Have a low threshold for using vein grafts in 2004;29:1150-8
order to reach adequate recipient vessels. Lukash FN, Zingaro EA, Salig J. The survival of free non-
vascularized bone grafts in irradiated areas by wrapping
4. If there is a coexistent pharyngeal defect, the
in muscle flaps. Plast Reconstr Surg. 1984;74:783.
fibula skin paddle or adipofascial paddle can be MacDonald RL, Fehlings MG, Tator CH, et al. Multilevel
used to perform a pharyngoplasty while simul- anterior cervical corpectomy and fibular allograft
taneously using the fibula bone to reconstruct fusion for myelopathy. J Neurosurg. 1997;86:990.
Mericli AF, Largo RD, Garvey PB, et al. Immediate recon-
the vertebral defect.
struction of complex spinal wounds is associated with
increased hardware retention and fewer wound-related
complications: a systematic review and meta-analysis.
Cross-References Plast Reconstr Surg Glob Open. 2019;7:e2076.
Metaizeau JP, Czonry A, Miahle C, et al. [Use of
vascularized bonegrafts in surgery of the spine. Apro-
▶ Tibial Bone Defect Reconstruction with pos of 6 cases]. Rev Chir Orthop Reparatrice Appar
Ilizarov and Free Flap Mot. 1989;75:166–171.
Moche JA, Chopra K, Gastman B. Vascularized free fibula
for cervical spine reconstruction following complicated
retropharygeal abscess. Otolaryngol Head Neck Surg.
References 2011;145:178.
Ng RLH, Beahm E, Clayman GL, et al. Simultaneous recon-
Aydinli U, Akin S, Tirelioglu O, et al. A new autogenous struction of the posterior pharyngeal wall and cervical
graft choice in pelvic reconstructions: free vascularized spine with a free vascularized fibula osteocutaneous flap.
rib (a case report). Arch Orthop Trauma Surg. Plast Reconstr Surg. 2002;109:1361.
2006;126:57–62. Park Y, Riew KD, Cho W. The long-term results of anterior
Bouchard JA, Koka A, Bensusan JS, Stevenson S, Emery surgical reconstruction in patients with postlaminectomy
SE. Effects of irradiation on posterior spinal fusions. cervicalkyphosis. Spine J. 2010;10:380–7.
A rabbit model. Spine (Phila Pa 1976). 1994;19: Powell DK, Jacobson AS, Kuflik PL, et al. Fibular flap
1836–41. reconstruction of the cervical spine for repair of
Burchardt H, Busbee GA, Enneking WF. Repair of exper- osteoradionecrosis. Spine J. 2013;13:e17.
imental autopsy autologous grafts of cortical bone. Rodriguez-Lorenzo A, Rydevik MM, Thor A, et al.
J Bone Joint Surg Am. 1975;57:814. Fibula osteo-adipofascial flap for reconstruction of a
312 A. F. Mericli
cervical spine and posterior pharyngeal wall defect. Tanaka M, Sugimoto Y, Takigawa T, et al. Cervical spine
Microsurgery. 2014;34:314. osteoradionecrosis. Acta Med Okayama. 2017;71:
Saraph VJ, Bach CM, Krismer M, Wimmer C. Evaluation of 345.
spinal fusion using autologous anterior strut grafts and Vaccaro AR, Falatyn SP, Scuderi GJ, et al. Early failure of
posterior instrumentation for thoracic/thoracolumbar long segment anterior cervical plate fixation. J Spinal
kyphosis. Spine. 2005;30:1594. Disord. 1998;11:410.
Singh K, Vaccaro AR, Kim J, et al. Biomechanical Wittenberg RH, Moeller J, Shea M, et al. Compressive
comparison of cervical spine reconstruction techniques strength of autologous and allogenous bone grafts
after a multilevel corpectomy of the cervical spine. for thoracolumbar and cervical spine fusion. Spine
Spine. 2003;28:2352. (Phila Pa 1976). 1990;15:1073–8.
Virtual Surgical Planning and
CAD/CAM for Mandible and Maxilla 32
Reconstruction with Free Fibula Flap
Richard Tee, Andres Rodriguez-Lorenzo, and Andreas Thor
Contents
Mandibular Reconstruction Using VSP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Intraoperative Images (Figs. 8, 9, and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
Maxillary Reconstruction Using VSP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Intraoperative Images (Figs. 18 and 19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Abstract
Virtual surgical planning (VSP) using computer-

aided design and manufacturing (CAD/CAM)
allows preoperative planning of complex facial
R. Tee · A. Rodriguez-Lorenzo (*) · A. Thor skeletal reconstruction. Complex regional anat-
omy with the goal of restoring bony contour,
placement of soft tissue flap, and placement of
Uppsala, Sweden
dental implants using autologous osteocutaneous
e-mail: andres.rodriguez.lorenzo@surgsci.uu.se; flap requires appreciation of individual patients’
andreas.thor@surgsci.uu.se

https://doi.org/10.1007/978-3-030-23706-6_129
314 R. Tee et al.
anatomy which can be difficult. Using high- an attempt to recreate and preserve a functional
definition imaging and advance software, the TMJ (Thor et al. 2009).
manipulation and segmentation of both the fib-
ula and facial skeletal images, allows both the Soft Tissue Defect
resection and reconstruction team to “rehearse” The pathology causing defect was mucosal SCC.
the procedures digitally. Rapid prototype (RP) The underlying bone was resected because of
technology utilizing three-dimensional (3D) involvement. The intraoral soft tissue defect thus
printer allows the generation of tools to guide lies directly over the resected bone. Muscle or skin
precise intraoperative osteotomy and flap place- taken with the fibula flap is required. No external
ment. The chapter uses two oncological cases to cutaneous skin defect was anticipated in this case.
illustrate the use, the limitations, and technical
pearls of VSP in maxillary and mandibular Recipient Vessels
reconstruction. In this patient with a virgin neck undergoing neck
dissection, the facial artery and branches of the
internal jugular vein are the authors’ first option as
Keywords
recipient vessels, second option being the superior
Fibula free flap · Virtual surgical planning · thyroid vessels.
CAD/CAM · Midface reconstruction ·
Mandible reconstruction
Treatment Plan
Mandibular Reconstruction Using VSP 1. Preoperative discussion at head and neck

multidisciplinary meeting to reach consensus
The Clinical Scenario regarding resection and reconstruction plan
(including dental assessment and intervention)
The patient is a 57-year-old patient presented with 2. Presurgical planning with VSP
left gingival squamous cell carcinoma (SCC). Clin- 3. Three-dimensional printing of cutting guides
ical staging was T4N1M0. The resection include for both tumor site and recipient site
mucosa and underlying involved mandible 4. Decision on osteosynthesis, e.g., standard mini
extending from the left-sided condyle to the para- plates or reconstruction plate
symphysis. Bilateral selective neck dissection of 5. Resection of SCC with clear margin
level I to III was required. Postoperative adjuvant 6. Selection of recipient vessels
radiotherapy was planned. 7. Postoperative multidisciplinary meeting for
discussion of oncological outcome and need
for adjuvant therapy
Preoperative Problem List/ 8. Consideration for dental rehabilitation
Osseous Defect Alternative Reconstructive Options

The intended resection extends from the left-
sided condyle to the left parasymphysis. A sin- Bone flap alternatives can be referred to ▶ Chaps.
gle osteotomy within the fibula flap is required to 18, “Mandible Reconstruction in Osteoradio-
create the angle of the mandible. The condyle is necrosis,” and ▶ 39, “Management of Bone Non-
disarticulated but sparing the disc in place. The union in Mandible Free Flaps with a Scapular Tip
fibula end was planned and shaped into a curva- Flap.”
ture to better fit the limited space of the soft Virtual surgical planning in other bone
tissue canal created up to into the articular flaps is possible. Experiences with scapular tip
space. The fibula was placed against the disc in bone flap based on the thoracodorsal vessels
32 Virtual Surgical Planning and CAD/CAM for Mandible and Maxilla Reconstruction with Free Fibula Flap 315
(Kass et al. 2018) and iliac crest bone flap based or discrepancies to surgical anatomy. Currently, its
on the deep circumflex iliac vessels (Kim et al. design only allows its use on the anterior and man-
2014) were reported. However, bulky muscle dibular body segmental defects (Fig. 1).
insertions and attachments of these two flaps Haptic-assisted surgery planning (HASP) is
made manufacturing of a “hand-in-glove” cut- a research prototype developed here at Uppsala
ting guide difficult. University (Uppsala, Sweden), allowing the use to
Conventional economical techniques for fib- virtual simulation in the form of augmented reality
ula wedge osteotomy. Understandably, not all prior to actual surgery, to include the soft tissue
healthcare system can afford VSP/CAD-CAM component of the operation and haptic feedback
session with customized cutting guides that cost (Olsson et al. 2015). Currently, experience is lim-
approximately 3000 US dollars per session. Con- ited and the prototype under development, how-
ventionally, easy-to-access template such as the ever, harbors great potential (https://www.
ruler template can be used (Kang et al. 2016) to youtube.com/watch?v¼2OWs7W8vx0g).
aid in shaping and osteotomy.
Intraoperative assembled cutting guide: Cur- Preoperative Evaluation and Imaging
rently, there exists on the market a cutting guide that
can be assembled during the surgery (L1® Mandi- Breaking Down VSP/CAD-CAM
ble ReconGuide, KLS Martin, Germany) for both In essence, reconstruction using VSP/CAD-CAM
resection and fibula shaping. The benefit of this can be broken down into two basic processes,
technology is allowing the most accurate measure- visualization and manufacturing.
ments when compared to preoperative imaging Visualization means the entire surgical team is
which may allow of some changes to tumor size able to simulate the entire surgery digitally.
Fig. 1 Intraoperative assembled cutting guide from KLS the figure which is only suitable for segmental defect of the
Martin. Allows intraoperative measurement and assembled anterior and body of the mandible
cutting guide. Currently, it comes in the model shown in
316 R. Tee et al.
Through a series of digital processes, the scans are Firstly, computed tomography (CT) images
converted into 3D images that allow manipulation. with high resolution (<1 mm slices) and relevant
A portion of the time spent in actual surgery think- angiography of both the donor site and recipient
ing is now brought forward, arguably reducing the site were obtained. The images obtained from the
stress and improve efficiency. Not only this, tools scanner can be exported as DICOM files (can be
required to simplify one of the most variable step, obtained from radiology). DICOM is then
i.e., shaping of the bone, can now be digitally uploaded to the company’s website using authors
planned. Cutting guides can be designed to fit the login. (Note: DICOM stands for digital imaging
resection site and the donor site precisely, reducing and communications in medicine. This is the raw
operator variability. Other technological advances data acquired and stored by the CT scanner. The
also allow metal plates and dental implants to be image we see on hospital computers are displayed
designed during this process. and manipulated using third-party application. The
The manufacturing process is when the engi- same raw data can be used by engineers to create
neer takes the digital files created from visualiza- more sophisticated images for manipulation and
tion process and began to fabricate the tools simulation through other software) (Fig. 3).
planned. In the most basic form, a model of the A teleconference meeting with the engineers
bony structures and cutting guides are fabricated. was arranged (can be within 24 h). VSP occurs at
this meeting, relevant members of the team will
Workflow Used (Fig. 2) need to participate in the meeting. During the
A checklist of the workflow at the authors institu- meeting, engineers used the uploaded DICOM
tion is listed in Fig. 2. data for three-dimensional (3D) rendering, a
Checklist for Virtual Surgical Planning, VSP (Uppsala University Hospital, Sweden)
Maxilla and Mandible Oncological Reconstruction
Prior to meeting with VSP engineer At the meeting with VSP engineer 1 week prior to surgery
Identification number of patient Consider laterality of flap (based Is there too much gap
requiring surgery on OR ergonomics and CTA between date of scan and
High resolution CT scan with vessel condition) date of surgery? (If yes-
<1mm cuts (Patient in occlusion) Consider flap pedicle and re-scan and/or prepare
DICOM images perforator/skin paddle placement second set of surgical
Optional dental implants planning Consider recipient vessel cutting guides?)
Upload to manufacturer website intended Doppler of perforators
(can be done directly from Plan osteotomies on pre- Mark skin paddle location
radiology systems operative scans and size
Check
Plan surgical date Bone contact
Contact dental rehabilitation team Osteotomies Are the cutting guides and
Midline position models received?
Position in relation to teeth ICU bed available?
(resection not too close to Any change to surgery
Organize meeting with VSP last teeth, preferably right time?
engineering (informing time, date through alveolus), nerve etc.
and location) Decision on reasonably planned
Contact and verify plan with and designed surgical guides
reconstructive surgeon, resection (slots to flanges, alternative plan
surgeon (already discuss donor with an extra guide?) and patient
site, vessels, resection length etc.) specific implants (in-house or
manufacturer)
Fig. 2 Checklist used at Uppsala University Hospital for Abbreviations: DICOM, Digital Imaging and Communi-
presurgical virtual surgical planning in the oncological cations in Medicine; OR, operating room; CT(A), com-
resection and reconstruction of the maxilla and mandible. puted tomography (angiography)
Fig. 3 Preoperative computed tomography (CT) images with arrows showing osteolytic lesion over the left mandible
(ramus, angle and body) indicating the invasion of the squamous cell tumor
process which produced a 3D model of the resec- an image acquired in DICOM format, through a
tion site (mandible) and both legs for the assess- CAD software transformed into STL files, which
ment of fibula flap donor sites (Figs. 4, 5, 6, is the format that allows 3D printing.)
and 7). This allow of the manipulations seen in This turnover for this process varies. The
the figures, a process termed “segmentation.” authors’ local experience is between 5 days to
During the meeting, the details listed in Fig. 2 10 days.
were discussed. The planning required at the resec-
tion, the recipient sites, and the design of the cut- In-House Versus External Planning
ting guides are illustrated in Figs. 4, 5, 6, and 7. There are several companies that provide online
It should be noted that the planning would not web-based VSP service. The workflow of the
consider soft tissue anatomy, progression of the external service requires different parts of the
tumor. Hence, some centers prefer a second set of manufacturing conducted in different geographical
cutting guides to cope with intraoperative changes locations. This results in potential long processing
(Shenaq and Matros 2018). time, which is an issue for oncology cases with
Following the simulation session with the rapid growing tumors. The alternative is to develop
engineers, the plan is then translated into 3D “In-house planning” which requires an engineering
models and actual cutting guides by the manufac- laboratory on location equipped with appropriate
turer using rapid prototyping (RP) technology in software and 3D printer (Maglitto et al. 2021).
the form of 3D printing (Jacobs and Lin 2017).
The data are first exported as standard triangula-
tion language (STL) files. STL files are then used Preoperative Care and Patient Drawing
by engineers to fabricate actual cutting guides or
even customized implants such as 3D printed For markings and positioning for a free fibula flap
plates are possible but not used in this case. Pre- dissection, ▶ Chaps. 20, “Reconstruction of Tem-
bending of the intended osteosynthesis implants poromandibular Joint with a Fibula Free Flap,”
were done on the 3D printed models. (Rapid pro- ▶ 30, “Midface Reconstruction with Soft Tissue
totyping technology: This is a technique used by and Bone Flaps,” and ▶ 18, “Mandible Recon-
the engineers to quickly fabricate a scale model of struction in Osteoradionecrosis,” for more details.
318 R. Tee et al.
Fig. 4 The design of the resection cutting guide. The of the guide should not be too big, which if it is, will need
cutting guide for resection was designed to fit snugly on wider area of dissections – hence, devascularization of the
mandible. The angle of the cutting guide should match the bone. The intended resection extends from the condyle to
angle of fibula cutting guides at the intended end. The size the parasymphysis (in red)
Fig. 5 The planning of the fibula configuration to generate and blue), the length of each fragment, the angles and
shape that resembles the mandible. During the VSP ses- number of osteotomies to achieve the shape intended
sion, by superimposing a fibula shaped structure (in green were obtained
Fig. 6 The planning of the

osteomies on the right-sided
fibula. The final shape
decided in Fig. 5 was then
superimposed on to the 3D
images of the fibula of the
leg. At this stage, the
direction of peroneal vessel
for anastomosis to the
recipient vessels should also
be noted. 80 mm of fibula
distally is preserved to
maintain stability of the
ankle joint. The wedge
osteotomy between the blue
and green fragment was
planned. The intended
condylar end is placed
distally on the fibula
Fig. 7 Designing of the cutting guides for the fibula osteotomies. The osteotomy cutting guide planning needs to consider
the side of the pedicle while able to fit onto the fibula snugly. The shape of the condyle was also designed here
320 R. Tee et al.
Surgical Technique Left-sided facial artery and two veins from the
internal jugular vein were used as recipient vessels
As surgical technique related to a free fibula flap (Fig. 10).
will be similar to the chapters outlined in the last
section, the authors will focus on aspects related to
VSP only. Technical Pearls
A cutting guide (designed from the VSP),
printed and autoclaved, was used to excise the Consider side of the leg, the pedicle of the flap if it
bony mandible (Fig. 8). The cutting guide itself will lie lingual or buccal, the location of the per-
can be secured to the bone by temporary screws forator and skin paddle (Fig. 10b and c) since the
through the perforations. The resection surgeons VSP process does not help with these soft tissue
can see along the guide so that the angle to the cut details.
will allow fitting of the fibula’s shape. The TMJ When performing wedge osteotomy for shap-
was disarticulated. ing, a periosteal elevator should be use to protect
A free fibula flap with a skin paddle designed the pedicle immediately deep to the bone, despite
for the templated alveolar/buccal defect was the presence of periosteum.
raised in a standard fashion. The cutting guide
was placed after the fibula was osteomized at
two ends (leaving 8 cm at each end of the fibula Intraoperative Images (Figs. 8, 9,
to preserve knee and ankle function) (Fig. 9b). and 10)
The shape of the fibula at each end and the wedged
osteomy can be performed in situ. Two miniplates Postoperative Management
were used to maintain the shape at the wedge For the postoperative management of patient
osteotomy site (Fig. 9c). receiving fibula free flap after mandibular recon-
Performing this step while the pedicle struction, ▶ Chaps. 20, “Reconstruction of Tempo-
remained intact reduced ischemia time on the romandibular Joint with a Fibula Free Flap,” ▶ 18,
fibula flap. “Mandible Reconstruction in Osteoradionecrosis,”
Fig. 8 Three-dimensional (3D) cutting guide to aid in the was disarticulated from the TMJ, the cutting guide only
resection of the hemi-mandible. A 3D-printed model to needs to fit onto one end of the remaining mandible
size is shown here. In this case, since the hemi-mandible
a b
c d
Fig. 9 Shaping of the right fibula in-situ using 3-D printed pre-bent plates are secured to maintain the shape of the
cutting guides. (a) the right fibula osteocutaneous flap is fibula (a 3D-printed model is placed next to the shaped flap
fully dissected leaving pedicle still intact in situ for flap for comparison), and (d) the distal end of the flap is shaped
perfusion, (b) the 3D-printed cutting guide designed in (yellow box) to fit into the TMJ against the preserved disc
Fig. 7 fits snugly onto the lateral side of the fibula, (c) where the condyle had been disarticulated
▶ 39, “Management of Bone Nonunion in Mandi- • A second set cutting guide can be planned to
ble Free Flaps with a Scapular Tip Flap,” and ▶ 30, anticipate for potential tumor enlargement, or
“Midface Reconstruction with Soft Tissue and doubts about the laterality of the fibula flap or
Bone Flaps.” recipient vessels that may require an opposite
mirror configuration instead.
• The size of the cutting guides, especially on the
Outcome, Clinical Photos, and Imaging tumor site, should not be too big. As the guide
needs to fit on healthy, unaffected mandible to
Radiological evidence of bone union was allow resection of the affected segment, space
achieved at 5 months post-surgery (Fig. 11). is required for its placement. A bulky cutting
guide may require further degloving of soft
tissues and may unnecessarily devascularize
Avoiding and Managing Problems the bone.
• Do not disconnect or begin osteotomies of the
• Careful assessment of the soft tissue and CT fibula free flap before checking with the resec-
images of vessels (both fibula and recipient) is tion team if the tumor is more extensive than
essential, if the leg do not have a three-vessel anticipated.
runoff, a contralateral fibula or a different flap • Intraoperative template should be fabricated to
need to be considered. ensure the soft tissue arrangement of the flap is
322 R. Tee et al.
a b d
e
c
Fig. 10 Insetting of the free osteocutaneous fibula flap. needs to turn under the fibula to sit in the oral surface
(a) The defect with dotted white line shows the (solid red arrow with dotted red arrow showing the perfo-
hemimandibular defect through a neck dissection incision. rator turning under the fibula), and (d) the pedicle will
The tongue is visible through an intraoral mucosal defect. come off anterior to the neck with option of performing
Two white arrows showing the facial artery (left) and the anastomosis to the contralateral neck vessels or (e) with a
branch of the internal jugular vein (IJV, right). (b) It is to be gentle curve turning toward the ipsilateral vessels. In this
remembered that the perforator to the skin paddle comes case it was anastomosed to the ipsilateral facial artery
posterior to the fibula (blue arrow) (c) to allow the skin (white arrow, red) and branch of the IJV (white arrow, blue)
paddle to line the intraoral defect, and the skin paddle
Fig. 11 Follow-up CT images of the reconstructed mandible at 5 months post-surgery showing good bone union and
shape comparable to the contralateral hemi-mandible
not a problem at recipient site (Driessen et al. Learning Points

2020).
• At the point of doing anastomosis, the curva- • Communication between the resection, recon-
ture allowed by the recipient pedicle needs to struction, and dental rehabilitation team (oral
be checked if recipient vessels should be ipsi- maxillofacial surgeons and prosthodontists)
lateral or contralateral due to kinking. with the engineers at the time of VSP is crucial
for the best outcome – particularly, it is not (Fig. 12a and b). The patient suffered from
always possible for all surgeons to be present severe sinusitis. The implants were removed at
at the engineer planning. A suboptimal but that stage and sinusitis resolved within months
practical alternative is to distribute screenshots of the procedure. While the sinusitis was
or digital files of the VSP instantly to all addressed, patient was unable to have normal
involved surgeons in the team for approval or oral intake and the midface contour deformity
comments for quick changes. The printed plan was apparent (Figs. 12c, d and 13).
can thereafter be communicated to the whole
surgical team including nurses and assisting
personnel before and during surgery. Preoperative Problem List/
• Despite the best planning, reconstruction Reconstructive Requirements
team needs to be flexible and anticipate
potential changes intraoperatively. This may The contrast to the mandible case is an immediate
require fluency in free-hand technique or reconstruction with adequate normal bone con-
preparation of a second set of cutting guides tour to design the fibula shape. This case has
in anticipation. neither a mirror image or an old normal scan for
• VSP is a great tool for surgeon’s visualization, reference.
planning, and executing complex bony cases. This patient has a lack of upper jaw dentition,
It is not foolproof with attention required to the complete loss of alveolar crest, and a midface
points mentioned in the above text. Soft tissue contour deformity. The aim of the reconstruction
and vasculature planning, in particular, are the is to deliver a vascularized bone for restoration of
weaknesses of VSP and thus will need further maxillary dentition. The height and position of the
innovations in this area. intended alveolar ridge and the bone contact with
the cranial skeletal structure to form a stable union
needed to be considered. Patient understood prior
Maxillary Reconstruction Using VSP to surgery that the contour deformity may not be
perfectly restored.
As the principles of VSP were outlined in the To separate the oral cavity from the nasal cav-
section prior, this section will be aimed at ity, a skin paddle was required. Stable soft tissue
outlining the differences between a case of max- was also required around the intended dental
illary reconstruction VSP as opposed to mandib- implant sites.
ular reconstruction. Since the main goal is to restore dentition,
position of dental implants needs to be planned
preoperatively.
A 60-year-old patient referred to the plastic and Preoperative Evaluation and Imaging
maxillofacial service due to chronic sinusitis and
severe form of maxillary atrophy. The condition Since there was no reference point to guide the
had been present for over 17 years. The alveolar/ VSP of the fibula placement, having the goal of
maxillary atrophy began from severe chronic peri- restoring maxillary dentition in mind, a process of
odontitis, combined with osteoporosis. Patient “backwards planning” (Figs. 14, 15, 16, and 17),
also suffered from systemic lupus erythromatous. was employed (Rohner et al. 2002).
After maxillary dental extractions 17 years ago, The mandibular dentition was used as a refer-
the condition has deteriorated. ence point. Working with the prosthodontists, a
At presentation, the patient had zygomatic barium sulfate (radiopaque material) prosthesis
implants placed into the zygoma that lasted for was created to fit into the space of the midface
5 years that was discharging purulent fluid cavity cranially, while caudally consisting of a
324 R. Tee et al.
a b
c d
Fig. 12 Computed tomography (CT) images prior and symptoms. (c) and (d) Three-dimensional
after the removal of zygomatic implants. (a) and (b) (3D) reconstruction CT view after removal of the zygo-
Chronic infection of the zygomatic implants placed within matic implants revealed the severity of the multifactorial
the zygoma that contributed to bone resorption and chronic maxillary atrophy
a b
Fig. 13 Preoperative images of severe maxillary atrophy can be seen discharging along the exposed implants (b)
(a) demonstrate the severe maxillary atrophy with the profile view demonstrating the patient’s midface contour
lateral pterygoid plates visible (arrows) and purulent fluid defect
mold of the dental cast of maxillary teeth comple- allowing the position of the fibula and hence the
ments the mandibular teeth. This barium sulfate location of the dental implants intended to be
prosthesis will be visible on the CT images taken planned (Fig. 14).
Fig. 14 “Backwards planning” of the maxillary recon- simulation of the intended teeth position. The radiopaque
struction. Using the mandibular teeth as a guidance for space occupied by the barium sulfate prosthesis also sim-
occlusion. A barium sulfate prosthesis (radio-opaque) is plified virtual surgical planning of the position of the fibula
fabricated by the prosthodontist. This allows the free flap
Fig. 15 Virtual surgical planning (VSP) of the dental cast complementing the mandibular teeth. The posi-
osseointegrated dental implant position. The barium sul- tions of the osseointegrated implants were planned (8 in
fate prosthesis (in purple) occupies the space by cranially total, in red)
contacting the bony structures and caudally forming a
326 R. Tee et al.
Fig. 16 Virtual surgical planning (VSP) of the free fibula that allows contact with the remaining midface bone (pter-
flap position. Once the position of the osseointegrated ygoids and remnants of posterior maxillary wall) and the
dental implants were determined, the intended fibula intended implant position
shape was determined by superimposing it in a position
Fig. 17 Virtual surgical planning of the intended followed by the designing of cutting guides. The final
osteotomies on the right-sided fibula bone. After the intended geometry of the fibula required was then trans-
shape of the fibula was decided in the previous figure, the posed onto the scan of the right-sided fibula CT scan for
dimensions and angle of each fragment were superimposed generation of cutting guides as in Fig. 7
onto the radiological images of the fibula. This step was
At the VSP consultation with the engineer, the miniplates were used to secure the flap construct
position of the dental implants can be planned to the cranial skeletal structures (Fig. 19a and b).
based on the occlusion created by the prosthesis The raw ends of the of the fibula flap were brought
(Fig. 15). After the position of the dental implants in contact with the pterygoid plates and remnants
was placed, the shape and position of the fibula of the posterior maxillary wall. The skin paddle
can be determined (Fig. 16). The oral side of the found to be too bulky for the inset and was thus
fibula will need to recreate the alveolar ridge with removed, leaving only adipofascial tissue behind
adequate height to fit the dental implants. Raw to mucosalized (Figs. 19c, 20, and 21).
bone surface contact is required to allow some
union of the fibula to the cranial skeletal structure.
In this case, the pterygoid plates and remnants of Intraoperative Images (Figs. 18 and 19)
the posterior maxillary wall were present and were
utilized for this purpose. This resulted in a “U”- Outcome, Clinical Photos, and Imaging
-shaped configuration of the fibula flap. Patient received osseointegrated implants
5 months post-surgery, after the adipofascial flap
mucosalized (Fig. 22). Further 2 months after
Surgical Techniques implants placement, patient was able to receive
implant retained bridge allowing oral intake and
After the fibula was shaped based on VSP printed profile contour defect was significantly improved
guides and models (Fig. 18), four 1.5 mm titanium (Fig. 23).
a b
c d
Fig. 18 Intraoperative images of the virtual surgical plan- of the VSP designed cutting guide onto the fibula flap on
ning (VSP) executed in reality. (a) 3D model of the facial the side table, and (d) confirmation of the intended fibula
skeleton with the intended fibula position generated to aid shape by placing the osteomized fibula flap and 3D-printed
the surgeons’ visualization, (b) the 3D-printed model of the model side by side
“U” shaped fibula flap intended, (c) “hand-in-glove” fitting
328 R. Tee et al.
Fig. 19 Surgical inset of shaped fibula osteocutaneous was too bulky, the skin was removed leaving an
free flap. (a) and (b) demonstrates the configuration of adipofascial flap behind to mucosalized (marked by aster-
the miniplates used to secure the shaped fibula flap to the isk), providing additional coverage of the osseous compo-
remaining midface skeletal structure. (c) As the skin paddle nent of the flap
Fig. 20 Three-dimensional (3D) reconstruction computed tomography (CT) images at 3 months post-surgery
Fig. 21 Gradual mucosalization of the adipofascial component of the fibula free flap (from left to right)
a b
c d
Fig. 22 Placement of osseointegrated dental implants. (a–c) Drill guides and dental prosthesis to guide placement of
implants based on previous virtual surgical planning. (d) Implantation of osseointegrated dental implants
Learning Points To obtain the best dental outcome, it is impor-

tant to utilize “backwards planning,” especially
The midface is further away from the neck recip- when no reference image is available.
ient vessels as opposed to the mandible. The ped- The fibula is a tube-like structure with the
icle length needs to be maximized. When medulla present at two ends of the bone flap.
planning the fibula, the distal osteotomy site These are the reliable sites to achieve direct bony
needs to be placed appropriately distally to max- union without potentially disrupting the blood
imize the pedicle length proximally. flow of the flap. This also poses challenge for
330 R. Tee et al.
Fig. 23 Post-dental implants frontal and profile view of patient showing excellent outcome
proper osteosynthesis and hence union for maxil- Jacobs CA, Lin AY. A new classification of three-
lary reconstruction owing to its complex shape. dimensional printing technologies. Plast Reconstr
Surg. 2017;139(5):1211–20.
The height required for the midface should be Kang SY, Old MO, Teknos TN. Contour and osteotomy of
at the alveolar ridge. This is often overestimated free fibula transplant using a ruler template. Laryngo-
(shorter than one thought), which can cause prob- scope. 2016;126(10):2288–90.
lems for the placement of dental implants. Kass JI, Prisman E, Miles BA. Guide design in virtual
planning for scapular tip free flap reconstruction.
Laryngoscope Investig Otolaryngol. 2018;3(3):162–8.
Kim N-K, Kim HY, Kim HJ, Cha I-H, Nam W. Consider-
Cross-References ations and protocols in virtual surgical planning of recon-
structive surgery for more accurate and esthetic
neomandible with deep circumflex iliac artery free flap.
▶ Atrophic Maxilla with Fibula Flap and Implant- Maxillofac Plastic Reconstr Surg. 2014;36(4):161–7.
Supported Prosthesis Maglitto F, Orabona GD, Committeri U, Salzano G, Fazio
▶ Management of Bone Nonunion in Mandible GRD, Vaira LA, et al. Virtual surgical planning and the
Free Flaps with a Scapular Tip Flap “in-house” rapid prototyping technique in maxillofacial
surgery: the current situation and future perspectives.
▶ Mandible Reconstruction in Osteoradionecrosis Appl Sci. 2021;11(3):1009.
▶ Midface Reconstruction with Soft Tissue and Olsson P, Nysjö F, Rodríguez-Lorenzo A, Thor A, Hirsch
Bone Flaps J-M, Carlbom IB. Haptics-assisted virtual planning of
▶ Reconstruction of Temporomandibular Joint bone, soft tissue, and vessels in fibula osteocutaneous
free flaps. Plastic Reconstr Surg – Glob Open.
with a Fibula Free Flap 2015;3(8):e479.
▶ Reconstruction of Total Maxillectomy and Rohner D, Bucher P, Kunz C, Hammer B, Prein J, Schenk
Orbital Floor with a Free Scapula Tip Flap RK. Treatment of severe atrophy of the maxilla with the
prefabricated free vascularized fibula flap. Clin Oral
Implants Res. 2002;13(1):44–52.
Shenaq DS, Matros E. Virtual planning and navigational
References technology in reconstructive surgery. J Surg Oncol.
2018;118(5):845–52.
Driessen C, Hout N, Kuppenveld P, Cristobal L, Liu T, Thor A, Rojas RA, Hirsch J-M. Functional reconstruction
Mani M, et al. Usefulness of a template-based ante- of the temporomandibular joint with a free fibular
rolateral thigh flap for reconstruction of head and neck microvascular flap. Scand J Plast Recons. 2009;42(5):
defects. Microsurgery. 2020;40(7):776–82. 233–40.
Vascularized Vastus Lateralis Nerve
Graft for Reconstruction of Composite 33
Facial Nerve Defect
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Outcome, Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
L. Vieira (*)
Microvascular Fellow, Department of Plastic and
Maxillofacial Surgery, Uppsala University Hospital and
Uppsala, Sweden
Uppsala, Sweden

https://doi.org/10.1007/978-3-030-23706-6_119
332 L. Vieira and A. Rodriguez-Lorenzo
Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Abstract tissue at the level of the angle of the mandible.

The authors present a clinical scenario of a After discussion in Head and Neck Tumor Board,
57 years-old man with a soft tissue sarcoma the patient was staged as T1AN0M0.
that underwent tumor resection including soft The patient was scheduled for tumoral mass
tissue, part of the mandible, and the marginal excision with a 2 cm macroscopic margin and
mandibular nerve branch, with a resulting nerve ipsilateral neck dissection (Fig. 2). The resulting
gap of 7 cm. Nerve reconstruction was per- defect was a marginal mandibulectomy, marginal
formed with a vascularized vastus lateralis branch of the facial nerve 7 cm gap, platysma
motor nerve graft along with a free anterolateral motor nerve defect, and soft tissue and skin over
thigh flap. Two years postoperatively, the patient the right mandible angle area.
is tumor-free and shows good symmetry and
function in the lower lip depressors and mentalis.
Vascularized nerve grafts are best suited Preoperative Problem List/
for reconstruction of large nerve defects and Reconstructive Requirements
when the local conditions are suboptimal
(e.g., radiation, scarred bed), since they pro- 1. Skin and soft tissue defect in the right jaw
vide more effective and faster nerve regener- area in a male patient. Achieving stable
ation. The free anterolateral thigh flap and the wound healing in proper timing enables the
vastus lateralis motor nerve are a good option patient to receive adjuvant therapy and resume
for the complex facial nerve and soft tissue his daily life activities earlier.
defects. After tumor excision, a large soft tissue
Critical steps in this procedure include the volume defect will ensue and this needs to be
use of intraoperative templates to shape the addressed by free tissue transfer.
ALT, selection of a proper vascularized nerve The final aesthetic outcome depends on the
graft donor site, pedicle and vascularized nerve proper reconstruction of the beard defect.
graft dissection, and final insetting of nerve, 2. Right Lower lip depressors denervation. The
vascular pedicle, and soft tissue. oncological safety requires the sacrifice of the
marginal branch of the facial nerve, leading to a
nerve defect of 7 cm. Nonreconstruction would
Keywords
lead to sequelae as resting asymmetry because
Vascularized nerve graft · Vastus Lateralis of lack of tone on the right lower lip; dynamic
Motor Nerve · Facial nerve · Composite asymmetry because of lack of movement in the
defect · ALT right lower lip in action such as smiling; func-
tional impairment in activities such as eating,
drinking or kissing; psychosocial impairment
The Clinical Scenario for the above reasons.
3. Marginal mandible defect. The bony defect
A 57 year-old man, otherwise healthy, presented does not lead to a discontinuity in the man-
with a soft tissue high-grade sarcoma over the right dible. Radiotherapy is a risk factor for the
mandible angle (Fig. 1). CT scan showed a prolif- development of osteopenia and pathologic
erating mass of 31 x 32 mm in the subcutaneous fractures.
33 Vascularized Vastus Lateralis Nerve Graft for Reconstruction of Composite Facial Nerve Defect 333

showing a soft tissue
sarcoma over the right
mandible angle and the
predicted surgical margins
Fig. 2 After tumoral

excision and neck
dissection, the resulting
defect comprised: marginal
mandibulectomy, marginal
branch of the facial nerve,
and skin and soft tissue over
the right jaw area
5. Reconstruction of external skin and soft

Treatment Plan
tissue defect in face and neck with Antero
Lateral Thigh (ALT) free flap. The ALT is a
1. Tumoral mass resection with 2 cm margin in
time-honored free flap for head and neck
every direction, resulting in a marginal
reconstruction for its many advantages: low
mandibulectomy, marginal branch of the facial
donor site morbidity, long and reliable pedicle,
nerve defect of 7 cm, skin, and soft tissue
a significant amount of skin and soft tissue,
defect over the right jaw area. the possibility of chimeric flaps, two-team
2. Ipsilateral neck dissection. approach. The ALT is a natural choice to recon-
3. Mandible defect reinforcement with plate struct this defect. The usual bulkiness of the
and screws for the prevention of pathologic ALT can, in this case, fill the dead space left by
fractures after radiotherapy. the neck dissection.
4. Selection of recipient vessels in the neck – 6. Marginal nerve gap reconstruction with a
Right superior thyroid artery and a branch of Vascularized Nerve Graft (VNG) from the
the internal jugular vein. Vastus Lateralis Motor Nerve (VLMN). The
rationale to use a vascularized nerve graft is its • Alternatives for Marginal Nerve Reconstruc-
higher chance of success and faster axonal tion in Acute Setting.
regeneration, indicated for a long nerve gap in – Non Vascularized Nerve Graft (NVNG)
this scenario of associated radiotherapy and from Greater Auricular Nerve (Malik et al.
scarred recipient bed (Koshima and Harii 2005).
1985; Terzis and Kostopoulos 2010; Klein Advantages: Low donor site morbidity,
et al. 2019). The reasons to use the VLMN simple technique.
are: blood supply coming from the ALT flap Disadvantages: Lower and slower axo-
pedicle, dissection similar to the ALT pedicle, nal growth, decreased success rates in irra-
low donor site morbidity, donor motor nerve to diated and scarred tissue, long nerve gap
reconstruct motor nerve gap (Kimata et al. – Nerve transfer from Masseteric Nerve or
2005; Brenner et al. 2006). Ansa Cervicalis (Cristóbal et al. 2017).
7. Secondary reconstruction. Flap revisions Advantages: Only one anastomosis site,
such as liposuction, serial partial excision for transfers the axonal growth to closer to the
beard area reconstruction are planned. target muscles, low donor site morbidity.
Disadvantages: Requires relearning
from the patient, risk for lacking spontane-
Alternative Reconstructive Options ity, low resting tone (Jensson et al. 2018)
– Nerve substitute interposition (Hu et al.
• Alternatives for reconstruction of external skin 2016).
and soft tissue defect: Advantages: No donor site morbidity.
– Radial Forearm Free Flap (Santamaria et al. Disadvantages: Cost, lower and slower
2000). axonal growth, decreased success rates in
Advantages: Easy dissection, large ped- irradiated and scarred tissue, long nerve gap.
icle length, large pedicle caliber.
Disadvantages: Donor site morbidity,
thin for the present defect, donor nerves Preoperative Evaluation and Imaging
for VNG are sensitive (Lateral or Medial
Antebrachial Cutaneous Nerve), Less hair Recipient site imaging – Fig. 3.
for beard area reconstruction, difficulty in Donor site evaluation – Exclusion of scars in
two team approach. the donor thigh, thigh circumference measure-
– Scapular or Parascapular Free Flap (Brown ment to estimate safe donor site direct closure
et al. 2010). (Boca et al. 2010), summary neurological exami-
Advantages: Low donor site morbidity, nation of lower limb, signs of peripheral artery
low rate of atherosclerosis in the vascular disease as marker for pedicle vascular status.
tree, versatile flap.
Disadvantages: One team approach,
higher morbidity if reconstruction with Preoperative Care and Patient
VNG (thoracodorsal or long thoracic nerves), Drawing
short pedicle.
– Pedicled Pectoralis Major Flap (Ahmad – The patient is not planned for Tracheostomy, as
et al. 2006). the airway is not invaded.
Advantages: No need for microsurgical – Anesthesia without muscle relaxant is pre-
skills/setting, short operative time, reliable ferred for facial nerve exploration.
vascularity. – The patient lies supine and a two-team
Disadvantages: Donor site morbidity, approach is favored.
does not fulfill every reconstructive require- – Donor site drawing follows previous descrip-
ments, poor final aesthetic outcome. tions (Wei et al. 2002): with the foot in a neutral
position, a line connecting the anterior superior site if a split thickness skin graft is needed for
iliac spine and the superior lateral border of the donor site closure.
patella marks the septum between vastus
lateralis and rectus femoris muscles. Perforators
are dopplered around the middle area of this Surgical Technique
line. The likely locations of the VLMN
(Oblique and Descending branches) are marked During the resection of the tumor and the neck
(Fig. 4). A large medial incision is planned. dissection, the flap harvest is performed as
– The donor thigh is circumferentially draped. described in the following steps:
The medial side of the thigh can be the donor
1. Medial incision down to fascia.
2. Subfascial dissection from medial to lateral,
looking for the dopplered perforators, which
can have an intramuscular or a septal course.
3. Perforator dissection until the descending
branch of the lateral circumflex femoral vessels.
4. Location of the descending branch of
the VLMN.
5. Dissection of the vascular pedicle and the
descending branch of VLMN in a proximal
direction. The VLMN oblique branch is pre-
served (Agrogiannis et al. 2009). If more VNG
is needed, distal dissection of VLMN can be
achieved.
6. Dissection should stop when enough pedicle
and nerve graft length is achieved and prefera-
bly, one vascular pedicle to rectus femoris
should be preserved.
Fig. 3 CT scan showing a 3 x 3 cm high grade sarcoma in When the tumor resection is finished, the recon-
the right mandible angle area structive requirements are confirmed – skin paddle,
Fig. 4 Preoperative
drawing for ALT flap
harvest. The likely locations
of the oblique and
descending branches of the
vastus lateralis motor nerve
are depicted. VLMNOb –
Vastus lateralis motor nerve
oblique branch; VLMN-db
– Vastus lateralis motor
nerve descending branch;
VL – Vastus lateralis; RF –
Rectus femoris
soft tissue, nerve gap. A template of the skin and 2. The template of the defect is an invaluable tool:
soft tissue defect is made (Driessen, C., van Hout, it should contemplate the skin defect, but also
N., et al., Usefulness of a template-based ante- the recipient vessels and the nerve defect to be
rolateral thigh flap for reconstruction of head and reconstructed.
neck defects – Article under revision in press). 3. Before completing the nerve anastomosis, the
pedicle should be confirmed to be in a smooth
1. The template is transferred to the donor site, course to the recipient vessels, with no kinking
and the skin paddle is incised accordingly. or twisting. Once the nerve is sutured, pedicle
Subcutaneous undermining provides adequate twisting cannot be corrected.
bulk for the reconstruction of the soft tissue 4. Arterial anastomosis first has several advan-
deficit at the recipient site. tages: filling of the draining veins allows an
2. A VLMN graft of 8–9 cm is harvested, left understanding of the flap hemodynamics and
attached to the vascular pedicle on the middle helps to avoid vein twisting.
region. Side branches are avoided, as this will
prevent axonal dispersion. The distal and prox-
imal ends are mobilized to later reach the mar- Intraoperative Images
ginal nerve stumps.
In the recipient site: See Figs. 5, 6, and 7.
1. The VLMN graft is sutured to the proximal and
distal nerve stumps. As the VLMN is attached
to the vascular pedicle, proper positioning Postoperative Management
should avoid kinking or twisting.
2. Vascular anastomoses are performed. After the operation the patient is transferred under
3. Final flap insetting. general anesthesia to an intensive care unit for the
first 24 postoperative hours and then to the ward.
Technical Pearls – Drains: Two passive drains are sutured in the

recipient site, one of them close to the anasto-
1. Avoid skeletonization of the perforator if in an mosis, but not in contact with it. They are left
intramuscular course. Keeping a small cuff of for 5–7 days, depending on the drainage. One
muscle avoids inadvertent injury to the small active drain is left in the donor site, in the
perforator veins. muscular plane, for around 3–5 days.
Fig. 5 Marginal nerve

7 cm gap and recipient
vessels exposed
Fig. 6 Descending branch

of the VLMN harvested
with the ALT pedicle. Note,
in the proximal part, the
VLMN oblique branch
Fig. 7 VLMN VNG used

to reconstruct a 7 cm
mandibular marginal nerve
gap in a composite facial
nerve defect
– Flap control: The flaps are closely monitored first week to avoid vascular spasm or
by the nursing staff by clinical inspection, compression/kinking of the vascular pedi-
manual Doppler and implantable Doppler cles. During the first three postoperative
(Cook-Swartz) according to our institution’s days, the patient stays in bed but is
protocol during 1 week. The frequency of con- instructed to do an active mobilization of
trols is as follows: once every 15 min in the first the extremities.
4 h, every 30 min in the next 4 h, and then once/ – Antibiotic and thromboprophilaxis: Pre-
hour the first day, every 2 h on day 2, every 3 h and perioperative antibiotic prophylaxis is
on day 3, every 4 h on day 4, every 5 h on day given using a combination cefotaxime and
5, and every 6 h on day 6. metronidazol antibiotics i.v. and thrombopro-
– Nutrition: Oral liquid feeding is started on the phylaxis is prevented by using daily subcuta-
first postoperative day and progressed as neous injection of low dose heparin
tolerated. (dalteparin) for 10 days. In addition, from
– Mobilization: The patient needs to avoid day 1 the patient takes low dose aspirin
excessive mobilization of the neck for the (75 mg) once a day for 1 month.
Fig. 8 Immediate post op and 15 months post op demon- lower lip depressors and mentalis, with symmetry in
strating effective progression of nerve regeneration of smile and outward movement of the lower lip
Outcome, Clinical Photos and Imaging
The surgery was uneventful. The patient stayed in

the intensive care unit for 24 hours and then in the
plastic surgery ward. The postoperative period
was uneventful and the patient was discharged
home on the 7th postoperative day.
Stable wound healing occurred both in donor
and recipient sites.
Radiotherapy was added to the treatment plan
after specimen pathological analysis.
At 2 years follow–up, the patient is tumor-free.
Good symmetry and function in the lower lip
depressors and mentalis was achieved (Fig. 8).
The patient is not interested in secondary
revision surgery: partial flap excision and
debulking or local tissue expansion for beard
area reconstruction (Fig. 9).
Fig. 9 Immediate postop appearance, demonstrating color
mismatch and hairless beard area. The patient was satisfied
Avoiding and Managing Problems with present reconstruction and chose not to undergo serial
excision of the flap or local tissue expansion for beard area
reconstruction
• Recipient site color mismatch/Patch Appear-
ance: The skin defect can be approached as a
staged reconstruction. After stable coverage and Learning Points
no recurrence, flap staged serial skin excision
and closure with local flaps was planned for • Vascularized nerve grafts do not depend on the
beard reconstruction. recipient bed vascularization, so they are best
• Smile asymmetry during nerve regenera- suited for long nerve gaps in thick nerves, as
tion: Small Botulinum toxin doses can be the facial nerve and its branches in the setting
applied to the left lower lip depressors to of radiotherapy and scarred bed. Vascularized
camouflage the asymmetry. nerve grafts are superior to non-vascularized
nerve grafts for nerve gaps reconstruction in Brown J, Bekiroglu F, Shaw R. Indications for the scapular
this scenario. Nerve reconstruction provides flap in reconstructions of the head and neck. Br J Oral
Maxillofac Surg. 2010;48(5):331–7. https://doi.org/
spontaneity and better resting tone when 10.1016/j.bjoms.2009.09.013.
compared with local nerve transfers. Cristóbal L, Linder S, Lopez B, Mani M, Rodríguez-
• The VLMN is a good donor nerve for facial Lorenzo A. Free anterolateral thigh flap and masseter
nerve reconstruction in composite facial nerve transfer for reconstruction of extensive peri-
auricular defects: surgical technique and clinical out-
defects: it depends on the ALT pedicle, it is a comes. Microsurgery. 2017;37(6):479–86. https://doi.
motor nerve, it is a long nerve, and it has a low org/10.1002/micr.30086.
donor site deficit. Hu M, Xiao H, Niu Y, Liu H, Zhang L. Long-term follow-
up of the repair of the multiple-branch facial nerve
defect using acellular nerve allograft. J Oral Maxillofac
Surg. 2016;74(1):218.e1–218.e11. https://doi.org/
Disclosure 10.1016/j.joms.2015.08.005.
Jensson D, Enghag S, Bylund N, Jonsson L, Wikström J,
The authors declare no financial disclosures. Grindlund M, Flink R, Rodriguez-Lorenzo A. Cranial
nerve coactivation and implication for nerve transfers to
the facial nerve. Plast Reconstr Surg. 2018;141(4):582e–
5e. https://doi.org/10.1097/PRS.0000000000004235.
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Klein HJ, Guedes T, Tzou CHJ, Rodriguez-Lorenzo A;
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Surg. 2010;126(5):1558–62. https://doi.org/10.1097/ Terzis JK, Kostopoulos VK. Vascularized nerve grafts for
PRS.0b013e3181ef8cb7. lower extremity nerve reconstruction. Ann Plast Surg.
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Hunter DA, Mackinnon SE. Repair of motor nerve e3181a5742.
gaps with sensory nerve inhibits regeneration in rats. Wei F-C, Vivek J, Naci C, Hung-chi C, Chwei-Chin. Have
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10.1097/01.mlg.0000229469.31749.91. Reconstr Surg. 2002;109:219–226.
Aesthetic Subunit Microvascular
Reconstruction of the Cheek 34
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Large Skin and Soft Tissue Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Malar Proeminence Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Facial Nerve Reconstruction and Reconstruction of Mimetic Muscles of Midface . . . 343
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
L. Vieira (*)
Uppsala, Sweden
Uppsala, Sweden

https://doi.org/10.1007/978-3-030-23706-6_120
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Abstract 2. Facial nerve palsy on the right side, affecting

The authors present the clinical scenario of a eye, nose, and mouth.
75-year-old female patient presenting with a 3. Oncological resection of the mimetic muscles
recurrent liposarcoma on the right cheek. As of the midface.
the oncological margins comprised more than 4. Malar proeminence deficiency caused by
60% of the cheek aesthetic subunit, the defect zygoma resection.
was extended to the subunit boundaries. The
reconstruction was successfully achieved by Treatment Plan
total subunit reconstruction of the cheek with
a free anterolateral thigh flap. 1. Tumor excision with safety margin in
Reconstruction of a total facial aesthetic sub- all planes. Skin margin extension to the
unit with free flaps yields better final aesthetic boundaries of the cheek aesthetic unit.
outcomes by avoiding the patch appearance. Margins of 2 cm were planned for oncological
Secondary reconstructions built on top of a safety, leading to resection of skin, mimetic
solid primary reconstruction are planned from muscles of midface, zygomatic butress, masti-
the start. catory muscles (right temporalis and masseter),
extratemporal facial nerve, and parotid gland.
Keywords
As the defect encompassed more than 60% of
Facial aesthetic subunit · ALT · Secondary the subunit area, the defect was extended in
reconstruction · Head and neck thickness and surface area to the boundaries of
the cheek aesthetic subunit, in order to provide a
reconstruction of the entire subunit with one
single flap, decreasing color and texture mis-
match deformity (Fisher et al. 2012; Gonzalez-
A 75-year-old otherwise healthy woman presented
Ulloa 1956).
with a recurrent mass in the right cheek diagnosed as
2. Recipient vessels dissection in the neck
well-differentiated grade 1 liposarcoma. The patient
through a separate incision.
had been operated three times before, the last time
3. Reconstruction with a free anterolateral
7 years ago with tumor resection in the temporal
thigh flap (ALT). After the defect was
fossa and reconstruction with an adipofascial radial
established, a template was fabricated and trans-
forearm flap. As a sequela of previous surgeries, the
posed to the donor site for flap design, account-
patient had a partial facial palsy with discrete oral
ing for pedicle course and perforator location.
commissure deviation, for which she received other
4. Secondary stage reconstruction(s). Secondary
secondary corrections somewhere else including fat
revisions should be planned initially in complex
grafting and fascia lata sling.
reconstructions to optimize contour, shape, and
skin color match. Secondary procedures may
Preoperative Problem List/ include suction lipectomy, dermabrasion, tissue
Reconstructive Requirements resuspension, and local tissue rearrangement.
Malar proeminence deficiency, lagophthalmos
1. Large skin and soft tissue volume defect of and ectropion, mouth resting asymmetry, smile
the right cheek comprising >60% of cheek asymmetry, and excessive flap bulk can be
aesthetic subunit. addressed in secondary reconstructions.
34 Aesthetic Subunit Microvascular Reconstruction of the Cheek 343
Alternative Reconstructive Options Disadvantages: The risk for post-

radiotherapy deformity and/or exposure, cost,
Large Skin and Soft Tissue Defect surveillance of recurrences.
• Alternative free flaps with large skin

component (scapular, parascapular, or TDAP) Facial Nerve Reconstruction
(Brown et al. 2010). and Reconstruction of Mimetic Muscles
Disadvantages: The position of the patient; of Midface
it does not allow to work in two teams, sequela
on donor site after skin graft. • Vascularized nerve graft from vastus lateralis
• Locoreginal flaps such as pre-expanded motor nerve for reinnervation of orbicularis
supraclavicular pedicled flap (Pallua and Noah oculi (Agrogiannis et al. 2009; Mohanty et al.
2000). 2020).
Advantages: Color match, no need for Advantages: Eye sequelae prevention,
microsurgical skill/setting. faster axonal growth, low donor site morbidity,
Disadvantages: Staged reconstruction in an spontaneity in facial function.
elderly patient, potential distal flap necrosis, Disadvantages: More complex flap inset-
not enough bulk, pedicled flap with a more ting, age of the patient.
difficult insetting. • Chimeric ALT and vastus lateralis innervated
• Allotransplantation of aesthetic subunit free flap (Gravvanis et al. 2017).
(Rodríguez-Lorenzo et al. 2016). Advantages: One-stage midface reanimation
Advantages: “Like with like” reconstruc- after mimetic muscle ablation.
tion, facial muscles restoration, facial nerve Disadvantages: Age of the patient, optimal
allograft reconstruction, no donor site morbid- muscle insetting difficulties because of recon-
ity, and malar buttress restoration. struction evolution over time.
Disadvantages: At present time, lifelong • Free functioning gracilis transfer (FFMT) with
immunossuppression adverse effects outweigh coaptation to masseter nerve or cross face
the benefits of selective facial aesthetic subunit nerve graft (Chuang et al. 2019).
allotransplantation, legal and ethical unresolved Advantages: Smile restoration, one-stage
issues, and technically demanding. procedure.
Disadvantages: Patient age and prognosis,
relearning, only one muscle transfer to restore
Malar Proeminence Deficiency all vectors of smile, two free flaps, long oper-
ative times, surveillance disturbance.
• Free bone flaps (fíbula, rib, scapula tip, iliac • Static oral commissure suspension with fascia
crest) (Rodriguez et al. 2008). lata slings (Rose 2005).
Advantages: One-stage reconstruction of Advantages: Early results, static symmetry,
bone and soft tissue defect; midface projection durable results.
and width reconstruction; minimization of soft Disadvantages: Anatomical distortion of
tissue descent, minimization of bone resorp- anchoring points, surveillance disturbance.
tion, hardware exposure, and late infection.
Disadvantages: Need for two free flaps, lon-
ger operative time, donor site morbidity. Preoperative Evaluation and Imaging
• Alloplastic implant (Orzell et al. 2017).
Advantages: No donor site morbidity, one Preoperative imaging showed a large infiltrative
stage reconstruction of skeletal and soft tissue mass in the cheek and temporal fossa with
defect, patient custom-made implant. destruction of the zygomatic bone (Fig. 1).
Fig. 1 Magnetic resonance imaging showing a large tumoral mass in the right cheek and temporal fossa
Preoperative Care and Patient Surgical Technique

Drawing
During the resection of the tumor and the neck
The patient receives antibiotic prophylaxis with a dissection, the ALT flap harvesting is performed
combination of cephotaxime and metronidazol as described in a standard fashion:
and thromboprophylaxis with subcutaneous injec-
tion of low dose heparin. 1. Medial incision down to the fascia.
2. Subfascial dissection from medial to lateral,
• The patient is planned for general anesthesia looking for the dopplered perforators, which
with supine position and a two-team approach can have an intramuscular or a septal course.
is favored. 3. Perforator dissection until the descending
• Donor site drawing follows previous descrip- branch of the lateral circumflex femoral
tions (Wei et al. 2002): With the foot in a vessels.
neutral position, a line connecting the anterior 4. Proximal dissection of the vascular pedicle
superior iliac spine and the superior lateral until enough pedicle length is achieved and
border of the patella marks the septum between preferably, one vascular pedicle to rectus
vastus lateralis and rectus femoris muscles. femoris should be preserved. Vastus lateralis
Perforators are dopplered around the middle motor nerve should be dissected and spared.
area of this line. A large medial incision is
planned. After tumor excision, a sterile foam template
• The donor thigh is circumferentially draped. (ALLEVYN Non-Adhesive, Smith & Nephew)
The medial side of the thigh can be the donor was shaped in the defect, resembling the shape
site if a skin graft is needed for donor site of the cheek subunit. Next, for oncologic safety,
closure. the template which was in the tumor field was
Fig. 2 Resection of liposarcoma on the right cheek and Fig. 3 The defect outline was transposed to the donor site
margin extension to cheek aesthetic subunit. A template for reconstruction of total cheek aesthetic subunit
has been fabricated based on the defect outline. Recipient
vessels are exposed through a separate incision. Two sus-
picious lymph nodes were sent to pathology, which
retrieved a negative result for cancer cells
covered circumferentially with clean OPSITE

(Smith & Nephew) (Fig. 2). The template is
placed on the thigh and the shape is traced with
marking pen. The skin paddle is incised accord-
ingly. Subcutaneous undermining provides bulk
for the recipient site soft tissue deficit in the tem-
poral area.
The recipient vessels are approached through a sep-

arate incision in the neck. Macroscopically suspi-
cious lymph nodes in level IIA were sent for
pathology. Fig. 4 Final flap inset. The patch appearance is avoided in
The free flap is transposed to the recipient site, this primary reconstruction
partial insetting is done, and the vascular anastomo-
ses are performed: arterial anastomosis to the supe-
rior thyroid artery and two veins to facial vein (T-T)
and to internal jugular vein (T-L). muscle avoids inadvertent injury to the small
After flap revascularization, flap insetting is perforator veins.
finished. • The template of the defect is an invaluable
tool: it should contemplate the skin defect,
Technical Pearls but also the recipient vessels. At our insti-
tution, this is usually performed routinely in
• Placing the incisions in the boundaries of the all head and neck reconstruction as it allows
cheek aesthetic subunit gives a more natural for more accurate design of the flap to the
appearance. In the areas where the boundaries defect (Driessen, C., van Hout, N., et al.,
are not so clear, wrinkles help in choosing the Usefulness of a template-based anterolateral
best place to make the incisions. thigh flap for reconstruction of head and
• Avoid skeletonization of the perforator if in an neck defects – Article under revision in
intramuscular course. Keeping a small cuff of press) (Figs. 3 and 4).
Intraoperative Images • Mobilization: The patient needs to avoid

excessive mobilization of the neck for the first
See Figs. 2, 3, and 4. week to avoid vascular spasm or compression/
kinking of the vascular pedicle. During the first
3 days postoperative, the patient stays in bed
Postoperative Management but is instructed to do an active mobilization of
the extremities.
After the operation, the patient is transferred under • Antibiotic and thromboprophylaxis: Pre-
general anesthesia to an intensive care unit for the and perioperative antibiotic prophylaxis are
first 24 postoperative hours and then to the ward. given using a combination of cefotaxime and
metronidazol antibiotics i.v. and thrombopro-
• Drains: One passive drain is sutured in the phylaxis by using daily subcutaneous injec-
neck incision, close to the anastomosis, but tion of low dose heparin (dalteparin) for
not in contact with it. It is left for 5–7 days, 10 days. In addition, from day 1 the patient
depending on the drainage. takes low dose aspirin (75 mg) once a day for
Two active drains are left under the flap, far 1 month.
from the pedicle and perforator course, for
around 3–5 days.
One active drain is left in the donor site, in Outcome, Clinical Photos, and Imaging
the muscular plane, for around 3–5 days.
• Flap control: The flaps are closely monitored The postoperative course was uneventful. The
by the nursing staff by clinical inspection, man- patient was discharged from the ICU to plastic
ual Doppler and implantable Doppler (Cook- surgery ward on postoperative day 1 and from
Swartz) according to our institution’s protocol the hospital on day 7.
for 1 week. The frequency of controls is as The patient did not receive adjuvant therapy
follows: once every 15 min in the first 4 h, for the treatment of this recurrent low-grade
every 30 min in the next 4 h, and then once/ liposarcoma.
hour the first day, every 2 h on day 2, every 3 h As a sequela of partial facial palsy, the patient
on day 3, every 4 h on day 4, every 5 h on day developed lower eyelid ectropion and asymmetry
5, and every 6 h on day 6. in the right oral commissure. The ectropion was
• Nutrition: Oral liquid feeding is started on the corrected with lateral tarsal strip procedure
first postoperative day and progressed as performed secondarily under local anesthesia.
tolerated. Good aesthetic result is depicted in Fig. 5.
Fig. 5 Postoperative result at 5 months. Total subunit reconstruction allows better aesthetic results
Avoiding and Managing Problems in facial nerve reconstruction: an anatomical cadaveric

study and clinical implications. Microsurgery.
2009;35:504–6.
In large complex defects in the head and neck area, Brown J, Bekiroglu F, Shaw R. Indications for the scapular
one of the critical factors is preoperative planning flap in reconstructions of the head and neck. Br J Oral
and analysis of the potential defect to plan properly Maxillofac Surg. 2010;48(5):331–7.
the reconstruction. A sound communication Chuang DCC, Lu JCY, Chang TNJ, Hamdi Sakarya A.
Using the ‘sugarcane chewing’ concept as the
between oncological and reconstructive teams directionality of motor Neurotizer selection for facial
allows a smooth workflow, less operative time, paralysis reconstruction: Chang gung experiences.
and overall improvement. Discussing and Plast Reconstr Surg. 2019;144(2):252e–63e.
establishing the reconstructive plan (primary and Fisher M, Dorafshar A, Bojovic B, Manson PN,
Rodriguez ED. The evolution of critical concepts in
secondary reconstructions) from the beginning aesthetic craniofacial microsurgical reconstruction.
help both the patient and the surgeon. Plast Reconstr Surg. 2012;130(2):389–98.
Gonzalez-Ulloa. Restoration of the face covering by means
of. Br J Plast Surg. 1956;9(3):212–21.
Learning Points Gravvanis A, Apostolou K, Anterriotis D, Tsoutsos D.
Single stage aesthetic and functional reconstruction of
composite facial gunshot wound with a chimeric func-
1. When >60% of a facial aesthetic subunit is to tioning muscle and fibular osseous flap. Case report and
be resected, margin enlargement to the entire review of the literature. Microsurgery. 2017;37
facial subunit (e.g., forehead, nose, chin) (6):674–9.
Mohanty AJ, Perez JL, Hembd A, Thrikutam NP, Bartley J,
allows reconstruction of the entire subunit Rozen SM. Orbicularis oculi muscle Reinnervation
with better aesthetic results. confers corneal protective advantages over static inter-
2. Reproducing the defect outline in a template ventions alone in the subacute facial palsy patient.
has several benefits: visual space orientation, Plast Reconstr Surg. 2020;145(3):791–801.
Orzell S, Yanik S, Tatum SA. Secondary repair of the
pedicle orientation, and flap incisions. “Plan Zygoma. Facial Plast Surg. 2017;33(6):571–80.
twice, cut once.” Pallua N, Noah EM. The tunneled Supraclavicular Island
3. In complex facial reconstruction, secondary flap: an optimized technique for head and neck recon-
reconstructions are necessary to achieve better struction. Plast Reconstr Surg. 2000;105(3):
842–51.
outcomes. Rodriguez ED, Bluebond-Langner R, Park JE, Manson
PN. Preservation of contour in periorbital and
Midfacial craniofacial microsurgery: reconstruction
Cross-References of the soft-tissue elements and skeletal buttresses.
▶ Midface Reconstruction with Soft Tissue and Rodríguez-Lorenzo A, Audolfsson T, Nowinski D,
Rozen S, Saiepour D, Wong C. Vascular perfusion of
Bone Flaps the facial skin: implications in Allotransplantation of
▶ Total Lower Face Reconstruction with Double facial aesthetic subunits. Plast Reconstr Surg. 2016;138
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Rose EH. Autogenous fascia Lata grafts: clinical appli-
cations in reanimation of the totally or partially
paralyzed face. Plast Reconstr Surg. 2005;116
References (1):20–32.
Wei F-C, Vivek J, Naci C, Hung-chi C, Chwei-Chin. Have
Agrogiannis N, Audolfsson T, Reddy R, Lorenzo A, we found an ideal soft-tissue flap an experie. Plast
Rozen S. Vastus lateralis vascularized nerve graft Reconstr Surg. 2002;109(7):2219–26.
SCIP Flap for Simultaneous
Management of Orocutaneous Fistula 35
and Facial Lymphedema
Susana Heredero and Maria Isabel Falguera Uceda
Contents
Preoperative Problem List / Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . 350
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Abstract
The development of an orocutaneous fistula

following head and neck surgery may result
in a severe problem, which can lead to social
S. Heredero (*) isolation, nutritional problems, or even lethal
Maxillofacial Surgeon, Department of Maxillofacial complication.
Surgery, Hospital Universitario Reina Sofía, Córdoba, Lymphedema following head and neck can-
Spain
cer therapy is not a well-studied complication.
M. I. Falguera Uceda In most patients, it is underdiagnosed and not
Department of Maxillofacial Surgery, Hospital
Universitario Reina Sofía, Córdoba, Spain

https://doi.org/10.1007/978-3-030-23706-6_124
350 S. Heredero and M. I. Falguera Uceda
treated. Current recommendations in the liter- hard skin over these areas (Fig. 2). In this patient, a
ature are not evidence based. secondary lymphedema had developed related to
We present a clinical scenario of a single- bilateral neck dissection, cervical wound infection,
stage reconstruction of a patient presenting an and radiotherapy.
orocutaneous fistula and facial lymphedema, Cancer recurrence was ruled out by carrying
as sequelae of the surgical treatment and radio- out multiple biopsies and a contrast computed
therapy for an intraoral carcinoma. tomography (CT) study. No signs of osteoradio-
Reconstruction was done using a thin super- necrosis were found in the CT scan. Once the
ficial circumflex iliac artery perforator (SCIP) fistula was clinically stable and there were no
flap, based on the concept of vascularized signs of infection, surgical reconstruction with a
lymph vessel transfer (VLVT), for treating thin superficial circumflex iliac artery perforator
both the fistula and the lymphedema. (SCIP) flap was planned.
The communication between the intraoral
space and the neck was closed, oral food intake
was restored, and facial appearance improved. Preoperative Problem List /
Keywords
Problems in this specific clinical scenario can be
Orocutaneous fistula · Lymphedema · SCIP · summarized as follows:
VLVT
1. The presence of an orocutaneous fistula
extending from the lingual aspect of the right
The Clinical Scenario body mandible to the ipsilateral submental
area.
A 48-year-old male patient with a T3N2 squa- 2. Previous surgery, wound infection, and radia-
mous cell carcinoma of the ventral tongue tion therapy, which leaded to poor quality and
underwent bilateral neck dissection, resection of scarred skin in the neck.
2/3 of the tongue and floor of the mouth, using a 3. Lack of recipient vessels related to previous
pull-through approach, and radiation therapy. bilateral neck dissection and free tissue transfer.
Reconstruction was done using a suprafascial 4. Lymphedema of the face.
anterolateral (ALT) free flap with a surface of
11 7 cm and a thickness of 0.4 cm. Infection Reconstruction options should include a thin,
of the wound in the neck appeared 1 week after pliable, and flexible flap to obliterate the fistula,
surgery, but it was successfully treated with anti- search of adequate recipient vessels, and if possi-
biotics and all the surgical wounds healed. The ble, provide a solution to improve the facial
patient underwent radiation treatment 5 weeks edema.
following the surgical procedure. Clinical follow
up was done every 2 months.
The patient presented with a progressive Treatment Plan
orocutaneous fistula starting 1 and a half years
following the initial surgery (Fig. 1). The fistula Surgical treatment plan involved tracheostomy,
was coming from the floor of the mouth and lingual resection of the orocutaneous fistula, harvesting
side of the mandible to the ipsilateral submental of a thin SCIP flap, and dissection of recipient
area. The quality of the skin in the submental area vessels in the neck.
and neck was poor, related to scarring from post- The SCIP flap was chosen in this specific clin-
operative infection and radiation therapy. Also, the ical scenario because it is a thin and pliable flap
patient presented an important edema of the face adequate for this patient, but also because it has the
causing aesthetic deformity. He had swelling in potential effect to improve lymphedema. Recently,
both cheeks and perioral region, with a thick and Chen et al. (2019) have developed the concept of
35 SCIP Flap for Simultaneous Management of Orocutaneous Fistula and Facial Lymphedema 351
Fig. 1 Clinical photograph of the patient with the orocutaneous fistula in the neck (a). Axial (b) and coronal (c) views of
computed tomography scan showing the fistula (*)
dorsal metatarsal vessels with favorable outcomes.

Pereira et al. (2019b) reported a successful result
treating a patient with an upper extremity post-
traumatic lymphedema using a thin SCIP flap. So
far, no other authors have reported the use of a thin
SCIP – VLVT flap for treating lymphedema.
The development of an orocutaneous fistula fol-

lowing head and neck surgery, with or without
adjuvant radiation therapy ranges between 2%
and 66% (Sadigh et al. 2016). This complication
may result in a disabling problem, which can lead
to social isolation, nutritional problems, or even
lethal complication.
The management of orocutaneous fistulae fol-
lowing head and neck cancer treatment ranges
from expectant local wound care, or the use of
negative pressure therapy, to surgical reconstruc-
tion using a variety of techniques. However, non-
Fig. 2 Preoperative clinical photograph of the patient acute large fistulae in previously irradiated
showing the facial edema in the perioral and infraorbital
patients require surgical treatment.
regions
Local flaps or regional flaps such as decto-
pectoral or pectoralis major musculocutaneous
vascularized lymph vessel transfer (VLVT) based flaps may still have a role in orocutaneous fistulae
on the use of a thin SCIP flap for treating extremity reconstruction. However, large fistulae with a long
lymphedema. They reported a series of six patients, vertical axis and poor quality of the local tissues are
all except one with secondary lymphedema, with better reconstructed using free tissue transfer (Chun
clear clinical and postoperative indocyanine green and Senderoff 1996). A thin, pliable, and flexible
lymphographic improvement. Koshima et al. free flap is three-dimensionally adapted more easily
(2016) reported the original concept of VLVT for than a regional flap, which is useful to obliterate the
patients with advanced lymphedema using the first dead space related to an orocutaneous fistula.
Lymphedema following head and neck cancer area (Philips Epiq 7, Royal Philips, Amsterdam,
therapy is estimated to be as high as 75.3% (Deng The Netherlands).
et al. 2012). Current recommendations in the lit-
erature are not evidence based (Tyker et al. 2019).
Functional complications related to progression of Preoperative Care and Patient
head and neck lymphedema, such as impaired Drawing
eyelid opening, dysarthria, alteration in food
intake, or hearing loss, have been previously The patient was maintained on tube feeding for
described in the literature (Alamoudi et al. 2018; 4 months prior the surgery, to reduce the debit
Mihara et al. 2011). In our particular patient, sec- through the fistula, to decrease the risk of local
ondary lymphedema was mainly an aesthetic con- infection, and to provide an adequate nutrition.
cern since no functional complications had been Data post-processing of the information from the
reported. However, slow progression of swelling CT angiography was done using the open-source
was noticed. software HorosTM v 1.1.7 (GNU Lesser General
Treatment of head and neck lymphedema can Public License, version 3), in order to generate
be done with techniques similar to the ones used three-dimensional images of the location of the
to treat extremity lymphedema (Tyker et al. superficial (medial) and deep (lateral) branches of
2019), like manual lymphatic drainage (Deng the superficial circumflex iliac artery. The flap was
et al. 2012) or liposuction (Alamoudi et al. designed using augmented reality, as initially
2018). Lymphaticovenular anastomosis has reported by Pereira et al. (2019a). Three-dimen-
also demonstrated improvement in a small num- sional images were imported to a smartphone, and
ber of studies (Alamoudi et al. 2018; Ayestaray a free-share augmented reality app was used to
et al. 2013; Inatomi et al. 2018; Mihara et al. superimpose them and make the marking in the
2011). operative field. Location of the branches of the
Although other thin and pliable free flaps as the superficial circumflex iliac artery was also con-
radial forearm or the thin ALT free flaps could firmed with duplex ultrasound. See Fig. 3.
have been used in this clinical scenario to obliter-
ate the orocutaneous fistula, the thin SCIP flap
also provides the advantage of VLVT and the Surgical Technique
possibility of treating lymphedema in a single
operation. Tracheostomy was performed at the beginning of
the operation.
The use of a lip splitting incision with a lateral
Preoperative Evaluation and Imaging extension into the previous neck incision was
planned to perform a paramedial mandibulotolomy.
Definition of the location of the fistula, definition The orocutaneous fistula was completely dissected
of its extension and assessment of possible recip- from the neck to the oral cavity and excised.
ient vessels were done using the contrast CT study The inferior thyroid artery, the external jugular
of the head and neck region. vein, and the anterior jugular vein in the ipsilateral
Related to donor site, preoperative assess- neck were dissected and assessed as favorable
ment of the SCIP flap was carried out with a recipient vessels.
CT angiography performed on a 64-slice multi- A left SCIP flap was designed to be 20 cm in
ple detector computed tomography scanner length by 8 cm width. Thickness of the flap ranged
(LightSpeed VCT; GE Healthcare, Milwaukee, from 0.4 cm to 0.7 cm. Flap harvesting proceeded as
WI, USA) using a standardized protocol. Color initially described by Hong et al. (2013). An inci-
doppler ultrasound was also used to double sion was made in the superior border until the
check the location of the vessels in the groin superficial fascia layer and dissection was carried
Fig. 3 Preoperative virtual planning and marking of the flap using augmented reality and duplex ultrasound. S ¼ super-
ficial branch; D ¼ deep branch; SV ¼ superficial cutaneous vein
out in that plane, allowing to save all lymph nodes

during flap elevation. Perforators of the superficial Technical Pearls
branches of the superficial circumflex vessels were
dissected towards the source vessels. The superficial 1. Preoperative assessment of the exact location
cutaneous vein in the fat layer was also included in and extension of the orocutaneous fistula is
the flap. mandatory.
The flap was folded and partially de- 2. Preoperative virtual planning and/or duplex
epithelized to provide both intraoral and external ultrasound are useful to better understand the
coverage. The superior part of the flap was anatomy of the SCIP flap, making the
directly sutured to the intraoral mucosa. The skin harvesting of the flap easier.
of the mid portion of the flap was used for external 3. To assure direct closure of the donor site, a
coverage of the neck. The flap was de-epithelized pinch test of the skin should be done while
in between these 2 portions, to tunnel the area designing the skin island of the SCIP flap.
between the oral cavity and the neck. The distal 4. The pedicle length of the SCIP flap is usually
part of the flap was also de-epithelized to provide very short. Designing the flap with a long axis
additional coverage to the site of the anastomoses and using partial de-epithelization of the distal
since the quality of the skin in that area was very skin can help the pedicle to reach the recipient
poor. Microvascular anastomoses were done from vessels.
the main pedicle of the flap to the inferior thyroid 5. The medial or superficial branch of the super-
artery and anterior jugular vein. The superficial ficial circumflex iliac artery enters the deep
vein was anastomosed to the external jugular vein. fascia medially. By opening the deep fascia
and extending the dissection towards the fem- regimen included low molecular heparin to pre-
oral vessels, pedicle length and diameter of the vent lower extremity deep venous thrombosis.
pedicle can also be increased.
6. To harvest a thin SCIP flap, elevation of the
flap should be done in the plane of the superfi- Outcome, Clinical Photos, and Imaging
cial fascia layer, which is the plane in between
the smaller superficial fat and the deep large fat No intraoperative nor postoperative major com-
lobules. plications occurred related to the surgical
procedure.
The patient was able to return to oral feedings
Intraoperative Images 2 weeks after surgery, with no fistula recurrence.
Facial edema was reduced and both the quality
Intraoperative photographs of the lip splitting and appearance of the skin improved (Figs. 10
incision, paramedial mandibulotomy, and dissec- and 11).
tion of the orocutaneous fistula are shown in Figs.
4 and 5.
The thin SCIP flap in the groin region, Avoiding and Managing Problems
before sectioning the pedicle, can be seen
in Figs. 6, 7, and 8. Flap setting is shown in 1. Although resection and reconstruction in the
Fig. 9. previous surgery was done through a pull-
through approach, lip splitting and paramedial
mandibulotomy was preferred to better excise
Postoperative Management the fistula, without dissecting most of the floor
of the mouth from its insertion in the mandible.
The patient was positioned with his head elevated 2. In a previously operated and irradiated neck
30°. Nutrition was maintained with a nasogastric with scarring, it is advisable to look for recipient
feeding tube. Tracheostomy cannula was removed vessels far from the most affected area, avoiding
on the seventh day. extensive dissection of the skin covering the
Close monitoring of the flap was performed carotid artery. In this particular case, the inferior
clinically for the first 6 days. Anticoagulant thyroid artery, external jugular vein, and
Fig. 4 Lip splitting and

mandibulotomy. F ¼ fistula;
N ¼ mental nerve
anterior jugular vein were easily found, close to 3. Oral intake must be delayed until complete
the area dissected to excise the fistula. In these healing to avoid recurrence of the fistula.
situations of complicated necks with scarring, 4. Diameter of the SCIP flap vessels can be very
good alternative recipients are the transverse small. Hong et al. (2013) reported in their
cervical vessels and the cephalic vein. series of 79 cases that the average diameter of
the artery was 0.7 mm, ranging from 0.4 to
1.2 mm. Thus, appropriate skills and instru-
ments for supermicrosurgery must be assured
before attempting this kind of reconstruction.
5. The deep fat with lymph inguinal nodes should
not be included in the flap to prevent possible
complications in the donor site.
Learning Points
1. Complications of intraoral cancer treatment as

orocutaneous fistula and facial lymphedema
can be successfully treated in a single proce-
dure using a thin SCIP – VLVT flap.
2. Limited elevation of the skin in the neck with
severe scarring must be considered, to avoid
complications.
3. Since the SCIP flap has a short pedicle and
small vessels, special care must be considered
on selecting adequate recipient vessels, design-
Fig. 5 Dissection of the orocutaneous fistula. F ¼ fistula; ing the flap, training the skills, and having
N ¼ mental nerve adequate instruments for supermicrosurgery.
Fig. 6 Thin SCIP flap.

A ¼ artery (from the
superficial branch of the
superficial circumflex iliac
artery); V ¼ vein (from the
artery); SV ¼ superficial
cutaneous vein
Fig. 7 Main pedicle of the

SCIP flap. A ¼ artery (from
the superficial branch of the
artery); V ¼ vein (from the
artery)
Fig. 8 Flap thickness of

the flap in the edges was
0.4 cm
Fig. 9 Setting of the thin

SCIP flap to obliterate the
dead space related to the
fistula. N ¼ mental nerve;
d ¼ de-epithelized areas of
the flap
Fig. 10 Pre (a) and postoperative clinical photographs, 10 days (b) and 4 months (c) following surgery. S ¼ skin island
Fig. 11 Pre (a) and postoperative clinical photographs, 10 days (b) and 4 months (c) following surgery. S ¼ skin island
Cross-References References
▶ Diabetic Foot Reconstruction Using SCIP Flap Alamoudi U, Taylor B, Mackay C, Rigby MH, Hart R,
▶ Thin Free Flap for Resurfacing of the Arm and Trites JRB, Taylor SM. Submental liposuction for the
Forearm management of lymphedema following head and neck
cancer treatment: a randomized controlled trial. Koshima I, Narushima M, Mihara M, et al. Lymphadiposal
Otolaryngol Head Neck Surg. 2018;47(1):22. https:// flaps and lymphatico-venular anastomoses for severe
doi.org/10.1186/s40463-018-0263-1. leg edema: functional reconstruction for lymph drain-
Ayestaray B, Bekara F, Andreoletti JB. p-Shaped lymphati- age system. J Reconstr Microsurg. 2016;32(1):50–5.
covenular anastomosis for head and neck Mihara M, Uchida G, Hara H, Hayashi H, Moriguchi H,
lymphoedema: a preliminary study. Plast Reconstr Narushima M, Iida T, Yamamoto T, Koshima I.
Aesthet Surg. 2013;66(2):201–6. https://doi.org/10. Lymphaticovenous anastomosis for facial
1016/j.bjps.2012.08.049. Epub 2012 Oct 4. lymphoedema after multiple courses of therapy for
Chen WF, McNurlen M, Ding J, Bowen M. Vascularized head-and-neck cancer. J Plast Reconstr Aesthet Surg.
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2019.00119. J, Sanchez L, Roa R. Augmented reality microsurgical
Chun JK, Senderoff DM. Microsurgical reconstruction of planning with a smartphone (ARM-PS): a dissection
difficult orocutaneous fistulas. Ann Plast Surg. 1996;36 route map in your pocket. J Plast Reconstr Aesthet
(4):417–24. https://doi.org/10.1097/00000637- Surg. 2019a;72(5):759–62. https://doi.org/10.1016/j.
199604000-00018. bjps.2018.12.023. Epub 2018 Dec 14.
Deng J, Ridner SH, Dietrich MS, Wells N, Wallston KA, Pereira N, Cámbara A, Kufeke M, Roa R. Post-traumatic
Sinard RJ. Prevalence of secondary lymphedema in lymphedema treatment with superficial circumflex iliac
patients with head and neck cancer. J Pain Symptom artery perforator lymphatic free flap: a case report.
Manag. 2012;43(2):244–52. https://doi.org/10.1007/ Microsurgery. 2019b;39(4):354–9. https://doi.org/10.
s00520-015-2893-4. Epub 2015 Aug 29. 1002/micr.30437. Epub 2019 Feb 15.
Hong JP, Sun SH, Ben-Nahki M. Modified superficial Sadigh PL, Wu CJ, Feng WJ, Hsieh CH, Jeng SF. New
circumflex iliac artery perforator flap and Super- double-layer design for 1-stage repair of orocutaneous
microsurgery technique for lower extremity reconstruc- and pharyngocutaneous fistulae in patients with post-
tion: a new approach for moderate-sized defects. Ann operative irradiated head and neck cancer. Head Neck.
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2018 May 13. 2019.05.024. Epub 2019 May 30.
Reconstruction of Total Maxillectomy
and Orbital Floor with a Free Scapula 36
Tip Flap
Luís Vieira, Riccardo Schweizer, and Andres Rodriguez-Lorenzo
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Intraoperative Images (Figs. 4, 5, 6, 7, and 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
L. Vieira (*)
Uppsala, Sweden
R. Schweizer
Department of Plastic Surgery and Hand Surgery,
University Hospital Zurich, Zurich, Switzerland
Uppsala, Sweden

https://doi.org/10.1007/978-3-030-23706-6_125
360 L. Vieira et al.
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Abstract T3N2bM0) with bone destruction of maxilla,

The scapula tip free flap is a well-suited flap orbital floor, and zygomatic bone as shown by
for total maxillectomy reconstruction; how- the preoperative CT (Fig. 1).
ever, when the orbital floor is included in the The patient was discussed at the multidisciplinary
resection, an additional method of reconstruc- head and neck tumor board that recommended a
tion is usually needed for the orbital floor, treatment plan including ablative surgery and post-
such as alloplastic material or bone grafts. In operative radiotherapy. The patient was scheduled
this chapter, a novel design of the Scapula tip for right-side maxillectomy (including the orbital
free flap with a thin vascularized bone used floor with preservation of the orbital content, part
for the orbital floor reconstruction after total of the zygomatic arch, and the soft tissue palate) and
maxillectomy is described. ipsilateral cervical lymphadenectomy.
Keywords
Preoperative Problem List /
Maxilla reconstruction · Bone free flaps · Reconstructive Requirements
Orbital floor reconstruction · Chimeric flaps
• Extensive composite defect of midface com-
prising anterior, medial, inferior, and lateral
The Clinical Scenario walls of maxilla, orbital floor, and zygoma.
This defect causes loss of projection of midface,
A 74-year-old female patient with medical history loss of support to the eye globe, communication
of hypertension, and hypothyroidism presented between the oral and nasal cavities, and loss of
with a primary squamous cell carcinoma of the the teeth in the first quadrant. Proper projection
right maxillary sinus (staged preoperatively as to the midface is mandatory for an acceptable
Fig. 1 Preoperative CT of
the patient showing a large
invasive squamous cell
carcinoma (red arrow)
arising at the right maxillary
sinus with destruction of the
maxilla anterior wall,
orbital floor, and
zygomatic bone
36 Reconstruction of Total Maxillectomy and Orbital Floor with a Free Scapula Tip Flap 361
aesthetic and functional result. Adequate globe 5. Postoperative Radiotherapy

support is needed to avoid dystopia, diplopia,
and enophthalmos. Separation between oral and
nasal cavities allows regular diet, speech, and Alternative Reconstructive Options
breathing. Dental rehabilitation allows normal
diet and superior aesthetic results. The latter is • Alternative Bone Flaps
not a primary goal in this case. – Iliac crest free flap. The Deep Circumflex
• Dead space. The excision will create a consid- Iliac Artery (DCIA) flap provides proper
erable dead space in the midface. Occlusion of bone stock with sufficient height and width
this dead space with soft tissue is vital to avoid for midface reconstruction. Soft-tissues
later complications such as infection, fistulas, vascularized by DCIA, like the internal
and sagging of the reconstruction. oblique muscle, can be included in the
• Burden of comorbidities. The ablative and reconstruction for dead space occlusion.
reconstructive procedures, besides the postop- The drawbacks of the DCIA flap are a
erative period, can cause decompensation of short vascular pedicle, unsuitable bone for
comorbidities. Selection of donor sites with orbital floor reconstruction, inability to
lower complication rates and early mobiliza- reconstruct both palate and orbital floor
tion in the postoperative period can improve with vascularized bone, and donor site con-
the reconstructive journey. siderable sequelae (Costa et al. 2015).
– Fibula osteocutaneous free flap (Chang
and Hanasono 2016). The fíbula
Treatment Plan osteocutaneous free flap provides enough
bone stock for reconstruction of total
1. Tumor resection comprising total maxil- maxillectomy defects, although it may be
lectomy, orbital floor, and part of the zygoma sometimes too bulky. It can be harvested
2. Ipsilateral neck dissection simultaneously to the oncological resec-
3. Selection of recipient vessels in the neck tion. The cutaneous component can be
(right facial artery and 2 facial veins) used for palatal reconstruction. However,
4. Reconstruction of maxilla with a chimeric the inset for maxillectomy defects is chal-
scapula tip and latissimus dorsi free flap. lenging, requiring several osteotomies.
Maxillary reconstruction with bony flaps Besides, in older comorbid patients, the
achieves superior results in terms of midface complications in the donor site are a com-
projection, globe position, vision, long-term mon problem.
maintenance of the reconstruction minimizing • Reconstruction with soft tissue flap alone
soft-tissue descent, and provides foundation for (ALT or Rectus abdominis myocutaneous
osseointegrated prostheses (Rodriguez et al. flap). Soft-tissue flaps with multiple skin islands
2008). The nonvoluminous good bone stock of can be used to reconstruct total maxillectomy
the scapula tip free flap is especially suited for defects. The risks of not including a bony flap
reconstruction of the alveolar ridge and zygo- are bulging of the soft tissue into the oral cavity,
matic arch after maxilla reconstruction. The making the use of dentures and prosthetics dif-
medial part of the scapula tip consists of a thin ficult (Cordeiro and Chen 2012).
bone lamella, with good match to the orbital • Alternatives for Orbital floor reconstruction.
floor in terms of curvature and thickness – Bone Grafts from calvarial or iliac bone
(Davies et al. 2018). The soft-tissue component for eye globe support (Cordeiro and Chen
provided by latissimus dorsi muscle allows 2012). The risks of using nonvascularized
proper dead space occlusion and closure of the bone grafts are graft resorption, especially if
soft palate. Mucosalization of the muscle sur- radiation is planned.
faces facing the oral and nasal cavity is expected – Alloplastic reconstruction of the orbital
to occur during the first postoperative weeks. floor is technically easier and good short-
term outcomes can be expected. However, Preoperative Care and Patient

risks for exposure, infection, and loss of the Drawing
reconstruction should be accounted for,
especially if radiotherapy is planned • Donor site drawing: With the patient standing,
(Chang and Hanasono 2016). the borders of the scapula are palpated and
marked. A 15 cm incision is planned between
latissimus dorsi and teres major muscles,
starting from the axilla. For chimeric flaps (scap-
Preoperative Evaluation and Imaging ula tip plus soft-tissue components), this incision
allows the decision to include latissimus dorsi
The anatomy of the scapula tip free flap is con- muscle, thoracodorsal perforator skin flaps, or
stant, therefore there is rarely need for vascular (para)scapular skin flaps. Bear in mind that
imaging of the donor site. Virtual surgical plan- shoulder flexion can distort the markings, so
ning tools for scapula tip free flap are in trend but reappreciation of the markings when the patient
not fully developed, therefore flap osteotomies is supine under anesthesia is advised.
and insetting is free-hand in our experience • The patient is put on general anesthesia.
(Kass et al. 2018). • The patient lies supine during the entire proce-
In patients with previous surgeries in the area dure. A two-team simultaneous approach is
(e.g., axillary dissection), latissimus dorsi func- usually not possible.
tion is assessed clinically giving an insight on the • The donor area is approached with the patient
status of the neurovascular bundle. For large in supine position. Shoulder flexion and inter-
defects of the maxilla usually the contralateral nal rotation exposes the lateral border of the
scapula is preferred using the natural curvature scapula for dissection.
of the scapula, and the most medial part of the • The entire arm is draped for free mobilization.
scapula is used for orbital floor reconstruction, for The scapular region is draped. The shoulder is
a better match in thickness with the orbital floor flexed to allow the scapula bone to rotate ven-
(Fig. 2). trally (Fig. 3).
Fig. 2 Schematic representation of the planned design for the scapula tip osteotomies and shape, with the fragment to the
orbital floor allocated in the medial part of the scapula
Fig. 3 Composition that represents the position of the scapular when flexing the shoulder in supine position. A more
ventral location of the tip allows for harvesting the scapula tip in supine position
ligated and dissection stops in the proximal

Surgical Technique
segment of the subscapular vessels.
4. For inclusion of a latissimus dorsi muscle seg-
1. A skin incision is made in between the superior
ment, the overlying skin is undermined, and
border of latissimus dorsi and the inferior bor-
der of teres major. the desired length and width of muscle are
2. The Latissimus dorsi muscle is retracted later- harvested, taking care to protect the
ally and the teres major superiorly and medi- thoracodorsal pedicle as it enters the latissimus
ally. The scapula tip is reached and its pedicle dorsi muscle.
is found (angular artery) in this space. This is 5. The reconstructive needs are reappreciated.
usually a branch of the thoracodorsal artery, Osteotomies are performed on the lateral bor-
but can also be a branch of the serratus anterior der of the scapula with a small oscillating saw.
pedicle. Teres major and infraspinatus muscles Up to 9 cm of bone have been harvested and
are detached from the scapula tip, leaving a remained viable on the angular artery. For
small cuff of muscle on the posterior surface nasal lining, soft-tissue palate reconstruction
of the scapula. and dead space occlusion, 5 5 cm of the
3. Dissection of the pedicle follows a proximal latissimus dorsi muscle are harvested based
direction. The circumflex scapular vessels are on the same pedicle as a chimeric flap.
6. For the maxilla reconstruction, an osteotomy is 3. Teres major reattachment is an important

performed to separate the proximal fragment maneuver to decrease donor-site morbidity as
that will be used for alveolar ridge reconstruc- well as early mobilization of the shoulder.
tion and horizontal projection of the maxilla and
the distal fragment for orbital floor reconstruc-
tion. The osseous flap is fixed with plates and Intraoperative Images (Figs. 4, 5, 6, 7,
screws. The latissimus dorsi muscle component and 8)
of the flap is sutured facing the nasal cavity and
soft tissue palate and occluding the dead space
(below the orbital floor bone fragment) in the
previous maxillary antrum. Postoperative Management
7. Anastomoses are performed to the facial artery
and vein with 9/0 S & T microsutures for the After the operation the patient is transferred under
artery and Venous Couplers for the vein. general anesthesia to an intensive care unit for the
8. For donor-site closure, three holes are drilled in first 24 postoperative hours and then to the ward.
the remnant of the scapula. These holes are
used for reattachment of the teres major mus- • Drains: Two passive drains are sutured in the
cle with non-resorbable sutures. Layered clo- recipient site, one of them close to the anasto-
sure is performed over a suction drain. mosis, but not in contact with it. They are left
for 5–7 days, depending on the drainage. One
active drain is left in the donor site, in the
Technical Pearls muscular plane, for around 3–5 days.
• Flap control: The flaps are closely monitored
1. Intraoperative position of the patient in supine by the nursing staff by clinical inspection,
position with a flexed shoulder flexion, for flap manual Doppler, and implantable Doppler
harvested allows for better and safe visualiza- (Cook-Swartz) according to our institution’s
tion of the vascular anatomy protocol during 1 week. The frequency of con-
2. After bone insetting, the course of the vascular trols is as follows: once every 15 min in the first
pedicle should be observed and carefully avoid 4 h, every 30 min in the next 4 h, and then once/
kinking and compression. hour the first day, every 2 h on day 2, every 3 h
Fig. 4 Specimen of Maxillectomy after surgical resection

Fig. 5 The resulting defect

after resection consisted of a
total maxillectomy defect
including the orbital floor,
with preservation of the
orbital contents and soft-
tissue palate resection
template on the left showing
the different flap
components and the
harvested flap on the right
with a scapula tip and
latissimus dorsi flap
on day 3, every 4 h on day 4, every 5 h on day in bed but is instructed to do an active mobili-
5, and every 6 h on day 6. zation of the extremities. On the third day, the
• Nutrition: Enteral nutrition is started on the patient is instructed to sit and later to ambulate.
first postoperative day. Oral liquid feeding is • Antibiotic and thromboprophylaxis: Pre and
started around the third to fifth postoperative perioperative antibiotic prophylaxis is given
days and progressed as tolerated. using a combination cefotaxime and metronida-
• Mobilization: The patient needs to avoid zole antibiotics i.v. and thromboprophylaxis is
excessive mobilization of the neck for the first prevented by using daily subcutaneous injection
week to avoid vascular spasm or compression/ of low dose heparin (dalteparin) for 10 days. In
kinking of the vascular pedicles. During the addition, from day 1 the patient takes low dose
first two postoperative days, the patient stays aspirin (75 mg.) once a day for 1 month.
Fig. 7 Photograph of the Insetting of scapula tip free flap floor reconstruction. The muscle cuff of teres major on the
for maxilla reconstruction. One osteotomy was performed; osseous fragments is expected to mucosalize in the oral
therefore the proximal bone fragment is used for the alve- cavity and the latissimus dorsi component is used for nasal
olar ridge reconstruction and distal fragment for the orbital lining and obliteration of the maxillary antrum
photograph at the end of the
reconstruction
Outcome, Clinical Photos, and Imaging gland infiltrating the facial nerve with progressive
facial paralysis and was scheduled for total
The postoperative period was uneventful. The parotidectomy.
patient stayed in the intensive care unit for 24 h
and was discharged home after 17 days (Fig. 9).
She received postoperative radiotherapy. The • In patients with previous axillary surgery, the
patient resumed normal diet and normal vision, status of the pedicle can be assessed by testing
without dystopia neither diplopia. The donor site for latissimus dorsi function.
healed uneventfully (Fig. 10). • Reattachment of teres major muscle to the
At 13 months postoperative follow-up, the scapula remnant helps to stabilize the shoulder
patient presented with metastasis in the parotid and avoid sequelae.
Fig. 9 Postoperative clinical status at 1 week showing on the left granulation over the muscle in the palate and
postoperative CT (right) demonstrating symmetrical projection of midface and proper orbital floor position
and also blood supply for the bone fragments

after the osteotomies.
Learning Points
• Donor site complications and sequelae of scap-

ula tip free flap harvest are low. This donor site
also allows early mobilization, important when
dealing with comorbid patients.
• Scapula tip free flap is a good option for total
maxillectomy defects reconstruction. It pro-
vides appropriate non-bulky bone stock for
reconstruction of the projection of the midface
and the orbital floor with vascularized bone. If
adjuvant radiotherapy is planned, vascularized
bone offers advantage over other forms of
Fig. 10 CT at 14 months postoperative showing viability reconstruction. The versatility of the sub-
of the scapula tip and the orbital floor component scapular system also allows the transfer of
vascularized soft tissue for dead space
• Orbital floor reconstruction after total occlusion.
maxillectomy is specially demanding. Proper
positioning of the reconstructed orbital floor is
both difficult and mandatory. After reconstruc- Cross-References
tion and still in the surgery room, forced
duction test should be performed to ensure no ▶ Atrophic Maxilla with Fibula Flap and Implant-
muscle entrapment has occurred. Supported Prosthesis
• Keeping a muscle cuff attached to the scapula ▶ Midface Reconstruction with Soft Tissue and
tip flap provides a surface for mucosalization Bone Flaps
References Davies JC, Chan HH, Bernstein JM, Goldstein DP, Irish
JC, Gilbert R. Orbital floor reconstruction: three-
Chang EI, Hanasono MM. State-of-the-art reconstruction dimensional analysis demonstrates comparable mor-
of midface and facial deformities. J Surg Oncol. phology of scapular and iliac crest bone grafts. J Oral
2016;113:962–70. https://doi.org/10.1002/jso.24150. Maxillofac Surg. 2018. https://doi.org/10.1016/j.joms.
December 2015. 2018.03.034.
Cordeiro PG, Chen CM. A 15-year review of midface Kass JI, Prisman E, Miles BA. Guide design in virtual
reconstruction after total and subtotal maxillectomy: planning for scapular tip free flap reconstruction.
part II. Technical modifications to maximize aesthetic Laryngoscope Investig Otolaryngol. 2018;3(3):162–8.
and functional outcomes. Plast Reconstr Surg. https://doi.org/10.1002/lio2.162.
2012;129(1):139–47. https://doi.org/10.1097/PRS. Rodriguez ED, Bluebond-Langner R, Park JE, Manson
0b013e318221dc60. PN. Preservation of contour in periorbital and midfacial
Costa H, Zenha H, Sequeira H, Coelho G, Gomes N, craniofacial microsurgery: reconstruction of the soft-
Pinto C, . . . Andresen C. Microsurgical reconstruction tissue elements and skeletal buttresses. Plast Reconstr
of the maxilla – algorithm and concepts. Br J Plast Surg. Surg. 2008;121(5):1738–47. https://doi.org/10.1097/
2015. https://doi.org/10.1016/j.bjps.2014.12.002. PRS.0b013e31816b13e1.
Reconstruction of Mandible
and Hemiglossectomy with a Chimeric 37
Scapula Tip and TDAP Flap
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Abstract
In the present clinical scenario, the authors pre-

sent the case of a 69-year-old female patient who
L. Vieira (*) presented with an advanced squamous cell car-
Maxillofacial Surgery, Uppsala University Hospital and cinoma in the floor of the mouth that underwent
Department of Surgical Sciences, Uppsala University, anterior mandibulectomy, hemiglossectomy,
Uppsala, Sweden floor of the mouth resection, and neck dissection.
A. Rodriguez-Lorenzo The defect was reconstructed with a chimeric
Department of Plastic and Maxillofacial Surgery, Uppsala flap based on the subscapular system, compris-
University Hospital, Uppsala, Sweden ing scapula tip bone for the mandible defect and
Department of Surgical Sciences, Uppsala University, thoracodorsal perforator skin flap for tongue and
Uppsala, Sweden soft tissue reconstruction.
https://doi.org/10.1007/978-3-030-23706-6_126
Chimeric flaps based on the subscapular squamous cell carcinoma in the floor of the mouth
system provide adequate bone stock for man- with infiltration of the left tongue and destruction
dible moderate-sized defects associated with of left mandible, classified as T4aN0M0 (Fig. 1).
extensive soft tissue defects. The low rate of After discussion at the institution’s Head and Neck
complications and sequela, and early postoper- Tumor Board, the patient was scheduled for
ative mobilization make it specially suited for mandibulectomy, hemiglossectomy, and neck dis-
complex reconstructions in patients with sev- section with mandible and tongue reconstruction
eral comorbidities. with a chimeric scapula tip and TDAP free flap.
Keywords
Mandible reconstruction · Tongue Reconstructive Requirements
reconstruction · Bone free flaps · Chimeric
flaps 1. Extensive composite defect of lower face
(mandible, tongue, and floor of the mouth).
A complex bony and soft tissue defect compris-
The Clinical Scenario ing anterolateral mandible, subtotal tongue, and
floor of the mouth poses several challenges.
A 69-year-old female patient with previous medi- Bony reconstruction of the mandible provides
cal history of colon and uterus cancer, hypothy- adequate projection to the lower face and sup-
roidism, hypokalemia, moderate smoking habits port for mastication and deglutition. Hemig-
and limited mobility, presented with an advanced lossectomy defects require bulky soft tissue
Fig. 1 The patient

presented with an advanced
squamous cell carcinoma in
the floor of the mouth with
infiltration of the left tongue
and destruction of left
mandible, classified as
T4aN0M0
37 Reconstruction of Mandible and Hemiglossectomy with a Chimeric Scapula Tip and TDAP Flap 371
free flaps to restore functions of eating and more limited bone stock, the chimeric scap-
speech. Floor of the mouth reconstruction aims ula tip and thoracodorsal perforator free flap
to achieve acceptable mobility of the tongue and is a versatile and safe flap for complex man-
watertight closure separating the oral cavity dible and hemiglossectomy reconstruction.
from the neck. Independent mobility of the soft tissue and
2. Dead space. The large resection creates soft osseous components of the flap is also
tissue dead space in the floor of the mouth, favorable. The soft tissue component is
peri-mandibular space, and neck. Occlusion more voluminous and reliable than in other
of dead space with vascularized soft tissue bony flaps (Blumberg et al. 2019; Wilkman
(fat, muscle, de-epithelialized skin) prevents et al. 2019).
infection, later sagging of reconstruction, and 5. Postoperative Radiotherapy.
is beneficial to protect bony hardware from
exposure.
3. Burden of comorbidities. The ablative and Alternative Reconstructive Options
reconstructive procedures, besides the postop-
erative period, can cause decompensation of • Bony reconstruction.
comorbidities. Selection of donor sites with – Fibula osteocutaneous free flap. The fibula
lower complication rates and early mobiliza- osteocutaneous free flap is the gold standard
tion in the postoperative period can improve in most centers for mandible bony recon-
the reconstructive journey. struction. Reasons for this are the amount of
4. Lower lip sensibility loss. Resection of the well-vascularized bone and the possibility
body of the mandible comprises also resection of performing several osteotomies without
of both mental nerves. Lower lip sensation is compromise to the vascular supply, bicorti-
important for protection, feeding, and social cocancellous structure, long and reliable
interaction. pedicle, possibility of use as a flow-through
for double flap reconstruction, possibility of
harvesting the sural nerve for inferior alve-
Treatment Plan olar nerve reconstruction through the same
incision, and a two-team approach. How-
1. Tumor resection comprising anterolateral ever, in the present case, the fibula free flap
mandibulectomy, hemiglossectomy, and floor is not the first option because of the burden
of the mouth. of patient’s comorbidities (the patient pre-
2. Tracheostomy and bilateral neck dissection. sented limited mobility and needed support
3. Selection of recipient vessels in the neck: to walk), which can compromise donor site
right facial artery and vein. healing and, furthermore, the soft tissue
4. Reconstruction of mandible, tongue, and component of fibula free flap is insufficient
floor of the mouth with a chimeric scap- in this case (Hidalgo 1989; Wallace et al.
ula tip and thoracodorsal artery perfora- 2010).
tor free flap. The subscapular vascular tree – Iliac crest free flap. Chimeric flaps based on
provides vascularization to several different the deep circumflex iliac artery (DCIA) can
structures: scapula bone; scapula tip bone; provide good length of thick bone, abdomi-
latissimus dorsi, teres major, and serratus nal wall muscles, and overlying skin. How-
muscles; and scapular, parascapular, and ever, the independent mobility of each one of
thoracodorsal perforator skin flaps. It is usu- the flap’s components is less than optimal,
ally spared from atherosclerosis, even in the pedicle length is short, the soft tissue
comorbid patients. Its complication profile volume is smaller, the skin flap vascularity
is more favorable when compared to other is sometimes problematic, and the donor site
bony flaps and allows faster donor site post- sequelae are pitfalls of this flap (Taylor et al.
operative recovery. At the expenses of a 1979).
– Reconstruction plate and soft tissue flap. Preoperative Evaluation and Imaging
Reconstruction of anterior mandible with
plate and soft tissue flap yields unfavorable – Donor site evaluation: The anatomy of the
results because of metal fatigue and expo- scapula tip free flap is constant. In patients
sure. This may only be acceptable for with previous surgeries in the area (e.g., axil-
patients with low masticatory demands and lary dissection), latissimus dorsi function
short life expectancy (Boyd et al. 1995). assessment gives an insight on the pedicle sta-
• Double free flap reconstruction. The combi- tus. For mandible reconstruction, usually the
nation of a fibula osteocutaneous flap for man- ipsilateral scapula tip is preferred (Fig. 1).
dible and floor of the mouth reconstruction, There is not routinely need for imaging of the
and an ALT free flap for tongue and soft tissue donor site. Preoperative evaluation of the
reconstruction is a viable option. It allows free thoracodorsal nerve function indicates integ-
mobility between bone and soft tissue compo- rity of the thoracodorsal pedicle in case of
nents for optimal insetting. However, two free previous surgeries in the axilla (Fig. 2).
flaps make the procedure lengthy, add anasto-
mosis and recipient vessels, and add morbidity Virtual surgical planning tools for scapula tip free
from two donor sites (Wei et al. 2002). flap are not fully developed. Osseous flap inset-
• Lower lip sensibility restoration. Many ting is free-hand in our experience (Kass et al.
options exist for reconstruction of inferior alve- 2018).
olar and mental nerve, mostly described in
benign pathology. Nerve gap bridging can be Preoperative Care and Patient Drawing
achieved with vascularized or non-vascularized – Donor site drawing: With the patient standing,
nerve grafts (greater auricular nerve, sural nerve) the borders of the scapula are palpated and
or nerve substitutes. Sensitive cross-face proce- marked. A 15-cm incision is planned between
dures from the infraorbital nerve with or without latissimus dorsi and teres major muscles,
nerve grafting have been described for benign starting from the axilla. For chimeric flaps (scap-
pathology (Chang et al. 2012; Tanaka et al. ula tip plus soft tissue components), this incision
2016; Zuniga et al. 2017). The treatment of the allows the decision to include latissimus dorsi
malignancy takes priority in this case. muscle, thoracodorsal perforator skin flaps, or
Fig. 2 Schematic representation of the segment of the left scapula tip harvested for left mandible body reconstruction
(para)scapular skin flaps. Bear in mind that clipped and dissection stops in the proximal
shoulder flexion can distort the markings, so segment of the subscapular vessels.
reappreciation of the markings when the patient 4. For inclusion of a thoracodorsal artery perfo-
is supine under anesthesia is advised. rator flap, the previously dopplered perforator
Thoracodorsal perforators are lateral to this inci- is found in the subfascial plane on top of
sion and can be dopplered 8 cm below the latissimus dorsi. Regular distal to proximal
axillary crease and 2 cm posterior to the anterior perforator dissection is performed. A small
border of latissimus dorsi. cuff of muscle is left attached to the perforator.
– The patient is put on general anesthesia and If only latissimus dorsi muscle is incorporated
tracheostomy is performed. in the flap, the overlying skin is undermined,
– The patient lies supine and change to lateral and the desired length and width of muscle is
position during flap harvest. A two-team harvested, taking care to protect the
simultaneous approach is usually not possible. thoracodorsal pedicle as it enters the deep sur-
– The donor area is approached with the patient face of latissimus dorsi muscle.
in supine position. Shoulder flexion and inter- 5. The reconstructive needs are reappreciated.
nal rotation exposes the lateral border of the Osteotomies are performed on the lateral bor-
scapula for dissection. The position can be der of the scapula with a small oscillating saw.
maintained in supine during flap harvesting if Up to 9 cm of bone can be harvested and
only a bone flap or in combination with a remain viable on the angular artery.
latissimus dorsi flap is needed; however, A template of the tongue defect is made.
when harvesting a perforator flap (TDAP), The lateral incision is made on the TDAP flap
slight lateralization of the patient allows for to match the reconstructive needs for tongue
more comfortable harvesting. reconstruction.
– The entire arm is draped for free mobilization. 6. The flap is put in ischemia.
The scapular region is draped. Better exposure 7. The osseous flap is inset and fixated with plates
can be achieved by placing pillows under the and screws. Preliminary insetting of the TDAP
ipsilateral hip. flap is made, with watertight sutures starting in
the posterior part of the tongue.
8. Anastomoses are performed: subscapular
Surgical Technique artery to facial artery and subscapular vein to
internal jugular vein branch. The soft tissue
1. A 15-cm long incision is made in the lateral inset is finished with watertight sutures.
border of the scapula, between the superior 9. For donor site closure, three holes are drilled in
border of latissimus dorsi and the inferior bor- the remnant of the scapula. These holes are
der of teres major. used for reattachment of the teres major mus-
2. Latissimus dorsi is retracted laterally and teres cle. Layered closure is performed over a suc-
major superior and medially. The scapula tip is tion drain.
reached and its pedicle is found (angular
artery) in this space. This is usually a branch
of the thoracodorsal artery, but can also be a Technical Pearls
branch of the serratus branch. Teres major and
infraspinatus muscles are detached from the – With proper shoulder flexion, the STFF can be
scapula tip, leaving a small cuff of muscle on harvested with the patient in supine position;
the posterior surface of the scapula. however, when including a TDAP, slight later-
3. Dissection of the pedicle follows a proximal alization of the patient facilitates the
direction. The circumflex scapular vessels are harvesting. This saves operative time.
– After bone insetting and before fixation with – Drains: Two passive drains are sutured in the
plates and screws, the pedicle course should be recipient site, one of them close to the anasto-
observed to avoid kinking and compression. mosis, but not in contact with it. They are left
– For mandible reconstruction, insetting of the for 5–7 days, depending on the drainage. One
bone fragments is made to match the inferior active drain is left in the donor site, in the
border of the mandible, providing adequate muscular plane, for around 3–5 days.
projection to the lower face. – Flap control: The flaps are closely monitored
– The soft tissue component can be tailored to by the nursing staff by clinical inspection,
the reconstructive needs. Scapular flaps do not manual Doppler, and implantable Doppler
allow as much mobility as TDAP or latissimus (Cook-Swartz) according to our institution’s
dorsi flaps. protocol during 1 week. The frequency of con-
– Thoracodorsal nerve and latissimus dorsi mus- trols is as follows: once every 15 min in the first
cle preservation, besides teres major reatt- 4 h, every 30 min in the next 4 h, and then once/
achment, are important maneuvers to decrease hour the first day, every 2 h on day 2, every 3 h
donor site morbidity. on day 3, every 4 h on day 4, every 5 h on day
5, and every 6 hours on day 6.
– Nutrition: Enteral nutrition is started on the
Intraoperative Images (Figs. 3 and 4) first postoperative day. Oral liquid feeding is
started around the third to fifth postoperative
days and progress as tolerated.
– Mobilization: The patient needs to avoid
excessive mobilization of the neck for the
Postoperative Management first week to avoid vascular spasm or compres-
sion/kinking of the vascular pedicles. During
After the operation, the patient is transferred the first 2 postoperative days, the patient stays
under general anesthesia to an intensive care unit in bed but is instructed to do an active mobili-
for the first 24 postoperative hours and then to the zation of the extremities. On the third day, the
ward. patient is instructed to sit and later to ambulate.
– Antibiotic and thromboprophylaxis: Pre-
and perioperative antibiotic prophylaxis is
given using a combination cefotaxime and
metronidazole antibiotics i.v. and thrombosis
is prevented by using daily subcutaneous injec-
tion of low-dose heparin (dalteparin) for
10 days. In addition, from day 1, the patient
takes low-dose aspirin (75 mg) once a day for
1 month.
The surgery was uneventful. The patient stayed in

the intensive care unit for 24 h and then in the
plastic surgery ward. During the postoperative
period, the patient developed an infection in the
Fig. 3 The resection specimen comprised the mandible recipient site that responded well to antibiotic treat-
from angle to angle, subtotal glossectomy, and floor of the ment. The patient was discharged home after
mouth 5 weeks. Stable wound healing occurred in both
Fig. 4 Chimeric flap on the

subscapular system
comprising scapula tip and
thoracodorsal
perforator flap
Fig. 5 Postoperative CT
(10 days postoperative)
showing bone
reconstruction of the
mandible with the scapula
tip flap
donor and recipient sites. Postoperative analysis of modified neck dissection, and passed away
the tumor resection showed radical resection of the 14 months postoperatively (Figs. 5 and 6).
tumor with close margin, upgrading the tumor stage
to pT3N3bM0. Postoperative radiotherapy (66 Gy)
was administered and the patient received a PEG Avoiding and Managing Problems
for nutrition. Dental rehabilitation was not pursued
in this case because of prognosis constraints. • In patients with previous axillary surgery, the
At 7 months postoperative, the patient devel- status of the pedicle can be assessed by testing
oped a metastasis in the right neck, underwent for latissimus dorsi function.
Fig. 6 Follow-up at 5 weeks postoperative period
• Reattachment of teres major muscle to the anterior muscles). The mobility between the
scapula remnant helps to stabilize the shoulder components of the flap is favorable.
and avoid sequelae.
• Keeping a muscle cuff attached to the scapula
tip flap preserves blood supply for the bone
Cross-References
fragments after the osteotomies.
▶ Reconstruction of Total Maxillectomy and
Orbital Floor with a Free Scapula Tip Flap
Learning Points ▶ Total Lower Face Reconstruction with Double
Free Flaps
• In patients with comorbidities (peripheral
▶ Virtual Surgical Planning and CAD/CAM for
artery disease, diabetes, etc.), scapula tip free
Mandible and Maxilla Reconstruction with
flaps are a good option for mandible recon- Free Fibula Flap
struction of defects up to 8–9 cm, because of
sufficient bone stock, possibility of versatile
Disclosure The authors declare no financial disclosures.
chimeric flaps, reliable and long pedicle spared
from atherosclerosis, and low rate of donor site
complications.
References
• Donor site complications and sequelae of scap-
ula tip free flap harvest are low. Blumberg JM, Walker P, Johnson S, Johnson B, Yu E,
• Chimeric flaps based on the subscapular sys- Lacasse MC, et al. Mandibular reconstruction with the
tem can include bone (scapula tip, scapula scapula tip free flap. Head Neck. 2019;41(7):2353–8.
https://doi.org/10.1002/hed.25702.
bone) and large soft tissue components (scap-
Boyd JB, Mulholland RS, Davidson J, Gullane PJ, Rotstein
ular, parascapular, thoracodorsal perforator LE, Brown DH, Freeman JE, C IJ. The free flap and
skin flaps and latissimus dorsi and serratus plate in oromandibular reconstruction: long-term
review and indication. Plast Reconstr Surg. 1995;95/6: 7 4 5 – 5 9 . h t t p s : / / d o i . o rg / 1 0 . 1 0 9 7 / 0 0 0 0 6 5 3 4 -

1018–28. 197912000-00001.
Chang YM, Rodriguez ED, Chu YM, Tsai CY, Wei Wallace CG, Chang YM, Tsai CY, Wei FC. Harnessing the
FC. Inferior alveolar nerve reconstruction with potential of the free fibula osteoseptocutaneous flap in
interpositional sural nerve graft: a sensible addition to mandible reconstruction. Plast Reconstr Surg.
one-stage mandibular reconstruction. J Plast Reconstr 2010;125(1):305–14. https://doi.org/10.1097/PRS.
Aesthet Surg. 2012;65(6):757–62. https://doi.org/10. 0b013e3181c2bb9d.
1016/j.bjps.2011.12.028. Wei FC, Celik N, Chen HC, Cheng MH, Huang
Hidalgo DA. Fibula free flap: a new method of mandible WC. Combined anterolateral thigh flap and
reconstruction. Plast Reconstr Surg. 1989;84(1): vascularized fibula osteoseptocutaneous flap in recon-
71–9. struction of extensive composite mandibular defects.
Kass JI, Prisman E, Miles BA. Guide design in virtual Plast Reconstr Surg. 2002;109(1):45–52. https://doi.
planning for scapular tip free flap reconstruction. org/10.1097/00006534-200201000-00008.
Laryngoscope Invest Otolaryngol. 2018;3(3):162–8. Wilkman T, Husso A, Lassus P. Clinical comparison of
https://doi.org/10.1002/lio2.162. scapular, fibular, and iliac crest osseal free flaps in max-
Tanaka K, Okazaki M, Homma T, Tomoyuki Yano illofacial reconstructions. Scand J Surg. 2019;108(1):
HM. Bilateral inferior alveolar nerve reconstruction 76–82. https://doi.org/10.1177/1457496918772365.
with a vascularized sural nerve graft included in a free Zuniga JR, Williams F, Petrisor D. A case-and-control,
fibular osteocutaneous flap after segmental multisite, positive controlled, prospective study of the
mandibulectomy. Head Neck. 2016;36(10):1391. safety and effectiveness of immediate inferior alveolar
https://doi.org/10.1002/HED. nerve processed nerve allograft reconstruction with
Taylor GI, Townsend P, Corlett R. Superiority of the deep ablation of the mandible for benign pathology. J Oral
circumflex iliac vessels as the supply for free groin Maxillofac Surg. 2017;75(12):2669–81. https://doi.
flaps clinical work. Plast Reconstr Surg. 1979;64: org/10.1016/j.joms.2017.04.002.
Double Free Flap Reconstruction in the
Complex Neck 38
Cristina Gomez-Martinez de Lecea and
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Abstract
Extensive composite head and neck defects are

challenging because they encompass different
C. Gomez-Martinez de Lecea (*)
anatomical and functional structures which
Department of Plastic and Maxillofacial Surgery, Uppsala need a meticulous repair. Furthermore, the lon-
University Hospital, Uppsala, Sweden ger-survival rates as well as the use of combine
A. Rodriguez-Lorenzo modalities for local tumor control have added
Department of Plastic and Maxillofacial Surgery, Uppsala additional surgical difficulty in these patients
University Hospital, Uppsala, Sweden which commonly present complex vessel-
Department of Surgical Sciences, Uppsala University, depleted necks. Here a related case report is
Uppsala, Sweden presented step by step to show a systematic
e-mail: andres.rodriguez.lorenzo@akademiska.se

https://doi.org/10.1007/978-3-030-23706-6_127
380 C. Gomez-Martinez de Lecea and A. Rodriguez-Lorenzo
medical approach, several technical tips, and he complained of an increase dysfunction for speech
additional reconstructive options. and swallowing during the last months. On physical
examination, he presented an inter-incisal distance
Keywords (IID) of 35 mm, a macroscopic lesion along the
surface of the tongue sparing its base, toughness on
Double free flap · Vessel-depleted neck ·
the floor of the mouth, as well as loss and exposure
Cephalic vein transposition · Transverse
of bone on the mandibular symphysis (Fig. 1a and
cervical vessels · Vein grafts
b). After a multidisciplinary approach, the patient
was planned to undergo a subtotal glossectomy,
resection of the floor of the mouth, anterior
mandibulectomy, and left I–III and V neck dissec-
tion. A tracheostomy and a percutaneous endoscopic
A 44-year-old man diagnosed of a squamous cell
gastrostomy tube were also scheduled.
carcinoma recurrence invading the mobile tongue,
induration of the floor of the mouth, and exposure of
the anterior mandible (cT4aN0M0). He had previ-
ous history of a right tongue cancer treated at another Preoperative Problem List/
hospital with neoadjuvant radiotherapy, right partial Reconstructive Requirements
tongue resection with primarily closure, and right
radical neck lymphadenectomy 16 years ago. Con- 1. An extended composite defect involving the
sequently, he developed a right brachial plexus anterior mandible (bone), floor of the mouth
injury and difficulty in swallowing. At presentation and vestibular mucosa (oral lining). Further
Fig. 1 Preoperative images

of the patient showing (a) a
normal mouth opening and
a macroscopic lesion
involving the anterior
surface of the tongue and
(b) bone loss and exposure
on the mandibular
symphysis
38 Double Free Flap Reconstruction in the Complex Neck 381
defect secondary to a subtotal glossectomy good quality of life, the absence of both trismus
planned. and postoperative radiotherapy, and the broad-
2. Limited recipient vessels on the right side due curative tumor resection planned were also con-
to previous radical neck dissection and radio- sidered in the preoperative reconstructive strat-
therapy. Additional surgical difficulty sec- egy. Therefore, a double free flap with an
ondary to a left cervical dissection (I–III and osteocutaneous fibula to restore the anterior man-
V levels) to be performed. dible and to supply new skin to the neck and a
3. Soft tissue fibrosis and sequalae of previous fasciocutaneous ALT to reconstruct the neo-
radiotherapy on the right neck and in the tongue and the floor of the mouth on the other
mouth. hand were devised.
4. Skin-tension release and pedicles coverage The selection of the recipient vessels was also
with the transfer of new healthy soft tissue contemplated preoperatively as the patient had
to the neck. already had radiotherapy and a right radical neck
5. Need of bony mandible reconstruction for dissection. However, the final decision was made
ensuring dental occlusion, minimize trismus intraoperatively once the left neck dissection was
and sunken appearance, and provide dental performed.
rehabilitation potential.
6. Mandibular soft tissue coverage to prevent
plate and bone exposure (especially in previ- Alternative Reconstructive Options
ously irradiated tissues), to avoid orocutaneous
fistula formation and maintain facial Patients’ comorbidities, their functional and cos-
contouring. metic needs, as well as the type of defects and
7. Bulky soft tissue flap to reconstruct the tongue tumor stage or prognosis are factors that will
and ensure contact of the neotongue with the determine the final decision in between the differ-
hard palate for optimizing swallowing and ent reconstructive combinations. Although the
speech. importance of reconstructing the tongue and the
8. Restoration of the floor of the mouth to rec- jaw separately has already been explained above,
reate the diaphragm of the neotongue and there are other less optimal reconstructive options.
give it some support. Other surgical options available in a downgrade
9. Reattachment of the neomandible to the therapeutical scale are:
hyoid bone to open up the epiglottis and
resuspend the neotongue. – Reconstructive plate with locoregional flap. A
10. Need for water-tight separation of the com- pedicled pectoralis major flap with a recon-
munication between the oral cavity and the struction plate can be a salvage procedure in
neck space. very comorbid patients with multiple previous
oromaxillofacial surgeries, vessel-depleted
neck, and poor candidates for free flaps. It
Treatment Plan would provide the advantage of repairing the
defect by a shorter and simpler procedure,
The present tissue defect required reconstruction without the need of microvascular anastomo-
of multiple components which differ in anatom- ses and is associated with reduced short term
ical and functional features (Al Deek et al. 2016). morbidity. However, it presents an awkward
Both the tongue and the mandible were decided insetting in this type of patient with scarred
to be repaired as two different structures, trying neck and is a suboptimal treatment in the long
to avoid the idea of “one flap can manage every- term. This procedure can easily develop post-
thing,” in order to provide the best possible operative complications like plate exposure,
results in swallowing, chewing, speaking, airway wound dehiscence, and oral incompetence
protection, and aesthetics (Chen et al. 1999, (Hanosono et al. 2008). Moreover, it would
Yazar et al. 2005). The patient’s age, his overall barely offer a good quality of life to patients,
failing to restore intelligible speech, adequate (mainly latissimus dorsi) and bone (scapular
swallowing, and good aesthetic results. For or scapula tip flaps) based on the same long
this reason, this reconstructive technique pedicle. This provides versatility and easier
should be considered as the last option or as a insetting of the different components. None-
salvage procedure in the event of surgical com- theless, the bone stock provided may not suf-
plications or cancer recurrence. fice to reconstruct a large defect as a total
– Reconstruction plate and soft tissue free flap: a anterior mandibulectomy due to the scapular
reconstructive plate plus an ALT for the bone variability in shape and thickness.
tongue. The ALT can be harvested as a
fasciocutaneous, musculocutaneous flap or
chimeric flap. Even though this surgical tech- Preoperative Evaluation and Imaging
nique may initially seem to be simpler and
safer for the patient, it fails to provide enough 1. From a general point of view, a thorough
soft tissue as well as to reconstruct properly an preoperative planning is crucial in this chal-
extensive anterior mandibular defect. This lenging group of patients with vessel-depleted
reconstructive combination has been demon- necks undergoing double free flaps. A stan-
strated to present high risk of postoperative dard clinical history including patient’s
complications such us plate exposure and comorbidities and nutrition assessment has
recourse to secondary salvage procedures to be complemented with a meticulous report
(Wei et al. 2003). of previous head and neck surgeries, previ-
– Fibula free flap and a pectoralis major regional ously used or dissected vessels, and comple-
flap. It will permit a thorough mandibular mentary radiotherapy treatment details. The
reconstruction but will fail to provide a proper clinical examination will help to assess the
tongue reconstruction because of the pectoralis patient’s functional baseline in terms of oral
major less pliable skin island, restrictive inset- competency, speech, mastication, swallow-
ting, and future soft tissue atrophy. Moreover, ing, and breathing. Moreover, the assessment
the pectoralis major transfer may compromise of postradiotherapy soft tissue changes and
the concomitant fibula microanastomoses by additional scars in the chest or upper limbs
pedicle compression and vein thrombosis helps to plan the surgical approach as well as
(Hanasono et al. 2008; Chen et al. 1999). to evaluate the possibility of using potential
Other vascularized bone free flaps such as the vessels such as the transverse cervical vessels,
iliac crest and radial forearm flaps remain sub- the thoracoacromial trunk, the internal mam-
optimal for reshaping the anterior mandible. mary, or the cephalic vein.
– Chimeric flaps. This is a more feasible and 2. From an oncological perspective, standard
reasonable option if a second set of micro- imaging tests such as Panorex or CT scan to
anastomoses is to be avoided, but maintains asses bone infiltration, MRI to evaluate soft
the option of bringing several soft tissue com- tissue changes and locoregional metastasis,
ponents. This flap can be based on either the and PET-CT scan for distant disease staging
peroneal or the subscapular systems. The pero- are commonly used.
neal system allows the possibility of harvesting 3. For identification of recipient vessels, CT or
adequate bone and abundant skin island. How- MR angiogram would help to identify viable
ever, it would add morbidity at the donor site recipient vessels. Recently, a dual-phase CT
and provide a suboptimal tongue reconstruc- angiography has been demonstrated to be help-
tion due to the lack of volume of the skin ful in the identification of target vessels candi-
islands and a more restrictive insetting of the dates for flaps anastomoses (Du et al. 2019).
flap. The subscapular system would allow to However, further studies are needed to see if
include separately one or two skin islands this new imaging test adds values compared to
(TDAP and/or parascapular flaps): muscle the traditional angio-CT scan.
4. For identification of donor vessels, the lower but in this case a bigger skin island was planned.
extremity angio-CT scan is the most common The skin vessels were located and marked on the
imaging test employed. Nonetheless, some two most distal thirds of the leg with the help of
other institutions only request it in comorbid the hand-held Doppler.
patients with peripheral arteriopathy and For the ALT marking, a line was drawn from
exclusively base their assessment on hand- the anterior superior iliac spine to the lateral edge
held Doppler results. of the patella. This line represents the axis of the
5. Finally, the gather of all this information plus a septum between the rectus femoris and the vastus
clear communication with the ENT and Maxillo- lateralis, where the septocutaneous vessels are
facial teams about their resection approaches commonly found. The skin vessels were marked
helps to establish a reconstructive plan. nearby the middle portion of this axis line with the
help of a hand-held Doppler. Then the anterior
In this case, the patient preoperatively presented skin incision was drawn in a curve shape and
little physical and functional sequelae from previous medial to the axis.
surgery and radiotherapy. He had started with diffi- Intraoperatively the patient was positioned in
culty in swallowing solids, as well as difficulty in supine with the left lower extremity included in
speech, most likely due to secondary tightness and the surgical field and a sterile tourniquet on the
shortening of the already operated tongue. He also leg.
presented a middle cervical scar, radiotherapy dam-
age in terms of brachial injury and skin tightness on
the neck, more evident on the right side. The MRI Surgical Technique
depicts infiltration of the mobile tongue and floor of
the mouth (Fig. 2a and b). A. The total operation time was 13 h and 36 min.
The CT scan views revealed osteolytic lesions of The surgical sequence was as follows:
the anterior mandible (Fig. 3a and b). 1. Tracheostomy
The FDG-PET/CT scan showed mobile tongue 2. Tumor resection and lymphadenectomy by
and anterior mandible involvement with a doubt- the ENT team (Fig. 5) and parallel harvesting
ful left metastasis, tentative staging T4aN1M0 of the free fibula flap from the left leg.
(Fig. 4a and b). 3. Fibula intraflap osteotomies using cutting
The lower extremity angio-CT scan demon- guides. The osteosynthesis was performed
strated complete 3-main-vessels permeability, in coordination with the maxillofacial
which were additionally checked with a hand- surgeons while the fibula was still attached
held Doppler. in the leg. Temporarily 1.5 mm plates and 2
crews on each osteotomy’s side were used
in this step.
Preoperative Care and Patient 4. Insetting of the fibula flap to the mandible
Drawing with definitive 1.5 mm prebent plates fixed
with 3 screws on each osteotomy side. The
Preoperative thrombotic prophylaxis consisted of microanastomoses were directly performed
subcutaneous low molecular weight heparin to the left facial artery and to the left inter-
(2500 IE) the day before the surgery. For antibiotic nal jugular vein through a 2 cm-vein graft.
prophylaxis, the patient perioperatively received The fibula skin paddle was tailored for cov-
three doses of cefatoxime and metronidazole. ering the anterior neck for skin-tension
The osteocutaneous fibula free flap was then release and pedicle protection. Parallel
premarked on the standard manner. The axial shaft harvesting of the subfascial ALT flap from
of the skin island laid on the posterior border of the left thigh.
the fibula. Usually a skin island up to 3.5 cm in 5. Insetting of the ALT flap to the remaining
diameter permits a direct closure of the donor site, tongue’s base and anterior vestibular
Fig. 2 Preoperative MRI

images: (a) sagittal section
(T1 FSE FS + ce) showing a
lesion of 37.24 mm along
the mobile tongue and floor
of the mouth and (b)
coronal section (FSE STIR)
depicts a lesion of
20.31 mm-width on the
anterior tongue
Fig. 3 Preoperative CT
scan images. (a) Sagittal
and (b) axial sections
showing osteolysis of the
mandible body
gingiva (Fig. 6). The microanastomoses graft and primary closure of the ALT
were directly performed to the left superior donor site were performed.
thyroid artery and external jugular vein. A B. Donor sites:
Cook–Swartz Doppler Probe was placed The fibula free flap was harvested in a stan-
for invasive surveillance of the free flap. dard fashion anterior approach once the
Closure of the fibular defect with a skin osteoseptocutaneous vessels were identified.
Fig. 5 Intraoperative image after tumor resection and left

neck dissection. Left facial (black arrow) and lingual
(white arrow) arteries were ligated. The left lingual nerve
(white star) was distally ligated. Notice the right neck skin
was left attached to avoid additional injuries
Fig. 6 Intraoperative image after flaps anastomoses and

insettings. The ALT was used for the neotongue (white
star) and for the floor of the mouth, the fibula for the
neomandible and its skin for releasing neck tightness and
pedicle coverage (black star)
Fig. 4 Preoperative FDG PET-CT images. (a) Sagittal and
(b) axial sections show hypermetabolism in the mobile
tongue, the mandibular symphysis and left cervical suspi- superficial leg compartments. Finally, the pero-
cious metastasis
neal vessels were raised along with the
osteoseptocutaneous flap and a split-thickness
The following systematic dissection proceeded skin graft was raised for the donor site closure.
from the lateral to anterior compartments and The ALT flap harvest was performed
then to posterior deep and to posterior using the medial subfascial approach, with
identification of the perforators first, followed by flap to push the food and liquids backwards
the dissection of the septum in between the and to facilitate lingual-palate contact for
rectus femoralis and vastus lateralis to then con- speech, as well as recreate a new gingiva-lin-
tinue with the intramuscular dissection of the gual sulcus in between flaps to decrease
perforators until the main source pedicle, which drooling and aspiration. The reattachment of
in this case was the descending branch of the the mandible to the hyoid bone enables to open
lateral femoral circumflex artery. The flap design up the epiglottis, resuspend the neotongue, and
was then tailored in accordance to a template minimize its falling backwards due to gravity
previously marked on the recipient site matching when the entire floor of the mouth has been
the defect area. Then the flap was completely removed.
raised. The donor site was closed primarily. 6. Ensure the distance in between the mandibular
C. Recipient sites: rami at the beginning of the surgery to optimize
The insetting of the osteoseptocutaneous the later fixation of the fibula, the mouth open-
fibula free flap was first performed. The ische- ing, as well as to reduce the risk of future
mia time was 77 minutes. The left facial artery mandible retraction.
was the recipient vessel for the anastomosis. A 7. Both preoperative virtual surgical planning of
2 cm-long and 3 mm-diameter vein graft and the fibula bone flap with CAD/CAM technology
the coupler were used to anastomose end to (Olsson et al. 2015) and intraoperative templates
end the veins in between the pedicle and a of the soft tissue defect (Driessen et al. 2020)
branch of the left internal jugular system. have several advantages further discussed in
The ALT was end to end anastomosed to ▶ Chap. 12, “Total Lower Face Reconstruction
the left superior thyroid artery and a branch of with Double Free Flaps.”
the external jugular system. The ischemia time
was 64 minutes.
Technical Pearls The patient spent the first night in the intensive
care unit. The flaps were monitored clinically and
1. Inter-multidisciplinary communication is by both Cook-Swartz and hand-held Dopplers
essential to establish a preoperative plan and once every 15 min during the first 4 h, every
to intraoperatively readapt the reconstructive 30 min during the next 4 h and then once/hour of
steps if needed. the first day. Afterwards the control was every 2 h
2. A two-team simultaneous approach is very on day 2, every 3 h on day 3, every 4 h on day 4,
important during the whole procedure to every 5 h on day 5, and every 6 h on day 6
decrease both the total operation time and the according to the institution’s protocol.
risk of future complications. The patient’s head was kept horizontally for
3. Avoid dissection on areas with scar and fibrosis the first 24–48 h and thereafter was progressively
that may increase the risk of damaging raised within the following days based on the
remaining anatomical structures or postopera- Cook-Swartz Doppler signal. During these days,
tive complications. the patient stayed in bed but started with active
4. Whenever possible use the ipsilateral and mobilization of the extremities. Patient’s mobility
healthy vessels. If not possible, use contralat- at bedside was initiated at day 3. At postoperative
eral traditional recipient vessels or contralat- day 5 the patient began to use an Aircast Boot that
eral vessels coming from the subclavian or allowed him to wander around with weight bear-
axillar systems. Vein grafts should be avoided ing on the donor leg.
or used for small gaps. The patient’s nutrition was maintained through
5. Subtotal glossectomy reconstruction should an NGT since postoperative day 1. Clear liquid
aim to: restore the neotongue with a bulky drinking was started at day 6 and escalating food
intake thereafter based on patient’s tolerance and He is completely tolerant to liquids but
the absence of orocutaneous fistula formation. gastrostomy tube dependent. The tracheostomy
The tracheostomy decannulation started in post- was successfully removed, and he has an intelli-
operative day 7 following the ENT indications. gible speech.
The passive drains at the sites of anastomoses The last CT scan shows bone union within the
were removed after 3 days. fibula osteotomies (Fig. 8).
For thrombotic prophylaxis, the patient contin-
ued with fraxiparine 5000 IE/24 h during the first
10 days. In addition, Aspirin 75 mg/24 h during Avoiding and Managing Problems
the first month was also prescribed. Paracetamol,
gabapentin, and oxycodone were employed for The recipient vessels commonly used in head and
pain management. neck reconstruction come mainly from the exter-
nal carotid system (Ciudad et al. 2017; Yazar et al.
2005) and from the internal or external jugular
Outcome, Clinical Photos, and Imaging veins. In the normal scenario, defects located in
the scalp, the skull base, or the midface can be
During admission, the patient presented 40% of managed with free flaps anastomosed to the super-
skin graft loss on the fibula flap donor site. For this ficial temporal vessels. Reconstructions on the
reason, he underwent a surgical revision for oral cavity, mid and lower face, and on the neck
debridement and placement of a new split-thick- (pharyngoesophageal area) usually employ the
ness skin graft. The patient was then discharged at occipital, facial, lingual, or superior thyroid arter-
postoperative day 25 without any additional acute ies and the retromandibular, facial, and superior
complication. The final report from Pathological thyroid veins. Patients considered with
Anatomy remarked a highly differentiated squa- vessel-depleted necks, with more distal defects
mous cell carcinoma of 30 19 18 mm, with- on the neck and the thoracic area can also benefit
out regional metastasis and with 19 mm tumor- from using vessels coming from the thyrocervical,
free margins (final stage T3NOMO). During the subclavian, or the axillary systems.
first postoperative months, the patient had diffi- The patient herein presented had also a com-
culty eating solid food, for what he underwent a plex neck, commonly known as a vessel-depleted
permanent PEG placement. Nineteen months neck. This concept does not mean there are no
postoperatively the patient is tumor free and sat- vessels available for flaps anastomoses, but that
isfied with the results, being independent for his there are vessels less suitable and in a neck with
daily activity and able to keep social interaction fibrosis and scars from previous surgeries or
(Fig. 7a,b,c). radiotherapy. It is in these cases in which
Fig. 7 Patient’s frontal photos 19 months after surgery (a, b, c)

2017). This fact allows to employ the trans-

verse cervical artery both directly or in a
reverse-flow manner when the flap’s pedicle
is short or traditional recipient vessels are not
available (Ciudad et al. 2017). The vessels’
length can be maximized by their dissection
within the trapezius muscle. Care must be
taken when manipulating the transverse cervi-
cal artery as the phrenic nerve runs under it,
just over the anterior scalenus muscle. More-
over, the right side is preferable if available in
order to avoid damage of the thoracic duct or, if
not, blunt dissection under magnification over
the supraclavicular fat pad is recommended.
2. Thoracoacromial trunk (Harris et al. 2002).
This vascular trunk comes from the axillary
system and gives off 4 branches (pectoral, del-
Fig. 8 Postoperative CT scan image 7 months after sur- toid, clavicular, and acromial) which can be
gery. Axial cut depicts the intra fibula osteotomies unions used for anastomoses in this region. The main
trunk has a diameter of 2.5–7 mm and its
identification and dissection of suitable recipient branches have a diameter size ranging from
vessels can become an arduous task (Ciudad et al. 1.2 to 2.4 mm. Its main disadvantage is the
2017; Jacobson et al. 2008). The main goal in potential loss of the vascular pedicle to the
these circumstances is to avoid employing recip- pectoralis major flap, precluding then its use
ient vessels within tight-radiated necks or sur- as a salvage procedure in the future.
rounding fibrous tissues, so as to reduce the risk 3. Internal mammary vessels (Urken et al. 2006).
of intraoperative additional damaging and postop- The internal mammary vessels arise from the
erative complications. subclavian system. The right third intercostal
Different recipient vessel options exist in the space is preferred in accordance to the vessels
vessel-depleted necks when the traditional vessels biggest size (vein and artery average of 3 mm
systems are unavailable (Breik et al. 2020; Ciudad and 2.36 mm, respectively). A recipient pedi-
et al. 2017; Hanasono et al. 2009; Urken et al. cle length of 2–3 cm can be harvested and can
2006): be also lengthened by removing additional car-
tilage from the superior rib. Care has to be
1. Transverse cervical vessels (Xu et al. 2015). taken to avoid violation of the pleura space.
These vessels come from the thyrocervical Their several disadvantages include increased
trunk. The dissection starts with a C-shape operation time, risk of compression along the
skin/platysma flap raise. The dissection is subcutaneous thoracic tunnel and the common
followed by the identification of the cervical need of vein grafts unless the defect is located
plexus cranially and the omohyoid muscle cau- very low in the neck (Hanasono et al. 2009).
dally, and the retraction of the latest. This 4. Cephalic vein (Chan et al. 2016; Harris et al.
maneuver exposes the transverse cervical ves- 2002; Hallock 1993). It is a reliable life boat
sels as well as the supraclavicular vein (which located in the axillary area and has several
arises from the subclavian vein) below the advantages. It has an excellent size match for
muscle, traveling in the supraclavicular loose microvascular anastomosis and its transposi-
fat pad. The transverse cervical vessels are tion allows to span long distances in the neck,
commonly preserved distally even in patients avoiding vein grafts and performing the anas-
with previous neck dissections (Ciudad et al. tomosis out of an irradiated or scarring area. Its
pivotal point is located where the cephalic vein 2. The reconstruction of concomitant tongue and
enters the costocoracoid fascia (Hanasono et al. mandible defects has to aim to repair the
2009), nearby the middle third of the clavicle. impaired function and anatomy and not just
The deltopectoral groove is its anatomical land- the defect size.
mark from which the dissection starts. 3. Close communication with the resection team
5. Veins grafts. Vein grafts are commonly harvested allows to establish a preoperative plan and to
from branches in proximity to the defect area. intraoperatively readapt the reconstructive
They can be used as interposition or as transpo- steps or preserve potential suitable recipient
sition grafts. The interposition vein graft is used vessels.
for either artery or vein and requires usually two 4. Selection of healthy recipient vessels outside
end-to-end microanastomoses. Whereas the the irradiated tissue and in an anatomically
transposition vein grafts can be used for vein reliable area to decrease the risk of
gaps with only one microanastomosis or as an complications.
arteriovenous loop to accomplish both an arterial 5. The transverse cervical vessels, the thoracoa-
and a vein gap needing the performance of 2 cromial trunk, the internal mammary vessels,
arterial microanastomoses and one venous previous free flaps pedicles, the cephalic vein,
microanastomoses (Inbal et al. 2018). Its down- and the supraclavicular vein are suitable recipi-
sides are the increase of operation time, the num- ent vessels in vessel-depleted neck patients.
ber of required microanastomoses, and the risk 6. Vein grafts remain the last option due to their
of developing thrombosis (Di Taranto et al. higher risk of thrombosis, kinking and flap
2019; Hanasono and Butler 2008). failure (Maricevich et al. 2018, Cheng et al.
6. Connection to a previous free flap (Tsao et al. 2012). If the vein graft is still needed, short
2016; Nakayama et al. 2002; Wells et al. 1994). vein grafts are less prone to fail.
This anastomosis can be performed either to
the distal end or to a proximal side branch of
the first flap (Hanasono et al. 2008; Yazar et al.
Cross-References
2005). This enables to avoid searching for
another recipient vessel or using vein grafts.
▶ Total Lower Face Reconstruction with Double
However, a serial connection to the distal ped-
Free Flaps
icle of the first flap may alter the arterial inflow,
produce a steal phenomenon on the previous
flap, and increase the risk of thrombosis (Wei et
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Management of Bone Nonunion
in Mandible Free Flaps with a Scapular 39
Tip Flap
Richard Tee and Andres Rodriguez-Lorenzo
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Medical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Alternative Bony Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Abstract
Nonunion of the neo-mandible post free fibula

osseocutaneous flap reconstruction is a complex
R. Tee (*) · A. Rodriguez-Lorenzo and challenging problem in head and neck recon-
Department of Plastic and Maxillofacial Surgery, Uppsala struction. There are often issues associated with
University Hospital, Uppsala, Sweden an irradiated field (contracted soft tissue and poor
Department of Surgical Sciences, Uppsala University, vascularity), as well as a frustrated patient who
Uppsala, Sweden has been through a major operation, unpleasant

https://doi.org/10.1007/978-3-030-23706-6_128
394 R. Tee and A. Rodriguez-Lorenzo
adjuvant radio-chemotherapy, suffering from

symptoms of nonunion and often a long unsuc-
cessful duration of conservative treatment. It is
thus important to aim for a single, lower morbid
but highly reliable procedure for treatment. This
can be achieved through careful preoperative
planning, utilizing a chimeric scapular tip osse-
ous flap carrying latissimus dorsi muscle, and
selecting recipient vessels away from the irradi-
ated field. In this chapter, we illustrate these steps
in a patient, while outlining the nuances in the
management of such a problem. Fig. 1 Infected discharging cutaneous fistula (red arrow)
developed 5 months post-initial wide local excision of right
gingival squamous cell carcinoma, segmental mandi-
bulectomy, ipsilateral cervical lymphadenectomy followed
Keywords
by adjuvant radio- and chemotherapy
Scapular tip free flap · Nonunion · Head and
neck · Osteoradionecrosis anterior fragment of the free fibula flap and the
native mandible (Fig. 2). PET CT showed a
nonviable anterior fragment (Fig. 2). This was
The Clinical Scenario managed nonsurgically for another 3 months.
Finally, 9 months post-primary reconstruction,
A 48-year-old fully dentate man with medical his case was brought forth to the head and neck
history of psoriasis and hyperlipidemia presented multidisciplinary team and it was recommended
with moderately differentiated primary squamous that he undergo surgical debridement and recon-
cell carcinoma (SCC) of the right mandibular struction with a vascularized osseous flap.
gingiva, at the location of teeth 46 and 47 (preop-
erative staging T4aN2bM0).
The recommended treatment plan from the Preoperative Problem List/
multidisciplinary head and neck meeting was wide Reconstructive Requirements
local excision including segmental mandibu-
lectomy (from number 43 to the right condyle), Osseous defect can be difficult to predict. Imag-
ipsilateral cervical lymphadenectomy (level I–V) ing may be helpful – while not always reliable –
and reconstruction with a free vascularized fibula PET CT scan was performed in this case, which
osseocutaneous flap. Two osteotomies were showed that the anterior fragment of the fibula flap
required for the inset, and the flap was anastomosed was nonviable. Plain X-ray films may be useful in
to the ipsilateral superior thyroid artery, a branch of some cases: rounded appearance of the bone edge
internal jugular vein (IJV) and external jugular vein may suggest healing potential (thus smaller
(EJV). The choice for osteosynthesis was three defect), while a lytic lesion may suggest ongoing
2.0 mm mandibular plates. Postoperatively, he necrosis (anticipate larger defect).
received adjuvant radiotherapy of 66 Gy and che- Soft tissue defect will be more extensive than
motherapy (cisplatin). it appears. These patients are usually irradiated,
One-month postradiation therapy, he devel- with friable local tissue and poor vascularity. An
oped a cutaneous fistula from the mandible oral cutaneous fistula is commonly present – such
(Fig. 1). Recurrence was excluded with pathol- as in this case. The local soft tissue is contracted
ogy. A plain CT showed nonunion between the and lost its usual compliance. Soft tissue to cover
39 Management of Bone Nonunion in Mandible Free Flaps with a Scapular Tip Flap 395
Fig. 2 (Left) 3-dimensional reconstructed computed the poor vascularity of the anterior segment (arrow) of the
tomography (CT) image demonstrating non-union at the fibula bone is demonstrated on the PET-CT image
interface of the fibula and native mandible (arrow). (Right)
potential mucosa, skin defect as well as provided and combination medical therapy. For this reason,
coverage over the pedicle (especially when the surgical planning must aim to deliver a single
required to reach the contralateral side) needs to operation utilizing all the reliable tools in a recon-
be considered. When selecting a vascularized tis- structive surgeon’s armamentarium. This includes
sue, the donor site must allow the harvest of careful planning, the use of a reliable flap and
reasonably sized soft tissue for coverage. reliable recipient vessel.
Recipient vessels need to be considered and
planned, as the ipsilateral neck is usually irradiated
and has had cervical lymphadenectomy. Explora- Treatment Plan
tion of the contralateral neck for facial or superior
thyroid artery is preferred, as in this case. Branches 1. Debridement of nonviable bone until bleed-
of the internal jugular system are preferred recipi- ing healthy bone edge visualized
ent venous drainage otherwise an end-to-side of the 2. Presurgical planning with pre-bent plate
IJV is preferred. The transverse cervical vessels are using three-dimensional model
the first option in bilateral vessel depleted neck 3. Dental casting and intermaxillary fixation
from previous bilateral lymphadenectomy. for maintenance of occlusion
Patient frustration is expected. The patients 4. Selection of healthy recipient vessel (contra-
(often post-adjuvant radio-chemotherapy) are lateral facial artery and branch of internal
tired and overwhelmed. Symptoms from the non- jugular vein)
union such as pain, inability for mastication, poor 5. Reconstruction of the consequent mandibu-
oral intake, and cutaneous fistula exacerbate the lar defect with free vascularized chimeric
frustration. In addition, they may have been scapular tip including latissimus dorsi muscle
treated as osteoradionecrosis and presented only 6. Postoperative dental rehabilitation with
after a long period of failed hyperbaric oxygen osseointegrated dental implants
Alternative Reconstructive Options be reserved for a longer defect, should there be a

recurrence. In this particular case, the patient was a
Medical Therapy drummer and was concerned that, if the right fibula
was harvested, his hobby might be affected.
In the presented case, one could argue that patient
fits the diagnosis of osteoradionecrosis (ORN) of Deep Circumflex Iliac Artery (DCIA) Iliac
the osseous flap. In reality, it is hard to define the Crest Flap
actual cause of the nonviable bone and nonunion The DCIA flap is an accepted osseous flap for bony
which could be attributed to the bone gap, the reconstruction of the mandible. It is known for its
radiation therapy, or osteotomy techniques that bone stock. The down sides of it, is well-reported,
resulted in the non-united interface between the which include a short pedicle, bulky soft tissue flap
fibula bone and the native mandible. In and donor site morbidity, including pain and con-
Dziegielewski et al.’s paper on ORN of the osseous tour deformity (Wilkman et al. 2018). In this case,
flap, they noted that of all the ORN cases, there was there is requirement of a soft tissue flap for draping
some form of union between the osseous flap and over a potentially large soft tissue defect, a small
the native mandible (Dziegielewski et al. 2020), segment of bone and a long pedicle to perform
while in our case, there was no evidence of union. anastomoses in the contralateral neck. The DCIA
It is appropriate that one suspects this as a case flap is thus not ideal as a secondary flap.
of ORN of the osseous flap, medical treatment
with a combination of pentoxifylline, high dose Medial Femoral Condyle Flap
Vitamin E, alendronate (Delanian et al. 2011; The medial femoral condyle osseous flap is well
Robard et al. 2014), and hyperbaric oxygen ther- reported in the treatment of nonunion of the upper
apy can be considered. The reported recovery time extremity (Banaszewski et al. 2019). Although
is around 12 months (Delanian et al. 2011; there are reports of its utility in head and neck region
Dziegielewski et al. 2020; Robard et al. 2014). (Lee et al. 2014), the use of this flap is uncommon.
Recovery is expected in the less severe form ORN It is based on the descending genicular artery which
of the native mandible, whereas, if the native is not as long of a pedicle when compared to the
mandible suffered from a fracture, surgical inter- subscapular artery. While soft tissue may be avail-
vention is indicated. The fact that there is no union able as in the form of the saphenous flap, the avail-
between the fibula and native mandible, with PET ability is limited without grafting of the donor site.
CT showing reduced uptake, suggest that it should Furthermore, the osseous flap would consist of
be treated as a severe ORN case. Furthermore, the unicortical bone, as opposed to a tricortical bone
patient suffers from pain and chronic fistula. In a of the scapula tip, and generally provides only
patient who has already undergone major surgery, 16cm3 of bone in order to avoid complications
it could be argued that instead of prolonged pain, a such as pain and iatrogenic fracture. Thus, in a
one-stage procedure that can resolve the problem complex head and neck case, with uncertain bone
may be indicated for improving quality of life. and soft tissue defect, it is not an ideal option.
Alternative Bony Flaps Preoperative Evaluation and Imaging
Fibula Osseocutaneous Flap For the defect, PET CT scan was used to deter-
The authors consider the fibula flap as a more mine the extent of nonviable bone and exclude
morbid procedure compared to the scapula tip par- recurrence of malignancy. Plain CT scan or ortho-
ticular in the elderly (Vieira et al. 2021). This is pantomography (OPG) were obtained for preop-
especially considered as the contralateral fibula had erative planning.
already been used. In older patients, there is con- Three-dimensional printing of the most recent
cern of the atherosclerotic lower limb vasculature. CT scan of the mandible and a pre-bent plate was
In addition, patients with SCC, the other fibula may required to aid surgical planning.
As outlined in ▶ Chap. 36, “Reconstruction of Surgical Technique

Total Maxillectomy and Orbital Floor with a Free
Scapula Tip Flap,” the anatomy of the scapula tip 1. The nonunion site was accessed with a sub-
free flap is fairly constant. Preoperative imaging is mental incision directly over the neo-mandible.
not required and the flap is normally shaped free- The incision crosses midline to the contralateral
hand. neck and the recipient vessels were dissected
(facial artery and a branch of the internal jugular
vein). The debridement of the anterior fragment
and native mandible was performed until
Preoperative Care and Patient healthy bleeding at the bone edges was visual-
Drawing ized. A template was fabricated to plan the size
and orientation of the osseous flap, the amount
Generally speaking, these patients do not need of required latissimus dorsi muscle, the inset,
tracheostomy. At the author’s institute, tracheos- and the necessary length of the pedicle (Fig. 3).
tomy is usually decided at intensive care postop- 2. The flap harvest can be described in five steps:
eratively if indicated. identifying the anterior border of the latissimus
Details and figures for the marking and patient dorsi muscle, identifying the septum between the
position are outlined in ▶ Chap. 36, “Reconstruc- latissimus dorsi muscle and the teres major mus-
tion of Total Maxillectomy and Orbital Floor with cle, identifying the angular branch from the
a Free Scapula Tip Flap.” In brief, the patient thoracodorsal vessel within the fatty tissue
donor site is marked with patient upright outlining between the two muscles, detaching the muscles
latissimus dorsi muscle and the scapula. The inci- attached to the scapular tip, and performing
sion is placed between the lateral border of the osteotomies and finally the dissection of the ped-
scapula and the latissimus dorsi muscle up to the icle. The latissimus dorsi muscle was harvested
axilla. Patient can be placed supine during general based on the fabricated template (Fig. 3) and the
anesthesia, but two-team simultaneous approach pedicle was ligated. Drill holes were made to
is not usually possible. As the shoulder needs to resecure the detached muscles. Layered closure
be flexed for scapular tip harvest, the upper limb was performed over a suction drain.
on the intended side for harvest needs to be free 3. The osseous portion of the flap measuring
drape for ease of mobilization. 31 19.7 12.3 mm was harvested and was
Fig. 3 (Left) intraoperative template to design the size of cervical recipient vessels. (Centre, Right) the chimeric
the scapular tip required to fill in the bone defect, the size of scapular tip flap incorporating a piece of latissimus dorsi
latissimus dorsi muscle required for coverage of skin muscle
defect and pedicle length adequate to reach contralateral
Fig. 4 (Left) Inset of the osseous scapular tip with a pre-bent plate (Right) Closure of the resultant soft tissue defect from
the approach to access the mandible with the latissimus dorsi muscle and meshed split thickness skin graft
secured with a 2.0 mm 10-hole mandibular Harvesting additional latissimus dorsi muscle
plate (KLS Martin™) and screws (Fig. 4). can be helpful for the coverage of this to avoid
4. The arterial anastomosis was performed using exposure.
9–0 S & T™ microsutures and the vein with 2. The utilization of a Cook Doppler probe not
the use of a venous coupler. only aids in postoperative monitoring, it also
5. An invasive Cook vascular Doppler was helps in picking up pedicle compression at
placed over the distal side of the venous anas- closure.
tomosis with care, ensuring the venous signal
is not an artifact (by occluding the vein proxi-
mal to the Doppler probe). The signal was used Intraoperative Images (Figs. 3 and 4)
as a guide while closing the neck wound, to
ensure no compression of the pedicle. The This section is modelled after other chapters, e.g.,
latissimus dorsi muscle was carefully inset chapter by Vieira et al ▶ Chap. 36, “Reconstruc-
into the resultant soft tissue defect in the neck tion of Total Maxillectomy and Orbital Floor with
(Fig. 4). a Free Scapula Tip Flap.” The section refers reader
6. A meshed split thickness skin graft was to the intraoperative images.
harvested and secured to the latissimus dorsi
muscle using 4-0 Vicryl Rapide suture (Fig. 4).
Technical Pearls The patient spent three nights at the intensive care
unit, and was then extubated and transferred to a
1. Define the defect first before harvesting the regular ward.
flap. This includes inspecting intraorally for Drains: A passive Penrose drain was placed in
any mucosal tear. If there is, be very wary of the neck wound on the side of the vascular anas-
the orientation of the denuded part of the bone tomoses. Two active drains were placed, one in
flap for placement of osteosynthesis plate. the donor site and another one in the neck wound
opposite to the vascular anastomoses, to avoid out of bed. The progression to subsequent
compression of the pedicle. Penrose drain typi- ambulation is dependent on the patient. This
cally is removed by day 3 and the active drains is especially important in the elderly patients,
removed when draining less than 30 cc over a has they tend to be deconditioned and require
24-h period. longer to recover to preoperative level of
Flap monitoring: The flap was monitored ambulation.
with a Cook Doppler probe on the venous end Antibiotics and thromboprophylaxis: Intra-
and a hand-held Doppler for arterial signal, based venous cefotaxime prophylaxis was adminis-
on our institution’s protocol: every 1 h for 24 h, tered for 1 week. Prophylactic dose of
then every 2 h for the following 48 h, and finally enoxaparin was given daily and compression
every 4 h until patient discharge. stockings were applied.
Nutrition and oral intake: Patient nasogastric
feed began on day 2 after the tracheostomy in this
patient, the patient is kept nil orally for 3 days Outcome, Clinical Photos, and Imaging
before the commencement of oral fluid. The naso-
gastric tube was removed on day 3, and parenteral Patient was admitted to intensive care unit for
nutrition support followed on day 4, while soft 3 days. Day 1 post-op, it was thought that he
diet started on day 5. would need a tracheostomy due to neck swelling,
Oral hygiene is maintained by patient daily which resulted in an additional 2 days stay in the
brushing of teeth and antibacterial mouth rinse intensive care. After returning to the ward, his
commencing on day 3. recovery was uncomplicated and he was discharged
Mobilization: The patient was instructed to from the hospital 16 days postoperatively.
maintain a neutral neck position for the first At 7 months follow-up, the patient’s external
week to protect the vascular pedicle. Patient wound healed with acceptable aesthetic result and
remained bed-bound for the first two postop- CT showed bone union (Figs. 5 and 6). The
erative days, while given instructions to per- patient declined the offer for a revision of the
form active mobilization of the extremities. neck skin graft and received 3 osseointegrated
Starting day 3, the patient is allowed to sit implants 17 months later.
Fig. 5 (Left) CT image 7 months post-operatively show- infection with healed soft tissue over the skin grafted
ing bony union of the scapula and native mandible at latissimus dorsi flap with acceptable aesthetic outcome
follow-up (Right) Resolution of the cutaneous fistula and
Fig. 6 Comparison of pre-operative PET CT (left) and at 7 months follow-up post-surgery (right) demonstrating
vascularity of the segment and healing of the previous non-union site
denuded exposed bone after the scapula tip

had been secured into position.
• For nuances related to the harvesting to scap-
• Dental occlusion is important for the patients’
ula tip flap, please refer to ▶ Chap. 36,
dental rehabilitation. Perioperative involve-
“Reconstruction of Total Maxillectomy and
ment of an experienced oral maxillofacial sur-
Orbital Floor with a Free Scapula Tip Flap.”
geon is thus critical. Intraoperatively, dental
occlusion can be restored or maintained by
expertly placed intermaxillary fixation. This can
also facilitate the placement of osseointegrated Learning Points
dental implants postoperatively.
• During the planning phase, it is advisable to be • Nonunion or osteoradionecrosis of the pseudo-
wary of potential deficiency of soft tissue both mandible after free flap reconstruction is a
in the irradiated neck and the oral mucosa. The highly morbid condition for an oral cancer
neck soft tissue after the access incision may survivor. As these patients have often been
often be difficult to close without compressing presented after long failing trial of conservative
the pedicle. Similarly, the intraoral mucosa is treatment, it is advisable to consider free
often irradiated and friable and occasionally is vascularized osseous flap management early
perforated or torn during dissection. This rather than later.
should be taken into account when harvesting • The goal should be to offer a single reliable
the scapula tip. The situation one hopes to procedure which involves careful planning,
avoid is to denude part of scapula in order for selection of a reliable flap, and choosing reli-
plate placement, only to realize the denuded able healthy recipient vessels away from the
portion of the osseous flap is facing side of the field of radiation.
torn mucosa intraorally. When one is conscious • A free vascularized chimeric scapular tip flap is
of this, additional portion of latissimus dorsi associated with low donor site morbidity and a
muscle can be designed to lie just over that long vascular pedicle that allows the reach to
the contralateral healthy vessels. The inclusion Delanian S, Chatel C, Porcher R, Depondt J, Lefaix J-L.
of latissimus dorsi muscle allows to address of Complete restoration of refractory mandibular
osteoradionecrosis by prolonged treatment with a
soft tissue defects. pentoxifylline-tocopherol-clodronate combination
• Placement of osseointegrated dental implants (PENTOCLO): a phase II trial. Int J Radiat Oncol
is still possible after the scapular tip free flap. Biology Phys. 2011;80(3):832–9.
The involvement of an experienced oral max- Dziegielewski PT, Bernard S, Mendenhall WM, Hitchock
KE, Gibbs CP, Wang J, et al. Osteoradionecrosis in
illofacial surgeon is key. osseous free flap reconstruction: risk factors and treat-
ment. Head Neck. 2020;42(8):1928–38.
Lee CCY, Hackenberg B, Halvorson EG, Caterson
EJ. Vascularized treatment options for reconstruction
Cross-References of the ascending mandible with introduction of the
femoral medial epicondyle free flap. J Craniofac Surg.
▶ Mandible Reconstruction in Osteoradionecrosis 2014;25(5):1690–7.
▶ Reconstruction of Total Maxillectomy and Robard L, Louis M-Y, Blanchard D, Babin E, Delanian
S. Medical treatment of osteoradionecrosis of the
Orbital Floor with a Free Scapula Tip Flap mandible by PENTOCLO: preliminary results. Eur
▶ Total Lower Face Reconstruction with Double Ann Otorhinolaryngol Head Neck Dis. 2014;131(6):
Free Flaps 333–8.
Vieira L, Isacson D, Dimovska EOF, Rodriguez-Lorenzo
A. Four lessons learned from complications in head and
neck microvascular reconstructions and prevention
References strategies. Plast Reconstr Surg Glob Open. 2021;9(1):
e3329.
Banaszewski J, Gaggl A, Andruszko A. Medial femoral Wilkman T, Husso A, Lassus P. Clinical comparison of
condyle free flap for head and neck reconstruction. Curr scapular, fibular, and iliac crest Osseal free flaps in
Opin Otolaryngol. 2019;27(2):13. Publish Ahead of maxillofacial reconstructions. Scand J Surg.
Print(NA;):NA 2018;108(1):76–82.
Part II
Upper Extremity
Complex Thumb Reconstruction Using
Free Chain-Linked “Mini Wraparound” 40
Great Toe and Dorsalis Pedis Flaps
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Abstract
The combination of an island dorsal foot flap

with a great toe transfer offers the possibility to
transfer two flaps vascularized tissue by one
R. Adani (*) vascular pedicle. The vascularization of the
Hand Surgery and Microsurgery, University of Modena,
Azienda Ospedaliero Universitaria Policlinico di Modena,
flap is the same as for the great toe. The partial
Modena, Italy great toe transfer restores adequate thumb
e-mail: adani.roberto@aou.mo.it length, good pulp, and an appearance of the
G. Petrella nail similar to the contralateral thumb. The dor-
Hand Surgery Department, Policlinico of Modena, salis pedis flap guarantees pliable skin very sim-
Modena, Italy ilar to the dorsum of the first metacarpal area.
e-mail: petrella.giovanna@aou.mo.it

https://doi.org/10.1007/978-3-030-23706-6_34
406 R. Adani and G. Petrella
Keywords reconstruct the distal phalanx of the thumb and

the dorsal aspect of the first ray simultaneously.
Mutilating injury · Thumb reconstruction ·
Mini wraparound technique · Dorsalis pedis
flap · Microsurgery
1. Mangling hand injuries are complex situations
A 47-year-old manual worker man sustained a that are challenging to manage. They require
severe crushing injury to his right hand (Fig. 1). careful planning and scrupulous execution of
After debridement, stabilization of the fractures treatment (Fig. 1). The first surgery is crucial
was performed by means Kirschner wires. The for salvaging joints, tendons, and nerves, to
vascularity of the distal thumb seemed severely prevent infection and to achieve bone stabili-
compromised, but at the initial surgery, no tissue zation. Definitive reconstruction can then
was discarded. Antibiotics therapy was adminis- follow.
tered due to the high risk of infection in this 2. Thumb reconstruction. One of the priorities for
compromised tissue. Three weeks after the initial mangled hand reconstruction is to have a stable
surgical procedure, debridement of the necrotic and opposable thumb of adequate length: the
tissue involving the thumb distal phalanx and the thumb should be preserved to all cost, and
dorsal aspect of the first ray was scheduled. It was major efforts to preserve it are justified (Del
decided to proceed with a transfer that could Piñal et al. 2016).
Fig. 1 A 47-year-old man, handworker, sustained a severe crushing injury to his right hand. Partial survival of the right
thumb following severe crushing injury to the hand
40 Complex Thumb Reconstruction Using Free Chain-Linked “Mini Wraparound” Great. . . 407
3. The specific quality of dorsal thumb skin perforator flaps harvested from the forearm (the
requires replacement tissue to have similar tex- radial or ulnar artery perforator flap) used as
ture for aesthetically satisfactory and func- either fasciocutaneous or adipofascial flaps
tional acceptable hand with appropriate (Adani et al. 2014). The posterior interosseous
selection of the skin coverage. flap represents another alternative option (Costa
et al. 1991).
3. Many techniques for distal thumb reconstruc-
Treatment Plan tion have been purposed and are often a
very similar one to the others (Adani et al.
In selected patients with strong motivation, the 1999; Del Piñal et al. 2014; Woo and Seul
loss of nail, sensible pulp, or the fine pinch may 1998). These techniques share a reconstruction
be indications to transfer part of the distal phalanx always performed using a custom-made osteo-
of the great toe. The partial great toe transfer offers onycho-cutaneous flap.
a cosmetic reconstruction; moreover, the nail rep-
resents a cosmetic as well as a functional advan-
tage. The cosmetic role of the thumbnail should Preoperative Evaluation and Imaging
not be underestimated. Some patients may have a
functional reconstructed thumb, but they underuse All our patients underwent a thorough preopera-
and hide it if the nail is not present. The functions tive investigation by using color Doppler ultra-
of the distal phalanx are not completely transfer- sound of the foot to establish the patency, location,
able to the remaining stump of the proximal pha- and course of the first dorsal metatarsal artery.
lanx. The method we use is the mini wraparound
flap (Adani et al. 2005). Simultaneously the flap
cover of the dorsal skin defect over the first meta- Preoperative Care and Patient
carpal ray was planned: it was decided to proceed Drawing
with a transfer that could reconstruct the distal
thumb and the dorsal skin defect employing the The patient is placed in a supine position. A tour-
dorsalis pedis skin flap in combination with partial niquet is applied on the thigh.
great toe transfer (Willemart et al. 1999). Generally, the ipsilateral foot is the first choice
because the use of the ipsilateral toe permits the
suture line to be on the radial side of the thumb
Alternative Reconstructive Options away from the ulnar contact surfaces encountered
during pinch.
1. Thumb amputation distal to the IP joint does Flap markings. Outline of the separate dorsalis
not cause any functional disability, and this pedis flap in continuity with the partial great toe
level of amputation does not necessarily transfer. Note the bridge between the great toe and
require microsurgical reconstruction. flap, which requires opening for access to the
2. For medium-sized defects located in the dorsal vascular pedicle (Fig. 2).
aspect of the first ray, pedicle flaps are a simple
solution, offering pliable skin very similar to
that of the dorsum of the thumb. The options
for regional pedicle flaps include the radial fore- Surgical Technique
arm fascial flap covered by a split-thickness skin
graft (Adani et al. 2001). The radial forearm flap 1. The donor site dissection is performed under
has been criticized because it requires the sacri- tourniquet control.
fice of a major artery in an already traumatized 2. The dorsalis pedis flap is outlined as an island
hand. A possible alternative may be represented separate 3 cm from the proximal level of the
by the dorsoradial flap (Demiri et al. 2013) or by great toe (Fig. 2).
Fig. 2 Right thumb amputation through the IP joint with vascularized by the common dorsal vascular pedicle. The
dorsal skin defect over the first metacarpal area. Markings elevated flaps showing the artery A, veins V, deep peroneal
for separate partial great toe transfer and dorsal pedis flap nerve N, and digital nerve N
3. The surgical procedure originates proximally dorsalis pedis vessels in continuity with
with identification of the dorsalis pedis artery. the mini wraparound flap (Fig. 2).
The dorsalis pedis artery is harvested in con- 9. The partial great toe transfer is inset into the
tinuity with the first dorsal metatarsal artery thumb defect, and the dorsalis pedis skin flap is
using a proximal dissection at the level of the used to cover the dorsal defect of the first ray.
dorsalis pedis artery. 10. Anastomosis is performed at the snuff box.
4. Two dorsal subcutaneous veins are identi- 11. The plantar digital nerve of the great toe is
fied in the dorsal aspect of the dorsalis pedis joined to the ulnar digital nerve of the thumb.
flap. 12. The great toe donor site is closed directly
5. The skin bridge between the great toe and employing the preserved medial strip of the flap.
dorsalis pedis flap is incised maintaining the 13. The dorsum of the foot and two residual
vascular supply for the mini wraparound flap. defects located on the dorsal aspect of the
A subcutaneous tissue is preserved between reconstructed thumb are covered with artifi-
the dorsalis pedis flap and the great toe flap cial dermis for 3 weeks before applying a
including the veins and artery (Fig. 2). split-thickness skin graft (Fig. 3).
6. We harvest the bone, nail plate, nail matrix,
and pulp from the medial aspect of the great
toe to achieve an appropriate circumference Technical Pearls
for the reconstructed thumb.
7. A longitudinal osteotomy is used to reduce 1. Attention needs to preserve the perforators to
the bone, leaving a medial flap of the distal the overlying dorsal foot skin during surgical
great toe to allow donor site direct closure. dissection of the dorsalis pedis artery.
8. The dorsalis pedis flap is elevated as a sepa- 2. The meticulous preservation of the extensor
rate proximal island along the course of the tendon paratenon is of crucial importance
Fig. 3 Dorsal skin defects

in the thumb and foot were
resurfaced with Integra ®
Dermal Regeneration
Template. (Integra ®
LifeSciences, Inc.,
Plainsboro, NY)
Fig. 4 After 3 weeks the

silicone sheet was removed,
and a thin split-thickness
skin graft from the lateral
thigh was used
because its presence, in the donor area, (1cp/100 mg per day for 3 weeks). The dorsalis
would reduce the risk of tendon adherence pedis flap and the reconstructed thumb were
to either the skin graft or Integra ® if used. examined every 2 h clinically and with Doppler
3. A bridge of the skin over the vulnerable for the first 4 days.
metatarsophalangeal joint region is
preserved.
4. Donor site coverage with Integra ® followed Outcome: Clinical Photos and Imaging
by STSG showed better results than the tradi-
tional technique (Figs. 4 and 5). Wound At follow-up 1 year after reconstruction, the static
healing with complete take of the skin graft two-point discrimination was 13 mm; the range
was obtained. of movement of the MP joints was 0–15 (Fig. 6).
Intraoperative Images Avoiding and Managing Problems
See Figs. 2, 3, 4, and 5. 1. Major morbidity occurs when a large segment

of dorsal foot skin is harvested in continuity
with the great toe. We suggest the use of the
Postoperative Management dorsalis pedis flap when a relatively small
amount of skin is requested.
Postoperatively the patients were treated for 2. The dorsalis pedis flap provides pliable and
7 days with low-molecular-weight dextran thin skin, but its major disadvantage is
(500 ml per day for 5 days) and cardioaspirin represented by the donor site scar, which is
Fig. 5 Complete skin graft

incorporation. K-wires were
removed after 6 weeks
Fig. 6 Result 1.5 year after reconstruction. Foot aspect in either the hand or the foot. Patient was satisfied and felt
showing skin grafted dorsal foot defect. Donor site result. comfortable with the appearance of the reconstructed
There were no significant problems with cold intolerance thumb
located in a very visible area as the dorsal 2. Some technical tips can help reduce donor site
aspect of the foot cannot be closed directly problems associated with the dorsalis pedis
and requires a skin graft. For this reason, the flap. The size of the flap should be limited,
dorsalis pedis flap is now rarely used because and surgeons should avoid raising the flap too
of its donor site morbidity, high incidence of distally; increased morbidity seems to accom-
graft loss, recurrence, ulceration, and scarring. pany flaps harvested up to 2 cm from the meta-
3. Donor site complications such as partial skin tarsophalangeal joint crease. The cosmetic
graft failure and extensor tendon exposure can appearance of the donor site can be improved
cause prolonged healing times after dorsalis by covering the site with artificial dermis for
pedis flap. The contracture of the graft site 3 weeks before applying a split-thickness skin
over tendons may cause tendon adhesion with graft (Fig. 3).
remarkable functional reduction of the foot. 3. K-wires should be left in situ for a minimum of
4. When the first dorsal metatarsal artery is defi- 6 weeks before obtaining complete bone
cient or absent, the plantar system should be fusion.
employed. When the artery is deep within the
interosseous muscle, the muscle which lies
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1. The dorsalis pedis flap is designed as a longi- from the great toe. J Hand Surg Br. 1999;24:437–42.
Adani R, Tarallo L, Caccese AF, Delcroix L, Cardin-
tudinal ellipse with the axis overlying the first
Langlois E, Innocenti M. Microsurgical soft tissue
metatarsal artery/dorsalis pedis artery vascular and bone transfers in complex hand trauma. Clin Plast
system. Surg. 2014;41:361–83.
Adani R, Tarallo L, Marcoccio I. Island radial artery Demiri EC, Dionyssiou DD, Pavlidis LC, Papas AV,
fasciotendinous flap for dorsal hand reconstruc- Kostogloudis NH, Lykoudis EG. Soft tissue recon-
tion. Ann Plast Surg. 2001 Jul;47(1):83–5. struction of the thumb with the dorsoradial forearm
Costa H, Comba S, Martins A, et al. Further experience flap. J Hand Surg Eur. 2013;38:412–7.
with the posterior interosseous flap. Br J Plast Surg. Willemart G, Kane A, Morrison WA. Island dorsalis pedis
1991;44:449–55. skin flap in combination with toe or toe segment trans-
Del Piñal F, Moraleda E, de Piero GH, Ruas JS, Galindo C. fer based on the same vascular pedicle. Plast Reconstr
Onycho-osteo-cutaneous defects of the thumb Surg. 1999;104:1424–9.
reconstructed by partial hallux transfer. J Hand Surg Woo SH, Seul JH. Distal thumb reconstruction with a great
Am. 2014;39:29–36. toe partial nail preserving transfer technique. Plast
Del Piñal F, Pennazzato D, Urrutia E. Primary thumb Reconstr Surg. 1998;101:114–9.
reconstruction in a mutilated hand. Hand Clin.
2016;32:519–31.
Free “Wrap-Around” Great Toe Flap
for Thumb Reconstruction After 41
Avulsion Injuries
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Outcome-Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Abstract
Numerous techniques have been described for

R. Adani (*) treating amputation at the midportion of the
Hand Surgery and Microsurgery, University of Modena,
Azienda Ospedaliero Universitaria Policlinico di Modena, proximal phalanx of the thumb, ranging from
Modena, Italy simple osteoplastic techniques to complex
e-mail: adani.roberto@aou.mo.it microsurgical procedures. Numerous varia-
G. Petrella tions of thumb reconstruction with the use
Hand Surgery Department, Policlinico of Modena, of toes from the foot are now available pro-
Modena, Italy viding a predictable outcome. Thumb recon-
e-mail: giovannapetrella@libero.it; petrella.
giovanna@aou.mo.it struction with a wrap-around free flap from

https://doi.org/10.1007/978-3-030-23706-6_35
the great toe gives good cosmetic and func- dorsal veins. Successful replantation was
tional result. The wrap-around technique is obtained (Fig. 2). Three days after the operation
ideally used in adult patients with an amputa- arterial thrombosis occurred at the thumb and
tion level distal to the metacarpophalangeal 8 days after the initial emergency procedure the
joint. thumb was amputated preserving the leftover
bone of the proximal phalanx.
Keywords Two weeks later, the patient was scheduled for
thumb reconstruction (Fig. 3).
Avulsion injury · Thumb reconstruction ·
Wrap-around procedure · Microsurgery
The Clinical Scenario Reconstructive Requirements
A 39-year-old woman manual worker sustained 1. Replantation of the thumb should be always
a complete left thumb avulsion–amputation. performed, as the outcomes of this treatment
The level of fracture was at the base of the prox- are superior to any secondary reconstruction
imal phalanx. The flexor pollicis longus tendon allowing the best functional and cosmetic
was completely avulsed at forearm level and results.
primary tendon reconstruction was not possible 2. Thumb reconstruction. Over time, surgeons
(Fig. 1). Replantation of the thumb was have tenaciously focused on thumb recon-
performed in emergency: osteosynthesis was struction by developing a variety of tech-
performed by means of two Kirschner wires niques for repair and reconstruction after
and the ulnar digital artery of the middle finger amputation. However, most surgeons consider
was dissected and transferred for anastomosis a thumb amputation with an intact meta-
with the ulnar digital artery of the thumb. The carpophalangeal (MP) joint to be an ideal can-
venous drainage was ensured by repairing two didate for toe-to-thumb transfer (Graham et al.
Fig. 1 A 39-year-old woman manual worker male sustained a complete left thumb avulsion–amputation
41 Free “Wrap-Around” Great Toe Flap for Thumb Reconstruction After Avulsion Injuries 415
Fig. 2 Replantation was

performed transferring the
ulnar digital artery of the
middle finger
dexterity and grasping of large objects (Pet et al.

2014). An ideal thumb repair or reconstruction
should follow the reconstructive criteria
suggested by Littler (1976): re-establish an
opposable, sensate, stable thumb of adequate
length while also considering strength and
mobility. Morrison et al. (1980) introduced a
novel reconstructive concept: aesthetically nor-
mal, since in aesthetic importance, the hand is
second only to the face (Morrison 1992). Con-
sidering the criteria of Littler (1976) and Morri-
son (1992), an optimal thumb reconstruction
should meet three main objectives: restore
thumb function, recreate its aesthetics, and min-
imize donor site morbidity.
3. Donor site morbidity. Among the various
techniques for great-toe transfers, the wrap-
around procedure has had the highest compli-
cation rate, perhaps due to the complex nature
Fig. 3 Amputation of the left thumb preserving the base of of flaps used to preserve the ray of the great
the P1 phalanx
toe or insufficient soft tissue to cover the IP
joint (Pan et al. 2011). Morrison et al. (1980,
1984; Morrison 1992) prefers to use a cross-
2016; Waljee and Chung 2013). Amputation toe flap; in the majority of our cases the great
proximal to the midportion of the proximal pha- toe is amputated at the base of the distal
lanx decreases hand span, affecting both pinch phalanx.
Treatment Plan 5. In addition to these procedures, some modified

twisted toe flap techniques are also available
The “wrap-around” technique (Morrison et al. (Kempny et al. 2013; Iglesias et al. 1995).
1980) is an ideal option for injuries that occurred These techniques combine the wrap-around
at the midportion of the proximal phalanx of the flap technique with the vascularized joint trans-
thumb. The best indication for this procedure fer and osteotendinous flap based on the single
is the thumb degloving injury (Adani et al. 1998; vascular pedicle.
Morrison 1992) with preserved skeletal elements 6. In order to reduce the donor site morbidity and
in which degloved skin replantation is not to maintain an intact skeleton of the great toe,
possible. The main advantage of this flap is its Zhang et al. (2016) suggested a reconstruction
well-matched size in relation to the normal con- of the thumb amputated at the proximal phalanx
tralateral thumb and reduced morbidity at the using an iliac bone graft plus a dorsal toenail
donor site. However, it is not useful for thumb flap to repair the dorsal defect and a dorsalis
reconstruction in children because it does not offer pedis flap to resurface the palmar defect.
any potential for growth (Morrison 1992). 7. For patients who refuse to remove a large por-
The drawbacks of this approach are manyfold: tion of their great toe, metacarpal lengthening
the reconstructed thumb has a limited range and an additional mini wraparound flap from
of motion and resorption of the bone graft the great toe represents another reconstructive
may occur (Lee et al. 2000). The patient must option (Adani and Woo 2017).
understand and accept the risks of operative
failure, donor site morbidity, and the functional
limitations of the transferred toe. Preoperative Evaluation and Imaging
The most important consideration in preoperative

Alternative Reconstructive Options planning for a microvascular free tissue transfer
for thumb reconstruction using the great toe as
1. Traditional non-microsurgical techniques: a donor site is the vascular supply to the donor
bone lengthening (Matev 1980), pollicization area. Patient goes through a preoperative investi-
(Ishida et al. 2006), or osteo-cutaneous radial gation by using color Doppler ultrasound of
flap and phalangization (Graham et al. 2016). the foot to establish the patency, location, and
2. Chinese authors (Pan et al. 2011; Shen et al. course of the first dorsal/plantar metatarsal artery
2016) suggested a newly modified wrap- system including the distal artery. Preoperative
around flap by preserving a plantar triangular evaluation does not include invasive studies
flap of the great toe. They reported excellent unless there is a history of previous trauma or
contour and functional outcome of the new congenital anomalies. Radiographs of the great
thumb, and the donor site morbidity in the toe, injured hand, and the normal thumb are used
foot seems acceptable. to determine the exact extent of the skeletal defect
3. The whole great toe can be transferred to compared with the normal thumb.
the thumb when the difference in nail width
between the thumb and the great toe is less than
3 mm, in patients whom the great toe is similar Preoperative Care and Patient
in size to the thumb (Adani and Woo 2017). Drawing
4. Trimmed great toe transfer (Wei et al. 1988)
includes a reduction of both the bony and soft The patient is placed in supine position.
tissues on the medial aspect of the great toe to Tourniquet is applied on the thigh. Generally, if
create a more natural-looking thumb. no variation exists in the arterial supply to the
great toe, the ipsilateral foot is the first choice 10. A longitudinal incision is employed to iden-
for the wrap-around flap, because the use of the tify the dorsal branch of the radial artery and
ipsilateral toe permits the suture line to be on the accompanying vein at the snuff box.
the radial side of the thumb away from the ulnar 11. A bicortical iliac crest bone graft is
contact surfaces encountered during the pinch placed between the proximal and the distal
movement. vascularized bone segments to increase the
Flap markings. Dorsal view: the entire big toe length of the reconstruction (Fig. 4b).
nail is included in the flap. Medial view: the 12. The distal phalanx of the wrap-around flap is
preserved medial skin is outlined. The proximal then secured to the iliac crest graft; K-wires
limit of the flap is determined by the length of the are used for skeletal fixation.
thumb to be reconstructed. As the ulnar side of 13. The skin of the flap is wrapped around the
the thumb is dominant, the flap is taken from the iliac crest graft (Fig. 4b).
ipsilateral toe to ensure good reinnervation and 14. The dorsal branch of the radial artery is
freedom at the level of the suture lines (Fig. 4a). sutured to the recipient vessel, and the digital
nerves of the flap are anastomosed to the
corresponding structures of the thumb.
Surgical Technique 15. The donor site may be closed by directly
employing the preserved medial strip of the
1. The donor site dissection is performed under flap. In alternative, a Hamilton cross toe flap
tourniquet control. could be used (Hamilton et al. 1979). A cross
2. The skin, nail, pulp, and the distal portion of toe flap from the dorsal aspect of the second
the distal phalanx are included in the flap. toe is taken for resurfacing the plantar aspect of
3. The difference between the circumference the great toe. A split-thickness skin graft is
of the thumb and the great toe determines applied to the dorsal defect of the great toe
the width of the flap remaining on the and second toes. The cross toe flap is divided
medial side of the great toe (usually about after 3 weeks.
1.5/1.6 cm) (Fig. 4a).
4. The flap can be based both on the dorsal or
plantar artery system. Technical Pearls
5. The plantar digital nerves are the main nerve
supply of the flap and are included and cut at 1. Early identification of the vascular anatomy of
the appropriate length. The deep peroneal nerve the first web space allows for less unnecessary
is also dissected and incorporated into the flap. dissection of an inadequate pedicle.
6. Two dorsal veins are identified at the dorsal 2. Artery spasm during surgery can be reduced
aspect of the foot. with meticulous dissection and ligation of the
7. The distal three-fourths of the bone distal secondary branches.
phalanx is harvested with the flap. The base 3. After deflating the tourniquet, the flap is allo-
of the phalanx including the insertion of the wed to perfuse for 15/20 min prior to ligation
flexor hallucis longus is not disturbed. and division of the vascular pedicle.
8. A longitudinal reduction osteotomy of the 4. The vascular pedicle is passed through
distal phalanx of the donor toe is done to a large subcutaneous tunnel from the proximal
reduce the circumference. incision and delivered distally; care is taken
9. When this compound transfer is entirely iso- to avoid any compression or rotation of
lated on its vessels, the tourniquet is deflated, the pedicle.
allowing the great toe wrap-around to perfuse 5. When the nail bed is diminished, the nail bed
while the recipient site is prepared. should be carefully reconstructed.
Fig. 4 (a) Skin incision for wrap-around toe flap. The Elongation of the skeleton with a bicortical iliac crest
circumference of the normal toe determines the width of bone graft initially inserted into the bone proximal pha-
the flap. The flap includes the nail and preserves a tibial lanx. The cortical-cancellous bone graft is shaped to the
strip of skin to be used to close the donor defect. (b) appropriate circumference and length for the thumb
Intraoperative Images better anchorage of the pulp to the bone allo-

wing a more precise fine pinch.
See Figs. 3 and 4. 2. Delayed union between the recipient thumb
phalanx and the bone graft may occur but
with no greater incidence than in other bone
Postoperative Management graft circumstance.
3. A trapdoor effect may occur at the junction
Postoperatively the patients were treated for 7 between donor and recipient site; this can be
days with low molecular weight dextran (500 ml prevented by a lax suture or by interruption of
per day) and cardioaspirin (100 mg per day). The the suture line with skin graft or with Integra
reconstructed thumb was examined every 2 h clin- and secondary skin graft.
ically and with Doppler for the first 3 days. Post- 4. The donor site presents some problems due to
operative intensive monitoring of the transferred the great amount of tissue harvested. Morrison
toe is mandatory. et al. (1980, 1984; Morrison 1992) prefers
to use a cross-toe flap; in the majority of our
cases, the great toe is amputated at the base
of the distal phalanx, and the insertion of
Outcome-Clinical Photos and Imaging
the flexor hallucis longus is not disturbed.
In patients in whom the long flexor of the
At follow-up 1 year after reconstruction, the
great toe is saved, gait analysis showed
static 2-point discrimination was 10 mm, and
a good thrust of the great toe with a normal
the moving 2-point discrimination was 8 mm;
propulsive step phase (Barca et al. 1995).
the range of movement of the MP joints is 0–
50 . The entire toe nail was used at the
time of transfer, and it is comparable to that
of the opposite thumb. The patient was very Learning Points
satisfied with the cosmetic (Fig. 5) and functional
results. 1. In assessing a candidate for thumb reconstruc-
tion, it is critical to build an individualized
treatment plan. A decision on the surgical
Avoiding and Managing Problems methods used depends on the age, health con-
dition, occupation, and functional demands
1. The most common complication (Steichen explicitly expressed by the patient. The maxi-
1991) is bone graft reabsorption. To try to mal age for complex thumb reconstruction
solve this problem, the bone graft was partially is around 60–65 years old.
modified (Morrison et al. 1984) by harvesting 2. Preoperative planning is crucial in design of
the flap together with a bone fragment distal to the wrap-around flap.
the P2. In this way, the bone graft harvested 3. After identifying the vessels in the first web
from the iliac crest is placed between two space of the foot, flap dissection in a proximal
vascularized fragments to reduce reabsorption and distal direction has been carried out using
and secondary fractures. This also gives a the retrograde approach.
Fig. 4 (continued) reconstruction and subsequently Regeneration Template (Integra LifeSciences, Inc.,
covered with a great toe wrap around flap (A artery, V Plainsboro, NY)
veins, N deep peroneal nerve and N digital nerve).
A dorsal skin defect was resurfaced with Integra Dermal
Fig. 5 A.Result 1 year after reconstruction. B.Comparison with opposite thumb. C.Donor site result. D.X ray result with
complete integration of the bone graft without signs of bone absorption
4. K-wires should be left in place until bony than a portion of the nail, which sometimes
fusion occurs, usually not before 7–8 weeks. results in a missing nail margin (except in
5. Drawbacks of the technique concern the cases where there is a marked difference
absence of growth potential (contraindicating in size between the normal thumb nail and
the technique in children) and the absence of the thumb nail of the great toe). The longitudi-
interphalangeal (IP) joint movement in the new nal reduction of the distal phalangeal bone
thumb. provides an improved nail appearance by
6. We prefer to transplant the entire great toe nail achieving better curvature using the “illusion
complex with the almost all of the pulp rather technique,” which, by curving the nail around
a narrow longitudinal segment of the toe distal ▶ First Toe-to-Hand Transfer and the Forearm
phalanx, creates the impression of a narrowed Radial Flap as Chain-Linked Flaps for Thumb
nail (Foucher and Sammut 1992). Reconstruction After Amputation
7. After reconstruction with the wrap-around
flap, the transplanted tissue will atrophy
gradually during the first year after surgery. References
This reduction in size of the transplanted
great toe does not always happen; if this reduc- Adani R, Woo SH. Microsurgical thumb repair and recon-
tion in size is not considered adequate by struction. J Hand Surg Eur. 2017;42(8):771–88.
Adani R, Busa R, Castagnetti C, Castagnini L, Caroli A.
the patient, a pulp plasty with longitudinal Replantation of degloved skin of the hand. Plast
excision of the skin and pulp as suggested Reconstr Surg. 1998;101(6):1544–51.
by Wei may be performed at a minimum of 1 Barca F, Santi A, Tartoni PL, Landi A. Gait analysis of
year after the primary reconstruction (Wei and the donor foot in microsurgical reconstruction of the
thumb. Foot Ankle Int. 1995;16(4):201–6.
Yim 1995). The indication for such secondary Foucher G, Sammut D. Aesthetic improvement of the
remodeling is based more on cosmetic than nail by the “illusion” technique in partial toe
functional grounds. transfer for thumb reconstruction. Ann Plast Surg.
8. The most disastrous complication of the wrap- 1992;28(2):195–9.
Graham DJ, Venkatramani H, Sabapathy SR. Current
around transfer is flap failure. The incidence reconstruction options for traumatic thumb loss. J
of flap failure was reported in 0–7% of Hand Surg [Am]. 2016;41(12):1159–69.
overall toe transfer cases (Adani and Hamilton RB, O’Brien BM, Morrison WA. The cross toe
Woo 2017). Operative failure is mainly due flap. Br J Plast Surg. 1979;32(3):213–6.
Iglesias M, Butron P, Serrano A. Thumb reconstruction
to failure to recognize and appropriately with extended twisted toe flap. J Hand Surg [Am].
treat vascular compromise. Re-exploration 1995;20(5):731–6.
should be carried out whenever vascular Ishida O, Taniguchi Y, Sunagawa T, Suzuki O, Ochi
insufficiency is suspected or does not improve M. Pollicization of the index finger for traumatic
thumb amputation. Plast Reconstr Surg. 2006;117:
after bedside management. Most vascular 909–14.
compromise is caused by arterial insuffi- Kempny T, Paroulek J, Marik V, Kurial P, Lipovy B,
ciency within 72 h following surgery. Huemer GM. Further developments in the twisted-toe
9. The technical difficulty of finding the nerve technique for isolated thumb reconstruction: our method
of choice. Plast Reconstr Surg. 2013;131:871e–9e.
stumps in the recipient site mainly in avulsion Lee KS, Park JW, Chung WK. Thumb reconstruction with
injuries led to a non-optimal suture, and the wrap-around free flap according to the level of ampu-
recovery of sensibility is generally not bril- tation. Microsurgery. 2000;20(1):25–31.
liant: static two-point discrimination returned Littler JW. On making a thumb: one hundred years of
surgical effort. J Hand Surg [Am]. 1976;1:35–51.
to 10 mm; pinch and grip strength are restored Matev IB. Thumb reconstruction through metacarpal bone
up to 70–75% of the contralateral hand. lengthening. J Hand Surg [Am]. 1980;5(5):482–7.
Morrison WA. Thumb reconstruction: a review and
philosophy of management. J Hand Surg (Br).
1992;17(4):383–90.
Cross-References Morrison WA, O’Brien BM, MacLeod AM. Thumb recon-
struction with a free neurovascularized wrap-around
▶ Combined Osteodistraction and Free “Mini flap from the big toe. J Hand Surg [Am].
Wraparound” Great Toe Flap for Thumb 1980;5(6):575–83.
Morrison WA, O’Brien BM, MacLeod AM. Experience
Reconstruction After Amputation at the Meta- with thumb reconstruction. J Hand Surg (Br).
carpophalangeal Level 1984;9(3):223–33.
▶ Complex Thumb Reconstruction Using Free Pan YW, Zhang L, Tian W, Tian G, Zhao J, Guo X. Donor
Chain-Linked “Mini Wraparound” Great Toe foot morbidity following modified wraparound flap for
thumb reconstruction: a follow-up of 69 cases. J Hand
and Dorsalis Pedis Flaps Surg [Am]. 2011;36(3):493–501.
▶ Free “Wrap-Around” Great Toe Flap for Pet M, Ko JH, Vedder NB. Reconstruction of the traumatized
Thumb Reconstruction After Avulsion Injuries thumb. Plast Reconstr Surg. 2014;134(6):1235–45.
Shen XF, Mi JY, Xue MY, Zhao G, Qiang L, Zhou X, Rui YJ, Wei FC, Yim KK. Pulp plasty after toe-to-hand
Chim H. Modified great toe wraparound flap with pres- transplantation. Plast Reconstr Surg. 1995;96(3):
ervation of plantar triangular flap for reconstruction of 661–6.
degloving injuries of the thumb and fingers: long-term Wei F-C, Chen H-C, Chuang C-C, Noordhoff MS.
follow-up. Plast Reconstr Surg. 2016;138(1):155–63. Reconstruction of the thumb with a trimmed-toe
Steichen JB. Complications and bad results of thumb recon- transfer technique. Plast Reconstr Surg. 1988;82(3):
struction by the microvascular “wrap-around” tech- 506–15.
nique. Ann Chir Main Memb Super. 1991;10(6):523–8. Zhang G, Ju J, Li L, Jin G, Li X, Hou R. Combined
Waljee JF, Chung KC. Toe-to-hand transfer: evolving foot flaps with iliac bone graft for reconstruction
indications and relevant outcomes. J Hand Surg [Am]. of the thumb. J Hand Surg Eur Vol. 2016;41(7):
2013;38(7):1431–4. 745–52.
Combined Osteodistraction and Free
“Mini Wraparound” Great Toe Flap for 42
Thumb Reconstruction After
Amputation at the
Metacarpophalangeal Level
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
Abstract
Amputation at metacarpophalangeal joint can

be treated employing different techniques
including pollicization of a finger, osteoplastic
R. Adani (*) reconstruction, free microvascular transfer of a
Hand Surgery and Microsurgery, University of Modena, toe, and distraction lengthening. Choosing the
Azienda Ospedaliero Universitaria Policlinico di Modena, optimal technique depends on the level of
Modena, Italy amputation and the patient’s age, sex, occupa-
e-mail: adani.roberto@aou.mo.it
tion, and functional demands. The reconstruc-
G. Petrella tion of a traumatically amputated thumb
Hand Surgery Department, Policlinico of Modena, requires matching the individual needs of the
Modena, Italy
e-mail: petrella.giovanna@aou.mo.it;
giovannapetrella@libero.it

https://doi.org/10.1007/978-3-030-23706-6_36
patient to one or more of the possible treatment at the metacarpophalangeal joint with severe
options available to the surgeon. retraction of the first web space (Fig. 1).
This case illustrates a combination of two
surgical procedures, metacarpal lengthening
and mini wraparound flap from the great toe, to
improve the donor site appearance while main- Preoperative Problem List-
taining the same aesthetic results for the thumb. Reconstructive Requirements
There were no complications or post-
operative vascular compromise. The mean 1. First web space release. The presence of an
pinch power was 66% of the contralateral adequate first web space is essential for thumb
hand. The static two-point discrimination of and prehensile hand function. The web contrac-
the reconstructed thumb was 8 mm. The patient ture may be the result of damage to the skin,
reported being satisfied with the treatment, and muscles, tendons, nerves, or bones of the first
the donor site morbidity was minimal. two rays, generally as a consequence of trauma,
The case shows that thumb reconstruction burn, infection, and neoplasia. If there is a
using metacarpal lengthening plus mini wrap- severe adduction of the thumb, it is necessary
around flap from the great toe can be performed to perform a wide release of all contracted deep
successfully. The treatment process is lengthy; first web structures, which results in a skin
however, the patient felt that the time invested defect on both sides of the hand. In this condi-
was well spent. This technique has been best
tion a local flap is inadequate, and it is necessary
accepted by young, well-motivated patients.
to perform a pedicle or a free tissue transfer (Del
Piñal et al. 2004; Adani et al. 2006; Gong and
Keywords Lu 2011; Kai et al. 2013).
2. Thumb reconstruction. Traumatic loss of the
Thumb reconstruction · Metacarpal
thumb presents a significant functional disability
lengthening · Matev technique ·
since the thumb is the most essential component
Microsurgery · Great toe transfer
of the hand; its amputation accounts for a loss of
50% in hand function (Shin et al. 1999). Signif-
The Clinical Scenario icant effort has been focused on thumb recon-
struction, and a variety of techniques have been
A 48-year-old man sustained a severe right developed to reconstruct the thumb, ranging
thumb infection caused by brown recluse spider from traditional techniques to microsurgical pro-
bite. He was initially treated elsewhere with cedures (Finsen and Russwurm 1996). The
multiple debridement in attempt to salvage the advent of microsurgery has in fact radically
thumb totally or partially. These necrotic lesions modified previous surgical approaches, and
are difficult to manage, and early surgery to now free flaps from the great toe are widely
remove dead tissue has not shown to improve used for the reconstruction of an amputated
outcomes (Wilson et al. 2005). Necrotic lesions thumb. Various surgical techniques have been
with careful cleaning are allowed to mature for reported, and opinions differ as to which tech-
weeks until spreading stops and healing appears nique represents the best solution for each level
to begin. Despite various efforts including nega- of amputation (Adani and Woo 2017).
tive wound pressure therapy and hyperbaric 3. Donor site morbidity. Patient was highly moti-
oxygen therapy, the thumb was amputated. vated to obtain a functional and aesthetic
Seven months following the initial injury, the reconstruction of the thumb using an alterna-
patient was referred to our institution for thumb tive way to reconstruct the thumb without
reconstruction. His right thumb was amputated removing a large portion of the great toe.
42 Combined Osteodistraction and Free “Mini Wraparound” Great Toe Flap for Thumb. . . 425
Fig. 1 Right thumb-

patient’s appearance
decrease the contractures. Once the web space has

Treatment Plan
been released, a pattern of the flap is prepared, and
this should be centered over the lateral aspect of the
The reconstruction of a traumatically amputated
ipsilateral forearm where the perforators of the
thumb requires careful assessment of both the
posterior interosseous artery are located.
patient’s needs and the different surgical proce-
dures available. Patients should be well-informed
about the various treatment options, and it is then
the patient’s choice that determines which tech- Alternative Reconstructive Options
niques to use. In Western countries, patients are
often reluctant to donate toes from the foot. 1. First web space release with lateral arm
To offer a satisfactory option to patients who refuse free flap (Scheker et al. 1988) or with ALT
to have a large portion of their great toe removed, flap (Adani et al. 2006).
like this patient, we propose distraction lengthen- 2. Traditional non-microsurgical techniques: polli-
ing in order to elongate the metacarpal, and then we cization (Ishida et al. 2006) or osteocutaneous
perform a partial great toe transfer (Adani et al. radial flap and phalangization (Cheema and
2013). The first web release must be performed. Miller 2009; Graham et al. 2016; Jones et al.
Release of the severely contracted web space starts 2008; Muzzaffar et al. 2005).
by incising the skin dorsally in a zigzag manner or 3. Microsurgical thumb reconstruction: if the
with straight-line incisions. The fascial contrac- metacarpal head is intact, the whole great
tures are released, and the origin of the first toe with its metatarsal-phalangeal ligaments
interosseous muscle from the first metacarpal is can be transferred, which may restore function
incised. The origin of the adductor pollicis from of the thumb MP joint (Buncke et al. 2007).
the third metacarpal can also be released to The trimmed-toe technique (Wei et al. 1988,
1994) combines the best parts of the total toe

transfer and wraparound procedures. MP joint
arthrodesis is frequently performed to ensure
stability and pinch to the new thumb.
4. Microsurgical thumb reconstruction and first
web release: great toe transfer plus dorsalis
pedis fascio-subcutaneous flap (del Piñal
et al. 2005).
The most important consideration in preoperative

planning for a microvascular free tissue transfer for
thumb reconstruction using the great toe as a donor
site is the vascular supply to the donor area. The
patient goes through a preoperative investigation
by color Doppler ultrasound of the foot in order for
the patency, location, and course of the first dorsal/
plantar metatarsal artery system including the distal
artery to be established. Preoperative evaluation
does not include invasive studies unless there is a Fig. 2 Osteotomy was done subperiosteally using
history of previous trauma or congenital anomalies. piezosurgery saw, and distraction callotasis (red arrow
Radiographs of the great toe, involving hand and indicates the site of bone distraction) was applied with a
lengthener (Orthofix)
normal thumb, are used to determine the exact
extent of the skeletal defect compared with the
normal thumb. Allen’s test is done to assess preop- Sciences, Inc., Plainsboro, NY). After 23 days
eratively vascular supply at the recipient side and the silicone sheet was removed, and a thin split-
allow us to observe palmar blush within 5 s. thickness skin graft was employed from the
lateral thigh.
Surgical Technique 4. Distraction was continued for an average of
2 months. To achieve bone consolidation, the
1. Metacarpal lengthening was performed 10 months fixator is left in place for an average of
after the initial injury. Our method uses the Matev 4 months. At that point the new thumb
technique (Heitmann and Levin 2002) to lengthen measured 23 mm in length (Fig. 4).
the stump with a lengthening device (Orthofix M- 5. Two months later, thumb reconstruction was
100, Orthofix srl, Verona, Italy). A longitudinal completed with a mini wraparound great toe
dorso-radial incision is made over the metacarpal, transfer. Under general anesthesia, the distal
and pairs of 2.5 mm pins are inserted. The three-fourths of the toe phalanx were harvested
osteotomy is done subperiosteally and distracted from the ipsilateral great toe and the base of
0.5 cm to ensure proper movement of the bone the toe distal phalanx. The flap included the
fragments and then closed leaving a bone gap of entire nail, most of the pulp, and the dorsal,
about 0.2–0.3 cm. (Fig. 2). lateral, and plantar skin of the great toe. A narrow
2. One month after the initial surgical procedure, medial skin flap (usually about 1.5 cm in length,
the web space was opened using a pedicle representing the difference between the great toe
reverse posterior interosseous forearm flap and the thumb circumferences) was preserved
(7.5 cm 4.3 cm in size) (Fig. 3). for closure. The plantar metatarsal artery was
3. The donor site was resurfaced with Integra Der- dissected using a distal dissection, due to the
mal Regeneration Template (Integra Life presence of hypoplastic first dorsal metatarsal
Fig. 3 Severe scar contracture at the first web space. After extensive release of the first web space, a pedicle posterior
interosseous flap was employed to fill the defect
Fig. 4 After the initial surgical procedure, the new thumb measured 23 mm in length: clinical and radiological aspect
upon removal of the external fixator
artery (type III) (Shin et al. 1999). The deep 5. The origin of the first dorsal interosseous
peroneal nerve and the lateral plantar digital muscle from the first metacarpal should be
nerves were also dissected. K-wires were used released while carefully avoiding injury to
for skeletal fixation and were left until bony the radial artery.
fusion occurred for 8 weeks. A longitudinal inci- 6. The origin of the adductor pollicis from the
sion was employed to identify the dorsal branch third metacarpal can also be released to
of the radial artery and the accompanying vein at decrease the contracture.
the snuff box. The dorsal branch of the radial 7. The posterior interosseous artery must be
artery was cut at the time of transfer and included in the adipofascial pedicle because
was anastomosed to the recipient vessel. The its sacrifice is not relevant for the hand blood
digital nerve of the flap was sutured to the ulnar supply and, additionally, it improves the
digital nerve of the thumb (Fig. 5). perfusion of the skin paddle.
8. A wide adipofascial pedicle enhances venous
Technical Pearls drainage and makes the procedure safer in
that venous congestion is prevented.
1. Osteotomy must be performed sub- 9. Careful preoperative assessment of the
periosteally with a Kirschner wire and a vascular system of the great toe.
fine chisel or employing a piezosurgery saw. 10. Retrograde dissection of the first dorsal/plan-
2. The average distraction is a maximum of tar metatarsal artery.
0.5 mm per day. 11. Use refined microsurgical suture techniques.
3. To achieve bone consolidation, the lengthener
should be left in place for an average of
120 days. Intraoperative Images
4. Maintain the lengthener in place until the
bone regenerates spontaneously. See Figs. 2, 3, 4, and 5.
Fig. 5 Preoperative view of the mini wraparound flap. under the artery). Final aspect of the flap: A artery, V veins,
Intraoperative view with partial great toe transfer based and N nerve
on the plantar artery system (surgical instrument positioned
Postoperative Management Avoiding and Managing Problems
Postoperatively the patients were treated for 1. Fracture of the lengthened bone may occur
7 days with low molecular weight dextran after removing the lengthener. The fracture
(500 ml per day) and aspirin (300 mg per day). in that case should be treated with an
The reconstructed thumb was examined every intramedullary Kirschner wire, and a cast be
2 h clinically and with Doppler for the first applied until bony fusion is achieved.
3 days. 2. To prevent vascular complications of the toe-to-
hand transfer, meticulous dissection and ligation
of the branch vessels, complete anastomosis of
the vessels, and postoperative intensive moni-
Outcome-Clinical Photos and Imaging toring of the transferred toe are necessary.
3. Re-exploration should be carried out whenever
At follow-up 81 months after reconstruction, vascular insufficiency is suspected.
the static 2-point discrimination was 7 mm,
and the moving 2-point discrimination was
6 mm. The pinch power was 4.6 kg (compared Learning Points
with 6.5 kg in the opposite hand), and the
Kapandji score was 5. The patient was very 1. Patient must be highly motivated to obtain a
satisfied with cosmetic (Fig. 6) and functional functional and aesthetic reconstruction of the
results. thumb.
Fig. 6 Appearance of the entire hand 2 years after thumb and first web space reconstruction. Donor site result of the great
toe and the forearm where the posterior interosseous pedicled flap was harvested
2. Our patient needed 4 months on average to gain Adani R, Corain M, Tarallo L, Fiacchi F. Alternative
approximately 23 mm using callotasis alone. A method for thumb reconstruction. Combination of 2
techniques: metacarpal lengthening and mini
good stump of the thumb provides sufficient wraparound transfer. J Hand Surg [Am]. 2013;38(5):
functional ability, and the reconstruction is not 1006–11.
necessary in a partial amputation if a strong Buncke GM, Buncke HJ, Lee CK. Great toe-to-thumb
pinch between the stump and the opposite fingers microvascular transplantation after traumatic amputa-
tion. Hand Clin. 2007;23(1):105–15.
is achieved. Matev’s progressive lengthening Cheema TA, Miller S. One-stage osteoplastic reconstruc-
cannot be considered as a cosmetic procedure, tion of the thumb. Tech Hand Up Extrem Surg.
and reconstructive surgery may still be necessary 2009;13(3):130–3.
to obtain a satisfactory thumb appearance. Del Piñal F, Garcia-Bernal FJ, Delgado J. Is posttraumatic
first web contracture avoidable? Prophylactic guide-
3. The posterior interosseous pedicle island lines and treatment-oriented classification. Plast
flap has some advantages: it is thinner, may Reconstr Surg. 2004;113(6):1855–60.
be very hairy in males, there is less morbidity Del Piñal F, García-Bernal FJ, Delgado J, Regalado J,
at the donor site, and the major artery is pre- Sanmartín M, García-Fernández D. Overcoming soft-
tissue deficiency in toe-to-hand transfer using a dorsalis
served. The greatest disadvantages reside in pedis fasciosubcutaneous toe free flap: surgical tech-
the limited sizes available for the flap: closure nique. J Hand Surg [Am]. 2005;30(1):111–9.
of the donor site can be achieved only if it is Finsen V, Russwurm H. Metacarpal lengthening after
less than 3-cm wide. traumatic amputation of the thumb. J Bone Joint Surg
(Br). 1996;78(1):133–6.
4. The partial great toe transfer offers a pleasing Gong X, Lu LJ. Reconstruction of severe contracture of the
cosmetic reconstruction, including the nail, first web space using the reverse posterior interosseous
which represents a cosmetic as well as a artery flap. J Trauma. 2011;71(6):1745–9.
functional advantage. Graham DJ, Venkatramani H, Sabapathy SR. Current
reconstruction options for traumatic thumb loss.
5. Combining distraction osteogenesis and microsur- J Hand Surg [Am]. 2016;41(12):1159–69.
gery represents an alternative way to reconstruct Heitmann C, Levin LS. Alternatives to thumb replantation.
the thumb amputated at MP joint level without Plast Reconstr Surg. 2002;110(6):1492–503.
removing a large portion of their great toe. Ishida O, Taniguchi Y, Sunagawa T, Suzuki O, Ochi M.
Pollicization of the index finger for traumatic thumb
6. This procedure eliminates the need for an iliac amputation. Plast Reconstr Surg. 2006;117(3):
bone graft, which may cause potential 909–14.
problems of bone fracture and reabsorption. Jones N, Jarrahy R, Kaufman M. Pedicle and free radial
7. The main disadvantage is the prolonged treat- forearm flaps for reconstruction of the elbow, wrist and
hand. Plast Reconstr Surg. 2008;121(3):887–98.
ment time. Kai S, Zhao J, Jin Z, Wu W, Yang M, Wang Y, Xie C, Yu J.
8. This method of thumb reconstruction does not Release of severe post-burn contracture of the first web
allow movement of metacarpophalangeal and space using the reverse posterior interosseous flap: our
interphalangeal joints. experience with 12 cases. Burns. 2013;39(6):1285–9.
Muzzaffar AR, Chaoo JJ, Friedrich JB. Posttraumatic
9. The reconstruction of a traumatically ampu- thumb reconstruction. Plast Reconstr Surg. 2005;116
tated thumb requires careful assessment of (5):103e–22e.
both the patient’s needs and the different Scheker LR, Lister GD, Wolff TW. The lateral arm free flap
surgical procedures available. Patients should in releasing severe contracture of the first web space.
J Hand Surg (Br). 1988;13(2):146–50.
be well-informed about the various treatment Shin AY, Bishop AT, Berger RA. Microvascular recon-
options, and it is then the patient’s choice that struction of the traumatized thumb. Hand Clin.
determines which techniques to use. 1999;15(2):347–71.
Wei FC, Chen HC, Chuang CC, Noordhoff MS. Recon-
struction of the thumb with a trimmed-toe transfer
technique. Plast Reconstr Surg. 1988;82(3):506–15.
References Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgical
thumb reconstruction with toe transfer: selection of
Adani R, Woo SH. Microsurgical thumb repair and various techniques. Plast Reconstr Surg. 1994;93
reconstruction. J Hand Surg Eur. 2017;42(8):771–88. (2):345–51.
Adani R, Tarallo L, Marcoccio I, Fregni U. First web-space Wilson JR, Hagood CO Jr, Prather ID. Brown recluse spider
reconstruction by the anterolateral thigh flap. J Hand bites: a complex problem wound. A brief review and
Surg [Am]. 2006;31:640–6. case study. Ostomy Wound Manage. 2005;51(3):59–66.
First Toe-to-Hand Transfer
and the Forearm Radial Flap as 43
Chain-Linked Flaps for Thumb
Reconstruction After Amputation
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Alternative Reconstruction Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Moment of Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Type of Reconstruction for the Thumb and Skin Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Outcome: Clinical Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
Abstract
Complex injuries of the hand with soft tissue

A. V. Georgescu (*)
Plastic Surgery, Aesthetic Surgery and Reconstructive defects and concomitant thumb amputation
Microsurgery, University of Medicine Iuliu Hatieganu, require an elaborated surgical approach to
Rehabilitation Hospital, Cluj Napoca, Romania

https://doi.org/10.1007/978-3-030-23706-6_37
432 A. V. Georgescu
address both soft tissue coverage and thumb FDP of the fourth finger (Fig. 1a and b) were
reconstruction. In our experience, for this kind injured. The amputated fingers were missing.
of lesions, the all-in-one reconstruction seems to
be best option especially in young patients. This
case refers to an 18-year-old male presenting a Preoperative Problem List:
complex circular saw injury of his left hand, Reconstructive Requirements
with thumb, index finger and fifth digital ray
amputation, and palmar and dorsal soft tissue 1. Aggressive but careful debridement, with
defect, involving both common vasculo- preservation of all the remaining functional ele-
nervous pedicles (VNP) for third and fourth ments (Godina 1986; Lister 1988; Georgescu
web spaces, flexor digitorum profundus (FDP) and Ivan 2003)
of the third finger, and both flexor digitorum 2. Elaborating the lesions balance sheet and
superficialis (FDS) and FDP of the fourth finger. establishing the repair priorities (Georgescu
After careful debridement, FDP repair of and Ivan 2003; Georgescu 2005)
the third and fourth finger, revascularization 3. Choosing the right moment for reconstruction
of the fourth finger, as well as reinnervation (Godina 1986; Lister 1988; Georgescu and Ivan
of the third and fourth finger was undertaken. 2003)
Finally, a contralateral radial forearm flow- 4. Absence of thumb and two more fingers
through flap was simultaneously used for cov- (Foucher et al. 1984; Wei et al. 1988; Georgescu
erage of the palmar and dorsal soft tissue defect 2005)
of the hand and for thumb reconstruction using 5. Requirement to reconstruct at least the thumb,
a big toe transfer. the two remaining long fingers, and the
The postoperative evolution was unevent- soft tissue defect (Georgescu and Ivan 2003;
ful, and the functional and morphological Georgescu 2005)
results were very good, with the regain of
70% from the hand functionality. Aesthetic
results were considered satisfactory for both
Treatment Plan
donor and recipient sites.
In the attempt to obtain an as functional as possi-
Keywords ble hand, we planned to do an all-in-one emer-
Complex hand trauma · Emergency all-in-one gency reconstruction. Thus, after an aggressive,
reconstruction · Radial forearm flow-through but very careful, debridement to avoid damaging
flap · Toe transfer · Hand reconstruction of the remaining functional elements, we planned
the following steps:
The Clinical Scenario – Regularization and closure of the stump of the

second finger
An 18-year-old male presented in emergency with a – Repair of the FDP of the third and fourth
complex injury by circular saw of the left hand, with fingers
complete amputation of the thumb and index finger – Revascularization of the fourth finger by
on the middle third of the first phalanx, fifth digital reconstruction of the common digital artery
ray amputation, and a palmar soft tissue defect over (CDA) of the third web space
the third and fourth metacarpals, extending over the – Neurorrhaphy of the common digital nerve
ulnar and dorsal aspect of the fourth metacarpal (CDN) of the third web space and ulnar proper
bone. Both common vasculo-nervous pedicles digital nerve (PDN) of the fourth finger
(VNP) for third and fourth web spaces and the – Coverage of the hand defect with a contralat-
flexor digitorum profundus (FDP) of the third finger eral radial forearm flow-through flap
and both flexor digitorum superficialis (FDS) and – Thumb reconstruction with big toe transfer
43 First Toe-to-Hand Transfer and the Forearm Radial Flap as Chain-Linked Flaps for Thumb. . . 433
Fig. 1 Preoperative aspect of the hand. (a) palmar aspect; (b) dorsal aspect
Moreover, a skin graft over the repaired

vessels and nerves is not the best choice.
Improvement of the hand functionality can
Moment of Reconstruction
be obtained later by secondary reconstruc-
tion of the thumb.
1. Two-stage procedure: debridement in the first
4. Skin graft over the hand defect and thumb
stage and reconstruction after 12–72 h (Godina
reconstruction by one of the following
1986; Lister 1988; Ninkovic et al. 1999). The
methods:
disadvantages of this method are represented
by the need of at least two surgeries and gen- – Emergency/secondary transposition of the
eral anesthesias and the risk of infection even if remaining first phalanx segment of the
the 72 h interval is considered safe regarding index finger, but with the disadvantage
sepsis (Godina 1986). of no nail and suboptimal optical
2. Two-stage procedure: debridement in the first appearance
stage and secondary reconstruction. The disad- – Emergency/secondary reverse island radial
vantage of this procedure is the development of flap including a segment from the radius
local fibrosis and sclerosis, which can compro- (Foucher et al. 1984). Disadvantage: bulky
mise a microsurgical procedure (Georgescu reconstruction, no nail
2005). – Emergency/secondary reconstruction by sec-
ond toe transfer (Yang and Yudong 1979).
Disadvantage: big discrepancy between the
Type of Reconstruction for the Thumb first phalanx of the thumb and the second toe
and Skin Defect transfer
– Secondary reconstruction by armed abdom-
3. Regularization of the stumps of the ampu- inal tubular flap (McGregor and Simonetta
tated fingers and skin grafting over the hand 1964). Disadvantages: very bulky flap
defect. This method does not offer enough needing secondary defatting procedures;
functionality to the reconstructed hand. risk of bone resorption
434 A. V. Georgescu
5. Secondary first metacarpal bone lengthening – Thumb amputation at the level of the mid-
(Matev 1970). Disadvantages: long procedure; dle third of the proximal phalanx, with
suboptimal appearance; limited functionality compromised digital arteries and radial
6. Free or regional flap to cover the hand defect digital nerve. The stump of the ulnar dig-
and thumb reconstruction by one of the above ital nerve in good condition.
described methods. Depending on the big toe – Amputation of the index finger at the level
dimensions, it can be harvested as a complete of the middle third of the first phalanx
segment (Georgescu 2015) or as a wraparound and of the fifth digital ray at the
(Morrison et al. 1980) or a trimmed-toe proce- carpometacarpal level.
dure (Wei et al. 1988). – Skin defect of 7 cm 4 cm over the third
and fourth metacarpals, extending over the
ulnar and dorsal aspect of the fourth meta-
Preoperative Evaluation carpal bone. FDS of the third finger and
FDP of both the third and fourth fingers
Preoperative evaluation of the donor right severed, as well as the common vasculo-
upper limb and left lower limb: the Allen test nervous pedicle for the third and fourth
by putting pressure alternatively on the radial web spaces.
and ulnar artery didn’t detect vascular prob- – The third finger was well-colored and with
lems in the hand; handheld Doppler examina- good capillary refilling, whereas the fourth
tion of the foot has shown a good vascular flow finger had a very slow capillary refilling.
through both posterior and anterior tibial – A palmar proximal incision, extended to
arteries. the forearm, was performed, and the
branch of the ulnar artery for the fourth
web space was prepared.
Preoperative Care and Patient 2. The FDP 3 and 4 were sutured by modified
Drawing Kessler flexor tendon repair technique.
3. The common digital nerve of the third web
With the patient in supine position, both upper space and the proper ulnar digital nerve of the
limbs and the left lower limb were prepared. All fourth digit were reconstructed by direct
the procedures were done under tourniquet. microsurgical epi-perineural coaptation.
A flap of 10 cm 6 cm was designed over the 4. The revascularization of the fourth digit was
palmar and radial aspect of the distal right fore- performed through microsurgical reconstruc-
arm, centered to the radial artery with its concom- tion (end-to-end anastomosis) of the third
itant veins and the cephalic vein. common digital artery.
The dimensions of the left big toe were very 5. Through small incisions from the proximal
similar with those of the thumb. Thus, the and distal edge of the designed flap on the
harvesting of all big toe with the respect right forearm, the radial artery and its con-
of the proximal half of the first phalanx was comitant veins were isolated. Then, an inci-
decided. The design on this level was performed sion on the ulnar, proximal, and distal edges
accordingly. of the designed flap was done, and its dissec-
tion started from medial to lateral in the
subfascial plan, but respecting the peritenon.
Surgical Technique Care was taken to include all the septum
containing the radial artery and to preserve
1. A relative aggressive but very careful all its perforators entering the skin. Finally,
debridement was performed by avoiding the the radial edge of the flap was incised, and
damage of the functional elements. The final the cephalic vein was also included in the
lesions balance sheet showed: flap. The radial artery and the cephalic vein
were ligated distally. After releasing the tour- waiting time was necessary to observe a nor-
niquet, the flap was very well-colored and mal capillary pulse and active bleeding of
with good capillary refilling. The flap was the flap.
detached from the donor site and applied to 9. The harvested big toe segment was detached
the recipient site. from its donor site. To increase the similarity
6. One surgical team worked to revascularize with the thumb, a longitudinal skin strip of
the forearm radial flap and a second surgical 1 cm width was excised on the lateral border
team to harvest the big toe. of the big toe. Then, a 1.5 mm Kirschner wire
7. The forearm radial flap was inserted in the was passed centromedullary through it. A
defect and positioned with a few sutures. The second centromedullary 1.5 mm Kirschner
proximal end of the cephalic vein was anas- wire was passed through the index finger
tomosed with a dorsal vein of the hand and stump. The big toe was applied to the thumb
the proximal end of the radial artery with the and fixed by advancing centromedullary the
branch for the fourth web space at its origin Kirschner wire. To preserve an open first web
from the palmar arch. space, an external fixator was applied. The
8. A circumferential incision was done on the flexor and extensor tendons and the proper
distal third of the first phalanx of the left big ulnar digital nerve were sutured. The vein of
toe, including a larger skin island on the plan- the big toe was tunneled to the dorsal aspect
tar aspect of the future big toe flap. A perpen- of the hand and anastomosed to a dorsal vein.
dicular dorsal sinuous incision was done from The first metatarsal artery was anastomosed
the previous incision over the big toe, first to the distal end of the radial artery of the
web space, and intermetatarsal space. First, Chinese flap. After wound closure, a very
through very careful dissection, the arterial good revascularization of both the radial
dominant inflow was checked. It proved forearm flap and new thumb was observed.
to be the dorsal one, with the first dorsal 10. The foot donor site was directly closed, but
metatarsal artery passing through the first the right forearm donor site had to be covered
intermetatarsal muscle. Three dorsal veins with free split thickness skin graft.
were found and carefully dissected proxi-
mally until their merging points with the
origin of the great saphenous vein. Then, the Technical Pearls
first dorsal metatarsal artery was dissected
proximally until 2–3 cm above its origin 1. Working in two surgical teams considerably
from the dorsalis pedis artery and distally shortens the operative time.
until the level it became digital artery and 2. The radial forearm flap is harvested as a
reached the circumferential incision. The fasciocutaneous flap, and its dissection pro-
extensor tendons were dissected, isolated, ceeds from medial to lateral.
and cut 2 cm proximally to the circumferen- 3. The septum including the radial artery and its
tial incision on the big toe. On the plantar concomitant veins should be carefully pre-
aspect, through a small incision of 3–4 cm, served and included in the flap.
the flexor tendon and the proper digital nerves 4. Inclusion of the saphenous vein in the flap is
were identified and cut 3 cm proximal to the beneficial for venous drainage of the flap.
circumferential incision. After undermining 5. Because of the lateral bending tendency of the
the plantar skin of the big toe, the periosteum big toe, it is better to harvest the big toe from
was cut circumferential, and the bone was the ipsilateral foot.
osteotomized at the desired level. The big 6. Because of the similar dimensions between the
toe remained attached to the donor site only big toe and the thumb in our case, it is not
through the artery and its draining vein. necessary to perform a true “trimmed” big toe
After releasing the tourniquet, about 15 min transfer by excising also part of the phalanx,
436 A. V. Georgescu
but is enough to excise just 0.8–1 cm skin strip

from the lateral border of the big toe.
7. The first step in harvesting the big toe should
be the identification of the arterial dominant
inflow.
8. We advise including as many small veins as
possible into the vascular pedicle, which
should all ideally drain into a single larger
vein segment of the dorsal foot.
9. After releasing the tourniquet, we advise
waiting for 15–20 min until the toe is optimally
perfused and presents a good capillary
refilling.
See Figs. 2, 3, and 4.
Fig. 4 Harvested big toe after the pedicle was cut. The
suture of the remaining wound after excising of 1 cm large
skin strip on the lateral border can be seen
Fig. 2 The right forearm radial flap before cutting the
On the first postoperative day, the aspect of
vascular pedicle
the reconstructed hand was very good (Fig. 5).
The flaps were postoperatively monitored,
checking the color, temperature, and capillary
refilling every hour in the first day, every 4 h in
the second day, every 6 h in the third day, every
8 h in the fourth day, and then two times per day.
Vasodilator (papaverinum hydrocloridum, 40 mg
every 6 h) and antispastic (drotaverine hydrochlo-
ride, 120 mg daily, divided in three doses) medi-
cation was administered for 14 days. Also,
antisludge (dextran 40) was administered for
5 days. Low molecular heparin was administered
Fig. 3 Harvested big toe, after releasing the tourniquet in the first 2 postoperative days, until the patient
and before cutting the pedicle started to walk.
the patient started the functional rehabilitation of

the reconstructed thumb.
Outcome: Clinical Photos
The patient had an uneventful evolution and fast

recovery.
One year postoperatively, the aspect of the
reconstructed hand and of both donor sites was
good. Complete flexion of the thumb and third and
fourth digits, very good opposition of the thumb,
complete opening of the first web space, good pre-
hensile function for both big and small objects, and
very good sensibility were observed. The left donor
foot didn’t present any functional problem.
The good morphological appearance and
the very satisfactory functional outcome helped
the patient to return back to his social and
professional life.

Fig. 5 First day postoperative aspect: the osteosynthesis The septocutaneous perforators of the radial artery
of the big toe was realized with a centromedullary Kirshner
wire. External fixation was applied to maintain the first web
to the skin can be better seen on the medial aspect
space opened of the septum. That’s why the dissection of the
flap should be performed from medial to lateral.
A protective splint was applied only for the
reconstructed hand. The patient was encouraged 1. The identification of the arterial dominant inflow
to ambulate and to use the right hand. is mandatory as first step when harvesting the
Postoperative X-ray control of the reconstructed big toe. In case of a plantar dominance, the
thumb was performed in the first postoperative day, surgical plan should be changed, because the
at 14 days before releasing the external fixator, and diameter of the plantar artery will allow its anas-
at 1 month. All images showed good alignment and tomosis to a palmar artery (Wei et al. 1988).
finally good callus formation. 2. Because of the vessels manipulation during
Slight passive and active movement of the harvesting, after releasing the tourniquet, the
second and third digits of the reconstructed hand big toe artery can appear spastic. Detaching the
was started on the third postoperative day. In the big toe before its refilling is a big mistake. Wait
first 7 days, the patient was encouraged to move for at least 15–20 min until refilling of the toe.
the fingers both passively and actively. Between If this is not happening, the vessels should be
the 7th and 14th postoperative days, he moved the carefully checked, and local antispastic should
fingers just passively, and then he started again to be used (Georgescu 2005).
move them actively. The external fixator was 3. Maintaining the first web space open prevents
released on the postoperative day 14, and then the vessels kinking and the postoperative
438 A. V. Georgescu
Fig. 6 (a, b, c, d) Morphological appearance and func- with the long fingers. (c) Good thumb opposition.
tionality of the hand 1 year following the reconstruction. (d) Complete opening of the first web space and the pos-
(a) Good morphological appearance of the reconstructed sibility to bring big objects. (e) Possibility to bring small
hand. Good extension of the second and third digits. objects. (f) Good sensibility
(b) Good pinching ability of the reconstructed thumb
involuntary movements, which can compro-

mise the anastomoses.
Learning Points
1. Complex hand injuries involving one or multi-

ple finger amputation, tendinous and vasculo-
nervous lesions, and skin defects require an
emergency complex and careful approach to
Fig. 7 Long-term postoperative aspect of the right donor obtain a convenient morphological appearance
forearm and satisfactory functional recovery.
▶ Complex Thumb Reconstruction Using Free

Chain-Linked “Mini Wraparound” Great Toe
and Dorsalis Pedis Flaps
▶ Free “Wrap-Around” Great Toe Flap for
Thumb Reconstruction After Avulsion
Injuries
References
Foucher G, Van Genechten M, Merle M, et al. Single stage
thumb reconstruction by composite forearm island flap.
J Hand Surg. 1984;9B:245–8.
Georgescu A. Toe to hand transfer. General considerations.
Timisoara Med J. 2005;1:8–16.
Georgescu A, Ivan O. Emergency free flaps. Microsurgery.
2003;3:206–16.
Godina M. Early microsurgical reconstruction of complex
trauma of the extremities. Plast Reconstr Surg.
1986;78:285–92.
Lister G. Emergency free flaps. In: Green DP, editor.
Operative hand surgery. 2nd ed. New York: Churchill
Fig. 8 Long-term postoperative aspect of the donor foot Livingstone; 1988. p. 1127–49.
Matev IB. Thumb reconstruction after amputation of the
2. Appling the flow-through-flap principle is of metacarpo-phalangeal joint by bone lengthening. A
preliminary report of three cases. J Bone Joint Surg.
great help, especially when both the thumb and 1970;52A:957–65.
a soft tissue defect need to be reconstructed McGregor IA, Simonetta C. Reconstruction of the thumb
simultaneously. by composite bone-skin flap. Br J Plast Surg.
3. The use of an axial fasciocutaneous flap (e.g., 1964;7:37–48.
Morrison WA, O’Brien BM, MacLeod AM. Thumb
forearm radial flap, anterolateral thigh flap) for reconstruction with free neurovascular wrap-around
covering the skin defect and simultaneously flap from the big toe. J Hand Surg. 1980;5:
revascularizing a big toe transfer seems to be 575–83.
a rational choice. Ninkovic M, Mooney EK, Ninkovic M, et al. A new
classification for the standardization of nomenclature
in free flap wound closure. Plast Reconstr Surg.
1999;103:903–14.
Cross-References Wei FC, Chen HC, Chuang CC, et al. Reconstruction of the
thumb with trimmed toe transfer technique. Plast
▶ Combined Osteodistraction and Free “Mini Reconstr Surg. 1988;82:506–15.
Yang D, Yudong G. Thumb reconstruction utilizing sec-
Wraparound” Great Toe Flap for Thumb ond toe transplantation by microvascular anastomo-
Reconstruction After Amputation at the Meta- sis. Report of 78 cases. Chin Med J. 1979;92:
carpophalangeal Level 295–301.
Serratus Anterior-Rib Flap
for the Reconstruction of Complex 44
Defects Involving the First Metacarpal
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
Moment of Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Type of Reconstruction for the Thumb and Skin Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
Outcome: Clinical Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Abstract reconstruction close to normal is mandatory.

The first digital ray is very important in the Sometimes, in case of missing bone associated
functional economy of the hand. Its absence with a soft tissue defect, complex reconstruc-
or damage can diminish the functional ability tive solutions become instrumental to achieve
of the hand up to 50%. That’s why its the desired functionality. This case refers to a
17-year-old female referred to our department
2 weeks after a crush injury of the right hand,
presenting a large soft tissue defect over the
A. V. Georgescu (*) dorsal aspect of the thumb, hand, and distal
Plastic Surgery, Aesthetic Surgery and Reconstructive forearm, with exposure of the necrotic previ-
Microsurgery, University of Medicine Iuliu Hatieganu,
Rehabilitation Hospital, Cluj Napoca, Romania ous fractured first metacarpal bone, necrotic

https://doi.org/10.1007/978-3-030-23706-6_38
442 A. V. Georgescu
base of the first phalanx, and remaining prox-

imal part of the previously fractured trapezium.
After careful debridement, a free composite
serratus anterior-rib flap was used to recon-
struct both the first metacarpal bone and the
skin defect. The muscle was covered with split-
thickness skin graft. The long extensor tendon
of the thumb was reconstructed using the
extensor indicis proprius tendon as a functional
tendon transfer.
The postoperative evolution was unevent-
ful, with regain of about 85% of the functional
capacity of the hand and a reasonable aesthetic Fig. 1 Preoperative aspect of the hand. Skin defect of
10 5 cm projected over the dorsal aspect of the thumb,
result for both donor and recipient sites. carpal region, and dorsolateral aspect of the wrist. Absence
of the extensor tendons of the thumb. Necrosis of the entire
first metacarpal bone and proximal phalanx base
Keywords
Crush injury · Hand · First metacarpal · Soft the thumb, trapezium, and scaphoid (Godina
tissue defect · Compound serratus anterior-rib 1986; Ninkovic et al. 1999; Georgescu and
flap Ivan 2003a, b)
2. Identification, isolation, and preparation of the
radial artery stump and the cephalic vein
The Clinical Scenario 3. Elaborating the lesions balance sheet and
establishing the reconstructive priorities
A 17-year-old female presented 2 weeks after (Pellegrini 2005)
suffering a crush injury of the right hand, with a 4. Choosing the right moment for reconstruction
neglected soft tissue defect over the dorsal aspect (Godina 1986; Ninkovic et al. 1999; Georgescu
of the thumb up to the proximal third of the first and Ivan 2003a)
phalanx distally and the dorsolateral aspect of the 5. Soft tissue defect of 50cm2, absence of the first
hand, radio-carpal joint, and distal forearm prox- metacarpal bone and thumb extensors (Pellegrini
imally. The extensor pollicis longus and brevis 2005; Jones et al. 2012; Georgescu and Ivan
tendons and the abductor pollicis longus tendon 2003b)
were missing. The radial artery was interrupted 6. Requirement to reconstruct the first metacar-
2 cm distal to the origin of the dorsal branch. The pal, the long extensor tendon of the thumb, and
base of the proximal phalanx of the thumb, the skin defect (Pellegrini 2005; Jones et al. 2012,
previously fractured first metacarpal, and the Ariff et al. 2015; Georgescu and Ivan 2003b;
remaining proximal part of the previously frac- Smith and Brushart 1985; Hein et al. 2016;
tured trapezium were denuded. The entire first Ariff et al. 2015; Lim and Babineaux 2016;
metacarpal bone and the base of the proximal Gosal et al. 2015; Punyaratabandhu et al.
phalanx were necrotic (Fig. 1). 2017; Dhinsa et al. 2011)
Preoperative Problem List: Treatment Plan

Taking into account the fact that the patient pre-
1. Aggressive debridement with excision of the sented 2 weeks after the accident and the initial
necrotic first metacarpal bone, but with careful debridement and according to the classifications
preservation of the base of the first phalanx of regarding free flap coverage after posttraumatic
44 Serratus Anterior-Rib Flap for the Reconstruction of Complex Defects Involving the First. . . 443
tissue loss, after careful debridement, we consid- 2. Three-stage procedure: debridement in the first
ered that bone reconstruction and coverage could stage, covering the defect with either a local or
be done in one surgical step, as a secondary free free fascio-cutaneous flap or free muscle flap
flap procedure (Ninkovic et al. 1999; Georgescu after 24–48 h and secondary reconstruction of
and Ivan 2003a, b). the first metacarpal bone. The main disadvan-
Knowing that loss of thumb function diminishes tages of this approach are represented by mul-
the functionality of the hand to 40–50% (Pellegrini tiple surgical steps needing general anesthesia,
2005), the priority was to reconstruct the first meta- multiple donor sites, and long recovery period.
carpal bone and the long extensor tendon of the
thumb. As we considered to proceed with a double
arthrodesis of the reconstructed metacarpal due to Type of Reconstruction for the Thumb
the missing base of the proximal phalanx and of the and Skin Defect
articular surface of the trapezium, there was no
need to reconstruct also the abductor pollicis 1. Non-vascularized autologous bone graft, i.e.,
longus and extensor pollicis brevis tendons. Thus, iliac crest, fibula, radius, ulna, and metatarsal
after an aggressive debridement, including the to reconstruct the first metacarpal (Athanasian
excision of the necrotic first metacarpal bone and et al. 1997; Pandey 2019; Hein et al. 2016;
of the proximal phalanx base, the reconstruction of Ariff et al. 2015; Lim and Babineaux 2016;
both the first metacarpal and the skin defect with a Basit et al. 2004; Calvert et al. 1985; Maini
compound osteo-muscular flap was decided. In this et al. 2011; Minhas et al. 2010; Saikia et al.
attempt, the following steps were planned: 2011; Sanjay et al. 1996; Dhinsa et al. 2011).
Defect coverage can be achieved using either
– Identification, isolation, and preparation of the local or free fascio-cutaneous or free muscle
radial artery stump and the cephalic vein flaps. The risks of possible partial or complete
– Harvesting of a segment of the eighth rib resorption, nonunion, stress fractures, and
together with two slips of the serratus anterior infections represent disadvantages of this
(SA) muscle method because the bone segment is a
– Insetting the compound flap in the defect non-vascularized one (Dhinsa et al. 2011).
– Bone fixation through a double arthrodesis of 2. Allograft bone (Smith and Brushart 1985;
the rib segment with the base of the proximal Patradul et al. 2001) and skin coverage with a
phalanx and the trapezium using a 1.5 mm free or local fascio-cutaneous or free muscle flap.
Kirschner wire 3. Metacarpal-shaped spacer bone cement with a
– Reconstruction of the long extensor tendon of partially incorporated screw (Gosal et al. 2015)
the thumb using the extensor indicis proprius and skin coverage with a free or local fascio-
tendon as a functional tendon transfer cutaneous or free muscle flap.
– Flap coverage with split-thickness skin graft 4. Titanium prosthesis created with 3D printing
technology (Punyaratabandhu et al. 2017) and
skin coverage with a free or local fascio-
Alternative Reconstruction Options cutaneous or free muscle flap.
5. Reverse island radial flap including a segment
Moment of Reconstruction from the radius and a vascularized tendon
(palmaris longus, flexor carpi radialis). Very
1. Two-stage procedure: debridement in the first advantageous method but impossible in this
stage and reconstruction after 24–48 h. The patient because of the missing connection of
disadvantage of this method is the need for at the radial artery with the superficial arterial
least two surgeries under general anesthesia arcade of the hand.
and high risk of accentuating the preexistent 6. Vascularized free composite flaps:
local fibrosis. osteocutaneous groin flap (Reinisch et al.
444 A. V. Georgescu
1984), fibular osteoseptocutaneous flap Surgery started with the patient in supine posi-
(Lee et al. 2000; Lin et al. 2005), serratus tion. A tourniquet was applied on the right arm,
anterior-rib flap (Hui et al. 1999; Georgescu and the entire upper limb was prepared.
and Ivan 2003b), medial femoral condyle
(Sammer et al. 2009).
Surgical Technique
Preoperative Evaluation 1. Surgery was done by a single team. So, surgery

started in supine position for the debridement
Having in mind the possible anatomical variations step. Then the patient was turned in lateral
of the subscapular system of vessels, its preoper- decubitus position for the flap harvest and
ative evaluation is indicated. Moreover, because finally again in supine position for the
the patient sustained a crush injury of the hand, we reconstructive step.
considered also necessary the vascular evaluation 2. A tourniquet was placed on the right arm, and
of the hand to check the patency of the ulnar artery then all the upper limb was prepared and
and the quality of arterial flux in the sectioned draped. A relatively aggressive but very care-
radial artery. Handheld Doppler examination has ful debridement was performed, thus avoiding
shown a good vascular flow through ulnar artery, damaging the remaining functional elements of
radial artery, and thoracodorsal artery (TDA). the thumb. The final lesions balance sheet has
shown the following:
– Skin defect of 10 cm 5 cm projected over
Preoperative Care and Patient Drawing the dorsal aspect of the thumb, carpal
region, and dorsolateral aspect of the wrist
Preoperatively, the lateral border of the latissimus – Missing extensor longus and brevis and
dorsi (LD) muscle was identified, and the location abductor longus tendons
and length of the incision were marked on left – Missing base of the proximal phalanx
hemithorax, by asking the patient to place the – Missing metacarpal
hand on the iliac crest and push inward toward – Viable proximal part of the previously frac-
the midline (Fig. 2a, b). tured trapezium
Fig. 2 Patient drawing. (a) Identification of the lateral border of LD and marking the line of incision; (b) length of the
incision
3. A careful hemostasis was done after releasing – A 12 cm incision on the previously marked
the tourniquet, and the permeability and flow line (Fig. 3a).
quality in the radial artery stump and cephalic – Identification of the lateral border of the LD
vein were checked. muscle (Fig. 3b).
4. The hand was temporarily covered with a – Partial undermining of the skin over the LD.
moist gauze. – Undermining of the LD and identification
5. To harvest the flap, the patient was positioned of the TDA branch for SA muscle (Fig. 3c).
in right lateral decubitus position, with the arm The dissection is continued proximally to
abducted at 90 and the forearm flexed at 90 . identify the origin of the TDA branch for
The left hemithorax was prepared and draped SA (Fig. 3d). The artery should be carefully
up to the axilla. dissected until reaching the muscle slips
6. Steps of flap harvesting: that would be harvested, and all the small
Fig. 3 The harvesting of the SA-rib flap. (a) Skin incision; identification of the TDA branch for SA muscle; (d) iden-
(b) identification of the lateral border of the muscle and tification of the origin of the TDA branch for SA; (e) the
skin undermining; (c) undermining of the LD and flap ready for free tissue transfer
446 A. V. Georgescu
branches for the other slips should be cau- remaining fragment of the trapezium bone,
terized. Care should be also taken not to thereby achieving a double arthrodesis on
damage the branches of the long thoracic the proximal and distal stump of the rib
nerve for the remaining muscle slips. bone graft. The use of a centro-medullary
– The muscle slips that would be harvested wire in this case was considered adequate
should be carefully isolated from the sur- because of the particular design of the vas-
rounding tissues to preserve the muscle- cularization of the rib through muscle-
periosteal connections. periosteal connections, which can be
– The seventh and eighth muscle slips and the destroyed by using a locking plate. The
eighth rib are measured and prepared. The angle of arthrodesis in the MCP joint was
length of the muscle slips was of about with the thumb in opposition and with a first
11 cm and centered by the rib segment. web space opening of about 70 . In the MP
Then, an incision of about 6 cm in length joint, the arthrodesis was realized in an
and 1–2 mm parallel to both sides of the rib angle of 30 . The muscular component of
and a transverse transperiosteal incision at the flap was inserted in the defect and
both ends of the measured segment are sutured with additional sutures. For recon-
done. To avoid the damage of the parietal struction of the thumb extension, the exten-
pleura, the deep aspect of the rib is sor indicis proprius tendon was cut distally
undermined subperiostally, leaving the at the level of the metacarpal-phalangeal
deep periosteum in contact with the parietal joint of the index finger and was transposed
pleura. Then the rib segment is resected by and sutured as a tendon transfer to the distal
performing two osteotomies, and its super- stump of the extensor pollicis longus, over
ficial periosteum containing the perforating the distal part of the proximal phalanx of the
vessels from the serratus muscle which thumb.
vascularize the bone segment is secured – The vein of the flap was anastomosed to a
with several stitches to the muscle. The branch of the cephalic vein and the artery of
vascular pedicle of the flap can be now the flap to the stump of the radial artery. A
cut, immediately after its origin from the very good perfusion of the flap was
thoracodorsal artery, and the flap is placed observed, with bleeding from both the mus-
in a moist dressing (Fig. 3e). The diameter cle and the rib segment. After complete
of the serratus anterior branch is very simi- suture, the flap was covered with expanded
lar with the diameter of the superficial radial split-thickness skin graft harvested from the
artery. right upper thigh.
– After placing a drainage tube in contact with
the parietal pleura and another one under the Technical Pearls
skin, in the attempt to prevent the winged
scapula, the remaining posterior portions of 1. Adding a skin component to the flap should be
the used slips of the SA are sutured to the avoided, especially in the forearm and hand,
periosteum of the superjacent and subjacent because of the bulky final appearance.
ribs. The donor site is directly sutured. 2. To have a very well-vascularized rib segment,
7. Steps of inserting the flap: the preservation of all musculo-periosteal con-
– The patient was turned again in supine posi- nections is mandatory.
tion, and the recipient site was again pre- 3. To avoid the damage of the parietal pleura, the
pared and draped. The rib segment was undermining of the deep aspect of the rib seg-
inserted to replace the missing metacarpal ment should be subperiosteal.
and was fixed using one centro-medullary 4. Attention should be taken to preserve the
1.5 mm Kirschner wire, placed from the motor nerves of the remaining slips of the SA.
base of the first phalanx of the thumb 5. Keeping 3–4 cm from the scapular insertion of
through the rib segment up into the the SA and suturing them to the superjacent
and subjacent muscle slips help in preventing consolidation. The patient was encouraged to
the scapula alata. move the interphalangeal joint from the first post-
6. Because the vascular pedicle of the SA lies on operative day. In our experience, this does not
its superficial aspect, the muscle should be affect the quality of bone healing. Moreover, if
immediately grafted. the cast is able to ensure a stable maintenance of
the CMC and MP joints, the movements in the
interphalangeal joint do not negatively influence
Intraoperative Images the osteosynthesis.
The drainage tubes were removed from the
See Fig. 3. donor site in the fifth postoperative day.
After the integration of the flap, the patient
was encouraged to use a compressive garment
Postoperative Management for 1 year.
The postoperative evolution was uneventful. The

flap was postoperatively monitored, checking the Outcome: Clinical Photos
color and muscle contractility every hour in the
first day, every 4 h in the second day, every 6 h in The patient had an uneventful evolution and fast
the third day, every 8 h in the fourth day, and then recovery.
two times per day. Vasodilator (papaverinum Six months postoperatively, the aspect of the
hydrocloridum, 40 mg every 6 h) and antispastic reconstructed hand and of the donor site was
(drotaverine hydrochloride, 120 mg daily, divided good. The position of the thumb was convenient.
in three doses) medication was administered for Complete flexion and extension of the distal pha-
14 days. Also, antisludge (dextran 40) was admin- lanx of the thumb was possible. Thumb opposi-
istered for 5 days. Low molecular heparin was tion was possible in the limits of about 30 , but the
administered in the first 2 postoperative days, prehensile function of the hand was compensated
until the patient started to walk. by the good range of motion of the long fingers.
A protecting palmar splint by leaving free the The regain of functional ability of the hand was
interphalangeal joint was applied and maintained judged at about 85% of normal, with good pre-
for 6 weeks. The wire was released after 4 weeks hensile function for both big and small objects.
after X-ray control, which had shown a good See Figs. 4, 5, and 6.
Fig. 4 Radiological
appearance 6 months
postoperatively
448 A. V. Georgescu
Fig. 5 (a, b). Morphological and functional appearance 6 months postoperatively
3. To avoid the opening of the parietal pleura, the

careful subperiosteal undermining of the deep
aspect of the rib should be performed. If
opened, the pleura should be sutured, and an
intrapleural drainage tube under negative pres-
sure should be placed.
4. To prevent the winged scapula, the preserved
SA muscular stump should be sutured to the
superjacent and subjacent ribs.
5. To avoid a seroma formation in the donor site,
the drainage should be maintained until the
daily drainage is under 10 ml.
Learning Points
1. Taking into account the paramount importance

of the thumb in the functional economy of the
Fig. 6 Donor site appearance
hand, the thumb should be reconstructed with
any price.
2. When there are concomitant soft tissue defects,
Avoiding and Managing Problems the use of a compound flap including
vascularized bone seems to be the best option.
1. The TDA branch for SA gives many small 3. The all-in-one reconstruction gives the best
vessels for the distal four slips of the muscle. results from functional point of view.
To avoid a postoperative bleeding and hema- 4. The rib is as good as any other vascularized
toma formation, all these small branches bone in the reconstruction of metacarpals. Its
should be carefully cauterized. diameter is very similar, and its structure
2. To avoid the paralysis of the SA, the careful ensures a very good bone healing and resis-
dissection of the motor nerves for the tance. The muscular component helps in cover-
remaining slips of the muscle is mandatory. ing the soft tissue defects and fighting infection.
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Free PIP Joint Transfer for Functional
Finger Reconstruction 45
Paolo Sassu and Martina Åhlén
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
Avoiding and Managing Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
....
Abstract
Free vascularized joint transfer is indicated in

young patients where other standard proce-
P. Sassu (*) · M. Åhlén dures such as joint fusion or arthroplasty are
Department of Hand Surgery, Sahlgrenska University not ideal. Good functional results rely on
Hospital, Gothenburg, Sweden
e-mail: sassupaolo@gmail.com; meticulous surgical dissection and thorough
martina.ahlen@vgregion.se understanding of the vascular anatomy of the

https://doi.org/10.1007/978-3-030-23706-6_39
452 P. Sassu and M. Åhlén
donor foot. The PIP (proximal interphalangeal)

joint of the finger is usually reconstructed with
the toe PIP joint, while the MCP (meta-
carpophalangeal) joint of the hand can be
reconstructed with either the toe PIP or MTP
(metatarsophalangeal) joint. We describe a
case of PIP joint reconstruction of the small
finger in a young adult who performed rock
climbing at a high level. The joint function was
restored with a vascularized toe PIP joint from
the third toe since the second toe, quite long in
its anatomy, was spared in order to maintain
excellent grip while wearing climbing shoe.
Even though uncommonly used, the third toe
PIP joint allowed full recovery in range of
motion (ROM) with no donor site morbidity.
The patient returned to his job within 3 months
and climbing 8 months after surgery.
Keywords
Joint transfer · Vascularized joint · Toe to

hand · Free joint transfer · Toe flap
An otherwise healthy 25-year-old man was Fig. 1 X-ray shows bone loss at the head of the proximal
phalanx as well as disruption of the base of the middle
referred to our clinic after falling from his motor- phalanx, small finger
cycle and injuring his left small finger. At physical
examination he presented with an open fracture
which resulted in bone loss at the head of the Preoperative Problem List:
proximal phalanx, extensor tendon injury, as Reconstructive Requirements
well as 2 cm dorsal skin defect around the PIP
joint. Plain x-rays showed that the base of the 1. Young patient very active as a rock climber,
middle phalanx presented with an osteochondral which was one of the major activities in his free
defect of about 60% of its surface making both time.
proximal and distal components of the joint 2. Specific functional requirements: restoration of
unservable (Fig. 1). The flexor tendons were intact a stable, durable, and mobile joint that could
as well as both digital nerves. Capillary refilling allow the patient to go back to all previous
was unremarkable, and the whole finger was well manual activities.
vascularized. The patient was taken to surgery the 3. Four different grips are specifically required in
same day for surgical revision and temporary rock climbing, which put the fingers at the high
bone fixation with K-wires (Fig. 2), which allo- level of stress: open, cling, pocket, and pinch
wed good healing of the skin and preservation of grip. All fingers not only need to be fully
finger length (Fig. 3), while several different alter- mobile with efficient strength but also able to
natives were extensively discussed with the produce independent movements. If, for
patient to find the best treatment option. instance, we consider the cling grip (Fig. 4a)
45 Free PIP Joint Transfer for Functional Finger Reconstruction 453
Fig. 3 Initial wound healing resulted in dorsal skin

contraction
Fig. 2 Preliminary bone stabilization and maintenance of

anatomical finger length were achieved with two K-wire
fixation Treatment Plan
or crack climbing (Fig. 4b), all fingers nicely Vascularized PIP joint transfer from the foot has the
adapt to irregular surfaces and pull the whole potential to provide all features we sought for this
body up developing full strength. Having a PIP young patient: stability, durability, and joint
joint completely stiff greatly limits the possi- motion. Stability is provided by bone healing and
bility of exploiting all the ravines in the rock, intact joint ligaments. Durability is guaranteed by
particularly when we consider the ring and its vascular supply that makes the transferred joint
small finger which, together with the long fin- behave as any other joint and survive in good
ger, are especially involved in power grips. conditions with no need for further surgeries
4. A further concern while considering options (Hierner and Berger 2008). Motion has been
for reconstruction was that the patient wore reported as 37 +/ 9 (Squitieri and Chung 2008)
special shoes while climbing, which typi- and does not differ much from joint arthroplasty. In
cally have a tight fit with almost no or little case of intervening arthritis, the insensate joint can
padding, sticky rigid sole, and a rubber rand still function acceptably for some time until the
(Fig. 5). Our patient had long toes with the patient reaches an age where the other previous
second being slightly longer than the great two options have a better role. Several drawbacks
toe. Reconstruction of the joint with the sec- in vascularized joint transfer must be kept in mind:
ond toe PIP joint would have most likely it is technically more demanding compared to both
created a rigid straight toe that impinged fusion and arthroplasty; it requires microsurgical
against the shoe. expertise and confidence with this specific flap; and
Fig. 4 (a–b) Crack climbing and cling grip require independent mobility for each finger which have to adapt to different
surfaces
impingement of the toe against the rubber rand

of the climbing shoe.
1. Joint fusion. It provides stability and durability,

with low risk of complications (Jung et al.
2018). In the small finger, an angle of approx-
imately 45–55 is chosen to allow a functional
grip in full-hand closure. At the same time, a
Fig. 5 Climbing shoes have a tight fit with almost no fixed position in the PIP joint limits the perfor-
padding mance of climbers, narrowing the range of
possible efficient grips in challenging situa-
even though poorly described, joint transfer has tions. As mentioned above, when fused at the
been shown to be exposed to more complications PIP level, the small finger has less possibilities
than arthroplasty, with surgical revision necessary to adapt to irregular surfaces, becoming a lim-
in 29% of cases (Squitieri and Chung 2008) due to iting factor in certain grips.
infection, skin necrosis, and bone non-union. 2. Joint arthroplasty. It has been largely used to
The third toe was selected as donor site instead restore mobility in both post-traumatic inju-
of the most commonly used second toe. The third ries and arthritic joints. Several materials have
toe in fact is shorter and less involved in toe grip been used varying from silicone implants to
while climbing. Moreover, we thought that fusion pyrocarbon with different results in terms of
with a conventional bone graft at the donor third arc of active motion and complications. In
toe would result in less risk to incur in their systematic review comparing silicone
versus pyrocarbon PIP joint arthroplasty, Chan palpable arteries, we do not find it necessary to
(Chan et al. 2013) reported good pain relief for perform any specific imaging to confirm the
both implants and an improvement in joint vascular anatomy. The rationale for not
mobility of 8.2 (silicone) and 8.0 (pyrocarbon), performing other investigations relies in the
having a postoperative total range of motion of well-described technique of retrograde dissec-
37.4 +/ 13.6 and 44.8 +/ 16.8 , respectively. tion of the vascular pedicle by Wei (Wei et al.
Both Chan and Squitieri (Squitieri and Chung 1995) in 1995. In this elegant description, the
2008) referred difficulties in finding univocal authors recommend to explore the first or sec-
and comparable data concerning complications. ond web space (depending on which type of
In those articles where extractable data were transfer is planned) in the foot and identify
available, Squitieri reported an overall compli- whether the first dorsal (FDMA) or plantar
cation rate of 18 and 33% for silicone and metatarsal artery (FPMA) has a dominant cali-
pyrocarbon implants, respectively. This rate ber. If the FDMA is dominant, the retrograde
includes both major and minor revisions due dissection of the vascular pedicle is straight-
to infection, bone resorption, or implant loosen- forward, and appropriate length is selected
ing. Best outcomes are achieved when the soft depending on the recipient site. In case the
tissues surrounding the joint are healthy and FPMA is dominant, the first operator moves to
well preserved. Our patient presented a dorsal the plantar surface of the foot in order to follow
skin loss of about 2 cm over the PIP joint and the the arterial pedicle (Lin and Sassu 2009). Many
insertion of the central band injured. Overall, detailed classifications (Gilbert 1976; May et al.
the young age of the patient, the local conditions 1977; Leung and Wong 1983; Hou et al. 2013)
of the finger, and the functional demand made have been described on the anatomy of the arte-
this alternative suboptimal. A young patient rial tree supplying the toes and the respective
receiving a PIP joint arthroplasty will most flaps, and they are especially focused on the
likely undergo reoperation multiple times in description of the course of the metatarsal arter-
his life, besides the fact that his high-level activ- ies in regard to the intermetatarsal muscles and
ities would decrease the life span of the implant. ligaments. Even though these descriptions are of
tremendous value and their knowledge is of
great help, the retrograde dissection of the
Preoperative Evaluation and Imaging vascular pedicle avoids the necessity of a pre-
surgical angiography or Doppler ultrasound,
The patient underwent plain radiographs of the and we now feel comfortable to take the
small finger. No other imaging was performed in patient to surgery with only previous clinical
the hand or foot. We considered using the radial examination.
digital artery of the small finger as recipient ves-
sel, and since there was no evidence of injury
proximal to the previous fracture, we did not find Preoperative Care and Patient
it necessary to investigate further on the vessel Drawing
anatomy of the hand. The palmar arterial arch is
always available, and, in situations where arterial The patient lies on the operating table in a supine
flow seems compromised, it can be easily position with the affected arm on the side table,
accessed by proximal dissection. one tourniquet applied in the arm and one in the
Regarding the donor site, the patient had no thigh.
previous injuries to the foot. During preopera- Hand: A “Z” type of incision is usually favored
tive clinical examination, we could easily pal- in the dorsal surface of the PIP joint (Fig. 6). This
pate the dorsal pedis artery in the dorsal foot and allows a wide exposure of the remaining joint,
the posterior tibial artery at the ankle joint. In isolation of the extensor tendon, and comfortable
the absence of previous traumas and with good inset of the transferred joint including a skin
Fig. 7 A rectangular skin paddle over the toe PIP joint has
two functions: it serves as a monitor for vascular control; it
helps skin closure in the recipient site
selected the third toe as donor site, and being the

arterial system at this level most likely dominant
in the plantar side, we have drawn also a volar
curved incision that gives us access to the FPMA.
Care must be taken to avoid scars over the meta-
tarsal heads, having the incision between the load-
Fig. 6 A “Z”-shape incision allows wide exposure of the bearing areas.
remaining joint, the extensor tendon, and vascular
structures
Surgical Technique
pedicle that serves for both monitoring and ease of
wound closure. Two-team approach is usually preferred. While
It is usually not difficult to identify a dorsal one team is dissecting the finger, the other team
vein of good caliber that is marked at the MCP is exposing the donor site.
joint level. If the vein system is not easily visual- Hand. After skin incision, two flaps, one radial
ized, the arm is left hanging down for a few and one ulnar, exposed the whole PIP joint area.
minutes possibly with a hemostatic lace to facili- The central band of the extensor tendon,
tate venous stasis. This simple action will make it completely injured from its insertion at the base
possible to mark one or two suitable recipient of the middle phalanx, was identified proximally.
veins. Volarly, an additional curved incision is A dorsal vein of good caliber was also identified at
marked around the distal palmar crease for arterial the MCP joint level and marked with a vessel
exposure. Priority is given to the radial digital loop. As shown by the x-rays, the entire head of
artery in the small finger, which is dominant and the first phalanx was lost. We sharpened the bone
has a better size than the ulnar one. transversely with an oscillating saw and removed
Foot: A rectangular flap is marked over the PIP 1 cm of the middle phalanx base so as to prepare
joint (Fig. 7). The size of the flap must allow direct the area for the inset of the new joint (Fig. 8). The
skin closure of the foot and, at the same time, flexor tendon was intact and not exposed. Volarly,
facilitate wound closure in the hand. The marking the radial digital artery was isolated at its origin
continues proximally in a zigzag manner in order and marked with a vessel loop.
to give access to a dorsal vein of sufficient length Foot. The incision started over the dorsal rect-
as well as the FDMA if this is dominant. Having angular skin flap and continued proximally
Fig. 8 Hand dissection: after debridement, the bone

stumps were prepared with an oscillating saw, and the
extensor tendon was isolated Fig. 9 Foot dissection: one vein is sufficient to guarantee
adequate venous outflow. After bone osteotomy, the tour-
having care not to injure the underlying vein sys- niquet is released for 20 min
tem. With the elevation of the skin flaps over the
first phalanx as well as the dorsal foot, a vein of for the surgeons and assessment of circulation in
appropriate size and length was selected. This first the toe before the actual transfer.
step was followed by exploration of the second Inset. Once circulation was confirmed in the
web space and assessment of the arterial system. toe joint (Fig. 10), we divided the artery, marking
As expected, the second dorsal metatarsal artery the stump with a hemoclip. The vein was
was inconsistent, and dissection of the second then divided applying no clips in its stump. This
plantar metatarsal artery became necessary. will allow easy identification after inset.
Before moving on to plantar dissection, the exten- Osteosynthesis was performed with a miniplate
sor tendon was isolated and divided proximally. and screws (Fig. 11), and good position was con-
The peroneal digital artery was also isolated, ligat- firmed by intraoperative x-rays. Then, suture of
ing all branches going to the joint. This step is the extensor tendon was performed with a side-to-
crucial for maintaining valid circulation in the side technique (Fridén et al. 2015), adjusting ade-
distal toe. Staying on the peroneal side of the quate tension. Vessel anastomosis started with the
joint, the flexor tendon retinaculum was opened vein in the MCP joint area, followed by artery
longitudinally, and the flexor tendons were freed anastomosis. Valid circulation was evaluated and
and not included in the transfer. The dissection the skin closed with no tension (Fig. 12).
continued in the plantar side. The second plantar Donor foot closure. With the aim to maintain
metatarsal artery lies deep under the thick fat pad. good length and aesthetics of the toe, a bone graft of
Autostatic retractors helped in keeping the fat on adequate dimensions was harvested from the iliac
the sides, and the artery was isolated for as long as crest having its size slightly shorter than the trans-
needed. If a long arterial pedicle is needed, we ferred joint to allow easier closure of the toe skin.
prefer to end the dissection in the midfoot The graft was secured with key wires, and the skin
avoiding further exploration and rather taking a was closed with nonabsorbable sutures (Fig. 13).
vein graft to increase vessel length. Once the
artery was fully isolated, through the dorsal
access, we proceeded with proximal and distal Technical Pearls
osteotomies with an oscillating saw, carefully pro-
tecting the soft tissues. The toe was then kept in Hand
place only with arterial inflow and venous outflow
(Fig. 9). Few stitches secured the third toe to the 1. If possible, no skin is discarded, but rather kept
tip of the second toe, and the tourniquet was intact in the dorsal finger. All soft tissues are
released for 20 min. This allowed a short break often swollen after several hours of surgery,
Fig. 10 Capillary refilling is assessed in the foot before

transferring the toe joint
Fig. 12 Skin closure with no tension and small drain
Fig. 11 Osteosynthesis with miniplate and screws
and the recipient site closure is not always

straightforward. Few millimeters of intact
extra skin will facilitate tensionless closure.
2. Smooth dissection of the artery and vein prox-
imal to the zone of injury reduces significantly
risks of spasm or thrombosis. As pointed out
by Dautel (2018), using a short vascular pedi-
cle in the finger is reliable and avoids further
dissection volarly in the hand with no need to
tunnelize the donor artery. Arterial diameter is Fig. 13 An iliac bone graft was harvested to restore
smaller than in the palm, but still adequate for proper length in the third toe. Two K-wires were used for
anastomosis for an expert microsurgeon. bone fixation
3. Osteosynthesis is generally performed with often found and is difficult to improve. An

two either parallel or perpendicular cerclages anatomical study (Waughlock et al. 2013)
and a K-wire and is our method of choice. followed by a series of clinical cases (Lam et
Plate fixation, as performed in this case, is al. 2013) has stressed the importance of inspec-
technically demanding and time-consuming tion of the central band at the joint level during
and probably has no real benefit in bone foot dissection. Correction of the undeveloped
healing and stability. Our patient had long central band might improve full active exten-
toes and fingers of quite big size, and this is sion of the reconstructed finger.
why we thought of providing a theoretical
more stable fixation for very early postopera-
tive rehabilitation. Intraoperative Images
4. When cerclage and K-wire fixation is used, the
K-wire is usually cut tangential to the cortical Hand and foot dissections are shown in Figs.
bone, remaining hidden in the finger. There is 8 and 9, respectively. Before the toe joint transfer,
usually no need to remove the hardware. capillary refilling is assessed (Fig. 10).
Osteosynthesis of the transferred joint with mini-
plate and screws is shown in Fig. 11.
Foot The skin closure at the recipient site is tension-
less and a small drain is inserted (Fig. 12). The
1. Keeping room temperature constant and warm length of the third toe is restored by iliac bone
might avoid vasospasm in the digital artery of graft fixated by K-wires (Fig. 13).
the toe.
2. The marking of the vein, as described in the
hand, might be facilitated by letting the foot Postoperative Management
hang off the operating table. This is often suf-
ficient to visualize several veins in the toe and Hand
follow them proximally in the MTP area up to
the greater saphenous. A rigid splint in a functional position was
3. Having in mind the anatomical variations and modeled, keeping the MCP joints flexed at
the dominant patterns of the arterial system about 70 and the PIP and DIP joints straight.
makes the dissection quite straightforward Immobilization is kept for about 7–10 days in
whether the dorsal or plantar artery is order to allow the pain as well as the swelling to
followed. slowly subside. Passive and assisted active
4. If a long vein is necessary, care must be taken ROM exercises were then started from 0 to 45
not to devascularize the medial part of the skin degrees of flexion in the first 7–10 days. In the
to the foot which might undergo necrosis, following 2 weeks, active ROM exercises were
keeping the dissection on the vein and incremented to 70–80 having the goal to reach
avoiding inappropriate detachment of the skin. as much as 90 degrees of passive and active
5. Insetting a vascularized joint transplant that is flexion within the first 5–6 weeks post-op. Stable
few millimeters shorter than the original joint bone fixation as well as strong tendon suture
helps recipient site closure and improves flex- obtained with the side-to-side technique allowed
ion potential of the new joint (Mohan et al. rapid mobilization after surgery, which is crucial
2017). to reach maximal mobility in the reconstructed
6. Extensor tendon. An extension lag of various joint. A straight static splint over the PIP joint is
degrees at the PIP joint of the transferred toe is worn at night for 3 months and during the day in
the first 6 weeks between the training sessions. the front foot protected and unloaded. The shoe is
Swelling is managed by the therapist as soon as worn until bone healing is evident at plain radio-
10–14 days after surgery by gentle compression graphs which usually comes after a minimum of
bands and massage. Buddy taping is extremely 6–8 weeks. Once bone healing is evident, both K-
important since the patient feels the finger pro- wires are removed, and the patient starts full load
tected allowing at the same time range of motion and regular activity. The swelling might take up to
exercises. 6–12 months before it subsides completely.
Full load of the hand is usually allowed 3 months
after surgery or when bone healing is evident.
Foot Bone healing occurred 4 months after surgery

(Fig. 14a–c). At the last follow-up, 12 months
The postoperative dressing consists of a rigid ban- later, the patient showed good active range of
dage around the foot. Elevated position is motion with an extension lag of about 15 and a
recommended in the first 7–10 days to reduce swell- flexion of 85 (Fig. 15a, b). He could perform a
ing and allow regular wound healing. The patient is full grip with no pain in the finger and was able to
provided with a special high heel shoe with a rigid use his hand normally in daily activities as well as
flat part in the front foot, usually used in toe surgery climbing. The foot healed without complications,
such as hallux valgus or mallet toe correction. The and the patient could wear regular shoes and
shoe allows loading the heel while walking, keeping climbing shoes without problems. The third toe,
Fig. 14 (a–c) Bone healing occurred about 4 months after surgery in both the hand and foot
Fig. 15 (a, b) Good range of motion at the PIP joint in flexion and extension
extension lag of variable degrees is seen in the

donor site.
Avoiding and Managing Problem
1. As already mentioned, it is fundamental to

verify the ROM of the PIP toe joint before the
transfer, to be sure that an acceptable motion is
obtained after surgery. It is not infrequent that
the toe joint is stiff, with a very limited active
and passive mobility. The chances to improve
an initial poor ROM are very low.
2. Once joint dissection in the foot is complete, it
is advisable to release the tourniquet for
20 min leaving the artery and vein still in
continuity. This allows to verify viable capil-
Fig. 16 The third toe healed without complications, and lary refilling in the flap and gives the oppor-
the patient was able to go back to climbing with no residual tunity to explore the vascular system in case
symptoms
of poor circulation. If the joint and its skin
paddle do not show signs of revascularization
rigid at the PIP joint and few millimeters shorter despite all attempts to re-establish good
than the contralateral (Fig. 16), showed no symp- inflow and outflow, the joint might be trans-
toms in walking, running, and climbing. ferred anyway without skin paddle. The risks
This particular transfer was very successful, of developing a Charcot joint are high, but,
but in the authors’ experience, the final results lacking intra-articular sensory feedback, the
usually show a total ROM closer to those reported patient is often pain-free and might gain an
by Squitieri (Squitieri and Chung 2008). Reasons acceptable function for few more years before
of success in our patient are probably related to the considering other options.
excellent collaboration in the training program, 3. Difficulties closing the recipient site are not
big anatomical structures that allowed a stable infrequent. Slight bone shortening, a good
bone fixation, and a strong tendon repair, thus size of the monitor flap, and short operative
improving confidence in the training progression. time might reduce swelling of the soft tissues
Furthermore, the initial ROM of the PIP joint in and allow better closure without tension. If
the toe was very good, with very little extension compression of the vessel is foreseen, either
lag and a flexion of almost 90 . This situation is local flaps or simply a skin graft might be
not always found in toe joint transfer, where an applied over the transferred joint.
4. Correct axial alignment must be verified during Learning Points

bone fixation in both extension and flexion in
order to avoid rotational malunion and poor 1. Proper selection of the patient is crucial. Best
functional and aesthetic results. Similar tests candidates are young, motivated adults who
are done during extensor tendon repair in order are willing to recover a stable, mobile joint
to adjust appropriate tension and obtain near- with good strength in sport and daily activities.
to full-joint extension with wrist flexion and a Vascularized joint transfer in children offers
good cascade of all fingers at wrist extension. the unique possibility to provide viable transfer
One temporary stitch in the tendon can be of the growth plate.
placed for preliminary ROM control. If ade- 2. Both joint fusion and arthroplasty are excellent
quate joint mobility is verified, then one can alternatives depending on the age, work, and
proceed with proper tendon suture. We have hobbies of the patient. These procedures often
suggested the side-to-side technique since it allow a rather quick recovery and lesser post-
has been shown to be strong and thin, allowing operative complications.
a quick start of the rehabilitation program after
surgery.
5. A delay in bone healing up to 3–4 months is
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Treatment of Scaphoid Nonunion
Using the Free Corticocancellous 46
Lateral Femoral Condyle Bone Flap
Lucian P. Jiga and Katarzyna Skibinska
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Preparation of the Recipient Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Flap Harvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
Scaphoid Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Abstract devitalized bone followed by reconstruction

Without treatment, scaphoid nonunions evolve with either non-vascularized or pedicled bone
toward carpal collapse and progressive degener- represents proven methods to achieve bone
ative changes known as scaphoid nonunion healing. The presence of significant bone gaps,
advanced collapse (SNAC). Debridement of however, demands vascularized bone transfer to
attain healing. Local pedicled flaps from the
distal radius although proven useful, provide
L. P. Jiga (*) · K. Skibinska limited amount of bone substance and rely on
Department of Plastic, Aesthetic, Reconstructive and Hand retrograde circulation. Vascularized bone flaps
Surgery, Evangelisches Krankenhaus, Medical Campus, from the femoral condyles can provide signifi-
University of Oldenburg, Oldenburg, Germany
e-mail: lucian.jiga@evangelischeskrankenhaus.de; cant amount of bone and can be harvested both
katarzyna.skibinska@evangelischeskrankenhaus.de as corticocancellous (with or without cartilage)

https://doi.org/10.1007/978-3-030-23706-6_43
466 L. P. Jiga and K. Skibinska
and corticoperiosteal constructs. Here we

present a patient with scaphoid nonunion,
where a free lateral femoral condyle corticocan-
cellous flap was successfully used for scaphoid
reconstruction. Three months postoperatively,
complete scaphoid healing allowed the patient
to return to his normal life, pain-free, and with a
normal-functioning wrist.
Keywords
Wrist reconstruction · Scaphoid nonunion ·

Vascularized bond transfer · Lateral femoral
condyle
Clinical Scenario
A 23-year-old patient fell on his left wrist during Fig. 1 Sagittal view CT scan. Nonunion with evident bone
playing football about 2 years ago. Although sclerosis, humpback deformity with dorsal luxation of the
proximal pole, and shortening of the scaphoid axis
complaining of a swollen hand and wrist pain,
he decided initially against a medical examina- a vascularized corticocancellous bone flap from
tion. Approximately 14 months after the accident the lateral femoral condyle were planned.
he started having progressive pain in his left wrist
which was exacerbated during sports or weight-
loading and forced wrist extension. Preoperative Problem List:
An X-ray of the wrist pointed out a scaphoid Reconstructive Requirements
fracture with nonunion, a circumstance which led
to his immediate referral in our service for further 1. Young active individual bound to daily car
evaluation and treatment. driving through his job and with an evident
The examination of the hand revealed a light inclination toward sports in his free time.
volar pressure pain directly above the projection 2. The primary treatment goal is the optimal
of the distal third of the scaphoid and a negative reconstruction of the scaphoid, thereby pre-
Watson test. The thumb could be moved actively venting carpal collapse and alleviating the
and was pain-free. The wrist X-ray revealed wrist pain syndrome, which significantly limits
a Herbert type B2 scaphoid fracture with evident both his professional and private life.
nonunion. The CT examination of the wrist 3. The primary operative target is the thorough
confirmed this diagnosis while revealing also debridement of the nonunion with excision of
a “humpback” deformity of the scaphoid with the entire sclerotic devitalized bone, followed by
significant volar dislocation of its distal pole the reconstruction of the scaphoid. Considering
(Fig. 1). the presence of a “humpback” deformity, scaph-
In spite of the severe deformity, the MRI scan oid reposition with reconstruction of its volar
indicated an unaffected optimal vascularization of cortical length, thus maintaining its physiologi-
the proximal pole of the scaphoid. cal bone length, is a mandatory element to pro-
After discussing with the patient several possi- vide an adequate functional reconstruction.
ble options of the treatment, debridement of the 4. Although the preoperative MRI examination
nonunion and reconstruction of the scaphoid with has shown preserved perfusion of the proximal
46 Treatment of Scaphoid Nonunion Using the Free Corticocancellous Lateral Femoral Condyle. . . 467
pole, it is the final intraoperative result, after the nonunions treated with pedicled VBGs based on
bone debridement, which will dictate the type of the 1,2 intercompartmental supraretinacular artery
reconstruction. For example, intraoperative (1,2 ICSRA), Chang et al. has shown only a 68%
diagnosis of a proximal pole ischemia mandates union rate (34 patients) (Chang et al. 2006). Some
its complete resection and scaphoid reconstruc- of the most important disadvantages of the pedi-
tion using a free vascularized cartilage graft cled VBGs lie in their unreliable vascularity based
from the trochlea. During the informed consent, on short pedicles with retrograde circulation,
the patient should be informed about all possible which in turn limits the graft maneuverability
types of bone flaps that might be employed for impending optimal inset and favoring failure.
reconstruction (including non-vascularized In contrast, free VBGs have been shown to
grafts from the iliac crest) as well as the directly overcome all these hurdles. However, microsurgi-
related donor site morbidity. cal expertise and accurate planning and execution
of bone harvesting are essential to warrant their
success in treatment of bone nonunion.
Treatment Plan During the last decade, the medial femoral
condyle (MFC) has been thoroughly described
Autologous non-vascularized bone grafts (NVBGs) as valid donor site for different VBG constructs
from the iliac crest or different pedicled bone flaps successfully used for bone reconstruction of the
from the radius combined with internal fixation carpus (Doi and Sakai 1994; Sammer et al. 2009;
(e.g., Herbert screws and/or K-wires) have been Larson et al. 2007). Lately, detailed anatomical
classically described for treatment of scaphoid non- studies have shown also the potential of lateral
union (Al-Jabri et al. 2014). However NVBGs pre- femoral condyle (LFC) as alternative donor site to
sent several limitations, mainly due to their the MFC for vascularized corticoperiosteal VBGs
non-vascularized nature especially in the presence (Wong et al. 2015). Based on the superolateral
of the avascular necrosis (AVN) of the distal or genicular artery (SLGA), these bone flaps can be
proximal pole of the scaphoid (Malizos et al. safely harvested without the need of sacrificing
2010). Several instrumental studies on vascularized a major artery in the area. The SLGA has
bone grafts (VBGs) have shown that an immediate also proven a more constant anatomy in terms of
blood flow into the transplanted graft from the its origin and branching as compared to the
transplantation time point leads to preservation of descending genicular artery which is the source
osteocyte population and increased osteogenic vessel for VBGs harvested from the MFC. One
capacity, thereby preventing the slower creeping significant disadvantage of the SLGA is its rather
substitution, thus rendering these mechanically short length and smaller caliber as opposed to the
superior as opposed to NVBGs (Sunagawa et al. descending genicular artery. However, when deal-
2000; Berggren et al. 1982; Tu et al. 2000). ing with scaphoid nonunions, the immediate prox-
The vascularized periosteum alone has been also imity of the recipient vessels (e.g., radial artery
proven to have important osteogenic capacity or its palmar branch) allows tension-free micro-
which can further improve graft viability, another vascular anastomosis even in the presence of short
solid argument favoring VBGs for treatment vascular pedicles.
of bone nonunions (Weiland et al. 1983).
Both dorsal and volar pedicle bone grafts from
the distal radius have been described for treatment Alternative Reconstructive Options
of scaphoid nonunion. However, in the presence
of severe dislocation (e.g., humpback deformity) 1. NVBG from the iliac crest. Not to be favored in
or carpal collapse, these failed to induce consis- the presence of humpback deformity and AVN
tent union. Analyzing the results of 50 scaphoid of the proximal scaphoid pole.
2. Pedicled VBGs from the dorsal or volar side (no leading from the cancellous bone of the
of the distal radius. Are not preferable when proximal pole after tourniquet release).
significant defects after bone debridement are
expected, due to two reasons: insufficient
volume of cancellous bone stock and limited Preoperative Evaluation and Imaging
maneuverability due to limited pedicle length.
3. Free iliac crest bone flap. Otherwise a very Before receiving a final treatment plan, all patients
reliable source for VBGs, the iliac crest with scaphoid nonunions undergo an X-ray, a CT,
is mostly favored when significant amounts and an MRI examination of the affected wrist. The
of bone stock are required (e.g., nonunions X-ray offers important information regarding
of the long bones). It has two major disadvan- the relation of the affected scaphoid with the
tages: a rather tedious harvesting technique and neighboring lunate, such as the possible presence
high short-term donor site morbidity (Sayegh of dorsal intercalated segment instability (DISI)
and Strauch 2014). or a simultaneous chronic rupture of the
4. Medial femoral condyle flap. Should be scapholunate ligament. The CT exam provides
considered always as backup plan and can be a detailed image of the lesion in terms of the
also indicated primarily for scaphoid recon- “nonunion anatomy” and degree of displacement
struction. This depends however on the expe- (Fig. 2a, b). On the sagittal images, detailed anal-
rience of each surgeon in one or the other flap ysis of the total length loss through shortening and
and anatomical area. the volar dislocation of the distal pole can be
5. Complete resection and reconstruction of undertaken (Fig. 1). The MRI is an instrumental
the proximal pole of the scaphoid using preoperative investigation because it provides
corticocancellous bone flaps as carriers for accurate analysis of the vascularity of all carpal
vascularized cartilage from either medial or bones and can easily identify a possible AVN of
lateral condyle. This technique is reserved for the proximal pole, which in turn advises certain
the cases showing AVN of the proximal pole changes in the development of the surgical treat-
either preoperatively (MRI) or intraoperatively ment plan.
Fig. 2 3D CT scan reconstruction. (a) “Anatomy of the appearance of the humpback deformity with evident short-
nonunion” in terms of the degree of displacement (dotted ening of the volar cortical axis of the scaphoid (white
red line) and location of sclerotic bone (small black arrows) arrow)
can be precisely evaluated preoperatively. (b) Volar
During the initial preoperative workup, a thor-

ough anamnesis and clinical examination of the
knee is mandatory. Previous surgery in the knee
area dictates the use of the contralateral healthy
knee for flap harvesting even if no scars are
present on either the medial or lateral condyle
area. Patients with already existing arthritis
of the knee joint represent generally an absolute
contraindication for harvesting any type of VBGs
from either condyle.
Surgical Technique
Fig. 3 Volar approach to the scaphoid. Untouched FCR
We perform the entire surgery under loupe mag- sheath (); palmar branch of the radial artery (); “dive-
nification (Prismatic Loupes 4.3x). The operation in” point to the radiocarpal joint capsule, radial to the
tendon sheath (arrow)
begins at the wrist. A two-team approach is not
favored, since the intraoperative aspect of the
scaphoid dictates the type of bone graft to be
used for scaphoid reconstruction.
With the patient supine on the operating table,
the entire arm, prepped and draped up to the level
of the cubital fossa, is abducted and placed on
a dedicated hand table while being fitted with a
tourniquet. The ipsilateral lower extremity is pre-
pped and draped up to the proximal third of the
thigh.
Preparation of the Recipient Site
After tourniquet application (300 mmHg), an

Fig. 4 Volar approach to the scaphoid. Joint capsule has
approximately 4 cm incision is performed on the been opened; Freer instrument inserted into the nonunion;
distal volar forearm along the skin projection of PP proximal pole, DP distal pole of the scaphoid
the flexor carpi radialis (FCR) tendon. In order to
prevent a possible postoperative scar with tendon proximal pole of the scaphoid and the scaphoid
irritation and chronic wrist pain, we approach the fovea. Using a Freer elevator, the nonunion is
scaphoid radially from the FCR, thereby avoiding identified (Fig. 4). To facilitate debridement, at
direct exposure of the tendon and its bed this point two 1 mm K-wires are placed into the
(unpublished observation by Dr. Heinz Bürger) proximal and distal pole of the scaphoid each and
(Fig. 3). Dissection at this level is performed used as “joysticks” to widely open the nonunion
with the bipolar electrocautery. area. Next the nonunion is excised. We prefer
Once the joint capsule is reached, a longitudi- excision using a fine oscillating saw blade. The
nal arthrotomy directly on top of the waist of the osteotomy lines are set at about 1–2 mm away
scaphoid is performed. Having the assistant pull from the macroscopically sclerotic bone at the
on the thumb while performing the arthrotomy level of the nonunion and are performed sepa-
facilitates the opening of the radiocarpal joint rately on both the proximal and distal poles of
and enables immediate optimal view of the the scaphoid. A thorough inspection of the
cancellous bone of both scaphoid parts must monopolar cautery, the subcutaneous tissues and
assure complete excision of the devitalized bone. the tibial band are opened longitudinally. At this
At this point the tourniquet is released, and, stage, a self-retractor to spread the iliotibial
after about 5 min of waiting, both parts are band is placed. Up to this point, the dissection is
inspected again. Spontaneous bleeding from the performed using only bipolar cautery. To uncover
cancellous bone should occur. In the case of no the lateral condyle, the distal part of the vastus
active bleeding from the proximal pole, a decision lateralis muscle is freed at a suprafascial level and
has to be made toward its complete resection and reflected cranially. During this maneuver, usually
reconstruction using a cartilaginous VBG. one significant perforator of the SLGA can be
After completing the debridement, it is always seen piercing the iliotibial tract toward the skin.
helpful to use bone wax to attain an “imprint” of Since the vastus muscle is reflected cranially,
the final bone defect. One piece of bone wax is the entire distal part of the lateral femoral condyle
warmed up at the body temperature and inserted is optimally exposed. The vascular anatomy of the
into a cut finger of a latex glove. The latex layer area can be now observed. The SLGA arises from
will prevent leaving any wax traces onto the soft the midportion of the popliteal artery and travels
tissues while taking the imprint and help extract laterally taking an abrupt curve over the lateral
the imprint from the defect as a whole piece with- supracondylar line toward the lateral condyle.
out deforming it. At this level, it splits into the distal and transversal
After the recipient area is cleaned from blood branches which in turn further split into smaller
clots and any remaining soft tissues, the wax-latex interconnected branches vascularizing the entire
construct is gently pressed with the operator’s surface of the lateral condyle up into the lateral
finger into the bone defect. Additional gentle pres- margin of the joint cartilage (Fig. 5).
sure on the wax is also performed with the Freer Corticocancellous VBG is harvested based on
instrument. Once the bone defect is entirely filled the SLGA and its distal branch. Using the wax
with the wax mold, the entire construct is extra- imprint, the dimensions of the bone graft are now
cted from the bone defect by gently pulling from transferred on the condyle using a sterile marker.
the latex. The latex layer is now opened using a
normal scissors, and the wax imprint of the bone
defect is now revealed.
Attention is now directed toward the recipient
vessels. The palmar branch of the radial artery and
one of its venae comitantes are exposed radially
from the arthrotomy site and dissected free over
a length of approximately 5–8 mm.
Flap Harvesting
The ipsilateral knee is lightly flexed by an assis-

tant sitting on the opposite medial site. First the
medial border of the patella, the lateral femoral
condyle, the trochlea, and the proximal lateral
margin of the intraarticular tibia are palpated and Fig. 5 Vascular anatomy of the lateral femoral condyle.
marked. The SLGA splits at the level of the lateral supracondylar
We harvest the corticocancellous VBG from line (thick arrow) into the distal (thin arrow) and transver-
sal branches (two thin arrows). The distal iliotibial tract
the lateral condyle through a 6–8 cm lazy S inci-
(black asterisk) as well as the distal part of the vastus
sion placed on top of the skin projection of laterals muscle (white asterisk) can be seen. The dotted
the most distal part of the iliotibial band. Using line marks the margin of the lateral femoral condyle
At this point it is crucial to precisely localize the needle set at a low frequency. By doing this, an
donor area directly in the condyle and not too optimal protection of the small distal branches
close to the joint area. irrigating the VBG is achieved.
Harvesting the graft too proximally is danger- At this point the four osteotomies are made
ous since it places at least one osteotomy outside using an oscillating saw. Usually the VBG has
the condyle, thereby destabilizing the strength of a depth of 1.5–1.8 cm. To avoid a too deep
the femur in this region and favoring major frac- osteotomy, we like to measure the depth on the
tures. Taking the graft too distally can in turn saw blade with a sterile marker. The most proxi-
destabilize the subchondral bone near the lateral mal osteotomy has to be performed under careful
joint. protection of the vascular pedicle by lifting it
Once the donor area has been marked, the using a nerve hook (Fig. 6b).
dissection of the pedicle begins in a proximal to Once all four osteotomies are made, using
distal fashion. First, the most distal portion of a thin AO chisel, the VBG is carefully freed
the SLGA is freed from fascial attachments at from its place and lifted up into the wound.
the level of the supracondylar line. The artery At this time point, one can observe active bleeding
and its one to two venae comitantes are wrapped from the VBG which remains now attached
into dense fatty tissue which should be included only through its vascular pedicle in the donor site.
in the pedicle. Once freed from its fascial attach- Lastly, the SLGA and its veins are minimally
ments, the artery can be dissected further medially freed from the surrounding fatty tissue, clipped,
toward the popliteal artery by ligation of several and cut. This step completes the flap harvesting.
side branches which lie very close to the femoral After thorough irrigation and control of
periosteum. the bleeding points, the bone gap in the condyle
After completing the proximal dissection, using is usually reconstructed using allogeneic decel-
the bipolar cautery and a Freer instrument, the lularized bone matrix. The iliotibial band
vascular pedicle is freed at a supraperiosteal level is closed using separate Vicryl 0-0 sutures. The
including two to four secondary interconnected skin is closed in two layers using resorbable
branches up to 2–3 cm before the most distal mar- monofilament sutures. An elastic bandage is
gin of the planned VBG (Fig. 6a). The last part of applied to the entire lower extremity from the
the dissection will be carried out subperiosteally by foot up to the proximal thigh. This prevents
incising the periosteum with a Colorado monopolar the swelling of the knee area postoperatively.
Fig. 6 Flap harvesting. (a) The pedicle has been incised using a Colorado monopolar needle. (b)
completely dissected. The most distal branches have been Osteotomies have been performed and the flap is lifted
ligated with Prolene (arrow), and the periosteum has been from the condyle
Scaphoid Reconstruction This will prevent unnecessary scarring of the

gliding structures around the tendon which might
The VBG is brought into the recipient site and lead to postoperative pain and limited range
carved to match exactly the dimensions of the wax of motion.
imprint (Fig. 7a, b). Using the joystick K-wires, the
bone gap is widely opened and the VBG is pressed 1. After incising the wrist skin, the palmar branch
inside. If designed correctly the graft should match of the radial artery is the first structure that
the bone defect perfectly. Releasing the tension on should be identified and protected.
the joystick K-wires leads to a physiological com- 2. Tight closure of the radiocarpal joint capsule
pression of the VBG in between the distal and should be avoided since doing this might stran-
proximal poles of the scaphoid, which in turn will gulate the vascular pedicle of the flap. One
fix the bone transplant in place without the need of or two 4-0 absorbable monofilament sutures
additional osteosynthesis. The final result is con- to loosely approximate the capsule will suffice.
trolled using a C-Arm. 3. When elevating the vascular pedicle, choose
The bone flap is oriented so that the margin of and include two to three periosteal branches
the flap where the vascular pedicle is attached will that interconnect in it. Make sure these all end
lie radially. The pedicle is then brought up to the into the distal branch of the SLGA.
recipient vessels. Using the operative microscope, 4. After marking the osteotomy lines on the con-
the flap is revascularized in an end-to-end fashion dyle, use either bipolar cautery or fine 7-0
using classical microsurgical technique (separate monofilament sutures to ligate the periosteal
Nylon 8-0 sutures) with the palmar branch of the branches distal to the osteotomy. In this way
radial artery and the already prepared venae you will avoid unnecessary bleeding in the
comitantes. Finally, the radiocarpal joint capsule is operating field.
loosely closed on top of the flap, and the wound is 5. After performing the osteotomies, do not try
closed over a thin Penrose drain. A dorsal wrist to forcefully elevate the VBG since it might
splint is used to assure immobilization immediately break at the interface between the cortical and
after surgery. cancellous layers of the bone. Using fine AO
chisels inserted into the osteotomy lines, try
to mobilize the VBG by slowly moving it
Technical Pearls from right to left.
6. After insetting the flap, please check under
Perform the palmar approach to the scaphoid out- direct view if the VBG is stable by passively
side the bed of the flexor carpi radialis tendon. abducting/adducting the hand. The scaphoid
Fig. 7 Flap modeling. The flap is carved to match exactly the wax model on all sides. (a) the cancellous () and the
cortical segments () of the flap can be seen. (b) Image of the flap from above. The pedicle of the flap can be seen
should move as a whole unit. Should the graft In the presence of bone healing, K-wires
be unstable, additional fixation is mandatory. (if any) are extracted, and passive ROM of the
In this situation, we usually use two 1 mm wrist is started allowing also gentle opposition
K-wires, which are first driven under direct and flexion/extension exercises of the thumb for
view through the distal scaphoid pole from a total of 4 weeks. Progressive resistive exercises
the osteotomy level proximally toward the with graduate pressure loading are allowed from
tuberculum distally. the third post month. From the fifth postoperative
7. We always recommend harvesting the pedicle month, normal pressure loading of the wrist is
up to the SLGA. This will assure optimal ves- allowed while avoiding heavy weight lifting.
sel caliber match with the recipient vessels and For the donor site, ambulation and full pressure
enough pedicle length to allow tension-free loading are allowed from the first postoperative day.
anastomosis. After harvesting of corticocancellous VBGs from
the lateral condyle, usually no physiotherapeutic
measures are needed for the donor extremity, all
Postoperative Management patients returning to normal ambulation immedi-
ately after surgery.
The patient is fitted with a dorsal wrist cock-up
splint including the base of the thumb and tailored
so that it cannot rotate and eventually compress the Outcomes
vascular anastomoses at the radial solar wrist. A
normal wrist X-ray will be usually performed dur- Bone healing was achieved 10 weeks postopera-
ing the first postoperative day, where the position tively (Fig. 9a, b). The inherent wrist stiffness and
of the LFC flap and the final scaphoid reconstruc- the postoperative scar were treated using physical
tion can be again scrutinized (Fig. 8a, b). After therapy and specific scar massage. The patient
14 days, in the presence of complete wound was able to return to his normal life by the third
healing, all patients receive a circumferential wrist postoperative month. From the fifth postoperative
orthosis for 10 weeks followed by a CT exam of the month, the patient was able to restart his daily
wrist. sports schedule doing push-ups. By the sixth
Fig. 8 X-ray of the wrist on the first postoperative day. (a) Correction of the humpback deformity (dotted line) and
Reconstruction of the scaphoid length can be observed. the periosteal component of the flap (arrows) can be seen
Metal clips still attached to the vascular pedicle. (b)
Fig. 9 (a) CT examination of the wrist 10 weeks postop- showing optimal integration of the flap with adequate
eratively. Bone union between the flap, proximal and distal reconstruction of the scaphoid
pole of the scaphoid can be observed. (b) Wrist X-ray
Fig. 10 Postoperative left wrist ROM 3 months postoperatively
postoperative month, the patient was declared CT exam also an MRI examination. This is
healed and returned to his normal life (Fig. 10). the only way to precisely evaluate the perfu-
sion of the proximal pole and thus avoid
unpleasant surprises during surgery.
Avoiding and Managing Problems 2. In the presence of AVN, a total resection and
reconstruction of the proximal pole using free
1. Adequate preoperative imaging is instrumental vascularized cartilage should be considered.
for the planning of the surgical procedure. 3. In our experience, the presence of a humpback
Scaphoid nonunions even without the presence deformity always requires extensive debride-
of a humpback deformity require besides the ment of both distal and proximal poles.
Therefore, the significant bone gap and the man- substance, or AVN of the proximal pole
datory reconstruction of the volar cortical length are definitely good candidates for NVBGs or
of the scaphoid favor the use of a free VBG, pedicle VBGs. Therefore the preoperative
thereby assuring both availability of necessary workup is crucial for proper patient selection.
cancellous bone stock and an adequate pedicle
length.
4. It is crucial to achieve a stable positioning
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1. Performing scaphoid reconstruction with free Tu YK, Bishop AT, Kato T, Adams ML, Wood MB. Exper-
VBGs is a demanding procedure which should imental carpal reverse-flow pedicle vascularized bone
be only performed by surgeons with solid grafts. Part I: the anatomical basis of vascularized ped-
icle bone grafts based on the canine distal radius and
experience in wrist surgery.
ulna. J Hand Surg [Am]. 2000;25:34–45.
2. The free LFC corticocancellous flap does nei- Weiland AJ, Moore JR, Daniel RK. Vascularized bone
ther exclude nor compete with the classical autografts. Experience with 41 cases. Clin Orthop
approach for the scaphoid nonunion using Relat Res. 1983;175:87–95.
Wong VW, Bürger HK, Iorio ML, Higgins JP. Lateral
NVBG from the iliac crest or local pedicle
femoral condyle flap: an alternative source of
flaps from the radius. Patients with simple non- vascularized bone from the distal femur. J Hand Surg
unions without severe dislocation, loss of bone [Am]. 2015;40(10):1972–80.
Treatment of the Avascular Necrosis
of the Lunate Using a Free 47
Vascularized Corticocancellous Bone
Graft from the Lateral Femoral
Condyle
Lucian P. Jiga and Zaher Jandali
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480
Preparation of the Recipient Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Flap Harvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Lunate Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Abstract instability with intractable wrist arthritis.

If left untreated, the avascular necrosis of Both vascular, anatomical, and genetic factors
the lunate (AVNL), also known as Kienböck’s have been shown to trigger AVNL, but
disease, leads to progressive ischemia, bone clear etiological mechanisms remain yet to be
collapse, and subsequent proximal carpal row discovered.
Depending on the osseous lesions at
the time of diagnosis and also on
L. P. Jiga (*) · Z. Jandali the perfusion/viability status of the lunate,
Department of Plastic, Aesthetic, Reconstructive and complex treatment recommendations from
Hand Surgery, Evangelisches Krankenhaus, Medical conservative splinting to lunate decompres-
Campus, University of Oldenburg, Oldenburg, Germany
e-mail: lucian.jiga@evangelischeskrankenhaus.de; sion, revascularization, and reconstruction
zaher.jandali@evangelischeskrankenhaus.de (e.g., free bone flaps) up to salvage procedures

https://doi.org/10.1007/978-3-030-23706-6_44
478 L. P. Jiga and Z. Jandali
(e.g., proximal row carpectomy, wrist fusion) hypoperfusion of the same region, signs typical
have been described. Revascularization of for the Kienböck’s disease (Fig. 2a, b). The CT
the lunate using free vascularized bone flaps examination has shown a Stage 2–3A (Lichtman
from the femoral condyles has been proposed classification) avascular necrosis of the lunate
as solid treatment option to prevent bone (AVNL) with collapse of the radial cortical facet
collapse and thereby restabilize the central of the lunate to the scaphoid (Fig. 3a, b).
wrist column and avoid arthritis. After discussing with the patient several
Here we present a patient with AVNL possible options of treatment, radical debridement
where lunate revascularization using a free of the lunate and revascularization using a free
corticocancellous bone flap from the lateral corticocancellous bone flap from the lateral fem-
femoral condyle was performed. Two months oral condyle was planned.
postoperatively, complete healing of the
lunate with evident revascularization was
achieved. Four months postoperatively, the Preoperative Problem List:
patient had a pain-free wrist and was able to Reconstructive Requirements
return to her normal life.
1. Young active person requiring complete
functional restoration of the affected wrist.
Keywords
However, when contemplating the possible
Wrist reconstruction · Lunate avascular prognosis while discussing the treatment
necrosis · Kienböck’s disease · Vascularized plan, the surgeon should always take into
bone graft · Lateral femoral condyle consideration the patient’s age, the revascular-
ization potential of the lunate, as well as the
secondary effects already present in the
Clinical Scenario affected wrist at the time of diagnosis (e.g.,
arthritis, bone collapse).
A 25-year-old female patient was primarily 2. The primary treatment goal is the revasculari-
referred to our service after complaining of zation of the lunate, which in turn will promote
unknown progressive pain of her right wrist, for pain relief and prevent further bone collapse
approximately 6 months in the absence of any and arthritis.
traumatic injury. Her primary care physician 3. The main operative target is the radical
recommended initially immobilization in a wrist debridement of the entire sclerotic cancellous
splint, with no symptom improvement. The initial bone content and its replacement with ade-
clinical examination of the wrist revealed solely a quate vascularized bone. Considering the ana-
slight tenderness over the volar projection tomical position of the lunate, the palmar
of the lunate in forced wrist extension with approach is favored (as compared to the dorsal
otherwise normal active ROM. The patient also approach) since it provides a much better expo-
mentioned an overwhelming increase of the sure to the proximal pole of the lunate and the
wrist pain after several hours of writing at the joint surface to the fovea lunata.
computer (e.g., continuous radiocarpal forced 4. The CT examination of the affected wrist has
extension). The X-ray examination of the affected shown a collapse of the cortical facet of
wrist has shown, besides a slight “ulnar-plus” the lunate to the scaphoid. This might be an
variance, a small depression of the radial facet indicator of an unstable structural situation
of the lunate to the scaphoid (Fig. 1a, b). in the affected lunate. Therefore, during
However the T2-weighted MRI images revealed the informed consent, the patient should
a diffuse increase of the signal intensity in be informed that only the result after
the radial-volar side of the lunate, while intraoperative bone debridement will dictate
T1-weighed images have shown a significant the final type of reconstruction. For example,
47 Treatment of the Avascular Necrosis of the Lunate Using a Free Vascularized. . . 479
Fig. 1 (a) The preoperative X-ray imaging of the right wrist showing a suspect collapse of the radial facet of the lunate to
the scaphoid (arrows); (b) lateral projection showing normal scapholunate angle
Fig. 2 The MRI of the affected wrist showing decreased the lunate, reflecting bone sclerosis, a finding characteristic
signal intensity in both T1-weighted (a, b) and for Stage 2 Kienböck’s disease
T2-weighted images (c) mostly on the volar-radial side of
intraoperative presence of an incomplete coro- complete resection and replacement of the prox-
nal fracture of the lunate which could easily lead imal pole of the lunate. This, in turn, will require
to bone fragmentation during debridement the transplantation of vascularized cartilage. In
(sometimes easily missed during CT evaluation) advanced cases, resection of the entire lunate
can require additional osteosynthesis or even and its complete replacement using vascularized
Fig. 3 (a and b) The CT examination showing compared to the other neighboring carpal bones, reflecting
evident collapse of the radial facet of the lunate to changes corresponding to the Stage 3 Kienböck’s disease
the scaphoid as well as light attenuation of the lunate
cartilage carrying free bone flaps and additional these patients advancing to intercarpal
arthrodesis to the capitate, to reconstruct the osteoarthritis. Later on, with a better anatomical
central column of the wrist, might be required. understanding of arterial arcades of the wrist,
The patient should be informed about all these several pedicled vascularized bone grafts
possible types of lunate reconstruction proce- (VBGs) from the second metacarpal, volar or
dures as well as their directly related possible dorsal distal radius, or os pisiforme were
complications and donor site morbidity. described (Heymans and Koebke 1993). Using
pedicled VBG from the dorsal distal radius,
Bochud et al. reported up to 43% good to
Treatment Plan excellent results (Mayo Wrist Score) in
26 patients, followed-up for an average of
The classical surgical approach to AVNL is 6.7 years (Bochud and Büchler 1994). Similarly,
dictated by a combination of bone- and Daecke et al. have shown in a 12-year follow-up
cartilage-based evaluations of the affected wrist. study an 80% improvement of pain and active
In initial stages, splinting, bone decompression range of motion (ROM) – compared to the con-
procedures (e.g., capitatum or radius shortening tralateral hand – in 23 patients where pedicle
osteotomy), and lunate revascularization or a VBGs from the pisiform bone were employed to
combination thereof were described (Lichtman revascularize the lunate (Daecke et al. 2005).
and Degnan 1993). In more advanced stages, Although offering good-quality vascularized
however, compromised articulations can be bone, pedicled VBGs have also several limita-
fused or completely excised (e.g., proximal row tions that should be taken into consideration
carpectomy, total wrist fusion). when planning a revascularization approach for
Historically, lunate revascularization AVNL.
procedures by transplantation of arteriovenous
bundles from the dorsal metacarpals combined 1. Limited amount and quality (e.g., high poros-
with non-vascularized cancellous bone grafts ity) of available corticocancellous bone which
from the radius have been described since can be harvested (e.g., distal radius).
over four decades (Elhassan and Shin 2009). Nev- 2. Limited length of the vascular pedicle limiting
ertheless, on a long-term, the outcomes proved the degree of movement and, thereby, making
modest with a significant number of the flap inset difficult.
3. Vascular pedicle based on retrograde circula- medial descending genicular system, found
tion including under-millimeter vessels prone approximately 3–4 mm proximal to the lateral
to kinking, spasm, thrombosis, and flap failure. knee joint line. Based on the SLGA as main vas-
4. In the majority of cases a dorsal approach to cular pedicle, one or several of these vascular
the lunate is required, which can make the branches can be used to harvest corticocancellous,
debridement of the sclerotic bone much corticoperiosteal, or osteocartilaginous bone flaps
tedious as compared to a volar approach. from the lateral femoral condyle (Fig. 4).
In our case, the plan was to debride the
Free vascularized corticocancellous or entire internal sclerosed cancellous bone while
osteocartilaginous bone grafts from the medial protecting the outer “articular shell” of the bone
femoral condyle based on the descending and finally reconstruct the lunate using a free
genicular artery (DGA) have long been described corticocancellous bone flap from the lateral fem-
as powerful tools for bone reconstruction of oral condyle.
the upper and lower extremity. The terminal However, as shown in the CT exam, the
branches of the DGA build over the entire surface articular surface of the lunate to the scaphoid
of the medial condyle a reliable perforator was already collapsed, so we had to elaborate
network which allows safe harvesting of also a reconstruction plan which could also deal
either corticoperiosteal, corticocancellous, or with a possible intraoperative loss of articular
osteocartilaginous (e.g., femoral trochlea) bone cartilage. Accordingly, all the preparations
flaps from this region (Bürger et al. 2014). have been made to allow harvesting of additional
Similarly, the lateral femoral condyle can cartilage from the lateral femoral trochlea, should
also provide an optimal donor site for an entire such a situation arise during surgery.
range of free VBGs based on either the transversal The distal radial artery and the venae
or the distal branch of the superolateral genicular comitantes, lateral to the most distal segment
artery (SLGA) (Wong et al. 2015). of the flexor carpi radialis tendon, were to be
The SLGA also provides several perforators to prepared as recipient vessels.
the skin which, after piercing the distal part of
the iliotibial tract, distribute into one independent
perforasome divided into three separate levels
(ventral proximal, ventral distal, and dorsal) at
the level of the lateral knee. This in turn allows,
as in the case of the descending genicular artery
system, harvesting of other soft tissue subunits
(e.g., the skin, tendon, vascularized fascia) for
reconstruction of complex defects including both
bone and soft tissue.
Studying the vascular anatomy of the lateral
femoral condyle, Parvizi et al. have found a
constant occurring SLGA in 28 cadavers (Parvizi
et al. 2016). After exiting from the popliteal
fossa, it enters the lateral knee region
and branches off into three arteries – the
Fig. 4 Intraoperative view of the lateral femoral condyle
fasciocutaneous, the superficial (patellar), and (blue dotted line) vascular anatomy. The superolateral
the profound (articular) branches. Of these, genicular artery emerging from underneath the distal lateral
the deep articular branch gives a transversal and femur (), branching into its transversal (thick arrow) and
the distal (thin arrow) segments. Perforator pedicles to the
a distal terminal branch, running in close contact vastus lateralis muscle () and the skin of the lateral knee
with the condyle periosteum and communicating (two arrows) piercing through the distal iliotibial band can
through an arterial arch, similar to the be seen
Alternative Reconstruction Options Lichtman Stages 1–2 with preserved integrity

of the lunate articular shell) or adjunctive
1. Non-vascularized corticocancellous bone (simultaneous with VBG reconstruction)
from the iliac crest is the least preferred option measures of lunate decompression. In our
for this case. The significant cancellous bone practice, radius shortening osteotomy will be
defect created after debridement favors imme- primarily indicated exclusively in patients with
diate vascularized bone grafting, thus creating ulna-minus variance, having a normal lunate
the ideal frame for a fast healing process. structure in plain X-rays (Lichtman Stages
2. Local pedicled VBGs from the distal radius 1–2) with partial bone necrosis (MRI)
have proved useful in the revascularization of and completely preserved radiocarpal and
the lunate without fragmentation of its mediocarpal cartilage surface as found by
outer shell or arthritic changes. However, the diagnostic wrist arthroscopy (Bain and Begg
limited available volume of the cancellous Stage 0 disease).
bone stock and limited maneuverability
due to limited pedicle length are important
drawbacks which prevent their use as first Preoperative Evaluation and Imaging
options in our practice.
3. Free VBGs from the iliac crest are a valid During initial examination, all patients referred to
option for revascularization of the lunate even our service will already have taken a standard
in patients with advanced Stage 3 Kienböck’s posteroanterior and lateral X-rays of the affected
disease which according to several groups can wrist. In cases with obvious radiological changes
provide similar results to VBGs from the (e.g., Lichtman Stage 3), we routinely perform
medial femoral condyle in the treatment of MRI and CT examinations for the evaluation of
the lunate AVN (Gabl et al. 2002). Possible the vascular and bone-cartilage status of the
disadvantages of this flap, as compared with lunate, these information being instrumental for
the VBGs taken from the femoral condyles, are planning of an optimal therapeutic approach.
its higher donor site morbidity and a more During inspection of the initial X-rays, thor-
tedious flap dissection and shaping of flap for ough evaluation of the ulnocarpal joint and the
the proper inset into the lunate. relation of the ulnar head with the distal radius is
4. Free VBGs from the medial femoral condyle important. The presence of ulna-minus variance in
(MFC). Equal to the lateral femoral condyle in a patient with dorsally located wrist pain and
terms of bone stock quality, it represents in our tenderness around the lunate should pinpoint to a
practice the plan B in all patients requiring possible evolving Kienböck’s disease. In such
lunate reconstruction but with previous surgery cases, even in the absence of any radiological
on the lateral knee or preference for a medial findings, an MRI becomes mandatory as it is
scar. However, the wide anatomical variation the only examination able to accurately detect an
of the descending genicular artery, which altered perfusion of the lunate (e.g., Lichtman
might determine an intraoperative change of Stages I–II).
plans in the approach of the vascular pedicle, Besides radiological evaluation, we routinely
must be kept in mind when planning this flap perform a simple Allen test to exclude a possible
(Garcia-Pumarino et al. 2014). very rare occurring radial vascular dominance of
5. In patients with lunate AVN presenting the hand (in case of which to avoid any possible
with ulna-minus or ulna-neutral variance, thrombotic events, we will restrict on preparing
several load-reduction procedures (e.g., radius solely its palmar branch or choosing the ulnar
shortening osteotomy, capitate shortening artery as recipient vessel).
osteotomy, temporary scaphotrapeziotra- Functional examination of the wrist with
pezoidal or scaphocapitate fusion) have been thorough measurements of the active ROM (exten-
proposed either as stand-alone (in patients with sion/flexion) as well as possible preoperative
functional deficits at this level (also independent of avoid injuring the superficial cutaneous branch of
the actual diagnosis) is precisely documented pre- the median nerve, which can sometimes run more
operatively. Besides serving as starting values for medially than its anatomical trajectory, coursing
evaluation of postoperative results (e.g., compara- directly above the median nerve as it approaches
tive), these are valuable elements should any foren- the thenar eminence (Fig. 5). The median nerve is
sic issues (e.g., law suits) arise after surgery. identified and protected radially. Here, excessive
Previous scars on the volar aspect of the wrist dissection should be avoided at all costs.
should be carefully evaluated, especially in The flexor tendons of the finger and thumb are
patients with previous surgery in this area (e.g., retracted to the ulnar side and fixed with a Henly
distal radius plating, flexor tendon repair, retractor. In preparing the flexor tendons, care
median nerve surgery). Such issues can hide should be exercised not to injure their fine syno-
major difficulties during the volar approach to vial layer which can lead to additional unwanted
the lunate (scar tissue with loss of anatomical scarring. The best way to achieve this is to isolate
planes, scarred median nerve) and thus predispose all flexor tendons as a whole unit and not try
to additional risks and related complications over dissecting them separately. Once the tendons are
which the patients should be thoroughly informed out of the way, the entire volar aspect of the
before surgery. radiocarpal joint capsule comes into view (Fig. 6).
At this time point, the radiocarpal joint line is
identified using a C-arm, and the lunate and
Surgical Technique the position of the fovea lunata are marked
using a sterile pen. To expose the lunate, an
We perform the entire surgery under loupe ulnar-based joint capsule flap of about
magnification (prismatic loupes 4.3). The 2 1.5 cm (length width) centered on the two
operation begins at the wrist. A two-team previously marked elements is sharply raised
approach is not favored since the intraoperative using a scalpel blade (Fig. 7). First, the joint
aspect of the lunate after thorough debridement surface of the proximal lunate is carefully
dictates the type of bone graft to be used for inspected. Any signs of lunate cartilage alterations
reconstruction. or even breakdown of ischemic origin (macro-
With the patient supine on the operating table, scopic light brown color of the cartilage or
the entire arm, prepped and draped up to the level
of the cubital fossa, is abducted and placed on a
dedicated hand table while being fitted with
a tourniquet. The ipsilateral lower extremity is
prepped and draped up to the proximal third of
the thigh.
Preparation of the Recipient Site
The lunate is approached under tourniquet

(300 mmHg) through a lazy-S 4 cm incision at
the level of the volar wrist about 1 cm ulnar from
the skin projection of the median nerve toward
the carpal tunnel. After incision of the skin, the Fig. 5 Volar approach to the lunate. During dissection of
entire preparation is done with dissection using the subcutaneous tissue, one must be aware of the possible
presence of the superficial cutaneous branch of the median
Stevens scissors and bipolar electrocautery. nerve which provides sensation to the thenar eminence
Before opening the volar forearm fascia, (nerve marked with dotted line) and must be protected
careful dissection in the subcutaneous tissue will *palmaris longus tendon
spontaneous lysis at the level of the subchondral radioscapholunate arthrodesis) or to a simulta-

bone) will dictate the complete resection of the neous replacement of the proximal pole of the
proximal pole and replacement with free lunate and fovea lunata with free vascularized
vascularized cartilage. The technique of proximal cartilage, also called the “kissing flap” procedure
pole resection and reconstruction is presented in a (also described in ▶ Chap. 48, “Treatment of
separate chapter of this book by Anoshina et al. Kienböck’s Disease Using Free Vascularized Car-
(▶ Chap. 48, “Treatment of Kienböck’s Disease tilage Bone Flaps from the Lateral Femoral Con-
Using Free Vascularized Cartilage Bone Flaps dyle,” by Anoshina et al. in this book).
from the Lateral Femoral Condyle”). If the proximal pole cartilage shows no
The fovea lunata should be also examined disease, using a fine burr, an approximately
carefully as any sign of arthritis dictates change 4 5mm window is made into the volar horn
of plans either to a salvage procedure (e.g., of the lunate. Through this approach, the
SHARC, scaphoid hemiresection and arthrodesis entire sclerotic cancellous bone is excavated
of the radiocarpal joint, or as alternative RSL, by burring under continuous irrigation to pre-
vent injury (through overheating) of the still
intact subchondral bone. At this point, special
care should be exercised especially on the
scaphoid side not to injure or destabilize the
scapholunate ligament in its volar and articular
segments.
Once the bone has been completely excavated,
using sterile wax, an imprint of the entire defect is
taken and will be used as template to carve the
final form flap and thus assure an easy inset.
Finally, the tourniquet is removed, and careful
hemostasis is achieved in the entire operating field
using bipolar cautery.
Fig. 6 Once the flexor tendons are retracted ulnarly en Attention is now directed toward the recipient
bloc with the median nerve, the volar aspect of the radio-
vessels. The palmar branch of the radial artery
carpal joint comes into view. The incision line for opening
the joint capsule is marked (blue dotted line) and one of its venae comitantes are exposed
radially to the arthrotomy site and dissected
free over a length of approximately 5 mm
(Fig. 8).
Fig. 7 After the ulnar-based flap from joint capsule has

been raised (being hold by the forceps), the volar part of the Fig. 8 Recipient vein (arrow) and palmar branch of the
lunate as well as the radiocarpal joint comes into view radial artery (two arrows) prepared
Flap Harvesting Once the donor area has been marked, the
dissection of the pedicle begins in a proximal-to-
The ipsilateral knee is lightly flexed by an distal fashion. First, the most distal portion of the
assistant sitting on the opposite medial site. First SLGA is freed from fascial attachments at the
the medial border of the patella, the lateral level of the supracondylar line. The artery and its
femoral condyle, trochlea, and the proximal lat- one to two venae comitantes are wrapped into
eral margin of the intra-articular tibia are palpated dense fatty tissue, which should be included in
and marked. the pedicle. Once freed from its fascial attach-
We harvest the corticocancellous VBG ments, the artery can be dissected further medially
from the lateral condyle through a 6–8 cm lazy-S toward the popliteal artery by ligation of several
incision placed on top of the skin projection of side branches which lie very close to the femoral
the most distal part of the iliotibial band. Using periosteum.
monopolar electrocautery, the subcutaneous tis- After completing the proximal dissection,
sues and the tibial band are opened longitudinally. using the bipolar cautery and a Freer instrument,
At this stage, a self-retractor to spread the iliotibial the vascular pedicle is freed at a supraperiosteal
band is placed. Up to this point, the dissection is level including two to four secondary
performed using only bipolar cautery. To uncover interconnected branches up to 2–3 cm before the
the lateral condyle, the distal part of the vastus most distal margin of the planned VBG (see
lateralis muscle is freed at a suprafascial level and Fig. 6a – Jiga et al. scaphoid chapter). The last
reflected cranially. During this maneuver, usually part of the dissection will be carried out sub-
one significant perforator of the SLGA can be periosteally by incising the periosteum with a
seen piercing the iliotibial tract toward the skin. Colorado monopolar needle set at a low fre-
Once the vastus muscle is reflected cranially, quency. By doing this, an optimal protection of
the entire distal part of the lateral femoral condyle the small distal branches irrigating the VBG is
is optimally exposed. The vascular anatomy of achieved.
the area can be now observed. The SLGA arises At this point the four osteotomies are made
from the midportion of the popliteal artery and under continuous irrigation using an oscillating
travels laterally, taking an abrupt curve over saw (we use blades with a length of 25 mm and
the lateral supracondylar line toward the lateral 0.4 mm thickness). Usually the VBG has a depth
condyle. At this level, it splits into the distal of 1.5–1.8 cm. To avoid a too deep osteotomy, we
and transversal branches which in turn further like to measure the depth on the saw blade with a
split into smaller interconnected branches sterile marker. The most proximal osteotomy has
vascularizing the entire surface of the lateral con- to be performed under careful protection of the
dyle up into the lateral margin of the joint cartilage vascular pedicle by lifting it using a nerve hook
(see Fig. 5 – Jiga et al. scaphoid chapter). (see Fig. 6b – Jiga et al. scaphoid chapter).
The corticocancellous VBG is harvested based Once all four osteotomies are made, using a
on the SLGA and its distal branch. Using the thin AO chisel, the VBG is carefully freed from its
wax imprint, the dimensions of the bone graft are place and lifted up into the wound. At this time
now transferred on the condyle using a sterile point, one can observe active bleeding from the
marker. At this point it is crucial to precisely local- VBG, which remains now attached only through
ize the donor area directly in the condyle and not its vascular pedicle in the donor site.
too close to the joint area. Harvesting the graft too
proximally is dangerous since it places at least one
osteotomy outside the condyle, thereby Lunate Reconstruction
destabilizing the strength of the femur in this region
and favoring major fractures. Taking the graft too The VBG is brought into the recipient site
distally can in turn destabilize the subchondral and carved to match exactly the dimensions of
bone near the lateral joint. the wax imprint (Fig. 9). The VBG is then
lie radially and remain protected even after the

closure of the ulnar-based joint capsule flap. The
pedicle is then brought up to the recipient vessels.
Using the operative microscope, the flap is
revascularized in an end-to-end fashion using clas-
sical microsurgical technique (separate Nylon 9-0
sutures) with the palmar branch of the radial artery
and the already prepared venae comitantes.
The wound is closed over a thin Penrose drain.
A dorsal wrist splint is used to assure immobili-
zation immediately after surgery.
Technical Pearls
Fig. 9 The lateral femoral condyle corticocancellous
bone flap carved according to the bone wax imprint. When
preparing the SLGA up to its emergence from the popliteal 1. Perform the palmar approach to the lunate by
artery, the pedicle of the flap can be as long as 5 cm avoiding separate dissection of the flexor ten-
dons and the median nerve. This will prevent
unnecessary scaring of the gliding structures
around both the tendon and the nerve, which
might lead to postoperative pain and limited
range of motion.
2. Tight closure of the radiocarpal joint capsule
should be avoided since this might strangulate
the vascular pedicle of the flap. One or two 4-0
absorbable monofilament sutures to loosely
approximate the capsule will suffice.
3. When elevating the vascular pedicle, choose
and include two to three periosteal branches
that interconnect in it. Make sure these all end
into the distal branch of the SLGA.
4. After marking the osteotomy lines on the
condyle, use either bipolar cautery or fine 7-0
monofilament sutures to ligate the periosteal
branches distal to the osteotomy. In this way
you will avoid unnecessary bleeding in the
Fig. 10 Intraoperative X-ray confirming the appropriate operating field.
position of the flap after inset into the lunate. Arrows point 5. After performing the osteotomies, do not try
to the cortical part of the lateral femoral condyle flap lying to forcefully elevate the VBG since it might
at the same level with the lunate corticalis
break at the interface between the cortical and
cancellous layers of the bone. Using fine AO
carefully inserted through the volar window made chisels inserted into the osteotomy lines, try to
in the lunate. If designed correctly, the graft mobilize the VBG by slowly moving it from
should match the bone defect perfectly without right to left and back.
the need of additional osteosynthesis. The final 6. After insetting the flap, please check under
result is controlled using a C-arm (Fig. 10). direct view if the VBG is stable by passively
The bone flap is oriented so that the margin of flexing/extending the wrist. The lunate should
the flap where the vascular pedicle is attached will move as a whole unit, and in flexion the pedicle
must remain tension- and pressure-free. followed by a CT exam of the wrist. In the presence
Should the graft be unstable, additional fixa- of bone healing, the orthosis is removed and
tion is mandatory. In this situation, we usually replaced with a normal splint leaving the base of
use one 1.2 mm titanium osteosynthesis screw the thumb free.
which is driven under direct view from volar/ Passive ROM of the wrist is started allowing
distal through the VBG in an oblique direction gentle opposition and flexion/extension exercises
toward the dorsal subchondral bone. of the thumb for a total of 4 weeks. Progressive
7. We always recommend harvesting the pedicle resistive exercises with graduate pressure loading
up to the SLGA which is prepared into the are allowed from the third post month. From
lateral popliteal fossa. This will assure optimal the fifth postoperative month, normal pressure
vessel caliber match with the recipient vessels loading of the wrist is allowed while avoiding
and enough pedicle length to allow tension- heavy weight lifting.
free anastomosis. For the donor site, ambulation and full pressure
loading are allowed from the first postoperative
day. After harvesting of corticocancellous
Postoperative Management VBGs from the lateral condyle, usually no
physiotherapeutic measures are needed for the
The patient is fitted with a dorsal wrist cock-up donor extremity, all patients returning to normal
splint including the base of the thumb and tailored ambulation immediately after surgery.
so that not to rotate and eventually compress
the vascular anastomoses at the radial volar wrist.
A normal wrist X-ray will be usually performed Outcomes
during the first postoperative day, where the posi-
tion of the LFC flap and the final lunate reconstruc- Bone healing was achieved 8 weeks postopera-
tion can be again scrutinized. After 14 days, in the tively (Fig. 11a, b). The inherent wrist stiffness
presence of complete wound healing, all patients and the postoperative scar were treated using
receive a circumferential wrist orthosis for 8 weeks physical therapy and specific scar massage.
Fig. 11 X-rays at 6 months (a) and 1 year (b) after surgery showing complete healing of the lunate and proper
reconstruction of its radial side to the scaphoid
Fig. 12 Active ROM of the affected right wrist showing minimal remaining stiffness, which however is of no further
impediment for the patient
The patient was able to return to her normal life executed. Any remaining gaps between the
by the third postoperative month. From the fifth bone graft and the lunate should be corrected,
postoperative month, the patient was able to and, if not possible, these should be filled with
restart her regular sport activities. By the sixth autologous cancellous bone.
postoperative month, in the presence of a minimal 4. If additional fixation is needed, we favor the
flexion deficit of the right wrist which did not use of 1.2 mm titanium screws.
bother her at all, the patient was declared healed
and returned to her normal life (Fig. 12a, b).
Learning Points
Avoiding and Managing Problems 1. If left untreated, the avascular necrosis of the
lunate (AVNL), also known as Kienböck’s
1. Adequate preoperative imaging is instrumental disease, leads to progressive ischemia, bone
in planning the surgical procedure. collapse, and subsequent proximal carpal row
Nevertheless, the decision on which type of instability with intractable wrist arthritis
reconstruction should be performed is taken (Kienböck 1910; Müller 1920; Gelberman
ultimately after intraoperative inspection. et al. 1980). Both vascular, anatomical, and
2. In the presence of arthritis of the proximal genetic factors have been shown to trigger
lunate pole, a total resection and reconstruction AVNL, but clear etiological mechanisms
using free vascularized cartilage (either from remain yet to be discovered (Bain et al. 2015).
the medial or the lateral femoral condyle) must 2. Performing lunate reconstruction with free
be considered. VBGs is a demanding procedure, which should
3. It is crucial to achieve a stable situation of be only performed by surgeons with solid
the lunate after flap inset. Therefore, the VBG experience in wrist surgery and microsurgery.
must be exactly tailored to the defect and 3. The free LFC corticocancellous flap does
the excavation of the sclerotic bone precisely neither exclude nor compete with other
approaches for lunate revascularization using Gabl M, Lutz M, Reinhart CI, Zimmermann R,
local pedicled VBGs or indirect lunate decom- Pechlaner S, Hussl H, Rieger M. Stage 3 Kienbock’s
disease: reconstruction of the fractured lunate using a
pression procedures. However, in experienced free vascularised iliac bone graft and external fixation. J
hands, free VBGs from the femoral condyles Hand Surg. 2002;27B(4):369–73.
offer several important advantages (e.g., long Garcia-Pumarino R, Franco JM. Anatomical variability
pedicle, good-quality cancellous bone) which of descending genicular artery. Ann Plast Surg.
2014;73(5):607–11.
play an important role in the optimal execution Gelberman RH, Bauman TD, Menon J, Akeson WH. The
of reconstruction and thus in the final func- vascularity of the lunate bone and Kienböck’s disease. J
tional result. Hand Surg Am. 1980;5(3):272–8.
Heymans R, Koebke J. The pedicled pisiform
transposition in Kienböck’s disease. An anatomical
and functional analysis. Handchir Mikrochir Plast
References Chir. 1993;25:199–203.
Kienböck R. Concerning traumatic malacia of the lunate
Bain GI, Yeo CJ, Morse LP. Kienböck disease: recent and its consequences: joint degeneration and compres-
advances in the basic science, assessment and treat- sion. Fortsch Geb Roentgen. 1910;16:77–103.
ment. Hand Surg. 2015;20(3):352–65. Lichtman DM, Degnan GG. Staging and its use in the
Bochud RC, Büchler U. Kienböck’s disease, early stage determination of treatment modalities for Kienböck’s
3–height reconstruction and core revascularization of disease. Hand Clin. 1993;9(3):409–16.
the lunate. J Hand Surg. 1994;19B:466–78. Müller W. Über die Erweichung und Verdichtung des Os
Bürger HK, Windhose C, Gaggl AJ, Higgins lunatum, eine typische Erkrankung des Handgelenks.
JP. Vascularised medial femoral trochlea osteochondral Beitr Klin Chir. 1920;119:664.
flap reconstruction of advanced Kienböck disease. J Parvizi D, Vasilyeva A, Wurzer P, Tuca A, Lebo P,
Hand Surg Am. 2014;39(7):1313–22. Winter R, Clayton RP, Rappl T, Schintler MV,
Daecke W, Lorenz S, Wieloch P, et al. Vascularized os Kamholz LP, Bürger HK. Anatomy of the vascularised
pisiform for reinforcement of the lunate in Kienböck’s lateral femoral condyle flap. Plast Reconstr Surg.
disease: an average of 12 years of follow-up study. 2016;137(6):1024e–32e.
J Hand Surg. 2005;30A:915–22. Wong VW, Bürger HK, Iorio ML, Higgins
Elhassan BT, Shin AY. Vascularized bone grafting for JP. Lateral femoral condyle flap: an alternative source
treatment of Kienböck’s disease. J Hand Surg. of vascularised bone from the distal femur. J Hand Surg
2009;34A:146–54. Am. 2015;40(10):1972–80.
Treatment of Kienböck’s Disease
Using Free Vascularized Cartilage 48
Bone Flaps from the Lateral Femoral
Condyle
Maria Anoshina, James P. Higgins, Lucian P. Jiga, and

Heinz Bürger
Contents
Preoperative Considerations: Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . 493
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Electronic supplementary material: The online version

M. Anoshina (*)
Trauma Hospital , Graz, Austria
“Millesi Center” for Reconstructive Microsurgery,
Peripheral Nerve Disease and Plexus Brachialis, Vienna
Privat Clinic, Vienna, Austria
e-mail: maria_anoshina@mail.ru
J. P. Higgins
The Curtis National Hand Center, Medstar Union
Memorial Hospital, Baltimore, MD, USA
e-mail: Higgins@Curtishand.com
L. P. Jiga
Department of Plastic, Aesthetic, Reconstructive and Hand
Surgery, Evangelisches Krankenhaus, Medical Campus,
e-mail: lucian.jiga@evangelischeskrankenhaus.de;
jigalucian@gmail.com
H. Bürger
Head of Hand- and Reconstructive Microsurgery
Department, Privat Clinic MariaHilf, Klagenfurt, Austria
e-mail: heinz.buerger.ordi@gmail.com

https://doi.org/10.1007/978-3-030-23706-6_45
492 M. Anoshina et al.

Outcome- Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Abstract The viable distal lunate is preserved along with

the scapholunate and lunotriquetral ligaments.
In 1910, Kienböck described the idiopathic The vascularized LFT flap heals to the pre-
progressive avascular osteonecrosis of the served distal lunate segment and restoring car-
lunate (Kienböck, Fortschr Geb Rontgenstr pal height, stability, and congruity. The LFT flap
XVI(2):77–103, 1910). A multitude of treat- provides a joint preserving alternative in cases
ment options have been described, as well as of advanced Kienböck’s disease. It has shown
clinical, radiographical, and arthroscopic stag- good clinical outcomes of pain reduction and
ing classifications. One of the most novel range of motion. Radiographic follow up has
recent reconstructive options is the use of free demonstrated healing of the reconstructed
osteochondral flaps from distal femur in cases lunate without further osteonecrosis, restoration
of advanced lunate fragmentation and collapse of carpal height, and stability and congruity of
(Lichtman stage IIIa-IIIb Kienböck’s disease). radiocarpal and midcarpal joints. An exemplary
Two harvest sites have been employed for case is used below to illustrate the surgical
these osteochondral reconstructive procedures: technique.
the medial femoral trochlea (MFT) based on
the descending geniculate artery (DGA), and
Keywords
the lateral femoral trochlea (LFT) based on the
superolateral geniculate artery (SLGA). This Osteochondral flaps from distal femur ·
installment will describe the senior author’s Osteochondral femoral condyle flap ·
preferred treatment using the lateral femoral Advanced Kienböck’s disease · Lateral
trochlea for lunate reconstruction. femoral trochlea flap · Lateral femoral
The SLGA demonstrates constant anatomy. osteochondral graft
The pedicle is a convenient length for wrist
reconstruction, and provides good caliber for
ease of microsurgery. The morphology of the The Clinical Scenario
LFT is favorable morphology for lunate recon-
struction. When examined on the axial plane, A 21-year right-hand dominant male reports pain
the angle created between the lateral cortical in dorsal right wrist exacerbated by weight lifting.
surface and the anterior cartilage surface He describes the pain limiting his ability to per-
closely approximates 90 (rather than the form his job duties as a roofer. His wrist demon-
more sloping angle encountered on the MFT strates dorsal tenderness and swelling, with
flap). After the fragmented and necrotic prox- reduced wrist motion (ROM 50-0-35 R/U 20-0-
imal lunate is excised, the LFT’s convex carti- 30) and grip strength.
lage surface is used to reconstruct the proximal X-Ray right wrist reveals a Kienböck’s disease
articular surface that articulates with the radius. Lichtman stage IIIa with fragmentation and
48 Treatment of Kienböck’s Disease Using Free Vascularized Cartilage Bone. . . 493
proximal collapse of the lunate. Diagnostic wrist Treatment Plan

arthroscopy shows damaged cartilage on the prox-
imal lunate articulation surface (Fig. 4). MRI con- Many authors described using free vascularized
firmed the diagnosis of Kienbock’s disease (Fig. 3) osteochondral grafts from distal femur as
established option for reconstruction in wrist
pathology with good outcome (Wong et al.
Preoperative Considerations: 2015; Bürger et al. 2014; Higgins et al. 2014,
Reconstructive Requirements 2016, 2018). Flap harvesting technique from
medial and lateral femoral condyle is similar but
1. Harvest and honing of the osteochondral seg- with some differences in anatomy:
ment to recapitulate lunate dimensions in three
planes. Particular attention is paid to the con- • Supplying vessel of MFT is the transversal
tour of the surfaces between the adjacent branch of Descending Geniculate Artery
scaphoid and triquetrum, as well as the (DGA) which originates from the Superficial
reestablishment of carpal height (Bürger et al. Femoral Artery. In around 15% cases, there is
2014; Higgins et al. 2014). anatomical variation, where the DGA is small
2. Providing a new and analogous convex carti- or absent and the transverse branch arises from
lage surface of the proximal lunate. In rare the superomedial geniculate artery (SMGA)
cases, there may also be degenerative changes which in turn originates from the Popliteal
in the lunate fossa of the radius. This surface artery (Higgins J.P., Bürger et al. 2013, 2014,
will be articulating with the reconstructed 2016, 2018). The LFT flap is perfused by is the
lunate. The surgeon may consider simulta- Superolateral geniculate artery (SLGA), which
neous reconstruction of the lunate fossa with always originates from the Popliteal Artery. In
a segment of the articulating lateral patella. comparison the SLGA pedicle (4.9 1.2 cm)
This combination of convex lateral trochlea is shorter than the DGA (8 cm), but demon-
and concave lateral patella can be harvested strates appropriate length for carpal reconstruc-
on the same vascular pedicle, with the patella tion and excellent vessel a caliber.
segment perfused via a superficial branch of • The morphology of the LFT is favorable mor-
the SLGA (Higgins and Bürger 2014). phology for lunate reconstruction. When
3. Maintaining carpal stability of the examined on the axial plane, the angle created
proximal row. between the lateral cortical surface and the
4. Selecting the surgical approach. The authors anterior cartilage surface closely approximates
select the approach based on the pattern of 90 (rather than the more sloping angle
fragmentation of the collapsed lunate, best encountered on the MFT flap) (Fig. 5).
visualized on sagittal images on CT scan.
When the diseased lunate exhibits avascular The procedure may be performed using two
sclerosis and collapse the nonviable bone is teams if desired. Either contralateral or ipsilateral
the proximal segment. After resection of the leg may be used as the morphology of the
necrotic bone, the surgeon will encounter via- harvested segment is similar. Harvest from the
ble bone in the distal horns. This distal viable ipsilateral side provides some advantages for the
segment may be preserved and fixed to the patient in the recovery period as discomfort in the
subsequently vascularized LFT segment. The knee will often result in the patient assisting
approach is determined by the characteristics ambulation or push off with the contralateral
and quality of this distal segment. If the largest limb. Harvest from the contralateral side provides
viable fragment of the distal lunate is dorsal, some advantages for the positioning surgical
then volar approach is chosen. If palmar, then a teams when a two-team approach is used. In this
dorsal approach to the lunate is preferred case example, an ipsilateral harvest with two-team
(Higgins and Bürger 2014). approach was performed.
With the goal of preserving the distal concave 2. 4 + 5 Extracompartmental Artery (ECA) bone
portion of the lunate and distal SL and LT ligaments, graft is mainly used for treatment of Kienböck’s
the size of the distal lunate fragments was assessed. disease Lichtman stage II-IIIa (Moran et al.
In this case, the larger segment was present dorsally. 2005; Tsantes et al. 2019)
For this reason, a volar approach was selected. In the 3. 2,3 Intracompartmental Supraretinacular Artery
volar approach the team working on the wrist pre- (ICSRA) or 1,2 ICSRA bone graft
pares the palmar branch of the radial artery to serve (Tsantes et al. 2019; Chang et al. 2006;
as the recipient site for an end-to-end anastomosis. Steinmann et al. 2002)
4. 2nd or 3rd metacarpal base bone graft
5. Free iliac crest bone flap (Gabl et al. 2002)
Alternative Reconstructive Options 6. Free osteochondral flaps from medial fem-
oral trochlea (Bürger et al. 2013, 2014,
1. Unloading procedures: Radius shortening 2016)
osteotomy, Scaphotrapezoidtrapezium (STT) 7. Lunate replacement (with pisiform transfer
fusion, or Scaphocapitate (SC) fusion (Fig. 1) (Saffir P. 2010), using polycarbon implant
Also, a capitohamate fusion or capitate (Bellemère et al. 2012; Werthel 2014))
shortening (combination) are used for lunate 8. Proximal row carpectomy (Welby and Alnot
unloading treatment (Tsantes et al. 2019). 2003)
Fig. 1 (a, b) A combination of proximal lunate reconstruction with a free vascularized osteochondral graft from lateral
femoral condyle and a temporary SC-pining (Trauma hospital Bad Ischl, Austria)
In the authors’ opinion nonoperative manage- capitate. The remaining segment of proximal
ment, lunate unloading procedures, lunate revas- lunate body and convex cartilage is then provided
cularization with pedicle grafts, or free by the LFT flap. The technique has been described
vascularized bone grafts should be considered (Gillis) as the primary step for reconstruction of
when the lunate architecture is intact (Lichtman Bain 2 Kienbock’s in conjunction with MFT
stages 0, I, and II, Schmitt stage A, and Bain grade reconstruction. The technique may be applied
0 of Kienböck’s disease). similarly in conjunction with LFT reconstruction
When the lunate demonstrates fractures, col- of these cases (Gillis 2018).
lapse, and loss of functional articular surfaces, the
authors employ LFT reconstruction to restore
lunate architecture and functional articular sur- Preoperative Evaluation and Imaging
faces (Lichtman stage 3, Bain stage 1,2).Other
options are proximal row carpectomy (PRC), 1. Allen-Test: In an effort to ensure safety, and
scaphotrapezoidtrapezial fusion (STT), and Allen’s test is performed to confirm perfusion
scaphocapitate fusion (SC) (Higgins and Bürger of the hand via radial and ulnar arteries. In the
2014) (Fig. 1a, b). volar approach, the smaller volar branch of the
The technically most difficult lunate recon- radial artery is utilized in an end-to-end fash-
struction is in Bain stage 2 Kienbock’s, where ion, while preserving the much larger dorsal
the lunate commonly demonstrates a fracture branch. Thus, the sacrifice of the palmar
into the midcarpal joint on the coronal plane. branch should not be a threat to distal perfusion
The volar and dorsal horns of the concave distal unless chronic vascular disease was present.
fragments may show displacement in a volar and This patient demonstrated a normal
dorsal direction, respectively. Allen’s test.
In these cases, the proximal lunate can be 2. X-Ray right wrist– a slight ulna-“minus” var-
resected. The two segments of distal lunate sur- iance, nearly neutral. Fragmented lunate with a
faces reduced and fixed with suture anchor fixa- collapsed proximal portion.
tion to restore midcarpal congruity. The concave 3. CT: demonstrated Lichtman stage IIIa
distal articulation surface of the lunate can so be Kienbock’s disease (Fig. 2). Visualization of
restored for midcarpal articulation with the the fragments of the damaged lunate is
Fig. 2 (a, b) Kienböck’s disease Lichtman stage IIIa-b A collapsed proximal lunate fragment with mostly intact
articulation surface of dorsal part of distal lunate fragment
important step for planning resection level and malalignment of the scaphoid in palmar direction.
the osteosynthesis. The carpal malarticulation in Stage IV leads to
wrist osteoarthrosis, often with free joint bodies
X-ray and CT-scan are gold standard for preop- and chondromatosis (Fig. 3). (Schmitt and Kalb,
erative diagnostic and operation planning. 2010)
4) MRI: In earlier Kienböck’s stages (Stage I, Wrist arthroscopy in Kienböck’s disease is an
X-ray signs are negative) reparative hyper- additional evaluation option for older patients or
vascularization and bone marrow edema in in cases, when the collapse of the lunate in
T2-weighted sequences. In Stage II ischemia and advanced Kienböck is provocated with a “stress-
sclerosis, decrease in signals in T1 and T2- trauma” like in this case of weight lifting. The
weighted sequences. Stage IIIa begins with infrac- arthroscopical view showed damaged proximal
tion at the proximal lunate pole and loss of the cartilage proximal surface of the lunate, but
lunate height. In Stage IIIb visible changes in acceptable fossa lunata surface (Fig. 4). The
anatomical relationship in the proximal wrist: arthroscopic classification of Kienböck disease
proximal migration of the capitatum, rotational based on the number of nonfunctional articular
Fig. 3 MRI image

of avascular lunate
Fig. 4 Arthroscopic view

to the proximal articulation
surface of the lunate
surfaces of the lunate is well described (Bain and In the dorsal approach, we open the 4th exten-
Durrant 2011; Bain et al. 2011; Bain and Begg sor compartment, and resect the NIP.
2006). If there are advanced degenerative changes All the other operative steps are quite similar,
in a corresponding surface, a “simple” reconstruc- except the need of a second incision for the later
tion with an osteochondral graft cannot be anastomosis in the snuffbox region.
recommended.
1. Here the volar approach to the lunate was
performed via an incision over the Flexor
Preoperative Care and Patient carpi radialis tendon (FCR). The palmar
Drawing branch of the radial artery was prepared and
protected. The palmar sensory branch of the
See Figs. 6 and 7. median nerve is identified and protected with a
vessel loop. One subcutaneous vein was pre-
pared. Dissection down to the wrist capsule
Surgical Technique proceeds radial to the median nerve and flexor
pollicis longus (FPL) and ulnar to the FCR
Wrist tendon.
Depending from the situation, we choose a palmar 2. The wrist capsule is opened and the lunate
or dorsal approach. identified. The distal part scapholunate and
Fig. 5 Donor site pre-OP

X-Ray of patella-femoral
joint (right lateral femoral
condyle, left medial
femoral condyle) (X-Ray
before LFC-C)
Fig. 6 Landmarks of
LFC-C flap. Fibula head,
tibial plateau, distal part of
the femoral condyle, and
skin incision
Fig. 7 Position of the leg.

No pressure in the popliteal
region!! An installed side
support fixation on the
tourniquet level and a step
fixation with flexed knee
joint to make the dissection
in the popliteal region easier
lunotriquetral ligaments are preserved along of 6–8 cm. Within the subcutaneous tissues, a
with the midcarpal capsule and the distal carti- perforator of the SLGA to the skin perforator
lage surface of the native lunate. is identified and ligated.
3. The diseased proximal segment of the lunate is 2. The fascia over Vastus Lateralis muscle
debrided. (VL) is incised longitudinally. The posterior
4. The resection level is confirmed with margin of the VL is mobilized and retracted
intraoperative C-arm using 2 1,0 mm anteriorly with a Langenbeck hook. Then the
Kirschner Wires parallel to the distal lunate SLGA is identified.
articulation surface. This helps guide the 3. The distal part of the iliotibialis tract (ILTB) is
resection of the remaining proximal necrotic vertically incised and retracted with a sharp
lunate with an oscillating saw. One K-Wire in hook. After incision of ILTB, the patellar
the distal fragment of the lunate can be branch of SGLA is encountered and ligated.
maintained as a joystick to facilitate manipula- The surgeon will then encounter a fibro fatty
tion (Fig. 11) layer of tissue that will need to be incised in
5. The lunate fossa is inspected. In this case, there order to access the underlying lateral femoral
is minimal degenerative change observed. condyle.
6. A bone wax model of the defect is created. 4. The surgeon will typically encounter the fol-
Bone wax is optimal for forming a model of lowing vascular anatomy of the SGLA:
the defect because of the soft consistence. branch to vastus lateralis (ligated), branch to
Therefore, it is recommended to use a “digit” ILTB (ligated), branch in the lateral collateral
of thin surgical glove (thin silicon of the glove ligament (ligated), femoral diaphyseal
enables to make an exact print of the defect on branch, and two periosteal branches. The lon-
the bone wax). It is also possible to use a bone gitudinal periosteal branch is ligated and the
cement. One of the disadvantages of this transverse periosteal branch is preserved as it
method is the hit emission. courses to the proximal cartilage of the lateral
femoral trochlea. The diaphyseal branch is
Leg also preserved. If the dominant branch to the
1. An unsterile tourniquet is utilized on the anteroproximal cartilage region is the trans-
proximal thigh above the draped surgical versal branch, the diaphyseal branch can be
field. The longitudinal mid-axial skin incision ligated.
begins two finger breadths proximal to the 5. A 2.5–3 cm arthrotomy is made in the joint
knee joint and extends proximally for a length capsule at the level of the desired cartilage
harvest site. A narrow strip of periosteal strip inserted into the defect of the proximal part of
is elevated housing the transversal branch of the lunate, while manual traction is applied to
SLGA (Fig. 13). This meticulous periosteal the wrist. The K-wire in the distal part of the
pedicle elevation is performed using low lunate is helpful to serve as a joy-stick during
power fine-tipped monopolar cautery and a inset/reduction (Fig. 19)
freer periosteal elevator. The periosteal strip 2. A freer is used to push the bone flap firmly
includes one artery and two veins (Figs. 14, against the prepared remaining distal lunate
15, 16, and 17) segment.
6. The pedicle is then dissected in the popliteal 3. Osteosynthesis is achieved with two mini-
direction (usually behind the biceps femoris screws (1,2 mm) under intraoperative
tendon) as long as needed to obtain adequate C-arm control. The first screw was directed
caliber for anastomosis. Branches of the from the graft into the distal lunate fragment,
SLGA to the posterior condyle region are while the second screw is to fix the graft from
identified, carefully dissected, and ligated palmar proximal to dorsal distal direction to the
(Fig. 12) lunate horn.
7. Utilizing the model of the defect, the bone 4. Motion in the wrist is evaluated using fluoros-
flap is outlined to achieve appropriate copy to insure congruent motion of the entire
dimensions reconstructed lunate (Video 2)
8. A thin osteotome or oscillating bone saw 5. The microscope is then brought into the surgi-
(1–1,5 cm wide) may be used. The desired cal field. An end-to-end anastomosis is
lateral-medial depth of the harvest performed between the SGLA and the palmar
(corresponding to the volar/dorsal dimension branch of the radial artery. One SLGV is anas-
of the lunate) is measured and marked with an tomosed to the SGLV, the second to a superfi-
operative pen on the osteotome/ saw blade. cial skin vein (Figs. 22 and 23)
Three osteotomies are created to the specified 6. To avoid compression of the vascular pedicle,
depth: one coronal, and two parallel trans- the wrist capsule (Fig. 20) and the skin are
verse. The remaining sagittal osteotomy is carefully and loosely closed with interrupted
created by levering the harvest segment ante- sutures. The region of the anastomosis is
riorly using an osteotome in the coronal marked with a long skin suture to assist in
osteotomy plane. If the first three osteotomies postoperative assessment.
are made with precision, the final osteotomy
will require little force to cleave the bone flap Technical Pearls
free (Fig. 15)
9. The tourniquet is then deflated and perfusion 1. The SGLA vessel system and its branches on
of the bone segment is visually confirmed. the lateral femoral condyle may be difficult to
Then the pedicle can be ligated and the identify in some cases. A safe technique is to
flap harvested. (Video 1) start dissection proximally, locating the larger
10. An intraarticular drainage is placed, and the caliber segment of the SGLA near the popliteal
knee capsule is closed. region. As you follow the vessels distally, you
11. The fibro fatty layer over the lateral femoral will encounter and ligate branches to Vastus
condyle is repaired. A subfascial drain is Lateralis muscle, then the branch to the diaph-
placed. The ILTB and fascia of the vastus ysis of the femur. These branches are best
lateralis is repaired. mobilized with a fine curved dissector
(Figs. 8 and 9). Next the surgeon will identify
Wrist the longitudinal and transversal periosteal
1. The size and shape of the bone flap is honed on branches. The longitudinal branch can be dis-
the backtable according to the observed mor- sected with a freer and then ligated. With the
phology of the model. The bone flap is then distal dissection near completion, attention is
Fig. 8 Elevatorium freer

(at the top of the picture),
dissector (underneath)
Fig. 9 The curved form of

the dissector is helpful
during dissection of SLGA
branches in the popliteal
region
turned to the origin of the pedicle (one artery this tendency toward subluxation A joy-stick in
and two veins) going to the Popliteal space.) A the distal part of the lunate and a freer elevator
good advice can be ligate the longitudinal peri- (Fig. 11) are useful for maintaining reduction
osteal branch before ligation of the femur shaft during the osteosynthesis. The congruous rela-
branch and control the most dominant blood tionship of the lunate fossa and the LFT flap
supply of the anteroproximal cartilage region segment is carefully scrutinized on lateral views
of LFC. Stroke the blood in the branches in the using intraoperative C-arm imaging.
cartilage direction and control a sure supply. 3. Microanastomosis can be performed end-to-
Additional branches to the posterior surface of end to R. palmaris A. radialis, or end-to-side
the distal femur may be ligated. The pedicle is to A. radialis, also a patch-technique possible
now widely mobilized and can be controlled (if volar approach), or to “snuff-box” vessels
with a vessel loop. Dissection distally to the (if dorsal approach).
trochlea is then continued as described earlier 4. During flap harvesting, it is helpful to use
in this chapter (Fig. 10). hemo-clips (liga-clips). It can save time with-
2. Fixation of the bone flap may be challenging. out loss of quality. But after the implantation
When placing the first screw from the flap into of the graft and performing the micro-
the distal native lunate, the flap segment may anastomosis, the authors can recommend to
tend to displace dorsally and not remain congru- remove the ligaclips in the wrist region and to
ent in the lunate fossa. The surgeon must apply ligate the small branches with a 9.0 micro-
dorsal pressure on the flap segment to prevent suture under the microscope.
Fig. 10 Elevatorium
freer – one end of the
instrument is sharp and
thin – can be perfectly used
for periosteal dissection
Fig. 11 Pin-retractor-
good option to open
proximal wrist joint
cast was used for 8 weeks, followed by removable

splint use for an additional 6 weeks. Then usual
hand physiotherapy.
See Figs. 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22,
The subfascial drainage is removed at the first
and 23.
postoperative day. The intraarticular drainage is
maintained for 2 days (ex on the second day
Postoperative Management postop) to avoid hemarthrosis. Ice packs are used
on the donor site as well as compression hose to
Postoperatively, the wrist is immobilized with a minimize swelling. The patient is encouraged to
well-padded dorsal splint to avoid a pressure in mobilize the joint with exclusion of hyperextension
the region of the anastomosis. The hand is posi- and hyperflexion (Fig. 26). For passive movement,
tioned at chest height on a pillow to help minimize a continuous passive motion machine can be used
swelling. A handheld acoustical Doppler is used (start with 0 - 0 - 30 ) three times during the day
for monitoring the anastomosis. At postoperative (morning, noon, and evening) for 15 min up to
day 10, the sutures are removed, a well-padded third postoperative day with addition of around
Fig. 12 The pedicle of

A. genu superior lateralis
(SLGA) runs behind the
biceps femoris tendon to
A. poplitea
Fig. 13 Subchondral well

perfused area of the hyaline
cartilage of anteroproximal
region of lateral femoral
condyle supplied by
R. transversus A. genu
superior lateralis. (Take care
of this blood supply! –
subperiosteal dissection
with a sharp end of the
freer)
Fig. 14 Arthrotomy of
the knee-joint
in anteroproximal cartilage
region of the lateral femoral
condyle. Perioststrip:
subperiosteal mobilization
of the strip subchondral,
then epiperiosteal
10 flexion every second day (but take care, pain M. vastus lateralis and M. vastus medialis impor-
can be a limit! if painful, stop earlier). In this case, tant for centralized patella gliding.
we recommended the continuous passive training Postoperative anticoagulation regime with
for 4 weeks postop and reached the flexion of 100 . low molecular heparin for 2 days (Lovenox
In active movement, it is the balance between prophylactic dosage- 40 mg once a day). As
Fig. 15 Bone wax model

of the defect with drawn
“cartilage” surface. Draw
the deep of the wax model
on the saw blade or
osteotome
Fig. 16 Flap harvesting.

Elevatorium freer is helpful
for this surgical step
Fig. 17 Mobilize and Cut

the periosteal strip after
identifying the limit of
subperiosteal and
epiperiosteal dissection
long as the intraarticular drainage placed is X-Ray obtained on the first postoperative day
recommended to limit the movement in the showed a good lunate morphology, restoration of
operated knee region. carpal height, radiolunate and scapholunate rela-
Intraoperatively a single dose of antibiotic is tionships, and good position and depth of the two
administered before tourniquet elevation. mini-screws (Fig. 24)
Fig. 18 Osteochondral
graft 1,5 1,2 1 cm with
pedicle (1 artery and
2 veins)
Fig. 19 Implantation in the

defect and reconstruction of
the proximal articulation
surface of the lunate (right)
and the pedicle (on the left
side of the picture)
Fig. 20 Capsule sutures

(respect capsule-band
apparat!) and pedicle (avoid
kinking and looping)
To control the graft position, the proportions The X-Ray-control after 1 year demonstrates
of the lunate and the consolidation between the healing of the reconstructed lunate with good
graft and the distal lunate part, 6 and 12 weeks congruency of the radiolunate articulation. The
after surgery a CT scan of the wrist is patient demonstrates 20 improvement in wrist
recommended. extension, wrist flexion and grip strength
Fig. 21 Intraoperative X-Ray C-arm control of the reconstructed lunate with 2 mini-screws: the position of the graft, the
screws (length), and the distal fragment. Also, a dynamical X-Ray control (Video 3)
Fig. 22 Vessel caliber of

the arteries.
Microanastomosis with
10.0 microsutures
Fig. 23 End-to-end
anastomosis: the pedicle
artery (SLGA) and one vein
to R. palmaris A. radialis
and the second vein to a
superficial vein were
anastomosed
that were unchanged from his preoperative The patient reported discomfort and swelling
measurements. The patient reports complete in his donor knee that persisted for approximately
pain relief and has returned unrestricted to his 4 weeks. The patient has subsequently returned to
preoperative employment as a roofer (Figs. 27 his routine athletic activities (primarily running
and 28) and biking) 3 months after surgery.
Outcome- Clinical Photos and Imaging 2. A bone-wax model of the defect is an inexpen-
sive and helpful method to plan flap
See Figs. 24, 25, 26, 27, and 28. harvesting. This tool aids in harvesting only
the desired amount of cartilage bearing
trochlea.
Avoiding and Managing Problems 3. Meticulous attention paid to the depth of the
osteotomies (1.5 cm is usually enough for car-
1. Preservation of the distal lunate fragment(s) in pal defects) is important to minimize harvest
continuity with the distal SL and LT ligaments size and donor site morbidity (Fig. 18).
and midcarpal capsule important for preven- 4. The subperiosteal dissection of the vessels will
tion of instability in the proximal wrist minimize the risk of pedicle injury. When
(Higgins and Bürger 2014, 2016). releasing the tourniquet to check graft
Fig. 24 X-ray 1 day

postop: Acceptable graft
position, screw length and
proximal contour of the
lunate postoperative
Fig. 25 CT scan 1 week

postop. Acceptable graft
position, reconstructed
proximal articulation
surface, and lunate height
Fig. 26 Donor site region

4 days postop. No pain, no
swelling
Fig. 27 CT-scan:
Reconstructed lunate
one-year postop. Complete
integration of the graft with
good proximal contour.
Restored anatomical
relations of the lunate and
remained distal lunate part
perfusion, or at the conclusion of the case after crepitus with sliding of the patella over this
micro anastomosis, 10–15 min of application region should be corrected by resecting sharp
of topical lidocaine, papaverine, or warm edges at the harvest site. The cartilage defect at
saline will assist in relieving vasospasm the donor site will be replaced with a regener-
(Video 4) ative cartilage over the course of 6–9 months
5. After harvesting the graft, all sharp edges of postoperatively. If patients have pain longer
the donor region should be evaluated. Any than normally anticipated (2–3 months),
Fig. 28 (a, b, c, d) Clinical outcome
anticipate that the knee discomfort will regress

in as the regenerative cartilage fills the donor Learning Points
defect. In an effort to minimize donor site
morbidity, efforts should be made to minimize 1. The osteochondral grafts from distal femur in
graft size, smooth graft bed edges after harvest the treatment of carpal disorders have been
and avoid any sharp instrumentation/retractors well described for carpal reconstruction, with
of the remaining patella or femoral surfaces. growing numbers of cases being performed for
6. Some cases will demonstrate small areas of scaphoid nonunion and Kienbock’s disease.
heterotopic ossification along the subcutane- The ideal application for LFT lunate recon-
ous pedicle because of the osteogenic potential struction is in cases where the lunate is
of the periosteal leash. In the unlikely event fragmented and collapsed (Lichtman stage 3a
that this appears to limit motion, the ossifica- and 3b, Bain stage 1 and 2) (Higgins and Bür-
tion can be safely resected in a subsequent ger 2014, 2016, 2018; Lichtman et al. 2016).
procedure after bone healing of the lunate is 2. Use of the LFT flap as an alternative to the
achieved. MFT donor site provides a vascular pedicle
7. Particular instruments we find facilitate sub- that is more constant in its anatomy and more
periosteal preparation, vessel dissection, and convenient length and caliber for carpal
separation (Figs. 8, 9, and 10). A pin-retractor reconstruction than the MFT analog (Wong
is also helpful for manipulations in the proxi- et al. 2015; Parvizi et al. 2016; Morsy et al.
mal wrist (Fig. 11). 2018).
3. The use of free vascularized osteochondral flap reconstruction of advanced Kienböck disease. J
grafts from distal femur has demonstrated Hand Surg Am. 2014;39(7):1313–22.
Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes
good results in young Kienbock’s and complications of 1,2-intercompartmental supra-
patients (Stage IIIa-IIIb) where salvage opera- retinacular artery pedicled vascularized bone grafting
tions are undesirable. In our experience, the of scaphoid nonunions. J Hand Surg Am. 2006;31
LFT patients have demonstrated reliable (3):387–96.
Del Piñal F, García-Bernal FJ, Regalado J, Ayala H,
healing of the reconstructed lunate, resolution Cagigal L, Studer A. Vascularised corticoperiosteal
of wrist pain, and preservation of range of grafts from the medial femoral condyle for difficult
motion and grip strength. The procedure effec- non-unions of the upper limb. J Hand Surg Eur Vol.
tively provides a solution to the process of 2007;32(2):135–42.
Elhassan BT, Shin AY. Vascularized bone grafting for
avascular necrosis of the lunate and restores treatment of Kienböck’s disease. J Hand Surg
carpal height and intercarpal relationships. Am. 2009;34(1):146–54.
The use of the MFT for lunate reconstruction Enzinger S, Bürger H, Gaggl A. Reconstruction of the
has been well studied, showing excellent clin- mandibular condyle using the microvascular lateral
femoral condyle flap. Int J Oral Maxillofac Surg.
ical and radiographic results. The donor site 2018;47(5):603–7.
morbidity of the osteochondral harvest has Fujiwara H, Oda R, Morisaki S, Ikoma K, Kubo T. Long-
been shown to be acceptable with excellent term results of vascularized bone graft for stage III
subjective outcomes scores, and objective Kienböck disease. J Hand Surg Am. 2013;38(5):904–8.
Gabl M, Lutz M, Reinhart C, et al. Stage 3 Kienböck’s
range of motion and radiographic analysis. disease: reconstruction of the fractured lunate using a
This relatively more novel technique of lateral free vascularized iliac bone graft and external fixation. J
femoral trochlea harvest requires further study. Hand Surg (Br). 2002;27(4):369–73.
Studies of intermediate outcomes are under- Gillis JA, Higgins JP. Coronal fracture of the lunate in
advanced Kienböck disease: Reestablishing midcarpal
way. It appears to provide a promising alterna- congruency to enable osteochondral reconstruction: a
tive for advance Kienbock’s reconstruction case report, June 13, 2018. JBJS Case Connector.
especially in young patients (Higgins et al. 2018;8(2):e37.
2014, 2016, 2018). Gstoettner C, Mayer JA, Aman M, Salminger S, Bürger H,
Hirtler L, et al. Cutaneous angiosome of the chimeric
SLGA perforator flap: anatomical study and clinical
considerations. J Plast Reconstr Aesthet Surg.
References 2019;72(7):1142–9.
Higgins JP, Bürger HK. Osteochondral flaps from the distal
Bain GI, Begg M. Arthroscopic assessment and classifica- femur: expanding applications, harvest sites, and indi-
tion of Kienbock’s disease. Tech Hand Up Extrem cations. J Reconstr Microsurg. 2014;30(7):483–90.
Surg. 2006;10(1):8–13. Higgins JP, Bürger H. The use of osteochondral flaps in the
Bain GI, Durrant A. An articular-based approach to treatment of carpal disorders. J Hand Surg Eur Vol.
Kienbockavascular necrosis of the lunate. Tech Hand 2018;43(1):48–56.
Up Extrem Surg. 2011;15(1):41–7. Jones DB Jr, Moran SL, Bishop AT, Shin AY. Free-
Bain GI, McGuire DT. Decision making for partial carpal vascularized medial femoral condyle bone transfer in
fusions. J Wrist Surg. 2012;1(2):103–14. the treatment of scaphoid nonunions. Plast Reconstr
Bain GI, Smith ML, Watts AC. Arthroscopic core decom- Surg. 2010;125(4):1176–84.
pression of the lunate in early stage Kienböck disease Keith PP, Nuttall D, Trail I. Long-term outcome of non-
of the lunate. Tech HandUp Extrem Surg. 2011;15 surgically managed Kienböck’s disease. J Hand Surg
(1):66–9. Am. 2004;29(1):63–674.
Bellemère P, Maes-Clavier C, Loubersac T, Gaisne E, Lichtmann DM, Pientka WF, Bain GI. The future of
Kerjean Y, Collon S. Pyrocarbon interposition wrist Kienböck’s disease: a new algorithm. In: Lichtman
arthroplasty in the treatment of failed wrist procedures. DM, Bain GI, editors. Kienböck’s disease in diagnosis
J Wrist Surg. 2012;1(1):31–8. and treatment. New York: Springer;2016. p.307
Bürger HK, Windhofer C, Gaggl AJ, Higgins Lutsky K, Beredjiklian PK. Kienböck disease. J Hand Surg
JP. Vascularized medial femoral trochlea osteocarti- Am. 2012;37(9):1942–52.
laginous flap reconstruction of proximal pole scaphoid Moran SL, Cooney WP, Berger RA, Bishop AT, Shin
nonunion. J Hand Surg Am. 2013;38(4):690–700. AY. The use of the 4 + 5 extensor compartmental
Bürger HK, Windhofer C, Gaggl AJ, Higgins vascularized bone graft for the treatment of Kienböck’s
JP. Vascularized medial femoral trochlea osteochondral disease. J Hand Surg Am. 2005;30(1):50–8.
Morsy M, Sur YJ, Akdag O, Eisa A, El-Gammal TA, vascularized pedicle bone graft for difficult scaph-
Lachman N, et al. Anatomic and high-resolution com- oid nonunion. J Hand Surg Am. 2002;27
puted tomographic angiography study of the lateral (3):391–401.
femoral condyle flap: implications for surgical dissec- Tsantes AG, Papadopoulos DV, Gelalis ID, Vekris MD,
tion. J Plast Reconstr Aesthet Surg. 2018;71(1):33–43. Pakos EE, Korompilias AV. The efficacy of
Parvizi D, Vasilyeva A, Wurzer P, Tuca A, Lebo P, vascularized bone grafts in the treatment of scaphoid
Winter R, et al. Anatomy of the vascularized lateral nonunions and Kienböck disease: a systematic
femoral condyle flap. Plast Reconstr Surg. 2016;137 review in 917 patients. J Hand Microsurg. 2019;11
(6):1024e–32e. (1):6–13.
Salmon J, Stanley JK, Trail IA. Kienböck’s disease: con- Welby F, Alnot JY. Resection of the first row of carpal
servative management versus radial shortening. J Bone bones: post-traumatic wrist and Kienbock’s disease.
Joint Surg Br. 2000;82(6):820–3. Chir Main. 2003;22(3):148–53.
Schmitt R, Kalb K. Imaging in Kienböck’s disease. Wong VW, Bürger H, Iorio ML, Higgins JP. Lateral fem-
Handchir Mikrochir Plast Chir. 2010;42(3):162–170 oral condyle flap: an alternative source of vascularized
Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 bone from the distal femur. J Hand Surg Am. 2015;40
intercompartmental supraretinacular artery as a (10):1972–80.
Augmentation of Bone Allograft
with Vascularized Medial Femoral 49
Condyle Periosteal Flap in Radius
Reconstruction
Eugene Park, Steven T. Lanier, and Jason H. Ko
Contents
Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
Abstract
Giant cell tumors of the distal radius can be

aggressive, resulting in destruction of local
anatomy and the need for wide resection.
Reconstruction of the distal radius using allo-
Electronic Supplementary Material: The online version
of this chapter (https://doi.org/10.1007/978-3-030-23706- graft bone augmented with a vascularized
6_46) contains supplementary material, which is available medial femoral condyle (MFC) periosteal flap
to authorized users. improves chances for bony healing while
reducing the donor-site morbidity seen with
E. Park · S. T. Lanier · J. H. Ko (*) vascularized bone flaps. In this chapter, a
Division of Plastic and Reconstructive Surgery, patient who required en bloc resection of a
Northwestern University Feinberg School of Medicine, giant cell tumor of the distal radius was
Chicago, IL, USA
e-mail: Jason.ko@nm.org

https://doi.org/10.1007/978-3-030-23706-6_46
512 E. Park et al.
reconstructed with a wrist arthrodesis using an 8 months (Figs. 1 and 2, Video 1). The patient
allograft distal radius in combination with a had sustained a fracture on his left distal radius
vascularized medial femoral condyle periosteal 2 years ago, which was treated nonoperatively.
graft. This patient achieved good bony healing Approximately 8 months ago, the patient noticed
with satisfactory functional results, and details a bump on the radial aspect of his left wrist. The
of our operative technique and helpful strate- mass grew rapidly, and the patient initially pre-
gies for success are provided. sented to an outside hospital where a biopsy was
performed, revealing a diagnosis of giant cell
tumor of the bone. The patient was referred to an
Keywords
orthopedic oncologist that scheduled the patient
Medial femoral condyle (MFC) flap · for an en bloc resection of the tumor, and the
Vascularized bone flap · Vascularized senior author was consulted to evaluate the patient
periosteal flap · Radius reconstruction · for reconstruction.
Allograft · Giant cell tumor An MRI obtained by the patient’s orthopedic
oncologist revealed an 11.1 11.3 12.6 cm
infiltrative heterogeneous mass centered in the left
Clinical Scenario distal radius (Fig. 3). The mass extended into the
proximal carpal row, obliterating the proximal
A 24-year-old otherwise healthy right-handed pole of the scaphoid, the proximal triquetrum,
dominant male was referred by his orthopedic and the entire lunate. The mass also invaded the
oncologist for evaluation of a left wrist mass that distal radioulnar joint (DRUJ) and abutted, but did
had been progressively enlarging for the past not invade, the distal ulna. The median and ulnar
Fig. 1 Giant cell tumor of the left distal radius. Clinical appearance at the time of presentation
49 Augmentation of Bone Allograft with Vascularized Medial Femoral Condyle Periosteal Flap in. . . 513
Fig. 2 Plain radiographs demonstrate a large mass obliterating the left distal radius and proximal carpus
nerves were unaffected. The radial extensor ten-

dons were encased in tumor, but all other flexor Reconstructive Requirements
and extensor tendons were uninvolved.
On examination, the patient was unable to 1. Obtain stable wrist reconstruction to bear
move his left wrist, and the skin overlying the weight and allow acceptable hand function.
tumor was thin and hyperpigmented. Range of The reconstructive procedure of choice
motion of the left shoulder, elbow, and fingers must maintain hand function. This is only pos-
were all within normal limits. An Allen’s test sible if the hand is supported by a stable
revealed patent radial and ulnar arteries with an reconstructed joint or by a robust arthrodesis.
intact arch, and capillary refill was normal in all 2. Achieve bony union of construct.
digits. Dorsalis pedis pulses were absent in both The optimal choice of reconstruction
lower extremities, and a posterior tibial pulse was must allow bony healing across the proximal
palpable only in the right lower extremity. site of osteosynthesis and, if a fusion is
Due to the abnormal lower extremity vascular performed, across the distal site, as well. Cer-
exam, a CT angiogram of the lower extremities was tain materials or techniques are prone to
obtained, which revealed bilateral peronea arteria higher rates of nonunion, as will be discussed
magna (Fig. 4). As this precluded the possibility of below.
using a free vascularized fibula flap to reconstruct 3. Maintain sufficient length of forearm and wrist
his radius, the patient was counseled regarding the to preserve tendon length and excursion.
use of allograft versus non-vascularized autograft If the reconstructed wrist is too short, the
bone for reconstruction of the distal radius. patient will have decreased tendon excursion,
514 E. Park et al.
Fig. 3 MRI demonstrated an 11.1 11.3 12.6 cm proximal triquetrum, and the entire lunate. The mass also
infiltrative heterogeneous mass centered in the left distal invaded the distal radioulnar joint (DRUJ) and abutted, but
radius. The mass extended into the proximal carpal row, did not invade, the distal ulna
obliterating the proximal pole of the scaphoid, the
effectively decreasing range of motion and 5. Provide supple, well-vascularized soft tissue
strength in the wrist and fingers. The chosen coverage.
construct must preserve the native length of the All bony constructs must be covered
forearm and wrist to allow optimal wrist and with well-vascularized skin in order to
hand function. decrease the chances of exposure and infec-
4. Reconstruct DRUJ. tion. This can be achieved with native skin, if
The DRUJ must be stabilized in order to there is sufficient skin present. Otherwise,
maintain pronation and supination of the vascularized skin must be recruited in the
wrist. form of a flap.
Fig. 4 CT angiogram of the lower extremities revealed bilateral peronea arteria magna
6. Repair tendons transected during tumor Moran et al. 2006; Weichman et al. 2015). Animal
resection. data, as well as growing body of clinical experi-
During resection of the tumor, the orthope- ence, supports the concept that the addition of
dic oncologist had to transect a portion of the vascularized tissue to an allograft stimulates
extensor pollicis longus tendon. improved revascularization and bony healing
(Gallardo-Calero et al. 2019; Mattos et al. 2019).
Ideally, a free vascularized fibula flap would
Treatment Plan have been used to perform a total wrist arthrodesis.
However, given this patient’s bilateral peronea
Upon completion of tumor resection, the defect in arteria magna, this was not an option. Additionally,
the distal radius measured 14 cm in length, includ- there was spillage of tumor in the surgical site
ing the distal portion of the radius and the proximal during the resection; therefore, another goal of the
carpal row. The patient’s wrist was then reconstruction was to minimize the amount of
reconstructed using fresh-frozen allograft bone donor-site burden in case of tumor recurrence.
augmented with a vascularized medial femoral Thus, the use of vascularized medial femoral con-
condyle (MFC) periosteal flap to increase the dyle bone or non-vascularized autologous fibula
chance of bony healing. The vascularized medial was not chosen. A fresh-frozen left radius allograft
femoral condyle periosteal flap is based on the was used to replace the resected bone, and a total
descending genicular artery and can provide up to wrist fusion was performed (Fig. 5). Since the
12 5 cm of thin, pliable, vascularized tissue (Doi proximal carpal row was infiltrated by tumor, the
and Sakai 1994; Iorio et al. 2011). Augmentation of radiocarpal joint could not be spared, requiring
allograft bone with a vascularized flap was initially fusion of the wrist (Fig. 6). The fusion construct
described for reconstruction of intercalary defects was wrapped with vascularized MFC periosteum
of the femur. Capanna et al. utilized a vascularized (Fig. 7), and an end-to-side microanastomosis
fibula graft placed into the medullary canal of a performed using the radial artery and a vena
femoral allograft for reconstruction after tumor comitans (Fig. 8). The DRUJ was repaired using
resection (Capanna et al. 1993). Several groups suture and supported with Kirschner wires. The
have since reported success with similar techniques extensor pollicis longus (EPL) tendon, which had
(Campanacci et al. 2018; Houdek et al. 2016; been transected during the tumor resection, was
516 E. Park et al.
repaired primarily, and the skin was closed without necessary to stabilize the wrist and hand. This is
tension. The patient’s wrist was immobilized until accomplished via arthroplasty, partial radiocarpal
CT scan demonstrated bony bridging at both the arthrodesis, or total wrist arthrodesis, each with its
proximal and distal osteosynthesis sites. Figures 9 own array of pros and cons. Radiocarpal joint
and 10 demonstrate postoperative radiographs. salvage through the use of an osteoarticular allo-
graft or fibular head graft preserves motion but is
prone to instability of the carpus and progressive
Alternative Reconstructive Options osteoarthritis (Kocher et al. 1998; Cheng et al.
2001). Minami et al. noted palmar subluxation
Aggressive giant cell tumors of the distal radius of the carpus with degenerative changes in all
often require en bloc resection to minimize the patients treated with a vascularized fibular head
risk of local recurrence, and reconstruction is graft and promoted fibula-scapholunate arthrode-
sis as a superior option for reconstruction
(Minami et al. 2002). Arthroplasty procedures
frequently require a concomitant DRUJ repair,
Sauve-Kapandji, or Darrach procedure to reduce
instability and pain and preserve pronation and
supination (Szabo et al. 2006; Saini et al. 2011;
Kocher et al. 1998). Radiocarpal arthrodesis, such
as with a vascularized fibula-scapholunate
arthrodesis, preserves motion through the mid-
carpal joint while preventing carpal subluxation,
but range of motion is inferior to joint salvage
procedures (Flouzat-Lachaniette et al. 2013;
Jaminet et al. 2012). Total wrist arthrodesis pro-
Fig. 5 A fresh-frozen left radius allograft was used to
vides stability with good long-term results but
replace the resected bone, and a total wrist fusion was completely eliminates flexion and extension of
performed the wrist (Vander Griend and Funderburk 1993;
Fig. 6 Since the proximal carpal row was infiltrated by tumor, the radiocarpal joint could not be spared, requiring fusion
of the wrist
Fig. 7 a. Medial femoral condyle vessels exposed demonstrating the transverse and longitudinal branches of the
descending geniculate vessels. b. The MFC periosteal flap after it has been harvested but still perfused in the knee.
Fig. 8 a. The free MFC periosteal flap after harvest. b. The distal radius allograft fusion construct was wrapped with
vascularized MFC periosteum
Puloski et al. 2007). Transposition of the distal reported the successful use of vascularized fibula
ulna onto the residual proximal segment of the grafts for distal radius reconstruction using a vari-
radius with wrist fusion has also been described ety of techniques (Minami et al. 2002; Jaminet
(Puri et al. 2010). The patient in this case ulti- et al. 2012; Muramatsu et al. 2005). Muramatsu
mately required total wrist arthrodesis due to et al. described a series of three patients who
tumor involvement of the proximal carpal row, underwent wrist reconstruction with a
and the choice of graft material was dictated by vascularized fibula graft after resection of the
tumor spillage within the surgical site. distal radius for giant cell tumor (Muramatsu
The distal radius can be reconstructed using et al. 2005). One patient underwent joint salvage
allograft, non-vascularized autograft, or with a fibular head graft, another underwent a
vascularized autograft. Although there is limited fibula-scapholunate arthrodesis, and the last
evidence establishing the superiority of one type underwent a total wrist arthrodesis. All patients
of bone over the others in this scenario, achieved a stable wrist with bony union, and the
vascularized autograft bone has advantageous first two patients had acceptable range of motion.
characteristics which may promote more robust Jaminet et al. also described a series of three
healing including greater osteocyte survival, patients who underwent fibula-scapholunate
improved mechanical properties, and faster rates arthrodesis (Jaminet et al. 2012). All patients
of union (Bakri et al. 2008). Several groups have achieved bony union within 8 weeks of surgery
518 E. Park et al.
Fig. 9 X-rays obtained 6 weeks post-operatively demonstrate stable alignment of the reconstruction
with approximately 30° of flexion and extension. extension of approximately 30–45° and pronation
Disadvantages of vascularized autograft bone and supination of 60–80° (Kocher et al. 1998).
include technical difficulty of flap harvest and The downside to allograft bone is that it is more
vessel microanastomosis and donor-site morbid- prone to nonunion and fractures (Kocher et al.
ity including the risk of vascular and neurologic 1998, Vander Griend and Funderburk 1993).
insults (e.g., peroneal nerve injury during fibula The patient in this clinical scenario underwent
harvest). Non-vascularized autograft bone results a total wrist fusion using an allograft augmented
in similar functional outcomes for each type of with a vascularized medial femoral condyle peri-
reconstruction (Flouzat-Lachaniette et al. 2013; osteal flap. Given the tumor involvement of the
Sheth et al. 1995; Vander Griend and Funderburk proximal carpal row and tumor spillage during
1993). Donor site morbidity is less than that of resection, this was deemed the most prudent
vascularized grafts. However, rates or nonunion choice of reconstruction.
between 15 to 40% have been reported (Saini et al.
2011; Vander Griend and Funderburk 1993).
The use of allograft bone for reconstruction of Preoperative Evaluation and Imaging
the distal radius has been described since the early
1970s and provides an anatomic reconstruction The most fundamental part of the preoperative
without the need for a donor site (Kocher et al. evaluation is the clinical examination. A thorough
1998; Vander Griend and Funderburk 1993). hand examination must be performed, and the
Kocher et al. reported satisfactory results using surgeon must document range of motion, skin
osteoarticular allografts with flexion and quality, and any neurologic deficits that are
Fig. 10 X-rays obtained 10 months post-operatively demonstrate that the proximal and distal junctions of the augmented
allograft fusion have healed
present. When preparing for reconstruction with a or scars must be investigated to ensure that they
vascularized flap, one must also perform an do not pose a threat to the vascularity of the flap or
Allen’s test to confirm patency of both radial and recipient site.
ulnar arteries and to check for an intact palmar
arch. Plain radiographs and an MRI of the hand
and wrist are also essential to determine the extent Surgical Technique
of tumor involvement, as this can help with plan-
ning of osteosynthesis, other potential reconstruc- The patient is positioned supine on the operative
tive needs, and recipient vessel selection. In this table, and general anesthesia is induced. The
patient, the preoperative MRI and radiographs involved arm is placed on a hand table, and both
revealed tumor involvement of the proximal car- the arm and donor leg are prepped simultaneously
pal row, which led us to plan for a total wrist to allow a two-team approach. Two separate
arthrodesis. instrument tables are set up to avoid cross-
A CT angiogram of the lower extremities is contamination between the arm and leg while the
helpful but not required when planning free tissue tumor is being resected.
transfer. In this patient, physical examination The donor leg is prepped all the way up to the
revealed abnormal pedal pulses, leading us to groin and placed in a frog-leg position (externally
suspect abnormal vascular inflow into the feet. rotated and flexed at the hip and knee) to allow
A CT angiogram in this case was necessary to access to the medial thigh and knee. A tourniquet
confirm the diagnosis of bilateral peronea arteria is placed as high as possible on the thigh to allow
magna, which prevented the use of a free easy access to the surgical site. The leg is gravity
vascularized fibula flap. Any previous incisions exsanguinated, and the tourniquet is activated to
520 E. Park et al.
the appropriate pressure. An incision is made at in slight extension. Lag screws are used to fixate
the posterior border of the vastus medialis along the step cuts in the proximal end of the allograft.
the axis of the medial column of the femur An appropriate length 3.5 mm LC-DC plate is
extending from the adductor hiatus to medial col- brought onto the field, contoured, and fixated
lateral ligament of the knee. The subcutaneous fat using a combination of locking and bicortical
and fascia of the vastus medialis is incised using screws. Proper alignment is confirmed with fluo-
electrocautery, and the vastus medialis muscle is roscopy. 2 mm drill holes are made in all surfaces
retraced anteriorly, revealing the descending of the allograft to allow potential vascular
genicular vessels underneath. The vessels are ingrowth from the flap which will be wrapped
traced proximally to its origin from the superficial around it. Adequate space is left between each
femoral vessels. A pedicle length of 12–14 cm can drill hole to prevent fracture of the graft.
usually be obtained. Distally, the vessels are dis- At this point, the field is irrigated with a copi-
sected until they are seen terminating over the ous volume of saline, and any tendons which had
medial condyle of the femur. The proximal been transected are repaired. The radial vessels are
descending genicular artery and its accompanying exposed through a volar incision if they had not
venae comitantes are freed circumferentially been already exposed during tumor resection. Pul-
while preserving their insertion into the perios- satile flow is confirmed in the radial artery, and the
teum of the medial femur and condyle. Electro- vessels are dissected free using tenotomy scissors.
cautery is used to outline the borders of the Once an adequate area for microanastomosis has
required dimensions of the periosteal flap, and been exposed, the flap pedicle in the leg is ligated,
the flap is elevated subperiosteally. At this point, and the flap is brought to the recipient site. The
the tourniquet is released, and the vascularity of periosteal flap is wrapped around the allograft and
the flap is confirmed by the presence of bleeding. secured with suture. The pedicle is tunneled to the
Hemostasis of the donor site is obtained, the field radial vessels and the microscope is brought into
is irrigated, and attention is turned to the the field. An end-to-side anastomosis is performed
recipient site. for the artery using 9-0 nylon suture, and the
An osteoarticular distal radius allograft is venous anastomosis is performed using a venous
thawed, placed in vancomycin powder, and coupler. A venous Doppler is placed around the
brought onto the field. A burr is used to decorti- vein for post-operative flap monitoring.
cate the distal end of the graft, as well as the The DRUJ is reconstructed using suture
appropriate surfaces of the carpal bones. In this anchors placed into the distal allograft, and
patient, the proximal carpal row had been resected 0.062-inch Kirschner wires are used to fixate the
with the tumor, so the proximal surfaces of the DRUJ in slight supination. Skins at the donor and
capitate and trapezoid were decorticated. A com- recipient site are closed in layers over drains, and
bination of saws and burrs are used to contour the the arm is placed in a sugar tong splint.
distal radius and carpal bones so that the graft lies
flush against the bone at the distal osteosynthesis
site. The radius graft is aligned with the third Technical Pearls
metacarpal. Reciprocating step cuts are made in
the proximal end of the graft and the distal end of • The size of the periosteal flap harvested should
the remnant native radius. The dorsal surface of be slightly larger than the measured recipient
the third metacarpal is exposed to allow place- site to account for contour irregularities and
ment of plates and screws. any flap contracture.
Once satisfactory alignment of the proximal • The donor leg should be placed in a frog-leg
radius, allograft, and hand are achieved, 0.054- position to allow easy access to the medial
inch Kirschner wires are used for temporary fixa- thigh and knee.
tion, and a headless compression screw is used to • The osteosynthesis should be performed prior
fixate the distal radius to the capitate with the wrist to microanastomosis to prevent possible
avulsion. The pedicle should then be tunneled Avoiding and Managing Problems
to the volar side of the wrist to allow easier
access to the recipient vessels and more ergo- • Meticulous care must be taken intraoperatively
nomic microsurgery. to ensure that the artery and vein lie without
• A two-team approach should be taken to avoid any kinking or twisting after anastomosis.
excessive anesthesia time. • If venous Doppler signals are lost postopera-
tively, the patient should be returned to the
operative room immediately for evaluation of
Intraoperative Images the flap and anastomoses.
• The allograft and arthrodesis construct must be
Postoperative Management of an adequate length to prevent limited tendon
excursion. Every effort should be made to
After placing the arm in a sugar tong splint imme- ensure that the reconstructed wrist and forearm
diately postoperatively, the patient is transferred is the same length as before surgery.
to the surgical intensive care unit for flap moni-
toring. The flap is checked via venous Doppler
tones every hour for the first 24 h, and drain out- Learning Points
puts are monitored closely to detect any hemato-
mas. The patient is monitored on the floor for 3–5 • The medial femoral condyle periosteal flap is a
days postoperatively and discharged home with useful source of robust, vascularized tissue
non-weight-bearing precautions for the involved which can be used to augment allograft bone
upper extremity. The arm should be kept in a sling in distal radius reconstruction after resection of
to avoid dependent positioning of the flap. a giant cell tumor.
The patient is seen in clinic 2 weeks postopera- • Although multiple forms of reconstruction are
tively where the splint and all drains are removed. available, the use of a vascularized flap
All incisions are examined, and the patient is increases a patient’s chances of achieving
placed in a long arm cast for 4 more weeks. The bony union.
patient is seen again at 4 weeks postoperatively for
an interim exam. Kirschner wires are removed
from the DRUJ at 6 weeks postoperatively, and References
active range of motion for pronation and supination
is initiated. A removable short arm splint is pro- Bakri K, Shin AY, Moran SL. The vascularized medial
vided. Weight-bearing and strengthening exercises femoral corticoperiosteal flap for reconstruction of
bony defects within the upper and lower extremities.
are initiated at 3 months postoperatively, and a CT Semin Plast Surg. 2008;22:228–33.
is obtained at this point to evaluate for bony union. Campanacci DA, Totti F, Puccini S, Beltrami G,
The patient is seen every 2 months until a year after Scoccianti G, Delcroix L, Innocenti M, Capanna
surgery to ensure appropriate healing. R. Intercalary reconstruction of femur after tumour
resection: is a vascularized fibular autograft plus allo-
graft a long-lasting solution? Bone Joint J. 2018;100-
B:378–86.
Outcome, Clinical Photos, and Imaging Capanna R, Bufalini C, Campanacci M. A new technique
for reconstructions of large metadiaphyseal bone
defects. J Orthop Trauma. 1993;2:159–77.
The patient in this case went on to achieve union Cheng CY, Shih HN, Hsu KY, Hsu RW. Treatment of giant
of his wrist arthrodesis and at the proximal end of cell tumor of the distal radius. Clin Orthop Relat Res.
the graft. At 1 year postoperatively, he had limited 2001:383, 221–8.
but adequate pronation and supination and had Doi K, Sakai K. Vascularized periosteal bone graft from the
supracondylar region of the femur. Microsurgery.
full range of motion of his elbow and fingers 1994;15:305–15.
(Video 2). The patient was back at work without Flouzat-Lachaniette CH, Babinet A, Kahwaji A, Anract P,
restrictions and did not have any pain in his wrist. Biau DJ. Limited arthrodesis of the wrist for treatment
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of giant cell tumor of the distal radius. J Hand Surg salvage in a pediatric and adolescent population. Plast
[Am]. 2013;38:1505–12. Reconstr Surg. 2006;118:413–9.
Gallardo-Calero I, Barrera-Ochoa S, Manzanares MC, Muramatsu K, Ihara K, Azuma E, Orui R, Goto Y,
Sallent A, Vicente M, Lopez-Fernandez A, De Shigetomi M, Doi K. Free vascularized fibula grafting
Albert M, Aguirre M, Soldado F, Velez for reconstruction of the wrist following wide tumor
R. Vascularized periosteal flaps accelerate excision. Microsurgery. 2005;25:101–6.
osteointegration and revascularization of allografts in Puloski SK, Griffin A, Ferguson PC, Bell RS, Wunder
rats. Clin Orthop Relat Res. 2019;477:741–55. JS. Functional outcomes after treatment of aggressive
Houdek MT, Wagner ER, STANS AA, Shin AY, Bishop tumors in the distal radius. Clin Orthop Relat Res.
AT, Sim FH, Moran SL. What is the outcome of allo- 2007;459:154–60.
graft and intramedullary free fibula (Capanna tech- Puri A, Gulia A, Agarwal MG, Reddy K. Ulnar transloca-
nique) in pediatric and adolescent patients with bone tion after excision of a Campanacci grade-3 giant-cell
tumors? Clin Orthop Relat Res. 2016;474:660–8. tumour of the distal radius: an effective method of
Iorio ML, Masden DL, Higgins JP. The limits of medial reconstruction. J Bone Joint Surg (Br). 2010;92:875–9.
femoral condyle corticoperiosteal flaps. J Hand Surg Saini R, Bali K, Bachhal V, Mootha AK, Dhillon MS, Gill
[Am]. 2011;36:1592–6. SS. En bloc excision and autogenous fibular recon-
Jaminet P, Rahmanian-Schwarz A, Pfau M, Nusche A, struction for aggressive giant cell tumor of distal radius:
Schaller HE, Lotter O. Fibulo-scapho-lunate arthrode- a report of 12 cases and review of literature. J Orthop
sis after resection of the distal radius for giant-cell Surg Res. 2011;6:14.
tumor of the bone. Microsurgery. 2012;32:458–62. Sheth DS, Healey JH, Sobel M, Lane JM, Marcove
Kocher MS, Gebhardt MC, Mankin HJ. Reconstruction of RC. Giant cell tumor of the distal radius. J Hand Surg
the distal aspect of the radius with use of an [Am]. 1995;20:432–40.
osteoarticular allograft after excision of a skeletal Szabo RM, Anderson KA, Chen JL. Functional outcome of
tumor. J Bone Joint Surg Am. 1998;80:407–19. en bloc excision and osteoarticular allograft replace-
Mattos D, Ko JH, Iorio ML. Wrist arthrodesis with the ment with the Sauve-Kapandji procedure for
medial femoral condyle flap: outcomes of vascularized Campanacci grade 3 giant-cell tumor of the distal
bone grafting for osteomyelitis. Microsurgery. radius. J Hand Surg [Am]. 2006;31:1340–8.
2019;39:32–8. Vander Griend RA, Funderburk CH. The treatment of
Minami A, Kato H, Iwasaki N. Vascularized fibular graft giant-cell tumors of the distal part of the radius.
after excision of giant-cell tumor of the distal radius: J Bone Joint Surg Am. 1993;75:899–908.
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Reconstr Surg. 2002;110:112–7. JJ. Lower extremity osseous oncologic reconstruction
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Free Medial Femoral Condyle Flap
for Salvage Arthrodesis of Carpal 50
Osteomyelitis
Steven T. Lanier, Eugene Park, and Jason H. Ko
Contents
Preoperative Problem List: Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
Preoperative Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Preoperative Marking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Flap Harvest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Flap Inset and Osteosynthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
Technical Pearls and Avoiding Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Abstract non-viable bone is essential, often leaving

Osteomyelitis of the carpus is a challenging extensive bone defects. Non-vascularized
reconstructive problem that is fortunately bone grafting is an option, but there is literature
rare. Aggressive debridement of infected and to suggest that vascularized bone reconstruc-
tion leads to faster and more successful union
rates, while maintaining low complication
rates. In this chapter, the use of a free medial
Supplementary Information: The online version of this femoral condyle (MFC) flap for salvage wrist
chapter (https://doi.org/10.1007/978-3-030-23706-6_47) arthrodesis to treat osteomyelitis of the entire
contains supplementary material, which is available to carpus is outlined.
authorized users.
S. T. Lanier · E. Park · J. H. Ko (*) Keywords

Northwestern University Feinberg School of Medicine, Medial femoral condyle (MFC) flap · Wrist
Chicago, IL, USA arthrodesis · Osteomyelitis · Vascularized bone
e-mail: jason.ko@nm.org

https://doi.org/10.1007/978-3-030-23706-6_47
524 S. T. Lanier et al.
The Clinical Scenario 3-month follow-up, the patient was clinically free
of infection. At this point, a reconstructive strategy
A 44-year-old right-hand dominant female pre- was needed to salvage function of her dominant
sented with swelling, erythema, and chronic hand (Fig. 4). Informed consent was obtained by
drainage from her right radiocarpal and midcarpal the patient to use photographs and video documen-
joints. She was found to have chronic septic tation for scientific work.
arthritis secondary to bacterial seeding from intra-
venous and intradermal drug abuse. The chronic-
ity of her infection ultimately resulted in Preoperative Problem List:
pan-carpal osteomyelitis with severe osteolysis Reconstructive Requirements
and carpal collapse that developed over the span
of 5 months (Fig. 1). A radical debridement In order to salvage hand function, the chosen
performed in two stages was required to clear the reconstructive strategy involved an arthrodesis of
infection. The resultant defect included a total the radial metaphysis to residual base of the third
carpectomy with partial resection of the bases of metacarpal, with the following reconstructive
the metacarpals as well as the distal radius articu- requirements:
lar surface (Fig. 2). The defect was filled with an
antibiotic spacer and spanned with an external 1. Sufficient bone stock to span the carpal defect
fixator to maintain length (Fig. 3). Transverse and maintain appropriate working length of the
Kirschner wires were utilized to maintain meta- flexor and extensor tendons
carpal rotational alignment. Operative cultures 2. Sufficient vascularity to achieve
grew methicillin-resistant Staphylococcus aureus osteosynthesis
(MRSA), and the patient was treated with a total of 3. Sufficient structural stability of the resultant
6 weeks of intravenous vancomycin followed by a fusion complex to bear loads across the wrist
course of oral sulfamethoxazole/trimethoprim. At 4. Supple and reliable soft tissue coverage
Fig. 1 Early radiographic changes are concerning for carpal osteomyelitis. (A) Five months later, complete destruction
and collapse of the carpus, radiocarpal joint, and distal radioulnar joint from infection is observed
50 Free Medial Femoral Condyle Flap for Salvage Arthrodesis of Carpal Osteomyelitis 525
Fig. 2 Initial treatment included radical carpectomy to the level of healthy, bleeding bone both proximally and
distally. External fixation device pins are seen in the third metacarpal
Fig. 3 The carpectomy defect is visualized, along with Kirschner wire stabilization of the metacarpals to maintain length
and prevent rotation. Antibiotic cement spacer and external fixator have been placed in the carpectomy defect
Treatment Plan corticocancellous bone supplied by the

The planned solution was a free medial femoral descending genicular artery (DGA), which origi-
condyle (MFC) corticocancellous osteocutaneous nates from the superficial femoral artery in the
flap to both bridge the carpal defect and provide distal medial thigh. It also provides a reliable
soft tissue coverage. The medial femoral cutaneous skin paddle, which aids with tension-
condyle provides a source of well-vascularized free soft tissue coverage and facilitates flap
Fig. 4 After 3 months, the patient presented to have the external fixator removed. Clinical photographs and radiographic
images demonstrated no evidence of infection and stable alignment
monitoring. A harvest from the medial knee can number of prior series have shown the utility of
be performed with convenient patient positioning the MFC flap to treat atrophic non-unions, avas-
in a supine position. Such positioning permits a cular necrosis, and primary fusions in the setting
two-team, simultaneous approach to flap harvest of previous osteomyelitis. The MFC flap has been
and recipient site preparation, decreasing opera- reported on most frequently to treat recalcitrant
tive times. Donor site morbidity is minimal with non-unions of the scaphoid (Doi et al. 2000;
the vast majority of patients achieving pain-free Larson et al. 2007; Jones et al. 2009, 2010), as
ambulation with full knee range of motion. well as for avascular necrosis of the lunate
However, out of the more than 100 published (Hachisuka et al. 2017) and capitate (Kazmers
cases of MFC harvest, 2 cases of iatrogenic et al. 2017). It has been utilized to successfully
femur fracture have been reported, 1 requiring treat non-unions of the humerus, radius, and ulna
internal fixation and the second a total knee (Del Pinal et al. 2007; Henry 2007; De Smet
arthroplasty (Hamada et al. 2014; Son et al. 2009). The free MFC flap has also been employed
2019). An experimental study has shown that the extensively in the lower extremity to treat femoral
femur is stable to torsional stability following and tibial non-unions (Cavadas and Landin 2008;
harvest of up to a 7 cm cortical segment of medial Choudry et al. 2008) as well as non-unions
femoral condyle, though overly aggressive can- and avascular necrosis of the foot and ankle
cellous bone harvest may destabilize the sub- (Haddock et al. 2013; Levinson et al. 2014). In
chondral bone (Endara et al. 2015). These are the setting of osteomyelitis, the free MFC flap has
the reasons for use of a hinged knee brace in this been used for thumb metacarpal reconstruction
patient postoperatively. (Sammer et al. 2009), to achieve union of pilon
The senior author has previously published a fractures and chronically infected tibial
case series including the index patient for this non-unions (Caterson et al. 2015; Kruger et al.
chapter, which represented the first report of the 2018), for septic digital bone loss (Henry 2015),
use of the MFC flap for treatment of osteomyelitis and for infected distal radius non-unions (Henry
for the wrist (Mattos et al. 2019). However, a 2017).
Alternative Reconstructive Options (Fig. 5). The saphenous branch originates on aver-
age 14.0 cm superior to the joint line, coursing in
Alternative sources of vascularized bone for proximity to the DGA within the adductor canal
reconstruction of a total carpal defect include a before joining the saphenous nerve to supply to
free vascularized fibula, free vascularized iliac skin of the medial knee. The direct cutaneous
crest, or free parascapular flap with scapula bone. branch of the DGA is preferred due to increased
A distinct advantage of the free MFC flap over reliability and ease of dissection, though the saphe-
the free fibula is that it does not require a sacrifice nous branch has been shown in cadaver studies to
of one of the major arteries supplying the distal perfuse a substantially larger angiosome and may
lower extremity. A further advantage of the be preferred if a large skin paddle is desired (Iorio
MFC flap is that it yields a large amount of et al. 2012). After giving off the DGA, the femoral
corticocancellous bone that can be easily tailored vessels pass inferiorly and posteriorly through
into the appropriate size and shape for a carpal Hunter’s canal, a hiatus in the adductor magnus
defect, even one involving the entire carpus, as in muscle, to course into the popliteal fossa.
this patient. The fibula yields a larger ratio of
cortical-to-cancellous bone, which is harder to
inset into geometrically complex defects. Further- Preoperative Marking
more, there is some evidence to suggest that the
greater amount of well-vascularized cancellous The patient is positioned supine on the operating
bone with the free MFC flap may translate to room table with the donor knee in a frog-legged
improved osteogenic potential when compared to position. The medial femoral condyle is outlined
the fibula (Brown et al. 2013). A corollary of the as is the superior aspect of the tibial plateau and
decreased cortical-to-cancellous ratio is that the the medial aspect of the patella. The axis of the
MFC may not offer the same degree of structural pedicle is marked with a straight line extending
stability as the fibula, though future studies com- from the medial femoral condyle proximally
paring these two are needed to more precisely along the posterior border of the femoral diaphy-
define indications. The ability to harvest the MFC sis (Fig. 6). Hunter’s canal can be palpated as a
without a position change and simultaneously with depression proximally along this line and can be
a second team preparing the recipient site is a marked. A handheld Doppler is utilized to locate
distinct advantage over the free parascapular flap. the cutaneous branch of the descending genicular
artery, which should be centered over the apex of
the medial femoral condyle. To mark the anterior
Preoperative Imaging border of the skin paddle, a curvilinear incision is
drawn beginning distally at the midpoint between
Preoperative imaging of the donor site is not the medial femoral condyle and the patella and
required. extending proximally in an arc that traverses
The superficial femoral artery and vein course Hunter’s canal to end at the mid-axis of the leg.
inferiorly through the medial thigh on the superfi- The posterior incision is designed after location
cial surface of the adductor longus and magnus and dissection of the DGA perforator.
muscles, deep to fibers of the vastus medialis. The
DGA is given off from the medial side of the
superficial femoral artery on average 14.2 cm supe- Operative Technique
rior to the joint line and courses inferiorly along the
medial aspect of the femoral diaphysis, supplying Flap Harvest
the medial femoral condyle and trochlea (Iorio
et al. 2012). Either a direct cutaneous branch of The leg is first gravity exsanguinated, and the
the DGA or the more proximal saphenous arterial tourniquet is inflated. The anterior incision is
branch allows harvest of skin paddle with the flap made with a 15 blade. The saphenous vein should
Fig. 5 Illustration outlining the vascular supply and relevant anatomy for the medial femoral condyle (MFC) flap
anteriorly and the sartorius posteriorly. The

DGA pedicle is exposed along the posterior bor-
der of the femur and dissected proximally, con-
tinuing to free fibers of the vastus medialis off of
the anteromedial septum. The DGA branches into
a longitudinal and transverse branch over the
medial femoral condyle, both of which are adher-
ent to the periosteum of the femoral condyle.
Proximal to this point, the cutaneous branch is
given off. As the dissection proceeds proximally,
the cutaneous branch should be identified at the
level of the femoral metaphysis, immediately
anterior to the adductor longus tendon, and pro-
Fig. 6 Surgical markings for the planned medial femoral tected (Fig. 7). Presence or absence of a more
condyle (MFC) flap with skin paddle proximal saphenous branch supplying the skin is
also noted. Dissection of the pedicle continues
be identified and protected by retracting it poste- proximally to its origin from the superficial fem-
riorly. The muscular fascia is then incised, and the oral vessels.
vastus medialis is retracted anteriorly. Fibers of Once the cutaneous branch is clearly identified
the vastus medialis can be freed from their poste- and dissected, the posterior incision of the skin
rior insertions into the tendon of the adductor paddle can be designed and elevation of the skin
longus, developing the interval for exposure of paddle completed. The borders of the
the DGA. A large self-retaining retractor can corticocancellous bone to be harvested are then
then be placed to retract the vastus medialis marked. The periosteum overlying the medial
Fig. 7 The medial femoral condyle bone flap is outlined,

along with the descending geniculate vessels isolated. The Fig. 8 The medial femoral condyle vascularized bone flap
Freer elevator highlights the skin perforator that supplies the and vascular pedicle is isolated, along with the “ultrathin”
skin paddle, which is being held by the surgeon’s hand skin paddle, which had been primarily thinned at the junc-
tion of the superficial and deep fat
femoral condyle contains the terminal branches of

the descending genicular artery and vein and is
harvested in continuity with the desired bone flap.
The periosteum is incised along the borders of the
flap with a 15 blade. Proximal to the area of bone
harvest, the periosteum and overlying descending
genicular vessels are elevated either sharply with a
15 blade or utilizing a freer periosteal elevator. A
sagittal saw is then utilized to osteotomize the
borders of the flap, while irrigating the bone to
prevent thermal injury. Completion of the
osteotomies with a handheld osteotome provides
improved control over the final dimensions of the
harvest. The size of the medial femoral condyle
bone harvested in this case was 4 3 2 cm, and
the skin paddle was 5 9 cm (Fig. 8).
At this point the tourniquet is deflated and
perfusion of the flap is verified. Bleeding should Fig. 9 Intra-operative photographs after vascular anasto-
be observed from both the cancellous bone mosis and inset of the skin paddle of the MFC vascularized
harvested and the skin paddle. Dissection of suf- bone wrist arthrodesis
ficient length on the descending genicular vessels
to permit a tension free inset at the donor site is given the patient’s likelihood of non-compliance,
ensured prior to ligation (Fig. 9). and two 2.7 mm plates were used radially and
ulnarly to prevent compression of the vascular
pedicle on the MFC periosteum. Vascular anasto-
Flap Inset and Osteosynthesis moses of the descending genicular artery and vein
were performed end-to-side into the radial artery
The flap was positioned into the carpal defect and in the wrist. Cancellous allograft bone was packed
tailored to fit. The external fixator was used to into the MFC donor site defect, and local fascial
stabilize the MFC wrist arthrodesis construct was used to close over the allograft using 2–0 PDS
suture through bone tunnels in the femur. The • A two-team approach should be taken to avoid
donor site was closed in layers over drains, and excessive anesthesia time.
she was placed in a hinged knee brace for 4 weeks.
Immediate weightbearing and ambulation in the
knee brace were allowed, but the hinged knee Intraoperative Images
brace was used to minimize torsional vectors on
the knee. Postoperative Management
Postoperatively, the wrist was protected with a

Technical Pearls and Avoiding removable splint, in addition to the external
Problems fixator, for 6 weeks. Two months postoperatively,
the patient returned to ask for her external fixator
• When debriding carpal osteomyelitis, aggres- to be removed. At that time, the MFC was deemed
sive removal of all non-viable bone to the level to be viable, but there was no union at the proxi-
of healthy bleeding bone both proximally and mal and distal fusion sites (Fig. 10). Therefore,
distally is essential. she returned to the operating room for iliac crest
• When incorporating a skin paddle, a curvilin- bone grafting and internal fixation with a 3.5 mm
ear incision should be designed anteriorly. LC-DC plate to span the MFC bone from the
After the skin perforator has been identified radial metaphysis to the third metacarpal
and confirmed to be located in the planned (Fig. 11). By 3.5 months postoperatively, there
skin paddle, the posterior border of the ellipti- was radiographic evidence of bony healing
cal skin paddle can then be incised. (Fig. 12), and the patient reported no pain
• The donor leg should be placed in a frog-leg (Fig. 13 and Video 1). By 11 months postopera-
position to allow easy access to the medial tively, plain radiographs and CT scans demon-
thigh and knee, and use of a thigh tourniquet strated that the MFC had successfully fused
is helpful for perforator visualization. (Fig. 14 and Video 2a, 2b).
• The osteosynthesis should be performed prior As mentioned previously, the patient was placed
to microanastomosis to prevent possible avul- in a hinged knee brace but was allowed to ambulate
sion of the vessels. for 4 weeks and then was allowed to discontinue
Fig. 10 By two months post-operatively, the skin paddle proximal and distal junctions of the MFC wrist arthrodesis
had healed, and radiographs seemed to indicate that the construct was seen on plan radiographs
MFC bone was still viable. Minimal healing across the
the knee brace thereafter. Postoperative knee Outcome: Clinical Photos and Imaging
X-rays were obtained at each postoperative visit,
and the patient demonstrated incorporation of the The patient demonstrated successful union of the
allograft bone at the knee donor site and reported carpal fusion at 3.5 and 11 months postoperatively
no pain or disability at the donor site. (Figs. 12 and 14). She reported no pain and had
full finger motion with pain-free supination and
pronation (Fig. 13).
Learning Points
• Chronic osteomyelitis should be treated

aggressively and completely eradicated (simi-
lar to a cancer resection) prior to attempting
reconstruction.
• The reconstructive technique for a large bony
defect after removal of all non-viable bone will
depend on the quality of the surrounding soft
tissue envelope and the dimensions of the bone
defect.
• In the setting of chronic osteomyelitis, the use
of vascularized bone may increase the chances
Fig. 11 Intra-operative photographs of the revision surgery of achieving bony union than non-vascularized
demonstrate a dorsal incision to access the MFC flap bone alternatives.
Fig. 12 At 3.5 months post-operatively, radiographs demonstrated bone healing across the proximal and distal
osteosynthesis sites
Fig. 13 At 3.5 months, the patient reported no pain and demonstrated good finger motion and thumb opposition, along
with forearm supination and pronation
Fig. 14 At 11 months post-operatively, there was radiographic evidence of successful fusion both proximally
• The medial femoral condyle is a versatile and an analysis of its form and a comparison with a con-
powerful source of vascularized bone, with a ventional-bone-graft. J Clin Orthop Trauma. 2014;5(1):
6–17.
chimeric skin paddle option, that can be used to Henry M. Genicular corticoperiosteal flap salvage of resis-
reconstruct three-dimensional bone defects tant atrophic non-union of the distal radius metaphysis.
with minimal donor site morbidity. Hand Surg. 2007;12(3):211–5.
Henry M. Free vascularized medial femoral condyle struc-
tural flaps for septic terminal digital bone loss. J Hand
Microsurg. 2015;7(2):306–13.
References Henry M. Vascularized medial femoral condyle bone graft
for resistant nonunion of the distal radius. J Hand Surg
Asian Pac. 2017;22(1):23–8.
Brown BJ, Higgins JP, Katz RD. Histological evaluation of
Iorio ML, Masden DL, Higgins JP. Cutaneous angiosome
a free medial femoral condyle flap at 21 months. Micro-
territory of the medial femoral condyle osteocutaneous
surgery. 2013;33(7):567–71.
flap. J Hand Surg Am. 2012;37(5):1033–41.
Caterson EJ, Singh M, Turko A, Weaver MJ, Talbot S. The
Jones DB Jr, Burger H, Bishop AT, Shin AY. Treatment of
medial femoral condyle free osteocutaneous flap for
scaphoid waist nonunions with an avascular proximal
osteomyelitis in pilon fractures. Injury. 2015;46(2):
pole and carpal collapse. Surgical technique. J Bone
414–8.
Joint Surg Am. 2009;91(Suppl 2):169–83.
Cavadas PC, Landin L. Treatment of recalcitrant distal
Jones DB Jr, Moran SL, Bishop AT, Shin AY. Free-
tibial nonunion using the descending genicular
vascularized medial femoral condyle bone transfer in
corticoperiosteal free flap. J Trauma. 2008;64(1):
the treatment of scaphoid nonunions. Plast Reconstr
144–50.
Surg. 2010;125(4):1176–84.
Choudry UH, Bakri K, Moran SL, Karacor Z, Shin AY. The
Kazmers NH, Rozell JC, Rumball KM, Kozin SH,
vascularized medial femoral condyle periosteal bone
Zlotolow DA, Levin LS. Medial femoral condyle
flap for the treatment of recalcitrant bony nonunions.
microvascular bone transfer as a treatment for capitate
Ann Plast Surg. 2008;60(2):174–80.
avascular necrosis: surgical technique and case report. J
De Smet L. Treatment of non-union of forearm bones with
Hand Surg Am. 2017;42(10):841e841–6.
a free vascularised corticoperiosteal flap from the
Kruger EA, Ben-Amotz O, Mendenhall SD, Levin LS. The
medial femoral condyle. Acta Orthop Belg. 2009;75
chimeric myo-osseous medial femoral condyle flap for
(5):611–5.
tibial nonunion: a case report. Eplasty. 2018;18:e23.
Del Pinal F, Garcia-Bernal FJ, Regalado J, Ayala H,
Larson AN, Bishop AT, Shin AY. Free medial femoral
Cagigal L, Studer A. Vascularised corticoperiosteal
condyle bone grafting for scaphoid nonunions with
grafts from the medial femoral condyle for difficult
humpback deformity and proximal pole avascular
non-unions of the upper limb. J Hand Surg Eur.
necrosis. Tech Hand Up Extrem Surg. 2007;11(4):
2007;32(2):135–42.
246–58.
Doi K, Oda T, Soo-Heong T, Nanda V. Free vascularized
Levinson H, Miller KJ, Adams SB Jr, Parekh
bone graft for nonunion of the scaphoid. J Hand Surg
SG. Treatment of spontaneous osteonecrosis of the
Am. 2000;25(3):507–19.
tarsal navicular with a free medial femoral condyle
Endara MR, Brown BJ, Shuck J, Bachabi M, Parks BG,
vascularized bone graft: a new approach to managing
Higgins JP. Torsional stability of the femur after harvest
a difficult problem. Foot Ankle Spec. 2014;7(4):332–7.
of the medial femoral condyle corticocancellous flap. J
Mattos D, Ko JH, Iorio ML. Wrist arthrodesis with the
Reconstr Microsurg. 2015;31(5):364–8.
medial femoral condyle flap: outcomes of vascularized
Hachisuka H, Sunagawa T, Ochi M, Morrison WA. A
bone grafting for osteomyelitis. Microsurgery. 2019;39
vascularized medial femoral condyle cortico-periosteal
(1):32–8.
graft for total lunate reconstruction. J Orthop Sci.
Sammer DM, Bishop AT, Shin AY. Vascularized medial
2017;25:354–8.
femoral condyle graft for thumb metacarpal reconstruc-
Haddock NT, Alosh H, Easley ME, Levin LS, Wapner
tion: case report. J Hand Surg Am. 2009;34(4):715–8.
KL. Applications of the medial femoral condyle free
Son JH, Giladi AM, Higgins JP. Iatrogenic femur fracture
flap for foot and ankle reconstruction. Foot Ankle Int.
following medial femoral condyle flap harvest eventu-
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ally requiring total knee arthroplasty in one patient. J
Hamada Y, Hibino N, Kobayashi A. Expanding the utility
Hand Surg Eur. 2019;44(3):320–1.
of modified vascularized femoral periosteal bone-flaps:
Reconstruction of the Upper Extremity
Using Free Proximal Fibula Flap after 51
Sarcoma Resection
Gerardo Malzone and Marco Innocenti
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
Surgical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542
Abstract but also allow the bone lengthening. This

Skeletal reconstruction in children is particu- case illustrates the reconstruction of the proxi-
larly complex, because it is important to deal mal humerus in a six-year-old boy suffering of
not only with function and form restoration, osteosarcoma. Following the oncological
resection, a vascularized free fibula epiphyseal
flap was done to provide an active physis for
growth and an articular interface for the
glenohumeral joint reconstruction. The post-
G. Malzone (*) · M. Innocenti operative period was uneventful and the
Department of Health Sciences, Unit of Plastic and
Reconstructive Microsurgery, “Careggi” University patient was discharged from the hospital
Hospital, Florence, Italy 4 days after surgery. The physical therapy
e-mail: marco.innocenti@unifi.it

https://doi.org/10.1007/978-3-030-23706-6_48
536 G. Malzone and M. Innocenti
was begun 6 weeks post-op. The follow-up at imaging (MRI) of the humerus, and whole-body
5 years showed a very satisfying axial growth Technetium-99 bone scan, which revealed no evi-
and good bone remodeling in the joint surface. dence of metastatic disease. The patient then began
neoadjuvant chemotherapy resulted in the near-
Keywords complete resolution of the soft-tissue extension of
the intrahumeral mass. At this point, the tumor
Free proximal fibula flap · Pediatric plastic
excision with limb-preserving surgery was
surgery · Limb reconstruction · Epiphyseal
planned. Parental permission and informed consent
reconstruction
for the proposed surgical procedure and pictures for
clinical research involving the child was obtained.
A right-handed six-year-old boy presented to his
primary care physician after having constant pain
Due to the patient’s young age and anticipated
localized to the proximal third of his right humerus,
growth of 8 cm, a reconstruction which could also
at rest and during activity without any history of
allow lengthening was desired and therefore a free
trauma during the last 2–3 weeks. Initial radio-
vascularized fibula epiphyseal transfer was planned.
graphs revealed a blastic-appearing lesion, and the
Pediatric patients undergoing oncologic resec-
patient was referred to an orthopedic oncology
tion of the proximal humerus require a durable
surgeon (Fig. 1). A core needle biopsy was
reconstruction that can facilitate longitudinal
performed which confirmed the diagnosis of high-
growth in the years after surgery (Innocenti et al.
grade osteosarcoma. Staging studies were
1998). Vascularized free fibula epiphyseal transfer
performed including a computed tomography
for upper extremity reconstruction provides an
(CT) scan of the chest, magnetic resonance
active physis for growth and an articular interface
for glenohumeral joint reconstruction (Innocenti
et al. 2002; Tsai et al. 1986; Innocenti et al. 2004).
Treatment Plan
The preoperative plan included a wide excision

sparing the most distal segment of the humerus,
dissecting out and preserving the radial nerve and
the rotator cuff which will be used to fix the fibula
transfer with suture anchors.
The proximal radial collateral artery and its
venae comitantes where chosen as recipient ves-
sels. A reverse flow anastomosis of the radial
collateral artery with the distal stump of the ante-
rior tibial vessels was planned.
Options such as the free iliac crest (Teot et al.

1999) or scapula flaps have been reported (Mayr
Fig. 1 Osteosarcoma involving the proximal epiphysis et al. 2000), but these flaps can only provide an
and the adjoining diaphysis in a 6-year-old child apophysis, which is not designed for an active
51 Reconstruction of the Upper Extremity Using Free Proximal Fibula Flap after Sarcoma Resection 537
joint such as the wrist. Furthermore, the hyaline upward and medially to form the proximal
cartilage coating the apophysis may suffer severe tibiofibular joint. From an anatomic point of
chondrolysis and progressive arthritis. Moreover, view, it is important to highlight the muscles and
both scapula and iliac crest are flat bones not ligaments inserting and originating near the lateral
easily adaptable to replace a long diaphyseal proximal aspect of the epiphysis: the biceps
bone like the radius. femoris tendon and the lateral collateral ligament,
and the peroneus longus and extensor digitorum
longus muscles. The fibular neck is crossed by the
Preoperative Evaluation and Imaging common peroneal nerve, which moves toward the
anterior compartment of the leg and divides in a
Both lower limbs were examined to exclude any superficial branch located between the extensor
possible obstruction of the vascular axis, and a digitorum longus and peroneus longus muscles
Doppler ultrasound study was performed to ascer- and a deep branch that reaches the interosseous
tain the presence of a patent plantar arch. membrane and joins the anterior tibial vessels
before giving several motor branches to the sur-
rounding muscles.
Preoperative Care and Patient Three small arteries provide the blood supply
Drawing for the upper fibular epiphysis: the inferior
genicular artery, a recurrent branch of the anterior
With the patient in a supine position and the leg in tibial artery (ATA), and a variably present
slightly internal rotation, the skin incision is unnamed artery directly rising from the popliteal
marked on the anterolateral aspect of the leg artery (Bonnel et al. 1981).
with a straight line extending proximally and pos- Several studies have been conducted to identify
teriorly in a lazy-S pattern from the neck of the the best pedicle of this flap, especially because in
fibula to the popliteal fossa. The point at which the order to allow a physiological growth, the epiphy-
incision should meet the common peroneal nerve sis must well vascularized. The majority of these
crossing the fibular neck is also marked (Fig. 2). reports confirm that the ATA is the pedicle that
provides the majority of the blood supply, through
the anterior and posterior recurrent branches direct
Surgical Anatomy to the epiphysis and several tiny musculoperiosteal
perforators to the periosteum of the proximal
The proximal fibular flap includes the epiphysis two-thirds of the shaft (Taylor et al. 1988).
and a variable amount of the adjoining diaphysis. The drawback of raising the flap on the ATA
The epiphyseal articular surface is oriented network is the short pedicle. To avoid this
Fig. 2 The pre-op marking

shows the anterolateral
approach for the harvest of
the proximal fibula based on
the anterior tibial vascular
system. The skin incision is
on the projection of the
intermuscular space
between the tibialis anterior
and extensor digitorum
longus muscles. The
incision is prolonged
proximally and posteriorly
over the tendon of biceps
femoris muscle
drawback, Prof. Innocenti introduced the reverse The fibula is then resected and separated from
flow epiphyseal flap dissecting the ATA distally the surrounding muscle and of the peroneal artery,
(Innocenti et al. 2005a), thus – providing an ade- which lies on its posteromedial aspect. The prox-
quate pedicle length and allowing an easy flap imal tibiofibular joint is then opened, taking care
inset and anastomosis – avoiding the need for to preserve as much of the lateral collateral liga-
vessel grafting. Another important tip is to pre- ment as possible to better stabilize the knee. A
serve a cuff of muscle around the proximal fibula longitudinal strip of biceps femoris tendon should
in order to avoid any injury to the tiny recurrent be included in the harvest. This strong tendon
branches coming from the ATA. inserts on the proximal epiphysis and increases
joint stability after transfer.
To provide an appropriate pedicle length suit-
Surgical Technique able for anastomosis, it is suggested to harvest the
flap on a reverse flow. The ATA and veins may be
The dissection is carried out in the intermuscular divided as distal at the ankle joint, offering a long
space between the tibialis anterior and extensor pedicle of remarkable size. The reversal of blood
digitorum longus muscles. The latter, together flow in the venae comitantes is guaranteed by
with the peroneus longus muscle, is sharply several shunts that interconnect the veins and
detached from its proximal insertion at the level of bypass the valves (Fig. 4).
the emergence of the peroneal nerve into the ante- To prevent knee joint instability after the har-
rior compartment of the leg. The proximal muscular vest, meticulous fixation of the lateral collateral
cuff must be left attached to the fibular head because ligament to the lateral aspect of the tibial meta-
it contains the recurrent epiphyseal branch of the physis, reinforced with the residual biceps femoris
ATA on which this transfer is based. During the tendon, must be obtained by means of staples or
diaphyseal dissection, as many periosteal branches transosseous nonabsorbable suture.
as possible are preserved. For this reason, it is A small cuff of capsule was harvested with the
recommended that a strip of interosseous membrane fibular head including a segment of the lateral
and muscle be included to protect the small collateral ligament for repair to the rotator cuff.
branches from the main artery to the diaphyseal The graft was then transferred to the brachium
periosteum of the proximal part of the fibula. and inserted intracapsularly after the remaining
The peroneal nerve turns around the fibular portion of the long head of the biceps tendon
neck in a submuscular location. To dissect off was released from the supraglenoid tubercle,
the nerve, the extensor digitorum longus and with preservation of the surrounding labrum.
peroneus longus muscles must be divided (Fig. 3). The articular surface of the fibular head is then
Fig. 3 The intraoperative

pics shows the meticulous
dissection of the pedicle;
great care must be paid to
isolating the peroneal nerve
and its motor branches to
the muscles of the anterior
compartment
aligned with the glenoid and the rotator cuff was The peroneal artery and vein were then anas-
placed over the top of the fibular head, and in tomosed in an end-to-end fashion to the radial
sequential order, the subscapularis, supra- collateral artery and its accompanying vein.
spinatus, infraspinatus, and teres minor were Finally, advancement of the deltoid to the
tenomyodesed to the remaining capsule and por- brachialis and tenomyodesis to the graft was
tions of the lateral collateral ligament and capsule performed. The long head of the biceps was
on the fibular head (Fig. 5). This was then purse- then tenomyodesed to the remaining deltoid
string sutured around the neck of the fibula, pro- and short head of the biceps. The latissimus
viding excellent stability of the reconstructed dorsi and pectoralis insertions were then
shoulder joint advanced and tenomyodesed to the deltoid.
Fig. 4 The proximal fibula

flap based on the ATA and a
portion of cuff of capsule
including a segment of the
lateral collateral ligament
for repair to the rotator cuff
Fig. 5 In order to prevent

subluxation, the strip of
biceps femoris tendon is
sutured to the residual
capsule and rotator cuff
Closed suction drains were placed, and the prox- Outcome-Clinical Photos and Imaging
imal and distal extents of the incision were
closed in layers. See Figs. 6, 7, and 8.

Technical Pearls
The complications in this procedure can be
• Start dissection distally: This approach sim-
divided in two groups.
plifies the dissection of the peroneal nerve
Regarding the donor site:
from the vascular pedicle.
• Save a strip of muscle between the vascular
Temporary palsy of peroneal nerve.
pedicle and the fibular diaphysis to avoid
Permanent deficit of EHL or EDL.
injury to the tiny musculoperiosteal branches.
Permanent deficit of TA.
• Identify the peroneal nerve at the neck of the
Ankle instability.
fibula and carefully dissect the muscular belly
Knee instability.
of peroneus longus and extensor digitorum
longus.
• The muscular cuff surrounding the epiphysis Regarding the recipient site:
must remain attached to the epiphysis because
it contains the recurrent branch. Premature closure of the growth plate.
• In cases of intersection of the motor nerve to Fracture.
the tibialis anterior muscle and the recurrent Subacromial displacement.
branch, a section of the nerve as close as pos- Nonunion.
sible to the muscle and subsequent microsur-
gical neurorrhaphy are needed.
• After the harvest of the fibula, a meticulous
reconstruction of the lateral collateral ligament
is needed. The ligament should be reinforced
with the residual strip of biceps femoris tendon
and finally reinserted on the lateral aspect of
the tibia.
In the postoperative period, shoulder motion was

restricted in an effort to encourage rotator cuff
ingrowth into the vascular graft. Postoperative
physical therapy was begun six weeks after sur-
gery beginning with passive shoulder motion,
gradually transitioning to active shoulder motion Fig. 6 Four years post-op XR showing an axial growth of
after three months. ca 3 cm and the remodeling of the fibular head
Fig. 7 Long-term CT
reconstruction shows the
remodeling of the fibular
head in the glenoid fossa
Fig. 8 (a, b) Clinical result 5 years postoperative, the axial growth and range of motion is very satisfying. A mild lack of
abduction is the major functional impairment that occurs in proximal humeral reconstruction
The precocious ossification of the growth plate cases, the epiphysis migrated subacromially. The
and consequent end of growth can happen. In our reasons for this complication are the anatomical
experience, this is more prone to happen when the mismatching between fibular head and glenoid
flap is based on peroneal vessels, which in our fossa and the extensive oncological excision of
opinion are not as reliable in ensuring correct muscles and ligaments with consequent joint
epiphyseal perfusion. Epiphyseal artery injury stability.
during the bone stabilization can represent Because of accurate reconstruction with trans-
another factor promoting this complication. osseous suture of the lateral collateral ligament at
Fractures of the neo-humerus can also occur. A the donor site, no residual instability of the knee
very careful and meticulous bone fixation is man- was ever observed.
datory. Incorrect alignment between the fibula In our series, paresis due to neuroapraxia of the
head and glenoid fossa was observed. In these peroneal nerve occurred in approximately
two-thirds of cases. This was probably caused by children. Indications and operative technique” in
stretching of the tiny motor branches during the Schuind, advances in upper and lower extremity micro-
vascular reconstructions. Singapore: World Scientific;
dissection. 2002.
This deficit resolved spontaneously within Innocenti M, Delcroix L, Manfrini M, Ceruso M, Capanna
1 year. In a very limited number of cases, the R. Vascularized proximal fibular epiphyseal transfer for
palsy can be permanent, in our series we had one distal radial reconstruction. J Bone Joint Surg
Am. 2004;86-A(7):1504–11.
patient suffering from permanent paresis of the Innocenti M, Delcroix L, Manfrini M, Ceruso M, Capanna
tibialis anterior and another patient where the R. Vascularized proximal fibular epiphyseal transfer for
extensor digitorum longus muscles remained distal radial reconstruction. J Bone Joint Surg
paretic. Am. 2005a;87(Suppl 1(Pt 2)):237–46.
Innocenti M, Delcroix L, Romano GF. Epiphyseal trans-
A valgus deformity of the ankle was observed plant: harvesting technique of the proximal fibula based
in one case due to overloading on the lateral on the anterior Tibial artery. Microsurgery.
portion of the growth plate and subsequent growth 2005b;25(4):284–92.
disturbance. Mayr JM, Pierer GR, Linhart WE. Reconstruction of part
of the distal tibial growth plate with an autologous
graft from the iliac crest. J Bone Joint Surg
Br. 2000;82:558–60.
References Taylor GI, Wilson KR, Rees MD, et al. The anterior
tibial vessels and their role in epiphyseal and diaph-
Bonnel F, Lesire M, Gomis R, Allieu Y, Rabischong yseal transfer of the fibula: experimental study and
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transplant techniques. Anat Clin. 1981;3:13–23. 451–69.
Innocenti M, Ceruso M, Manfrini M, et al. Free Teot L, Giovannini UM, Colonna MR. Use of free scapular
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resection in children. J Reconstr Microsurgery. dures. Clin Orthop Relat Res. 1999;365:211–20.
1998;14:137–43. Tsai TM, Ludwig L, Tonkin M. Vascularized fibular epiph-
Innocenti M, Ceruso M, Delcroix L. “Vascularized epiphyseal transfer: a clinical study. Clin Orthop. 1986;
yseal transfer in upper limb skeletal reconstruction in (210):228-234.
Transverse Sensate Thoracodorsal
Artery Perforator Flap for Finger 52
Reconstruction
Cheng-Ta Lin and Lee-Wei Chen
Contents
Patient 1: Reconstruction of a Dorsal Finger Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552
Patient 2: Reconstruction of a Palmar Finger Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
C.-T. Lin (*)

Division of Plastic and Reconstructive Surgery, Kaohsiung
School of Medicine, National Yang-Ming University,
Taipei City, Taiwan
e-mail: ctl@vghks.gov.tw
L.-W. Chen
Division of Plastic and Reconstructive Surgery, Kaohsiung
Institute of Emergency and Critical Care Medicine,
National Yang-Ming University, Taipei City, Taiwan
e-mail: lwchen@vghks.gov.tw

https://doi.org/10.1007/978-3-030-23706-6_50
544 C.-T. Lin and L.-W. Chen

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556
Patient 3: Reconstruction of a Circumferential Thumb Defect . . . . . . . . . . . . . . . . . . . . 556
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Abstract Avoiding and managing problems are

In the chapter, authors demonstrate three discussed, and certain patients not suitable for
clinical cases using transverse sensate reconstruction by using the flap are listed.
thoracodorsal artery perforator flaps to recon- In conclusion, the transverse sensate
struct soft tissue defects of fingers. The three thoracodorsal artery perforator flap is an option
cases consist of dorsal, palmar, and circumfer- of soft tissue reconstruction when sensory
ential soft tissue defects of the fingers and recovery is critical.
thumb. Treatment plan and reconstructive
Keywords
options are discussed. For surgical planning,
authors show steps of operating preoperative Transverse · Sensate · Thoracodorsal ·
color Doppler sonography to identify and Perforator · Doppler
locate thoracodorsal artery perforators and
intercostal arteries. The location of intercostal
artery helps to mark the approximate course of Patient 1: Reconstruction of a Dorsal
intercostal nerve because of their concomitant Finger Defect
relation. The conjoint and separate relations
between thoracodorsal artery perforator and The Clinical Scenario
intercostal nerve are described, which influ-
ence subsequent flap thinning. Transverse or A 46-year-old male sustained a crush injury at his
oblique orientation of flap design is advocated right-side middle finger in his workplace, and
for better coverage of perforasome and derma- he was taken to a nearby hospital for first aid
tome and more acceptable donor site scar. The immediately. The patient had a 10-year history
flap harvest and technical pearls are presented. of well-controlled hypertension. First operation
Preoperative preparation and postoperative was performed on the day of injury, including
management of the cases are shown, including Kirschner wire fixation of his fractured distal
the tools for assessment of sensory recovery. phalangeal bone and wound repair. Wound
52 Transverse Sensate Thoracodorsal Artery Perforator Flap for Finger Reconstruction 545
debridement was carried out on the eighth day Treatment Plan

after injury because of wound infection.
Intraoperatively, necrosis of the dorsal skin, the First-stage operation: Reconstruction of soft tis-
radial side digital neurovascular bundle, the sue defect and restoration of soft tissue sensibility.
extensor tendon, and the capsule of proximal It was scheduled on the 16th day after injury, just
interphalangeal joint were found. After infection shortly after admission to our hospital.
control thorough debridement, and antibiotic Second-stage operation: Reconstruction of
treatment, the patient was left with a soft tissue extensor tendon and possible flap debulking sur-
defect on the dorsal surface of the finger. On the gery. It was scheduled at least 1 month after the
14th postoperative day, he was transferred to our first-stage operation, in order to ensure optimal
hospital for soft tissue reconstruction. Figure 1 perfusion of the soft tissue bed.
shows his right-side hand and the wound on the
16th day after injury.
Preoperative Problem List/ 1. Regional flap (groin or abdominal flap)

Reconstructive Requirements Advantages: Easy to harvest, less donor site
morbidity, no need of microsurgery
1. Soft tissue defect, proximal interphalangeal Disadvantages: Bulky skin flap, needs post-
joint exposure/soft tissue coverage operative immobilization for at least 2 weeks,
2. Loss of soft tissue sensibility/restoration of soft unable to provide direct sensory neurotization
tissue sensibility of flap
3. Extensor tendon injury/reconstruction of 2. Free radial forearm flap
extensor tendon Advantage: Easy to harvest, constant vas-
cular supply, thin skin flap, able to provide
direct sensory neurotization of flap
Disadvantage: Hairy skin flap, requires skin
grafting for donor wound closure, limited flap
size, needs sacrifice of a major vessel, possible
donor site morbidity (noticeable scar,
contracture, paresthesias)
3. Free lateral arm flap
Advantage: Constant vascular pedicle,
enables restoration of sensibility through direct
sensory neurotization of the flap
Disadvantage: Limited flap size, bulky skin
flap, possible donor site morbidity (noticeable
scar, paresthesias, injury to the radial nerve,
limitation of elbow motion)
4. Free medial plantar artery perforator flap
Advantage: Durable soft tissue coverage,
identical soft tissue quality to the palmar
surface of the finger, enables sensory recon-
struction through direct sensory neurotization
of the flap
Disadvantage: Limited flap size, requires
Fig. 1 Soft tissue defect at dorsal surface of the right-side skin grafting for donor wound closure,
middle finger in patient 1 possible donor-site morbidity (scar, contracture,
paresthesias, injury to the medial plantar nerve), 1. The patient is placed in right lateral decubitus
needs sacrifice of a major vessel position with the contralateral side-arm
5. Free facial flap with skin grafting abducted, thus facilitating an optimal exposure
Advantage: Thin soft tissue flap of axilla and thoracic wall. Use B-mode to
Disadvantage: Needs onlay skin grafting, identify the lateral border of latissimus dorsi
secondary contracture of skin graft, unable muscle and the edge of scapula, and draw them
to provide direct sensory neurotization of flap on the skin with markers. The subcutaneous
6. Free arterialized venous flap layer, deep fascia, and latissimus dorsi muscle
Advantage: Thin skin flap, enables are also identified in B-mode.
sensory restoration through direct sensory 2. Switch from B-mode to color Doppler mode,
neurotization of the flap and find the main trunk of thoracodorsal
Disadvantage: Limited flap size, prone to vessels at the undersurface of latissimus dorsi
marginal ischemic necrosis and venous muscle. It is located between the lateral border
congestion of latissimus dorsi muscle and the lateral edge
of scapula (Fig. 2).
3. Move the probe slowly and steady in caudal
Preoperative Evaluation and Imaging direction along the thoracodorsal vessels,
focus on the descending branch, and trace the
In the harvest of transverse sensate thoracodorsal color signals of its smaller branches. Use
artery perforator flap, the most important issue markers to draw the course of the main trunk
is to identify the locations of thoracodorsal artery and descending branch of thoracodorsal ves-
cutaneous perforators and intercostal nerves. sels on the skin.
Many methods have been presented to identify 4. Trace the color signals of smaller branches that
cutaneous perforators before harvesting perforator run superficially and touch the deep facial
flaps, including audible Doppler sonography layer, these are the cutaneous perforators.
(Giunta et al. 2000), computed tomographic angi- Most perforators are of musculocutaneous
ography (Mun et al. 2008), magnetic resonance type, coursing through the latissimus dorsi
angiography (Neil-Dwyer et al. 2009), and fluo- muscle and deep fascial layer toward the
rescence angiography (Matsui et al. 2009). In subcutaneous tissue. Some perforators are
contrast to these methods, color Doppler sonog- of septocutaneous type, coursing laterally
raphy is low-cost, portable, and widely available between latissimus dorsi muscle and serratus
in medical facilities. It is noninvasive and does anterior muscle to subcutaneous tissue. Use
not expose the patient to contrast medium or radi- markers to label the points where cutaneous
ation. It provides quantitative and qualitative perforators touch the deep fascial layer.
information on both vascular and soft tissue struc- 5. Move the probe anterior to the lateral border of
tures in real time, having a sensitivity and speci- latissimus dorsi muscle, and identify the inter-
ficity exceeding 90% (Blondeel et al. 1998; Lin costal artery emerges from the inferior border
et al. 2008, 2009). Although it is operator- of the rib. The horizontal range of scanning
dependent with a steep learning curve, color area is about 6–8 cm extended anteriorly from
Doppler sonography is always the first choice in lateral border of latissimus dorsi muscle. The
our facility. proximal limit of the scanning area is about
The color Doppler sonographic examination half of the flap width above the most proximal
and mapping is usually performed few days pre- perforator, and the distal limit is approximately
operatively. The thoracic side contralateral to the half of the flap width below the most distal
injured finger is chosen as flap donor site in order perforator (Lin et al. 2009). Mark the course
to facilitate simultaneous two-team approach. of the intercostal artery (Fig. 3).
The steps necessary to identify the thoracodorsal
artery perforators and intercostal nerves using the Intercostal neurovascular bundle can be
color Doppler sonography are listed below. divided into four segments from the posterior
Fig. 2 Color Doppler sonography to locate and identify structures. White arrows indicate the deep fascial layer.
the thoracodorsal artery perforators and intercostal arteries A, axillary artery; T, thoracodorsal artery;
in real time and facilitate the flap design and harvest by Sc, septocutaneous perforator; Mc, musculocutaneous per-
assessment of quality and size of perforators, distinction of forator; I, lateral cutaneous branch of intercostal
different types of perforators, and identification of the neurovascular bundle; L, latissimus dorsi muscle; Sa,
relation between perforators and the surrounding serratus anterior muscle; R, rib
Fig. 3 Preoperative design

at the left-side posterior
thoracic wall in patient
1 showing the thoracodorsal
artery perforator (P),
intercostal nerve (I), and the
skin flap (4 7 cm in size).
L, lateral border of
latissimus dorsi muscle;
TDA, thoracodorsal artery;
S, scapula
midline to anterior midline as follows: (1) verte- leaves the intercostal space. It emerges between
bral, (2) costal groove, (3) intermuscular, and the interdigitations of serratus anterior muscle and
(4) rectus (Daniel et al. 1978). The lateral cutane- external oblique muscle, reaches the deep subcu-
ous branch of intercostal neurovascular bundle taneous tissue, and separates into a larger anterior
originates from the costal groove segment, and it division and a smaller posterior division in most
cases. Early separation into two divisions occurs advised in high-risk patients, including recipi-
deeply in the intercostal space in only about 30% ents of mechanical heart valve, atrial fibrilla-
of reported cases (Badran et al. 1984). The lateral tion, and recent venous thromboembolism (less
cutaneous branch consists of about 90% of sen- than 3 months).
sory fascicles, allowing for sensory neurotization
of the flap (Freilinger et al. 1978). The location of
intercostal artery indicates the approximate course Surgical Technique
of its nearby intercostal nerve (Lin et al. 2009; Lin
and Chen 2014). Position of Patient
It is important to keep the patients calm and The patient was placed on the operating table in
relaxed while performing color Doppler sonogra- right lateral decubitus with his left arm elevated
phy. Unwanted movement or rapid breathing will and his elbow flexed, thus facilitating optimal
cause disturbing noise signals. In clinical practice, exposure for flap harvest. A cushion was placed
keeping awake patients still in the flap-marking under his right axilla, with right arm anterior ele-
position over prolonged times can frequently vation and straight forward. The position facili-
cause discomfort. For such patients, performing tated two-team approach, with simultaneous flap
the sonographic examination immediately after harvesting and preparation of the recipient wound.
the completion of general anesthesia and just An air-cuff tourniquet was applied at the right
before scrubbing of the operative field may be upper arm to provide a bloodless field during the
considered. entire preparation.
In free flap reconstruction for fingers, digital
artery, and dorsal cutaneous vein can be used as Design of Flap
recipient vessels. However in traumatized hands Transverse or oblique orientation of the flap skin
and fingers, these vessels are always within the paddle is superior to its vertical design due to the
injury zone. In our case, the anatomical snuffbox following anatomic and surgical considerations:
vessels were selected as recipient, including the
radial artery, its concomitant veins, and cutaneous 1. The dermatomes of intercostal nerves are
veins. They were beyond the injury zone and thus transversely distributed.
more reliable. In the patients with extensive inju- 2. The axis of perforasome of thoracodorsal
ries or vascular diseases, preoperative image stud- artery perforator is in oblique-transverse direc-
ies should be conducted to evaluate the recipient tion (Schaverien et al. 2008; Saint-Cyr et al.
vascular quality such as color Doppler sonogra- 2009).
phy or angiography. 3. Transverse donor-site scar is more acceptable
(Lee and Mun 2008).
4. Breast distortion is caused by horizontal
Preoperative Care and Patient Drawing tension line of skin closure.
Cigarette consumption is prohibited for all The territory of flap is closely related to the
patients before surgery. In patients on anti- location of thoracodorsal artery perforator and the
thrombotic therapy for medical illnesses, we course of intercostal nerve. The chosen perforator
routinely stop any antiplatelet medication for and nerve are put in lateral one-third or near the
5–7 days, whereas anticoagulant medication is central region of flap (Fig. 3). The width of flap
stopped 3–5 days prior to surgery. We routinely depends on the size of recipient wound. Primary
perform blood coagulation analysis including wound closure is possible in most cases when the
platelet count, partial thromboplastin time, flap width is within 8–9 cm. The reliable length of
international normalized ratio, and activated flap depends on the quality and the number of
partial thromboplastin time. Preoperative con- included perforators. With a single perforator,
sultation by a cardiovascular physician is the circulation is safe in flaps up to 15 cm in length
and marginal in flaps with length between 20 and superficial subcutaneous tissue was preserved
25 cm (Kim and Kim 2009, Lin and Chen 2012). under the dermis (Fig. 6).
Flap Elevation Preparation of Recipient Wound, Nerve,

Under loupe magnification, flap was elevated and Vessels
from inferomedial border toward superolateral The recipient wound was debrided. The stump of
direction through subfascial plane. Using electro- radial side digital nerve at proximal wound edge
cautery for subfascial dissection created a blood- was identified, and unhealthy nerve fascicles were
less surgical plane, which helped to identify and trimmed. An incision was made at the anatomical
see the perforator clearly (Fig. 4). After identifi- snuffbox. The branch of cephalic vein situated in
cation of the thoracodorsal artery perforator, sub- the subcutaneous tissue, the radial artery, and its
fascial dissection proceeded laterally. The concomitant veins lying on the floor of the ana-
posterior division of lateral cutaneous branch of tomical snuffbox were found and marked with
intercostal nerve was identified in the deep subcu- vessel loops. The side branches of the superficial
taneous tissue over the lateral border of the radial nerve traveling in the subcutaneous tissue
latissimus dorsi muscle. The nerve was liberated should be always identified and protected while
from surrounding soft tissue with blunt tip dissec- dissecting the recipient vessels. A subcutaneous
tors or scissors. It was traced laterally to the bifur- tunnel between the recipient wound and the ana-
cation of lateral cutaneous branch and cut at this tomical snuffbox was created.
level to maintain the continuity of anterior divi-
sion. Intramuscular dissection was performed to Microsurgical Coaptation of the Nerve
liberate the perforator, which was irrigated with and Vessels
2% lidocaine solution and 10% MgSO4 solution The flap was transferred to the recipient wound at
to relieve vasospasm. Retrograde vascular dissec- the right middle finger. Using few temporary
tion was routinely performed to obtain adequate stitches to fix the flap on the recipient wound
pedicle length, the thoracodorsal nerve being prevented inadvertent traction to the vascular ped-
always spared. In this case, the conjoint relation icle. The skin over the subcutaneous tunnel was
between the posterior division of intercostal nerve lifted with retractors. Irrigating the tunnel with
and the thoracodorsal artery perforator was found warm normal saline facilitated the passing of the
(Figs. 4 and 5). The conjoint relation allowed vascular pedicle to the anatomical snuffbox. After
more aggressive flap thinning procedure without the delivery of the vascular pedicle to the wound, it
causing injury to perforator and nerve. The deep was important to check and eliminate any possible
subcutaneous tissue was excised, and a layer of torsion or kinking of the pedicle in the tunnel.
Fig. 4 The conjoint

relation between the
musculocutaneous
thoracodorsal artery
perforator (P) and the
posterior division of lateral
cutaneous branch of
intercostal nerve (I).
Subfascial dissection by
electrocautery creates a
bloodless surgical field. The
arrowhead points the
bifurcation of lateral
cutaneous branch of
intercostal nerve
Fig. 5 In conjoint relation, the thoracodorsal artery perfo- subcutaneous tissue at different points. An additional soft
rator and the intercostal nerve enter the subcutaneous tissue tissue cuff around the nerve is required in flap thinning
together. During the flap thinning procedure, a soft tissue procedure, which results in a bulkier flap. I, intercostal
cuff is preserved around the conjoint perforator and nerve. nerve; Mc, musculocutaneous perforator; T, thoracodorsal
In a separate relation, the perforator and nerve enter the artery
Fig. 6 The flap in patient

1 was elevated and thinned
without injury to the
conjoint perforator and
nerve
We performed nerve coaptation first, because Wound Closure

flap bleeding after vascular anastomosis obscured The donor wound was closed after flap transfer,
the view field of recipient wound. Under micro- and a 19 Fr Jackson-Pratt drain was placed. The
scope, the nerve was coapted with epineurial repair recipient wound and the wound at the level of the
using interrupted 10-0 nylon sutures. The ends of the anatomical snuffbox were closed with interrupted
thoracodorsal artery and the two concomitant veins 4-0 nylon sutures. Small-sized Penrose drains
at vascular pedicle were clearly cut and prepared. were placed in both wounds.
The proximal ends of recipient vessels in anatomical
snuffbox including radial artery, concomitant vein, Technical Pearls
and a branch of cephalic vein were also clearly cut
and prepared. End-to-end anastomosis between the 1. In the design of small flap, it is crucial to
donor and recipient vessels was done subsequently identify the precise locations of thoracodorsal
using interrupted 10-0 nylon sutures. artery perforator and the intercostal nerve.
2. Transverse design of the flap is better than the Kirschner wire was extracted at the seventh
vertical design. week after operation.
3. The perforator and nerve should be oriented in
lateral one-third or near the central region of
flap in order to cover the perforasome and Outcome, Clinical Photos, and Imaging
dermatome.
4. Preservation of the anterior division of lateral No postoperative bleeding, hematoma, wound
cutaneous branch of intercostal nerve avoids infection, or wound healing problems were
paresthesia at lateral thoracic wall. encountered. The contour of the right middle fin-
5. Preservation of thoracodorsal nerve decreases ger was acceptable, and no further flap debulking
postoperative functional impairment of was arranged (Fig. 7).
latissimus dorsi muscle. No obvious deficit of motor function at the left
6. Using electrocautery for flap elevation allows shoulder and arm was found. The flap harvest did
us to identify the perforator and nerve in a not cause obvious sensory disturbance at the right
bloodless surgical plane. axilla except for mild temporary paresthesia of the
surgical scar site.
Two tests were applied at outpatient settings
Intraoperative Images for the evaluation of sensory recovery at the center
of the flap. The Semmes-Weinstein monofila-
See Figs. 1, 3, 4, and 6. ments test, which evaluated the slowly adapting
fibers, was used for assessing sensory threshold
of cutaneous pressure. The monofilament num-
Postoperative Management bers represent logarithm of ten times the force in
For all patients undergoing microvascular sur-

gery, cigarette consumption was prohibited for
at least 1 month after the surgery. We did not
routinely use antithrombotic therapy after micro-
vascular surgery. Intravenous antibiotics based
on previous antibiogram were prescribed for
7 days. The right hand and forearm were kept
elevated to prevent swelling or wound bleeding.
Compressive wound dressing or external pres-
sure at the right hand was avoided. The room
temperature should be kept warm to prevent
flap from vasospasm.
In order to monitor the viability of flap, the
primary care nurses checked the temperature,
color, and capillary refilling time of the flap
every 2 h in the first postoperative 3 days. The
frequency of the visits was shifted to every 6 h
between the fourth and seventh day.
Aspirin was withheld for 3 days. The wound
drains were removed in a week. The stitches at
both donor and recipient wounds were removed at
2 weeks after operation.
The patient was unwilling to undergo subse- Fig. 7 Appearance of the right hand in patient 1, 1 month
quent extensor tendon reconstruction, and the postoperatively
milligrams required to bow filament when applied 4. Overzealous flap thinning may harm flap per-
perpendicularly to the skin. The static two-point fusion and sensory recovery. If the flap size is
discrimination test, which assessed the density still bulky after thinning, consider two-stage
of reinnervation of large myelinated fibers, was operation.
applied for evaluation of functional level of 5. It is important to spare the thoracodorsal nerve
sensation. while dissecting the vascular pedicle. In the
The scales of the two tests are listed below case of accidental nerve division, always repair
(Hunter et al. 1995; Berger and Weiss 2004). it after flap harvest.
Light touch sensation with Semmes-Weinstein 6. The locations of intercostal nerve, recipient
monofilaments: nerve, and nerve coaptation should be
documented in detail. If a second operation
Normal – Between 1.65 and 2.83 for the recipient site is required, all relevant
Diminished – Between 3.22 and 3.61 information is valuable in order to avoid injury
Diminished protective – Between 3.84 and 4.31 to the nerve during exploration.
Loss of protective – Between 4.56 and 6.45 7. The flap may be contraindicated in patients
Unresponsive – Between 6.65 or no response with (Strauch et al. 2016):
– Significant peripheral neuropathies
Two-point discrimination with Mackinnon- – Very extensive injury around the recipient
Dellon Disk-Criminator: wound
– Requirement of postoperative radiotherapy
Normal – Detected distance is between 1 and at the recipient wound
5 mm. – Obesity
Fair – Detected distance is between 6 and 10 mm.
Poor – Detected distance is between 11 and
15 mm. Learning Points
Protective – Only one point is perceived.
Anesthetic – No points are perceived. 1. The thoracodorsal artery perforator flap
exhibits a large skin flap and abundant soft
In our patient, 11 months after operation, the tissue volume which allows reconstruction of
monofilaments test was 3.22 (diminished light extensive and complex wounds.
touch), and the two-point discrimination test was 2. It can also be used for resurfacing of shallow
7 mm (fair). defects with flap thinning procedure (Lin et al.
2006).
3. The vascular pedicle is long, which allows micro-
Avoiding and Managing Problems vascular anastomosis outside the injury zone.
4. The donor site wound can be primarily closed
1. Careful hemostasis during the flap harvest is in most cases. The donor site scar can be easily
important to facilitate identification of perfora- hidden, and donor site morbidity is rare.
tor and nerve. 5. The transverse sensate thoracodorsal artery
2. Anterior division of the lateral cutaneous branch perforator flap can provide sensory recovery
of the intercostal nerve should be preserved to to the recipient wounds (Strauch et al. 2016).
prevent paresthesia of the lateral chest wall. In the reconstruction of hands and fingers, the
3. Flap thinning procedure might cause injury to flap is an option because sensory recovery is
perforators or nerves. Trimming the subcuta- important (Lin et al. 2009; Lin and Chen
neous tissue under microscope is preferable 2014).
because perforators and nerves in adipose tis- 6. Doppler sonography is used to identify the
sue may not be seen clearly under loupe thoracodorsal artery perforators and intercostal
magnification. nerves before operation.
7. Transverse or oblique orientation of the flap Preoperative Problem List/

skin paddle is superior to its vertical design. Reconstructive Requirements
1. Soft tissue defect, flexor tendon exposure/soft

Patient 2: Reconstruction of a Palmar tissue coverage
Finger Defect 2. Loss of soft tissue sensibility/restoration of soft
tissue sensibility
A 55-year-old male sustained a crush injury at his Treatment Plan

right index finger when working, and he was
taken to our emergency room immediately. First A plan for a two-stage operation was set.
operation was performed on the day of injury, First-stage operation: Reconstruction of soft tis-
including Kirschner wire fixation of the fractured sue defect and restoration of soft tissue sensibility.
distal phalangeal bone and wound repair at the It was scheduled on the 11th day after injury, just
palmar aspect of the finger. The ulnar side digital after adequate debridement of the wound.
nerve was not repaired because a gap existed. Second-stage operation: Possible tenolysis for
Debridement surgery was done on the ninth day adhesion of flexor tendons and flap debulking sur-
after injury because of wound necrosis. A soft gery might be required if limitation of finger flex-
tissue defect with exposure of the flexor tendons ion or bulky size of flap was encountered and was
was left at the palmar surface of the finger. Soft scheduled few months after reconstructive surgery.
tissue reconstruction was scheduled on the 11th
day after injury (Fig. 8).
Please refer to the “Alternative Reconstructive

Options” of patient 1.
Please refer to the “Preoperative Evaluation and

Imaging” of patient 1. In this case, preoperative
color Doppler sonography was done together with
the debridement surgery on the ninth day after
injury. The left posterior thoracic wall, which was
contralateral to the side of the injured finger, was
chosen as the flap donor site. The vessels in the
anatomical snuffbox were chosen as recipient ves-
sels because they were beyond the injury zone and
were size-matched to the thoracodorsal vessels.
Please refer to the “Preoperative Care and Patient

Fig. 8 The soft tissue defect at the palmar surface of right- Drawing” of patient 1. The patient ceased ciga-
side index finger in patient 2 rette consumption in the admission.
Surgical Technique included the superficial vein situated in the sub-

cutaneous tissue, the radial artery, and its concom-
Please refer to the “Surgical Technique” of itant veins at the floor of the anatomical snuffbox,
patient 1 in terms of the position of patient, which were found and marked with vessel loops.
design of flap, and flap elevation (Fig. 9). In The superficial branches of radial nerve were
this case, the most robust perforator detected in spared. A subcutaneous tunnel between the recip-
color Doppler sonographic examination was ient wound and the anatomical snuffbox was
chosen. However, a separate course in the created.
flap subcutaneous tissue between the posterior The transfer and inset of the flap, the microsur-
division of intercostal nerve and the selected gical coaptation of nerve and vessels, and wound
thoracodorsal artery perforator was found closure were similar to patient 1 (Fig. 12).
(Fig. 10). Conservative thinning at periphery of Epineural nerve coaptation was carried out first
the flap was performed in this situation (Figs. 5 with interrupted 10-0 nylon sutures. The
and 11). thoracodorsal artery and two concomitant veins
The preparation of recipient wound, nerve, and of the vascular pedicle were anastomosed to the
vessels was similar to patient 1. The proximal radial artery, concomitant vein, and superficial
stump of the severed ulnar side digital nerve was vein, respectively, in end-to-end fashion with
identified and refreshed. The recipient vessels interrupted 10-0 nylon sutures.
Fig. 9 Preoperative design

at the left-side back of
patient 2, showing the
perforators (P1 and P2),
intercostal nerve (I), and the
skin flap (3.5 9 cm in
size). L, lateral border of
latissimus dorsi muscle; D,
descending branch of
thoracodorsal artery; S,
scapula
Fig. 10 Separate relation

between the
musculocutaneous
perforator (P2) and the
posterior division of lateral
cutaneous branch of
intercostal nerve (I). The
perforator and nerve enter
the subcutaneous tissue
separately, limiting the
extent of safe flap thinning
Fig. 11 The flap was

elevated, and the
thoracodorsal nerve
(asterisk) was spared. P2,
perforator; I, intercostal
nerve
Technical Pearls
Please refer to the “Technical Pearls” of patient 1.
See Figs. 8, 9, 10, 11, and 12.
Please refer to the “Postoperative Management”

of patient 1. The wound drains were removed
within postoperative 1 week. The stitches at both
donor and recipient wounds were removed at
2 weeks after operation. The Kirschner wire was
extracted at 2 months after operation.

Fig. 12 Immediate postoperative result of the right hand
The postoperative course was uneventful without in patient 2. The separate relation between the
donor site morbidity. Rehabilitation to improve musculocutaneous thoracodorsal artery perforator and the
the motion of the finger was conducted after posterior division of lateral cutaneous branch of intercostal
nerve resulted in a bulky flap
removal of Kirschner wire. However, limitation
of finger flexion due to the bulk of the flap was
found. tendon was explored through the incision, and
Flexor tenolysis and flap debulking surgery the debulking was limited to the radial border of
were performed at 5 months after reconstructive the flap. At 1 year postoperatively (Fig. 13), the
surgery. To prevent injury to the intercostal nerve monofilaments test was 3.84 (diminished protec-
and ulnar-side digital nerve, we incised along tive), and the two-point discrimination test was
the radial side border of the flap. The flexor 8 mm (fair).
Fig. 13 Postoperative result at 1 year after flap reconstruc- Fig. 14 Palmar view of the circumferential soft tissue
tion in patient 2 defect of the right thumb in patient 3. Crush injury around
the palm and dorsal hand is shown
the wound. The degloved skin envelope distal to
Please refer to the “Avoiding and Managing Prob- the metacarpophalangeal joint of the right thumb
lems” of patient 1. was not replanted as it was comminuted. The
exposed digital bone of the right thumb was tem-
porarily covered with a synthetic dressing. Recon-
Learning Points struction for the circumferential soft tissue defect
of the right thumb was scheduled on the sixth day
Please refer to the “Learning Points” of patient 1. after injury (Figs. 14 and 15).
Patient 3: Reconstruction of a Preoperative Problem List/

Circumferential Thumb Defect Reconstructive Requirements
The Clinical Scenario 1. Circumferential soft tissue defect/soft tissue

coverage
A 35-year-old male sustained a crush injury of his 2. Loss of soft tissue sensibility/restoration of soft
right hand and was send to our emergency room tissue sensibility
immediately. The first operation on the day of
injury included Kirschner wire fixation of the
fractured proximal phalangeal bone of the index Treatment Plan
finger, repair of flexor tendons of the index finger,
microsurgical repair of the radially sided digital First-stage operation: Reconstruction of soft tis-
artery and nerve of the index finger, and repair of sue defect and restoration of soft tissue sensibility.
It was scheduled on the sixth day after injury and Alternative Reconstructive Options
allowed us to meanwhile observe the condition of
the surrounding crushed soft tissue. Please refer to the “Alternative Reconstructive
Second-stage operation: Possible revision of Options” of patient 1.
scars and flap debulking surgery. It was scheduled
in the case of scar contracture or bulky size of flap
was encountered and few months after the first Preoperative Evaluation and Imaging
reconstructive surgery.
Please refer to the “Preoperative Evaluation and
Imaging” of patient 1. In this case, preoperative
color Doppler sonography was carried out on the
day before reconstructive surgery. The left-side
thoracic wall, which was contralateral to the
injured hand, was chosen as donor site. The ves-
sels in anatomical snuffbox were not chosen as
recipient vessels because they were within the
injury zone. The radial vessels at the palmar
aspect of right wrist were preferred, as located
beyond the injury zone.
Please refer to the “Preoperative Care and Patient

Drawing” of patient 1. The patient also ceased
cigarette smoking on admission.
Surgical Technique
Please refer to the “Surgical Technique” of patient

Fig. 15 Dorsal view of the circumferential soft tissue
defect of the right thumb in patient 3. Crush injury around 1 in terms of the position of patient, design of
the palm and dorsal hand is shown flap, and flap elevation (Fig. 16). During flap
design on the left thoracic
wall of patient 3 showing
the thoracodorsal artery
perforators (P1, P2, P3),
intercostal nerve (arrow),
and the skin flap
(7.5 20 cm in size). L,
lateral border of latissimus
dorsi muscle; T,
thoracodorsal artery; S,
scapula
design, the nerve and perforators were positioned excised, and a thin layer of superficial subcutane-
near the junction between the anterior and middle ous tissue was preserved under the dermis
third of the flap, and the middle third of flap was (Figs. 18 and 19). The anterior third of the flap
designated for soft tissue coverage. The conjoint was excised, and the curved anterior margin of
relation between the posterior division of inter- flap was created.
costal nerve and the selected musculocutaneous The stump of the ulnar side digital nerve of the
thoracodorsal artery perforator was found thumb was identified, and its unhealthy fascicle
(Fig. 17). The deep subcutaneous tissue was ending was trimmed. The radial artery and its
concomitant veins at palmar aspect of the wrist
were identified as recipient vessels and looped. A
subcutaneous tunnel between the thumb wound
and the recipient vessels was created.
The flap was transferred to his right thumb and
fixed on the recipient wound bed with temporary
stitches. The skin over the subcutaneous tunnel
was lifted with retractors, and the tunnel was
irrigated with warm normal saline. The vascular
pedicle was delivered through the tunnel to the
recipient vessels, and the pedicle was checked for
any torsion or kinking in the tunnel.
Epineurial nerve coaptation was done first with
interrupted 10-0 nylon sutures. In order to keep
the continuity of radial artery, the end of the
thoracodorsal artery perforator was anastomosed
to the side of radial artery with interrupted 10-0
nylon sutures. The thoracodorsal veins were
coapted with the concomitant veins of radial
artery in end-to-end fashion with interrupted
10-0 nylon sutures.
For wrapping the circumferential defect of the
thumb, we planned to use the middle-third part of
Fig. 17 Intraoperative picture showing the conjoint rela-
tion between the most robust musculocutaneous the flap to get better flap viability and dermatome
thoracodorsal artery perforator (P1) and the posterior divi- coverage. Before the flap was transferred to the
sion of lateral cutaneous branch of intercostal nerve (I) recipient wound, we excised its anterior third to
Fig. 18 The flap was

elevated and thinned
without injury to the
conjoint perforator and
nerve. P1, thoracodorsal
artery perforator; I,
intercostal nerve
Fig. 19 Undersurface of
the homogeneously thinned
flap. A thin layer of
subcutaneous tissue was
preserved under dermis.
The anterior third of flap
was excised, and a curve-
shape anterior margin of
flap (arrow) was created to
facilitate subsequent flap
inset. P1, thoracodorsal
artery perforator; I,
intercostal nerve
create a curved anterior margin. The anterior mar-

gin of flap was sutured with the circumferential
wound edge of the right thumb by using
interrupted 4-0 nylon sutures. Then the upper
and lower margins of the flap were approximated
to each other to wrap around the shaft of digital
bone along the side of the thumb. Finally, the
excess posterior third of the flap was trimmed,
and the thumb tip wound was closed.
Small-sized Penrose drains were placed in the
recipient and wrist wounds, and the wrist
wound was closed with loose interrupted 4-0
nylon sutures. Closure of the flap donor wound
was similar to the previous two patients.
Technical Pearls
Please refer to the “Technical Pearls” of patient 1.
Fig. 20 Appearance of the right hand in patient 3, 3 weeks
See Figs. 14, 15, 16, 17, 18, and 19. postoperatively

No early postoperative complication was encoun-
Please refer to the “Postoperative Management” tered at the donor and recipient wounds including
of patient 1. The wound drains were removed bleeding, hematoma, wound infection, or wound
within a week. The stitches at both donor and healing problems (Fig. 20).
recipient wounds were removed at 2 weeks post- No obvious motor or sensory disturbance
operatively. The Kirschner wires for fixation of happened to the donor site. However, hyper-
fracture at the right index finger were extracted at trophic scar with scar paresthesia was noted at
2 months. the left side of the chest wall (Fig. 21).
Scar revision surgery was not performed. Con-

servative treatment including local steroid
injection of scar tissue, scar massage, and top-
ical silicone gel was applied. Scar release of
the first web space and flap debulking surgery
were performed 4 months postoperatively.
The debulking procedure included excision
of 1 cm in width of the flap tissue along the
radial side of the thumb scar to prevent injury
to the intercostal nerve and ulnar side digital
nerve.
Long-term aesthetic result of the recipient site
was acceptable (Figs. 22 and 23). At 15th month
after operation, the monofilaments test was 4.08
(diminished protective), and the two-point dis-
crimination test was 9 mm (fair).
Please refer to the “Avoiding and Managing Prob-

lems” of patient 1.
Fig. 21 Donor site scar in patient 3, 15 months
postoperatively
Fig. 22 Appearance of the palmar surface of the right Fig. 23 Appearance of the dorsal surface of the right hand
hand in patient 3, 15 months postoperatively in patient 3, 15 months postoperatively
Learning Points Lin CT, Chen LW. Inclusion of extra perforators – a single
and efficient measure to prevent vascular insufficiency
in unreliable thoracodorsal artery perforator flaps.
Please refer to the “Learning Points” of patient 1. J Plast Reconstr Aesthet Surg. 2012;65:342–50.
Lin CT, Chen LW. Surgical refinements and sensory recov-
ery of using transverse sensate thoracodorsal artery
Cross-References perforator flaps to resurface ring-avulsed fingers. Ann
Plast Surg. 2014;72:299–306.
Lin CT, Huang JS, Yang KC, et al. Reliability of anatom-
▶ Thin Free Flap for Resurfacing of the Arm and ical landmarks for skin perforators of the thoracodorsal
Forearm artery perforator flap. Plast Reconstr Surg.
2006;118:1376–86.
Lin CT, Huang JS, Hsu KC, et al. Different types of
suprafascial courses in thoracodorsal artery skin perfo-
References rators. Plast Reconstr Surg. 2008;121:840–8.
Lin CT, Yang KC, Hsu KC, et al. Sensate thoracodorsal
Badran HA, El-Helaly MS, Safe I. The lateral intercostal artery perforator flap: a focus on its preoperative design
neurovascular free flap. Plast Reconstr Surg. and harvesting technique. Plast Reconstr Surg.
1984;73:17–26. 2009;123:163–74.
Berger RA, Weiss AC. Hand surgery. Philadelphia: Matsui A, Lee BT, Winer JH, et al. Image-guided perfora-
Lippincott Williams & Wilkins; 2004. p. 105–22. tor flap design using invisible near-infrared light and
Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler validation with x-ray angiography. Ann Plast Surg.
flowmetry in the planning of perforator flaps. Br 2009;63:327–30.
J Plast Surg. 1998;51:202–9. Mun GH, Kim HJ, Cha MK, et al. Impact of perforator
Daniel RK, Kerrigan CL, Gard DA. The great potential of mapping using multidetector-row computed tomo-
the intercostal flap for torso reconstruction. Plast graphic angiography on free thoracodorsal artery per-
Reconstr Surg. 1978;61:653–65. forator flap transfer. Plast Reconstr Surg.
Freilinger G, Holle J, Sulzgruber SC. Distribution of motor 2008;122:1079–88.
and sensory fibers in the intercostal nerves: Neil-Dwyer JG, Ludman CN, Schaverien M, et al.
Significance in reconstructive surgery. Plast Reconstr Magnetic resonance angiography in preoperative plan-
Surg. 1978;62:240–4. ning of deep inferior epigastric artery perforator flaps.
Giunta RE, Geisweid A, Feller AM. The value of preoper- J Plast Reconstr Aesthet Surg. 2009;62:1661–5.
ative Doppler sonography for planning free perforator Saint-Cyr M, Wong C, Schaverien M, et al. The
flaps. Plast Reconstr Surg. 2000;105:2381–6. perforasome theory: vascular anatomy and clinical
Hunter JM, Mackin EJ, Callahan AD. Rehabilitation of the implications. Plast Reconstr Surg. 2009;124:
hand: surgery and therapy. 4th ed. St. Louis: Mosby; 1529–44.
1995. p. 129–52. Schaverien M, Saint-Cyr M, Arbique G, et al. Three- and
Kim JT, Kim YH. Initial temporary vascular insufficiency four-dimensional arterial and venous anatomies of the
in latissimus dorsi and thoracodorsal perforator flaps. thoracodorsal artery perforator flap. Plast Reconstr
Plast Reconstr Surg. 2009;124:e408–18. Surg. 2008;121:1578–87.
Lee SH, Mun GH. Transverse thoracodorsal artery perfo- Strauch B, Vasconez LO, Herman CK, et al. Grabb’s ency-
rator flaps: experience with 31 free flaps. J Plast clopedia of flaps: head and neck. 4th ed. Philadelphia:
Reconstr Aesthet Surg. 2008;61:372–9. Lippincott Williams & Wilkins; 2016. p. 372–81.
Extracutaneous Free Triple Split SCIP
Flap for Simultaneous Reconstruction 53
of Multiple Soft Tissue Defects of the
Fingers
Contents
Preoperative Problem List – Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . 565
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Alternative Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Preoperative Care and Flap Marking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Initial Debridement on the Day of Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
Reconstruction of Vital Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
Preparation of the Recipient Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
Flap Elevation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
Flap Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
Flap Thinning Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Intraoperative Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Z. Jandali · B. Merwart (*) · L. P. Jiga

Department of Plastic, Aesthetic, Reconstructive and Hand
Surgery, Evangelisches Krankenhaus, Medical Campus,
e-mail: dr@jandali.de; zaher.
jandali@evangelischeskrankenhaus.de;
benedikt.merwart@evangelischeskrankenhaus.de;
lucian.jiga@evangelischeskrankenhaus.de

https://doi.org/10.1007/978-3-030-23706-6_51
564 Z. Jandali et al.

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Abstract The recovery time of all four stages was

Circular saw injuries of the hand commonly uneventful, with an acceptable aesthetic and
include tendon laceration, fractures, and functional result.
neurovascular compromise. In addition, they
Keywords
are often accompanied by a significant loss of
soft tissue that leaves the injured structures Circular saw · Complex injury · Hand · Free
exposed. flap
While even minor trauma to the hand can
limit its function, extended trauma often ren-
ders the hand completely dysfunctional. Since The Clinical Scenario
the interconnected anatomy of the hand is the
basis for its flawless function, the functional A 54-year-old male presented to our clinic with an
reconstruction following complex hand inju- accidental circular saw injury of his right hand.
ries displays a severe challenge to the recon- Even though the initial physical examination was
structive surgeon. The accompanying tissue limited due to significant pain and wound contam-
loss makes these cases even more challenging. ination, a gross examination in the emergency
This case illustrates a four-stage reconstruc- department showed an involvement of all five fin-
tion of an accidental circular saw injury of the gers of the affected hand. Unless the patient is in a
right hand with injuries of the neurovascular hemodynamic unstable condition, a gross inspec-
system, the flexor tendons, and a significant tion of the extent of the injury should always be
loss of soft tissue in three of the fingers, leaving done preoperatively. Important key points like
all of the injured structures exposed. The first color and turgor of the fingers, loss of skin, and
stage involved thorough debridement and dam- exposed structures can quickly be assessed. This
age control. To initially cover the vital struc- may help to inform the operating room staff of the
tures, a temporary VAC®-therapy was chosen necessary special instruments and can save pre-
(VAC®, KCI, San Antonio, TX, USA). cious time (Neumeister and Brown 2003).
The second stage was performed 72 h after In this patient, none of the fingers were ische-
the initial injury and involved the soft tissue mic. Preoperative x-ray imaging didn’t show any
coverage with an extracutaneous free SCIP flap fractures. The patient received broad-spectrum
as well as the reconstruction of the compromised antibiotics, which are mandatory for such cases
structures, which could either be sutured directly until definitive cultures and the antibiogram return.
or, in case of the ruptured deep flexor tendon of After thorough debridement and irrigation of
the index finger, using a Palmaris longus the wounds, a defect of the deep flexor tendon of
interpositional graft and osseous refixation. The about 3 cm in Zone 2, as well as a significant loss
long segmental defect of the radial finger nerve of soft tissue of the index finger extending from
of the ring finger was reconstructed in the same the middle of the proximal phalanx to the basis of
session, using an ipsilateral, lateral antebrachial the distal phalanx, became obvious. Furthermore,
cutaneous nerve interpositional graft. Three a rupture of the deep flexor tendon, also in Zone 2,
weeks later, the third stage included dividing with a concomitant loss of soft tissue from the
the skin pedicle of the free flap, while another proximal phalanx to the crease of the distal
8 weeks later a flap thinning procedure was interphalangeal joint of the middle finger, was
performed as the fourth and final step. shown. Also, a lesion of the radial neurovascular
53 Extracutaneous Free Triple Split SCIP Flap for Simultaneous Reconstruction of Multiple Soft. . . 565
system of the ring finger, accompanied by a sig- further demarcation nor any signs of an infection,
nificant loss of soft tissue, became visible. The it was possible to proceed with the soft tissue
thumb showed a massive subungual hematoma as coverage. In planning the reconstructive proce-
well as a superficial dermal defect of the dorsal dure, the aim was towards an early mobilization
distal phalanx. The small finger showed superfi- of the affected hand. Therefore, tendons,
cial lacerations, which could be closed primarily neurovascular structures, and the soft tissue defect
after debridement (Fig. 1). needed to be repaired in one single procedure.
With the exception of the deep flexor tendon of
the right index finger and the radial finger nerve of
Preoperative Problem List – the ring finger, all of the affected structures were
Reconstructive Requirements sutured directly. Due to the long-segment defect
of the deep flexor tendon of the index finger
1. Laceration and long-segmental defect of the an ipsilateral Palmaris longus autologous
deep flexor tendon of the index finger in Zone 2. interpositional graft was used for the reconstruc-
2. Laceration of the deep flexor tendon of the tion. Because the defect included the insertion of
middle finger in Zone 2. the flexor tendon, a bone anchor was used to
3. Compromise of the radial artery and long seg- reinsert it into the base of the 3rd phalanx. The
mental defect of the radial nerve of the ring long segmental defect of the radial finger nerve
finger at the level of the PIP joint. of the ring finger was reconstructed using an
4. Soft tissue defects that result in an exposure of ipsilateral, lateral antebrachial cutaneous nerve
the reconstructed structures in all of the interpositional graft.
affected fingers excepting the small finger. The definitive soft tissue coverage was achieved
by using a free SCIP flap from the contralateral
side. The SCIP flap is, in our opinion, an ideal flap
Treatment Plan for the reconstruction of multiple, simultaneous,
palmar soft tissue defects. Its main advantage
After initial evaluation of the tissue damage, a resides in the fact that the skin island of the flap is
treatment plan in four consecutive stages was perfused by septal perforators running above the
intended. After thorough debridement in the first fascia. Thus, one skin paddle can be split into two
procedure, vacuum-assisted coverage was utilized or more separate units designated for multiple
as a temporary wound closure. Since 72 h after the defects of the same recipient region. Another
first surgery, the soft tissue had shown neither any advantage is the thickness of the flap. Because it
Image of the injury pattern,
after irrigation and before
debridement
can be raised relatively thin, the flap normally 3. Soft tissue reconstruction using pedicled flaps:
doesn’t have to be thinned out several times. e.g., the pedicled groin flap (Neumeister et al.
Nevertheless, the SCIP flap has its disadvan- 2010). One of the disadvantages is the restricted
tages, too. Because of the anatomical variations, motion until the pedicle is divided and will end
the preparation of its pedicle can be very tedious. in joint stiffness of the affected fingers.
Furthermore, the pedicle is relatively short (Choi 4. Other free flaps, such as the ALT flap
et al., 2014) compared to other perforator flaps. This (Neumeister et al. 2010) or the DIEP flap,
is why the SCIP flap should be primarily indicated have the disadvantage of the thickness and
for defects where the recipient vessels are collated usually require multiple thinning procedures
superficially (e.g., hand, head and neck, and foot). compared to the SCIP flap.
In order to avoid enlarging the actual wounds, 5. Immediate soft tissue coverage with an emer-
the flap was placed extracutaneously. gency free flap (Chen et al. 1992; Godina 1986;
Another advantage of the extracutaneous lie of Scheker and Ahmed 2007). There is no con-
the pedicle is the localization of the recipient clusive evidence that immediate soft tissue
vessels, which is distant to the defect and therefore reconstruction of the upper extremity would
not affected by the initial injury. Three weeks after either eliminate or increase complications
the second surgery, the skin pedicle was divided (Harrison et al. 2013). Due to the contamina-
and the flap was debulked for the first time. tion of the wounds an emergency free flap was
Another 8 weeks later, a second flap thinning not an option, still with the exposed tendons
procedure was performed, as the fourth and and neurovascular structures, an early recon-
final step. struction is essential for a good outcome.
Alternative Treatment Plan Preoperative Evaluation and Imaging
1. Soft tissue coverage using local flaps of the Preoperative ultrasound Doppler was used to iden-
hand (Rehim and Chung 2014) is possible, but tify potential perforators in the recipient area, as well
not the preferred option for this case. Even as to verify the presence of perforators in multiple
though multiple Cross-Finger flaps could have possible donor sites, including the right and left
been used to cover all of the defects, the huge groin area as well as both thighs. In such difficult
disadvantage of this flap is the need for a 3-week cases, it is necessary to have a backup plan if your
immobilization period before separating it from first-choice flap fails. In this case, a super-thin ALT
the donor site. This would, especially in the was chosen as the second choice. Because of the
elderly patient, end in joint stiffness and lead considerable anatomical variations of the SCIP flap,
to an impaired functional outcome. Addition- it may also be helpful to utilize a preoperative
ally, there is the huge disadvantage of the donor colored Doppler ultrasound imaging (Tashiro et al.
site defect, that usually has to be covered using 2015). MRI or CT angiography can also be used.
full-thickness skin grafts.
2. In general, it is a good option to replace like with
like. The medial plantar artery flap could provide Preoperative Care and Flap Marking
like with like replacement, and it is per se a good
option for volar defect reconstruction of the fin- The patient is placed in the supine position. The
gers. Nevertheless, the possible flap size was a right arm is put on an arm table with 90 abduction
limiting factor in this case and could therefore in the shoulder. A well-padded tourniquet is
not be used to cover all three defects in one placed around the upper arm.
single procedure. In addition, the donor site can- The inguinal crease and the superior anterior
not be closed primarily and requires split thick- iliac spine are identified and a line is drawn
ness skin grafting to close the wound. between them. Using this landmark, a hand held
acoustic 8 MHz ultrasound Pencil Doppler is used foundation for the microsurgical reconstruction is
to identify the perforators of the superficial circum- set. (Neumeister et al. 2010; Scheker and Ahmed
flex iliac artery (SCIA). 2007; Ng et al. 2015; Li et al. 2016). The result of
You start by palpating the common femoral the debridement was an estimated soft tissue
artery about 1–2 cm below the inguinal ligament. defect of about 4 1.5 cm on the index finger,
You then look for the origin of the SCIA from the extending from the palmar proximal phalanx to
common femoral artery and follow it laterally as it the fingertip area. Neurovascular structures, as
divides into a superficial branch, which lies more well as the ruptured tendon were fully exposed.
medially and has a septocutaneous route and a The middle finger showed a soft tissue defect of
deep branch of the artery, which usually lies about 3 1.5 cm from the palmar distal proximal
more laterally and perforates the Sartorius muscle phalanx to the proximal distal phalanx, leaving
and the fascia. Usually, the superficial branch can the lacerated deep flexor tendon with no soft tissue
be followed cranially before following the flap coverage in that area. Furthermore, the ring finger
skin paddle perforator, which is a septal one, as showed a 1 1 cm soft tissue defect in the area
it runs over the ingual ligament and then again of the palmar middle phalanx that left the
lateral right above the superior iliac spine. It can neurovascular structures exposed. Additionally,
be dopplered as high as 30 cm cranial to the origin the thumb showed a dermal defect of the dorsal
of SCIA. distal phalanx, that was closed with Epigard ®
The outlines of the flap are then marked along (Fig. 2). Instead of a direct reconstruction of the
this axis, with as many perforators as possible functional structures as well as the soft tissue
included in the design. A pinch test can be used defect, the wound was temporarily closed using
to determine the maximum width of the flap and negative pressure VAC ®-therapy in order to await
to confirm primary closure of the donor site
(Goh et al. 2015).
Surgical Technique
The entire surgery is performed under loupe mag-

nification (Prismatic Loupes 4.0), the operation
microscope when it comes to the vessel
anastomoses.
Initial Debridement on the Day of

Injury
The procedure began with what is the cornerstone

of every reconstructive procedure in complex
hand injuries: debridement. Clearly devitalized
tissue should be thoroughly excised. Sometimes
mechanical debridement through pressure irriga-
tion helps further eliminate debris and bacteria
from the wound avoiding further damage of vital
tissues. Debridement should always start from the
skin and then proceed to deeper layers. Once the Fig. 2 Extent of the soft tissue defect. Neurovascular
contaminated wounds are debrided properly, the structures and tendons have already been partially
risk for infection is minimized and the necessary reconstructed
further delineation of possible avital tissue on the now reconstructed, attention was drawn to the
wound edges. This helps to avoid infection or preparation of the recipient vessels.
further tissue loss after soft tissue reconstruction
(Neumeister et al. 2010; Brenner et al. 1997; Li
et al. 2016). Since 72 h after the first surgery, the Preparation of the Recipient Vessels
soft tissue had shown neither any further demar-
cation nor any signs of an infection, it was decided Then the radial artery, which was the chosen
to proceed with the reconstruction of the vital recipient vessel, was prepared. The vessels were
structures and the soft tissue coverage. approached via a lazy-s type incision in the snuff
In such cases, a two team approach is preferred box. Both artery and commitant vein were of good
for allowing simultaneous flap elevation and prep- caliber. Once the quality of the recipient vessels
aration of the recipient area. The patient is placed was verified with hand-held Doppler ultrasound,
in the supine position. The right arm is placed on the attention was turned to the left groin.
an arm table with 90 abduction in the shoulder. A
well-padded tourniquet is fitted around the upper
arm. The contralateral lower extremity and the Flap Elevation
groin area are prepped and draped up to the prox-
imal third of the thigh. The dimensions of the SCIP flap were outlined as
per the size of the defect. The first incision was
made along the cranial medial and cranial lateral
Reconstruction of Vital Structures border of the flap. The dissection plane, which lies
just above the SCARPA-fascia, was then identi-
The deep flexor tendon on the middle finger was fied. The plane can be hard to identify in very
sutured directly with Ethibond 4-0 nonabsorbable skinny patients, but is most clearly visible in the
suture, using modified Kirchmayer-Kessler tech- lateral inferior border of the flap. The preparation
nique, followed by suturing the peritendineum continued from cranial to caudal towards the per-
with a 5-0 Prolene nonabsorbable suture. Due to forators. Usually the deep branch of the SCIA lies
the long-segmental defect of the deep flexor ten- more lateral and is identified first, followed by the
don of the index finger, an ipsilateral Palmaris more medial superficial branch. The perforators
longus tendon graft was used for reconstruction were then followed down to the fascia. Once their
(Ng et al. 2015). The tendon was harvested using a suitability was confirmed, the deep branch was
longitudinal lazy-s incision beginning at the wrist clamped to check if the flap perfusion was still
joint and going around 4 cm proximal along the good. With the perfusion of the flap still being
tendon. Because the defect included the insertion sufficient, the deep branch was clamped and the
of the flexor tendon, a MITEK ®-anchor was used flap was raised on the superficial branch (Fig. 3)
to reinsert it to the bone. The proximal part was (Goh et al. 2015; Fuse et al. 2018)
sutured with Ethibond 4-0 nonabsorbable suture,
using modified Kirchmayer-Kessler technique,
followed by suturing the peritendineum with a 5- Flap Anastomosis
0 Prolene nonabsorbable suture, just like on the
middle finger. Attention was then drawn to the The flap was then anastomosed end-to-end to the
approximately 2.5 cm long defect of the radial radial artery and end-to-end to the cephalic vein
nerve of the ring finger. For its reconstruction, an with a 9-0 Ethilon suture. After flap revasculariza-
autologous graft from the lateral antebrachial tion and a waiting time of approximately 20 min,
cutaneous nerve was chosen to bridge the nerve the flap was adjusted to the defect. Meanwhile, the
gap through an epiperineural coaptation with 10- donor site was closed using multiple 2-0 Vicryl
0 Ethilon suture material under the operation quilting sutures to prevent seroma formation,
microscope. Since all of the vital structures were followed by a multilayer closure, starting with the
SCARPA-fascia and ending with vertical and lon- Technical Pearls

gitudinal corium sutures. Once the flap had shown
a persistent perfusion, the distal part was split in 1. Cranial to the inguinal ligament elevating the
three and was adjusted to the defects. The exposed flap superior to the SCARPA-fascia is safe.
fatty tissue of the skin pedicle was covered with Caudal to the inguinal ligament it is recom-
temporary xenograft dressing (Epigard®). (Fig. 4). mend to only harvest the pedicle and leave
the lymphatics, including the vessels and
lymph nodes intact.
Flap Thinning Procedure 2. Reach out for a superficial vein, it occurs
approximately 1–2 cm distal to the artery.
The third surgical stage took place 3 weeks later 3. The pedicle is usually relatively short, some-
and involved the division of the temporary skin times there is need to use a vein graft to achieve
pedicle of the SCIP flap. Another 8 weeks later, a an appropriate length.
flap thinning procedure was performed. The initial
liposuction was complemented by excision of the
skin excess. Intraoperative Imaging
Fig. 3 Elevated SCIP flap
Fig. 4 Three- split SCIP

flap adjusted to the defects
of the three fingers
Postoperative Management Outcome: Clinical Photos and Imaging
Postoperatively the patient was closely monitored. After all four reconstructive stages, the patient
In the first 2 days, the flap was evaluated hourly with experienced uneventful and fast recovery. Six
respect to its color, turgor, and temperature. The months after the initial surgery, the patient pre-
inspection intervals were then increased to 2 and sented with a satisfactory functional and a
3 h after 3 and 4 days, respectively. In addition to pleasing aesthetic result. He had full range of
the clinical monitoring a handheld 8 MHz ultra- motion of all the affected fingers (Fig. 5a, b).
sound Pencil Doppler is used to verify the presence Neither the radial fingertip of the ring finger nor
and determine the quality of the vascular signal of the flap itself had any sensation on the day of
the flap. It gives us the opportunity to react immedi- evaluation.
ately to possible blood flow changes. For easier The right hand still lacked in strength com-
assessment, spots with strong vascular signals pared to the left hand. The donor site was never
throughout the flap are marked with nonabsorbable, an issue.
dyed suture-material. To always maintain a stable
temperature of the flap, a Warmtouch® device is
applied for the first 3 days following surgery. For Avoiding and Managing Problems
the first 7 days, the right hand was slightly elevated
on a pillow to support venous backflow. Anticoag- 1. Flap size must be adequate.
ulant regimen included low molecular heparin from 2. For larger defects, the deep branch of the SCIA
day one and oral aspirin, starting 2 days after surgery can be included.
until 6 months postoperative. After every recon- 3. Caudally to the inguinal ligament preserve
structive stage, the patient received physical therapy, lymph vessels and nodes intact, to avoid
each time starting the first day after surgery. lymphedema.
Fig. 5 Postoperative result at 6 months, demonstrating full closure of the fist

4. As mentioned before, if the pedicle is too short, References

use a vein graft to avoid tension on the pedicle.
5. Start the patient on broad-spectrum antibiotics Brenner P, Lassner F, Becker M, et al. Timing of free
microsurgical tissue transfer for the acute phase of
and then according to the antibiogram, in order
hand injuries. Scand J Plast Reconstr Surg Hand Surg.
to avoid hand infection. 1997;31(2):165–70.
Chen SH, Wei FC, Chen HC, et al. Emergency free-flap
transfer for reconstruction of acute complex extremity
wounds. Past Reconstr Surg. 1992;89(5):882–8.
Learning Points Choi DH, Goh T, Cho JY, et al. Thin superficial circumflex
iliac artery perforator flap and supermicrosurgery tech-
1. The treatment of complex hand injuries starts nique for face reconstruction. J Craniofac Surg.
with a gross evaluation of the injury in the 2014;25:2130–3.
Fuse Y, Yoshimatsu H, Yamamoto T. Lateral approach to
emergency department. Even though the initial
the deep branch of the superficial circumflex iliac artery
examination of the injured hand may be limited harvesting a SCIP flap. Microsurgery. 2018;38(5):589–
due to pain or significant wound contamination, 90.
important key points like color and turgor of the Godina M. Early microsurgical reconstruction of complex
trauma of the extremities. Plast Reconstr Surg. 1986;78
fingers, loss of skin and exposed structures can
(3):285–92.
still be assessed (Neumeister and Brown 2003). Goh TL, Park SW, Cho JY, et al. The search for the ideal
2. Thorough debridement is the cornerstone for thin skin flap: superficial circumflex iliac artery perfo-
treating complex hand injuries. It lowers the rator flap – a review of 210 cases. Plast Reconstr Surg.
2015;135(2):592–601.
risk for infection and sets the necessary foun-
Harrison BL, Lakhiani C, Lee MR, Saint-Cyr M. Timing of
dation for the microsurgical reconstruction traumatic upper extremity free flap reconstruction: a
(Scheker and Ahmed 2007; Ng et al. 2015). systematic review and progress report. Plast Reconstr
3. The SCIP-flap is a reliable flap for the func- Surg. 2013;132(3):591–6.
Li X, Cui J, Maharajan S, et al. Neo-digit functional recon-
tional reconstruction of palmar defects,
struction of mutilating hand injury using transplanta-
because it can be elevated with a minimal tion of multiple composite tissue flaps. Medicine
thickness compared to other perforator flaps. (Baltimore). 2016;95(27):e4179.
4. Raising the SCIP flap from lateral to medial, Neumeister MW, Brown RE. Mutilating hand injuries:
principles and management. Hand Clin. 2003;19
starting at the inferior lateral border makes it
(1):1–15.
easier to identify the right plane. Neumeister M, Hegge T, Amalfi A, et al. The reconstruc-
5. Preoperative colored Doppler ultrasound tion of the mutilated hand. Semin Plast Surg. 2010;24
imaging may help avoid intraoperative compli- (1):77–102.
Ng ZY, Askari M, Chim H. Approach to complex upper
cations due to the considerable anatomical var-
extremity injury: an algorithm. Semin Plast Surg.
iations of the SCIP flap. 2015;29(1):5–9.
6. Even though the SCIP flap can be elevated Rehim SA, Chung KC. Local flaps of the hand. Hand Clin.
really thin, debulking is necessary most of the 2014;30(2):137–51.
Scheker LR, Ahmed O. Radical debridement, free flap
times, when transplanted to the hand.
coverage, and immediate reconstruction of the upper
7. Early commencement of physical therapy is extremity. Hand Clin. 2007;23(1):23–6.
mandatory to gain an optimal range of motion Tashiro K, Harima M, Kato M. Preoperative color Doppler
after reconstruction of complex hand injuries. ultrasound assessment in planning of SCIP flaps. J Plast
Reconstr Aesthetic Surg. 2015;68(7):979–83.
8. Because of possible further demarcation of
injured tissue, an emergency free flap may not
always be the best option.
Reconstruction of Palm Defects
in Children Using Microsurgical Free 54
Flaps
Luigino Santecchia
Contents
First Patient Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 574
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
Second Patient Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Learning Points and Special Measures for the Success of a Free Flap in
Pediatric Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592
Abstract
The hand of the child can often suffer serious

L. Santecchia (*)
injuries that occur with different mechanisms.
Department of Surgery – Orthopaedic Unit of Palidoro,
“Bambino Gesù” Children’s Hospital (Research Institute The modality of trauma includes meat
of Rome, Italy), Rome, Italy grinders, saws, bicycles, doors, hinges,
https://doi.org/10.1007/978-3-030-23706-6_52
574 L. Santecchia
explosives, guns, firecrackers, animal bites, First Patient Clinical Scenario

lawnmowers, and burns from both hot water
and exposed heating elements or electricity. The 14-year-old patient had been burned as a
Burns remain the most frequent injury of the newborn in the middle of the palm of his right
child’s hand (contact, electrocution, and fire- hand, being treated during the acute stage with
crackers). The reconstruction is mandatory not escharotomy and total skin grafting. During
only in emergency but even following tumor somatic growth, the palm gradually produced
resection, burns sequelae, vascular anomalies, scar hypertrophy which induced in turn, over the
and congenital hand malformations. Once a years, functional retraction along with the skin
more conservative treatment failed, a fair num- graft (spoon-hand), leading to impaired extension
ber of available flaps can be adopted for recon- of the third, fourth, and fifth fingers and decreased
struction. The hand, mostly the palm, thumb abduction (Fig. 1). The retracting scar
represents a particular challenge, because it is extended for more than 50% of the entire surface
highly mobile and a delicate segment of the of the palm to the central and hypothenar area.
body, with very high operational and psycho-
logical implications. The search for the best
result cannot ignore functional recovery, Preoperative Problem List:
which must be given a special place in the Reconstructive Requirements
overall therapy. As such, large flaps may be
too bulky and limit the patient’s ability to hold 1. Remove the scar area in a single block, starting
or grasp objects. Here, two children with soft from the flexor retinaculum proximally, to the
tissue reconstruction of the palm are shown,
where microsurgical techniques were success-
fully used to solve different problems. These
summarize the philosophy adopted for such
defects in the daily practice, which foresees
the use of microsurgical techniques as a pri-
mary indication to solve challenging defects in
a single surgical procedure, as Gottlieb con-
ceived in his “reconstructive lift.” The first
case presented with extensive central palm
scarring after a deep burn sequela, while the
second patient was born with a congenital hand
malformation (brachysyndactyly) already
operated on by skin grafting in neonatal age.
Both children underwent microsurgical recon-
struction in adolescence, through which they
earned overall improvement in dynamic func-
tionality of their hand, amelioration of the
thumb excursion, and the ability to grasp
even smaller objects in a short term in a
reliable way.
Keywords
Pediatric hand injuries · Congenital hand Fig. 1 Right palm wide retracting scar. Decreased thumb
anomalies · Free tissue transfer · Pediatric hand abduction and extension reduction of third, fourth, and fifth
reconstruction fingers
54 Reconstruction of Palm Defects in Children Using Microsurgical Free Flaps 575
metacarpal heads of the third, fourth, and fifth 2. The plan is treating the scar of the palm and the
fingers distally. The scar tissue covers disor- hypothenar zone differently with respect to the
dered anatomical planes, encompassing both last three fingers. For the latter, multiple
vessels, nerves, and flexor tendons almost Z-plastys are planned to lengthen the scar and
completely, thus making dissection truly obtain subsequently complete physiological
uncomfortable. extension. The scar block of the palm will be
2. The palmar belt is cemented as a single scar removed in one piece until the palmar
block that adheres to the previously placed skin aponeurosis.
graft, so it is necessary to create a surgical 3. Three individual age groups are established: A
cleavage, preserving parts of the palmar fascia, (<10 years) – B (between 10 and 14 years) – C
vessels, and nerves. (>14 years) (see Table 1).
3. The dissection must be meticulous, preserving 4. The vessels can be significantly smaller in the
first of all the arterial palmar arch distally, lower and middle age groups, leading to an
which extends up to the transverse median unexpectedly disappointing result or even total
fold of the palm, the branches of the metacarpal flap failure. The main criterion is to choose the
arteries to the third, fourth, and fifth fingers, largest available caliber, or alternatively a
and its own digital branches from the third to smaller vessel, but with better flow, and have a
the fifth finger. The nerve dissection must be well-represented venous outflow. These two
done even more carefully, isolating the sensi- things give the best security and guarantee of
tive branches of the median nerve for the third success. Take special care for good correspon-
finger and the sensitive branches of the ulnar dence with the recipient vessels (see Table 1).
nerve for the fourth and fifth fingers. 5. The type of coverage mainly derives from the
4. The plan is to treat the portion of the palm clinical characteristics of the wound in the palm,
differently, compared to the retractable scars the type of missing tissue in addition to the skin.
of the fingers. For the latter, multiple Z plastys 6. The opportunity for a comfortable position of
planned from the distal flexion crease of the the patient on the operating table, the availabil-
palm toward the flexion crease of the MCP/PIP ity of a second surgical team, and the search for
joints will favor full physiological extension. a donor site with glabrous skin as close as
The soft tissue coverage of the palm will be possible to the recipient area are not negligible
achieved by means of a microsurgical flap of (see Table 2).
good texture and glabrous skin surface. 7. The final choice to cover the palmar defect is a
5. The planned possible recipient pedicles of the highly reliable microsurgical flap with good
microsurgical flap to the distal third of the texture, and glabrous skin surface, matching
forearm are the ulnar artery and vein, in addi- donor/recipient vessels, such a contralateral
tion to other superficial veins of the median radial free forearm flap (cRFFF).
region of the volar forearm. 8. A total skin graft would be taken from the
6. The scar block (and finally the soft tissue medial portion of the left arm for the donor
defect) measures 12 8 cm making several site closure and the wound closed primarily.
flaps as a feasible reconstructive option.

Treatment Plan
Theoretically, there is a wide array of flaps avail-
1. In a friction zone, a fasciocutaneous flap able for palmar reconstruction, each with different
instead of a skin graft makes a big difference characteristics and difficulty in raising them
in terms of functionality, esthetic appearance, (see Table 1). Not all of them possess the ability
sensitivity, and grip, leading to better long- to successfully and reliably resurface a palmar soft
term results. tissue defect. Sensitivity, skin thickness, texture,
576
Table 1 Chart of the flaps theoretically available to cover the palm

Skin
Artery Vein Pedicle Recipient Vessels Skin grafting Useful Ease of
Flaps caliper caliper length Outflow matching texture required surface area dissection Overall
Radial free forearm 1–2 mm 2 mm 12–16 cm Good Very good Good No Wide Easy ++++
flap (RFFF)
Reverse (r-RFFF) 1–2 mm 2 mm 10 cm Sometimes Microdissection; Good No Wide Moderately +++
supercharged no Anastomosis easy
Groin 1–2 mm 2 mm 2–5 cm Good No Fair No Wide Moderately ++++
easy
SCIP 1–2 mm 2 mm 2-5 cm Good No Fair No Wide Difficult +++
Latissimus dorsi 2–5 mm 3–6 mm Up to Good Good Good + Wide Easy +++
(LD) muscle flap 15 cm
Myocutaneous 2–5 mm 3–6 mm 15 cm Good Good Good Wide Easy +++
(LD) flap
Gracilis 1–2 mm 2 mm Up to Good Good Fair + Moderate Easy ++
6 cm
Transverse upper 1–2 mm 2 mm 6–8 cm Good Good Fair 11 25 cm Easy ++
gracilis (TUG)
Media sural artery 1–1.5 mm 2 mm 5–7 cm Fair Good Fair 10 5 cm Moderately ++
perforator (mSAP) difficult
Anterolateral Thigh 1.5–2.5 mm 2–2.5 mm Up to Good Good Good 8 25 cm Moderate +++
(ALT) 7 cm
Temporo-parietal 1 mm 0.8–1 mm Up to Fair Good Good + Wide Moderately +++
fascia flap (TPF) 3 cm difficult
Dorsalis pedis 1–1.5 mm 1.5–2 mm 3–4 cm Fair Good Hairy 8 10 cm Easy ++
Lateral arm 1–1.5 mm 1.5–2 mm 3–4 cm Good Good Good 8 12 cm Moderately +++
difficult
Tensor fascia lata 1–1.5 mm 1.5–2 mm 8 cm Fair Fair Fair + Wide Easy ++
(TFL) muscle flap
Scapular 2–2.5 mm 2–3 mm 7 cm Good Good Fair 10 2 5 cm Easy +++
L. Santecchia
54
Parascapular 2–2.5 mm 2–3 mm 7 cm Good Good Fair 10 25 cm Easy +++

Osteoseptocutaneous 1.5–3 mm 2–3 mm 10–15 cm Good Good Good Wide Moderate ++
fibula
medial plantar (skin 1–1.5 mm 1.5–2 mm 3 cm Discrete Fair Very 10 5 cm Moderately ++
and fascia) good easy
Thoracodorsal artery 0.5–1 mm 1–1.5 mm 4 cm Discrete Fair Good 10 7 cm Moderate +
perforator (t-DAP)
Greater omentum flap 2–3 mm 3–4 mm 4–5 cm Good Good Fair + 15 12 cm Moderate +
laparoscopic
Posterior interosseous 1–1.5 mm 2 mm 10–12 cm Supercharged Fair Fair 10 5 cm Difficult +++
In our practice, we established three individual age groups:
A (<10 years) – B (between 10 and 14 years) – C (>14 years)
Groups A and B represent the most at-risk populations in reference to the caliber of the vessels. In these two age groups, the search for donor vessel size and venous drainage must
be oversized compared to group C. The problem of vasospasm is common to all three groups and affects regardless of size. Rather, more attention should be given to the initial
preparation and isolation of the adventitia away from the surrounding tissues
Reconstruction of Palm Defects in Children Using Microsurgical Free Flaps
577
578 L. Santecchia
Table 2 Considerations to get a customized flap. (Modified from Wei-Mardini-Flaps and Reconstructive Surgery, 2nd
Edition Elsevier 2016)
1. Characteristic of the missing tissue (glabrous skin, crushed, location, function)
2. Kind of tissue needed (skin, bone, tendon, other soft tissues)
3. What tissue replacement provides the most “like with like”
4. Better skin or fascia for a certain wound?
5. Body patient habitus (too bulky-defatting procedure)
6. What flap would provide the most restoring function (size, shape, sensibility, glide, range of motion, durability)
7. Need for secondary procedures
8. Flap versatility if multiple tissues needed (skin and bone, tendon and nerve loss)
9. Consequences in the donor site (primarily closure, skin grafting, pain, seroma, wound complication, function)
10. Best intraoperative position and surgical efficiency
color, durability, binding of the flap to underlying (BPF) retain indeed their reconstructive
structures, donor site morbidity, secondary recon- validity and guarantee a good tissue match,
structive procedure possibilities, surgeon experi- requiring only one surgical team and no
ence, and operative structures must be considered. microsurgery to manage the procedure
The general difficulties of palm reconstruction completely. However, PIF and the rRFFF
arise from specific anatomical and functional would sometimes require a supercharged
characteristics of the palmar surface of the hand venous outflow, both requiring many inci-
as well as from its esthetic needs as a communi- sions at the wrist for a rather not comfortable
cation tool. The last functional use of a hand flap inset into the defect.
depends on the sensation in its working surfaces 3. Becker’s ulnar perforating flap, as a propeller,
and the sliding of the tendons. has a short and small pedicle and does not
Substantially, among various possible flaps allow full coverage up to the radial portion of
available to cover the palm, the choice arises the palm in children.
from a series of parameters, that must be carefully 4. Larger muscle flaps may be too bulky into the
taken into consideration: the clinical condition of palm and limit the patient’s ability to hold or
the wound, the typology of missing tissue in addi- grasp objects.
tion to the skin, the matching of the donor flap 5. Free flaps such as the medial plantar flap,
vessels with the receiving area, and the venous ALT flap, or distant flaps (e.g., abdominal
outflow appropriate to the amount of the raised flap) can also be used. The free medial plantar
tissue. The opportunity for a comfortable position flap is an ideal choice; there is, however, a
of the patient on the operating table, the availabil- potential limitation due to the flap size. (The
ity of a second surgical team, and the search for a maximum is approximately 5 10 cm.)
donor site with hairless skin, as close as possible 6. According to some authors, it is possible to
to the recipient area, are also not negligible con- rely on an algorithm (Horta et al. 2016) that
ditions (see Table 2). helps to select the best microsurgical flap to
reconstruct the palm of the hand. For first web
1. The basic concept is that some flaps, available reconstruction, scapular and parascapular flaps
in adults, are not necessarily equal in terms of provide consistent vascular anatomy (cutane-
indications and potential success in children ous parascapular branch of the circumflex
as smaller vessels and vasospasm can make a scapular artery), easily accessible vascular
substantial difference when facing different pedicle, and desirable vessel diameter. It also
age groups (see Table 1). provides a moderate amount of subcutaneous
2. Pedicled flaps such as the posterior tissue and hairless skin. However, this flap is
interosseous flap (PIF), reverse radial free not logistically convenient in relation to the
forearm flap (rRFFF), and Becker Flap intraoperative patient’s position.
7. The lateral arm flap may be used as an alter- upper part supplied by the lateral thoracic
native; it is based on the posterior branch of artery and the lower part by the terminal
the radial collateral artery and can also be branches of the thoracodorsal artery (two
transferred in a tendo-fascio-cutaneous pat- dominant vascular pedicles type III,
tern with a central strip of the triceps tendon. according to Mathes and Nahai Wink et al.
It is usually bulkier, and there is a tendency to 2020). The SMF comprises the inferior three
hairiness in males. slips of the muscle, although this can be mod-
8. Large substance losses, which leave tendons ified as required. The vascular pedicle is
and vascular or bone structures exposed, formed by the serratus artery, and its venae
require also a larger flap such as a contralat- commitantes, but may be harvested back to
eral radial free forearm flap (cRFFF) which the subscapular vessels to provide additional
can incorporate palmaris longus tendon in length and caliber. Unlike other muscle flaps,
case of tendon loss and even a bone frame. the multiple digitations make this muscle
9. RFFF has several widely known disadvan- highly malleable and less bulky when used
tages, the most important of which is the as a free flap, allowing versatile contouring of
sacrifice of the radial artery of the forearm the flap to fit irregular hand defects. The abil-
(Pabst et al. 2018). We lately overcome this ity to harvest up to 15 cm of pedicle makes
problem rebuilding the artery by a reverse this flap a versatile option for reconstruction.
superficial vein from the forearm itself. If The demonstrated dynamic potential of this
the timing of the procedure is right on sched- muscle flap is intriguing, particularly in the
ule, and if you have two surgical teams, the replacement even of damaged thenar intrinsic
artery reconstruction is helpful and highly musculature (Kitazawa et al. 2018). Skin
recommended (“personal experience”). If a grafting the muscle provides stable coverage,
composite flap is raised with a part of the and subsequent atrophy of the muscle (for
radius, the bone must be strengthened with nondynamic muscle transplants) yields a sur-
plates and screws, to avoid high fracture com- prisingly smooth contour several months
plication rate, following the weakening of the postoperatively. However, muscle flap may
bone. The radial sensory nerve must be care- be harvested with a skin paddle, through the
fully preserved during the dissection, reduc- intercostal vascular supply. The disadvantage
ing the onset of painful neuromas at the scar to the use of this flap first is a very long and
area. It is also advisable to keep the paratenon unsightly residual scar, even though hidden
layer above the brachioradialis, flexor carpi on the axillary lines. Meticulous raising is due
radialis, and palmaris longus (last if not to the wide variability of the terminal
included in the flap), in order to assure the branches. VII variants of vascular branching
skin graft a physiological sliding plane with- of the inferior anterior dentate muscle have
out scar adhesions. been described, which in turn contract differ-
10. Generally, free flaps offer the microsurgeon ent topographical relationships with the long
the freedom to select a donor area better tai- thoracic nerve, running above, below, or
lored to the defect requirements (see Table 2). alongside it. Injury of the long thoracic
11. Free muscle flaps such as the Latissimus nerve, if necessary, results in the winged scap-
Dorsi flap (LD) have traditionally resulted in ula. Its dissection most of the time is fairly
excellent functional outcome and sufficient elaborate and time-consuming.
defect coverage. However, muscular flaps 13. Perforator flaps gave hope for new exciting
need to be covered with split-thickness alternatives on the reconstruction. However,
skin grafts further increasing donor-site the artery size of a specific perforator can be a
morbidity. serious limitation in the pediatric field. We
12. The anterior Serratus Muscle Flap (SMF) and know that sometimes children have bigger
fascia have a dual blood supply, with the vessels in the same region as adults. Still, it
580 L. Santecchia
is not advisable to resort to this type of flaps,

because of the risk of more vasospasm com-
pared to the adult.
An Allen test performed in comparison on both

hands gave a negative result, showing normal
patency of the anastomotic vascular networks in
the palm. A Doppler Ultrasound was subse- Fig. 2 The carpal ligament and the pisiform bone are the
main reference points. The skin incisions describe two
quently performed by external obliteration of the convexities near the ulnar side of the palm and distal
two arteries alternately confirming normal forearm, which converge in the center, at the radial side
patency of both (Roter and Denault 2019). Bilat- of the tuberosity of the pisiform bone. The first half-bent
eral CT angiography was done next, to explore the skin incision starts from the distal forearm, and it continues
toward the hypothenar eminence, pivoting on the pisiform
distal microcirculation topographically, ensuring and the hooked bones. In the palm, the incision is about
correct proper perfusion for every single finger 1 cm away from the boundary of the scar to be removed. At
(Du et al. 2019). Potential arterial course anoma- the head of the fifth metacarpal bone, it goes on trans-
lies or caliber stenosis, which could prove critical versally toward the radial side of the palm up to the root
of the second finger. Finally, another skin incision starts at
for the procedure, was evaluated. the metacarpal shaft of the second finger and goes inside
the proximal palmar line, which anatomically divides the
1. Beware of congenital coagulation deficits in thenar eminence from the palm, rejoining the apex of the
the child, which could dramatically influence two concavities where the median nerve enters inside the
carpal tunnel
the destiny of any flap.
2. Complete preoperative coagulation screening
is mandatory, and in the last 5 years the study
Surgical Technique
of single coagulative factors and related sub-
groups has been included in routine practice.
1. The access to the recipient area in the distal
ulnar site is provided by a large curvilinear
Preoperative Care and Patient Drawing skin incision, which exposes the fascia of the
forearm up to visualize the flexor carpi
1. The supine rather than the lateral or prone ulnaris, surrounding the pisiform bone radi-
position of the patient minimizes the ally. The incision passes through the flexor
anesthesiological maneuvers, eluding too retinaculum, which must be open for easier
many body shifts, and globally reducing the insetting of the flap and its pedicles subse-
time of the procedure, thus preventing further quently. We continue forward, following the
possible pressure sores and peripheral com- natural line that separates the palm from the
pression neuropathies. This position allows, thenar eminence.
whenever possible, setting up two separate 2. The cRFFF is raised on a suprafascial plane,
operating fields simultaneously. exposing the cephalic vein first, then the
2. The procedure requires a tourniquet radial artery and comitant veins, up to 10 cm
(250 mmHg) on the right arm, given the wide- beyond the proximal edge of the skin design.
spread bleeding that normally comes from the Interruption and ligation of the radial pedicle
scar tissue. On the left, the forearm donor flap distally.
can be performed without using a tourniquet 3. Carefully preserve the sensory branches of
(Fig. 2). Preoperative drawings are performed the radial nerve.
on the donor and recipient area as shown in 4. The skin island attached to the pedicle is
Fig. 3. gradually raised, remaining inside the groove
Fig. 3 Doppler assessment and preoperative drawings. with 9-0 Nylon. The venous outflow is represented by the
Above: spoon-shaped right hand due to retractable scars. cephalic vein of the flap that is anastomosed (end to end
Below: left forearm donor site. Radial flap raising is made with Synovis Coupler Device ® 2 mm diameter) to the ulnar
following the radial artery axis and its comitant veins, recipient vein in the right forearm. The comitant veins of
including the superficial cephalic vein, thus obtaining two the flap are connected end to end to two superficial veins on
substantial venous outflow systems. After flap insetting, the volar median side of the right distal forearm
the anastomosis between the radial artery of the flap and (S&T© Microsurgical, Switzerland Nylon 9-0)
the ulnar artery of the recipient site is performed end to end
formed by the flexor carpi radialis medially after the push). We use such concentration
and by the brachioradialis tendon radially. of heparin to clean the vessel stumps over
The groove floor is made of the flexor pollicis the first two centimeters from the entrance
longus. Proceed distally to proximally by cut- from tenacious thrombi. If the procedure is
ting all the septal perforators of the radial carried out several times, reaspiration of the
artery and inside the fascia that incorporates heparinized solution decreases the risk of
the brachioradialis tendon, by a microbipolar introducing too much heparin into the circu-
(Pabst et al. 2018). lation. However, small quantities of concen-
5. The right recipient area must be already pre- trated drug remain locally but are
pared, with the pedicles of the ulnar artery progressively diluted by rinsing out with a
clamped by two bulldogs. Fasciocutaneous saline solution all along during the anastomo-
flaps are known for their tolerance to ischemia sis procedure.
as compared with muscle flaps. Generally, it 8. The flap insetting must be comfortable, with-
does not have a crucial rule on having the out stretching the pedicle, avoiding twisting
recipient vessels clamped when cutting the or angulation especially of the venous pedi-
vascular pedicle of the flap, but in this situa- cles. Pay particular attention to the vessels
tion the position of the patient allows it, if we within the open carpal tunnel. Make sure to
have two teams and it saves time. prevent slippage on the carpus canal floor or
6. Detachment of the RFFF and ligation of between the bundles of the superficial and
donor vessels with © Ethicon USA, LLC. deep flexor tendons.
Vicryl ™ 3-0. 9. The right-side anastomosis between the radial
7. Rinse the artery and veins with heparinized artery of the flap and the ulnar artery of the
solution (EPSODILAVE 500 I.U./2–1 ml recipient site in the forearm is performed end
inside the vessels by aspirating the liquid to end with S&T, Switzerland Microsurgical
582 L. Santecchia
Nylon 9-0 suture, 4 mm Needle. The venous sensory nerves for the third, fourth, and fifth
outflow is represented by the cephalic vein of fingers (Krane et al. 2020).
the flap that is anastomosed (end to end with 3. It is mandatory to open the carpal tunnel of
Synovis Coupler Device ® 2 mm diameter) the recipient site for an easy insetting of the
to the ulnar recipient vein, as routine. flap. This prevents excessive tissue pressure
The comitant veins are connected end to on the pedicles from the outside. In the same
end to other two superficial veins on the way, attention must be paid to any disloca-
median side of the distal right forearm tions of the pedicles that may occur when
(S&T© Microsurgical, Switzerland Nylon the carpal tunnel is left open, such as slip-
10-0 suture, 4 mm Needle). One must be ping on the bony canal floor or interlacing
careful to cover the device with the adipose through the tendons of the superficial and
tissue thus avoiding possible extrusions from deep flexors of the fingers (Panse and
the skin (Wu et al. 2020). Bindu 2020).
10. A corrugated fall drain is placed under the 4. When opening the carpal tunnel, pay attention
flap. A microinfusion tube is also put into in particular to the sensory branch of the
the wound near to the anastomotic site, con- median nerve for the thenar eminence of the
veying push of 1 ml 2% Lidocaine ® (1 ml/ wrist, but above all, preserve the motor branch
2 h) for the next 24–48 h. This trick dramat- of the median nerve, taking into account all the
ically reduces the onset of vasospasm of very possible anatomical variations described
reactive vessels. (Soubeyrand et al. 2020).
5. If a coupler device for venous anastomosis is
used, do not let it remain too superficial,
Technical Pearls because it can decubitate on the overlying
skin and expose itself (Rodi et al. 2018).
1. The patient must lie supine, with both arms 6. Venous anastomoses on vessels below 1 mm of
abducted at 90 , supported by tables. The tour- caliber are performed preferably in the tradi-
niquet is positioned only on the right arm with tional way with S&T© Microsurgical, Switzer-
a max working pressure of 250 mmHg. land Nylon 10-0.
2. During removal of the scar block in the palm,
carefully preserve the distal arterial palmar
arch, the metacarpal arteries, and the branching Intraoperative Images
of these into their own digit. The same atten-
tion should be paid to the median and ulnar See Figs. 4 and 5.
Fig. 4 End of procedure

before medication.
Complete extension of the
palm is shown after flap
insetting. Thumb abduction
reaches 90 naturally.
Dressing is light single layer
and can be easily lifted to
the inspection and
monitoring along the first
72 hours
the body for 72 h, thus favoring the

microcirculation.
6. Monitoring vascular flow, on the anastomosis
site, is performed every 2 h with a pocket-sized
Doppler ultrasound along the first 48 h. After
transferring the patient to the ward, Doppler
check is performed every 8 h while changing
the dressing, for an additional 5 days. NIRS
(near-infrared spectroscopy) monitoring
(Newton et al. 2020) is a novel technique for
free flap monitoring that has the propensity for
early detection of vascular compromise when
Fig. 5 Final scar of the donor skin graft area in the medial
side of the left arm. The latter is to cover the radial flap compared to the current gold standard, clinical
donor area (RFFF) in the left distal forearm monitoring (CM). After 8 days, postoperative
monitoring Doppler/US check is done once a
Postoperative Management day, until the 10th day, then leading the check
outdistance once every 3 days until the patient
1. Low molecular weight sodic enoxaparin is discharge.
used routinely (e.g., Clexane ® from 2000 to 7. The hand is washed daily with running water
6000 U.I/die s.c. based on body weight) to and liquid Marseille soap. A broad spectrum of
prevent postoperative deep venous thrombosis liquid antiseptic is applied to the wound. In the
until the patient is discharged. Low-dose aspi- end, water-based tincture (2% eosin) is
rin is used frequently (30–50 mg/die per os for brushed on once a day.
3 weeks) whereas dextran has been abandoned 8. The sutures are removed after 14 days. The
by many practitioners because of the increased patient begins short active and passive mobili-
risk for fluid overload and pulmonary edema. zation exercises at home, and a short cycle of
2. No cast is used for dressing alongside the first joint physiotherapy after 10 days.
72 h. As long as the patient remains in the ICU, 9. A cast that keeps the thumb abducted at 90 is
we do cover the receiving area as little as packaged after the third week after surgery, and
possible. This approach is useful for initial it is removed every time the patient has to do
monitoring and allows us not to replace the physiotherapy.
bandage too many times in the first 24–48 h.
3. Classical Monitoring (C.M.): The systemic
pressure must remain constant (100/70 mmHg), Outcome: Clinical Photos and Imaging
and the heart rate 70/80 bpm. Large fluctuations
in body temperature (37 C) and in the environ- See Figs. 6 and 7.
ment (21 C) must be prevented.
4. The analgesic coverage takes place by means
of a continuous infusion pump using a cocktail Second Patient Clinical Scenario
of drugs (paracetamol-morphine) that block
the onset of pain, avoiding triggering increases The 13-year-old patient was born with a congen-
in systemic pressure. The protocol also pro- ital hand malformation (brachysyndactyly),
vides brachial plexus anesthesia on the upper consisting in shorter fingers (brachyfalangia),
limb with permanent microcatheters for syndactyly, thumb anomaly, and first web shrink-
24–48 h. age. He has already been operated several times
5. An airflow heater keeps that body portion through classic Z-plastys and skin grafts to sepa-
warmer on the receiving site than the rest of rate fingers. Nothing has ever been done on the
584 L. Santecchia
Fig. 6 Early postoperative view (7 days). The wounds

appear dry, without serous-blood collections in the subcu-
taneous tissues. The flap is completely perfused and have
normal refill
Fig. 8 Preoperative view of left hand brachysyndactily

sequelae. Note the adducted thumb and the shell shape of
the hand
2. During the first step, scar tissue is removed and

the first commissure is enlarged, enabling the
90 abduction of the thumb. After scar release,
Fig. 7 One-month follow-up after surgery. Standard soft tissue coverage is achieved using new,
opening of the right palm allows third, fourth, and fifth elastic tissue of good consistency such as a
finger extension. Overall improvement of the hand perfor-
free flap.
mance and correct use of writing tools
3. The tissue to be replaced must be thin with
resistant and adaptable skin enabling the
thumb. The Z and reverse Z-shape thumb is a three-dimensional movements of the thumb.
main feature also found in the Apert syndrome It should be preferably glabrous skin.
and arthrogryposis (Figs. 8 and 9). The first web 4. The second step is scheduled 1 year later and
constriction was too serious and could not be will be focused on improving the thumb’s
resolved using flaps from the dorsal hand. function. The program is a tendon rebalance
by means of EIP (extensor indicis proprius) to
EPL (extensor pollicis longus) tendon trans-
Preoperative Problem List: fer. The functional improvement will also
Reconstructive Requirements affect indirectly the shape of the thumb. The
same time, we will proceed debulking the
1. In this case, was preferred to plan the surgical residual fatty tissue in the flap used for
correction into two distinct steps. reconstruction.
number of authors have reported flaps surviv-

ing that were over 30 cm in length and 15 cm in
width. The donor site scar is excellent as it can
usually be closed directly by undermining the
abdominal skin and flexing the hip. This pro-
cedure may produce a spread scar, but it will be
well hidden under the bathing suit area. How-
ever, the disadvantages of this flap are the
particular bulkiness in its medial half and not
suitable in a fat person. The pedicle is small
and short, and there are many anatomical var-
iations to the vascular supply. The color of the
flap is pale and yellowish and will carry pubic
hair on its medial aspect.
2. The mSAP (medial sural artery perforator
flap), or the medial plantar flap (MPF), allows
excellent patient positioning, significant
improvement with the texture, hairless skin,
and color match with the palmar tissue. How-
ever, they do not have enough elasticity when
compared to a SCIP flap.
3. Superthin ALT and the brachial flap (BF) are
not easily used in the pediatric patient due to
Fig. 9 Preoperative view of brachisyndactily sequelae.
the criticality in the size of the pedicles and less
The shrinked first web space creates a bridle on the
Z-shape thumb, with limitation of abduction at 45 extensibility.
SCIP flap raising enables a favorable and
Treatment Plan ergonomic position for the patient, which
allows two separate fields simultaneously.
1. The search for thin thickness tissue, with high The SCIP must be raised very thin in the
elasticity and retractable capacity, made us groin area, correctly identifying the superficial
decide a SCIP flap (Superficial Circumflex and deep perforator vessels, through a careful
Iliac Artery Perforator) (Berner et al. 2020; selection of perforators dependent on SCIA or
Carrasco-Lopez et al. 2019). SIEA. The donor area closes directly with an
2. At a second stage, Z-shape thumb correction, excellent scar. The main disadvantages are as
throughout an EIP (extensor indicis proprius) follows: high to very high variability of the
to EPL (extensor pollicis longus) tendon trans- vascular anatomy and pedicle, the notorious
fer (Kamoi et al. 2019), and FPB (flexor small diameter of the SCIA (Gentileschi et al.
pollicis brevis) release were planned. 2019). The annoying hair growth is the real
3. The first web flap would be debulked afterward, disadvantage of the flap, and this drawback
obtaining better functionality and a pleasantly can be further corrected by the epilation laser.
reshaped thumb (Figs. 17, 18, 19, and 20).

1. The Allen test was not mandatory in this case,
1. The groin flap (GF) provides a large piece of as we expected to use the dorsal branch of the
skin and subcutaneous fat. The size of flap radial artery at the anatomical snuffbox. The
available depends upon the patient’s build. A end-to-end anastomosis to this branch does not
586 L. Santecchia
alter the deep palmar arch patency, unless there the dorsal branch of the radial artery, which
are unknown congenital vascular anomalies lies above the scaphoid bone in the anatomi-
(Taghinia and Upton 2018). cal snuffbox.
2. As a principal examination, CT angiography 4. Evaluate the exact size of the flap to be taken
rules out any potential anomaly, whether con- and especially the pedicles’ length.
genital (vascular anomaly) or post-traumatic 5. Once the correspondences of the perforators
(stenosis) with accurate exploration of the ves- on the skin have been found and marked, the
sel tree. The exam is also extended to the skin island is drawn to incorporate as many
inguinal area to study the perforators. perforators as possible within its perimeter,
3. Doppler was done both in the radial and ulnar and then go to skin prep.
artery, by external obliteration tests, and 6. The access to the receiving area in the distal
detected regular vessels patency. ulnar site provides a large curvilinear skin
4. Doppler is repeated before the procedure, find- incision, which exposes the fascia of the fore-
ing the skin perforators by tracking them with arm up to visualize the flexor carpi ulnaris,
permanent markers. surrounding the pisiform bone radially. The
incision passes the carpus through the flexor
retinaculum, which must be opened orthogo-
Preoperative Care and Patient Drawing nally. The maneuver allows for easier inset-
ting of the flap and its pedicles subsequently.
1. The patient can lie on his back with his left arm We continue forward, following the natural
resting on a table abducted at 90 , where the line that separates the palm from the thenar
tourniquet is installed. eminence.
2. Hair removal of the surgical area is usually 7. SCIP flap raising starts from the infero-
done in the ward, with a dry hand razor in the lateral portion of the drawn skin island, fol-
groin region, the forearm, and back of the lowing the anatomical plane above the Scarpa
hand, about 30 min before entering the operat- band (a thin whitish band that separates the
ing room. The procedure has been shown to small fat lobules, from the deep larger lob-
reduce the onset of infection on the surgical ules, to be left in place (Fig. 10a, b).
site when performed at this stage. 8. Proceeding from lateral to medial, the deep
3. Raising the SCIP flap allowed setting up two branch of the SCIA is encountered first. Mov-
separate surgical fields simultaneously. ing medially and slightly downward, we will
4. The supine position of the patient minimizes meet the superficial shorter one. Once both
the anesthesiological maneuvers, eluding too pedicles are prepared, choose which one we
many body shifts, and globally reducing the want to base our flap on, evaluating alter-
time of the procedure, thus preventing further nately the best perfusion of the skin by apply-
possible pressure sores and peripheral coming a bulldog (Sidhoum et al. 2017).
pression neuropathies. 9. Once the pedicle is chosen, a retrograde dis-
5. Preoperative drawings on the right inguinal section proceeds beyond the deep fascia, up
donor area are performed as shown in Fig. 10a, b. to the main artery, depending on the pedicle
length we need, obtaining a larger caliber to
Surgical Technique perform the anastomosis.
10. The anastomosis is performed end to end,
1. Landmarks must be signed as seen in cutting the receiving artery flute-like for
Fig. 10a, b. more matching. There is also another possi-
2. Highlight the perforators with a pen Doppler bility to increase the size of the donor vessel,
with 8 MHz probe (Kehrer et al. 2021). which we will discuss later. The sutures used
3. Prepare the receiving pedicle inside the ana- are S&T© Microsurgical, Switzerland Nylon
tomical snuffbox, after Doppler at 8 MHz of 10-0. Particular attention should be paid to the
Fig. 10 (a) Frontal view and (b) lateral view. Skin mark- the deep fascia on the lateral aspect (deep branch) of the
ings and flap design. The inguinal ligament (white line) is flap. Superior circumflex iliac artery perforators (SCIPs)
highlighted from the pubic tubercle (PT) to the anterior- are displaced in a skin area (green circle) above the black
superior iliac crest (ASIS). 2. A black line is drawn from line. Superficial inferior epigastric artery perforators
the beginning of the inguinal fold to the ASIS. Superficial (SIEAPs) are located above the black line too, but slightly
circumflex iliac artery (SCIA) vessels can be found in a medially to the FA (light blue area). Finally, the flap we are
skin area (pink circle) below the black line, lateral to the going to draw will incorporate as many perforators as
femoral artery (FA). There are two major types of perfora- possible inside, taking into account the thickness we
tors that are presumed to originate from the SCIA, the need, and the chimerism concept exploitable in this huge
medial perforator with a direct cutaneous vessel (superfi- vessel hub. However, one must always be ready to identify
cial branch), located relatively medially on the flap, and the a good perforator and to elevate it as a freestyle approach to
lateral perforator, traveling laterally beneath the deep fas- overcome the variations wherever the perforator may
cia and often with an intramuscular pathway penetrating originate from
preparation of the adventitia, bearing in mind Technical Pearls

that any excess manipulation with forceps
almost always leads to vasospasm. 1. One of the critical points of the SCIP flap is the
11. Flap insetting is fairly straightforward, and small pedicle, which is truly possible to dissect
the anastomosis is left over the EPL, EPB up to the superficial femoral artery anyhow
extensor tendons, and APL. (total 7 cm in length) (Hong et al. 2013). The
12. Skin sutures used are monofilament Prolene recipient vessel caliber can be increased to
or Nylon 4 and 5-0 with detached stitches. realize a wider anastomosis, taking a small
The skin above the anastomosis should not be portion of the femoral artery at the bifurcation,
stretched, otherwise a local flap and a skin rather than binding it after branching, as done
graft is used. traditionally (Ciudad et al. 2018). The donor
13. A nonaspirated corrugated drain is inserted portion on the femoral artery takes place trans-
into the subcutaneous tissue on the first com- versely on the vessel, with respect to the lon-
missural space and maintained in place for gitudinal axis to avoid shrinkage.
72 h. Also there, an Argyle catheter is placed 2. We must be aware to avoid eventual distal flow
approximately 2 cm away from the anasto- impairments on the femoral artery through this
mosis infusing 1 ml 2% Lidocaine in 10 ml/ delicate and extremely risky maneuver.
saline every 2 h to reduce vasospasm during 3. A double venous outflow is advisable on the
the 48 h following the end of surgery. superficial epigastric vein.
588 L. Santecchia
4. Always place suction drainage in the groin to Postoperative Management

reduce the onset of hematomas and seromas in
the postoperative period. The ICU stay 48/72 h after surgery is always
5. Intradermal sutures for the skin are not mandatory in children. The patient journey fol-
recommended, because hematomas and lows previously established protocols, including
seromas could not be evacuated in case of overall management of the child’s approach,
necessity. postoperative monitoring, and correct child’s
bed position when back in the ward.
Low-molecular-weight sodic enoxaparin is used
Intraoperative Images routinely (e.g., Clexane ® 2000 to 6000 U.I/die
s.c. by weight) to prevent postoperative deep
See Figs. 11 and 12. venous thrombosis until the patient is
discharged. Low-dose aspirin is used frequently
(30–50 mg/day per os for 3 weeks), whereas
dextran has been abandoned by many practi-
tioners because of the increased risk for fluid
overload and pulmonary edema. The hand is
daily washed with running water and Marseille
liquid soap. A broad spectrum of liquid antisep-
tic is applied to the wound. Water-based tincture
(2% eosin) is brushed on once a day. Sutures are
removed after 14 days. The patient begins short
active and passive mobilization exercises at
home and a cycle of joint physiotherapy after
10 days. A cast that keeps the thumb abducted
at 90 degrees is packaged the third week after
Fig. 11 Pedicles arrangement. We always try to get more surgery, and it is removed every time the patient
veins, even if we will not use all of them in the end. It is
needs to do physiotherapy.
necessary to test the vessels by occluding them with bull-
dogs alternately, to analyze how the color of the flap
changes before definitively dissecting them
See Figs. 13, 14, 15, 16, 17, 18, 19, and 20.
1. Maintaining the patient’s temperature with a

warming device can reduce the likelihood of
wound infection and vasospasm.
2. Donor site closure should not be neglected.
Primary closure is usually best, when possible.
However, skin grafting might be required in
some cases.
Fig. 12 The flap detached from its peduncles is seen from 3. Early mobilization and rehabilitation are
below. The artery (black bulldog) and the veins (gray
recommended, although the ICU stay after sur-
bulldogs) are seen on the right. On the left, there is addi-
tional venous outflow through the superficial epigastric gery is always mandatory in children, and is
vein closed by a bulldog included within a path established by the
Fig. 13 Postoperative follow-up 1 month after surgery.

The scars are normally consolidated, and the patient is able
to abduct the thumb without difficulty
Fig. 15 Easy opening and closing movements of the palm
after 2 months
Learning Points and Special Measures

for the Success of a Free Flap in
Pediatric Patients
1. The basic principles of microvascular trans-

fers between adult and pediatric patients
remain unchanged, but children should not
be treated as miniature adults (Van Landuyt
et al. 2005).
2. Microsurgery in the child was considered a
challenge, due to their small vessels size and
excessive reaction to surgical manipulation.
Vice versa, the child endures longer operating
periods and has better wound healing and
faster functional recovery than an adult.
Fig. 14 Postoperative follow-up 2 months after surgery. 3. The functional reserve of these young
Note how the flap progressively drains the residual edema patients is greater than adults, lacking other
and reduces the volume of the fatty portion comorbidities such as diabetes, atherosclero-
sis, hypertension, smoking, alcohol, and drug
hospital as the overall management of the abuse.
child’s approach, monitoring after surgery, 4. The most significant anatomical differences
and the child’s bed position when back in in children compared to adults are smaller but
the ward. healthy vessels, very prone to vasospasm
590 L. Santecchia
Fig. 16 The complete closure of the fist occurs progres-

sively as the edema is reabsorbed, so part of the adipose
tissue is emptied of its content too Fig. 17 One year later after primary microsurgery and
2 weeks after Z-shape thumb correction, throughout an
EIP (extensor indicis proprius) to EPL (extensor pollicis
(Turin et al. 2017). One of the factors respon- longus) tendon transfer, and release of the FPB (flexor
sible for vasospasm is probably due to the raw pollicis brevis). The flap was debulked and reshaped at
excision of the adventitia during the the same time, expanding the first commissural space,
thus obtaining optimal functional result (near 95% of
atraumatic dissection. thumb abduction)
5. The anatomy in children is clearly well defined,
often not already altered by previous surgery.
6. Free flap donor sites are particularly poor in
children, due to the need for a long and reli-
able vascular pedicle of adequate size.
7. A focal point is the pedicle length in respect to
the recipient’s vessels.
8. It is often difficult to find the regional vessels
in large damaged surfaces, and sometimes
there is a need to sacrifice the main vessel to
anastomize the flap directly.
9. As an alternative, the sacrifice of the main
vessels could be prevented, connecting on to
secondary branches, or a perforating vessel as
a recipient, through supermicrosurgery tech-
niques (Koshima et al. 2004).
10. The introduction of new tools and techniques, Fig. 18 One year later after primary microsurgery and
and the accumulating of microsurgical 2 weeks after tendon transfer of the EIP, pro EPL
Fig. 20 One year later after primary microsurgery. Dorsal

view. Three small skin incisions, taking access to the EIP
Fig. 19 One year later after primary microsurgery. The on the second finger, and the tendon pivot on the extensor
thumb 2 weeks after tendon transfer of the extensor indicis retinaculum area. Third incision is on the dorsal thumb to
proprius (EIP), pro extensor pollicis longus (EPL) allow fixation of the transferred tendon
experience, has led to high success rates and surgery and the possibility of scar contracture
excellent results in pediatric free flap recon- always remains.
struction and is no longer considered a taboo.
11. The pedicle sizes are much larger in children
than in adults in relation to their body size Cross-References
(Van Landuyt et al. 2005). There have been
hypotheses about the least represented muscle ▶ Extracutaneous Free Triple Split SCIP Flap for
layer in the children’s vessels being responsi- Simultaneous Reconstruction of Multiple Soft
ble for clinically less relevant vasospasm. Tissue Defects of the Fingers
12. The vessels characteristics of the teens group, ▶ Major Amputations at the Arm and Forearm
aged between 13 and 19 years, are compara- Level: Replantation Strategy and Technique
ble in practice to those of adults. ▶ Reconstruction of Complex Finger Defects
13. The vessel walls are thicker and more elastic Using the Free Ulnar Artery Perforator Flap
in older children. On the contrary, they are ▶ Serratus Anterior-Rib Flap for the Reconstruc-
translucent and had a gelatinous consistency tion of Complex Defects Involving the First
in the younger ones. Metacarpal
14. Growth and functional recovery in donor and ▶ Thin Free Flap for Resurfacing of the Arm and
recipient sites are problems related to pediat- Forearm
ric reconstructive surgery, because the mus- ▶ Transverse Sensate Thoracodorsal Artery Per-
culoskeletal system continues to grow after forator Flap for Finger Reconstruction
592 L. Santecchia
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lymphaticovenular anastomosis under local anesthesia
Berner JE, Nikkhah D, Zhao J, Prousskaia E, Teo TC. The for leg lymphedema. Ann Plast Surg. 2004;53:261–6.
versatility of the superficial circumflex iliac artery per- Krane NA, Mowery A, Azzi J, Petrisor D, Wax
forator flap: a single surgeon’s 16-year experience for MK. Reconstructing forearm free flap donor sites using
limb reconstruction and a systematic review. J Reconstr full-thickness skin grafts harvested from the ipsilateral
Microsurg. 2020;36(02):093–103. arm. Otolaryngol Head Neck Surg. 2020;162(3):277–82.
Carrasco-Lopez C, Suñe CH, Vila-Poyatos J, Senosian Miller R, Wormald JCR, Wade RG, Collins DP. Systematic
OG, Priego D, Del Rio M, Malagon P, Huesa L, review of fibrin glue in burn wound reconstruction. Br J
Reina-de-la-Torre F, Car-rera-Burgaya A. SCIP flap in Surg. 2019;106 (3):165–73.
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additional superficial venous patterns and implications DW. Outcomes of free flap reconstructions with near-
in caucasian patients. J Plast Reconstr Aesthet Surg: infrared spectroscopy (NIRS) monitoring: a systematic
JPRAS. 2019;72:1121–1128. review. Microsurgery. 2020;40(2):268–75.
Ciudad P, Vijayan R, Pafitanis G, Pont LP, Kaya B, Pabst AM, Werkmeister R, Steegmann J, Hölzle F, Bartella
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Du E, Sagar P, Huang B, Patel SN. Dual-phase CT angiog- Rodi T, Geierlehner A, Mosahebi A, Tanos G, Wormald
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depleted neck. Head Neck. 2019;41(9):2929–36. devices versus hand-sewn anastomosis for microsurgical
Gentileschi S, Servillo M, De Bonis F, Albanese R, Pino V, free flap reconstruction. Syst Rev. 2018;7(1):186.
Mangialardi ML, Valente I, et al. Radioanatomical study Roter E, Denault AY. Radial artery reliability using arterial
of the pedicle of the superficial circumflex iliac perfora- Doppler assessment prior to arterial cannulation. Can J
tor flap. J Reconstr Microsurg. 2019;35(9):669–76. Anaesth. 2019;66(10):1272–3.
Hong JP, Sun SH, Ben-Nakhi M. Modified superficial Sidhoum N, Dast S, Perez S, Assaf N, Herlin C, Sinna
circumflex iliac artery perforator flap and super- R. [Superficial circumflex iliac artery perforator flap
microsurgery technique for lower extremity reconstruc- (SCIP Flap): revival of the inguinal donor site?]. Ann
tion: a new approach for moderate-sized defects. Ann Chir Plast Esthet. 2017;62(6):646–51.
Plast Surg. 2013;71(4):380–3. Soubeyrand M, Melhem R, Protais M, Artuso M, Crézé
Horta R, Silva P, Costa-Ferreira A, et al. Microsurgical soft- M. Anatomy of the median nerve and its clinical appli-
tissue hand reconstruction: an algorithm for selection of cations. Hand Surg Rehabil. 2020;39(1):2–18.
the best procedure. J Hand Microsurg. 2016;03:73–7. Taghinia AH, Upton J. Vascular anomalies. J Hand Surg
Kamoi F, Kondo M, Hayashi M, Uchiyama S, Kato H. A Am. 2018;43(12):1113–21.
new technique to determine the tension in extensor Turin S, Walton R, Dumanian G, et al. Current practices in
pollicis longus reconstruction. J Hand Surg Eur. the management of postoperative arterial vasospasm in
2019;44(8):790–4. microsurgery. J Reconstr Microsurg. 2017;34:242–9.
Kehrer A, Heidekrueger PI, Lonic D, Taeger CD, Klein S, Van Landuyt K, Hamdi M, Blondeel P, et al. Free perfo-
Lamby P, Sachanadani NS, Jung EM, Prantl L, da Silva rator flaps in children. J Reconstr Microsurg.
NPB. High-resolution ultrasound-guided perforator 2005;21:159–169
mapping and characterization by the microsurgeon in Wink JD, Gandhi RA, Ashley B, Levin LS. Flap recon-
lower limb reconstruction. J Reconstr Microsurg. struction of the hand. Plast Reconstr Surg. 2020;145(1):
2021;37(1):75–82. 172e–83e.
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for reconstruction of dorsal hand and finger defects. tomotic couplers: a systematic review of the literature. J
Case Rep Plast Surg Hand Surg. 2018;5(1):1–8. Reconstr Microsurg. 2020;36(6):403–411.
Thin Free Flap for Resurfacing of the
Arm and Forearm 55
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 594
Outcome: Clinical Photo and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
Abstract
Soft tissue reconstruction of the upper extrem-

ity especially at the joint area requires a thin
W. Tonaree
and pliable flap for coverage to maximize the
Department of Surgery, Faculty of Medicine Siriraj cosmetic outcome and facilitate early mobili-
Hospital, Mahidol University, Bangkok, Thailand zation preventing joint stiffness.
Department of Plastic Surgery, Asan Medical Center, This case presents a patient with a
University of Ulsan, Seoul, Republic of South Korea myxofibrosarcoma at proximal forearm. After
H. P. Suh · J. P. Hong (*) wide excision of the tumor, the defect extended
Department of Plastic Surgery, Asan Medical Center, from the proximal forearm to the elbow area. A
University of Ulsan, Seoul, Republic of South Korea free tissue transfer was chosen to maximize
e-mail: joonphong@amc.seoul.kr

https://doi.org/10.1007/978-3-030-23706-6_53
594 W. Tonaree et al.
function and cosmetic appearance. Superficial

circumflex iliac artery perforator (SCIP) flap
was chosen in regard to thickness, ease of
elevation, size, pliability of the flap and the
superficial location of the recipient vessel.
Early compression of the flap was
performed postoperatively in this patient to
reduce the edema, stabilize the flap during
early ambulation and achieve good contour.
Keyword
Sarcoma reconstruction · Elbow coverage ·

Forearm coverage · Superficial circumflex iliac
artery perforator flap · SCIP
A 72-year-old male presented with a mass at Fig. 1 Preoperative picture showing a transverse surgical
scar at proximal forearm
proximal forearm for 1 year. The mass was slowly
growing without tenderness. The first excision
3. Thin and pliable flap to reconstruct the proxi-
performed at a local clinic showed pathological
mal forearm and elbow reliable enough to tol-
result with myxofibrosarcoma grade 2 and the
erate radiation therapy.
following information;
1. Size of tumor: about 5 cm.

Treatment Plan
2. Cellular morphology: spindle cells and focal
round cells.
Due to the uncertainty of the excision from the
3. Nuclear atypia: mild.
previous hospital, magnetic resonance imaging
4. Mitosis count: 2/10HPF.
was performed to identify any residual mass.
5. Tumor necrosis: not identified.
Additional tumor staging workup was performed.
6. Tumor border: infiltrative.
Important considerations were the size of the
7. Angiolymphatic invasion: not identified.
defect, thickness of the elbow region native skin,
8. Perineural invasion: not identified.
location of the recipient vessels, possibility of
9. Indeterminate resection margin.
postoperative radiation therapy, and early mobili-
zation as well as good cosmetic appearance.
Physical examination showed transverse surgi-
Upon the initial assessment of the anticipated
cal scar at the proximal forearm 3.7 cm in Length.
defect, the superficial circumflex iliac artery
No Mass Was Palpated (Fig. 1).
perforator (SCIP) flap was suitable as the first
choice.
1. Myxofibrosarcoma at proximal forearm.
2. Anticipated soft tissue defect after wide exci- 1. Skin grafting is a simple and easy procedure
sion involving proximal forearm and elbow for coverage of any size of defect when the
that would not be closed primarily. bone or tendon is not exposed. However, in
55 Thin Free Flap for Resurfacing of the Arm and Forearm 595
the joint region, contracture after skin graft can

cause limited range of motion. Furthermore,
postoperative radiation will not be tolerated
by the skin graft and may lead to ulceration of
the elbow (Stevanovic and Sharpe, 2013).
2. Locoregional axial pattern fasciocutaneous
flaps such as radial forearm flap and lateral
arm flap have the advantages of being in the
same region and avoiding the need for micro-
vascular surgery. However, the anticipated
large defect will not allow enough tissue to be
mobilized and even if possible will leave a
large donor site scar requiring skin grafting.
In distal forearm area, the scar will be obvious,
up to 20% of the patients may develop donor
site wound problem (Kelley and Chung, 2015).
Finally when using the radial forearm flap, Fig. 2 MRI showed the residual mass at proximal forearm
sacrifice of a major artery will be required
and may lead to future problems.
3. Perforator pedicled propeller flaps have
the advantages of being of similar texture as
the defect skin. However, primary closure of
the flap donor site will be difficult and most
likely require a 180-degree rotation of the pro-
peller flap increasing the risk of ischemia and
failure. Furthermore, early mobilization of the
joint, which is essential for optimal functional
outcome, may cause tension to the perforator
leading to flap dysphagia.
4. Pedicled latissimus dorsi flap (Hacquebord
et al., 2018) can be another choice that has
the advantage of avoiding microvascular sur-
gery. The flap is bulky and furthermore, func-
tional impairment of shoulder in terms of range
of motion and muscle strength could develop
after latissimus dorsi muscle flap transfer.
Other free tissue transfer options are always
available such as anterolateral thigh free flap.
But one must weigh the benefits that each flap
brings into the equation.
Fig. 3 PET scan showed mild hypermetabolic soft tissue

Preoperative Evaluation and Imaging mass in medial aspect of left forearm
To evaluate any residual tumor, Magnetic reso- The authors usually recommend using modal-
nance imaging was performed for this patient. ities to evaluate the vascularity over the recipient
Distant metastasis was evaluated using the PET and donor site. In this case, the patient had both
scan which showed no metastasis (Figs. 2 and 3). good pulse on the radial and ulnar arteries and
good Allen’s test and further vascular evaluation Preoperative Care and Patient
for the arm was considered as unnecessary. How- Drawing
ever, for the donor site, preoperative CT angiog-
raphy was performed to evaluate the vascular The plan was to obtain a 2 cm. excision margin
anatomy of the superficial branch of superficial and to perform immediate reconstruction using
circumflex iliac artery of the SCIP flap. If CT the SCIP free flap. As mentioned above, preoper-
angiography is not available, hand-held Doppler ative imaging was used to map and design the
can work just as fine but CT angiography provides SCIP flap as well as to locate potential recipient
more information regarding the vasculature of the vessels. Initial design of the flap and pedicle was
pedicle and the precise anatomy, thus reducing the done for the SCIP flap. On the day of the surgery,
operative time. Duplex ultrasonography can also the authors use low molecular weight heparin for
be used to identify the location of superficial high-risk patients in the morning before surgery.
branch of superficial circumflex iliac artery and The patient was placed on supine position with
also superficial circumflex iliac vein. For the SCIP good cushioning over the bony prominences. The
flap, there are two anatomical patterns for the patient was prepped and draped from below costal
superficial branch after penetrating the deep fas- margin to both feet and also left upper extremity
cia; the first type is the axial pattern artery which area (Fig. 5).
travels beyond the anterior superior iliac spine and
the second type is the direct anchoring pattern
with a short pedicle anchoring into the dermis Surgical Technique
(Suh et al., 2017; Tashiro et al., 2015; Goh et al.,
2015). By understanding these types of the perfo- 1. The patient underwent a wide excision with the
rator, one can design the flap in relation to the flap margin of 2 cm and the deep fascia at left
skin size. Thus, in order to design a large flap, an proximal forearm including elbow area was
axial pattern will be more feasible whereas when removed. The final defect was 15 8 cm
needing a smaller flap, direct anchoring will suffice. with exposed muscles, tendons, and bone. All
This finding justifies the use of CT scan (Fig. 4). the nerve, muscle, and main vessels were
preserved.
2. Immediately after resection, dissection for the
recipient vessel in the defect was performed.
Ulnar artery and superficial vein were identi-
fied and prepared within the defect not requir-
ing a long flap pedicle.
3. The flap design was modified to accommodate
the defect and recipient vessels. The SCIP flap
was designed based on the superficial branch
of superficial circumflex artery and superficial
circumflex iliac vein that we marked on the day
before surgery by the duplex ultrasonography.
In this case, the recipient vessel being located
in the middle of the defect, the flap perforator
was located on the center of the flap. The size
of the flap was 18 8 cm. A slightly larger flap
is taken to accommodate stretching during
movement of the elbow.
Fig. 4 Both superficial branches of superficial circumflex 4. The incision was made at the inferior and lat-
iliac artery eral border of the flap where the superficial
Fig. 5 Preoperative
marking of the pedicles and
design
fascia can be most evident. The elevation is

made on this plane from lateral to medial and Technical Pearls
from caudal to cephalic. The superficial cir-
cumflex iliac vein and superficial branch of 1. Preoperative imaging such as CTA and duplex
superficial circumflex iliac artery are identified ultrasonography are effective tools for provid-
and included within the elevating flap. ing the information about the pedicle course of
5. Once the perforator and the superficial vein is the SCIP flap.
identified, the incision is then made at the 2. Flap elevation should be performed above the
superior border of the flap. Once the perforator superficial fascia for a super thin flap eleva-
and veins are identified, dissection towards the tion. Another advantage by elevating on this
source vessels is made demonstrating the free plane is preserving the deep fat which con-
style approach. tains the lymphatic vessels, lymph nodes, and
6. When the perforator is traced to the deep fas- cutaneous nerve. Preservation of the deep
cia, the fascia should be opened to reach and structures prevents lymphorrhea and wound
dissect the SCIA. Meticulous dissection dehiscence.
around the pedicles was performed. The super- 3. The authors prefer Colorado fine tip mono-
ficial branch of SCIA was ligated from the polar bovie dissection to minimize small
femoral artery and the SCIV was ligated from branch bleeding. During superficial fascia
the saphenous vein. plane elevation, traction, and counter traction
7. The flap was transferred to the defect site. The of the flap margin is critical to identify the
SCIV was anastomosed end to end with the superficial fascia.
superficial vein and superficial branch of SCIA 4. The perforator pathway of SCIP flap must be
was anastomosed end to side to ulnar artery axial type or use the deep (lateral) branch
without tension. when the flap is extending beyond ASIS, but
8. The flap covered the defect, 2 silastic drains when the flap is of moderate size use of any
were placed, and sutured subcutaneously with reliable perforator will suffice. The flap
3–0 Vicryl and the skin was sutured with 4– should be designed along the axis of the
0 Nylon by horizontal mattress. pedicle including the superficial vein if
9. A Jackson-Pratt drainage was placed at the possible.
SCIP donor site which was then closed 5. The anastomosis to the main artery should
primarily. be performed end-to-side in order to
preserve the blood supply to the distal part Postoperative Management

and also avoid the risk of size discrepancy.
In cases where the distal end artery is used, The patient is closely monitored especially the
end to end anastomosis will suffice. flap inspected for any sudden changes. A duplex
6. The superficial circumflex iliac vein usually ultrasonography can be used to access blood flow
travels separately but close to the superfi- within the flap. An open cast is used to maintain
cial branch of superficial circumflex iliac the position of the elbow at about 120 degrees. If
artery. fluid collection or hematoma underneath the flap
7. The venae comitantes which run along the are suspected, gentle manual compression of the
SCIA mostly drain into the superficial vein flap will be performed from the day of surgery to
which has a larger caliber (Figs. 6, 7, 8, 9, drain the fluid. The patient starts ambulation on
and 10). the very next day with an arm sling to support the
Fig. 6 The defect at left

proximal forearm and
elbow after wide excision of
myxofibrosarcoma
Fig. 7 Superficial
circumflex iliac artery
perforator flap (anterior
surface)
Fig. 8 Superficial
perforator flap, the donor
artery and vein were located
on the center of the flap
weight heparin is administered until the patient

starts ambulation for preventing the venous
thromboembolism. Oral aspirin is also prescribed
for 2 weeks postoperatively (Jin et al., 2019).
Early compression was started at day 3 with
light compression and gradually increasing the
pressure until reaching 30–40 mmHg to prevent
the shearing and swelling of the flap. (Suh et al.,
2019).
At the SCIP donor site, the incisional negative
pressure therapy was applied for 5 days after
primary closure (Peter Suh and Hong, 2016).
Outcome: Clinical Photo and Imaging
After the wound was healed, the patient

underwent postoperative radiation therapy. No
complication was observed during radiation
therapy.
The flap showed good contour, cosmetic and
functional outcome. No limited range of motion
of the elbow was observed. Pressure garment was
maintained for 6 months postoperatively (Fig. 11).
Fig. 9 Immediate postoperative picture in flexion position
arm. On day 4, passive elbow motion is started Avoiding and Managing Problems
followed gradually by active physiotherapy until
full range of motion is achieved in 10 days. 1. Due to the variation of pathway of the pedicles
Postoperative intravenous prostaglandin E1 is both artery and vein of the SCIP flap, preoper-
started continuously for 5 days and low molecular ative evaluations including CT angiography
Fig. 10 Immediate
postoperative picture in
extension position
Fig. 11 Postoperative 1 year pictures showed good contour
and duplex color ultrasonography are

recommended tools (Suh et al., 2017; Goh Learning Points
et al., 2015).
2. The deep fat layer at groin area should be 1. Reconstruction of upper extremity especially
preserved to prevent injury to the lymph in the joint area needs a pliable and thin flap to
nodes which can lead to secondary lymph- achieve optimal cosmetic and functional
edema. In case a thicker flap is needed, the outcomes.
deep fat layer in the lateral part can be included 2. The SCIP flap can be ideal for upper extremity,
(Zeltzer et al., 2017). However, other flaps as the recipient vessels are located superficially
should be considered to gain more thickness. and make the use of innate short pedicle SCIP
3. When the patient starts ambulation, transient flap sufficient.
congestion and edema commonly occur. Early 3. Superficial circumflex iliac artery perforator
compression with 30 to 35 mmHg can be used flap is the ideal for reconstruction with a thin
safely for reduction of edema, obliteration of and pliable flap. Knowledge of the anatomical
dead space, stabilization of flaps during ambu- characteristics of the pedicle is essential. When
lation, and achievement of good contour. using the medial branch, the flap can be
designed over the anterior superior iliac spine undergoing reconstructive surgery. Acta Anaesthesiol
if the pedicle is of axial pattern type. Another Scand. 2019;63(1):40–5.
Kelley BP, Chung KC. Soft-tissue coverage for elbow
option is to use the lateral branch when the flap trauma. Hand Clin. 2015;31(4):693–703.
extends beyond the ASIS. Peter Suh HS, Hong JP. Effects of incisional negative-
pressure wound therapy on primary closed defects
after superficial circumflex iliac artery perforator flap
harvest: randomized controlled study. Plast Reconstr
Cross-References Surg. 2016;138(6):1333–40.
Stevanovic M, Sharpe F. Soft-tissue coverage of the elbow.
Plast Reconstr Surg. 2013;132(3):387e–402e.
▶ Diabetic Foot Reconstruction Using SCIP Flap Suh HS, Jeong HH, Choi DH, Hong JP. Study of the medial
▶ SCIP Flap for Tongue Reconstruction superficial perforator of the superficial circumflex iliac
artery perforator flap using computed tomographic
angiography and surgical anatomy in 142 patients.
References Suh HP, Jeong HH, Hong JPJI. Early compression therapy
after perforator flap safe and reliable? J Reconstr
Goh TL, Park SW, Cho JY, Choi JW, Hong JP. The search Microsurg. 2019;35(5):354–61.
for the ideal thin skin flap: superficial circumflex iliac Tashiro K, Harima M, Kato M, Yamamoto T, Yamashita S,
artery perforator flap–a review of 210 cases. Plast Narushima M, et al. Preoperative color Doppler ultra-
Reconstr Surg. 2015;135(2):592–601. sound assessment in planning of SCIP flaps. J Plast
Hacquebord JH, Hanel DP, Friedrich JB. The Pedicled Reconstr Aesthet Surg. 2015;68(7):979–83.
latissimus Dorsi flap provides effective coverage for Zeltzer AA, Anzarut A, Braeckmans D, Seidenstuecker K,
large and complex soft tissue injuries around the Hendrickx B, Van Hedent E, et al. The vascularized
elbow. Hand (N Y). 2018;13(5):586–92. groin lymph node flap (VGLN): anatomical study and
Jin SJ, Suh HP, Lee J, Hwang JH, Hong JPJ, Kim YK. flap planning using multi-detector CT scanner. The
Lipo-prostaglandin E1 increases immediate arterial golden triangle for flap harvesting. J Surg Oncol.
maximal flow velocity of free flap in patients 2017;116(3):378–83.
Major Amputations at the Arm and
Forearm Level: Replantation Strategy 56
and Technique
Pierluigi Tos, Alessandro Crosio, Francesco Giacalone, and

Bruno Battiston
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
Learning Points: Maximum of Five Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
P. Tos (*) · A. Crosio Abstract

Hand Surgery and Reconstructive Microsurgery
Department, Orthopedic Institute ASST Gaetano Amputations at the arm and forearm level
Pini – CTO Hospital, Milan, Italy are an emergency frequently associated with
e-mail: pierluigi.tos@unito.it
potentially fatal concomitant injuries. The
F. Giacalone loss of a big segment of the upper limb is,
Orthopaedics and Traumatology 2 – Surgery of the Hand
and Upper Limb, AOU City of Health and Science –
however, a source of high disability for the
Trauma Hospital, Turin, Italy patients, so every effort to replant the
B. Battiston
severed part should be made. First of all, the
U.O.C. Traumatology, Hand Surgery, Microsurgery, A.S. patients have to be evaluated by the anesthesi-
O. Città della Salute e della Scienza, CTO - Hospital, ologist to understand the risk of replantation.
Torino, Italy Many different characteristics concerning the
e-mail: bruno.battiston@virgilio.it

https://doi.org/10.1007/978-3-030-23706-6_54
604 P. Tos et al.
mechanism of trauma, ischemia time, and injury. The muscles and the skin of the amputated
actual condition of the stump have to be con- segment were crushed, contaminated, and torn
sidered before deciding whether to replant (Fig. 1a and b).
or not. The second patient was a 37-year-old climber
Once the indication is confirmed, the proce- who, during a mountain expedition, had his left
dure has to be done as soon as possible. Reduce wrist amputated by a stone slab that hit its fore-
ischemia time by installing a temporary vascu- arm. Moreover the amputated part felt down in a
lar shunt is one of the first measures to be cleft. The patient was immediately transported to
undertaken. This provides the surgeon enough the emergency department, but the hand was
time for radical debridement and exposure of found and brought to us about 6 h later (Fig. 2).
all soft, bony, and vascular structures at the
level of the amputated segment and the stump.
Replantation is then performed from the
bone to the soft tissues. Internal fixation is
preferred to external fixation if possible. Ten-
don suture with six-strand technique is funda-
mental to enable a safe postoperative early
mobilization of the replanted segment. Usually
vascular and nerve grafts are required. If
replantation is not indicated, consider
other alternatives such as maintaining a long
stump with fillet flap or, in very selected cases,
performing ectopic replantation. Further surgi-
cal procedures are usually required and usually
functional recovery will be modest; however,
all patients will be more satisfied having got
the chance to keep their own arm or forearm
instead of having a prosthesis.
Fig. 1 (a, b) Amputated left arm due to a traction mech-
anism. Note the avulsed terminal branches of the brachial
Keywords plexus
Arm replantation · Forearm replantation ·
Temporary vascular shunt · Microsurgery ·
Hand surgery
In this chapter two explicative cases are presented

concerning major upper limb amputation and show
the surgical approach for replanting a big (arm) and
a smaller segment amputation (forearm).
The first patient is a 40-year-old female that
was brought to the emergency department due to
an arm avulsion during work.
Fig. 2 Amputated hand at wrist level due to a stone slab.
Her left arm was avulsed at the proximal third Note the injury’s edges that appear more regular than in the
of the arm. All the terminal nerves of the brachial previous case. In this patient the amount of muscle fibers is
plexus were visible due to the tear mechanism of lower compared to an arm amputation
56 Major Amputations at the Arm and Forearm Level: Replantation Strategy and Technique 605
Preoperative Problem List: 4. Avulsion and crush injuries cause extensive

Reconstructive Requirements damage of all tissues and may preclude replan-
tation. Injuries extensively contaminated with
1. Life before limb: Amputations are often a soil, especially from the barnyard, carry a high
consequence of high-energy trauma; therefore, risk of significant infection. Chemical contam-
associated lesions (cranial, thoracic, abdomi- ination of the amputated part by glue, paints,
nal, and pelvic) must be addressed first to solvents, lubricating oils, and aniline dyes is
save patient’s life (Neumeister and Brown almost unanimously accepted as an absolute
2003). local contraindication for replantation. Multi-
2. Replant or not replant: According to the ple level lesions are generally contraindica-
actual scientific evidence, unanimous consen- tions for replantation, but exceptions may
sus regarding the three main criteria for decid- exist (Chen and Huang 2005).
ing whether or not to replant exists: patient’s 5. In replantation of the lower extremity, there are
age and general conditions, ischemia time, several scores based on which one can evaluate
and level, type, and extent of tissue damage the indication for replantation. In the upper
(Battiston et al. 2007). Associated multiple limb, the Mangled Extremity Severity Score
lesions (head trauma, internal organ lesions, system (MESS) is the most commonly used
etc.) and state of shock are absolute algorithm. However several studies suggested
contraindications. For patients with severe that MESS score alone is not enough to decide
medical comorbidities, severe chronic or between amputation and limb salvage, due to
uncompensated medical illnesses, such as cor- the high functional complexity of the upper
onary artery disease, myocardial infarction, limb (Bonanni et al. 1993).
malignant neoplasms, and chronic renal or 6. Nowadays it is well known that, despite the
pulmonary disease, may increase the anes- increased high functional challenges of a major
thetic risk, precluding replantation. Smoking upper extremity amputation without replanta-
significantly worsens the outcomes of a replan- tion, a significant number of patients will
tation (Larson et al. 2013; Waikakul et al. be unable to either accommodate or tolerate
1998). a prosthesis (Iorio 2019). As such, patients
3. Ischemia time is a fundamental issue in proxi- must be informed on the fact that after success-
mal segment replantation because of the possi- ful major upper limb replantation, the road
ble reperfusion injury of the replanted part. If to recovery will be a long trip of at least
segments contain large muscular masses, their 24 months. Although replantation is the proce-
necrosis increases the risk of renal failure dure with the highest satisfaction rate, it is a
resulting from myoglobinuria, acidosis, and long surgical procedure and, if successful,
hyperkalemia. Even in the case of good pres- will require other staged procedures to improve
ervation of the distal segment (cold ischemia, the function of the replanted segment.
at about 4 C), revascularization time must
not exceed 6 h. After that time, skeletal muscle
undergoes irreversible necrotic changes. Treatment Plan
Therefore, respecting this cutoff not only guar-
antees limb survival but also avoids severe Alert as soon as possible the operating room. A
postoperative complications such as cardiac multiple team approach is preferred since surgery
or renal failure (Prucz and Friedrich 2014). can be initiated at the same time on multiple sites
The ischemia time is less strict in patients (proximal stump, amputated part, lower limbs
with amputation level at the half or distal to harvest vascular or nerve grafts). A valid tran-
third of forearm due to lower amount of muscle sitory option is the use of temporary vascular
mass present in the amputated segment, as we shunts, which reduces ischemia time (Nunley
also show in the second case presented here. et al. 1981; Cavadas et al. 2009).
606 P. Tos et al.
During the primary evaluation, intravenous Start with arterial shunting and purging of the
antibiotic prophylaxis should be given immedi- amputated segment to wash out catabolites and
ately, ideally within 3 h: first-generation cephalo- reduce the risk of ischemia reperfusion syndrome.
sporin is indicated, whereas the addition of a third- Bone fixation has to be performed as quickly as
generation cephalosporin, aminoglycoside, and/or possible but should be as definitive as possible to
penicillin remains controversial. Early adminis- minimize the need for further surgical procedures
tration of IV antibiotics reduces the risk of infec- and to permit early motion. In the first case, a 4.5
tion (Iorio 2019; Nanchahal et al. 2009). LCP was used to fix the humeral fracture. In the
Modular external fixator, plate, and screws second patient, two LCP 3.5 mm plates were used.
(4.5 mm or 3.5 mm LCP) should be available. If Then perform tendon or muscular repair
adequate debridement is achieved, an internal according to the amputation level. Four or six
definitive fixation is preferable (Hanel and Chin core sutures with a nonabsorbable braided suture
2007). An external fixation should be available if and stainless steel, followed by an epitendinous
internal fixation is not feasible due to long ische- suture, are advised in order to permit early passive
mia time (Meyer 1985) or other specific local and active motion. We prefer Tsuge suture or
issue. cruciate four-strand suture as described by JB
Surgical microscope should be immediately Tang. Usually a 3-0 suture is used for core recon-
available in the preparation room. struction and a 6-0 resorbable material for the
Ideally, two teams should begin the surgery: epitendinous suture (Klifto et al. 2018).
one team deals with exploration and debridement Definitive vascular repair follows tendon
of the amputated part and the other team with suture, either with direct reconstruction or an
preparation of the proximal stump. interposed graft. Start with arterial repair. Nerve
First start with the debridement of soft tissue repair should be delayed if tissues are highly con-
and bone. The soft tissue debridement should start taminated. The main nerves are usually
from the skin to the muscles in a circular way. reconstructed. Also here, direct suture or nerve
Usually the superficial flexor tendons and their grafts could be required.
muscles are excised in arm amputation. Although
excision of muscles in the amputated segment
leads to an “elementarization” not only of the Alternative Reconstructive Options
muscle (Brunelli et al. 1985) but also of the func-
tion, it has been documented that it dramatically The alternative to replantation is revision amputa-
reduces the risks of heart complications or renal tion, but it leads, especially in arm amputation, to a
failure after revascularization and the possibility very short amputation stump, not fit for a prosthe-
of compartmental syndromes (Green and Wolfe sis. As mentioned before, a revision amputation
2011). The debridement of all crush tissue is also should be performed when an absolute contraindi-
the key to avoid infections and early complica- cation to replantation exists. In order to achieve the
tions of the wound closure site. best functional results as possible, the surgeon can
Following soft tissue debridement, bone shorten- approach the patient in different ways, keeping in
ing is performed. In the proximal stump, the bone mind the motto “life before limb.”
debridement continues until the “paprika sign” is In very selected cases, is it possible to replant
seen. The same procedure has to be repeated after the amputated limb at a second stage?
revascularization (to reassess tissue vitality). The first alternative involves using parts of the
This phase also allows identifying arteries, distal segments as free flap to cover the proximal
veins, nerves, and tendons. Mark these elements stumps. Flurry et al. described eight cases of com-
with sutures, vessel loops, or methylene blue. posite forearm free fillet flaps covering humeral
A temporary vascular shunt is placed to reduce and shoulder soft tissue defects following trau-
ischemia time and allow for the debridement pro- matic amputation. The flap consists of radial and
cedure to be completed (Cavadas et al. 2009). An ulnar artery vascular pedicles, the adjacent mus-
artery and a superficial vein should be shunted. cles, and the skin (Flurry et al. 2008). Oliveira
described a series of free fillet flaps composed by Perform x-ray studies of the proximal stump
an extensive radial artery-based flap. In their and the amputated part to understand how many
paper seven patients were treated with preserva- bone injury levels are present. This could influ-
tion of humerus length and elbow joint (Oliveira ence the decision-making process concerning
et al. 2009). In 2004, Cavadas and Raimondi replantation. No other imaging studies are
published two cases in which the skin from the required for the amputated limb.
hand, based on both palmar arches, was used to
preserve the proximal third of the forearm and
maintain the elbow joint. In the second case, the Preoperative Care and Patient
skin of a degloved upper limb including the hand Drawing
was used to cover the arm and the forearm to
maintain the elbow joint (Cavadas and Raimondi Patient should be under general anesthesia in
2004). supine position.
In all these patients, the amputated limbs were Include in the operative field also the entire
considered not replantable. The goal of this tech- lower limb from the groin to the foot, in case a
nique is the preservation of an adequate length of great saphenous vein graft or a sural nerve graft is
the proximal stump, enabling the fitting of an needed.
adequate prosthesis. Place the tourniquet at the arm in case of fore-
In case of high-risk patients, temporary arm amputation. It should be as proximal as pos-
ectopic implantation of the amputated part to a sible in case of ex-fix placement or extension of
healthy recipient site allows the patient to recover skin incision above the elbow crease.
from critical combined injuries and be able to In the operating theater, a C-arm amplifier and
undergo normotopic replantation once the clini- sterile saline packs (the same used in arthroscopic
cal situation is stabilized. Wang and colleagues surgery) should be available.
reported two cases in which the amputated fore-
arm was implanted on the groin (connected to the
circumflex femoral artery system) and on the Surgical Technique
contralateral forearm (Wang et al. 2006). These
procedures were performed in young patients 1. First of all, accurate cleaning and debriding
with life-threatening conditions. In this series of the necrotic structures was performed.
the secondary replantation was performed after A two-team approach leads to a quicker
81 and 320 days from injury, respectively. In a debridement procedure. In the proximal
recent systematic review, Tu et al. retrieved six stump, bleeding skin, muscle, and bone
cases of hand and two cases of forearm hetero- (paprika sign) were obtained. To obtain this,
topic replantation. The ectopic implantation time bone shortening was done.
was between 1 and 6 months. Different recipient 2. In the amputated segment, grossly contami-
sites were used, the most preferred ones being the nated parts were completely excised. Some
forearm and lower abdomen (Tu et al. 2018). The authors suggested excising the flexor
more time the segment remains in its ectopic digitorum superficialis tendons and muscles
position, the lower functional results could be in arm amputation.
obtained. 3. Major saline lavage was performed (at list 5 l
of saline solution) as described for the treat-
ment of exposed fractures (Nanchahal et al.
Preoperative Evaluation and Imaging 2009).
4. Vessels, nerves, and tendons in the distal and
Decide with the anesthesiologist the risk of limb proximal stumps were identified and resected
replantation according to coexisting injuries. until viable tissues were encountered.
Evaluate accurately soft tissue condition and 5. A stable osteosynthesis was obtained in these
investigate the mechanism of injury. cases with plate and screws. Even in
608 P. Tos et al.
contaminated injuries, an internal fixation secondary complications, such as necrosis or

with plates does not increase the risk of infec- Volkmann’s contractures.
tions compared to external fixators
(Nanchahal et al. 2009).
6. Frequently an arterial gap is present. In the Technical Pearls
first case, a vein graft was used to reconstruct
the humeral artery. The great saphenous vein • Rapid access to the operative theater reduces
was harvested at the level of the thigh. Micro- ischemia time. Reduce as much as possible the
vascular anastomoses were performed using a time spent for preoperative imaging.
7-0 suture for the humeral artery or an 8-0 for • During anesthesiological assessment, have the
the radial/ulnar arteries of the second case. amputated part brought in the theater and start
7. Once the revascularization was obtained, the to perform debridement and identification of
sequence of repair from this point was from the anatomical structures needed for replanta-
deep to superficial. Muscle and/or tendon tion (Iorio 2019).
repair were performed after debridement of • Bone shortening is crucial to reduce risk of
the necrotic or denervated parts. A four- or infected non-union and perform direct vascular
six-strand core sutures were used for tendon and nerve repair.
repair (Iorio 2019). In proximal arm amputa- • Vascular temporary shunts should be placed to
tions, a muscular suture was performed. reduce ischemia time (Cavadas et al. 2009). If
8. In order to leave enough time for flushing of possible, a 3 French to 6 French tube should be
toxins, venous anastomoses were the last to selected to allow adequate flow without
be performed. At least two veins for each clotting at the ostium. The tie should be placed
artery must be reconstructed. close to the vascular stump edge to prevent a
9. Nerve repair is essential to guarantee a good large zone of vascular injury that needs to be
functional result. Usually is difficult to per- resected prior to the anastomosis. This tech-
form a direct suture even after adequate bone nique allows washout time to reduce the risk of
shortening. In the presented cases, an imme- metabolic complications (Iorio 2019) and
diate nerve reconstruction was performed due reduces ischemia time, permitting precise
to bone shortening, and, in the first case, the debridement of distal segment. This is espe-
proximal part of the terminal branches of cially useful in arm replantation (Nunley et al.
the brachial plexus was conserved in situ. In 1981; Cavadas et al. 2009).
case of high contamination or tear injuries • Usually the great saphenous vein is the most
needing nerve grafting, the definitive recon- frequently used vascular graft, but there may
struction can be delayed up to 3 weeks after be a slight benefit to arterial grafts when used
surgery (Rinker and Vyas 2014). However, if for revascularization as compared to venous
possible the “all-in-one repair” generally grafts (Iorio 2019). Common arterial donor
leads to the best results. Nerve reconstruction vessels include the thoracodorsal, inferior epi-
is performed with sural nerve grafts (some- gastric, and the descending branch of the lat-
times bilateral nerve grafts are required) or eral femoral circumflex arteries (LFCA). This
with medial cutaneous brachial and ante- option should be carefully considered to not
brachial nerves (if available). In “not neat” preclude a viable flap option (Iorio 2019).
nerve lesions (e.g., avulsion, tear) and also • A running suture can be performed for a faster
in mixed nerves (proximal segments), emer- and stronger anastomosis, paying attention not
gency tubulization, especially in case of short to create a circumferential vascular stenosis or
nerve gaps, may restore the continuity of the a twist of the suture site (Iorio 2019).
nerve, avoiding the need for secondary nerve • Do not perform immediate nerve reconstruc-
grafting (Tos et al. 2012). tion using nerve grafts. Perform direct suture
10. Extensive fasciotomies were performed, after if possible. In avulsion, crush injuries or
revascularization of the arm, to prevent severe highly contaminated injuries, delayed nerve
reconstruction is preferable. Nerve stumps

should be marked with a suture and approxi-
mated to facilitate secondary reconstruction to
decrease the gap. Nerve conduits (muscle in
vein graft or other materials), if possible, offer
sometimes a viable option to restore nerve
continuity with good results. According to the
intraoperative examination in certain cases,
secondary definitive reconstruction might rep-
resent the procedure of choice (Tos et al. 2012;
Rinker and Vyas 2014; Battiston et al. 2000).
Fig. 3 Intraoperative pictures – arm replantation. Note
Direct muscle neurotization should be how superficial and easy to find the vascular and nerve
performed in nerve avulsion injury from the structures are. Direct neurotization of musculocutaneous
muscle belly. nerve is performed in emergency into the biceps (Brunelli
• In the presence of exposed bone, vessels, and/ and Monini 1985) all nerves were repaired immediately
or nerves, flaps may be considered. They can
be performed immediately (Georgescu and
Ivan 2003) or bridged using temporary vacuum
therapy or a full-thickness skin graft and cov-
erage performed a few days later. Do not place
vacuum therapy on vessels and nerves. If the
outcome of the replantation is questionable,
skin allografts can be used. If the limb sur-
vives, the allograft is replaced with autografts
within 5 days after replantation.
See Figs. 3 and 4.
Fig. 4 Final aspect of the replanted hand. Note the partial

closure over the flexor muscles due to swelling and loss of
Postoperative Management substances. In this case skin grafting could be performed a
few days later
Drains should be placed under suture and left in
place for 7 days. Do not use suction drains close to Intravenous antibiotic therapy should be
vascular and nerve sutures. discontinued at least 72 h after replantation
After revascularization, an immobilization (Nanchahal et al. 2009) and should be continued
splint becomes mandatory to protect the in case of certain infection diagnosis according to
reconstructed sutures (Fig. 5). clinical symptoms and intraoperative cultures.
Capillary refill, temperature, and oxygen satu- To prevent thrombosis, we suggest using
ration check at the fingertip level need to be con- acetylsalicylic acid and LMWH (low-molecular-
stantly monitored. The tissue perfusion should be weight heparin) at prophylactic doses.
checked hourly for the first 24 h and then every 2 h Hydration must be adequate and blood trans-
up to 48 h after surgery. Admission to an intensive fusions should be performed if necessary. Hemo-
care department is suggested to enable fast iden- globin levels should be kept above 10 and
tification and therapeutic measures of possible systemic pressure preferably over 120/70 mmHg.
systemic complications, such as sepsis or rhabdo- Some authors suggest the use of hyperbaric
myolysis (e.g., renal failure). oxygen therapy (HBOT) to improve the survival
610 P. Tos et al.
ROM recovered; the replanted arm helps the

other in managing large objects.
In the second patient, the recovery was differ-
ent. A wrist-level amputation led to a quicker
recovery of the transected nerves. It means, as
showed in picture 7, that intrinsic muscles
maintained tone. The flexor tendons, sutured at
wrist level, led to a 90 flexion of the PIP joints.
This allowed the patient to handle medium- and
small-size objects. Unfortunately the restitutio ad
integrum is impossible; the MP joints remained
stiff and impaired to reach the close fist position.
Also a stiff wrist was present, and a small degree
in flexion and extension was allowed. Otherwise
Fig. 5 Custom-made postoperative plaster cast for arm
replantation. In the first 5–7 days after surgery, the
the patient was very satisfied of the recovery and
replanted limb should be medicated as little as possible. got back to hiking and climbing (Fig. 7).
The patient should be admitted in an intensive care depart-
ment. Movement of the replanted segment should be
avoided to prevent vascular spasm
rate or reduce soft tissue complications. Chiang Systemic complications (primarily cardiac and
et al. suggested that, when combined with deli- renal failures) are life-threatening problems that
cate microsurgery, early intervention using can be prevented through careful patient selection
adjunctive HBOT is effective in preserving par- for replantation, correct timing of the procedure,
tially viable tissue and restoring hand function in and accurate postoperative monitoring. This is
patients with a mutilated hand injury. Actually why it is mandatory to perform such surgery in
there is no evidence that HBOT can improve the trauma centers with expert anesthesiologists and a
survival rate for replanted limbs in literature specialized intensive care unit.
(Chiang et al. 2017). Our suggestion is to use The main local complication is failure of
this resource only in stable patients as an adjunc- replantation due to ischemic events, either
tive “weapon,” but not as an alternative to surgi- through insufficient arterial inflow or venous con-
cal debridement. gestion (thrombosis, anastomosis failure, vascular
compression due to hematoma, or increased com-
partmental pressure) in a distal (small) replanted
Outcomes segment. In big segment replantation, the main
failure is due to bleeding at the site of anastomosis
There is a significantly different type of recovery due to tension or suboptimal tissue coverage.
considering the level of amputation. The first These problems can be minimized by an accurate
patient after 1 year recovered a good motion of bone shortening to avoid tension on the anasto-
the elbow and wrist flexor and extensor muscles, mosis site, meticulous vessel preparation and
but the extrinsic and intrinsic muscles of the fin- suture, use of anticoagulant agents, and covering
gers did not recover properly. This is due to the the anastomosis with viable soft tissue of adequate
long distance required especially for ulnar nerve quality. We use low-molecular-weight heparin
to reach the innervated muscles. In Fig. 6a and b, (4000 U s.c./per day), sometimes with
the final range of movement gained by the patient acetylsalicylic acid (100 mg/per day) for 20 days.
is presented. Despite 1-year physiotherapy, a neg- A standardized post-op monitoring by means
ative hand appeared due to intrinsic muscle atro- of oximetry and clinical observation (i.e., local
phy. The patient was otherwise satisfied of the temperature, capillary refill, color, turgor) is
Fig. 6 (a, b) Functional results after 1 year. Note the good fingers and hand’s intrinsic muscles did not recover
results of proximal muscle recovery of the flexor and properly
extensor of the wrist, but the flexor and extensor of the
crucial. This allows for an immediate return in the difficult to take a decision whether and when to
operating theater for vascular re-exploration if perform secondary amputation, but timing is cru-
necessary. cial in order to prevent the extension of the necro-
Late complications are usually due to progres- sis and to avoid systemic sepsis than can threaten
sive necrosis and infection. It is sometimes patient’s life.
612 P. Tos et al.
Fig. 7 In middle third/distal forearm amputation, the of the long fingers was obtained. However, the patient
patient displayed only a moderate recovery of the flexion could finally handle medium-sized or big objects, and he
and extension of the wrist. Interphalangeal and meta- returned to mountain climbing
carpophalangeal joints were stiff, and incomplete closure
Antibiotic-impregnated poly(methyl methac- loops are placed through skin staples in a “zigzag”
rylate) (PMMA) beads with gentamycin and van- fashion and progressively tightened.
comycin can be placed deep into the wound and Partial skin or muscle necrosis is a frequent
changed during daily debridement to reduce the event. This demonstrates how difficult it is to
risk of infection, especially in highly contami- evaluate correctly the extent of the soft tissue
nated patients (Cavadas 2007). damage in emergency, especially in traction or
In one patient Cavadas reported the possibility crush injuries. In such cases, skin graft, local
to reamputate and replant in a heterotopic site flaps, or free flaps can be used to fill the gaps.
as salvage procedure in a case of impending Delayed unions or bone non-unions are fre-
ischemia in a replanted forearm affected by deep quent due to high-energy trauma, contamination,
infection. The forearm was sutured to a saphenous and periosteal stripping. To prevent this, extensive
vascular loop anastomosed to the superficial femoral bone shortening needs to be performed. In the
artery. Nine days postoperatively, after controlling case of non-union, revision, new fixation with
the deep infection, the segment was re-replanted bone grafting is required.
again normotopically (Cavadas et al. 2006). Sometimes it is difficult to recognize brachial
Another devastating complication is ischemic plexus palsies associated with arm amputation
contracture (Volkmann’s syndrome) due to (avulsion injuries) because the patients arrive
increasing compartment pressure following reper- in the ER already under general anesthesia. In
fusion of the replanted segment. In order to those cases, if the replanted segment survives,
avoid this, it is mandatory to perform extensive brachial plexus reconstruction must be performed
fasciotomies of the forearm and the hand. The in a delayed fashion.
skin left partially open can be closed over several Other minor local complications such as
days using progressive suture technique. Vessel stiffness, partial motor, or sensory deficits are
solved by standard secondary procedures (func- Bonanni F, Rhodes M, Lucke JF. The futility of predictive
tioning muscle transfers, tendon transposition, or scoring of mangled lower extremities. J Trauma.
1993;34(1):99–104.
tenolysis). According to the literature, an average Brunelli G, Monini L. Direct muscular neurotization.
of three secondary surgical procedures per patient J Hand Surg [Am]. 1985;10(6 Pt 2):993–7.
is needed to achieve the expected results (Fufa Brunelli G, Vigasio A, Brunelli F. Muscular
et al. 2014). elementarization in the “borderline” replantation and
revascularization of the forearm. Ann Chir Main.
1985;4(4):337–9.
Cavadas PC. Salvage of replanted upper extremities with
Learning Points: Maximum of Five major soft-tissue complications. J Plast Reconstr
Learning Points Aesthet Surg. 2007;60:769–75.
Cavadas PC, Raimondi P. Free fillet flap of the hand for
elbow preservation in nonreplantable forearm amputa-
1. The replantation of the upper limb is a proce- tion. J Reconstr Microsurg. 2004;20(5):363–6.
dure that should follow specific steps. It has to Cavadas PC, Landin L, Navarro-Monzonis A, et al.
be done as fast as possible. The ischemia time, Salvage of impending replant failure by temporary
ectopic replantation: a case report. J Hand Surg [Am].
associated injuries, and contamination always 2006;31:463–7.
guide the decision-making process. Cavadas PC, Landín L, Ibáñez JJ. Temporary catheter
2. The real contraindication of primary replanta- perfusion and artery-last sequence of repair in macro-
tion is a life-threatening condition. In this case, replantations. Plast Reconstr Aesthet Surg.
2009;62(10):1321–5.
in selected patients, an ectopic implantation Chen ZW, Huang Q. Principles of replantation and revas-
should be performed. cularization. In: Weinzweig N, Weinzweig J, editors.
3. In situations that replantation is not possible, The mutilated hand. Philadelphia: Elsevier; 2005. p.
use the amputated parts (e.g., fillet flap) to 193e216.
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possible. ries? Int Wound J. 2017;14(6):929–36.
4. The use of temporary vascular shunts is funda- Flurry M, Melissinos EG, Livingston CK. Composite fore-
mental to reduce ischemia time and increase arm free fillet flaps to preserve stump length following
traumatic amputations of the upper extremity. Ann
the possibility of the replanted segment to sur- Plast Surg. 2008;60:391–4.
vive. Moreover, it reduces the risk of ischemia Fufa D, Lin CH, Lin YT, Hsu CC, Chuang CC, Lin CH.
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5. Functional results are not optimal, but patients upper extremity replantation. Plast Reconstr Surg.
2014;134(4):713–20.
are usually satisfied. During postoperative Georgescu AV, Ivan O. Emergency free flaps. Microsur-
care, all patients should receive psychological gery. 2003;23(3):206e16.
support as post-traumatic distress is frequently Green DP, Wolfe SW. Green’s operative hand surgery.
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Hanel DP, Chin SH. Wrist level and proximal-
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Surg. 2007;60:849e855. Sanderson F, et al. Standards for the management of
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Plastic, Reconstructive and Aesthetic Surgeons; 2009. mary repair of crush nerve injuries by means of biolog-
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Reconstruction of Complex Finger
Defects Using the Free Ulnar Artery 57
Perforator Flap
Mario Cherubino and Tommaso Baroni
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
Treatment Plan: Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
Abstract
Hand trauma and resections of tumors may

create degloving injuries to the fingers leading
M. Cherubino (*) to extensive and circumferential soft tissue
ASST Settelaghi, Hospital, Department of Biotechnology
defects that require a complex surgical man-
and Life Sciences (DBSV), Plastic Surgery, University of
Insubria, Varese, Italy agement in terms of both skin coverage and
functional outcomes. For this purpose, several
Hand and Microsurgery Unit, Division of Plastic and
Reconstructive Surgery, Microsurgery and Lymphatic local or locoregional flaps have been advo-
Surgery Research Center, Department of Biotechnology cated in literature. Furthermore, good recon-
and Life Sciences, University of Insubria, Varese, Italy structive results can be obtained by
T. Baroni transferring soft tissue from the toes as well.
Hand and Microsurgery Unit, Division of Plastic and Free tissue transfers are ordinarily indicated in
Reconstructive Surgery, Microsurgery and Lymphatic
case of major finger defects. Proximal ulnar
Surgery Research Center, Department of Biotechnology
and Life Sciences, University of Insubria, Varese, Italy perforator free flap represents a valid recon-
structive option since it allows avoiding the
ASST Settelaghi, University of Insubria, Varese, Italy

https://doi.org/10.1007/978-3-030-23706-6_55
616 M. Cherubino and T. Baroni
most common drawbacks deriving from the The greatest limitations of these flaps lie in poor
use of the average free flaps. advancement, resulting large scars, possible post-
The authors report a case of a patient sus- operative cold intolerance, and insufficient skin
taining a complex hand trauma with underly- coverage for larger defects. For the above reasons,
ing exposed structures covered with pliable, their use is mostly reserved for small finger loss of
sensitive, and similar texture-matching skin substance of the tip.
harvested from the proximal volar forearm The widespread development of microsurgical
based on the proximal ulnar perforator. techniques has allowed surgeons to use free tissue
No vascular complications, wound dehis- transfers in the field of complex finger defects
cence, or infections were observed. No cold reconstruction. Specifically, finger reconstruction
intolerance was reported, and partial fine tactile with free flaps is indicated for those defects
sensibility was obtained. The patients showed extending to more than 1 phalanx in length or
good mobility and limited impairment in daily more than half the phalangeal circumference in
life activities. The overall cosmetic result was width or for multi-digit distal coverage
satisfying. (Cherubino et al. 2017). Different free flaps can
Ulnar artery perforator free flap should be be brought into play in this regard, each with its
considered as a potentially superior alternative own advantages and drawbacks.
in digit reconstructive surgery. It can be
harvested under single brachial plexus block,
providing satisfactory functional and aesthetic The Clinical Scenario
results. Even though established microsurgical
skills are required, the high reliability of its A 54-year-old man presented with a complex
vascular anatomy and the low rate of crushing trauma of the right hand with sub-
neurovascular bundle injury during dissection amputation of the 2nd, 3rd, 4th, and 5th finger.
make this flap feasible for the most hand The fingers appeared avascular with multiple and
surgeons. multi-fragmented fractures of the phalanges, con-
firmed by the preoperative X-rays (Fig. 1a, b).
A four-finger regularization at the proximal
Keywords
phalanx level was performed in urgency. In the
Proximal ulnar flap · Free flap · Finger next few days, a necrosis of the third residual
reconstruction · Thumb reconstruction · Ulnar finger at the level of the metacarpophalangeal
perforator joint happened, and the defect size was about
7 3 cm. It was not possible to reconstruct the
third finger using local flaps due to the impossi-
Introduction bility of obtaining similar tissue from adjacent
fingers and adequate advancement from more
Hand trauma and tumor resection may create proximal hand regions.
degloving injuries to the fingers leading to exten-
sive and circumferential soft tissue defects with
the consequent exposure of noble structures such Treatment Plan: Reconstructive
as tendons and neurovascular bundles. These Requirements
types of defects more often require a complex
surgical management in terms of both skin cover- At the current state of the art, it is probably not
age and functional outcomes. possible to determine the best reconstructive
Several local or locoregional flaps have been option for large digit defects. Nevertheless, in
advocated in literature for finger reconstruction the opinion of the authors, an “ideal free flap”
such as the V-Y flap and the modified Moberg for finger reconstruction should present the fol-
flap for thumb reconstruction (Tang et al. 2014). lowing features:
57 Reconstruction of Complex Finger Defects Using the Free Ulnar Artery Perforator Flap 617
Fig. 1 a, b Preoperative right-hand x-ray showing a complex crushing hand trauma
• Thin, hairless, and similar texture-color skin distal medial forearm (ascending branch) and
• Reliability of the vascular pedicle and anatomy opposite direction (descending branch), and the
• Preservation of the main neurovascular bundle last one to the pisiform bone. This flap, however,
• Possibility of nerve or tendon transfer finds a great indication in small finger defects
• Matching diameter between flap and recipient reconstruction.
vessels Several recent anatomical studies (Mathy et al.
• Good functional and aesthetic outcome 2012; Yu et al. 2012; Sun et al. 2013) have allo-
• Primary closure and minor morbidity of the wed the identification of two main clusters of
donor site perforators (with a diameter up to at least
0.2 mm) in the forearm along the line connecting
Reconstruction of the soft tissue of the the pisiform bone to the medial epicondyle,
remaining fingers was planned in order to main- corresponding to the intermuscular septum
tain an adequate length of the fingers, necessary to between the flexor carpi ulnaris (FCU) and the
allow a subsequent finger prosthesis placement. flexor digitorum superficialis (FDS). The distal
The ulnar free flap was described for the first cluster of perforators is located at about 4–7 cm
time in 1988 by Becker and Gilbert, as a reverse from the pisiform bone while the proximal one at
perforator flap suitable for wrist up to meta- about 12–16 cm. According to the authors’ find-
carpophalangeal joint defects (Becker and Gilbert ings, the ulnar artery is almost always found
1988). It was later repurposed as a free flap by within this septum, and the vast majority of the
Lovie et al. in 1984 for head and neck reconstruc- ulnar perforators are septocutaneous, mostly
tion (Lovie et al. 1984). Inada et al. were the first located around the midpoint of the pisiform-
to use the ulnar free flap for finger reconstruction elbow line and slightly ulnar than this. Further-
(Inada et al. 2004). The flap is based on the dorsal more, adjacent perforators form chains of cutane-
branch of the ulnar artery that divides in a proxi- ous branches parallel to the intermuscular gap
mal, a medial, and a distal branch at about 3–5 cm described above.
from the pisiform bone. The first is directed to the The first described ulnar free flaps were there-
flexor carpi ulnaris, the second to the skin of the fore classified as distal, since they were based on
the dorsal branch of the ulnar artery (Kim et al. 2013; reconstruction of missing thumbs since its first
Liu and Zheng 2014), the Becker branch. Only in use in 1969 by Cobbett (1969). Considerable
recent years have been reported flaps nourished by functional and aesthetic results can be obtained
more proximal ulnar perforators (Wei et al. 2014). by transferring soft tissue from the toes, even if
An important contribution in this regard was pro- performing a complex surgical procedure under
vided by our first case report of a thumb general anesthesia and depriving patients of their
reconstructed with a proximal ulnar free flap anatomically relevant lower terminal appendages.
(Cherubino et al. 2017). Using more proximal ulnar In this case, a heterodigital reconstruction was
perforators would have the following advantages: not possible considering the injury extent; there-
fore only a venous flap could be a valid alterna-
• Larger area of the flap with the same diameter tive. Due to the instability of venous flaps, a
supplied by musculocutaneous perforators, perforator flap was considered as a better choice.
more frequently located at the proximal region Another alternative free flap could be the medial
of the forearm plantar flap.
• Minor donor site sensory deficit due to the
greater likelihood of sensory territories to
overlap Preoperative Evaluation and Imaging
• Possibility to harvest larger flaps (the forearm
is bigger proximally) Standard Doppler may prove to be unpredictable
• More mobile and less hirsute skin over the and not suitable to identify the ulnar artery perfo-
distal forearm region rator signal. An (ultrasound, US) eco-color Dopp-
• Easier opportunity to close the donor site by ler is recommended, even if it is radiologist
primary intention, due to the softness of the dependent.
proximal skin of the forearm
Despite all, it is good to remember that in the Preoperative Care and Patient
proximal forearm the intermuscular septum is Drawing
thicker, with tight junctions between the vascular
bundle and the skin flap, which make the dissec- Surgery is performed under single brachial block
tion less simple. and tourniquet control. The patient is placed
supine with the upper limb on appropriate sup-
port. The superficial venous circle of the forearm
is drawn, being careful to mark the superficial vein
Alternative Reconstructive Options all along its course.
In order to localize the arterial axis of the flap, a
Digit reconstruction with parascapular free flap, line connecting the pisiform bone and the medial
anterolateral thigh free flap, and medialis or humeral epicondyle is outlined on the volar fore-
dorsalis free flaps has been advocated in literature arm. An (US) eco-color Doppler is used to detect
(Ono et al. 2017). Anterolateral thigh flap does not the perforator at its middle third (approximately
pose size limitations but presents poor texture and 12 cm from the pisiform bone) and slightly ulnar
color match. Furthermore it is a typical bulky flap. (0.5 cm from the pisiform-elbow line) (Fig. 2).
On the other hand, medialis and dorsalis free flaps
are characterized by good color, texture, and sen-
sory recovery. Unfortunately, several disadvan- Surgical Technique
tages should be considered such as the significant
donor site mobility and their size limitation. Recipient vessels are prepared. The princeps
Microsurgical toe transfer, in particular, can be pollicis artery is chosen for thumb reconstruction
considered as an established method for or a lateral digital artery for the remaining fingers.
Fig. 2 To mark the flap, a

line between the pisiform
bone and the medial
epicondyle is drawn
For all the other fingers, the choice is between the completely harvested flap is finally arranged to
radial or the ulnar proper palmar digital artery. cover the soft tissue defect (Fig. 7).
One or two superficial dorsal veins are then The pedicle is anastomosed end-to-end to the
selected. recipient vessels with the use of an operating
Under loupe magnification and pneumatic microscope.
tourniquet ischemia, a skin incision is performed
along the radial side of the flap. A superficial
picked vein is marked before the beginning of Technical Pearls
the surgery and isolated for few centimeters in
the subcutaneous layer until a sufficient length is The PUPF presents the following advantages:
reached. After this, the dissection is extended to
the deep fascia and proceeds ulnarwardly until the • Completion of the surgical procedure under
perforator is recognized (Fig. 3). single brachial block and tourniquet control
The tendon of the FCU is exposed and • Thinness, hairlessness, and similar texture with
retracted radially until it is possible to detect the the digital skin
ulnar neurovascular bundle, as it emerges at the • Safety of the vascular pedicle
gap between the FCU and the FDS. Following the • Preservation of the ulnar neurovascular bundle
ulnar artery, it is then possible to identify the • Matching diameter between flap and recipient
perforator branch (perforator C sec. Yu, Yu et al. vessels
2012) (Fig. 4). • Possibility to harvest it as sensate flap includ-
In case of musculocutaneous perforator, we ing the medial cutaneous nerve
proceed with intramuscular dissection following • Primary closure of the donor site when the flap
its course through the FCU or FDS bellies. Venae is less than 4 cm in width
comitantes or superficial veins are isolated, and • Acceptable donor site morbidity
the terminal branch of the medial cutaneous nerve • Scar concealability
can be included if a sensate flap is required
(Figs. 5 and 6). The authors favor the proximal perforator over
The tourniquet is released, and blood circula- the distal one because it presents a more consistent
tion resumed, to verify the viability of the flap. anatomy, it nourishes a potentially larger skin
The flap can be tailored on the defect extension, paddle with greater elasticity and pliability, and
with the nurturing perforator at the medial border the donor site can be easily closed by primary
of the cutaneous island and the superficial vein at intention. Moreover, the proximal wound bed,
about 90 degrees. The pedicle isolated and the represented by the muscle bellies of the FDS and
Fig. 3 The anterior border

of the programmed flap is
incised until the subfascial
plane is reached
Fig. 4 A small perforator

can be easily identified in
the subfascial layer, then a
dissection to the main
vessels is started
Fig. 5 If a sensate flap is

required, the terminal
branch of the cutaneous
medial forearm nerve can be
included. A superficial vein
is chosen and dissected
as well
FCU, accepts a skin graft more readily than the Even though a skilled microsurgical technique
flexor tenosynovium encountered at the distal or is required for the identification of the intramus-
radial forearm (Mathy et al. 2012; Yu et al. 2012). cular course of the proximal pedicle, this
Fig. 6 The flap harvest is

completed with the
intramuscular dissection to
the ulnar artery
Fig. 7 The flap in the final appearance in both sides
intramuscular dissection is limited, due to the alterations inside the main vessel following inten-
dimension of the FUC compared with other mus- tional damage to the wall. If necessary, the entire
cular districts of the body. The authors recom- ulnar artery could be cut and repaired with an end
mend starting the dissection from the radial to end anastomosis; however the diameter of the
border and proceeding ulnarwardly to have a bet- pedicle may be too big for the finger
ter view of the perforators and, thus, to avoid reconstruction.
damaging them inadvertently. As donor vein, a minor superficial vein is pre-
If the diameter of the perforator is too small, a ferred, as the basilic vein, to obtain a diameter and
portion of the ulnar artery can be raised and a greater length of venous pedicle.
repaired to facilitate the anastomosis due to its The perforator is not necessarily centered in the
bigger diameter, anyway. In this case, the pedicle middle of the skin island, but could stay in an
is cut transversely to the longitudinal axis of the eccentric position to allow a more easily shaped
ulnar artery, in order to avoid possible blood flow configuration of the defect. The superficial vein is
Fig. 8 The donor site

defect is closed primary.
Immediate and after
6-month postoperative
aspect
usually located at 90 degrees from the arterial

pedicle, and the recipient dorsal veins can be Avoiding and Managing Problems
tunneled in a new volar position.
A good knowledge of the vascular anatomy com-
bined with the aid of preoperative US Doppler
Postoperative Management enable good reliability of the surgical procedure.
The postoperative complications of the PUPF
The hand and forearm are immobilized with the are the same of every free flap: hematoma, venous
aid of a loose orthosis, and the cutaneous paddle is congestion, arterial thrombosis, infection, and
clinically monitored at regular intervals consider- wound dehiscence necrosis due arterial or venous
ing color, temperature, texture, and capillary refill. thrombosis.
Arterial and venous signals are evaluated by The risk to hamper the ulnar nerve is low
means of a (US) Doppler. because the dissection spares the main
Patient has to comply with complete rest and neurovascular bundle; however careful dissection
elevation of the arm for the first 5 days after surgery. should be performed, and the ulnar nerve must be
Perioperative single administration of intrave- gently separated by the artery.
nous antibiotics is performed, and enoxaparin If it is necessary to remove part of the ulnar
sodium (4000 U/die) should be administered at artery wall in order to obtain a larger and similar
least for the first week in bedridden patients. diameter to the receiving artery, the cut is
Smoking, caffeine, and foods containing tyro- performed in a transverse direction to the longitu-
sine are not allowed until healing is complete, to dinal axis of the main vessel to reduce the risk of
avoid vasospasm and wound dehiscence, as well thrombosis inside the lumen.
as careful pain control with analgesics is needed. Long-term functional impairment at the donor
The patient is then referred to a skilled hand site is uncommon: equal grip strength and sensi-
therapist for the planning of a rehabilitation pro- tivity between donor and nondonor forearm are
gram (Fig. 8). usually reported.
The closure of the donor site by first intention, Liu J, Zheng H. Free distal ulnar artery perforator flaps for
when possible, reduces the risk of bad rooting of the reconstruction of a volar defect in fingers. J Plast
Reconstr Aesthet Surg. 2014;67(11):1557–63.
the skin graft with consequent exposure of the Lovie MJ, Duncan GM, Glasson DW. The ulnar artery
muscular bellies or tendon structure. forearm free flap. Br J Plast Surg. 1984;37(4):486–92.
Finally, a sensitive flap can be reached, includ- Mathy JA, Moaveni Z, Tan ST. Perforator anatomy of the
ing the terminal branch of the medial cutaneous ulnar forearm fasciocutaneous flap. J Plast Reconstr
Aesthet Surg. 2012;65(8):1076–82.
forearm nerve. Ono S, Sebastin SJ, Ohi H, Chung KC. Microsurgical flaps
in repair and reconstruction of the hand. Hand Clin.
2017;33(3):425–41.
References Sun C, Hou ZD, Wang B, Ding ZH. An anatomical study
on the characteristics of cutaneous branches-chain per-
forator flap with ulnar artery pedicle. Plast Reconstr
Becker C, Gilbert A. The ulnar flap – description and Surg. 2013;131(2):329–36.
applications. Eur J Plast Surg. 1988;11(2):79–82. Tang JB, Elliot D, Adani R, Saint-Cyr M, Stang F. Repair
Cherubino M, Corno M, Valdatta L, Adani R. Thumb and reconstruction of thumb and fingertip injuries: a
reconstruction with thin proximal ulnar perforator free global view. Clin Plast Surg. 2014;41(3):325–59.
flap. J Hand Surg Am. 2017;42(2):e133–8. Wei Y, et al. Vascular anatomy and clinical application of
Cobbett JR. Free digital transfer. Report of a case of trans- the free proximal ulnar artery perforator flaps. Plast
fer of a great toe to replace an amputated thumb. J Bone Reconstr Surg Glob Open. 2014;2(7):e179.
Joint Surg Br. 1969;51(4):677–9. Yu P, Chang EI, Selber JC, Hanasono MM. Perforator
Inada Y, et al. Free dorsoulnar perforator flap transfers for patterns of the ulnar artery perforator flap. Plast
the reconstruction of severely injured digits. Plast Reconstr Surg. 2012;129(1):213–20.
Reconstr Surg. 2004;114(2):411–20.
Kim SW, Jung SN, Sohn WI, Kwon H, Moon SH. Ulnar
artery perforator free flap for finger resurfacing. Ann
Plast Surg. 2013;71(1):72–5.
Complete Brachial Plexus Lesion:
Multistaged Reconstruction 58
of the Sensory-Motor Function
Christian Heinen and Karthik Krishnan
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626
Third Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628
First Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
Second Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630
Third Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631
Fourth Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632
Third Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634
Fourth Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634
Outcome, Clinical Photos, and Imaging: Functional and Aesthetic Outcomes . . . 634
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
Abstract
C. Heinen (*) Complete lesions of the brachial plexus are

Department of Neurosurgery, University of Oldenburg difficult to treat and have a deep impact on
Evangelisches Krankenhaus, Oldenburg, Germany
patient’s life. The main problem is the lack of
e-mail: christian.heinen@uol.de
axon donors to facilitate useful and
K. Krishnan
encompassing reinnervation. Therefore, all
The Division of Neurosurgery, Frankfurt-Main-Taunus-
Hospital, Bad Soden, Frankfurt, Germany

https://doi.org/10.1007/978-3-030-23706-6_57
626 C. Heinen and K. Krishnan
available modalities need to be combined to Preoperative Problem List/

enable best possible results for the patients. Reconstructive Requirements
A young woman presented with a complete
brachial plexus lesion after motor cycle accident 1. Assessment of available axon donors
undergoing a multistaged reconstruction. The 2. Assessment of recipient quality
first operation consisted of an ipsilateral combi- 3. Prioritization of movement reconstruction fol-
nation of autologous grafting and nerve trans- lowing patient’s individual requirements
fers for shoulder and arm flexion 10 weeks after • Dynamic shoulder stabilization
trauma. During the second session, a nerve • Arm flexion/extension
transfer of the contralateral c7 spinal nerve and • Hand flexion/extension
the ipsilateral intercostal nerves 3 and 4 to the • Finger flexion/extension
median nerve on the affected nerve 14 weeks
after trauma was performed. To enhance grip
strength, during a third surgery a graft was Treatment Plan
placed from lateral pectoral nerve to prepare
for a free functional muscle transfer in a fourth After intense counselling, the plan for surgical
session. Throughout no complications and espe- reconstruction was set. The first stage consisted
cially no donor deficits occurred. of the exploration and reconstruction of the bra-
The patient regained a stable and active chial plexus using the ipsilateral axon donors
shoulder, arm flexion, wrist extension, and 10 weeks after trauma. The main goal was
grip. Furthermore, using an orthosis as a third dynamic shoulder stabilization and elbow
treatment modality function could be improved flexion.
significantly. During the second stage 14 weeks after trauma,
attention was drawn to the sensomotory resusci-
tation of the hand using ipsilateral intercostal
Keywords
nerves and the contralateral c7 spinal nerve.
Brachial plexus lesion · Nerve grafting · Nerve The clinical course showed reinnervation of
transfer · Free functional muscle the hand. However, the grip power and endurance
did not suffice. Thus, a third stage was scheduled
2.5 years after trauma. A nerve graft was coapted
The Clinical Scenario to the ipsilateral lateral pectoral nerve and brought
into a subcutaneous area at mid-arm level, thus
A 16-year-old young woman suffered from a preparing for the fourth stage – a free functional
severe motor cycle accident. Besides fractures of muscle transfer to enhance grip strength (sched-
the right radius, a compartment syndrome of the uled for end of 2019).
right hand had to be treated surgically. In addition,
the femur, tibia, and ankle were fractured on the
right side and required osteosynthesis. Wound Alternative Reconstructive Options
healing of the right leg was complicated as the
patient needed skin transplantation. Single staged nerve transfer only surgery without
At first presentation 4 weeks after trauma, the brachial plexus exploration: The main disadvan-
clinical exam revealed a subtotal brachial plexus tage is the neglect of possible powerful axon
affection with only some C5 function in the rhom- donors such as the spinal nerves and the possibil-
boid and levator scapulae muscles left. From the ity of neurolysis to improve function. The patient
elbow on there was complete loss of sensory regained active wrist extension although c7 was
function (Fig. 1). avulsed. This can only be due to c8 innervation
58 Complete Brachial Plexus Lesion: Multistaged Reconstruction of the Sensory-Motor Function 627
Fig. 1 Schematic drawing of the preoperative situation and the surgical strategy of the nerve reconstruction
after meticulous removal of the compressive scar.

The advantage of nerve transfers is the mostly Preoperative Evaluation and Imaging
short distance from axon donor the recipient mus-
cle (e.g., Oberlin transfer/Somsak procedure) Aside from careful assessment of patient’s his-
(Oberlin et al. 1994; Leechavengvongs et al. tory, the clinical exam is crucial. As described,
2003; Hu et al. 2018). there was a complete loss of motor function and
Arthrodesis/primary muscle tendon or free mus- atrophy of the right arm muscles with the excep-
cle transfers without nerve surgery: As the patient tion of levator scapulae and rhomboid muscles
presented early after trauma (4 weeks), nerve (c5-innervated). Trapezius muscle was intact too
reconstruction to allow for reinnervation of the (accessory nerve-innervated). From the elbow on
“original” muscles and thus active movement with- to the fingers, sensory function was completely
out the need to weaken other body functions by lost.
harvesting muscles or tendons was performed. Fur- In addition, electrophysiology was performed.
thermore, wound healing of the legs was not com- EMG showed denervation activity without signs
plete, impeding harvesting of the gracilis muscle. of reinnervation in deltoid/biceps/triceps/thenar
Amputation: We generally refrain from ampu- and hypothenar 4 weeks after trauma. The exam
tation in brachial plexus patients as reconstructive was repeated on admission (4 weeks later) with no
techniques have improved allowing for significant changes.
daily life function. It goes against our principles of The main imaging modality is MRI to detect
reconstructive microsurgery. root avulsions or ruptures and extraspinal
alterations. In our patient MRI of the right-sided active abduction beyond the horizontal was not
plexus revealed avulsion of c6 and c7 and a mas- possible owing to joint stiffness (apparently pas-
sive paraspinal scarring. sive movements of the shoulder joint above the
horizontal is possible during intensive phases of
physical therapy, when the joint has been mobi-
Preoperative Care and Patient lized). Internal rotation of the shoulder (major
Drawing pectoral muscle) accounted to grade 4+/5,
whereas external rotation (infraspinatus) was
In general, this kind of operations is performed in none. Axillary grip (latissimus dorsi and teres
a microsurgical setting using a microscope, nerve major) was quite weak with grade 2/5, whereas
stimulation, and intraoperative electrophysiology the rhomboids and levator scapulae muscles
(NAP/EMG) (Tiel et al. 1996). Patients receive showed a strength of 4+/5. Elbow extension (tri-
standard single-shot antibiotics which are ceps) was 4/5, and elbow flexion was grade 4+/5
renewed after 4 h. (mainly operated by biceps, the role of
The first surgery was performed in a supine brachioradialis in stabilizing the elbow flexion
position with a pillow placed between both scap- was unclear). At this point, wrist flexion was
ulae to give better supraclavicular access. Both 1/5; flexion of index to little fingers was 2/5.
legs were prepared for harvesting of both sural Extension of wrist, fingers, and thumb and
nerves as autologous grafts using a special thumb abduction was absent (grade 0/5).
TARZAN drape. Skin incisions were right-sided The reconstructive strategy for this individual
supraclavicular and infraclavicular and at the patient at this point was as follows:
proximal medial upper arm enabling complete
brachial plexus exposure from its origin to the (1) Improve grip function of the hand (possible
main nerves. at this stage only by means of free muscle
During the second stage surgery, a supine posi- transfer in two sub-stages. The first
tion was chosen. Both legs were prepared for sub-stage will bring in a motor axon donor
bilateral saphenous nerve harvesting (again (in this case the lateral pectoral nerve) as near
TARZAN drape). In addition, a skin incision as possible to the site of inset of the free
was planned in the medial axillary line to access muscle using a nerve graft. After this first
the intercostal nerves. For the contralateral c7 sub-stage, approximately 6–8 months are
transfer, a supraclavicular skin incision was allowed for the axonal endplate to grow
placed on the left side. The right infraclavicular from the proximal nerve suture area between
was prepared for the median nerve coaptation (see the graft and the lateral pectoral nerve. This
Figs. 2 and 3a–d). can be clinically tested by the migration of the
Tinel’s sign from the point of the proximal
nerve suture along the course of the graft with
Third Stage passage of time. In other words, when the
patient is reexamined 4–6 months after the
The patient is reevaluated in periodical intervals, grafting, the Tinel’s sign will have migrated
in order to study the development of the individ- to a more distal point along the nerve graft.
ual muscles or muscle groups reinnervated during When the Tinel’s sign has reached the distal
the previous stages. The following biomechanical scar, where the nerve has been submerged, the
functional result was documented at a repeat exam second stage is warranted. A more modern
4 years after initial injury, physical examination also more complex instrumental method to
showed the following results: shoulder elevation check the level of the axonal endplate is to
(trapezius)- grade 5/5, shoulder abduction was perform a high-resolution MR-neurography
possible till approximately 60 (supraspinatus) with peripheral nerve fiber tracking. This
and till the horizontal (deltoid) with grade 3/5; method, however, is quite cumbersome and
Access right sural and bilateral

saphenous nerves
subcutaneous graft route
access intact
supraclavicular C7
affected side
Fig. 2 Positioning and draping for contralateral C7 procedure
has not been established yet. The simple clin- made of thermoplastic with soft padding or
ical test of the migrating Tinel’s sign has been by internal means by arthrodesis of the thumb
evidence enough for proceeding with the sec- in a physiological position.
ond sub-stage. The second sub-stage consists (3) Wrist joint stabilization in a physiologically
of moving a free vascularized and innervated semi-extended position – either external or
muscle flap (preferably the gracilis muscle) to internal. This will enhance the functionality
the forearm, thereby connecting the proximal of the transplanted free muscle.
end of the muscle either to the medial (4) Reanimation of shoulder joint external rota-
epicondyle or the brachioradialis muscle itself tion by means of tendon or muscle transfer.
at the distal third of the arm and then
connecting the tendon of the gracilis muscle
to the deep flexors of the fingers Surgical Technique
“commonized into one,” thus resulting in a
global finger flexion, reinnervating the free First Stage
muscle flap by means of micro-neurorrhaphy
between the motor nerve of the muscle and the Dissection was started with the supraclavicular
distal end of the graft that was placed and left plexus following the anatomical landmarks
subcutaneously 6–8 months ago and lastly by (sternocleidomastoid muscle, omohyoid muscle,
revascularizing the muscle flap by micro- anterior scalene muscle, phrenic nerve, subclavian
anastomosing the flap vessels to the brachial artery). Subsequently, the plexus was dissected:
vessels or its branches/tributaries (there is a c5-th 1 spinal nerves and superior, middle, and
rich choice) at the recipient site. The technical inferior trunk and their ventral and dorsal divi-
aspects of these sub-stages are described else- sions. There was massive scarring of the superior
where (vide infra) and middle trunk; however the suprascapular
(2) Improve thumb opposition either by means nerve could be identified and prepared as a recip-
of an external stabilizing custom-orthosis ient. Cutting back c5 was considered to be useful,
a b
C8/Th1/ inferior trunk C8/Th1/ inferior trunk
C7/ middle trunk

C7/ middle trunk
bipolar super-selective stimulation probe bipolar super-selective stimulation probe
c d
sural nerve graft

cut hemi-C7/ middle trunk
intact dorsolateral hemi-C7/ middle trunk
cut ventromedial hemi-C7/ middle trunk
suture site
Fig. 3 (a + b) show the super-selective bipolar stimulation probe); (c), showing the cut aspect of the ventromedial
of the supraclavicular plexus for identification of the C7; (d), showing the suture site with the graft
proper axon donor site (asterisk: bipolar stimulation
whereas c6 and 7 were destructed. The scar of nerve transfer from the accessory nerve via 4 cm
inferior trunk was removed. The accessory nerve graft to the suprascapular nerve. A 10-0 Black
was identified using the same supraclavicular Nylon and additional fibrin glue were used.
access.
Then, the infraclavicular plexus was explored.
The musculocutaneous nerve showed an addi- Second Stage
tional distal lesion proximal to entrance point
into the coracobrachialis muscle. The common In this stage, dissection of the healthy left supra-
origins of axillary and thoracodorsal, the ulnar clavicular plexus using the same landmarks was
and the median nerves, were identified. The performed. In addition, deltoid/biceps/latissimus/
medial cutaneous antebrachial nerve was prepared triceps/pectoralis major/wrist and finger flexors
for grafting. and extensors were provided with EMG needles
Both sural nerves were harvested for grafting on the left side. Intraoperatively, a bipolar stimu-
via a small incision using the nerve stripper. lation at 1.5 mA was used to assess the individual
Nerve coaptation consisted of c5 via 22 cm innervation pattern of each spinal nerve. C7 sup-
graft to the musculocutaneous nerve distal to the plied most of the triceps and finger extensors
neuroma, 2 12 cm graft from c5 to the common impeding a complete c7 transfer. The ventrome-
origin of axillary and thoracodorsal nerve, and dial aspect of c7 mainly provided the major
pectoral together with c6. Therefore, only this has been transected. Using a nerve stimulator with
aspect of the contralateral c7 was used. a stimulation strength of 1 A, the soft tissue is
Then, the right intercostal nerves 3 and 4 were explored in a blunt fashion. Usually the nerve is
identified. Microsurgical coaptation was found immediately medial to the pulsating artery
performed as follows: contralateral ventromedial but can show some variations. This is the lateral
aspect of c7 via 32 cm graft and subcutaneous pectoral nerve, the stimulation of elicits EMG
route to the right infraclavicular median nerve potentials from the major pectoral muscle.
and 10 cm graft from intercostal to right median Depending on the caliber, either the main trunk
nerve covering the complete diameter. of the nerve or one or two of its branches is slung
with a veseloop. The axon donor is transected
now, the graft is brought to this site, and one end
Third Stage of the graft is sutured to the axon-donor under
microscope magnification using 10-0 non-
Also please refer to the discussion of the strategic absorbable monofilament sutures (Ethilon –
rationale for these two stages (vide supra). Ethicon®) and tissue glue (Tisseal ® – Baxter).
Pectoralis major muscle had a strength of 4+/5, Now another skin incision is made at a spot on
which is a clinically apparent evidence that the the medial aspect of the arm between its middle
lateral pectoral nerve contains viable motor axons, and lower thirds. A subcutaneous tunnel is created
which can be used to reinnervate the free muscle between this wound and the clavicular wound and
flap used at a later stage for enhancing grip. How- a suture is pulled though. The end of the suture is
ever, the lateral pectoral nerve is anatomically tied to the distal end of the graft at the clavicular
located too far away for a direct neurorrhaphy incision, and the graft is pulled through to the
with the motor nerve of the free muscle flap. distal would. The distal end of the nerve graft is
Thus, a nerve graft is required between the wrapped in a colored silicon flap (usually used a
motor axons of the lateral pectoral nerve and the background whilst performing microsutures), so
motor nerve of the free muscle flap. If one would that this can be easily found during the second
decide to do this in one stage, the sprouting motor sub-stage, when the free muscle flap will be
axons might never get to the target free muscle brought to the forearm. The technique for
flap at a time point when the muscle still remains harvesting the nerve graft is as follows: both the
receptive (it has to be taken into account dener- sural nerves and almost both the saphenous nerves
vated muscles tend to atrophy and transform have been utilized in this patient already during
themselves into connective tissue, when the inner- the earlier stages of reconstruction. Judging from
vation is not reestablished in a timely manner). the scars, a good measure of 20 cm of the saphe-
This is the reason why the free muscle transfer for nous nerve was still available on the right side.
enhancing grip is delayed in two sub-stages. This is harvested as follows: a lazy-S skin incision
Through a horizontally placed incision along the is placed on the medial aspect of the lower third of
lower border of the clavicle, the insertion of the the thigh along an imaginary line that connects the
pectoralis major muscle to the lateral aspect of the medial most aspect of the pubic symphysis to the
clavicle is divided. Careful microsurgical dissec- medial femoral condyle. The saphenous nerve is
tion is carried out proceeding into the depth along found in the subcutaneous area along this projec-
the imaginary line joining the acromioclavicular tion line with an error of 1–2 cm in the anterior-
joint to the nipple of the ipsilateral side. This is the posterior axis. Once this nerve has been identified,
projection line of the lateral pectoral nerve. Micro- it can be slung in a veseloop and traced proximally
surgical dissection is either using a 3.5 magni- as far as required, extending the skin incision as
fying surgical loupes or an operating microscope, required. The Assmus ® nerve stripper (Aesculap,
depending of personal preference. The pulsating Germany) can be used for this purpose from this
lateral pectoral artery is always present at this point onward (REF – Krishnan-Stripper). All
area, once the inner layer of the muscle insertion wounds are closed in layers after achieving
meticulous hemostasis. The wound at the mid-arm interphalangeal joints of the fingers and the
level, where the distal end of the nerve-graft has thumb. A subcutaneous tunnel is made between
been left subcutaneously, should be closed in a the wound in the forearm region and the one at the
rough fashion using heavy non-absorbable suture mid-arm level, where the free muscle flap will be
material in order to encourage rough superficial lodged. For a description of the harvest of the free
scarring and ease the re-identification of the nerve muscle flap vide infra.
graft during the second stage. The free muscle flap is inserted between the
two wounds. The tendon of the FMT is sutured to
the isolated FDP and FPL in the Pulvertaft fashion
Fourth Stage (the tendon is woven into the other tendons and
secured using 2-0 Ethibond ®, non-absorbable,
In this particular case, the fourth stage, namely, braided synthetic suture). The alternative is to
the free functional muscle transplant has not yet use silk. The proximal part of the muscle flap is
been performed. However, the surgical operation fixed to the biceps muscle midway in the arm. The
is described here as it is usually performed, so as resting tension of the muscle is given thus. Now
to enable the reader a certain continuity of the microvascular anastomoses between the artery
thought. of the FMT and the brachialis artery is performed
The preparation of the recipient area for the free end-to-side using 9-0 Ethilon ®, non-absorbable,
muscle transfer (FMT): The patient is positioned monofilament sutures. As soon as the micro clamp
supine and the arm is abducted on a hand table. The is released from the artery, good perfusion should
rough-scarring from the previous stage at the be observed, and there should be immediate abun-
mid-level of the arm is excised and reopened, so dant venous return through both the flap veins.
as to identify the colored silicon flap immediately. Initially the venous return is quite dark in color as
The nerve end, which was also marked with a compared to the bright red of the arterial blood. If
non-absorbable suture, is left wrapped inside this a brisk venous return is not observed, check the
silicon flap. Usually one sees a stump neuroma at arterial anastomosis again, and redo it if
this end, which is a good sign of axonal regenera- necessary.
tion. Some surgeons prefer to take a biopsy of the Now the veins are connected using the same
nerve end at this point, close up the wound again, fashion. The venous anastomoses can be
and wait for the results to see if viable axons are performed in an end-to-end fashion. It possible
available here. This approach is evidence based. both veins are anastomosed separately. If the
The presence of the stump neuroma and the long- draining vein is quite large, a so-called confluence
time lapse between the nerve lengthening graft and anastomosis can be performed. Both the venae
this stage, however, are evidence enough to pro- comitantes are connected to each other in a half
ceed with the FMT surgery. side-to-side fashion, thereby creating a common
Now the wound is extended both proximally confluence exit orifice. Now this orifice is
and distally in a zig-zag fashion. The brachial connected to the recipient vein either end-to-end
artery and the comitant veins as well as several (end-to-end-confluence anastomosis) or end-to-
subcutaneous veins are microsurgically prepared side (end-to-side-confluence anastomosis).
for anastomoses. A patty soaked in 0.2% Many surgeons connect only one vein at the
papaverin solution is placed until the time of anas- recipient site. This is usually quite sufficient.
tomoses in order to dilate the microvessels. Now a However, connection of two veins decrease the
separate zig-zag incision is made on the border probability of muscle edema during the immedi-
between the middle and lower third of the forearm ate postoperative phase and has served well over
on the volar aspect. Here the tendons of the flexor the years, especially in cases of facial reanimation.
digitorum profundus (FDP) and the flexor pollicis After finishing the vascular anastomosis, the anes-
longus (FPL) can be easily detected by tugging at thetist is asked to administer 5000 IU of heparin
them and observing the flexion of the distal intravenously as a one-time dose.
Once the vascular anastomoses are established pulled through to the proximal incision. Now the
and functioning well, the nerve suture is under- major vascular pedicle of the gracilis flap is
taken between the nerve of the free muscle flap microsurgically followed to its origin either
and the end of the axon-donor implanted during from the medial femoral circumflex vessels or
the previous stage. from the profunda femoris vessels and transected
A Blake drainage with mild suction is intro- there between ligature clips. It is only now that
duced at the area of the muscle and leave it for the proximal attachment of the gracilis muscle is
2 days. transected using bipolar cautery and sharp dis-
Harvest of the free functional gracilis muscle section. Now the entire gracilis muscle has been
flap: The patient is supine, the hip-joint of the harvested as a free functional muscle flap for
FMT donor lower extremity externally rotated, transplantation. A heavy number 15 Blake drain-
the knee mildly flexed, and the foot everted and age is placed on the loge of the harvested muscle.
placed on a gel-pillow. This exposes the inner The wounds are closed in layers. The harvested
aspect of the thigh. The innermost point of the muscle is kept wrapped in a mildly cool towel
pubic symphysis is marked and joined with a until the time it is inset into the recipient area.
straight line with the medial femoral condyle. The ideal time to revascularize the muscle flap is
The gracilis is located 2/3 posterior to this line within the next hour after harvest.
and 1/3 anterior. A point 6–7 cm from the inner-
most aspect of the pubic symphysis marks the
entry point of both the major vascular pedicle Technical Pearls
and the motor nerve. Gracilis muscle has one
dominant vascular pedicle and 3–4 smaller sec- Orientation using the anatomical landmarks and
ondary pedicles located along the distal course of respecting the surgical planes allows for safe and
the muscle. It is quite sufficient to use only the quick dissection even in massively scarred tissue.
major vascular pedicle. The skin incision is placed Microsurgical technique is mandatory in bra-
on the medial aspect of the upper third of the thigh chial plexus surgery.
directly on top of the gracilis muscle. The gracilis The combination of anatomic features and
muscle can be easily identified as being of medial intraoperative electrophysiology enhances the
most muscle approximately 8–12 cm in width at assessment of depth of trauma (Kline 2008;
this level. Beware that the gracilis may be absent Millesi et al. 1993). Furthermore, intraoperative
in 0.1–0.5% of the cases. During approximately ultrasound gives direct visual information
300 gracilis harvests for various purposes, the (Koenig et al. 2011).
absence of this muscle was encountered in one Proper positioning allowing for access to both
case only; the adductor longus was used in this plexus and grafts should be considered.
case as a substitute. Once the gracilis is freed
from its attachments, it is medialized, and the
vascular pedicle is identified immediately and Postoperative Management
the lateral inner aspect of the muscle at the
marked place. The nerve is stimulated with For the first and second stage surgery, the patient’s
0.1 mA nerve detector and asserted that this is affected arm is put into a sling. No antibiotics are
indeed the motor nerve of the gracilis muscle. administered routinely; only prophylactic anti-
The nerve is followed proximally toward the thrombotic low-dose heparin is given.
obturator foramen transected as high as possible Patients are instructed to have maximal passive
to gain a long nerve pedicle length. Now the mobilization of 20 in each movement axis for
muscle itself is distally followed, thereby trans- 3 weeks to protect the suture sites. After these
ecting all the secondary vascular pedicles. The 3 weeks, patients are scheduled for physiotherapy,
tendon is transected through a separate incision ergotherapy, and electrostimulation for at least 2.5
on the medial aspect of the knee. The tendon is years with a minimum of 4 sessions per week.
Third Stage triceps MRC 3/5 and supraspinatus MRC 2/5;

4 months later elbow flexion was MRC 3/5. The
After the inset of the lengthening nerve graft as patient could flex her fingers 12 months after the
preparation for the free muscle flap, the patient is contralateral c7 with co-contraction of the contra-
encouraged to passively or actively move his lateral pec major. Hand extension was possible
extremity as soon as possible, in order to prevent 36 months after the first surgery. At the same
joint contractures. The use of exponential current time, the median nerve provided part of the hand
after nerve grafting has been shown to not only regained sensory function.
prevent synapse degeneration in muscle tissue but However, thumb opposition and grip strength
also enhance axonal sprouting and growth. This is still did not suffice patient’s needs. Therefore,
recommend even though the nerve has not been stage 3 and 4 were scheduled.
connected yet to a target muscle. Furthermore, the In the following, postoperative photos, poten-
joints to be reanimated are kept supple by means tial complications and relevant photos, videos and
of physical therapy. Dressings are changed during imaging are presented.
the first day to look for signs of any bleeding. If (see Fig. 4a –f).
none found, then the dressings are changed only
as per soiling.
Fourth Stage When performing the contralateral c7, meticulous

intraoperative electrophysiological assessment of
The recipient arm is placed above heart level to the individual innervation pattern of the healthy
encourage venous drainage and prevent edema. In plexus is mandatory. Using a superselective tech-
the beginning heparin was applied intravenously nique, the ventromedial pec major providing aspect
as a continuous perfusor and double the PTT of the c7 spinal nerve can be identified and used for
value (60 s) as compared to the initial levels. the transfer without a high risk of functional loss.
This had sometimes (rarely) led to bleeding, espe- The correct positioning is crucial. It should
cially after bone transplants. As a consequence, allow for proper access to the complete plexus
this practice was left altogether. Presently, a body (supra- and infraclavicular as well as axillar and
weight-adapted Clexane twice daily (2 40 mg upper arm) and possible axon donors (accessory
s.c. injections) for the first 5 days is administered, nerve/intercostals/contralateral plexus). In addi-
and the patient is put on aspirin 100 mg once daily tion, enough grafts should be accessible (bilateral
for 3 months. The drains are removed after 3 days. sural/saphenous nerves/cutaneous arm nerves,
If the wounds appear normal, the dressings are etc.) without the need of reposition or re-draping.
changed only upon soiling. No physiotherapy is Nerve coaptations should be tension-free, and,
administered during the first 4 weeks, in order to if possible, an “overgrafting” should be performed.
allow the muscle and the tendons to heal. After Preventive steps, technical details to avoid com-
that mild physical therapy is begun. plications and recovery problems, management of
postoperative problems and complications, and
potential reoperations are described.
Outcome, Clinical Photos,
and Imaging: Functional and Aesthetic
Outcomes Learning Points
The immediate postoperative courses after all stages 1. Timing is essential and time is muscle.
were uneventful with early mobilization on the first 2. Early presentation and intense assessment of
postoperative day. All wounds healed per primam. the depth of trauma including clinics, imaging,
The first clinical signs of recovery appeared and electrophysiology allows for early inter-
already 8 months after the first surgery with ventions and better results.
Fig. 4 Postoperative results 18 months after the contralateral c7 procedure, before muscle transfer
3. Combination of all available reconstructive Kline DG. Nerve surgery: where we are and where we
modalities warrants best outcome for patients; might go. Neurosurg Clin N Am. 2008;19(4):509–16–v.
Koenig RW, Schmidt TE, Heinen CPG, Wirtz CR,
thus it should not be limited to just one Kretschmer T, Antoniadis G, et al. Intraoperative
technique. high-resolution ultrasound: a new technique in the
4. Long-term follow-up is required to assess the management of peripheral nerve disorders.
quality of improvement and to recognize the J Neurosurg. 2011 Feb;114(2):514–21.
Leechavengvongs S, Witoonchart K, Uerpairojkit C,
necessity of further treatment. Thuvasethakul P. Nerve transfer to deltoid muscle
5. Intense and long-term physio-/ergotherapy in using the nerve to the long head of the triceps, part II:
combination with electrostimulation is crucial a report of 7 cases. J Hand Surg. 2003;28(4):633–8.
for the success. Millesi H, Rath T, Reihsner R, Zoch G. Microsurgical
neurolysis: its anatomical and physiological basis and
its classification. Microsurgery. 1993;14(7):430–9.
Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge
References MC, Sarcy JJ. Nerve transfer to biceps muscle using a
part of ulnar nerve for C5-C6 avulsion of the brachial
Hu C-H, Chang TN-J, Lu JC-Y, Laurence VG, Chuang plexus: anatomical study and report of four cases.
DC-C. Comparison of surgical strategies between prox- YJHSU. 1994;19(2):232–7.
imal nerve graft and/or nerve transfer and distal nerve Tiel RL, Happel LT, Kline DG. Nerve action potential
transfer based on functional restoration of elbow flex- recording method and equipment. Neurosurgery.
ion. Plast Reconstr Surg. 2018;141(1):68e–79e. 1996;39(1):103–9.
Adult Immediate Brachial Plexus
Reconstruction 59
Lukas Pindur and Andrés A. Maldonado
Contents
Preoperative Problem List/Reconstructive Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
Time of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
Available Donor Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
Treatment Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
Supplementary Information: The online version

contains supplementary material available at [https://doi.
org/10.1007/978-3-030-23706-6_59].
L. Pindur
Department of Plastic, Hand and Reconstructive
Microsurgery, BG Trauma Center, Frankfurt am Main,
Germany
Academic Hospital of the Goethe University, Frankfurt am
Main, Frankfurt am Main, Germany
A. A. Maldonado (*)
Department of Plastic, Hand and Reconstructive
Microsurgery, BG Trauma Center, Frankfurt am Main,
Germany
Academic Hospital of the Goethe University, Frankfurt am
Main, Frankfurt am Main, Germany
Department of Plastic Surgery, University Hospital Getafe,
Madrid, Spain
e-mail: Mail@andresmaldonado.es

https://doi.org/10.1007/978-3-030-23706-6_59
638 L. Pindur and A. A. Maldonado

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 648
Abstract examination (Video 1, 2, and 3) and imaging, the

Brachial plexus injuries are one of the most following diagnoses were made: lesion of bra-
complex nerve injuries. Each of these injuries chial plexus, a displaced fracture of the humerus
has its own unique characteristics as well as shaft, nondisplaced fractures of the transverse
typical findings. During the first 6 months after vertebral processes C4 to C7 and bilateral lung
the injury (immediate reconstruction), a broad contusion. The patient showed a deficit in the
spectrum of surgical techniques is available: shoulder abduction (Fig. 1a) and external rota-
nerve grafts, nerve transfers, tendon transfers, tion as well as elbow flexion (Fig. 1b), typical for
free functioning muscle transfer, etc. When the C5–C6 injury. Additionally, loss of active elbow
time from injury to surgery is greater than extension pointed to the possible involvement of
9–12 months (delayed or secondary recon- the C7 segment. The MRI showed an avulsion of
struction), some of these reconstructive options C7 with the presence of traumatic pseudo-
are not available. While reconstructive options meningocele while there were no signs of avul-
offered are often based on surgeon preferences sion of C5, C6, C8, and T1. As such, the lesion
and his/her educational background, it seems could be classified as C5–C7 injury, or “Erb’s
best to optimize outcomes by combining a plus” pattern. The injury pattern as confirmed
variety of surgical techniques spanning differ- later intraoperatively and the mechanism of
ent surgical disciplines in a team approach to injury of the high-energy trauma with an impact
reconstruction. on the shoulder with a widening of the shoulder-
This chapter will attempt to highlight the neck angle leading to traction on the upper part of
current strategies and techniques for an imme- the brachial plexus are shown in Fig. 1c. The
diate brachial plexus injury. As an example, the humerus shaft fracture was treated by the ortho-
upper trunk scenario will be reviewed. Patient pedic surgeon by open reduction and plate fixa-
selection, the timing of surgery, prioritization tion. The fractures of the transverse vertebral
of restoration of function, and the available processes did not require any specific therapy
donor nerves will be discussed. while lung contusion healed spontaneously
under supportive therapy.
Keywords
After a 4 months period of observation, the
patient presented no signs of spontaneous restora-
Brachial plexus · Nerve injury · Nerve tion of the paralyzed muscles innervated from
transfer · Nerve graft · Upper trunk segments C5 and C6 after the injury while the
elbow extension improved from initial complete
palsy (M0) to full range of motion against gravity
The Clinical Scenario and reduced resistance (M4). The rest of the fore-
arm and hand musculature were fine (M5). The
A 20-year-old man sustained an injury to the right sensibility of all fingers was reduced with follow-
shoulder and neck region after a motorcycle acci- ing 2-point discrimination: thumb and index fin-
dent (>100 km/h). After an initial physical ger >15 mm, middle, ring, and little finger 8 mm.
59 Adult Immediate Brachial Plexus Reconstruction 639
a b
Fig. 1 (a) Persistent loss of active shoulder abduction flexion (M0) on the right side 4 months after the injury. (c)
(deltoid and suprascapular muscles M0) on the right side Illustration of the injury pattern: postganglionic C5–C6
4 months after the injury. (b) Persistent loss of active elbow roots and preganglionic C7 root injury
the coronal plane with elbow flexion) which limits

functional use of the upper extremity (Elhassan
Reconstructive Requirement et al. 2010). After elbow flexion and shoulder
stability/external rotation are restored, the func-
After any brachial plexus injury (BP), elbow flex- tional priorities become even more controversial.
ion is widely accepted as the most important func- If rudimentary hand function is a goal such as in
tion to restore after a pan-plexus injury (Brophy pan-plexus injury (not in our case as the nerves for
and Wolfe 2005). Following the successful resto- muscles of the hand and forearm were largely
ration of elbow flexion, subsequent functional spared), FFMT can be performed spanning both
priorities of reconstruction are debated. Shoulder shoulder and elbow joint on the anterior aspect.
function is the second priority, and specifically the The insertion of the FFMT (typically gracilis mus-
restoration of external rotation. The lack of shoul- cle) is on the clavicle/acromion proximally and to
der external rotation leads to the “hand-on-belly” the FDP- and FPL-tendons distally. In order to
position (the hand cannot be rotated anteriorly to make the flexion of the fingers effective the
elbow must be stabilized with a functioning elbow strengthen functioning muscles. Concomitant
extensor. Therefore, the triceps reinnervation is of injuries like rib or upper extremity fractures
utmost importance. Finally, the protective sensa- should also be considered.
tion should be considered as a goal. In the case here presented, biceps and shoulder
In summary, in the case here presented, the muscles did not show any sign of recovery. Inten-
reconstructive problems/requirements are as sive physical therapy was started from the begin-
follows: ning to avoid contractures. Finally, the humerus
fracture was treated by the orthopedic surgeon by
1. Loss of elbow flexion (denervated biceps open reduction and plate fixation.
brachii, brachioradialis and brachialis muscle).
2. Loss of shoulder abduction (denervated supra-
spinatus and deltoid muscle). Time of Surgery
3. Loss of shoulder external rotation (denervated
infraspinatus muscle). The timing is the second key factor. It is
4. The requirement to restore elbow flexion, influenced by the mechanism and type of injury,
shoulder abduction and external rotation physical examination, imaging findings, and sur-
through reinnervation of the denervated mus- geon preferences. Operating early may not allow
cles before complete and irreversible degener- sufficient time for spontaneous reinnervation but
ation of motor end-plates occurs (by 18 months waiting too long before operating may compro-
after injury). mise the viability of the motor endplate and
decrease the chances of successful reinnervation.
Early exploration and reconstruction (between
Treatment Plan 3 and 6 weeks) are indicated when there is a
high suspicion of a root avulsion. Routine explo-
BP and many peripheral nerve injuries are com- ration is performed 3 to 6 months after a plexus
plex lesions with a wide spectrum of reconstruc- injury in patients who have not demonstrated ade-
tive options. A multispecialty and multimodal quate reinnervation. Outcomes following delayed
approach is key to optimize the best treatment. (6 to 12 months) or late (>12 months) surgery are
Moreover, other critical concepts need to be con- poorer because the time for the nerve to regenerate
sidered prior to surgical treatment such as patient to the target muscles is greater than the survival
selection, timing, and prioritizing of restoration of time of the motor endplate after denervation. The
function (Shin et al. 2005; Giuffre et al. 2010, ideal timing for surgical reconstruction is within
2015). 6 months after injury (Shin et al. 2005; Giuffre
et al. 2010, 2015).
In our case, several facts indicated that high-
Patient Selection grade nerve injury occurred warranting an early
exploration and reconstruction. Firstly, the
Surgery should be performed in the absence of mechanism of injury. During a high energy
clinical or electrophysiological evidence of recov- trauma such as a motorbike accident with a
ery or when spontaneous recovery is not antici- velocity of over 100 km/h more severe nerve
pated. Despite improvements in electrodiagnostic injury is likely. Secondly, accompanying inju-
studies and imaging, selecting when and on whom ries – fractures of transverse vertebral pro-
to operate remains one of the most difficult deci- cesses, humerus fracture, and bilateral lung
sions in peripheral nerve surgery. During the contusion also point to considerable severity of
observation period (from the time of injury to the injury. Lastly and most importantly, lack of
6 months post-injury), physical therapy should any signs of clinical and electrophysiological
be performed to prevent contractures and to reinnervation.
Available Donor Nerves grade lesions (Sunderland II–III) with good

potential for spontaneous regeneration necessi-
Before planning the reconstruction, it is important tating only external neurolysis. A specialized
to know which nerves are available for potential neurophysiologist or a neurologist should be pre-
transfer and which nerve roots are anticipated to sent during the surgery and help with the
be viable for grafting. In a panplexus avulsion decision-making process.
(preganglionic) injury, there are typically only
two extraplexus donor nerves that can be poten-
tially used: spinal accessory nerve (SAN) and Treatment Goals
intercostal (motor and sensory) nerves (ICN).
While the phrenic nerve has been described as a Restoration of the elbow flexion is the primary
reliable and safe donor nerve for transfer (Gu et al. goal in the reconstruction of the upper extremity.
1989; Luedemann et al. 2002), not all centers use In 1994, Oberlin (Oberlin et al. 1994) described a
it routinely. In an upper trunk injury (such as the novel nerve transfer of a portion of the normal
case here presented), multiple donor nerves are ulnar nerve to the biceps motor branch of the
available. Typically the spinal accessory nerve, musculocutaneous nerve to restore elbow flexion.
pectoral nerves, and selected motor fascicle from The outcome of this procedure (carrying the
the median or ulnar nerve are used as donor eponym of the senior author – “Oberlin proce-
nerves. A motor branch of the radial nerve to the dure”) has resulted in excellent elbow flexion
long triceps head (Leechavengwong procedure) recovery with minimal deficits in the ulnar nerve
or other triceps motor branch, which would nor- distribution for patients with C5–C6 or even
mally be potential donors for the axillary nerve in C5–C7 BP injuries (Tsai et al. 2015) The idea
C5–C6 injuries, was not preferred in this case as introduced by Oberlin was a revolutionary con-
there was an avulsion of the C7 segment and cept: BP injuries are not treated where the injury is
although the radial nerve receives a contribution (in the nerve roots), but distal to it. This allowed
from C8 segment we did not want to perform a for earlier recovery, improved outcomes, and
transfer with possibly damaged donor nerve expanded the time window for surgery in patients
risking inadequate reinnervation of the deltoid with late presentation. Even 20 years later, distal
muscle. Moreover, depriving the triceps of a part nerve transfers are still recognized as one of the
of its innervation could lead to undesired weak- best ways to improve elbow flexion after a C5–C6
ness of elbow extension in this case. BP injury.
Finally, it is important to point out that the Restoration of shoulder abduction and exter-
brachial plexus exploration is almost always nec- nal rotation is the second goal in the reconstruc-
essary to evaluate potential intraplexus donor tion plan, after elbow flexion. First, the brachial
nerves (roots). While visual and palpatory eval- plexus is explored to evaluate the C5 and C6
uation of the plexus injury by the surgeon roots. In patients with a viable spinal C5 or C6
remains valuable it may often be inaccurate. To nerve, the reconstruction is performed via autolo-
help more precisely evaluate the viability of the gous cable nerve grafting to the posterior division
spinal roots and functioning axons over a certain of the upper trunk or directly to the axillary nerve
nerve segment, somatosensory and motor provided that the injury is less than 6 months. If
evoked potentials SSEP/MEP and intraoperative neither of the C5 and C6 roots is available, the
nerve action potentials (NAP), respectively, were spinal accessory nerve to the suprascapular nerve
introduced and became a gold standard in many and a triceps branch of the radial nerve to the
centers over time. NAP can distinguish between axillary nerve – Leechavengvongs procedure
high-grade nerve lesions (Sunderland IV) with (Leechavengvongs et al. 2003) to restore shoulder
little to no potential for spontaneous regeneration abduction and external rotation are the standard
necessitating excision and grafting and low- plan B.
In summary, after carefully evaluating the pre- is found upon exploration the surgeon may
operative findings and making the indication for decide between grafting and nerve transfers.
the operative exploration and reconstruction in the 3. The function of the suprascapular nerve may
case here presented we were prepared for several be restored by cable graft (typically sural nerve
solutions depending on the intraoperative findings as a donor) from C5. Alternatively, nerve trans-
during the exploration: fer from the spinal accessory nerve to the
suprascapular nerve is performed. No clear
1. Neurolysis: the least likely option as we benefit in outcome has been shown in the liter-
expected high-grade injury. ature of one method against the other. How-
2. Grafting: if viable proximal nerve stumps are ever, in the situation where a healthy proximal
present. stump of C5 is available, grafting is usually
3. Nerve transfers: if no viable proximal stumps preferred taking into account the higher axonal
are present. load from the root vs. from a distal nerve trans-
4. Combination of grafting and nerve transfers: if fer. The same consideration is made for
some of the proximal stumps are viable or if all reinnervation of the deltoid muscle through
proximal stumps are viable but we expect bet- the axillary nerve, where grafting from C5 to
ter results from nerve transfer that grafting. the posterior division of the upper trunk or
directly to the axillary nerve is possible and
the nerve transfer from the triceps motor
Alternative Reconstructive Options branch of the radial nerve (usually from the
long triceps head) is the alternative. Regarding
If avulsion is found, only nerve transfers come in the musculocutaneous nerve innervation of
question as no proximal stump is present for biceps brachii muscle (root innervation C5
grafting. Different nerve transfers and modifica- and mainly C6 with usually insignificant con-
tions have been described in the literature. Three tribution from C7) the primary transfer is pre-
possible alternative reconstructive options are ferred (Oberlin procedure) to the grafting from
presented: C6 to the anterior division of the upper trunk,
lateral cord or directly to the
1. For the reconstruction of the elbow flexion, a musculocutaneous nerve. The nerve transfer
double nerve transfer described by Mackinnon may be performed as either single transfer
(Mackinnon et al. 2005) could be considered (from flexor carpi ulnaris portion of the ulnar
whereby a portion of the median nerve is trans- nerve to motor branch to biceps) or double
ferred to the brachialis branch of the transfer (from flexor carpi ulnaris portion of
musculocutaneous nerve in addition to the the ulnar nerve to motor branch to biceps and
transfer of the portion of the ulnar nerve to from flexor digitorum superficialis portion of
the biceps branch of the musculocutaneous the median nerve to the motor branch for the
nerve. Theoretically, the reinnervation of two brachialis muscle).
muscles (the biceps and brachialis muscles)
instead of only one (the biceps muscle), should
increase the strength for elbow flexion. How- Preoperative Evaluation and Imaging
ever, other studies have not found any clini-
cally significant difference (Carlsen et al. 2011; The goal of the preoperative evaluation is deter-
Martins et al. 2013). mining the location, extent, and severity of the
2. For reinnervation of the deltoid muscle – trans- nerve injury. It is based on the exact medical
fer from a motor branch of the radial nerve for history as well as on observation of the nerve
the long head of the triceps (Leechavengwong) regeneration in the first 3–6 months, physical
or medial head (Mackinnon) to the axillary exams, imaging, and electrodiagnostic studies
nerve can be used. In case a proximal stump (EDX).
Physical exams are performed in a complex nerve lesion with root avulsion and postgangli-
manner addressing all possible injuries. The phys- onic injury having occurred together in which
ical examination of the brachial plexus should be case the findings may lead to false conclusions
comprehensive evaluating: (SNAP is negative with clinical anesthesia of the
skin resulting from root avulsion). Also, the type
1. Range of motion of all joints of the upper of injury pre-/postganglionic of the sensible root
extremity. does not necessarily have to correspond to the
2. Strength of all muscles of the upper extremity type of injury of the ventral motor root.
and shoulder. Valuable information is delivered by the needle
3. Skin sensibility. electromyography (EMG) with signs of patholog-
ical spontaneous activity (PSA) such as fibrilla-
For muscle strength quantification, British tion or positive sharp waves being typical markers
Medical Research Council grading system has of muscle denervation. The evaluation of muscle
been established with values from M0 – no mus- unit potentials (MUP), on the other hand, may
cle contraction to M5 – normal muscle contrac- help detect partial nerve lesions or later on, the
tion. Skin sensibility is documented as normal, signs of muscle reinnervation. Overall, the analy-
hypoesthesia or anesthesia, etc. Also, it is useful sis of EDX is complex and belongs in the hands of
to examine the two-point discrimination of each an experienced neurologist. The surgeon should,
finger. The exams should be performed at regular however, be able to interpret these findings.
intervals for evaluation of the functional restora- The standard in the diagnostic algorithm in
tion. Knowledge of root innervation of the indi- patients suspected of brachial plexus injury is
vidual muscles enables making a very precise MRI of the cervical spine and of the brachial
assessment of the location (level of trunks, divi- plexus. Edema, large neuromas, abnormalities in
sions, cords, or peripheral nerves) and extent the region of the nerve roots, and other changes
(which spinal segments are affected) of the lesion. may help localize and describe the lesion more
In our case, typical loss of shoulder abduction and precisely. Traumatic pseudomeningocele is a find-
external rotation combined with elbow flexion ing pathognomonic for root avulsion. However,
was highly suggestive of an injury to the upper even MRI can provide falsely positive or negative
trunk. information so that the findings should always be
EDX studies belong to the standard examina- considered in the context of medical history, phys-
tion and may help better characterize the location ical exam, and EDX together.
of the lesion as well as evaluate the possible In our case, the MRI finding described a root
regeneration during serial exams at regular inter- avulsion of the C7 segment with the presence of
vals. The EDX should not be performed before pseudomeningocele and “thinning” with signal aug-
10–14 days after the injury as the pathological mentation in segments C5 and C6 at around 5 cm
changes may not yet be fully detectable due to distal to the intervertebral foramen which correlated
incomplete Wallerian degeneration. Sensory with the intraoperative finding (Fig. 2a, b). In the
nerve action potentials (SNAP) examine the con- x-ray of the right shoulder 3-month post-injury,
duction in sensory nerves. The presence or subluxation can be seen due to the deltoid muscle
absence of SNAP may help determine if pregan- paralysis (Fig. 2c).
glionic (nerve avulsion) or postganglionic injury
occurred. Since the dorsal root ganglion is located
outside the spinal cord, in avulsion there is anes- Preoperative Care and Patient
thesia in the affected dermatome with normal Drawing
SNAPs as the Wallerian degeneration did not
occur while in postganglionic lesion there is anes- Brachial plexus surgeries usually take several
thesia with the absence of SNAPs. However, hours and require adequate anesthesiological
sometimes the injury may lead to multisegmental preparation with secure vascular access, urinary
Fig. 2 (a) Coronal MRI of the cervical spine showing segment on the right side. (c) X-ray of the right shoulder
traumatic pseudomeningocele of the C7 segment on the 3 months after injury – substantial subluxation in the
right side – frontal plane. (b) Axial MRI of the cervical shoulder joint due to deltoid muscle atrophy
spine showing traumatic pseudomeningocele of the C7
catheter, intubation, and general anesthesia. Mus- The preoperative markings of our patient are
cle relaxants would prevent intraoperative nerve shown in Fig. 3a, b
stimulation and should, therefore, be avoided. The
patient is in a supine position, with their shoulder
blade supported by a pillow and head turned in the Surgical Technique
opposite direction. The operated upper extremity,
axilla, hemithorax, and neck are prepped and 1. Supraclavicular exploration: 6 cm long skin
draped so that the position of the arm can be incision around 2 fingerbreadths above and
adapted during the surgery. Also, the motor parallel to the clavicle over the posterior trian-
response of the nerve stimulation can be directly gle of the neck. Subcutaneous tissue with
observed from the shoulder to the fingers. One or platysma was divided and the sensible supra-
both lower legs are prepped for the possibility of clavicular nerves were spared. The external
the sural nerve graft harvest. Careful attention jugular vein was retracted. The posterior bor-
should be taken to adequate padding of all bony der of the sternocleidomastoid muscle and
prominences considering the likely prolonged anterior border of the trapezius were identified
duration of the surgery. and the superficial cervical fascia was opened.
a b
Fig. 3 (a) Patient position and preoperative marking for planned skin incision. (b) Preoperative marking on the
the suprascapular exploration on the rights side. Marked right medial upper arm for the planned Oberlin transfer
are the midline, clavicle, posterior border of the sternoclei-
domastoid, course of the external jugular vein and the
The inferior belly of the omohyoid muscle, as coracoid process to expose the structures in
well as the transverse cervical artery, were the axilla.
divided. Then, the supraclavicular part of the 5. Lateral, posterior, and medial cords were
brachial plexus could be visualized. identified. Through stimulation of the poste-
2. The anterior scalene with the phrenic nerve rior cord (1 mA), a strong contraction of the
running on its ventral surface was visualized wrist and finger extensor was observed
and carefully retracted. Then the upper trunk (Video 4) while no contraction of the elbow
was dissected and examined. Substantial flexor was detected during stimulation of the
scaring was present with a neuroma in conti- lateral cord (2 mA). Then, the axillary nerve
nuity at the level of the upper trunk while the was dissected more proximally. No contrac-
nerve roots C5 and C6 looked healthy. The tion of the deltoid muscle was seen after stim-
avulsion of the C7 segment, seen in the pre- ulation of the axillary nerve (2 mA).
operative MRI, was confirmed. The clinically 6. Nerve grafting was performed to reinnervate
normal lower trunk was not explored. the suprascapular and axillary nerve from
3. The intraoperative examination of NAP con- C5-segment. The sural nerve from the contra-
firmed the high-grade nerve injury (Sunderland lateral side was harvested. A long incision
IV) to the upper trunk with no signal being was made over the sural nerve from the lateral
transferred through the neuroma in continuity. ankle side to the popliteal region with 4 nerve
The suprascapular nerve was also visualized cables being formed, two cables 12 cm long,
(at the level of bifurcation of the upper trunk two cables 7 cm long (Fig. 4b). The
in the anterior and posterior division) with no neurorrhaphy was performed under micro-
contraction seen in the supra- and infraspinatus scope magnification. C5-segment was
after direct stimulation of the nerve. divided using a neurotome and the proximal
4. Exploration of the infraclavicular part of the fascicles were carefully examined to confirm
brachial plexus followed (Fig. 4a). A skin that they are outside the injury zone. Two
incision was made running from the ventral 9 cm cable grafts were sutured first distally
part of the first incision distally over the clav- to the suprascapular nerve, then to the C5
icle and the deltopectoral groove. Subcutane- nerve root by epiperineural repair with
ous tissue was divided with the cephalic vein Nylon 9.0 and two 12 cm graft were sutured
being retracted. The tendon of the pectoralis to the axillary nerve, passed under the clavicle
minor was divided close to its insertion on the proximally and sutured to the C5 segment.
Fig. 4 (a) Supra and infraclavicular approaches. Note the muscle (superior), motor branch of the brachialis muscle
axillary nerve (target of the sural nerve graft from C5) is (left), and FCU fascicle of the ulnar nerve (inferior). (d)
marked with a blue vessel-loop. (b) Sural nerve with The FCU portion of the ulnar nerve and the motor branch
4 cables being formed, two cables 12 cm long, two cables of the musculocutaneous nerve for the biceps brachii were
7 cm long. (c) Proximal arm dissection for an Oberlin divided and sutured
procedure. In blue vessel-loops: motor branch of the biceps
All neurorrhaphies were reinforced with fascicular anatomy (Fig. 4c, Video 5). Intra-
fibrin sealant (Tisseel). After careful hemo- fascicular dissection was performed and
stasis and placement of suction drains, the after confirming that the dissected fascicles
wounds were closed. were associated with the FCU muscle with a
7. Thereafter, the reconstruction of the elbow nerve stimulator, further proximal dissection
flexion was performed through the Oberlin followed.
procedure. A separate skin incision was 9. The FCU portion of the ulnar nerve and the
made on the medial side of the upper arm motor branch of the musculocutaneous
from the axilla to around 5 cm proximal nerve for the biceps brachii were divided
from the elbow crease. Ulnar and mus- and sutured with Nylon 9.0 with reinforcing
culocutaneous nerves were identified. The tissue sealant (Fig. 4d). The neurorrhaphy
motor branch of the biceps brachii was was performed with the arm abducted and
followed from the point where it enters the externally rotated to make sure that it would
muscle proximally to allow for a tensionless not stand under tension with the motion of
nerve transfer. the shoulder. All wounds were closed in
8. The motor portion of the ulnar nerve for layers after drainage placement.
flexor carpi ulnaris (FCU) muscle in the 10. A dressing was placed on the wounds and
middle third of the upper arm was localized Gilchrist-bandage was applied on the
based on the intraneural topographical operated side.
Technical Pearls The patient could actively abduct the shoulder

up to 90 (Fig. 5a) and externally rotate 40
1. During the exploration of the supraclavicular (Fig. 5b). The elbow flexion was possible to
part of the brachial plexus use typical anatom- 120 (Fig. 5c). The strength according to BMRC
ical landmarks for orientation: of the deltoid muscle was 2+/5, of the supra-
A. The phrenic nerve lies on the ventral sur- spinatus and infraspinatus muscle 4/5 and of the
face of the anterior scalene muscle. biceps brachii 4+/5. In EMG, in all reinnervated
B. The phrenic nerve gets contribution from muscles signs of axonal regeneration could be
C5 nerve whose identification can be con- confirmed. The considerable initial subluxation
firmed in this way. in the shoulder joint was corrected completely at
C. The upper trunk division resembles “trifurca- the 18-month follow-up suggesting an improve-
tion” with suprascapular nerve, anterior and ment of the muscle tone of the deltoid muscle
posterior division arranged from cranial to (Fig. 5d). The sensibility in the segment C5–C7,
caudal. i.e., affecting the thumb, index, and middle finger
2. When harvesting the sural nerve use a single was reduced. Further improvement of muscle
long incision or multiple incisions as close to strength in the next 12 months is possible.
each other as to enable complete visualization
of the nerve at all times during its dissection to
minimize its damage. Avoiding and Managing Problems
3. Perform the neurorrhaphy in the shoulder
region (graft or transfer) with the shoulder • Early presentation allowing the planning of
abducted to 90 and maximally externally timely and effective reconstruction.
rotated to prevent tension on the repair site • Emphasize that realistic goals are set before the
during postoperative mobilization. therapy and the patient understands and
4. While performing a nerve transfer, such as in accepts them and is willing to undergo the
the “Oberlin procedure” follow the principle lengthy and arduous postoperative therapy.
“donor distal, recipient proximal” meaning the • Injury location should be preoperatively
distal division of the donor nerve and proximal suspected based on images (MRI) and EDX
division of the recipient nerve to allow a studies. Surgical plan must be clear. Prepare a
tension-free nerve repair (Mackinnon 2016). surgical algorithm with reconstructive options
for all thinkable intraoperative findings.
• Emphasize the importance of physiotherapy to
Postoperative Management prevent contractures.
• Importance of perfect nerve coaptation without
Gilchrist-Bandage for shoulder immobilization tension.
for 3 weeks. Thereafter, physical therapy for
range-of-motion exercises for all joints of the
arm and hand. As soon as muscle contraction of Learning Points
the reinnervation muscle is noticeable, specific
EMG biofeedback, reeducation, and strengthen- 1. Brachial plexus injuries may be devastating con-
ing training are initiated. ditions for the patients. After careful evaluation,
realistic expectations must be discussed with the
patient involving all possible therapeutic options
Outcome, Clinical Photos, and Imaging 2. While preoperative clinical assessment,
electrodiagnostic studies, and imaging
The last follow-up occurred 18 months after methods describe the type of lesion with a
surgery (Video 6, 7, 8, and 9). The patient was great degree of precision, the exact type (avul-
compliant and followed the postoperative protocol. sion, neuroma-in-continuity, etc.) and the
Fig. 5 (a) Active abduction in the rights shoulder at the right elbow at 18 months follow-up. (d) X-ray of the
18 months follow-up. (b) Active external rotation in the right shoulder at 18 months follow-up. Note the better
right shoulder at 18 months follow-up. (c) Active flexion of position of the glenohumeral joint
location of the injury should be confirmed muscle to the motor branch of the
intraoperatively. musculocutaneous nerve for the biceps brachii
3. In upper trunk injuries of the brachial plexus muscle.
showing no spontaneous regeneration several
established procedures may be performed with
predictable results involving nerve grafting References
and nerve transfers.
4. In an avulsion of nerve roots, only distal nerve Brophy RH, Wolfe SW. Planning brachial plexus surgery:
treatment options and priorities. Hand Clin.
transfers may be performed as there is no prox-
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imal nerve stump for nerve repair. Carlsen BT, Kircher MF, Spinner RJ, Bishop AT, Shin
5. Nerve transfers most commonly used in upper AY. Comparison of single versus double nerve transfers
trunk injuries are: (1) spinal accessory to supra- for elbow flexion after brachial plexus injury. Plast
Reconstr Surg. 2011;127(1):269–76.
scapular nerve, (2) a branch of the radial nerve
Elhassan B, Bishop A, Shin A, Spinner R. Shoulder tendon
for triceps muscle to the axillary nerve, and transfer options for adult patients with brachial plexus
(3) motor branch of the ulnar nerve for FCU injury. J Hand Surg Am. 2010;35(7):1211–9.
Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin Mackinnon SE, Novak CB, Myckatyn TM, Tung TH.
AY. Current concepts of the treatment of adult brachial Results of reinnervation of the biceps and brachialis
plexus injuries. J Hand Surg Am. 2010;35(4):678–88; muscles with a double fascicular transfer for elbow
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Giuffre JL, Bishop AT, Spinner RJ, Shin AY. The best of Martins RS, Siqueira MG, Heise CO, Foroni L, Teixeira
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Reconstr Surg. 2015;135(3):617e–30e. fascicular transfer to restore elbow flexion after bra-
Gu YD, Wu MM, Zhen YL, Zhao JA, Zhang GM, Chen chial plexus injury. Neurosurgery. 2013;72(5):709–14;
DS, et al. Phrenic nerve transfer for brachial plexus discussion 714–5; quiz 715.
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Leechavengvongs S, Witoonchart K, Uerpairojkit C, MC, Sarcy JJ. Nerve transfer to biceps muscle using a
Thuvasethakul P. Nerve transfer to deltoid muscle part of ulnar nerve for C5–C6 avulsion of the brachial
using the nerve to the long head of the triceps, part II: plexus: anatomical study and report of four cases.
a report of 7 cases. J Hand Surg Am. 2003;28(4):633–8. J Hand Surg Am. 1994;19(2):232–7.
Luedemann W, Hamm M, Blömer U, Samii M, Tatagiba Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult
M. Brachial plexus neurotization with donor phrenic traumatic brachial plexus injuries. J Am Acad Orthop
nerves and its effect on pulmonary function. Surg. 2005;13(6):382–96.
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Mackinnon SE. Donor distal, recipient proximal and other objective muscle strength in C5–C6 and C5–C7 bra-
personal perspectives on nerve transfers. Hand Clin. chial plexus injury patients after double nerve transfer.
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Brachial Plexus Secondary
Reconstruction with Contralateral C7 60
Lisa Wen-Yu Chen, Annie Wang, Yu-Ching Lin,
Cheyenne Wei-Hsuan Sung, and Tommy Nai-Jen Chang
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652
Preoperative Care and Patient Marking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654
Avoiding and Managing Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661
L. W.-Y. Chen · C. W.-H. Sung · T. N.-J. Chang (*)

Department of Plastic and Reconstructive Surgery, Chang
Gung Memorial Hospital, Linkou Medical Center and Chang-
Gung University, School of Medicine, Taoyuan, Taiwan
A. Wang
Division of Plastic, Reconstructive & Aesthetic Surgery,
Department of Surgery, University of Toronto, Toronto,
ON, Canada
e-mail: anniem.wang@mail.utoronto.ca
Y.-C. Lin
Department of Medical Imaging and Intervention, Chang
Gung Memorial Hospital, Keelung and Chang Gung
University, Taoyuan, Taiwan

https://doi.org/10.1007/978-3-030-23706-6_60
652 L. W.-Y. Chen et al.
Abstract there were no concomitant brain, cervical

spine, chest, or intra-abdominal injuries, he did
A successful reconstruction for brachial plexus develop total right upper limb palsy (flail arm
injury requires the accurate diagnosis of the with muscle power all zero) immediately after
injury level through physical examination, injury, with prominent Horner’s syndrome and
neurological and imaging interpretation, the shooting pain all over the injured limb. There
logical design for donor/recipient nerves was no clinical improvement after 2 months’
based on anatomy and function, and meticu- rehabilitation (Fig. 1).
lous microsurgical technique.
This case illustrates the one-stage nerve-
based reconstruction in a 19-year-old male Preoperative Problem List/
with right side traumatic complete palsy of Reconstructive Requirements
C5-T1. Given that the patient had no function
recovery after 2 months of rehabilitation, 1. Relationship of the shoulder dislocation and
surgery was indicated. Due to the total palsy the associated nerve injury (Echalier et al.
status lacking the available intraplexus 2019; Mansukhani 2013; Gutkowska et al.
neurotizers, the contralateral C7 served as 2020)
donor for the median nerve with a vas- 2. Formulating the diagnosis of total brachial
cularized ulnar nerve graft; the ipsilateral plexus injury (Tubbs et al. 2010; Chuang
phrenic nerve served as donor for the supra- 2009; Yeow et al. 2021)
scapular nerve, and the ipsilateral T3-T5 3. Reconstructive options in total brachial plexus
intercostal nerves served as donor for the injury (Chuang 2010; Chuang and Hernon
musculocutaneous nerve. 2012; Hu et al. 2018; Lanier et al. 2020)
At postoperative 39 months, the patient 4. Outcomes and prognosis of total brachial
had achieved 110 degrees of shoulder abduc- plexus injury (Chuang 2009, Chuang and
tion, elbow and finger flexion both improved Hernon 2012, Armas-Salazar et al., 2021)
to M4 power, and hand grip strength was
2 kilogram-weight; also the protective hand
sensation was achieved, and the autonomic Treatment Plan
function was better. This one-stage surgery
can successfully restore the basic function of Due to the acute nature of the injury, the main
the injury limb. goal of reconstruction is trying to reanimate the
target muscles to restore basic functions of the
injured limb. In this case, since there was per-
Keywords
sistent total palsy with a complete flail limb, no
Brachial plexus injury · Total roots avulsion · sensation, and debilitating shooting pain
Contralateral C7 2 months after injury, total roots injury was
highly suspected and therefore comprehensive
reconstruction planned.
The Clinical Scenario The main functional goals in total palsy are
shoulder abduction, elbow flexion, and finger
This 19-year-old previously healthy male was flexion. Because intraplexus neurotizers are usu-
involved in a motorcycle collision sustaining ally not available in these types of devastating
right acromioclavicular joint dislocation, injuries (only C5 stumps are available some-
which was treated by open reduction internal times), extraplexus neurotizers should be evalu-
fixation without any complications. While ated preoperatively as potential donors. For
60 Brachial Plexus Secondary Reconstruction with Contralateral C7 653
a b c
Fig. 1 (a) Shoulder abduction and elevation was absent in were also absent. (d) Right-sided Horner’s syndrome was
the right arm, and the black cross-hatching indicated the present with ptosis
area of numbness. (b, c) Elbow flexion and wrist extension
shoulder abduction, phrenic nerve and spinal to reconstruct the elbow extension include
accessory nerve usually serve as the main donors, neurotize the posterior division of upper trunk,
and suprascapular nerve and posterior division of or intercostal nerve direct neurotize the radial
the upper trunk are prioritized as recipients. In the nerve (Chuang 2009). Finger flexion is also an
case of severe avulsed spinal nerves, sometimes important goal for daily life maintenance. The
recipient nerves are directly underneath the clav- preferred method of reinnervating forearm flexors
icle, or even at the infraclavicular level, and thus is contralateral C7 (or sometimes ipsilateral C5)
may require nerve grafting to bridge the gap. At transferred to median nerve, with the gap bridged
the elbow, flexion is more important for activities by vascularized ulnar nerve. Regardless of the
of daily living whereas extension is sometimes method of nerve transfer, one healthy neurotizer
ignored due to the paucity of available should be preserved as donor for possible future
neurotizers. Options for donor nerves for elbow functioning free muscle transplantation, and the
flexion function include intercostal nerves, or con- spinal accessory nerve or intercostal nerves are
tralateral C7 combined with median nerve, preferred options (Chuang 2009; Chuang and
coapted to musculocutaneous nerve. The options Hernon 2012; Hu et al. 2018).
Alternative Reconstructive Options including pain, temperature, and two-point

discrimination; Tinel’s sign; and other related
Compared with the above nerve-based recon- findings such as Horner’s syndrome) (Fig. 2). In
struction strategy, another strategy of treating the presented patient, motor and sensory function
total brachial plexus palsy is functioning free were both absent, there was prominent Horner’s
muscle transplantation. The authors only consider syndrome and shooting pain, and grip power was
functioning free muscle transplantation as first zero kilogram. So, total roots avulsion was highly
choice when patients have contraindications to suspected.
harvesting a vascularized ulnar nerve graft Nerve conduction velocity (NCV) revealed
(Allen’s test negative), or in scenarios where out- decreased sensory nerve action potential of right
comes can be improved by performing nerve- radial (8.4 uv) and ulnar (6.7 uv) nerves, and no
based reconstruction and functioning free muscle sensory response of right musculocutaneous
transplantation simultaneously to enhance the nerve. Electromyography (EMG) showed fibrilla-
outcome, or chronic denervated cases that the tions without motor units of right serratus anterior,
reinnervation of the muscles is not possible. pectoralis major, teres major, latissimus dorsi,
While motor function outcomes between nerve- deltoid, biceps, first dorsal interosseous (FDI),
based reconstruction and functioning free muscle- extensor digitorum communis (EDC), and abduc-
based reconstruction are comparable, functioning tor pollicis brevis (APB). There was no F-wave
free muscle-based reconstruction, when response of median and ulnar nerves. Overall,
performed alone, lacks the potential for sensory NCV/EMG findings demonstrated right C5-T1
and autonomic recovery (Chuang 2009; Chuang injuries with severe active denervation changes,
and Hernon 2012; Hu et al. 2018). with C5/6 region being most severe, and possibly
In this pattern of total brachial plexus palsy, combined with preganglionic root lesion
distal nerve transfers are usually not possible (Chuang’s level I).
given that most distal nerves are involved in the The key imaging modality used to evaluate
injury itself, and therefore multiple intercostals brachial plexus injury is MRI, including various
are used as donors instead. However, one should protocols such as myelogram, STIR, CUBE, and
bear in mind that if the patient has simultaneous FIESTA. The main goal is to differentiate between
chest trauma with rib fractures, intercostal nerves root avulsion or rupture, which dictates the surgi-
may be unavailable as well. cal plan. In the presented case, MR myelogram
showed right-sided Chuang’s level I C6, C7 root
partial avulsion but only one rootlet preserved
Preoperative Evaluation and Imaging respectively which was not usable, and C5, C8,
T1 complete avulsion with T1 meningocele pre-
The goals of preoperative evaluation are to: deter- sent (Yeow et al. 2021) (Fig. 3). Inspiration and
mine the level and extend of injury, objectively expiration chest x-ray is used to assess function-
quantify the severity of injury, assess the quality ing of the phrenic nerve as a donor. In the pre-
of target muscles, and evaluate potential sented case, preoperative chest X-ray showed
neurotizers to guide the operative plan. Besides normal diaphragmatic excursion indicating nor-
the physical examination, MRI and nerve conduc- mal phrenic nerve function (Fig. 4).
tion studies are important adjuncts in the preoper-
ative evaluation as well.
Every brachial plexus patient in the authors’ Preoperative Care and Patient
institution has a special clinical chart completed, Marking
which includes demographics, presenting illness,
associated injury, and findings on physical exam- The patient was scheduled for nerve reconstruc-
ination (motor function by examining muscle tion. After endotracheal intubation, the patient
powers in all related muscles; sensory testing was placed in the supine position, and bilateral
Fig. 2 The clinical chart completed for this patient documenting general demographics, history of presenting illness, and
findings from the physical exam and neurological study
neck, chest, and upper limbs were carefully pro- adequate forearm perfusion, the zig-zag incision
tected, draped, and prepped as usual. The location was planned along the patient’s ulnar forearm
of the upper trunk was marked first: midpoint of according to the course of the ulnar vessels and
the line between the mastoid process and the the nerve. At the elbow, the marking followed the
sternal notch. A c-shaped incision along the pos- nerve, but not the vessel through the cubital tun-
terior border of the sternocleidomastoid to upper nel, then extended to the medial arm.
border of clavicle (including the point marked for
the upper trunk) was designed on both necks. For
the left (contralateral healthy) side, since the main Surgical Technique
target was C7, the incision line was planned to be
slightly lower. The right neck marking was 1. The right brachial plexus was explored first
extended to the axilla through the deltopectoral through the C-shape incision. The platysma
groove and medial arm, to allow dissection of the was incised along with the skin, the space
median and musculocutaneous nerves. Another separated underneath it, identified the
incision was made from the axilla and crossed sternocleidomastoid, and then dissected later-
the lateral chest wall for exposure of third to fifth ally until reaching the internal jugular vein.
intercostal nerves (Fig. 5a). The C-shaped adipofacial flap was elevated,
The drawing from the right forearm was for the exposing the anterior scalene where the
vascularized ulnar nerve graft harvest. (Fig. 5b). phrenic nerve can be seen overlying the mus-
After Allen’s test was positive and confirmed cle. Normal phrenic nerve function was
a b
c d
Fig. 3 The magnetic resonance imaging (MRI) of the solid arrow). (c) Another shot on coronal FIESTA showed
brachial plexus injury of the target patient. (a) Fast imaging left C6 (white solid arrow) and C7 (white dotted arrow) had
employing steady-state acquisition neurography (FIESTA) one rootlet left, and C5, C8, and T1 had all rootlet
lateral view showed normal right C4 (white solid arrow) completely avulsed. (d) Reformatted coronal short-tau
with normal five rootlets but absent in C5-T1 except one inversion-recovery MIP image revealed the entire right
rootlet seen in C7 (white dotted arrow). (b) Coronal side brachial plexus distally displaced, and right brachial
FIESTA showed normal left side C4-T1 with intact rootlets plexus suggesting a severe injury or rupture (white thick
but right side only C7 had one rootlet left in this shot (white arrowheads)
a b
Fig. 4 Preoperative chest x-ray demonstrating symmetrical diaphragmatic excursion during inspiration (a) and expira-
tion (b), indicated functioning right phrenic nerve as a potential donor
Severe dense scarring was noted at the supra-

clavicular level. The supraclavicular dissection
was fairly straightforward given that its pur-
pose was to identify the donor and the recipient
nerves, so therefore, the dissection of the entire
plexus was not required. However, due to the
entire plexus being distally displaced as a result
of the injury, the suprascapular nerve (which
was the recipient nerve) was identified at the
infraclavicular level, so exploring the
infraclavicular brachial plexus was needed as
well. And then, the medial and lateral cord at
a the axillary level were identified. In this
patient, the phrenic nerve was found to be
long enough to reach the suprascapular nerve
via direct coaptation without nerve grafting. It
is important to note that all the nerves should
be repositioned to their original anatomical
b level (i.e., in the retro-clavicular plane).
2. Due to no available ipsilateral healthy spinal
Fig. 5 Preoperative plan. (a) Planned neck and axillary
incisions. (b) Plan of the vascularized ulnar nerve graft nerve stumps, the contralateral (left) C7 (CC7)
after Allen’s test positive confirmed was explored through the C-shaped incision,
and good nerve quality was confirmed. Note
checked preoperatively by inspiratory and that accurate identification of C7 should be
expiratory chest X-ray, and this was confirmed confirmed carefully with its anatomic feature
with a nerve stimulator intraoperatively. (C7-middle trunk is underneath the upper trunk
without branches at supraclavicular level) and chosen as the recipient vessels. Because ipsi-
its expected function before transection. To lateral vessels were available, the vascularized
check its function, an assistant needed to hold ulnar nerve graft was inset in an antegrade
the patient’s hand while the primary surgeon fashion for the vascular anastomosis. The
stimulates C7, with resultant wrist movement proximal nerve stump of the ulnar nerve graft
only and not the fingers. C7 should be was coapted to CC7 via a subcutaneous tunnel
harvested to have as much length as possible, at neck, and the distal stump was coapted to the
although its site of harvest distally should be median nerve at the level of the bifurcation of
proximal to the convergence of the posterior the medial and lateral cords.
divisions from the upper and the lower trunks 4. Right T3–5 intercostal nerves were dissected
to avoid compromising radial nerve function. carefully through the lateral chest incision, cut
3. To bridge the defect between CC7 and the proximally at level close to the midline, and
target nerve, right vascularized ulnar nerve then transferred to the musculocutaneous nerve
graft was harvested based on its vascular ped- in an end-to-end fashion for elbow flexion. To
icle through a zig-zag incision at the forearm. avoid tension, extensive and careful dissection
The length of the harvested graft was from the of the intercostals is required for length and to
level of the wrist to above the elbow over the avoid pleural injury. From experience, even
cubital tunnel. If a very long nerve graft is when the phrenic nerve and multiple intercos-
needed, superior ulnar collateral artery perfo- tal nerves are simultaneously used as donors,
rators can be included as well. At the distal any respiratory functional compromise is sub-
forearm level, the dorsal sensory branch of clinical (Chuang 2009) (Fig. 6).
the ulnar nerve can be included to increase 5. All incisions are closed primarily with multiple
the graft caliber. After the total length required penrose drains inserted. Note that the drains
for the graft is determined, a 3–5 cm distal should never contact with the nerves to avoid
ulnar nerve stump should be preserved at the irritation and even disruption of the transfers.
wrist level to allow it to be coapted in an end-to The posture of the patient and the surgical site
side fashion to the median nerve, to restore need to be secured to protect the reconstruc-
ulnar digital sensation after the reinnervation tion. In this case, the patient’s neck was pro-
from contralateral C7. Before the vascular ped- tected by a customized splint, and the
icle is clamped, its anatomy and its supply to paralyzed limb was gently taped at the groin
the ulnar nerve are checked carefully, and the area. After a smooth endo-tracheal extubation,
recipient vessels are fully prepared. In this the patient was sent to the ward for the postop-
case, the ipsilateral transverse cervical artery erative monitoring (Fig. 7).
(TCA) and the external jugular vein were
Fig. 6 The reconstructive diagram of the planned proce- CC7: contralateral C7; EJV: external jugular vein; TCA:
dure on the white board inside the operation theater. The transverse cervical artery; ICN: intercostal nerve; MN:
dotted line indicates the right clavicle, with the nerve median nerve; MCN: musculocutaneous nerve; VUNG:
reconstruction tunneled underneath the clavicle. Abbrevi- vascularized ulnar nerve graft; e-f: elbow flexion; s-abd:
ations: Ph: phrenic nerve; SS: suprascapular nerve; shoulder abduction
discharged 5–7 days postoperatively, and the

sutures could be removed 2 weeks postopera-
tively. Neck splint should be worn full time for
at least 3 weeks in adults and 4 weeks in children
to prevent neck range of motion.
After suture removal, rehabilitation can be
started including passive and active range of
motion. Induction exercise (use the function of
the donor nerve to train the function of the recip-
ient nerve and the downstream muscles) can also
begin. In this case, left (contralateral) arm abduc-
tion to induce right hand flexion, deep breathing
exercises with thoracic expansion (to activate
intercostals) to induce right elbow flexion, and
deep breathing exercises with abdominal disten-
sion (to activate phrenic nerve) to induce right
shoulder abduction are needed. Electro-
stimulation of the target muscles, especially
focusing on shoulder elevation, elbow flexion,
and wrist and fingers flexion, should also be
started after suture removal and can continue for
up to 1.5–2 years. The patients were followed up
Fig. 7 The senior author (TNJ-Chang) demonstrating the in clinic every 2–3 months. It is very important to
customized neck splint we use (arrowhead) postoperatively make sure the patient is positive to the course, is
to protect the brachial plexus reconstruction
regularly doing the rehabilitation program, and
understands how to perform the induction exer-
cise, with adequate setup and under the guidance
Technical Pearls of the experienced therapists, also family support.
If the clinical outcome does not improve by time
1. CC7 reconstruction (Tinel sign not progress, the motor and sensory
2. Vascularized ulnar nerve graft function does not recover as expected), closer
3. Intercostal to musculocutaneous nerve transfer monitoring is required, and the reason needs to
4. Simultaneous use of phrenic nerve and multi- be analyzed. Patients are encouraged to contact
ple intercostal nerves doctors any time via instant messaging software
for any disease-related questions.
See Fig. 8a–d.
The presented patient received regular rehabilita-
tion and follow-up at clinic every 2–3 months
Postoperative Management postoperatively. Tinel’s sign of the vascularized
ulnar nerve graft progressed as predicted, around
Penrose drains and the tape securing the limb to 3 cm/month. At 1 year postoperatively, shoulder
the groin area should be removed in 3–5 days. In abduction recovered to 90-degree against gravity,
the acute postoperative period, monitor for lym- elbow flexion improved to M3, and Tinel’s sign of
phatic drainage especially from the contralateral CC7 arrived at the right wrist, with right finger
side, as in rare cases reexploration is required to flexion present with M1 power. At 2 years post-
seal off lymphatic leakage. The patient can be operatively, shoulder abduction improved to
a b
c d
Fig. 8 Intraoperative figures. (a) Right neck dissection at vascular anastomoses completed. (d) Dissection of the
supra-clavicular level (Chuang’s level II). (b) Vascularized right chest and brachial plexus at the infra-clavicular
ulnar nerve graft harvest successfully. (c) Inset of the level, also the T3-5 intercostal nerves dissected
vascularized ulnar nerve graft, coapted to CC7 with the
100-degree against gravity, elbow flexion wrist arthrodesis to stabilize the joint and thumb
improved to M4, and finger flexion improved to arthrodesis at the opposable pinch position could
M2–3. At 39 months (3.3 years) postoperatively, be completed first. One year after this surgery, the
shoulder abduction had achieved 110 degrees thumb and wrist plates could be removed, and
against gravity, elbow and finger flexion both tendon transfer performed from flexor carpi
improved to M4 muscle power, and the grip radialis to extensor digitorum communis to extend
power of right hand was 2 kilogram-weight (left the fingers so gripping will be easier.
side was 3.5 kilogram-weight). Hand sensation
also recovered. Monofilament studies demon-
strated 8 grams at the radial side of the hand and Avoiding and Managing
100 grams at the ulnar side, with S1 sensation on Complications
average. The ulnar digits also gained protective
sensation. Autonomic function also recovered, For this devastating injury, the most important
with return of sweating and hair growth, and the aspects of management are accurate diagnosis,
resolution of Raynaud’s phenomenon (Fig. 9). thorough planning, meticulous surgical tech-
This chapter demonstrated the clinical result of nique, and aggressive rehabilitation. The patient
a one-stage nerve-based reconstruction in a total needs to understand that to even get basic function
roots avulsion brachial plexus patient. Because of back, there is a long road ahead involving physical
the good recovery of elbow and finger flexion, and psychological strains, multiple surgeries, and
functioning free muscle transplantation was not prolonged rehabilitation. The surgeon needs to
required. However, further reconstruction could work closely with the patient, therapists, and the
be considered for better grip control. To do this, patient’s family to optimize outcomes. Peer-
Fig. 9 At postoperatively
39 months (3.25 years), the
patient’s elbow and finger
flexion both improved to
M4. He could bear 3.5
kilogram-weight on the
elbow and 2.5 kilogram-
weight using his fingers.
The scars of the neck, chest,
and upper arm well healed,
without any donor site
morbidity
a b
support between patients is also important, and so Chuang DC. Brachial plexus injury: nerve reconstruction
the authors created online groups for patients with and functioning muscle transplantation. Semin Plast
Surg. 2010;24:57–66.
similar injuries, and used instant messaging soft- Chuang DC, Hernon C. Minimum 4-year follow-up on
ware to communicate with them in order to pro- contralateral C7 nerve transfers for brachial plexus
vide support and be partners in their healing. injuries. J Hand Surg Am. 2012;37:270–6.
Echalier C, Teboul F, Dubois E, Chevrier B, Soumagne T,
Goubier JN. The value of preoperative examination
and MRI for the diagnosis of graftable roots in total
Learning Points brachial plexus palsy. Hand Surg Rehabil. 2019;38:
246–50.
• How to treat total roots avulsion brachial Gutkowska O, Martynkiewicz J, Urban M, Gosk
J. Brachial plexus injury after shoulder dislocation: a
plexus injury – compare nerve-based recon- literature review. Neurosurg Rev. 2020;43:407–23.
struction with functioning free muscle-based Hu CH, Chang TN, Lu JC, Laurence VG, Chuang
reconstruction DC. Comparison of surgical strategies between proxi-
• How to best use the CC7 as donor in total roots mal nerve graft and/or nerve transfer and distal nerve
transfer based on functional restoration of elbow flex-
avulsion – technical pearls to achieving opti- ion: a retrospective review of 147 patients. Plast
mal motor, sensory, and autonomic outcomes Reconstr Surg. 2018;141:68e–79e.
• Possible adjuvant procedures Lanier ST, Hill JR, James AS, Rolf L, Brogan DM, Dy
• How to achieve the best outcomes in these CJ. Approach to the pan-brachial plexus injury: varia-
tion in surgical strategies among surgeons. Plast
patients – combine efforts of surgical team, Reconstr Surg Glob Open. 2020;8:e3267.
therapy team, patients, and their families Mansukhani KA. Electrodiagnosis in traumatic brachial
plexus injury. Ann Indian Acad Neurol. 2013;16:
19–25.
Tubbs RS, Jones VL, Loukas M, Cömert A. Surg Radiol
References Anat. 2010;32:261–70.
Yeow YJ, Yeow KM, Su IH, Wu YM, Chen CM, Tseng JH,
Armas-Salazar A, García-Jerónimo AI, Villegas-López Huang JL. Predicting healthy C5 spinal nerve stumps
FA, Navarro-Olvera JL, Carrillo-Ruiz JD. Clinical out- eligible for grafting with MRI, Tinel test, and rhomboid
comes report in different brachial plexus injury surger- electromyography: a retrospective study of 295 consec-
ies: a systematic review. Neurosurgical review. 2021; utive brachial plexus surgeries. Radiology. 2021;300:
https://doi.org/10.1007/s10143-021-01574-6 141–51.
Chuang DC. Adult brachial plexus reconstruction with the
level of injury: review and personal experience. Plast
Reconstr Surg. 2009;124:e359–69.
Part III
Lymphedema
Combined Autologous Breast
and Lymphedema Reconstruction 61
with a Predesigned DIEP
and Lymph-Node Flap
Efterpi Demiri and Dimitrios Dionyssiou
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
Abstract reconstruction of the breast and the upper-

Breast-cancer related lymphedema is a major limb lymphedema is yet a well-established
debilitating complication following breast can- procedure. This case illustrates a single-stage
cer treatment. Simultaneous autologous autologous breast reconstruction with a deep
inferior epigastric perforator (DIEP) flap com-
bined with vascularized lymph-node transfer
(vLNT) in a 47-year-old female patient, who
E. Demiri (*) · D. Dionyssiou presented with a left mastectomy and a Stage II
Department of Plastic Surgery, School of Medicine, lymphedema of the ipsilateral upper limb. Pre-
Aristotle University of Thessaloniki, Thessaloniki, Greece operative planning of the DIEP flap was based
e-mail: demirie@auth.gr; diodi@auth.gr

https://doi.org/10.1007/978-3-030-23706-6_107
666 E. Demiri and D. Dionyssiou
on the measurements of the contralateral A pitting left-arm edema was documented without
breast; a two-dimensional template was pre- signs of infection. Perometry measurements of
pared and centered over the selected perforator, both upper extremities showed an excess volume
guided by the abdominal wall computed- of 560cc between the two arms; a diagnosis of a
tomography angiography (CTA). A preopera- Stage II breast-cancer related lymphedema of the
tive SPECT-CT of both inguinal areas was left upper limb was set. According to her medical
performed in order to select the most functional history, no other comorbidities were reported.
lymph nodes for transfer without jeopardizing
the lymphatic drainage of the donor limb.
Thus, a bi-pedicled chimeric DIEP-vLNT flap Preoperative Problem List:
was designed and transferred to the thorax; two Reconstructive Requirements
pairs of anastomoses were performed to
re-vascularize the flap, one medially on the 1. Breast reconstruction after mastectomy with
internal mammary vessels, and the second lat- autologous tissues (Nahabedian et al. 2002)
erally on branches of the thoracodorsal vessels. 2. Post-radiation delayed breast reconstruction
The postoperative course was uneventful. (Lindegren et al. 2012)
Physiotherapy with manual drainage and com- 3. Breast cancer-related lymphedema manage-
pressive therapy started immediately after sur- ment (Becker et al. 2006)
gery, while elastic garments were used for 4. Simultaneous breast and upper limb lymph-
6 months. Follow-up at 28 months showed edema reconstruction (Saaristo et al. 2012;
44.6% of volume difference reduction between Nguyen et al. 2015; Chang et al. 2018)
upper limbs. The aesthetic outcome of the 5. Iatrogenic donor-site lymphedema (Dayan
reconstructed breast was very satisfactory et al. 2015; Demiri et al. 2018)
with natural appearance and good symmetry
with the contralateral one.
Treatment Plan
Keywords
A plan for autologous delayed breast reconstruc-
DIEP breast reconstruction · Breast-cancer tion with simultaneous vascularized lymph-node
related lymphedema · Lymph-node transfer · transfer was set. A free abdominal deep inferior
Selected inguinal lymph-node flap · Combined epigastric artery perforator (DIEP) flap was
breast-lymphedema reconstruction planned for left breast reconstruction combined
with an inguinal lymph-node flap for treating the
breast-cancer related lymphedema of the ipsilat-
The Clinical Scenario eral upper limb (Saaristo et al. 2012; Nguyen et al.
2015; Dionyssiou and Demiri 2021).
A 47-year-old woman presented to the Breast and
Lymphedema clinics of our department, following
a left mastectomy and axillary node clearance Alternative Reconstructive Options
performed 10 years ago; the patient also received
postoperative chemo- and radiotherapy (Fig. 1). 1. Latissimus dorsi (LD)-based breast reconstruc-
About 20 months after completion of the breast tion with pedicled lateral thoracic lymph nodes
cancer treatment, she progressively developed or free vascularized inguinal lymph-node flap
edema of her left upper limb which remained (Cheng et al. 2013; Inbal et al. 2017).
untreated. At clinical examination, the healthy Disadvantage of the LD-based breast recon-
right breast was found of medium size with struction is the need for extra volume, either
grade B ptosis; she presented laxity of the abdom- with an implant or with fat transfer; the LD flap
inal wall with a Body Mass Index at 27 kg/m2. was the second option for this case.
61 Combined Autologous Breast and Lymphedema Reconstruction with a. . . 667
Preoperative evaluation of the patient included

measurements of the contralateral healthy breast,
clinical assessment of the abdominal tissue and its
availability for breast reconstruction, and the
pulse status of the perforators shown by the CTA
in order to select the dominant one (Fig. 2).
Clinical evaluation and perometry of both arms
was performed for lymphedema staging. A
SPECT-CT of both groin areas was performed in
order to visualize and preoperatively select the
most radioactive inguinal lymph nodes for trans-
fer, as shown in Fig. 3 (Dionyssiou et al. 2019).

Drawing
Daily preoperative physiotherapy started 2 weeks

before surgery with manual lymphatic drainage of
the left arm and bandage. The day before surgery,
with the patient in standing position, measurements
of the healthy breast were used to prepare a
two-dimensional template, which was checked
Fig. 1 Patient’s appearance at first consultation, 10 years against the patient after reversing the design for
after left mastectomy and axillary lymph node clearance; a the left breast and centered over the selected perfo-
Stage II lymphedema of the left upper extremity was rator (Dionyssiou et al. 2014). The median thoracic
documented
line was drawn and the new submammary fold was
traced mirroring the fold of the right breast (Fig. 4).
2. Combined breast and lymphedema reconstruc- With the patient lying in supine position, the
tion with deep inferior epigastric perforator location of the selected lymph nodes was drawn
flap and gastroepiploic vascularized lymph- over the left inguinal skin, according to the SPECT-
node transfer (Ciudad et al. 2020). CT guided Selected Lymph-Node flap (SeLyN)
Disadvantage of this technique is the need technique (Dionyssiou et al. 2019). More specifi-
for laparotomy for lymph nodes harvesting. cally, the distances of the nodes from fixed anatom-
3. Breast reconstruction associated to lymphatico- ical landmarks, that is, the median line, the skin
venous anastomoses (Chang. 2012). surface, and the antero-superior iliac spine, were
Disadvantage of this reconstructive option accurately measured; these measurements were
is lymphedema recurrence following transferred on the selected groin area (Fig. 5).
LVA-based reconstruction, especially when A cutaneous bridge connecting the two flaps,
dealing with a secondary breast-cancer related that is, the DIEP cutaneous island and the SeLyN
lymphedema case. flap, was also pre-planned.
Preoperative Evaluation and Imaging Surgical Technique
A CT angiography of the abdominal wall was 1. The mastectomy scar was resected and the
performed to map the deep inferior epigastric cutaneous flaps were elevated above the mus-
artery perforators (Masia et al. 2006). cle, creating a pocket to accommodate the
free abdominal flap; this subcutaneous pocket descending branch of the left thoracodorsal
extended from the subclavicular area to the artery and vein were identified, dissected, and
predesigned submammary fold, and from the prepared for the anastomoses with the pedicle
left parasternal area medially to the anterior of the lymph-node flap component.
axillary line laterally. After incising the 3. Abdominal flap’s dissection started with the
pectoralis major muscle, the third costal car- preparation of the left inguinal lymph-node
tilage was resected and the left internal mam- flap. The selected lymph nodes were
mary vessels were dissected and prepared for approached through a cutaneous incision
the anastomoses with the vascular pedicle of over the left inguinal area, following the
the DIEP flap. lower border of the preplanned skin pattern
2. Dissection continued laterally with complete of the DIEP flap. The Scarpa fascia was
axillary scar tissue resection; thereafter, a incised and the superficial circumflex iliac
(SCI) vessels were identified and ligated lat-
eral to the lymph-node flap; palpation of the
area revealed the presence of the selected
lymph nodes located exactly at the
pre-planned site, lateral to the femoral vessels
and above the inguinal crease.
4. Elevation of the lymph-node flap continued
above the deep fascia, always remaining
attached caudally to the abdominal flap tis-
sues; the superficial inferior epigastric (SIE)
vessels were identified and dissected down to
their origin from the femoral vessels, giving a
4 cm long vascular pedicle.
5. The DIEP flap was elevated just above the
Fig. 2 Preoperative CTA of the abdominal wall showing abdominal muscle fascia and following the
the selected right-sided perforator, 2 cm below the umbili- preoperative drawings, including a fusiform
cus level (arrow) infra-umbilical skin island. The selected
Fig. 3 Coronal view of the

SPECT-CT of the groin
areas showing the selected
left-sided inguinal lymph
nodes, located 5.8 cm
lateral to the median line
and 1.17 cm above the
pubic tuberosity
epigastric vessels, providing a 10 cm long

vascular pedicle (Fig. 6).
6. Abdominal tissue outside of the pre-planned
template was discarded and the triangular
skin area delimited by the vertical lines was
de-epithelialized. The SIE vessels were
clamped and the combined DIEP-LNT flap
was left is situ for 15 min before cutting the
vascular pedicles to assess blood perfusion.
7. After ligation of both artery and veins at their
distal aspect, the free chimeric flap was
ready for transfer and revascularization
(Fig. 7). Two pairs of micro-anastomoses
were performed: the DIEP-component of
the chimeric flap was revascularized end-
to-end on the internal mammary pedicle,
while for the LNT-component, end-to-end
micro-anastomoses were performed on
thoracodorsal vascular branches.
8. After flap revascularization, the lymph-node
component was stabilized into the left axillary
fossa with loose 4/0 vicryl sutures. The DIEP
Fig. 4 Preoperative drawing of the DIEP skin island based skin island was shaped to produce the breast
on the measurements of the contralateral breast and cen- conus, placed in the thoracic pocket and
tered on the marked perforator sutured in situ; volume, shape, and projection
of the new left breast were assessed for sym-
metry with the contralateral one.
9. The flap donor-site was primarily closed; the
abdominal fascia was meticulously repaired
with permanent sutures.
10. Nipple reconstruction was secondarily
performed, 20 months after breast and lymph-
edema reconstruction.
Technical Pearls
1. Elevation of the superior abdominal skin flap

Fig. 5 Close-up view of the combined flap drawing: the starts just above the Scarpa’s fascia; subfascial
DIEP skin island is centered over the selected perforator fat is included to the DIEP flap in order to fill
(arrow) and the lymph node flap component was drawn the upper pole of the new breast.
based on the SPECT-CT measurements. Subcutaneous fat
is left attached to the superior abdominal flap, just opposite
2. Leave some subcutaneous fat attached to the
to the selected lymph-node flap, to fill the defect after superior abdominal flap, just opposite to the
harvesting the inguinal lymph nodes selected lymph-node flap, in order to fill the
defect after harvesting the inguinal lymph
perforator, located at the right hemiabdomen, nodes (Maldonado et al. 2017)
was identified and dissected intramuscularly 3. Care should be taken to keep the upper part of
down to the origin of the deep inferior the lymph-node flap attached to the DIEP flap.
Skin island in not harvested with the lymph-

node flap.
4. Revascularization of the chimeric flap starts
with the anastomoses of the DIEP-pedicle on
the internal mammary vessels and continues
with anastomosing the LN-flap’s pedicle on
the thoracodorsal vascular branch. Even if the
whole composite flap is well perfused after the
first pedicle’s suturing, a second arterial and
venous anastomosis of the lymph-node flap
must be performed to enhance vascular supply
to the transferred lymph nodes and avoid
venous congestion.
5. Four suction drains are placed before closure:
two in the thoracic and another two in the Fig. 6 Ventral view of the combined flap showing the
abdominal site. It is suggested to leave the vascular pedicle of the DIEP flap component and the
clipped vascular pedicle (arrow) of the lymph-node com-
drain of the LN-flap donor area in place, until ponent (λ)
fluid is less than 30 ml per day, in order to
avoid postoperative collection or lymphocele
formation (Hamdi et al. 2021).
6. As the selected lymph nodes were located ipsi-
lateral to the mastectomy, the DIEP skin pat-
tern was designed in an orthograde fashion;
there is no need to rotate the combined flap
when insetting it to the thorax.
See Figs. 6 and 7.

Fig. 7 Free bipedicle chimeric DIEP-LNT flap: the solid
arrow indicates the site of the selected DIEA perforator and
Postoperative Management the dashed circle indicates the lymph-node flap component
(λ)
Postoperatively, the flap was closely monitored
for the first 5 days with physical examination Outcome: Clinical Photos and Imaging
and a hand-held Doppler. The patient was mobi-
lized from the second postoperative day; anti- The postoperative course was uneventful and the
coagulant regimen included low-molecular patient remained hospitalized for 6 days having a
heparin and oral aspirin for 3 weeks. Manual smooth recovery. At 14 months after surgery,
lymphatic drainage and bandage of the left arm lymphoscintigraphy of both arms was performed
started the day after surgery and continued for and showed improved radiotracer clearance on the
4 weeks, followed by an elastic sleeve for operated limb compared to the preoperative
5 more months; thereafter systematic physio- findings.
therapy and use of compressive dressings was At the 28-month follow-up a satisfactory result
discontinued. was recorded, regarding the left breast
reconstruction with natural appearance and good

symmetry with the contralateral one; there was no
need for revision surgeries. Clinical assessment of
both upper limbs revealed a 44.6% of volume
difference reduction (Fig. 8). No clinical evidence
of lymphedema of the left leg was recorded. ICG-
lymphography of both lower extremities con-
firmed normal lymphatic flow of the donor lower
limb, comparable to the contralateral one.
The patient reported high level of satisfaction
with the postoperative results of both the breast
and the lymphedema reconstruction; she returned
to her work and normal social activities, and
reported improvement of function and symptoms
related to upper limb lymphedema (i.e., feeling of
heaviness, local pain); no infection episodes
occurred after surgery.
1. Recipient vessels for the lymph-node flap on

the lateral thoracic area, that is, thoracodorsal
branches, should be dissected at a minimum
6–7 cm length, ligated distally and turned Fig. 8 Patient’s appearance 28 months following the
upwards in order to facilitate micro-anas- reconstruction with a nice projection and symmetrical
breast image; significant volume reduction of the
tomoses in the axillary area. If those vessels lymphedematous left arm was recorded
are not available, lateral thoracic vessels or
subscapular branches may be used utmost importance. SPECT-CT guidance is
alternatively. highly recommended for a safe lymph-node
2. If the selected lymph nodes are located contra- selection (Demiri et al. 2018; Dionyssiou
lateral to the mastectomy site, the combined et al. 2019). Otherwise, the reverse lymphatic
flap is rotated 180 in order to place the lymph mapping with technetium or ICG injection is
nodes into the axillary area (Nguyen et al. mandatory (Dayan et al. 2015).
2015); in that case, the template of the DIEP
flap is designed in a reverse fashion, always
centralized over the selected DIEA perforator. Learning Points
3. The DIEA perforator, which will be used for
the flap’s revascularization, is preferably 1. A free DIEP flap coupled with inguinal lymph
located at the opposite side of the selected nodes may provide an aesthetic delayed breast
lymph nodes, so that a longer tissue bridge reconstruction and address breast-cancer
connecting the two flaps may be obtained and related lymphedema in a single operation.
facilitate the placement of the vascularized 2. Appropriate preparation and preoperative
lymph nodes into the axillary fossa. planning of this combined flap is mandatory
4. When harvesting the lymph-node flap, avoid- to achieve a very good result and minimize
ance of iatrogenic donor-site lymphedema is of complications or revision surgeries.
3. The use of a CTA and SPECT-CT assisted cancer related lymphedema: a systematic review of the
predesigned chimeric DIEP-inguinal lymph literature. Lymphat Res Biol. 2018;16:2–8.
Dionyssiou D, Demiri E. A comprehensive treatment algo-
node flap allows for a precise preoperative rithm for patients requiring simultaneous breast and
planning of the whole procedure and reduction lymphedema reconstruction based on lymph node
of the operative time, while optimizing aes- transfer. Ann Breast Surg. 2021; https://doi.org/10.
thetic outcome and minimizing postoperative 21037/abs-20-142.
Dionyssiou D, Demiri E, Tsimponis A, et al. Predesigned
complications. breast shaping assisted by multidetector-row computed
tomographic angiography in autologous breast recon-
struction. Plast Reconstr Surg. 2014;133:100-8e.
Dionyssiou D, Demiri E, Sarafis A, et al. Functional lym-
Cross-References phatic reconstruction with the “Selected Lymph Node”
technique guided by a SPECT-CT lymphoscintigraphy.
J Surg Oncol. 2019;120:911–8.
▶ Superior Gluteal Artery Perforator (SGAP) Flap Hamdi M, Ramaut L, De Baerdemaeker R, et al. Decreas-
in Delayed Autologous Breast Reconstruction ing donor site morbidity after groin vascularized lymph
node transfer with lessons learned from a 12-year expe-
rience and review of the literature. J Plast Reconstr
Aesthet Surg. 2021;74:540–8.
References Inbal A, Teven C, Chang D. Latissimus dorsi flap with
vascularized lymph node transfer for lymphedema
Becker C, Assouad J, Riquet M, et al. Postmastectomy treatment: technique, outcomes, indications and review
lymphedema: long-term results following microsurgi- of literature. J Surg Oncol. 2017;115:72–7.
cal lymph node transplantation. Ann Surg. 2006;243: Lindegren A, Halle M, Docherty Skogh AC, et al. Post-
313–5. mastectomy breast reconstruction in the irradiated
Chang DW. Lymphaticovenular bypass surgery for lymph- breast: a comparative study of DIEP and latissimus
edema management in breast cancer patients. Handchir dorsi flap outcome. Plast Reconstr Surg. 2012;130:10–8.
Mikrochir Plast Chir. 2012;44:343–7. Maldonado AA, Garza RM, Artz J, et al. Abdominal flap
Chang EI, Masià J, Smith ML. Combining autologous for closing the donor site after groin lymph node trans-
breast reconstruction and vascularized lymph node fer. J Surg Oncol. 2017;115:390–1.
transfer. Semin Plast Surg. 2018;32:36–41. Masia J, Clavero JA, Larrañaga JR, et al. Multidetector-
Cheng MH, Chen SC, Henry SL, et al. Vascularized groin row computed tomography in the planning of abdom-
lymph node flap transfer for post-mastectomy upper inal perforator flaps. J Plast Reconstr Aesthet Surg.
limb lymphedema: flap anatomy, recipient sites, and 2006;59:594–9.
outcomes. Plast Reconstr Surg. 2013;131:1286–98. Nahabedian MY, Momen B, Galdino G. Breast reconstruc-
Ciudad P, Manrique OJ, Bustos SS, et al. Combined micro- tion with the free TRAM or DIEP flap: patient selec-
vascular breast and lymphatic reconstruction with deep tion, choice of flap and outcome. Plast Reconstr Surg.
inferior epigastric perforator flap and gastroepiploic 2002;110:466–77.
vascularized lymph node transfer for postmastectomy Nguyen AT, Chang EI, Suami H, et al. An algorithmic
lymphedema patients. Gland Surg. 2020;9:512–20. approach to simultaneous vascularized lymph node
Dayan JH, Dayan E, Smith ML. Reverse lymphatic map- transfer with microvascular breast reconstruction. Ann
ping: a new technique for maximizing safety in Surg Oncol. 2015;22:2919–24.
vascularized lymph node transfer. Plast Reconstr Saaristo AM, Niemi TS, Viitanen TP, et al. Microvascular
Surg. 2015;135:277–85. breast reconstruction and lymph node transfer for post-
Demiri E, Dionyssiou D, Tsimponis A, et al. Donor site mastectomy lymphedema patients. Ann Surg.
lymphedema following lymph node transfer for breast 2012;255:468–73.
Submental Lymph Node Transfer to
the Lower Extremity 62
Courtney Chen and Ming-Huei Cheng
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 680
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
Abstract
C. Chen
UC San Diego School of Medicine, San Diego, CA, USA
Lower extremity lymphedema can be from
e-mail: coc025@ucsd.edu either primary or secondary causes. Regard-
M.-H. Cheng (*)
less, surgical management is largely guided
Division of Reconstructive Microsurgery, Department of by Cheng’s Lymphedema Grading correlated
Plastic and Reconstructive Surgery, Chang Gung with the Taiwan Lymphoscintigraphy Staging.
Memorial Hospital, College of Medicine, Chang Gung Lower extremity lymphedema with Cheng’s
University, Taoyuan, Taiwan
Lymphedema Grading of Grades II–IV with
Center for Tissue Engineering, Chang Gung Memorial total obstruction on lymphoscintigraphy is an
Hospital, Taoyuan, Taiwan
indication for vascularized lymph node
Division of Plastic Surgery, Department of Surgery, transfer. Vascularized submental lymph node
University of Michigan, Ann Arbor, MI, USA

https://doi.org/10.1007/978-3-030-23706-6_108
674 C. Chen and M.-H. Cheng
(VSLN) transfer is a highly efficacious, low fibroadipose tissue deposition, and frequent and
complication treatment option with a donor recurrent cellulitis secondary to lymphatic fluid
basin rich in lymph nodes with consistent anat- accumulation. Lower extremity lymphedema
omy, suitable pedicle length, and sufficient largely presents unilaterally, although bilateral pre-
donor veins and arteries. sentation is not uncommon. There are primary and
This clinical case illustrates the work-up, con- secondary causes of lower extremity. Primary
siderations, techniques, operative tips, postoper- lymphedema is typically the result of inherited or
ative management, functional outcomes, and congenital aberrations of the lymphatic vessels; it
pitfalls of performing a VSLN flap transfer. often presents with younger ages of onset at
Work-up involves a clinical history, physical 38.5 years old (Vignes et al. 2013) for upper
exam, and multimodal imaging approaches extremity lymphedema and is thought to affect
including lymphoscintigraphy, indocyanine females more than males. In comparison, second-
green (ICG) lymphography, ultrasound Doppler, ary lymphedema has a wide range of etiologies and
and computed tomography (CT) or magnetic is much more common than primary lower extrem-
resonance imaging (MRI). Harvesting the sub- ity lymphedema. Globally, the leading cause of
mental lymph node flap requires careful dissec- secondary lymphedema is from infection by
tion, and the recipient site has an equally Wuchereria bancrofti which causes filariasis. In
challenging dissection of recipient pedicles with developed and developing countries, however, the
the creation of a pocket to inset the flap. Postop- leading causes of secondary lymphedema are onco-
erative management relies on confirmation of logic-related, linked with ablative surgery, lymph
patent anastomoses with Doppler and clinical node resection, and/or radiation. As treatment of
signs to detect any potential vascular insuffi- cancer continues to rise in developed countries,
ciency requiring re-exploration. Functional out- there is also a concomitant rise in lymphedema
comes of VSLN flap transfer are reliably good, prevalence. However, lymphedema remains a chal-
with significant limb circumference reduction, lenging entity to treat due to difficulty in obtaining
decreased cellulitis incidence, and quality of an accurate diagnosis and also due to underutiliza-
life improvement. Aesthetics are equally satis- tion of recent surgical methods instead of less
factory, with minimal scarring and easily hidden efficacious, labor-intensive complex decongestive
incisions, particularly after skin paddle excision therapy and/or compression garments.
1 year postoperatively. This patient presented with secondary right uni-
lateral lower extremity lymphedema of 15 years
post radical hysterectomy, bilateral pelvic lymph
Keywords
node dissection, and postoperative radiotherapy
Extremity lymphedema · Submental lymph (Fig. 1). Her lymphedema was Cheng’s Lymph-
node · Vascularized lymph node transfer · edema Grade IV with an average of three episodes
Cheng’s Lymphedema Grading · Taiwan per year of cellulitis. Preoperative lymphoscin-
Lymphoscintigraphy Staging tigraphy revealed total lymphatic obstruction in
the right leg starting at the ankle (Fig. 2).
Lower extremity lymphedema occurs in 20–30% Preoperative Problem List:

of gynecological cancer patients and has a Reconstructive Requirements
cumulative incidence of 41.1% in breast cancer
patients (Zikan et al. 2015; Pereira et al. 2017). 1. Severe lower extremity swelling with
Lymphedema is the manifestation of low-output restricted range of motion and associated pain.
failure of the lymphatic system in the lower extrem- 2. Repeated episodes of cellulitis requiring
ities, characterized in later stages by swelling, intravenous antibiotics and hospitalization
62 Submental Lymph Node Transfer to the Lower Extremity 675
9. Work-related impairment/requirement for

special accommodations.
10. Impaired quality of life and social
impairment.
Treatment Plan
Patients with lower extremity lymphedema can

be treated conservatively or surgically. Treatment
depends on the patient’s preference, Cheng’s
Lymphedema Grading (CLG), and Taiwan
Lymphoscintigraphy Staging (TLS).
Non-operative management typically consists
of complex decongestive therapy with life-
long compression garments worn for at least
16 hours per day. Complex decongestive therapy
requires a strict level of patient compliance and
self-care, incorporating daily compression gar-
ments on top of regular skin care, exercises, and
self-manual lymphatic drainage in order to be
efficacious. Patient non-compliance results in
loss of at least 1/3 of the initial benefits received
from complete decongestive therapy (Ko et al.
1998).
Fig. 1 Patient’s preoperative right lower extremity lymph-
If the patient is a candidate for surgical
edema treated with complex decongestive therapy. Note
the loss of native knee and ankle flexure folds, dimpling, management, the patient’s surgical options
and uneven contour of the right lower extremity compared are categorized into non-physiologic or physio-
to the unafflicted contralateral leg logic procedures and are guided by CLG. Non-
physiologic options include liposuction, wedge
with associated soft tissue inflammation resection, or a Charles’ procedure. Physiologic
changes. options available include lymphovenous anasto-
3. Necessity of flap transfer with adequate mosis (LVA) or vascularized lymph node transfer
lymph nodes and reliable vascular pedicle (VLNT). For CLG I–II, a LVA may be sufficient
(at least one artery and one vein). with good long-term outcomes. For CLG II–IV, a
4. In donor lymph node basin selection, the sub- VLNT is indicated (Allen and Cheng 2016).
mental space is preferable due to its reliably Among donor lymph node basins, the submental
robust arterial and venous pedicle, greater lymph node basin is considered the most effective
number of lymph nodes, reliable skin paddle option. Patients who undergo VLNT report a bet-
with a mean of four cutaneous perforators, ter quality of life, improved perception of body
and minimal donor-site morbidity. appearance, better functionality, and improved
5. Fibrotic, entrapped, stenosed recipient ves- mood alongside fewer cellulitis events (Patel
sels requiring adventitectomy. et al. 2015).
6. Fibrotic soft tissue deposits in the lower For this case, the patient was a candidate for
extremity requiring resection to allow for VLNT with a CLG of IV. The patient underwent
inset of donor flap. vascularized submental lymph node (VSLN) flap
7. Requirement of multiple vessels anastomoses. transfer for her lower extremity lymphedema,
8. Necessity to verify patency of anastomoses. which was placed distally at her right ankle.
Fig. 2 Preoperative evaluation of lymphatic flow by ankle level with diffuse dermal backflow equivalent to
lymphoscintigraphy for the patient’s lower extremities Taiwan Lymphoscintigraphy Staging of T5
revealed complete obstruction of lymphatics at the right
challenging dissection, and wider anatomic

variation (Pappalardo et al. 2018)
5. Vascularized thoracic lymph node flap: two
1. Lymphovenous anastomosis: selection of a
sets of pedicles – thoracodorsal or lateral tho-
distal lymphatic channel in the affected
racic vessels, smaller and fewer lymph nodes,
extremity with a neighboring veinule compat-
may need to cut the motor nerve of latissimus
ible in size and performing either an end-to-end
dorsi (Pappalardo et al. 2018)
or side-to-end anastomosis technique (Al-
Jindan et al. 2019)
2. Vascularized groin lymph node flap: must
take into consideration the reliability Preoperative Evaluation and Imaging
and proven clinical outcomes against inherent
risk of donor-site lymphedema, smaller donor The patient is first evaluated with an in-depth
artery/veins, shorter pedicle, and less limb cir- history and physical examination. Major risk
cumference improvement compared to VSLN factors for extremity lymphedema, such as an
(Ho et al. 2018) oncologic history, radiation, trauma, congenital
3. Omental lymph node flap: shorter pedicle defects, infection, or family history, are noted.
length with a sizeable artery, small pedicle On physical exam, notable findings include
veins, and incision concealment versus risk of swelling, a positive Stemmer’s sign, skin dim-
intraperitoneal surgery and lack of cutaneous pling, asymmetric firm fibrosis along the lower
flap component for monitoring (Pappalardo extremity, decreased range of motion, decreased
et al. 2018) sensation, and possibly cellulitis. In the affected
4. Vascularized supraclavicular lymph node flap: extremity, the limb circumference is often also
less reliable pedicle vein for lymph drainage, notably larger than the normal limb. Initial evalu-
inconsistent perforator for a skin paddle, risk of ation includes measurements taken at several
lymph/chyle leakage, special left site, levels on the lower limb (most frequently at
15 cm above the knee, 15 cm below the knee, and The head of the patient was positioned
10 cm above the ankle). slightly hyperextended with slight left lateral
After there is clinical suspicion for extrem- flexion in preparation for the right VSLN flap
ity lymphedema, imaging methods are crucial harvest. The neck and underside of the mandible
for diagnosis and grading with understanding of were sterilely prepped and draped, with the cor-
the severity of lymphatic obstruction for potential ner or the mouth and lower lip also prepped but
VSLN flap transfer. Lymphoscintigraphy is left exposed to help visualize the facial nerve
performed to evaluate the functional status of the course and in anticipation of nerve stimulation
lymphatic system with the added benefit of flow monitoring. An elliptical shaped skin paddle
dynamics. Indocyanine green injection with infra- 10 5 cm was drawn 1 cm beneath and parallel
red imaging can yield real-time visualization of to the inferior margin of the mandible. As part of
superficial lymphatic vessels with drainage the technique, the medial platysma may be pre-
patterns. served for 5 cm in width to decrease the chance
For evaluation of the VSLN flap, an MRI is of pseudo-marginal mandibular palsy. Cutaneous
ordered to visualize the number and sizes of the perforators were traced with assistance of a pen-
submental lymph nodes in soft tissue and to iden- cil Doppler inside the designed elliptical skin
tify potential anatomic challenges in the sub- paddle (Fig. 4).
mental space (Asuncion et al. 2018). Additional
evaluations of lymph node numbers in the sub-
mental space as well as evaluations of vascular Surgical Technique
flow in the recipient vessels are performed via
ultrasound Doppler. The proximal recipient site A submental lymph node flap was harvested with
is also assessed with ultrasound Doppler to eval- an elliptical skin paddle designed along the lower
uate for any concomitant deep vessel anomalies in mandible border. The incision was started from
addition to assessing the flow and diameters of the the upper skin paddle border with incision
great saphenous vein, anterior tibial vessels, and through the platysma. A 5-cm wide portion of
posterior tibial vessels to assist with the selection the medial platysma is preserved to decrease the
of recipient vessels (Cheng et al. 2017; likelihood of marginal mandibular nerve pseudo-
Sachanandani et al. 2018; Tzou et al. 2017). paralysis (Poccia et al. 2017). Care was taken to
preserve the marginal mandibular nerve and to
divide the distal facial artery and vein while max-
Preoperative Care and Patient imizing submental lymph nodes and avoiding
Drawing damage to submental artery perforator vessels
(Fig. 5). The marginal mandibular nerve was dis-
The patient was placed in supine position with sected under a microscope, stimulated with a
padding underneath the knee of the affected nerve probe, and confirmed to be intact. The vas-
limb to obtain a better angle for exposure of cular pedicle and lymph nodes were taken en bloc
the dorsal ankle. The entire leg from hip down- with submental soft tissue to maximize the harvest
ward circumferentially, including the dorsal of lymph nodes (Fig. 6).
aspect of the foot up to the phalanges, was ster- The right ankle was incised with a lazy S
ilely prepped and draped. The courses of the incision at the dorsal ankle, and deep fibroadipose
expected recipient anterior or posterior tibial tissue was partially excised to create a pocket
artery and vein were drawn. A lateral line for the flap inset (Fig. 7). The recipient vessels
approximately 15 cm in length was drawn across (great saphenous vein and anterior tibial vessels)
the dorsal ankle and along the great saphenous were dissected and isolated from the anterior com-
vein course for demarcation of the incision to be partment. The donor and recipient vessels (one
made at the recipient site at the dorsal ankle artery and two veins) were anastomosed in end-
(Fig. 3). to-end fashions with interrupted sutures carefully,
3. Tracing the facial veins and arteries distally

helps identify the marginal mandibular nerves,
which are perpendicular to the facial vessels.
4. The marginal mandibular nerves can be well
preserved by dissection under microscope and
use of a nerve stimulator.
5. Identification of additional possible recipient
veins is valuable in the advent of two vein
anastomoses.
6. The lymphedema adipose tissue is typically
Fig. 3 Recipient right ankle incision site demarcated with subject to fibrotic changes. Resection of part
a solid lazy S-shape line. The anterior tibial artery, identi-
of the fibrotic tissue to create a pocket for the
fied using pencil Doppler, is marked with the dashed line
flap inset is critical to decrease the chance of
pedicle compression and compromise.
7. The anastomosed pedicle vein must remain
uncompressed and without tension. This is
achieved by having a good-quality recipient
vein with a reliable skin paddle to release the
tension of the wound closure.
8. Another technique of delayed primary reten-
tion sutures with secondary tightening down of
the flap over 5–7 days to decrease soft tissue
swelling for flap accommodation is also help-
ful for avoiding compression of the pedicle
vein. This might decrease re-exploration and
total complication rates (Koide et al. 2020b).
Fig. 4 Operative schematic of intended elliptical donor
flap to be harvested from the submental lymph node basin
and the flap was inset without tension into the
created pocket (Fig. 7). Intraoperative patency of See Figs. 5, 6, 7, and 8.
the anastomoses was tested with two forceps and
pencile ultrasound Doppler. The flap was sutured
in place with delayed primary retention sutures. Postoperative Management
Two Penrose drains were left in place in the lower
extremity (Fig. 8). The patient was postoperatively managed in a
specialized microsurgery ICU for 7 days before
being transferred to a regular ward. A protective
Technical Pearls frame was placed over the limb with the VSLN
flap and had a blanket draped over it with a radiant
1. At least one cutaneous perforator should be warmer intermittently placed several feet above
preserved to keep the skin paddle of VSLN the protective frame. Daily monitoring of the
flap viable, which may decrease the tension patency of the venous and arterial anastomoses
of the wound closure at the recipient site. was performed by pencile Doppler ultrasound and
2. Planning of the VSLN flap must be done such remote imaging via smartphone.
that the closed incision falls naturally at the The flap was monitored for signs of arterial
jaw-neck flexure for an aesthetic, minimally insufficiency such as cooler temperature, pal-
visible scar. lor skin paddle, poor capillary refill, as well as
Fig. 5 Raising the submental donor flap. The red vessel White vessel loops are carefully placed to isolate two
loop encircles the distal facial artery. The superior blue marginal mandibular nerves. Yellow arrows indicate siz-
vessel loop demarcates the distal facial vein, and the infe- able lymph nodes
rior blue vessel loop isolates the proximal facial vein.
also subjectively evaluated daily, along with the

presence or absence of Stemmer’s sign. After
3 days with good progress, the patient was allo-
wed to intermittently elevate her leg on a pillow
and, by postoperative days 5–7, was allowed to
dangle her leg to gravity off the bed for a few
hours. By discharge, the patient was ambulating
with stay sutures completely tightened, flap
approximated to the ankle incision, and drains
removed with good flow through arterial and
venous anastomoses proven on pencil Doppler.
The patient was seen routinely monthly for
6 months and then every 3 months. At 1 year
postoperatively, the patient was offered and
underwent excision of the VSLN flap skin paddle,
Fig. 6 Harvest of the submental lymph nodes (yellow
arrows) with two veins (blue arrows) and one artery (red yielding a pleasing aesthetic result of a barely
arrow) as the vascular pedicle to be anastomosed with the visible, single incision that meld into natural
recipient great saphenous vein, anterior tibial vein, and joint flexure folds.
anterior tibial artery, respectively
venous insufficiency, evidenced by congestion or

a bluish hue. Drain outputs were monitored, and Outcome: Clinical Photos and Imaging
regular gentle exploration of any gaps between
sutures, flap, and the dorsal ankle was performed At a follow-up of 67 months, the patient had a
to remove any debris, excess exudate, or possible circumferential reduction rate of 67%, 75%, and
pus/nidus for infection. Delayed primary retention 59.5% above the knee, below the knee, and above
sutures were gradually tightened down after day 7 the ankle of right lower extremity lymphedema,
with edges of the flap skin paddle approximated respectively (Fig. 9). Sixty-seven months since
with the lazy S incision of the dorsal ankle. The the vascularized submental lymph node transfer,
lower extremity’s firmness at the thigh, above the she has experienced only a single episode of
knee, below the knee, and above the ankle was cellulitis to date.
complications have comparably robust long-

term outcomes to their uncomplicated counter-
parts (Koide et al. 2020a).
2. The marginal mandibular nerve has 1–3
branches near the distal facial artery and vein.
The chance of marginal mandibular nerve
damage and pseudoparalysis should not be
taken lightly. However, postoperatively,
minor difficulty in lower lip movement is not
uncommon and usually resolves spontane-
ously within 3 months without lasting effects.
3. Daily skin paddle evaluation postoperatively
for perfusion and congestion alongside and
Doppler flow monitoring for anastomoses are
critical. If there is evidence of vascular com-
Fig. 7 Donor-site preparation. Retention hooks and stay promise, the patient must be taken for urgent
sutures are placed to help retract highly dense, resistant soft re-exploration/revision of the pedicle
tissue. The superior blue vessel pictured encircles the great immediately.
saphenous vein and the blue vessel loop in the inferior 4. While the submental lymph node flap provides
aspect of the image encircles the isolated anterior tibial
vein a reliable and sizable vascular pedicle, the
facial vein (4–5 mm) is typically mismatched
in size to the anterior tibial vein (2–4 mm) and
usually matched with the great saphenous vein
(4–6 mm). Despite the size discrepancy, a
larger donor vein tends to allow for easier
anastomoses at the recipient site and increases
lymph node drainage function.
Learning Points
Fig. 8 Completion of a vascularized submental lymph 1. A VSLN flap has a vascular pedicle composed
node flap transfer, including a skin paddle with two Pen- of the submental – facial artery and vein with a
rose drains in place
pedicle length of 6.4 0.9 cm and
4.6 0.5 cm, respectively. The flap contains
Avoiding and Managing Problems a mean of three sizable lymph nodes from level
IA and IB neck nodes. The marginal mandib-
1. The critical arterial ischemic time of ular nerve is within the submental space, so
vascularized lymph node in a rat model is 5 h nerve stimulation along with careful dissection
(Yang et al. 2018). Venous occlusion damage near distal facial vasculature under microscope
of vascularized lymph node in a rat model is will greatly reduce the risk of nerve injury.
seen at 4 h (Tinhofer et al. 2019). As such, 2. The available recipient vessels are the great
while ischemia is unideal, venous damage is saphenous vein, anterior tibial artery/veins,
more severe and has a quicker onset, and thus, and posterior tibial artery/veins in the ankle.
venous anastomoses should be prioritized The flap inset and donor and recipient pedicle
to avoid damage to the transferred lymph configurations should be meticulously
nodes. If any instance of venous occlusion is mapped before the pedicle anastomoses
promptly addressed, VSLN flaps with venous intraoperatively.
rapidly damaging to lymph node function

than arterial ischemia. The VSLN flap must
be promptly re-explored in the advent of
venous congestion developing.
References
Al-Jindan FK, Lin CY, Cheng MH. Comparison of outcomes
between side-to-end and end-to-end lymphovenous anas-
tomoses for early-grade extremity lymphedema. Plast
Reconstr Surg. 2019; 144(2):486–496.
Allen RJ Jr, Cheng MH. Lymphedema surgery: patient
selection and an overview of surgical techniques.
J Surg Oncol. 2016;113(8):923–31.
Asuncion MO, Chu SY, Huang YL, Lin CY, Cheng MH.
Accurate prediction of submental lymph nodes using
magnetic resonance imaging for lymphedema surgery.
Plast Reconstr Surg Glob Open. 2018;6(3):e1691.
Cheng MH, Lin CY, Patel KM. A prospective clinical
assessment of anatomic variability of the submental
vascularized lymph node flap. J Surg Oncol.
2017;115(1):43–7.
Ho OA, Lin CY, Pappalardo M, Cheng MH. Comparisons
of submental and groin vascularized lymph node flaps
Fig. 9 Patient’s right unilateral lower extremity lymph- transfer for breast cancer-related lymphedema. Plast
edema at 67 months status post vascularized submental Reconstr Surg Glob Open. 2018;6(12):e1923.
lymph node transfer to the right ankle. At this timepoint, Ko DS, Lerner R, Klose G, Cosimi AB. Effective treatment
the transferred flap’s skin paddle has been removed, and of lymphedema of the extremities. Arch Surg.
postoperative changes of the appearance of skin folds and 1998;133(4):45208.
decreased soft tissue volume are appreciable despite dis- Koide S, Lin CY, Chen C, Cheng MH. Long term outcome of
continuation of complex decongestive therapy after the lower extremity lymphedema treated with vascularized
VSLN transfer lymph node flap transfer with or without venous compli-
cations. J Surg Oncol. 2020a;121:129–137.
Koide S, Lin CY, Cheng MH. Delayed primary retention
3. A distal recipient site (ankle) is preferred over suture for inset of vascularized submental lymph node
more proximal sites (groin, knee) for lower flap for lower extremity lymphedema. J Surg Oncol.
extremity lymphedema based on the proposed 2020b;121:138–143.
Pappalardo M, Patel K, Cheng MH. Vascularized lymph
mechanism of vascularized lymph node flap
node transfer for treatment of extremity lymphedema:
transfers acting as collection basins with an overview of current controversies regarding donor
pumps to drive lymph back into venous circu- sites, recipient sites, and outcomes. J Surg Oncol.
lation, augmented by the catchment effect 2018;117(7):1420–31.
Patel KM, Lin CY, Cheng MH. A prospective evaluation of
and gravity effect.
lymphedema-specific quality-of-life outcomes follow-
4. Recipient sites may require resection of ing vascularized lymph node transfer. Ann Surg Oncol.
fibroadipose tissue with some undermining in 2015;22(7):2424–30.
order to create a space for the submental lymph Pereira R, Koifman RJ, Bergmann A. Incidence and risk
factors of lymphedema after breast cancer treatment: 10
node flap to be inset.
years of follow-up. Breast. 2017;36:67–73.
5. The pedicle vein anastomoses must be tension- Poccia I, Lin CY, Cheng MH. Platysma-sparing
free in order to circumvent possible hematoma vascularized submental lymph node flap transfer for
or swelling and to optimize lymph absorbed by extremity lymphedema. J Surg Oncol.
2017;115(1):48–53.
the transferred lymph nodes.
Sachanandani NS, Chu SY, Ho OA, Cheong CF, Lin CY,
6. Venous congestion of the VSLN flap is a seri- Cheng MH. Lymphedema and concomitant venous
ous complication that is potentially more comorbidity in the extremity: comprehensive
evaluation, management strategy, and outcomes. J Surg Vignes S, Arrault M, Yannoutsos A, Blanchard M.
Oncol. 2018;118:941–52. Primary upper-limb lymphoedema. Br J Dermatol.
Tinhofer IE, Yang CY, Chen C, Cheng MH. Impacts of 2013;168(2):272–6.
arterial ischemia or venous occlusion on vascularized Yang CY, Ho OA, Cheng MH, Hsiao HY. Critical ischemia
groin lymph nodes in a rat model. J Surg Oncol. 2019; time, perfusion, and drainage function of vascularized
121:153–162. lymph nodes. Plast Reconstr Surg. 2018;142(3):688–97.
Tzou CH, Meng S, Ines T, Reissing L, Pichler U, et al. Zikan M, Fischerova D, Pinkavova I, Slama J, Weinberger
Surgical anatomy of the vascularized submental lymph V, et al. A prospective study examining the incidence of
node flap: anatomic study of correlation of submental asymptomatic and symptomatic lymphoceles follow-
artery perforators and quantity of submental lymph ing lymphadenectomy in patients with gynecological
node. J Surg Oncol. 2017;115(1):54–9. cancer. Gynecol Oncol. 2015;137(2):291–8.
LYMPHA Approach for Axillary
Clearance Surgery 63
Boccardo Francesco and Dessalvi Sara
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 684
Outcome, Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687
Abstract
Many attempts have been made to try to pre-

vent lymphedema secondary to axillary node
dissection. The LYMPHA technique repre-
B. Francesco (*) · D. Sara sents the most effective surgical procedure for
Unit of Surgical Lymphology – Department of Cardio- the primary prevention of lymphedema. This
Thoracic, Vascular and Endovascular Surgery, S. Martino technique is usually applied for the prevention
University Hospital, Genoa, Italy
of lymphedema secondary to axillary dissec-
Department of Surgical Sciences and Integrated tion for breast cancer. The use of Patent Blue
Diagnostics – DISC, University of Genoa, Genoa, Italy
e-mail: francesco.boccardo@unige.it and ICG is indispensable to identify brachial

https://doi.org/10.1007/978-3-030-23706-6_109
684 B. Francesco and D. Sara
lymphatics. There are clinical and instrumental lymphedema following breast cancer treatment.
criteria for assessing the risk of the onset of LYMPHA was afterwards used to prevent lower
secondary lymphedema and for identifying limb secondary lymphedema as well.
patients at greater risk. The reduction in the
incidence of lymphedema obtained with the
LYMPHA technique is very significant, to the Alternative Reconstruction Options
point of being able to indicate it in all cases of
complete lymph node dissection. Finally, the The simplified LYMPHA was afterwards descri-
LYMPHA technique represents the most effec- bed in which the technique is finished only with
tive method in the primary prevention of second- the first invaginating suture. The problem of sim-
ary lymphedema of the upper limb, surpassing plified LYMPHA is that you may have leaking
the results obtained from the use of the sentinel around the lymphatics and the invaginating suture
lymph node procedure and the ARM technique. may have transected the lymphatic collectors.
These two technical aspects may justify a possible
Keywords failure of the technique. On the other hand, the
original LYMPHA includes the removal of the
LYMPHA technique · Lymphedema
first invaginating suture, just to be sure to leave
prevention · Lymphatic-venous by-pass ·
the collectors free into the vein lumen.
Secondary lymphedema · Lymphatic
microsurgery
Lymphoscintigraphy may be used to assess risk
patients before breast cancer treatment, show-
LYMPHA technique represents one of the preven-
ing an impaired lymphatic TI, and may dem-
tative surgical procedure to try to avoid lymph-
onstrate the improved lymphatic drainage in
edema following nodal dissection. Looking to the
the follow-up.
Literature we can notice an increasing awareness in
improving prevention and the outcomes of surgery
result significantly better than conservative therapy.
Drawing
Preoperative Problem List
Several papers report the risk factors for lymph-
edema pointing out overweight, obesity, number
Among surgical techniques SLNB, ARM, and
of positive lymph nodes, etc. But, important is the
LYMPHA have shown to reduce the incidence
fact that they underline the necessity to assess the
of lymphedema. However, ARM could not be
risk before surgery in order to prevent the occur-
indicated for clinically positive nodes because
rence of lymphedema. That is why we have pro-
metastatic rate of ARM nodes is high. That’s
posed a Lymphedema Risk Score that includes
why LYMPHA technique was conceived and car-
10 parameters based on which a low, medium, or
ried out, to dissect also ARM nodes and avoid
high risk is calculated and recommendations are
closure of afferent brachial lymphatics.
reported according to each grade of risk. At low
risk, preoperative assessment and ongoing sur-
Treatment Plan veillance of the arms at regular intervals allow to
apply preventative measures at the initial stage of
LYMPHA was originally performed 13 years ago the pathology; at medium risk, ARM for SLN
and the first paper was published in 2009, and the biopsy and LYMPHA for ALND are recom-
technique was initially applied to prevent mended; at high risk, LYMPHA is indicated
63 LYMPHA Approach for Axillary Clearance Surgery 685
(McLaughlin et al. 2017; Boccardo et al. 2007, Intraoperative Images

2013a, 2014a, 2016, 2017; Witte et al. 2005,
2011, 2012; Johnson et al. 2019). See Figs. 1, 2, 3, and 4.
Surgical Technique Postoperative Management
Patent blue and ICG are injected 7–10 cm below There is no need of any postoperative physiother-
the axilla at the biceps groove, just after preparing apy or elastic compression hosiery.
the surgical field. A wet gauze with hot saline
solution is put upon the injection site and a slight
massage is made for 30 s. During nodal dissection Outcome, Clinical Photos and Imaging
brachial lymphatics are identified thanks to the
fluorescence and the blue dye and a venous branch LYMPHA has helped to decrease secondary
is prepared for anastomosis. After completing lymphedema rate nearly to 4% compared with
nodal dissection, the lymphatic-venous by-pass 40% of lymphedema following complete axillary
is performed. LYMPHA technique is performed dissection.
using the sleeve technique with an invaginating
suture and some tacking sutures inserted laterally
(Boccardo et al. 2009a, b, 2010a, b, 2011, 2012, Avoiding and Managing Problems
2013b, 2014b; Morotti et al. 2013; Casabona et al.
2008). Other groups’ experiences have obtained almost
the same results with little higher percentages if
radiotherapy is added.
Technical Pearls
Attention must be paid to pick up a properly long Learning Points

vein and check the valve continence.
– After identifying patients at risk, ARM alone
or ARM þ LYMPHA is performed in SLNB
and LYMPHA in ALND.
– LYMPHA can be used also to prevent lymph-
edema following the axillary lymph nodal
dissection for the treatment of trunk skin
melanoma
– LYMPHA can be applied contemporarily to
femoral-inguinal and iliac-obturator nodal dis-
section for groin metastases from trunk skin
melanoma or vulvar cancer.
– Patent blue and ICG are injected 10–12 cm
below the inguinal crease, during nodal dis-
section lymphatic pedicles coming from the
thigh and evidenced by fluorescence and the
blue dye are dissected and prepared for
anastomosis.
Fig. 1 Injection of BPV and ICG at the brachial area just – Nodal dissection + LYMPHA helps to decrease
before skin incision for the nodal dissection the early lymphatic complications as well, such
Fig. 2 (a)Nodal dissection

and Identification of
brachial lymphatics. (b)A
vendor branch is prepared
for LV by-pass.
Fig. 3 LYMPHA
Technique
Fig. 4 LYMPHA Technique - Preop and postop Lymphoscintigraphy

63 LYMPHA Approach for Axillary Clearance Surgery 687
as lymphorrhea, wound dehiscence, cellulitis, lymphedema: techniques and indications for better
and lymphocele. results. Ann Plast Surg. 2013a;71(2):191–5. https://
doi.org/10.1097/SAP.0b013e31824f20d4.
Boccardo F, De Cian F, Campisi CC, Molinari L, Spinaci S,
Dessalvi S, Talamo G, Campisi C, Villa G, Bellini C,
Conclusions Parodi A, Santi PL, Campisi C. Surgical prevention and
treatment of lymphedema after lymph node dissection
in patients with cutaneous melanoma. Lymphology.
Prevention and early treatment are the keys to 2013b;46(1):20–6.
success in the hard battle against lymphedema Boccardo F, Casabona F, De Cian F, Friedman D,
and this is possible only through a proper inter- Murelli F, Puglisi M, Campisi CC, Molinari L,
Spinaci S, Dessalvi S, Campisi C. Lymphatic micro-
connection in-between surgical oncologists and surgical preventing healing approach (LYMPHA) for
microsurgeons. primary surgical prevention of breast cancer-related
lymphedema: over 4 years follow-up. Microsurgery.
2014a;34(6):421–4. https://doi.org/10.1002/micr.
22254.
References Boccardo F, Dessalvi S, Campisi C, Molinari L, Spinaci S,
Talamo G, Campisi C. Microsurgery for groin
Boccardo F, Bellini C, Eretta C, Pertile D, Da Rin E, lymphocele and lymphedema after oncologic surgery.
Benatti E, Campisi M, Talamo G, Macciò A, Microsurgery. 2014b;34(1):10–3. https://doi.org/10.
Campisi C, Bonioli E, Campisi C. The lymphatics in 1002/micr.22129.
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pected role of microsurgery. Microsurgery. 2007;27(4): Dessalvi S, Campisi CC, Villa G, Campisi
339–45. https://doi.org/10.1002/micr.20347. C. LYMPHA technique to prevent secondary lower
Boccardo FM, Ansaldi F, Bellini C, Accogli S, Taddei G, limb lymphedema. Ann Surg Oncol. 2016;23(11):
Murdaca G, Campisi CC, Villa G, Icardi G, Durando P, 3558–63. https://doi.org/10.1245/s10434-016-
Puppo F, Campisi C. Prospective evaluation of a pre- 5282-4.
vention protocol for lymphedema following surgery for Boccardo F, Dessalvi S, Villa G, Campisi CC, Campisi
breast cancer. Lymphology. 2009a;42(1):1–9. Erratum C. Surgical prevention of Lymphedema following
in: Lymphology. 2009; 42(3):149 lymphnode dissection: LY.M.P.H.A. technique.
Boccardo F, Casabona F, De Cian F, Friedman D, Villa G, JTAVR. 2017;2(3):137–43.
Bogliolo S, Ferrero S, Murelli F, Campisi Casabona F, Bogliolo S, Ferrero S, Boccardo F, Campisi
C. Lymphedema microsurgical preventive healing C. Axillary reverse mapping in breast cancer: a new
approach: a new technique for primary prevention of microsurgical lymphatic-venous procedure in the pre-
arm lymphedema after mastectomy. Ann Surg Oncol. vention of arm lymphedema. Ann Surg Oncol.
2009b;16(3):703–8. https://doi.org/10.1245/s10434- 2008;15(11):3318–9. https://doi.org/10.1245/s10434-
008-0270-y. 008-0118-5.
Boccardo F, Bellini C, Girino M, Campisi C, Vidali F, Johnson AR, Feldman SM, James TA, Spiguel L,
Corazza GR, Campisi C. Diagnostic assessment and Boccardo F, Singhal D. Comment on a letter to the
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Boccardo F, Campisi CC, Murdaca G, Benatti E, related clinical lymphedema after axillary lymph node
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Cian F, Ansaldi F, Campisi C. Surgical prevention of Hutchison NA, Mendez J, MacNeill F, Vicini F,
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Witte MH, Ohkuma M, Andrade M, Campisi C, Boccardo Witte MH, Dellinger MT, Papendieck CM, Boccardo
F. Nature’s historic gap: the 20th century of F. Overlapping biomarkers, pathways, processes and
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Supermicrosurgical
Lymphaticovenular Anastomosis 64
(LVA) for Early-Stage (Stage 1–2)
Extremity Lymphedema
Takumi Yamamoto
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
Surgical Technique and Intraoperative Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697
Abstract lymph vessels, resulting in lymphatic valvular

Lymphedema is a progressive edematous dis- insufficiency and further retrograde lymph
ease due to abnormal lymph circulation. Most flows. Since irreversible changes occur in
lymphedema cases are secondary to lymph the lymph vessels (lymphosclerosis) and soft
flow obstruction. Obstruction of lymph flow tissue (fat deposition and fibrosis) with pro-
causes hypertension and dilatation of distal gression of lymphedema, lymph circulation
should be improved at an early stage. Although
a mainstay of treatment, compression therapy
is merely an anti-symptomatic one and cannot
T. Yamamoto (*) stop progression of lymphedema. Lymph
Department of Plastic and Reconstructive Surgery, reconstructive surgery is required to improve
National Center for Global Health and Medicine (NCGM),
lymph circulation.
Tokyo, Japan
e-mail: tyamamoto-tky@umin.ac.jp

https://doi.org/10.1007/978-3-030-23706-6_110
690 T. Yamamoto
Among various surgeries, super- fibrotic change or lymph leakage, excluding ele-
microsurgical lymphaticovenular anastomosis phantiasis or lymphorrhea. Past history included
(LVA) is a least invasive surgery effective atrial fibrillation on warfarin (PT 1.5–2.0) and
for progressive lymphedema. LVA can be chronic obstructive pulmonary disease; general
done under local infiltration anesthesia via anesthesia was considered of a substantial risk.
a 2-cm skin incision without hospitalization.
However, LVA is hardly effective for pro-
gressed lymphedema complicated with severe Preoperative Problem List
lymphosclerosis. Early diagnosis is the most
important to maximize the efficacy of the 1. Progressive edema refractory to class 3 stock-
minimally invasive surgery. Indocyanine ing. Bandage is difficult because of her age and
green (ICG) lymphography is recommended daily activity.
for early diagnosis, since it has the highest 2. Frequent cellulitis episodes in spite of mainte-
sensitivity to detect abnormal circulation. ICG nance antibiotic therapy. Drug-resistance
lymphography and LVA are key to successful infection is considered, which can cause life-
management of lymphedema. threatening sepsis.
3. Undiagnosed right LEL is suspected; normal
range of LEL index is 200–250 (Yamamoto
Keywords
et al. 2011a, b, c, d, e, 2016a, b, c). Treatment
Lymphedema · Supermicrosurgery · should be started when lymph circulation is
Lymphaticovenular anastomosis (LVA) · abnormal (subclinical lymphedema) regardless
Indocyanine green (ICG) lymphography · of subjective symptoms (Yamamoto et al.
Bypass 2011a, b, c, d, e)
4. Surgery requiring general anesthesia should be
avoided because of her relatively poor general
The Clinical Scenario conditions.
5. Warfarinization should be kept as possible to
An 82-year-old female suffered from progressive minimize a risk of thromboembolism. Spinal
lower extremity lymphedema (LEL) refractory anesthesia should be avoided.
to compression therapy. She had undergone radi-
cal hysterectomy with pelvic lymph node dissec-
tion and postoperative radiotherapy for uterine Treatment Plan
cervical cancer 19 years ago. Three years later,
she noticed her left lower limb edema, and class Minimally invasive surgery, LVA, is a first
3 stocking and outpatient weekly manual lymph choice for such an aged patient with progressive
drainage were started with diagnosis of LEL. LEL and systemic comorbidities. LVA can be
In spite of the stocking compression, her left leg done without general, spinal anesthesia, nor
showed progressive edema, and cellulitis had stopping warfarinization (Yamamoto et al.
been attacking several times a year since 5 years 2011a, b, c, d, e, 2013a, b, c, d, 2014a, b, c, d).
ago, requiring maintenance antibiotic treatment. Meticulous supermicrosurgical dissection
Bandage was impossible to continue because allows bloodless surgery even in patients on
of her low daily activity. warfarin. When ICG lymphography shows
Physical examination revealed pitting edema abnormal lymph circulation on the left lower
of both lower extremities (right groin, thigh, extremity, LVA should be done on both lower
lower leg, and left groin), and LEL index (body- extremities (Yamamoto et al. 2011a, b, c, d, e,
type-corrected lymphedematous volume) was 2013a, b, c, d). Since LVA improves lymph cir-
311 in the left and 260 in the right leg (Yamamoto culation by draining congested lymph into
et al. 2011a, b, c, d, e) (Fig. 1). Skin showed no venous circulation, decrease in volume and
64 Supermicrosurgical Lymphaticovenular Anastomosis (LVA) for Early-Stage (Stage 1–2). . . 691
anesthesia. In this case, LVA is an only recon-

structive option.
3. Debulking procedures such as liposuction and
Charles procedure. They are far more and
too invasive in this case and should not be
performed not to cause life-threatening
complications.
ICG lymphography is the most useful

imaging modality for lymphedema surgery.
When ICG lymphography is not available,
lymphoscintigraphy, SPECT/CT, or MR lym-
phography can be done alternatively (Baulieu
et al. 2013; Zeltzer et al. 2018). ICG (2.5 mg/ml)
is injected subcutaneously at the 2nd web space
and medial/lateral malleolus. At an early phase
(immediately after ICG injection), Linear pattern
(lymph flows in the collecting lymph vessel) is
marked. At a plateau phase (2 or more hours later),
extension of dermal backflow (DB: Splash,
Stardust, or Diffuse) pattern is marked (Fig. 2)
Fig. 1 LEL index was 311 in the left and 260 in the right (Yamamoto et al. 2011a, b, c, d, e). Overlapping
lower extremity
area, where Linear pattern is seen at an early phase
and DB pattern is seen at a plateau phase, is the
prevention of cellulitis are expected (Yamamoto most recommended site for LVA (Yamamoto et al.
et al. 2013a, b, c, d, 2015). 2017, 2018a, b). Area showing only Linear pat-
tern without edema should be avoided for LVA,
because lymph vessels and flows are intact there.
Alternative Reconstructive Options Based on ICG lymphography findings, patho-
physiological severity can be determined (Fig. 3)
1. More strict compression therapy. Bandage (Yamamoto et al. 2011a, b, c, d, e, 2013a, b, c, d).
can be re-tried under hospitalization by LVA is best indicated for limb with ICG stages
specialized lymphedema therapist. However, I–IV. In ICG stage V, lymph vessels are very likely
once discharged, the patient seems to be to be severely sclerotic, and LVA is not
difficult to continue by herself/himself. recommended.
If appropriate social assistance is available, ICG lymphography revealed that ICG stage
bandage can be considered. Even if bandage was IV in the left and II in the right lower extrem-
is possible, her lymphedema would progress in ity. Stardust pattern was seen in most areas of the
spite of bandage. It should be noticed that left lower extremity, and Linear pattern could be
bandage may further deteriorate her daily seen in some parts of the lower leg and the foot.
activity. In the right lower extremity, Stardust pattern was
2. Other reconstructive lymph surgeries such seen in the proximal thigh, and Linear pattern was
as vascularized lymph node transfer (LNT). seen in most area.
LNT is very difficult to perform under local In this case, PT should be checked before
infiltration anesthesia without general or spinal surgery. If PT is over 2.0, warfarinization should
692 T. Yamamoto
Fig. 2 ICG lymphography

findings can be classified
into normal Linear pattern
and abnormal dermal
backflow patterns (Splash,
Stardust, and Diffuse
patterns)
Fig. 3 Dermal backflow

(DB) stage based on ICG
lymphography findings
be adjusted for PT to be within the range of patient was kept in a supine position with
1.5–2.0. When PT is well controlled, warfarin is slightly abduction of the lower extremities. The
not stopped perioperatively. operative field was disinfected from the lower
abdomen to the left distal thigh and to the
left foot.
Preoperative Care and Patient Incisions were designed at the left thigh,
Drawing the left lower leg, and the right proximal thigh,
where ICG lymphography showed overlapping
Since the patient had already been treated with pattern (Linear and then Stardust), approximately
appropriate conservative treatments, no addi- 2–3 cm along the relaxed skin tension lines.
tional preoperative care was done except for When there are multiple supermicrosurgeons and
routine preoperative IV cefazolin admini- microscopes, LVAs are simultaneously performed
stration 30 min before skin incision. The at multiple sites to shorten operation time.
Urinary catheter should be inserted as the

patient may be likely to feel the need for urination
during surgery. Showing operative procedures via
a monitor may help to reduce the patient’s stress
and to understand the importance of postoperative
care; a surgeon should explain the procedures
during LVA surgery.
Surgical Technique and Intraoperative

Images
1. Local infiltration anesthesia is done by

injecting 1% lidocaine with epinephrine
intradermally.
2. The dermis is cut with a surgical scalpel,
Fig. 4 Lymph vessel is marked with a 3-0 nylon
and the recipient vein is dissected in the
superficial fat layer using a needle-tip electric
cautery at power sign of 7 (three times weaker damage the intima of the lymph vessel.
than perforator dissection). The vein is irrigated with heparinized saline
3. A recipient vein is cut as distal as possible to wash out any potential minimal clot
to include more valves inside. A vein with if possible.
diameter around 0.5 mm is better. It is ideal 8. Supermicrosurgical anastomosis, intima-to-
to prepare a vein without venous reflux when intima coaptated anastomosis, is performed.
transected. 11-0 is used when vessels are larger
4. The superficial fascia is explored as widely as than 0.3 mm (external diameter), whereas
possible. Never try to find lymph vessels 12-0 is recommended when a vessel is
at this stage; almost always, lymph vessels smaller than 0.3 mm. In most cases, six
suitable for effective LVA exist just below stitches are applied to complete anastomosis;
the superficial fascia. four stitches are enough when vessels are
5. The superficial fascia is incised very carefully smaller than 0.2 mm.
with the electric cautery. A lymph vessel is 9. Anastomosis patency and leakage are evalu-
dissected in the deep fat layer. When found, ated after completion of anastomosis (Fig. 6).
a lymph vessel is kept with a 3-0 nylon thread When a limb distal to the field is massaged,
not to be lost (Fig. 4). The lymph vessel is the recipient vein should be expanded with
dissected widely enough to the proximal and lymph (washout). When the vein is collapsed,
the distal direction. there should be leakage which should be fixed
6. According to the vessels available in the with additional suture. Patency can be con-
field, an optimal anastomotic configuration firmed by observing red-color change in the
is selected from end-to-end (EE), end-to-side lymph vessel (venous reflux).
(ES), side-to-end (SE), and side-to-side 10. Anastomosed vessels are placed under fat as
(SS) anastomosis (Yamamoto et al. 2011a, b, deep as possible to be protected from sheer
c, d, e, 2013a, b, c, d, 2014a, b, c, d) (Fig. 5). stress caused by compression garment (Fig. 7).
In most cases, a simple EE anastomosis is 11. The wound is closed esthetically with dermal
selected. stitches using 4-0 absorbable monofilament
7. The vessels are prepared for anastomosis. suture. Surface stich is not necessary, but
The adventitia is trimmed if it disturbs the should be applied when the wound shows
anastomosis. Care should be paid not to significant discharge.
694 T. Yamamoto
Fig. 5 Four basic

configurations of LVA
Fig. 6 Anastomosis site of LVA
Fig. 7 Vessels are placed enough deep in the fat

Technical Pearls
1. Local anesthetic should be injected at an area 3. When a surgeon does anatomical dissection
1 cm wider than the skin incision design so that (interlobular dissection and explore the superfi-
elongation of skin incision is ready when cial fascia widely) and cannot find a lymph ves-
needed. sel just below the superficial fascia, there would
2. During intra-adiposal dissection, interlobular be no lymph vessel. Therefore, skin incision
dissection is essential, dissecting between fat should be elongated, or the operation field should
lobules, not destroying fat lobules. Since all be changed (another incision).
important structures such as blood/lymph ves- 4. Temporary lymphatic expansion (TLE)
sels and nerves exist between fat lobules (not maneuver is useful to evaluate lympho-
in the fat lobules), interlobular dissection sclerosis; clamp a lymph vessel proximally
plays an important role not to damage them and massage the distal limb. When a lymph
accidentally. vessel is expanded by TLE maneuver, the
Fig. 8 Temporary
lymphatic expansion (TLE)
maneuver
vessel is not sclerotic, and lymphotomy

is possible for SE or SS anastomosis. When
not expanded, lymphotomy should not be
done, and EE anastomosis is recommended
(Yamamoto et al. 2013a, b, c, d) (Fig. 8).
5. A surgeon should not try to insert forceps into
the lymph vessel before completing the first two
stitches, because it may cause intimal dissec-
tion; once the intima is fixed by two stitches,
forceps can be inserted to assist sutures.
6. Intravascular stenting (IVaS) method can
be used, if a surgeon feels difficulty in super-
microsurgical anastomosis. A 5-0 or 6-0 nylon
thread is inserted into vessels’ lumen to assist
sutures (Yamamoto et al. 2011a, b, c, d, e).
7. ICG lymphography navigation is helpful to Fig. 9 Intraoperative ICG lymphography for evaluation
localize lymph vessels and to check anastomo- of anastomosis
sis patency and leakage (Yamamoto et al.
2013a, b, c, d) (Fig. 9). resulting in continuous lymph-to-venous flow. Dur-
8. Tension-free anastomosis is important to pre- ing 2 postoperative weeks and until endo-
vent postoperative problems; during wearing thelialization is completed at the anastomosis site,
stockings, significant tension and shear stress the compression garment should be applied nearly
are put on the anastomosis site. Never trim the 24 h, except for shower time. Two weeks after LVA,
vessel too much; kinking is not problematic in compression garment is used for only day time.
LVA surgery. Strict compression should be continued for at
least 6 months postoperatively. Only when meet-
ing all the following criteria, compression can be
Postoperative Management gradually relieved:
The same compression garment should be applied 1. Sustained volume reduction

immediately after LVA surgery to reduce a risk of 2. No episode of cellulitis without need for main-
venous reflux and subsequent anastomosis site tenance antibiotics
thrombosis. Since lymphatic system is closed 3. Release of tension due to progressive edema
(proximally obstructed), while venous system
is open (not obstructed), external compression Compression relief starts from reducing
makes only lymphatic pressure higher and thus strength; change class 3 garment to class 2
leads to lymph-to-venous pressure gradient, one. Then, reducing time for compression
696 T. Yamamoto
gradually, it should take 3–6 months. If one of the

abovementioned criteria is not met, compression
should not be relieved, and postoperative com-
pression therapy must be continued.
Outcome
During LVA surgery, both legs were becoming

softer. Maintenance antibiotic was stopped
postoperatively. At postoperative day 1, physical
examination revealed that LEL index was
270 in the left and 252 in the right. Since both
legs significantly decreased in volume, smaller
stockings were applied for maintenance postoper-
ative compression therapy.
At postoperative 6 months, there had been no
cellulitis episodes since LVA, the patient felt sig-
nificant relief of tension, and LEL index decreased
to 258 in the left and 250 in the right. At 6 months
postoperatively, the stocking was changed to class
2, while from postoperative 9 months, the time for
wearing stocking was shortened to day time
of weekdays.
At postoperative 1 year, no cellulitis attack was Fig. 10 LEL index was 248 in the left and 240 in the right
lower extremity
seen without the use of maintenance antibiotics,
the patient felt no tension, and LEL indices were
within normal range (248 in the left and 240 in the movement. Especially in the groin or lower
right) (Fig. 10). abdomen, the field is significantly affected by
respiration and talking.
4. LVA is avoided for at least 2 weeks after
Avoiding and Managing Problems cellulitis attack. Wound problem rate is
higher, and lymph vessels’ conditions are
1. Before considering LVA, a patient must under- poor; lymph vessels can be very fragile, and
stand the importance of perioperative compres- lymph can form clots because of inflamma-
sion therapy and limitations of the surgery. tory reactions; lymph also contains clotting
Without appropriate compression, LVA can factors.
hardly be effective. 5. When cellulitis is not prevented or volume
2. A surgeon must master supermicrosurgical reduction is not enough postoperatively, addi-
techniques: meticulous bloodless dissection tional surgical treatment is considered; repeat
and fine intima-to-intima coaptated anastomo- LVA or LNT may be considered.
sis of supermicro-vessels smaller than 0.5 mm.
Supermicrosurgery is a minimum requirement
for LVA. Learning Points
3. A surgeon should also be familiar with “mov-
ing” supermicrosurgery. Since LVA is done 1. LVA is a minimally invasive surgical treatment
under local infiltration anesthesia, the surgical for lymphedema refractory to conservative
field can be moved because of the patient’s treatments. Patients with history of cellulitis
are strongly recommended to undergo LVA Yamamoto T, Yamamoto N, Hara H, Mihara M,

surgery for future cellulitis prevention. Narushima M, Koshima I. Upper extremity lymph-
edema (UEL) index: a simple method for severity
2. LVA is hardly effective for progressed lymph- evaluation of upper extremity lymphedema. Ann Plast
edema with severe lymphosclerosis. Surg. 2013a;70(1):47–9.
3. ICG lymphography has the highest sensitivity to Yamamoto T, Yoshimatsu H, Narushima M, Seki Y,
detect abnormal lymph circulation and is a key to Yamamoto N, Shim TWH, Koshima I. A modified
an ideal lymphedema management, early diag- side-to-end lymphaticovenular anastomosis. Microsur-
gery. 2013b;33(2):130–3.
nosis with ICG lymphography, and early curative Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N,
treatment with minimally invasive LVA. Koshima I. Split intravascular stents for side-to-end
4. Appropriate perioperative compression ther- lymphaticovenular anastomosis. Ann Plast Surg.
apy is critical for patients undergoing LVA. 2013c;71(5):538–40.
Yamamoto T, Yoshimatsu H, Yamamoto N,
Postoperative compression should be resumed Narushima M, Iida T, Koshima I. Side-to-end
immediately after LVA surgery in the lymphaticovenular anastomosis through temporary
operation room. lymphatic expansion. PLoS One. 2013d;8(3):
e59523. Epub 2013 Mar 25
Yamamoto T, Narushima M, Yoshimatsu H, Seki Y,
Yamamoto N, Oka A, Hara H, Koshima I. Minimally
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Todokoro T, Mihara M, Koshima I. Lambda-shaped Aesthet Surg. 2014d;67(11):1573–9.
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safe and effective lymphaticovenular anastomosis. Hayashi A, Koshima I. Indocyanine green lymphogra-
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Narushima M, Iida T, Koshima I. Indocyanine green Koshima I. Practicality of lower extremity lymph-
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Yoshimatsu H, Todokoro T, Ogata F, Mihara M, component superficial circumflex iliac artery perforator
Narushima M, Iida T, Koshima I. The earliest finding (SCIP) flap: a chimeric SCIP flap for complex ankle
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Lateral Thoracic Artery Lymph Nodes
(LTLN) for Lower Limb Lymphedema 65
Ayush K. Kapila and Assaf A. Zeltzer
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700
Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
Surgical Technique and Technical Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
Intraoperative Images and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705
Clinical Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 706
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707
Abstract be offered to patients. Vascularized lymph

Lower limb lymphedema is a significant debil- node transfer (VLNT) involves the transfer of
itating condition requiring a multidisciplinary functional lymph nodes by vascular micro-
approach in its management. Recent advances anastomosis to the recipient bed to restore lym-
in microsurgical techniques have allowed an phatic flow to an area of the body where the
increase in surgical treatment options that can native lymph nodes are not present or are
removed. Besides measurable improvements
in edema, the literature reflects improvements
in quality of life when VLNT is performed for
lymphedema in general. As such, knowledge
A. K. Kapila · A. A. Zeltzer (*) of VLNT is essential for any microsurgeon
Department of Plastic, Reconstructive & Aesthetic Surgery offering patients lymphedema treatment. This
includes appreciating and mastering the possi-
Belgium ble donor sites that can be used for VLNT.
e-mail: ayush.kapila@uzbrussel.be;
assaf.zeltzer@uzbrussel.be

https://doi.org/10.1007/978-3-030-23706-6_111
700 A. K. Kapila and A. A. Zeltzer
The lateral thoracic fasciocutaneous flap for Following the oncological treatments, the
soft tissue reconstruction was described in the patient developed mainly left lower limb lymph-
1970s, however it did not gain widespread edema. She initially started manual lymphatic
popularity due to the anatomic variations in drainage (MLD) treatment as well as compression
the origin and presence of the vascular pedicle. therapy, however this was to little avail. Three
Nonetheless, the advent of VLNT and the pres- years prior to presentation, she had two
ence of lymph nodes in the axillary area led to lymphovenous anastomoses (LVA) at an external
the use of the lateral thoracic axillary lymph institution. Unfortunately, this did not improve
nodes (LTLN) as a donor site by Trevidic and her clinical situation despite compliance with
Cormier in the 1990s. Since then, the uptake of twice weekly MLD and compression therapy.
the LTLN has been slow. Recent advances in With progressing lymphedema and recurrent epi-
anatomical knowledge and technical know- sodes of cellulitis and lymphangitis, the patient
how have now allowed surgeons to approach presented to the lymphedema clinic requesting a
the LTLN flap with increased confidence and more sustainable solution.
safety. This chapter provides a case and a step- Clinical examination revealed significant
by-step approach on how to approach LTLN pitting edema of the left lower limb, most notice-
flap reconstruction for VLNT. ably up till the knee (Fig. 1). The left side
corresponded to a World Health Organization
(WHO) lymphedema stage 1–2 (late stage
Keywords
1, early stage 2) (Fig. 2). A venous duplex of the
Lymphedema · Vascularized lymph node flap · lower limbs revealed no issues in the deep venous
Lateral thoracic lymph-node flap · Lower limb circulation with full resolution of the previous
lymphedema deep venous thrombosis, and neither did it show
any superficial venous insufficiency. A lower limb
arterial CT angiography found good three-vessel
Clinical Scenario distal flow. A radionuclide lymphoscintigraphy
(LSC) exam revealed severely compromised lym-
A 63-year-old-lady presented to the lymphedema phatic drainage of the left lower limb with drain-
consultation 6 years after being diagnosed with a age only occurring via cutaneous collaterals,
stage T2bN1 moderately differentiated epidermoid reflecting severe lymphatic disease of the left
cervical cancer for which a radical hysterectomy lower limb. The right limb also showed minor
was performed. A lymph node dissection was done lymphatic disease on LSC.
of the iliac nodes and the aorto-caval nodes up till
the renal arteries. Histopathological analysis con-
firmed the presence of neoplastic lymph nodes, and Treatment Plan
the patient received adjuvant radiochemotherapy.
Postoperatively, the patient had developed throm- After discussion with the patient, it was decided to
bosis of the left ovarian vein and left common iliac address the lymphedema of the left lower limb
vein for which prophylactic antithrombotic therapy surgically. Based on the workup with LSC and
was given with low-molecular-weight heparin indocyanine green (ICG) lymphography, the
(LMWH) for 5 years. Other comorbidities included patient was deemed to be a poor candidate for
hypercholesterolemia, gastroesophageal reflux dis- LVA. As such, it was decided to perform a
ease (GERD), asthma, hypothyroidism, and previ- vascularized lymph node transfer (VLNT) to the
ous tobacco history of 20 pack years (stopped in left ankle. Due to the location of the lymphedema
2016). Medications included daily prophylactic in the lower limbs and possibility of exacerbating
LMWH injections, aspirin, levothyroxine, panto- the situation, use of the groin as a donor site was
prazole, and rosuvastatin. avoided. Abdominal-based lymph node flaps
65 Lateral Thoracic Artery Lymph Nodes (LTLN) for Lower Limb Lymphedema 701
Fig. 2 This image represents the preoperative pitting

oedema present on compression of the lower calf. This
Fig. 1 In this clinical image one can compare the left pitting oedema is permanent and does not improve with
lower limb to the contralateral side. It is clearly noticeable leg elevation. There is no major long-term improvement
that the left lower limb is significantly more swollen as with manual lymphatic drainage nor compression. It does
compared to the right. This is most prominent up till the not present, however, with any fibrotic changes or fat
knee, however above the knee an increased volume is deposition of the lower limb. As such the patient was
noticeable as well staged to be between stage 1 and 2 (late stage 1, early
stage 2), as pure stage 2 is seen classically with early
fibrotic changes
were also avoided due to the nature of the primary
cancer surgery. It was decided to use the lateral of lymphedema is vital and can be stratified by use
thoracic artery lymph nodes (LTLN) from the of the WHO lymphedema scale. Presence of fatty
right hemithorax to the left ankle. degeneration of the lymphedema, lipedema, or
elephantiasis is preferably managed by liposuc-
tion or resection techniques in the first instance.
Reconstructive Options WHO stage 1 or 2 patients with persistent debili-
tating lymphedema are thus the best candidates
A successful surgery is only possible when appro- for this type of surgery. Furthermore, one should
priate patients are offered VLNT. All patients always consider whether LVA is possible in the
presenting to a lymphedema consultation should case of residual lymphatic function. First and
have a thorough history and examination. This foremost, this requires assessment by ICG lym-
includes previous surgical, infectious, or oncolog- phography. If there is a complete lack of physio-
ical history as this may affect the lymph nodes logical lymphatic channels or residual channels
causing secondary lymphedema. Age of onset and are sclerotic and nonfunctional, then LVA will be
family history is important to identify primary of little use. In this case, the patient had a complete
lymphedema. Clinical assessment of the severity lack of draining inguinal and iliac lymph nodes,
and a lack of physiological lymphatic channels in lymphedema, as venous congestion can affect
the left lower limb. As such, a VLNT flap was the interstitial fluid balance and contribute to
warranted. lymphedema. In such cases, a referral to the vas-
cular surgery department is warranted. The use of
intravascular venous stents may help lower
Preoperative Evaluation and Imaging extremity venous outflow and provide treatment
to persisting lower limb edema secondary to
The donor site should also be controlled for pre- venous insufficiency in well-selected cases (Raju
vious procedures, including breast and axillary et al. 2001; Kapila et al. 2017).
surgery. In these cases, a different donor site Furthermore, LSC is important to map the flow
should preferably be sought such as the groin, progression in the lymphatics of the lower limbs.
submental, supraclavicular, or intra-abdominal This allows an appreciation of whether there are
sites (Schaverien et al. 2018). Preoperative imag- functioning lymphatic channels. If this is not the
ing with ultrasound may be necessary to clarify case, LSC can further help identify if this is just
the presence of lateral thoracic axillary lymph poor lymphatic function shown by delayed radio-
nodes, and/or the presence of the lateral thoracic nuclide tracer progression, or if there is no phys-
artery and vein (LTA/V) pedicle (Patel et al. iological lymphatic function shown by a lack of
2014). This was not deemed necessary for this radionuclide tracer progression at all except in
case; however, use of the abdomen as donor site dermal collaterals, and lastly whether the
was avoided due to the presence of previous collecting nodes are present and patent. It is
scarring. important to note that the protocol for LSC differs
Patients should be advised to quit smoking at among diagnostic centers, including the choice of
least 4 weeks before the procedure. Insight into radiotracer, the type and site of injection, the use
whether a patient will be compliant to postopera- of dynamic and static acquisitions, and the acqui-
tive instructions is equally important. This sition times themselves (Szuba et al. 2003). It is
includes no weight-bearing for the first two therefore important that surgeons thoroughly ver-
weeks after the procedure, followed by MLD ify the content of the LSC report and discuss this
three to five times a week 3 weeks after surgery, with the performing nuclear medicine specialist
and compression therapy after 4 weeks. where required. Alternatively, SPECT/CT or MR
An important factor is the patient’s vascular lymphography can be done (Baulieu et al. 2013).
status, both venous and arterial. Venous insuffi- MR lymphography is a more recent modality that
ciency will offset any improvements one may not only provides information on the lymphatic
hope to achieve with VLNT and should be system but also provides insight into the soft
addressed first. Concurrently, good arterial distal tissue changes associated with lymphedema. An
lower limb flow, preferably in all three lower leg added benefit of MR lymphography is that it high-
vessels, or at least in two of three vessels, is lights fibrosis and chronic soft tissue changes
essential when performing a VLNT. Not only secondary to lymphedema which may require a
will this affect the viability of the transferred different approach than VLNT (Chang et al. 2016;
flap, but also avoid lower limb ischemia. In this Zeltzer et al. 2018). In cases where functional
case, good three-vessel outflow was noted. lymphatics are noted, a supplementing ICG lym-
Besides a thorough history and examination, phography can be performed to plan a potential
patients should undergo the following investiga- LVA procedure.
tions when selected for a VLNT. The patient Lastly, when a VLNT is the indicated proce-
discussed in this chapter underwent each of dure, it is important to assess the patency of the
these. This starts with a venous duplex scan to recipient vessels. This can be done clinically by
exclude any significant venous insufficiency assessing the dorsalis pedis artery and posterior
requiring treatment in the first instance. Treatment tibial artery pulses, and by performing an ankle-
for venous insufficiency may improve brachial pulse index (ABPI). Bedside doppler
ultrasound, as well as arterial duplex sonography of the vascular pedicle (Taylor and Daniel 1975;
or CT angiography can supplement this. Boeckx et al. 1976; Harii et al. 1978). The advent
of VLNT and the presence of lymph nodes in the
axillary area led to the use of the lateral thoracic
Preoperative Care and Patient axillary lymph nodes (LTLN) as a donor site by
Drawing Trevidic and Cormier in the 1990s (Trevidic and
Cormier 1992). Since then, the uptake of the
Routine protocol of our center for VLNT was LTLN has been slow. Recent advances in anatom-
followed in this case. This is as follows: the ical knowledge and technical know-how have
patient is admitted to hospital the day before sur- now allowed surgeons to approach the LTLN
gery. The donor (axilla) and recipient sites (lower flap with increased confidence and safety.
leg) are shaved. Thromboprophylaxis with The same surgical steps are followed in all
LMWH is subcutaneously injected in the abdo- patients, including this case. On the day of surgery,
men 12 h prior to the procedure, which is the the patient is installed in a lateral decubitus position
protocol for all microsurgical free flaps in our in the operating table with the donor upper extrem-
center. Another important step stems from knowl- ity stabilized at 90 degrees. Disinfection and drap-
edge that axillary lymph nodes have separate ing are done as per standard protocol (Fig. 3).
interconnecting groups that drain the thorax and A two-team approach is recommended, with one
the upper limb (Suami et al. 2008). It is therefore
possible to harvest axillary lymph nodes without
causing iatrogenic upper extremity lymphedema
if appropriate precautions are taken. This includes
preoperative reverse lymphatic mapping. Modi-
fied reverse lymphatic mapping is routinely
performed by injection of 0.3cc of patent blue
vital (PBV) dye in webspace one and three,
respectively, of the left hand as popularized by
Dayan. This would lead to intraoperative staining
of the lymph nodes draining the upper extremity,
thereby allowing the surgeon to selectively dissect
the lymph nodes necessary (Thompson et al.
2007; Vignes et al. 2013; Dayan et al. 2015).
Preoperative doppler ultrasound at the donor site
for the lateral thoracic artery and thoracodorsal
artery perforators is performed as well as at the
recipient site to outline the path of the distal limb
vessels. The posterior tibial artery and vein
(PTA/V) are preferred as recipient vessels where
possible.
Surgical Technique and Technical Fig. 3 The patient is installed in lateral decubitus towards
Pearls the left side and is draped after sterile disinfection. Only the
relevant anatomical areas are exposed; i.e., the recipient
The lateral thoracic fasciocutaneous flap for soft site which is the left leg and the donor site which is the right
axilla. At the left leg, the posterior tibial artery is identified
tissue reconstruction described in the 1970s, how-
using handheld doppler and marked to facilitate dissection.
ever, did not gain widespread popularity due to At the right axilla, the course of the lateral thoracic artery is
the anatomic variations in the origin and presence identified using handheld doppler where possible
team responsible for the flap harvest and one team correlates with improvement in lymphatic drainage
for the recipient vessel preparation. An incision is (Nguyen et al. 2016). As such, Tinhofer concludes
made between the anterior and mid-axillary line in her study that the LTLN donor site could be
approximately 2–10 cm below the axillary apex. considered as a superior flap in terms of lymphatic
Generally, a relatively straightforward dissection is function.
performed to the lateral border of the pectoralis Bearing the above in mind, an incision is rou-
minor muscle which corresponds to the origin of tinely made in between the anterior and
the lateral thoracic pedicle after which it crosses the mid-axillary line to allow an intraoperative switch
lymphatic chain. It then progresses downwards to to the TDA/V pedicle if required. When the LTA
give tributaries to the pectoral muscles and the is present, it always irrigates the lymph nodes. If a
lateral intercostal artery perforators. The LTA is skin paddle is needed, careful dissection can often
found posteriorly to the intercostobrachial nerve allow alternative cutaneous pedicles. Nowadays,
which provides sensory innervation to the medial our preference is to not take a skin paddle, in order
proximal arm, and as such care must be taken. The to offset the risk of skin necrosis in the case of
LTV is often found separate to the LTA (Kim et al. lacking LTA perforators to the overlying skin. If a
2011). The thoracodorsal artery and vein (TDA/V) skin paddle is required, intraoperative ICG fluo-
are found further, deep to the latissimus dorsi mus- roscopy is used. In order to monitor anastomotic
cle near the long thoracic nerve. In the case that the patency, an internal doppler probe is employed.
LTA is absent, one is able to harvest the flap based In this case, the LTA was traced to its origin on
on the TDA/V pedicle. This is important as the the axillary artery supplying the LTLN bundle.
LTA can be absent in approximately 10–20% of Care was taken to preserve the intercostobrachial
cases as suggested by early studies (Taylor and nerve. The LTV was dissected in a similar fashion
Daniel 1975; Harii et al. 1978; Bhattacharya et al. and the estimated caliber of the vessels was 2 mm.
1990). A more recent cadaveric study by Barreiro Pedicle length was 3 cm (Figs. 4 and 5). Simulta-
and colleagues showed that the LTV is always neously, at the lower limb PTA/V were prepared
present, and the LTA is present in 87.5% of cases. as recipient vessels. All three vessels were known
The LTA has an average length of 2.7 cm from its to be patent in the distal foot. A 7 cm incision was
origin from the axillary artery until reaching the performed starting 1 cm superior and post-
lymphatic chain. Once reaching the lymph nodes eromedial to the medial malleolus and extending
the pedicle has an average length of 4.2 cm until cranially following the path outlined by preoper-
reaching the subcutis. The vein caliber ranges from ative doppler assessment. Careful dissection was
1.5–3.0 mm and the artery caliber from performed, and the PTA/V were identified along
1.0–1.5 mm. Perforators to the skin are absent in with the tibial nerve between the soleus and flexor
22.5%. About three to seven lymph nodes can be hallucis longus muscle posteriorly, and the flexor
isolated for use in VLNT (Barreiro et al. 2014). In a digitorum longus muscle anteriorly (Fig. 6). The
study by Tinhofer et al., it was found that in 15 out vessels were clipped caudally and readied for
of 16 dissections, the LTA branches off the axillary microsurgical anastomosis. A suprafascial pocket
artery, and in one case it branches off the sub- was prepared for the LTLN bundle to rest in. End-
scapular artery. The external diameter of the LTA to-end anastomoses were completed with Ethilon
averages 2.01 mm and of the LTV 2.84 mm. The 9-0 (Ethicon, Johnson & Johnson, USA). Anasto-
mean pedicle length from origin to flap margin is motic patency was confirmed, and ischemic time
3.91 cm. In 68.75%, an additional segmental lateral was 65 min. A Cook-Swartz Doppler Flow Probe
thoracic pedicle is found, and in 12.5% a third (Cook Medical, USA) was placed over the vein to
vessel is noted. In 87.5%, there are perforators allow continuous monitoring of the microsurgical
present to the overlying skin. In this study, there anastomoses, as no skin paddle was taken with the
is an average of 13.06 LTLN that can be raised flap. The donor site was closed meticulously over
(Tinhofer et al. 2017). In 2016, Nguyen suggested a drain with Vicryl 2-0 for the fascia, Vicryl 3-0
that the quantity of lymph nodes transferred for the subcutis, and Monocryl 3-0 as a
donor site drain as well as the Cook-Swartz probe
Fig. 4 This is an intraoperative image showing the LTLN

flap with its vascular pedicle cranially; i.e., LTA/V. The
incision is made between the anterior and mid axillary line
2–10 cm below the axillary apex. Careful dissection is
performed, and retraction is performed of the pectoralis
major and minor muscles to identify the pedicle
Fig. 5 A 5 4 cm lateral thoracic lymph node flap is
subcuticular running suture (Ethicon, Johnson & harvested with a pedicle length of 3 cm and vessel caliber
Johnson, USA). This was followed by application of approximately 2 mm
of skin adhesive glue and a dry dressing. The flap
site was closed with deep Vicryl 2-0 sutures for was removed. On day 16 the staples were
the flap inset followed by Vicryl 3-0 for the sub- removed; gentle mobilization was commenced
cutis and staples for the skin, followed by a light and MLD was started avoiding compression on
noncompressive bandage. the flap inset area. Compression therapy was
restarted after three weeks once the wound was
healed. The patient had further a swift recovery,
Intraoperative Images and Outcomes without donor site complications and with an
improvement of symptoms and volumetric
assessment.
It is essential to note that postoperative reha-
Postoperative Management bilitation and compliance is as important as tech-
nical completion of the procedure. For this, a
Postoperatively, the patient made a good recovery multidisciplinary approach with a trained
and was discharged on day 4 postoperatively. No in-house physiotherapy and nursing team is
weight-bearing was allowed and prophylactic important. Weight-bearing (especially with
LMWH was continued. On day 8 postoperatively, VLNT to the ankle) and pressure is not permitted
the patient presented for her first control and the as it risks flap failure due to shearing forces and
Fig. 7 Photo taken 1 year postoperatively. There has been

a significant reduction in pitting oedema, with volumetric
analysis revealing a 67% decrease in excess fluid. No
further cellulitis or lymphangitis episodes have been
witnessed
Fig. 6 The flap is brought to the donor location and
readied for microsurgical anastomosis. The distal ends of started. Three months postoperatively new volu-
the PTA/V are clipped, and an end-to-end anastomosis is metric assessment can be performed which is then
performed between the LTA/V and the PTA/V using
Ethilon 9-0 (Ethicon, Johnson & Johnson, USA). A supra-
repeated yearly.
fascial pocket is prepared for the LTLN bundle to rest in
pressure. The patient should be in a supine posi- Clinical Outcome

tion in bed for the first 24 h, with the lower limb
elevated and in exorotation to be in a gentle rest- The patient has currently been followed up for
ing position, preferably raised above the level of over 1 year and has made significant improve-
the patient over a cushion. On day 2, gentle mobi- ments postoperatively. Volumetric analysis has
lization to a chair adjacent to the bed is allowed revealed a 67% reduction in excess fluid (Fig. 7).
with elevation of the leg. The patient can be The patient has experienced a significant
discharged following day 3 or 4 once if there are improvement in her quality of life and function,
no postoperative issues. The donor site drain is which is consistent with the literature on VLNT
generally left in situ and is only removed once (Patel et al. 2015; De Brucker et al. 2016; Gratzon
there is less than 20cc on two consecutive days. et al. 2017). Postoperatively, she has not had any
Two weeks postoperatively, the staples in the further episodes of cellulitis nor lymphangitis
lower leg can be removed and the patient can which has been a major symptomatic relief. The
commence gentle mobilization and manual lym- patient has been advised to continue with class II
phatic drainage 3 to 5 times a week avoiding the compression stockings, as well as regular twice
flap recipient site and wound. About 4–6 weeks weekly manual lymphatic drainage to comple-
postoperatively compression therapy can be ment the surgical outcome.
Learning Points Plast Reconstr Surg. 2016;137(6):1673–80. https://doi.

org/10.1097/PRS.0000000000002169.
Gratzon A, Schultz J, Secrest K, Lee K, Feiner J, Klein
1. Vascularized lymph node transfer (VLNT) can RD. Clinical and psychosocial outcomes of
be performed when lymphatic vessels are non- vascularized lymph node transfer for the treatment of
functional and/or sclerosed, as long as pitting upper extremity lymphedema after breast cancer ther-
edema is present. apy. Ann Surg Oncol. 2017;24(6):1475–81. https://doi.
org/10.1245/s10434-016-5614-4.
2. The lateral thoracic lymph nodes (LTLN) pro- Harii K, Torii S, Sekiguchi J. The free lateral thoracic flap.
vide a donor site with ample lymph nodes with Plast Reconstr Surg. 1978;62(2):212–22. https://doi.
a straightforward dissection and good opera- org/10.1097/00006534-197808000-00009.
tive outcome when performed correctly. Kapila AK, Esland JDT, Gwozdz AM, Sharp O, Saha P,
Black SA. Stenting as a treatment modality for acute and
3. Reverse lymphatic mapping is essential when chronic venous disease. Phlebolymphology. 2017;24(2):
harvesting LTLN to prevent iatrogenic upper 88–96.
extremity lymphedema. Kim JT, Ng SW, Naidu S, Kim JD, Kim YH. Lateral
4. The lateral thoracic artery pedicle is absent in thoracic perforator flap: additional perforator flap
option from the lateral thoracic region. J Plast Reconstr
12.5% of cases according to recent cadaveric Aesthet Surg. 2011;64(12):1596–602. https://doi.org/
studies and as such the thoracodorsal vessels 10.1016/j.bjps.2011.06.048.
should be considered as a backup. Nguyen DH, Chou PY, Hsieh YH, Momeni A, Fang YHD,
5. A multidisciplinary approach is essential for Patel KM, Yang CY, Cheng MH. Quantity of lymph
nodes correlates with improvement in lymphatic drain-
operative success by ensuring compliance to age in treatment of hind limb lymphedema with lymph
focused postoperative rehabilitation. node flap transfer in rats. Microsurgery. 2016;36(3):
239–45. https://doi.org/10.1002/micr.22388.
Patel KM, Chu SY, Huang JJ, Wu CW, Lin CY, Cheng
MH. Preplanning vascularized lymph node transfer
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Free Transfer of Cervical Lymph Nodes
to a Lower Limb Lymphedema 66
Bien-Keem Tan, Michael Hsieh, and Fumio Onishi
Contents
Case Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 710
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 710
Preoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 712
Vascular Anatomy of Submandibular Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 712
Operative Procedure (Video) (Tan et al. 2016) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 713
Revascularization of the Lymph Node Flap at the Recipient Site . . . . . . . . . . . . . . . . . . . . . . 714
Outcomes, Clinical Photos, and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718
Abstract
Vascularized lymph node transfer is an emerg-

ing method of lymphatic reconstruction in the
B.-K. Tan (*) · M. Hsieh surgical management of lymphedema. The cer-
Department of Plastic, Reconstructive, & Aesthetic vical region is a useful donor site because of
Surgery, Singapore General Hospital, Singapore,
Singapore
the abundance of lymph nodes. The clinical
approach to a 67-year-old patient who pre-
F. Onishi
Department of Plastic Surgery, Saitama Medical Center,
sented with secondary lower extremity lymph-
Saitama Medical University, Saitama, Japan edema and cellulitis after pelvic surgery is

https://doi.org/10.1007/978-3-030-23706-6_118
710 B.-K. Tan et al.
described. She underwent vascularized lymph node dissection for a stage IA ovarian endo-
node transfer from her submandibular region to metrioid adenocarcinoma. Clinically, swelling
the groin and liposuction of her legs and outer was observed over the entire lower extremity,
thigh. Perometry 2-years postoperatively including her thigh. Her skin was supple and she
showed 44% reduction in volume from had non-pitting edema suggesting the presence of
14,243 to 7938 ml. She had no further episodes fat hypertrophy. There was no dermatosis.
of cellulitis in the 3 years of follow up.
The lymph node flap harvesting technique
emphasizes visualization of the hilar arterioles Preoperative Problem List
and venules supplying the submandibular
lymph nodes and delineating their connections (A) Swelling of the lower extremity with symp-
to named pedicles in the neck. The submandib- toms of heaviness and tightness, affecting her
ular lymph nodes are supplied by the facial mobility.
artery and its branches, namely, the facial (B) Recurrent cellulitis. Three months prior to
branch and the submental branch. Based on admission, she had fever with inflammation
location, they are classified as superficial, of the lower extremity requiring hospitaliza-
deep, and submental. The venous drainage of tion and intravenous antibiotics. She had
cervical lymph nodes is variable, and the veins 3 previous episodes of cellulitis over 2 years.
do not necessarily run in parallel with the arter-
ies. Submandibular lymph nodes drain into the
facial vein, the external jugular or anterior jug- Treatment Plan
ular veins. The surgical technique utilizes an
upper cervical skin crease incision and a step- Vascularized lymph node transfer is an emerging
wise approach to locating lymph nodes. A method of lymphatic reconstruction in the surgical
delicate technique which is demonstrated in management of lymphedema. It is postulated that
our surgical video is emphasized (video). the transferred lymph node acts by two mecha-
Indocyanine green angiography is used to con- nisms: (1) lymphangiogenesis, where new lym-
firm the vascularity of the flap. In the lower phatic channels connect to existing lymphatic
extremity, vascularized lymph nodes are trans- pathways (Aschen et al. 2014), and (2) as a
ferred to the groin or medial leg, utilizing vascularized lymphovenous bypass “station,”
matching recipient vessels. where lymphatic fluid is siphoned by the node
and conveyed directly into the recipient vein of
the lymph node flap (Moore and Bertram 2018;
Keywords
Cheng et al. 2014).
Lymphedema · Vascularized lymph node The transferred lymph nodes also play a fun-
transfer · Cervical damental role in immune surveillance. Lymph
nodes filter the siphoned lymph from its drain-
age basins to survey for antigens and to mount
Case Scenario an appropriate response. Antigen loaded den-
dritic cells entering the lymph node via afferent
A 67-year-old female presented with International lymphatics present antigens to T lymphocytes,
Society of Lymphology grade III lymphedema of which then activate, differentiate and prolifer-
the left lower extremity with recurrent cellulitis ate. T helper cells, a subset of activated T lym-
(Fig. 1). This was secondary to a total abdominal phocytes, migrate to the B cell area to activate
hysterectomy, bilateral salpingo-oophorectomy antigen specific B cells, which subsequently
with pelvic lymph node and para-aortic lymph differentiate into plasma cells for antibody
66 Free Transfer of Cervical Lymph Nodes to a Lower Limb Lymphedema 711
are now available in lymphedema treatment and

what in each modality targets is different. Com-
bining modalities is now practiced widely.
Lymphaticovenous bypass is useful in cases of
mild to moderate lymphedema where the swelling
is predominantly due to fluid accumulation. To
determine eligibility for bypass, indocyanine
green lymphography and magnetic resonance
imaging are used to locate lymphatic channels.
In this patient, indocyanine green lymphography
showed extensive dermal backflow and paucity of
functioning lymphatic channels indicating moder-
ate to severe lymphedema. Additionally, she had
non-pitting edema, suggestive of fat hypertrophy,
so liposuction in combination with vascularized
lymph node transfer was chosen. Debulking sur-
gery is invasive and reserved for patients with
extensive fibrosis.
Alternate lymph node flaps are the supra-
clavicular flap, lateral thoracic lymph node flap,
gastroepiploic flap, and jejunal mesenteric lymph
node flap (Schaverien et al. 2018). The neck
region is a useful donor site because of the abun-
dance of lymph nodes (Maldonado et al. 2017).
Hence, the risk of donor site lymphedema is neg-
Fig. 1 Preoperative photography of the patient. Perometry ligible in contrast to other sites such as the axilla
calculated her left lower extremity volume as 14,243 ml and groin. Reverse lymphatic mapping to differ-
entiate nodal basins (Dayan et al. 2015) is thus not
necessary.
production. These activated effector T and B
cells then leave the lymph node and travel to
the inflamed area to combat infection (Buettner
and Bode 2012). Preoperative Evaluation and Imaging
The treatment plan was to perform
vascularized lymph node transfer from her upper Diagnostic lymphoscintigraphy (Fig. 2) showed
neck to the left groin, coupled with liposuction of left lower limb lymphatic disruption with exten-
her leg and lateral thigh. She was hospitalized one sive dermal backflow. The main lymphatic chan-
week prior to the procedure for bed-rest and nels and lymph nodes were not visualized four
decongestive pressure therapy. hours after Tc-99m-labelled-colloid injection.
Indocyanine green lymphography showed dermal
backflow with stardust and diffused patterns, con-
Alternative Reconstructive Options sistent with the findings from radionuclide scans.
Perometry of the left lower extremity calculated
Multiple modalities including lymphaticovenous the volume as 14,243 ml.
bypass, vascularized lymph node transfer, Magnetic resonance imaging can also be used
suction-assisted lipectomy, and debulking surgery to quantify edema in soft tissue, which typically
volume and the patient’s tolerance. Within a week

there was noticeable reduction in limb girth and
improvement of skin suppleness, indicating suc-
cessful decongestion.
Surgical Technique
Vascular Anatomy of Submandibular

Lymph Nodes
The submandibular lymph nodes are defined as

nodes located in the submandibular triangle which
is bound by the inferior border of the mandible
superiorly and the anterior and posterior bellies of
the digastric muscle. These nodes correspond
approximately to levels IA and IB nodes
according to the American Head and Neck Soci-
ety classification (Robbins et al. 2002). They are
supplied by the facial artery (Fig. 4). Like grapes
hanging by their stalks, the lymph nodes “hang”
from the facial artery by the stalk of their hilar
vessels (Fig. 5). Furthermore, as the facial artery
has a tortuous course, it supplies the lymph nodes
via its branches; namely, the glandular branches
(majority), facial branch, and submental branch.
Two to three lymph nodes are consistently
found in three anatomical locations: (1) superficial
Fig. 2 Lymphoscintigraphy scan using Tc-99m-labelled- and posterior to the submandibular gland (33%),
colloid injection showed extensive dermal stasis with (2) deep, between the superficial and deep lobes of
absent lymphatic tracks the gland (50%), and (3) anterior to the gland
(17%). They are classified as (1) superficial,
appears as a honeycomb pattern (Zeltzer et al. (2) deep, and (3) submental, respectively (Non-
2018). In cases where there is fat hypertrophy, omura et al. 2018). The superficial lymph nodes
MRI also distinguishes fat from fluid, which are supplied by hilar arterioles from the facial
assists in the selection of patients eligible for artery and dissection is easy without having to
liposuction (Sen et al. 2018). High-resolution trace the intraglandular portion of the facial artery
magnetic resonance lymphangiography allows (Fig. 4). They are drained by the facial veins.
for the location of deep lymphatics and their dif- Figure 4 shows the blood supply of the overlying
ferentiation from veins. neck skin which can be harvested as a monitoring
skin paddle. The deep nodes are sandwiched
between the deep and superficial parts of the sub-
Preoperative Care mandibular gland and are supplied by the glandu-
lar branches of the facial artery and drained by the
The patient was hospitalized 1 week before sur- facial veins (Fig. 5). Harvesting of the deep nodes
gery for bed-rest and graduated compression ban- entails removal of the superficial part of the sub-
daging (Fig. 3). The tightness of the bandages was mandibular gland. To preserve their blood supply,
adjusted daily according to changes in the limb the superficial gland is removed in a piecemeal
fashion, carefully tracing the serpiginous path of anterior to the gland and perfused by the terminal
the facial artery. The submental nodes are located branch of the facial artery, the submental artery
(Fig. 5).
The venous network is more complicated and
variable than the arterial. Hilar veins drain into the
facial vein and other surrounding draining veins
such as the anterior jugular and external jugular
veins, ultimately draining into the internal jugular
vein (Fig. 4) (Nonomura et al. 2018).
Operative Procedure (Video) (Tan et al.

2016)
The patient is positioned supine with a shoulder

roll to extend the neck as this gives access to the
Fig. 3 Preoperative compression bandaging cervical lymph nodes. The submandibular or
Fig. 4 Left submandibular area showing the facial artery (yellow arrow) is supplied by the proximal segment of the
and vein, and their supply to the skin, submandibular facial artery and vein. The same artery gives rise to a skin
gland, and lymph nodes. The superficial lobe of the sub- perforator. The veins are superficial to the artery and con-
mandibular gland has been excised. A solitary lymph node verge as the common facial vein
Fig. 5 Right submandibular area showing 3 lymph nodes artery (big arrow). The anterior two nodes are wedged
(arrows) and their hilar vessels supplied by the facial artery. between the deep and superficial parts of the submandibu-
The submandibular gland has been removed. The posterior lar gland and are supplied by the glandular branches of the
lymph node is supplied by the facial branch of the facial facial/submental artery
upper jugular nodes are chosen after the field is draining veins such as the anterior jugular and
exposed depending on the nodes identified. Usu- external jugular veins, ultimately draining into
ally, an upper neck skin crease incision is utilized, the internal jugular vein (Fig. 4) (Nonomura
creating access and exposure to both groups. First, et al. 2018). It is essential to preserve multiple
the skin incision is deepened to the subplatysmal hilar veins to facilitate venous drainage.
plane. The cervical skin flaps are mobilized supe-
riorly and inferiorly to expose the sternoclei-
domastoid muscle laterally and thyroid gland Revascularization of the Lymph Node
medially. The surgical exposure can be widened Flap at the Recipient Site
by extending the skin crease incision anteriorly,
if required. Next, the sternocleidomastoid muscle In the groin, the superficial circumflex iliac artery
is retracted laterally to identify the upper jugular is used for flap revascularization. Tributaries of
nodes. These nodes correspond roughly to levels the great saphenous vein including the external
II and III nodes according to the American Head pudendal vein, superficial epigastric vein, and
and Neck Society classification. When present, superficial circumflex iliac vein may be used for
the upper jugular nodes will be located adjacent venous drainage. In the leg, the medial sural artery
to or overlying the internal jugular vein, nestled is a suitable recipient artery. The tributaries of the
between the thyroid gland medially and the short saphenous vein are used for drainage.
retracted sternocleidomastoid muscle laterally. Around the ankle, the posterior tibial artery and
Once the upper jugular lymph nodes are identi- venae comitantes can be used for revasculariza-
fied, dissection then proceeds by identifying the tion and an end-to-side arterial anastomosis is
hilar blood supply of the lymph nodes and deter- routinely performed to preserve blood supply to
mining their origin(s). If these nodes are not visu- the foot.
alized, the submandibular lymph nodes are In the patient’s case, a right submandibular
explored. vascularized lymph node transfer based on the
The submandibular nodes can be found anteri- facial artery and veins was performed to the left
orly in the submental area, wedged between the groin. The artery was anastomosed to a deep
superficial and deep lobes of the submandibular branch of the superficial circumflex iliac artery.
gland, or abutting the submandibular gland poste- The dominant hilar vein supplying the lymph
riorly. These nodes are supplied by the facial node was anastomosed end-to-end to a superficial
artery proper or by its submental branch. A skin vein in the left groin. In addition, she underwent
paddle can be included in this flap (Fig. 4). The liposuction of the left leg and thigh with removal
hilar vessels are found closely related to the sub- of 1400 ml of lipoaspirate (Hoffner et al. 2018).
mandibular gland, and the superficial part of the
submandibular gland is routinely reflected if the
superficial nodes are absent to uncover the deep Technical Pearls
nodes. As the facial artery takes a tortuous course
through the submandibular gland giving rise to its Lymph nodes and their hilar vessels are enveloped
glandular branches, always remove the salivary in fat and this layer should not be denuded. Peri-
gland in piecemeal fashion to preserve the glan- nodal fat has been shown to express high levels of
dular branches supplying the lymph nodes. Once vascular endothelial growth factor-C which pro-
the lymph nodes and their pedicles are identified, motes lymphangiogenesis (Viitanen et al. 2013).
dissection is carried out towards the origin of the Thus, lymph nodes and their perinodal fat are
facial artery. The venous network is more compli- handled delicately, to prevent crush injury. The
cated and variable than the arterial. Hilar veins operating microscope is used for visualization of
drain into the facial vein and other surrounding these structures. Once completely mobilized, their
vascularity can be confirmed using indocyanine thromboembolism prevention protocol. Pharma-

green angiography. cological prophylaxis is not routinely prescribed
Vascularized lymph nodes are “mini flaps” unless the patient is at risk, with risk factors being
because of their small volume and pedicles obesity, ongoing malignancy, prior venous throm-
which are usually smaller than recipient vessels. boembolism, or cardiac issues such as dysrhyth-
Hence, there is a physiologic risk of overwhelm- mias. If needed, subcutaneous enoxaparin (a low
ing inflow. To circumvent this, two veins are molecular weight heparin) at a dose of 30–40 mg/
routinely used in the flap to provide adequate day is administered, but one needs to look out for
venous drainage. After revascularization, healthy bleeding in the lipoaspirated leg. This can present
nodes should appear pink and not possess a dark as prolonged hemoserous discharge in the drains.
or purple hue, a sign of venous congestion. Either In terms of mobilization, the patient was allo-
the distal or proximal end of the arterial pedicle is wed to dangle her leg for up to 30 min a day on the
used for anastomosis, depending on the recipient fourth postoperative day. She was mobilized on a
vessel caliber and intended perfusion pressure. wheelchair for 30 min a day to go to the toilet.
Apart from these mobilization intervals, she
rested in bed with her leg elevated. Walking super-
Intraoperative Images vised by the physiotherapist commenced 10 days
postoperatively. Upon discharge at 2 weeks, she
Intraoperative indocyanine green angiography was walking independently and instructed to ele-
was used to check the vascularity of the flap. vate her leg when she was sitting down at home.
After isolating the flap on its pedicle, 15–20 mg The postoperative physiotherapy program cen-
of indocyanine green diluted in water was injected tered around compression bandaging. In the first
intravenously. Vivid dynamic images of pulsatile 3 days, the patient’s lower extremity was ban-
arterial inflow using the near infrared camera were daged using regular elastic bandages over thick
obtained 1–2 min after injection. Uniform filling cotton padding from her toes to the upper thigh.
and fluorescence of the lymph node flap indicated As the drains began to come off after 5–7 days,
good perfusion (Fig. 6). Poor or non-filling of the compression in between the incision sites was
lymph node flap, contrasted with fluorescence of increased. Once all drains were removed, layered
surrounding intact tissues, suggests that the nodes graduated bandaging comprising padding, foam
have no blood flow. The same procedure was bandages and short-stretch compression bandages
repeated after revascularization of the flap at the were applied by the physiotherapist. Compression
recipient site. A monitoring skin paddle was not bandages were reapplied daily to allow shower, skin
used in this case. inspection and moisturization, wound care, and
importantly, adjustment of pressure according to
the changing limb girth. This routine also allowed
Postoperative Management the physiotherapist to train the patient to perform
self-wrapping at home. Graduated compression to
The patient was kept in bed for the first 3 days to facilitate lymphatic drainage was emphasized. The
allow the circulation of the lymph node flap to patient was discharged at 2 weeks.
stabilize as any movement can kink its newly The patient was seen at weekly intervals in the
joined vessels causing thrombosis (The outpatient clinic with the physiotherapist in atten-
co-author [F-O] administers intravenous prosta- dance to chart her limb girth using perometry. At
glandin E1 at a dose of 120 mcg/day for 3 days 1 month, her limb volume had stabilized, and she
to promote vasodilation). The patient was taught was measured for a BauerfeindTM Class 2 flat knit
deep breathing exercises in bed. A calf pump was custom-made compression stocking (Fig. 7)
applied to the unaffected leg as part of our venous which took 2 weeks to arrive.
Fig. 6 Left: A cluster of cervical lymph nodes isolated on its hilar artery (big arrow) and hilar vein (small arrow). Right:
Near infrared scan of the lymph nodes after intravenous indocyanine green injection shows good perfusion
Outcomes, Clinical Photos,

and Imaging
Perometry 2-year postoperatively showed 44%

reduction in volume from 14,243 to 7938 ml.
She had no further episodes of cellulitis in the
3 years of follow up (Fig. 8).
In a separate case of vascularized lymph node
transfer to the leg, new functioning lymphatic
channels were seen 2 years after vascularized
lymph node transfer on lymphoscintigraphy and
3D high resolution magnetic resonance imaging
lymphangiography (Fig. 9). These findings sug-
gest that a latent period exists between lymph
node implantation and quantifiable lymphogenic
activity, as opposed to, say, lymphovenous bypass
where fluid drainage is immediately affected.
Flap elevation is performed under microscopic

magnification for precise dissection and to
avoid injuring surrounding neurovascular struc-
tures and lymph nodes. Care has to be exercised
not to damage the marginal mandibular branch
Fig. 7 Customized compression stocking worn of the facial nerve which supplies the lip
Suction drains are used in a diagnostic manner

and can be removed in the early postoperative
period.
Learning Points
1. The indications for surgery were the severity of

lymphoedema affecting mobility and recurrent
cellulitis. Liposuction-assisted lipectomy in
combination with vascularized lymph node
transfer was chosen as opposed to lymp-
hovenous bypass alone based on the presence
of localized adiposity coupled with the absence
of active lymphatic channels on indocyanine
green lymphography. MRI is a useful adjunct
to study the relative distribution of fat and
fluid, and to document the changes in subcuta-
neous architecture such as fat hypertrophy
(honeycomb pattern) and adipose tissue
remodeling (amorphous pattern). Lymphati-
covenous anastomosis as the sole treatment in
this case would have been less effective.
2. Inflammation was arrested by the treatment
offered. Pathological processes in lymph-
Fig. 8 3-year postoperative appearance edema consist of an interplay between lymph
stasis, adipose tissue accumulation and
remodeling, inflammation, and fibrosis
depressors. Injury of this nerve results in an (Azhar et al. 2020). Adipose tissue remodeling
asymmetrical smile and an inability to “pull leads to dysregulation of adipokine production
down” the lower lip when opening the mouth (a homeostatic cytokine) and a low-grade
wide. The nerve may be found up to 1.5 cm inflammation through release of pro-
below the inferior border of the mandible inflammatory cytokines (TNF-ɑ, IL-6,
(Ziarah and Atkinson 1981). It is avoided by MCP-1, IL-8) that promote immune cell infil-
starting with a low incision at the upper neck tration. Therefore, adipose tissue reduction in
crease and approaching the submandibular combination with lymph node transfer was
gland in a caudal-to-cranial direction, thereby effective in reducing her cellulitis episodes.
preserving the nerve in the cranially reflected 3. An established physiotherapy protocol in the
submandibular gland capsule. acute postoperative period set the stage for
Seroma and hematoma collection can develop permanent limb girth reduction. This required
if vessels are improperly sealed. The LigaSureTM daily attention and patient cooperation to
(Medtronic) bipolar forceps and micro-hemoclips achieve a successful surgical decompression
are routinely used to seal fine vessels. Larger that will be maintained by the customized com-
vessels are securely ligated with silk sutures. pression stocking.
Fig. 9 This 30-year-old female presented with Interna- (99m Tc) sulfide colloid injected intradermally shows the
tional Society of Lymphology stage III congenital lymph- transferred nodes after 4 h (circle). Middle: Coronal 3D
edema. She underwent vascularized lymph node transfer to high resolution magnetic resonance imaging lymphangi-
the medial aspect of the left leg. The lymph node flap was ography shows lymphatic channels emanating from the
revascularized end-to-side using the posterior tibial artery lymph nodes in a reticular pattern (circle). Right: Coronal
and its venae comitantes. Left: Lymphoscintigraphy T2-weighted image showing the lymph nodes located in
performed 2 years after surgery using technetium 99 m the medial calf subcutaneously (circle)
Cheng MH, Huang JJ, Wu CW, Yang CY, Lin CY, Henry
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Part IV
Lower Extremity
Soft-Tissue Reconstruction in Exposed
Total Knee Arthroplasty 67
Rik Osinga, Ilario Fulco, and Dirk Johannes Schaefer
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734
Abstract
Patients with a periprosthetic joint infection

(PJI) of the knee in combination with a soft-
tissue defect, including possible extensor appa-
R. Osinga (*) ratus deficiency, are a growing clinical prob-
Centre for Musculoskeletal Infections, University Hospital lem. As this presents a reconstructive
Basel, Basel, Switzerland
challenge, a multidisciplinary strategy –
Department of Plastic, Reconstructive, Aesthetic and Hand including a thoroughly planned orthoplastic
approach – is imperative. Treatment algo-
Canniesburn Plastic Surgery Unit, Glasgow Royal rithms have been successfully proposed for
Infirmary, Glasgow, UK
PJI, but there is no uniformly accepted treat-
I. Fulco ment concept for PJI with a concomitant soft-
Department of Plastic, Reconstructive, Aesthetic and Hand
Surgery, University Hospital Basel, Basel, Switzerland tissue defect. Such a lack of concept may lead
e-mail: ilario.fulco@usb.ch to further soft-tissue damage with bone stock
D. J. Schaefer loss and, eventually, to limb amputation. Mul-
Centre for Musculoskeletal Infections, University Hospital tiple comorbidities contribute to host-related
Basel, Basel, Switzerland risk factors, aggravating the potential for fail-
Department of Plastic, Reconstructive, Aesthetic and Hand ure. These considerations underline the
e-mail: dirk.schaefer@usb.ch

https://doi.org/10.1007/978-3-030-23706-6_90
724 R. Osinga et al.
importance of referring these patients early to a

specialized bone and joint infection unit.
The technical approach of a center for mus-
culoskeletal infections is herein presented, as
part of the multidisciplinary treatment concept,
from a plastic surgeon’s perspective. The prin-
ciple to reconstruct tissue “like with like” is
favored to achieve the best functional and aes-
thetic result. Workhorses are the free sensate
extended lateral arm flap (s-ELAF) for small
soft-tissue defects and the free anterolateral
thigh (ALT) flap for larger soft-tissue defects.
In patients who do not qualify for free flap
surgery, a pedicled medial sural artery perfora-
tor (MSAP) gastrocnemius flap is used. These
three flap types can be extended by simulta-
neously raising vascularized autologous tendi-
nous tissue (ALT with the fascia lata, s-ELAF
with the triceps tendon, and MSAP gastrocne-
mius with the tendinous back of the medial
gastrocnemius muscle) for extensor apparatus
reconstruction if necessary.
Fig. 1 First-stage preoperative photo of the soft-tissue
defect over the right medial knee after total knee
Keywords arthroplasty. The markings indicate debridement planning
on the right leg and flap raise planning of a free ALT from
Knee · PJI · Soft-tissue defect · Orthoplastic · the contralateral left leg. Note the wound plaster over the
Treatment concept site of joint aspiration a few days earlier performed laterally
to the wound to avoid contamination
The Clinical Scenario completely dry. The patient was not obese. Arte-
rial hypertension, chronic obstructive pulmonary
A 74-year-old woman presented 8 weeks after disease, and reflux were well controlled.
primary total knee arthroplasty of the right leg
and 5 weeks after revision surgery due to inlay
dislocation with wound breakdown and exposed Preoperative Problem List/
knee prosthesis (Fig. 1). The soft-tissue defect Reconstructive Requirements
resulted after a medial parapatellar approach. It
measured 5 3 cm and was located over the Treatment of a periprosthetic joint infection (PJI)
incision line just distal to an older oblique medial of the knee and soft-tissue reconstruction should
scar that resulted from meniscal surgery 8 years be performed with a multidisciplinary team
earlier. The wound was almost dry with little approach at an experienced bone and joint infec-
secretion over a central sinus, and no further tion unit (Garceau et al. 2019; Leckenby and
local or systematic signs of infection were appar- Grobbelaar 2016; Kendall et al. 2019). Such a
ent. Active function of the knee was good with team includes an orthopedic surgeon, an infec-
90/0/0 (flexion/extension). The patient had spent tious disease specialist, and a plastic surgeon. To
several weeks in a musculoskeletal rehabilitation evaluate the vascular status of the leg, it is
center and reported that since revision surgery recommended to perform an angiological exami-
5 weeks earlier, the wound had never been nation or arteriography, involving vascular
67 Soft-Tissue Reconstruction in Exposed Total Knee Arthroplasty 725
surgeons if necessary. Eventual comorbidities was no longer possible and surgery became the
(e.g., diabetes, renal function) should be opti- cornerstone of treatment. Without adequate sur-
mized prior to reconstructive surgery. In frail or gery, infection could be suppressed, but not cured.
bedridden patients, it may be reasonable to choose Therefore, a two-stage procedure was planned
a palliative strategy as in patients with excessive with prosthesis removal, spacer insertion, and
risk for reinfection, as it is found in patients with soft-tissue reconstruction at the first stage. Flap
active IV-drug abuse. elevation, spacer removal, and insertion of a new
prosthesis would be done at the second stage
Infection 6 weeks later.
Prior to reconstructive surgery, the infection and The rationale to reconstruct the soft tissue as
its causative microorganisms must be properly early as possible relies on the following argu-
diagnosed through blood tests, arthrocentesis, ments: Firstly, early surgery maximizes the time
imaging, and biopsies (Zimmerli 2014; Zimmerli for the soft tissue to heal and integrate. Of note,
and Sendi 2017). Only then are the chances of 8 weeks of protection time would be needed for
long-term elimination of the infection favorable. repair of a fully interrupted extensor apparatus.
Secondly, well-vascularized reconstructed soft
Reconstructive Surgery tissue can act as a vehicle for the transport of
Thorough preoperative analysis of the soft-tissue antimicrobial agents to the site of infection.
defect defines the damaged structures to be Thirdly, the smaller the number of interventions,
reconstructed. These structures usually consist of the lower the rate of complications and the num-
the following tissue types: (i) cutis, (ii) subcutis, ber of anesthetic procedures (Osinga et al. 2020).
and sometimes (iii) tendon. Tendon reconstruc- In the patient presented here, because of the rela-
tion is needed only if the extensor apparatus is tively large defect, a free ALT was chosen for soft-
deficient (Osinga et al. 2020). Therefore, active tissue reconstruction (Fig. 1).
knee function must be analyzed preoperatively. It
must also be anticipated that the longer the dura- Reconstructive Surgery Including
tion of PJI, the greater the risk of extensor appa- Alternative Reconstructive Options
ratus deficiency, due to the chronicity of the The principle of replacing tissue “like with like” is
infection around the artificial knee joint. favored, as it provides the best functional and
aesthetic result. By following this procedure,
vascularized autologous tissue replaces skin with
Treatment Plan cutaneous and subcutaneous tissue and it replaces
tendon with tendinous tissue. The choice of flap
A multidisciplinary case discussion should define depends both on the preoperative analysis of the
whether the aim of treatment is cure or suppres- soft-tissue defect and on the individual patient’s
sion. Cure should always be strived for and sup- characteristics. Two techniques that exemplify
pression represents only the exception to this rule. these principles are (i) a free sensate extended
Cure implies elimination of all microorganisms lateral arm flap (s-ELAF) in the case of a small
and preservation or restoration of a pain-free soft-tissue defect and (ii) a free anterolateral thigh
joint with good function. (ALT) flap in the case of a larger soft-tissue defect.
A pedicled medial sural artery perforator (MSAP)
Infection Elimination gastrocnemius flap is used in patients who do not
Because the knee prosthesis in this patient had qualify for free flap surgery (Hallock 2014;
been exposed for 5 weeks, microorganisms were Osinga et al. 2020).
likely to have been adhering to the prosthesis for These flaps can be extended by simultaneously
more than 4 weeks. As the age of the biofilm, thus, raising vascularized autologous tendinous tissue
exceeded 1 month, complete elimination of all (s-ELAF with the triceps tendon, ALT flap with
microorganisms with antimicrobial therapy alone the fascia lata, and MSAP gastrocnemius flap with
the tendinous back of the medial gastrocnemius

muscle) for extensor apparatus reconstruction,
should this be necessary (Osinga et al. 2020). If
an ALT flap is chosen, it is usually taken from the
leg without PJI.
Most structures of the leg are anatomically
arranged in “longitudinal” fashion (e.g., blood
and lymphatic vessels, nerves, muscles, and ten-
dons, the extensor apparatus, the axis of the long
bones). To minimize damage to native structures,
the aim is to reconstruct as “longitudinally” as
possible. This implies cutting the skin perpendic-
ular to Langer’s lines both at the donor and the
recipient site and designing the flaps longitudi-
nally, as is commonly done when raising an ALT
or s-ELAF. In patients who do not qualify for free
flap surgery, this principle is partially
compromised, as the medial gastrocnemius mus-
cle is typically placed in an oblique fashion,
whereas the skin over the MSAP can be placed
longitudinally. As most PJI of the knee is treated
in a two-stage procedure and soft-tissue recon-
struction should be performed at the first stage, Fig. 2 Intraoperative photo after debridement, prosthesis
elevating the flap for spacer removal and knee removal, harvesting of biopsies, rinsing, spacer insertion,
and capsula closure after medial arthrotomy
prosthesis implantation must be anticipated and
is easier when reconstruction is performed longi-
tudinally (as with the ALT or s-ELAF) and not
obliquely (as with the MSAP gastrocnemius flap).
In addition to performing a complete physical

examination of the patient, the following diagnos-
tic tools were used for preoperative assessment
and planning.
Conventional Radiograph
Conventional radiographs can show bone
Fig. 3 Intraoperative photo after medial incision to raise
remodeling in the case of PJI. Serial radiographs the ALT flap from the left thigh before defining the final
over time are often helpful to assess changes to the flap design
cortical bone/bone stock.
Arteriography Angiological Examination

In addition to clinical assessment of peripheral Assessment of the venous situation is equally
pulses, arteriography is typically used to assess important, especially in patients with history of
the arterial situation of the lower extremity for deep vein thrombosis or previous surgery at the
donor vessels evaluation in free flap reconstruction. site of donor vessels. The angiology specialist is
Fig. 4 Complete ALT flap

isolation based on one
single perforator before
dissection of the pedicle
Fig. 5 Free
fasciocutaneous ALT flap
with its pedicle
able to demonstrate the patency of concomitant Preoperative Care and Patient Drawing
veins in addition to the arterial evaluation.
The cutaneous perforators/pedicle identified with
Handheld Doppler a handheld Doppler are marked on the skin. As a
A handheld Doppler can be used to identify the rule, if a free ALT flap is used, the contralateral
axial vessel within the intermuscular septum of thigh is marked (Fig. 1). If an MSAP gastrocne-
the s-ELAF, or the perforators of the ALT flap mius flap is used, the ipsilateral perforators are
(Fig. 1) or MSAP over the medial gastrocnemius marked because it is a pedicled flap.
flap. Of note, MSAPs are sometimes tortuous and
do not always directly correlate with the Doppler Surgical Technique
signal (Mazur et al. 2019; Cavadas et al. 2001; After debridement, arthrotomy, prosthesis
Kim et al. 2006). removal, biopsies sampling, rinsing, and spacer
Fig. 6 Provisional flap

inset. The flap was turned
around placing the proximal
end of the flap distally, so
that the rather short pedicle
of the flap could reach the
anterior tibial donor vessels
Fig. 7 Close-up of the

intraoperative situation after
microvascular anastomoses
as presented in Fig. 6. The
anterior tibial artery and
vein were distally ligated
and turned proximally. The
arterial anastomosis was
performed using a 9–
0 suture (vertical white
arrow), for the venous
anastomosis a 2.5 mm
coupler was used (oblique
white arrow)
photo of the right leg at the
end of the first stage
demonstrating
perigenicular soft-tissue
reconstruction with a free
ALT flap from the
contralateral leg
Fig. 10 Second-stage preoperative photo 6 weeks after

first stage (see Fig. 1). The markings indicate the pedicle of
the free ALT flap identified with a handheld Doppler. They
correlate exactly with the intraoperative position of the
pedicle 6 weeks earlier (see Figs. 6 and 7)
position between the anterior superior iliac spine

and the upper lateral border of the patella. The
skin perforators are marked on the contralateral
leg around the midpoint of that line with the use of
Fig. 9 Preoperative arteriography demonstrating a three- a handheld Doppler. The provisional flap design is
vessel runoff. The black arrow indicates the anterior tibial
artery, which was later used as donor vessel for free flap
centered around the perforator markings. The flap
anastomosis is raised through a medial incision over the rectus
femoris muscle and deepened subfascially to ver-
ify the perforator anatomy (Fig. 3). The skin flap
insertion, it was noted that the extensor apparatus design can then be finalized around the visualized
appeared to be intact. The overlying soft-tissue perforators off the descending branch of the lateral
defect measured 28 x 7 cm (Fig. 2). The soft-tissue femoral circumflex artery (Figs. 4 and 5). The flap
defect was large and therefore, as outlined earlier, is provisionally set into the defect and the micro-
reconstruction with a free ALT flap was indicated. vascular anastomoses are then performed (Fig. 6).
In the case reported here, the flap was anasto-
Free ALT Flap mosed to the anterior tibial vessels in an end-to-
The procedure used is consistent with later reports end fashion after ligating the vessels distally and
of technical refinements after being first described turning them proximally (Fig. 7). To avoid stress
by Song et al. (1984). In brief, a line is drawn on on the soft tissue during later knee mobilization,
the donor leg with the foot in a strictly supine the skin is closed in a multilayer fashion with the
view after lateral incision of
the ALT flap and medial
arthrotomy before spacer
removal
view after spacer removal
and implantation of the
definitive knee prosthesis
knee bent up to 90 (Fig. 8). A drain may be descending branch of the lateral femoral circum-
placed at both the donor and the recipient site if flex artery can sometimes be useful if distally
necessary. strong enough. Medially, the descending
genicular artery can be used, or the flap can
directly be anastomosed onto the superficial fem-
Technical Pearls oral artery. However, the rather short pedicle of
the lateral arm flap or the longer pedicle of the
Donor Vessels ALT flap can reach these vessels only if the flap is
It can be difficult to find suitable donor vessels for not placed too distally. In our case, the only suit-
free flap surgery around the knee. The vessels able perforator of the ALT flap was rather proxi-
above and below the knee need to be evaluated mal, resulting in a shorter pedicle (Figs. 4 and 5).
according to microsurgical principles (e.g., size Therefore, in this patient, it was decided to use the
match to the chosen flap vessels, length and anterior tibial artery and vein in an end-to-end
maneuverability, blood pressure). Laterally, the fashion. Before proceeding, the vessel being
Fig. 13 The patient standing upright, fully weight bearing Fig. 14 Left lateral view showing both the left donor thigh
and entirely pain-free six weeks after second stage surgery and the well-integrated soft-tissue around the right knee
ligated must be evaluated to ensure that it is not explantation (Fig. 11) and definitive implantation
the only vessel perfusing the distal lower leg and of the knee prosthesis (Fig. 12).
foot, as this could otherwise result in critical per-
fusion of the area. Here, preoperative arteriogra-
phy proved that all three lower leg vessels were Postoperative Management
patent (Fig. 9).
During the first 24 h after surgery, free flaps are
Intraoperative Images monitored hourly. The interval is gradually
As presented here, most patients in our unit with lengthened until day 5, assuming the anastomoses
PJI of the knee and soft-tissue defect are treated in are stable by then, as the endothelium has covered
a two-stage procedure. It must be anticipated that the stitch material. From day 6 on, flap training
the flap will need to be elevated again in the near begins. The knee is held in full extension with a
future and care must be taken at the second stage brace for this first week. Thereafter, full weight
not to damage the pedicle of the flap. Therefore, it bearing is allowed with the knee brace on. In
can be helpful to take photographs showing the parallel, gradual continuous passive motion of
intraoperative position of the pedicle (Fig. 6) and the knee joint starts under physiotherapeutic
to verify its location with a handheld Doppler instruction and supervision. Thromboprophylaxis
prior to second-stage surgery (Fig. 10), as its is administered on the day of surgery and contin-
position could have changed. This may prove ued until normal ambulation. Drains are removed
especially helpful if a surgeon not involved in after mobilization once less than 30 ml liquid over
the first stage needs to raise the flap before spacer 24 h are produced.
Fig. 15 Anterior view 6 weeks postoperative Fig. 16 The right lateral view shows only little extra
contour around the knee. The active function of the right
knee was 90/0/0 (flexion/extension)

The outcome of the patient presented here was
favorable. All wounds healed seamlessly after Consider PJI of the knee if wounds are not
both first- and second-stage surgery, and function completely dry within 14 days of surgery and
was good 12 weeks after the second stage refer patients to a bone and joint infection unit
(Figs. 13, 14, 15 and 16). Postoperative radio- quickly. The earlier the referral, the better the
graphs showed good alignment of the hinged outcome (Garceau et al. 2019; Leckenby and
knee prosthesis (Figs. 17 and 18). Grobbelaar 2016; Colen et al. 2018). If PJI is
The literature reports an overall success rate of diagnosed, thorough multidisciplinary discussion
PJI – indicating cure of infection and good, pain- and planning with a team that includes an ortho-
free function of the artificial joint at least 1 year pedic surgeon, an infectious disease specialist,
postoperatively – between 80% and 95%, provided and a plastic surgeon is key to success.
that the patient is treated strictly according to a
validated orthoplastic treatment algorithm in an
experienced bone and joint infection unit (Zimmerli Learning Points
and Sendi 2017; Zimmerli et al. 2004; Osmon et al.
2013). Of note, if the extensor apparatus is deficient 1. If wounds are not completely dry 14 days after
in PJI of the knee and needs reconstruction, the total knee arthroplasty, consider PJI.
outcome is much worse, with a success rate as low 2. If in doubt, refer the patient as quickly as
as 23% (Anderson et al. 2018). possible to an established bone and joint
Fig. 17 Antero-posterior radiograph 6 weeks after second

stage surgery showing good position and alignment of the
Fig. 18 Lateral radiograph 6 weeks after second stage
hinged knee prosthesis
surgery confirming good position and alignment of the
hinged knee prosthesis
infection unit and do not apply negative pres-
sure wound dressing. case of a small soft-tissue defect, a free ALT
3. The earlier the patient’s referral, the better the flap in the case of a larger soft-tissue defect,
outcome. and a pedicled MSAP flap in patients who do
4. If PJI is considered, thorough preoperative not qualify for free flap surgery.
multidisciplinary planning involving an ortho- 6. These soft-tissue reconstructive techniques can
pedic surgeon, an infectious disease specialist, be extended by simultaneously raising
and a plastic surgeon is key to success. vascularized autologous tendinous tissue
5. If there is a soft-tissue defect after total knee (ALT with the fascia lata, s-ELAF with the
arthroplasty, the treatment algorithm presented triceps tendon, and MSAP gastrocnemius
here follows the principle of replacing “like with the tendinous back of the medial gastroc-
with like” in a “longitudinal” fashion. It distin- nemius muscle) for extensor apparatus recon-
guishes between various techniques of soft- struction, should this be necessary.
tissue reconstruction, depending on the size 7. If free flap reconstruction is planned, consider
of soft-tissue defect: a free s-ELAF in the arteriography and angiological assessment
preoperatively to evaluate suitable arterial and muscle flap reconstruction. J Bone Jt Infect.
venous recipient vessels. 2019;4(4):181–8.
Kim HH, Jeong JH, Seul JH, Cho BC. New design and
identification of the medial sural perforator flap: an
anatomical study and its clinical applications. Plast
References Reconstr Surg. 2006;117(5):1609–18.
Leckenby JI, Grobbelaar AO. Strategies for soft-tissue
Anderson LA, Culp BM, Della Valle CJ, Gililland JM, management of complex joint revision arthroplasty: a
Meneghini RM, Browne JA, et al. High failure rates of 10-year experience. Plast Reconstr Surg. 2016;138(6):
concomitant periprosthetic joint infection and extensor 1344–51.
mechanism disruption. J Arthroplast. 2018;33(6): Mazur N, Osinga R, Lo S. Split median superficial sural
1879–83. artery perforator (MSSAP) flap and medial sural artery
Cavadas PC, Sanz-Gimenez-Rico JR, Gutierrez-de la perforator (MSAP) flap for posterior thigh sarcoma
Camara A, Navarro-Monzonis A, Soler-Nomdedeu S, reconstruction. BMJ Case Rep 2019(0):e233352.
Martinez-Soriano F. The medial sural artery perforator Osinga R, Eggimann MM, Lo SJ, Kuhl R, Lunger A,
free flap. Plast Reconstr Surg. 2001;108(6):1609–15. dis- Ochsner PE, et al. Orthoplastics in periprosthetic joint
cussion 16-7 infection of the knee: treatment concept for composite
Colen DL, Carney MJ, Shubinets V, Lanni MA, Liu T, soft-tissue defect with extensor apparatus deficiency.
Levin LS, et al. Soft-tissue reconstruction of the J Bone Jt Infect. 2020;5(3):160–71.
complicated knee Arthroplasty: principles and pre- Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W,
dictors of salvage. Plast Reconstr Surg. 2018;141(4): Steckelberg JM, et al. Diagnosis and management of
1040–8. prosthetic joint infection: clinical practice guidelines by
Garceau S, Warschawski Y, Dahduli O, Alshaygy I, the Infectious Diseases Society of America. Clin Infect
Wolfstadt J, Backstein D. The effect of patient institu- Dis. 2013;56(1):e1–e25.
tional transfer during the interstage period of two-stage Song YG, Chen GZ, Song YL. The free thigh flap: a new
treatment for prosthetic knee infection. Bone Joint free flap concept based on the septocutaneous artery. Br
J. 2019;101-B(9):1087–92. J Plast Surg. 1984;37(2):149–59.
Hallock GG. Medial sural artery perforator free flap: legiti- Zimmerli W. Clinical presentation and treatment of ortho-
mate use as a solution for the ipsilateral distal lower paedic implant-associated infection. J Intern Med.
extremity defect. J Reconstr Microsurg. 2014;30(3): 2014;276(2):111–9.
187–92. Zimmerli W, Sendi P. Orthopaedic biofilm infections.
Kendall JV, McNally M, Taylor C, Ferguson J, APMIS. 2017;125(4):353–64.
Galitzine S, Critchley P, et al. The effect of age on Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint
outcome in excision of chronic osteomyelitis with free infections. N Engl J Med. 2004;351(16):1645–54.
Tibial Tuberosity Coverage Using
Venous Supercharged Distally Based 68
Pedicled ALT Flap
Andreas Gravvanis, Jonathan A. Britto, and

Despoina D. Kakagia
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740
Abstract
A. Gravvanis (*) The reconstruction of the exposed tibial tuber-

Plastic, Reconstructive and Aesthetic Surgery, osity requires well-vascularized tissue to
Metropolitan Hospital of Athens, Athens, Greece implement optimal wound healing and to reli-
J. A. Britto ably support any further orthopedic interven-
Great Ormond Street, Hospital for Children, London, UK tion. Local muscle and perforator flaps are
e-mail: j.britto@doctors.org.uk effective but often unavailable as they may be
D. D. Kakagia affected by the injury. Distant flaps with reli-
Professor in Plastic Surgery, Medical School, Democritus able arterial perfusion are safer even compared
e-mail: dkakagia@med.duth.gr

https://doi.org/10.1007/978-3-030-23706-6_91
to free flaps, which require intact recipient resurfacing, perfused from outside the zone of
vessels at the knee area. injury.
Distally based pedicled anterolateral thigh 2. Inherent lack of soft tissue at the
(ALT) flap has been reported as a safe and ver- infrapatellar area.
satile option for knee soft tissue reconstruction, 3. Extensive scarring at the knee and calf area,
mainly due to adequacy of the pedicle length and rendering local flaps unreliable.
possible combination with tensor fascia lata for 4. Possible damage to the leg vasculature due to
concomitant tendon reconstruction. previous injury and surgery, precluding its use
Herein a patient with severe lower leg injury as recipient vessels for free flap transfer. The
is presented. A distally based pedicled ante- nearby anterior tibial vessels were intact but
rolateral thigh flap with a venous supercharge their deep position at this level would make the
was used to reconstruct the tibial tuberosity anastomoses challenging.
and prevent possible venous congestion of 5. Minimal donor site morbidity.
the flap.
Keywords Treatment Plan

Knee reconstruction · Infrapatellar · Perforator
Distally based ALT perforator flap is a well-
flaps · Anterolateral thigh flap · Venous
established, safe, and reliable option in knee
supercharge · Distally based flaps
reconstruction (Kosutich 2020; Yildirim et al.
2003; Pan et al. 2004).
The authors have supported its superiority over
the gastrocnemius muscle flap in terms of greater
flexibility of size and shape, better color and tex-
A 52-year-old male patient was referred by the
ture match, less bulkiness, longer arc of rotation to
Orthopedic Department, with an open wound of
reach suprapatellar defects, and ease of
the left tibial tuberosity (Fig. 1). The patient had
re-elevation from the recipient site should ortho-
previously sustained serious injury in a road traf-
pedic revision be required. Furthermore, ALT
fic accident and undergone several orthopedic
may be combined with tensor fascia lata for con-
stabilization surgical procedures. No prosthetic
comitant tendon reconstruction (Lucattelli et al.
material had been used in the left knee or tibia;
2019) and is associated with less donor site mor-
however, there were several scars at the medial
bidity and better functional and aesthetic outcome
and lateral aspect of the knee, infra-patellar, and
for the donor site (Gravvanis et al. 2005).
calf area as a result of the initial injury and
previous surgery. Distally based pedicled ante-
rolateral thigh (ALT) was decided to resurface
the wound, as most of the alternative reconstruc-
tive options in the left lower leg were considered
perilous due to the initial trauma and the follow-
ing surgeries.

1. Exposed tibial tuberosity with a 9.5 cm X

6,5 cm soft tissue defect, requiring thin, Fig. 1 Exposed bone, skin and soft tissue defect at the
pliable, and well-vascularized skin for tibial tuberosity
68 Tibial Tuberosity Coverage Using Venous Supercharged Distally Based Pedicled ALT Flap 737
Although the ALT flap is technically more recipient site available in this case because the
demanding, it allows for early mobilization and more superficially located medial sural vessels
return to normal daily activity (Gravvanis et al. were most likely injured. The nearby anterior
2006). The properties of the pedicled ALT flap are tibial vessels were a secondary alternative but
beneficial for tibial tuberosity resurfacing. Never- their deep position at this level would make the
theless, the tibial tubercle is below the knee, and anastomoses challenging (Gravvanis and
gastrocnemius could be a more convenient choice Britto 2009).
due to the shorter arc of rotation, despite the poor
functional and esthetic effects upon its donor site.
(Chung et al. 2002; Buchner et al. 2003) In this Preoperative Evaluation and Imaging
patient, however, the presence of severe scarring
rendered the use of local flaps risky due to distor- Flap perforators were mapped by Doppler preop-
tion of their vasculature by trauma and surgery, eratively. Although Doppler is not highly specific
therefore, the resurfacing with distally based ALT in identification of the dominant perforator, it is
flap was decided. useful to identify the perforators and outline the
skin paddle accordingly. A pinch test was
performed to ensure direct donor site closure.
Alternative Reconstructive Options Preoperative angiograms and MRI or CT angi-
ography can also be used as a guide in many
1. Pedicled muscle flaps, such as gastrocnemius circumstances.
and soleus, have been the workhorse for knee
resurfacing. They have proved to be reliable,
safe, and fast reconstructive options (Hyodo Preoperative Care and Patient
et al. 2004). Drawing
Especially for infrapatellar defects, these muscle With the patient placed in the supine position, the
flaps require a shorter arc of rotation compared to leg internally rotated and the ipsilateral hip ele-
the ALT flap and are faster and less technically vated, the area proximally to the thigh and distally
demanding. Nevertheless, they provide bulky tis- to the ankle level was prepped and draped so that
sue and are associated with less favorable func- the lower extremity was exposed from the ingui-
tional and aesthetic outcome for the donor site and nal ligament to the ankle.
longer rehabilitation period. In the herein pre- A straight line from the anterior iliac spine to
sented patient, extensive initial injury and scarring the lateral border of the patella was drawn and a
of the knee and calf area rendered this choice less mark 2 cm lateral to the midpoint of this line
safe. was made.
2. The same concerns apply for the use of sural

artery perforator flap, which would otherwise Surgical Technique
provide thinner skin, better tissue match for
resurfacing, and better functional and aesthetic The skin incision was performed medially, above
donor site outcome than muscle flaps the rectus femoris muscle and down to the sub-
(Umemoto et al. 2005). fascial plane. The dissection was continued under-
3. Free flap transfer would require uncom- neath the deep fascia and extended laterally until
promised vasculature around the knee to the perforators were encountered.
serve as recipient, which was not the case in Since a good size and volume perforator was
this patient as the area was included in the identified, the septum between the vastus lateralis
initial zone of injury and had sustained deep and rectus was explored to trace the trunk of the
scarring. The popliteal vessels were the only descending branch of the lateral circumflex
femoral artery (LCFA). The dominant perfora- wound was 28 cm, a 10 cm flap skin paddle with a
tor was followed to the descending branch by 3 cm width was designed (Fig. 3).
intramuscular dissection (Yildirim et al. 2003; The skin paddle was entirely elevated and the
Pan et al. 2004). The descending branch was descending branch was then clamped proxi-
dissected proximal to the origin from the mally to assess the retrograde flow into the
LCFA at a length of 6 cm, and distally to the flap. The pedicle was found adequate to sustain
anastomotic point with the lateral superior arterial supply and venous drainage to the flap;
genicular artery. therefore, the proximal inflow was ligated, trans-
The pivot point was located just proximally to ected, and was added to the flap as a precaution,
this anastomotic site, approximately 6 cm above in case of vascular insufficiency after flap
the patella. The pedicle length from the distal transposition.
pivot point to the junction of the perforator and The flap was then dissected along its length
then up to the fascia was 20 cm (Fig. 2). As the distally until the pivot point and was easily inset
total distance required from the pivot point to the into the wound. The skin lateral to the patella from
the distal wound to the proximal donor site was
split, to inset the pedicle and proximal part of the
skin paddle.
The donor site was closed in layered fashion,
and tension free closure was achieved throughout
the donor site.
At this point, the flap became slightly
congested. The superior inset of the flap was
released and the vascular pedicle-perforator was
inspected. Both the pedicle and the perforator
were flowing perfectly well and no kinking or
compression was identified. To overcome
venous congestion, a branch of the adjacent
medial accessory saphenous vein was dissected
and anastomosed end to end to the proximal end
Fig. 2 Elevation of distally based ALT flap. The flap is of the descending branch of the LCFV (Fig. 3
based on a muscle perforator. Dissection of the pedicle at
inset). A short period of shunting followed and
20-cm length including the perforator and descending
branch of LCFA. The proximal end of the LCFA was eventually the flap settled down to a well-
preserved and added to the flap perfused state.
Fig. 3 The flap skin paddle

was 10 cm long and
transferred on a 20 cm
pedicle to cover without
tension the distal part of the
defect at 28 cm from the
pivot point. Inset: A branch
of medial accessory
saphenous vein was end-to-
end anastomosed to the
proximal end of the
descending branch of the
lateral circumflex femoral
vein to address the venous
congestion of the flap
Technical Pearls of the descending branch of the LCFV, as seen in

Fig. 3 inset.
1. Make a small incision and slide your index
between the muscle and the thin fascia to
open the fascia of the rectus femoris easily. Postoperative Management
2. Separate gently the fascia lata from the vastus
lateralis lateral to the perforators. The patient was postoperatively closely moni-
3. In order to gain length, and allow transposi- tored by physical examination and Doppler for
tion of the flap as distally as possible, the the first 5 days. Anticoagulant regimen included
pedicle can be dissected to include the low molecular heparin and oral aspirin. He was
descending branch of the LCFA (Lin and also monitored for development of thigh compart-
Chien 2006). ment syndrome. The patient was partially mobi-
4. The flap design may need to be readjusted and lized on Day 2, and the drain at the thigh was
this must be done before making the lateral removed on Day 4.
skin incision. The knee was splinted in the extended position
5. To reach the distal end of the tibial tuberosity for only a week and thereafter the patient was able
defect, a long (10 cm) flap skin paddle was to walk without supports. Skin sutures at the
harvested to allow flap transposition around donor site and the leg were removed 2 weeks
the pivot point and tension free suture at the postoperatively.
recipient site.
6. The vascularity of the distally based ALT flap
relies on the anastomoses of the descending Outcome: Clinical Photos and Imaging
branch of the LCFA with the lateral superior
genicular artery (Zhang 1990) or profunda The recovery period for this patient was fast and
femoris or both. Especially in trauma cases uneventful. The patient was able to demonstrate a
the reliability of arterial supply and venous full range of knee motion and resume his daily
outflow of the flap could be questionable
(Yildirim et al. 2003; Pan et al. 2004).
7. Flap recharging in severe injury cases should
be always considered in the case of vascular
insufficiency after flap transposition and the
proximal end of the descending branch of the
LCFA should be added to the flap as a precau-
tion (Belmahi et al. 2007; Gravvanis and Britto
2009).
In Fig. 2, distally based ALT flap is elevated,

based on a muscle perforator. Note the 20 cm
length of the pedicle (perforator and descending
branch of LCFA), as well as the preservation of
the proximal end of the LCFA that was added to
the flap.
To overcome venous congestion, a superficial
vein, branch of medial accessory saphenous vein,
Fig. 4 The outcome immediately post op (left) and three
was end-to-end anastomosed to the proximal end months postoperatively (right)
activities 2 weeks postoperatively. Three months proximal end of LCFA is added to the flap as
postoperatively the aesthetic and functional a precaution for flap recharge should venous
results were satisfactory (Fig. 4). insufficiency be observed.
Free ALT flap provided durable and expedient
coverage of the exposed tibial tuberosity.
Cross-References
Avoiding and Managing Problems ▶ Anterolateral Thigh (ALT) Free Flap Recon-
struction of a Complex Chest Wall Defect
1. For distally based ALT Flap dissect as long a ▶ Anterolateral Thigh Flap for Poland’s
pedicle as possible including the perforator and Syndrome
the descending branch of the LCFA, and ▶ Microvascular Reconstruction of Soft Tissue
design a long flap skin paddle to resurface the Defects of the Scalp
tibial tuberosity. ▶ Soft-Tissue Reconstruction in Exposed Total
2. Always inspect the pedicle for kinking after Knee Arthroplasty
flap transposition and before the final flap inset.
3. If there is evidence of vascular compromise,
explore the pedicle immediately. References
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end of the LCF pedicle and add it to the flap in Belmahi A, Oufkir AA, Fejjal N. A simple way to secure
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Gravvanis A, Britto J. Venous augmentation of distally
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further incisions to the already injured area. osity in a severely injured leg. Ann Plast Surg. 2009;62:
For free flaps, recipient vessels in the area 290–5.
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and Britto 2017; Lin and Chien 2006; mius with soleus bi-muscle flap. Br J Plast Surg.
Gravvanis and Britto 2009). 2004;57:77–82.
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provided a long pedicle is dissected and the 2020;73:758–63.
Lin RY, Chien WH. Experiences in harvesting type II Umemoto Y, Adachi Y, Ebisawa K. The sural artery perfo-
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M. Quadriceps tendon reconstruction using a fascia lata Yildirim S, Avci G, Akan M, et al. Anterolateral thigh flap
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Microsurgery. 2019;39:642–6. knee. Plast Reconstr Surg. 2003;111:1630–7.
Pan SC, Yu JC, Shieh SJ, et al. Distally based anterolateral Zhang G. Reversed anterolateral thigh island flap and
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Complete Peroneal Nerve Palsy:
Functional Reconstruction 69
with Tendon Transfers
Giulia Colzani, Paolo Titolo, and Bruno Battiston
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749
Abstract
The management of complete traumatic com-

mon peroneal nerve palsy is very challenging
and functional results are highly variable.
Many surgical techniques have been described
G. Colzani (*) · P. Titolo
Department of Orthopaedics and Traumatology, Division
including neurolysis, nerve reconstructions,
of Hand Surgery and Microsurgery, CTO Hospital, nerve and tendon transfers, or combinations
University of Turin, Turin, Italy thereof. Multiple variables play a role in the
B. Battiston choice of the reconstructive technique and in
U.O.C. Traumatology, Hand Surgery, Microsurgery, A.S. determining outcomes, among these the time
O. Città della Salute e della Scienza, CTO - Hospital, elapsed from the trauma. A case of a chronic
Torino, Italy

https://doi.org/10.1007/978-3-030-23706-6_94
744 G. Colzani et al.
traumatic complete palsy of the common pero- reconstructive strategy by means of tendon trans-
neal nerve in a 35-year-old patient is presented, fers instead of a nerve repair, to enable a reliable,
in which a transfer of the tibialis posterior to safe, and fast recovery.
the tibialis anterior and of the flexor digitorum
longus to the extensor digitorum longus and
extensor hallucis longus tendons according to Preoperative Problem List:
the Vigasio’s technique was performed. At the Reconstructive Requirements
final follow-up the recovery was satisfactory,
allowing the patient to regain a good ambula- 1. Evaluation of the previous knee surgery (what
tion and to return to normal daily and work has been done; which is the result)
activities without the need for any orthosis 2. MRC scoring of the affected muscles’ strength
and aids. as well as the donor healthy muscles
3. Check of the ankle passive range of motion
(pROM) and of eventual posterior capsular or
Keywords
Achille’s tendon retraction
Traumatic common peroneal nerve palsy · 4. Radiological ankle control to exclude osteoar-
Tendon transfers · Foot drop · Nerve palsy in thritic changes
knee strain · Functional reconstruction in
peripheral nerve palsy
Treatment Plan
The Clinical Scenario A tendon transfer was proposed to the patient in

order to correct the alignment and dropping of
A 35-year-old man came to the Orthopedic and the foot. The preferred technique is the one
Traumatology Center of Turin 18 months after a described by Vigasio et al. (2008). This consists
traumatic strain to his left knee consequent to a in the transposition of the tibialis posterior ten-
motorcycle accident, showing a complete post- don through the interosseous membrane to the
traumatic common peroneal nerve palsy. proximally severed and rerouted tibialis ante-
He was initially treated elsewhere for knee rior. The tibialis anterior’s distal insertion is
instability with arthroscopic ligamentous recon- maintained but functionally moved to the base
struction. The peroneal nerve palsy was reported of the third cuneiform passing the proximally cut
from the initial injury in his medical records, but tendon through an osseous tunnel (thus creating
no surgical procedures had been performed at a pulley) in order to rebalance foot inversion.
that time. The flexor digitorum longus is also transferred
At the time of the clinical consultation, the through the interosseous membrane to the
knee appeared stable and the ankle supple thanks extensor digitorum longus and extensor hallucis
to adequate previous physiotherapy. A complete longus.
peroneal palsy was evident, with all the extensor
muscles (tibialis anterior, extensor hallucis
longus, extensor digitorum longus, and peroneus Alternative Reconstructive Options
longus and brevis) graded M0 according to the
British Medical Research Council (MRC) scor- Injury of the common peroneal nerve is a rele-
ing system. The patient showed a foot drop with vant problem in lower limb traumas. In case of
tendency to inversion and consequent gait. He severe knee sprain or dislocation, the anatomical
also did not tolerate the prescribed ankle-foot features make this nerve susceptible to trauma at
orthosis. the fibular head where it is relatively fixed.
Considering the absence of spontaneous clini- Except for partial injuries showing high expec-
cal improvement over the months and the time tations of spontaneous recovery, prognosis in
elapsed since the trauma, the choice turned on a case of complete palsy is often not favorable. In
69 Complete Peroneal Nerve Palsy: Functional Reconstruction with Tendon Transfers 745
such cases a strict patient observation and a pro- for reconstruction is within 12 months after the
mpt treatment should be planned when clinical injury.
and electrodiagnostic signs of nerve recovery are In chronic injuries several nerve transfers from
not evident within 6–8 months after presentation. tibial nerve for compensation of common pero-
At present, the choice of the most appropriate neal nerve palsy have been proposed (Emamhadi
treatment in cases of traumatic lesion of the com- et al. 2020; Giuffre et al. 2012; Leclère et al. 2015;
mon peroneal nerve is variable due to the lack of Nath et al. 2008). According to the literature opti-
univocal data in the literature, and often surgical mal results can be achieved when the interval
strategy is still entrusted to the preference and between trauma and surgical treatment is no lon-
experience of the surgeon. Several surgical ger than 12 months, and when muscle degenera-
options and techniques have been described in tion is absent. Although no comparative
the literature and performed in order to treat investigations of nerve transfers have been
common peroneal nerve palsy (Vigasio et al. reported in the literature, commonly soleus
2008; Ho et al. 2014; Kim et al. 2004; Terzis branches, flexor digitorum longus, and flexor
and Kostas 2020; Emamhadi et al. 2020; Giuffre hallucis longus are selected as donors for deep
et al. 2012; Leclère et al. 2015; Nath et al. 2008; peroneal nerve branches.
De Marchi et al. 2000; Lingaiah et al. 2018; At present, tendon transfers represent, in
Molund et al. 2014; Werner et al. 2017). They chronic drop foot caused by common peroneal
included neurolysis, nerve repair, nerve recon- nerve palsy, the most common surgical treatment.
struction by means of grafts, nerve transfers, At 12 months motor end plates in denervated
tendon transfers, and various combinations of muscle may be involved by nonreversible degen-
the abovementioned techniques. As with all eration process and attempts of nerve repair or
nerve lesions, many variables play a role in the nerve transfers are unsuccessful (Samson et al.
choice of strategy. They are represented by: the 2017), so, as in this case, tendon transfers become
time elapsed from the trauma, the type of injury the only possible reconstructive strategy. Many
(strain, contusion, partial or complete section, techniques of tendon transfer are described for
and the length of the residual neuroma), the this palsy but they generally need difficult distal
eventual previous interventions, the local condi- bone reattachment of the transferred tibialis pos-
tions (passive joint mobility, signs of arthritis, terior tendon without the possibility of regulation
skin scars, capsular or tendon retractions, and of the correct tendon tension, as it is conversely
presence of concomitant lumbar radiculo- possible with the Vigasio’s technique.
pathies), and the characteristics of the patient An ankle fusion was also excluded due to the
(age, comorbidities, compliance, work and young age of the patient and the possibility of
sport activity, and functional requests). future recovery of good walking without limping
Based on the current literature nerve explora- with an active reconstruction.
tion in open injuries is mandatory, with nerve
repair or neurolysis (if the nerve is in continuity).
Direct nerve repair is performed in sharp injuries, Preoperative Evaluation and Imaging
while reconstruction with grafts can be considered
when a nerve gap is present. This approach can An accurate assessment of the muscular strength
also be adopted in knee trauma requiring early was conducted according to the MRC scale. The
surgical repair of ligamentous lesions. Favorable tibialis anterior, extensor digitorum longus,
results with these techniques have been reported extensor hallucis longus, and peroneal tendons
by some authors in acute and early phases. None- were graded M0, while the tibialis posterior and
theless, a combination of neurolysis or nerve flexor digitorum longus M5. Ankle and toes were
repair with tendon transfers have been proposed passively fully supple. Neither posterior capsular
in order to reach a faster and reliable functional retraction nor shortening of the Achille’s tendon
recovery (Ho et al. 2014; Ferraresi et al. 2003; was evident. Electromyographic and nerve con-
Garozzo et al. 2004). In these cases, the ideal time duction study confirmed the complete peroneal
nerve palsy with conduction block at knee level. 6. A window was created in the interosseous
Radiographs of the foot and ankle did not show membrane through the medial retromalleolar
degenerative signs. incision at the distal third of the leg, wide
enough to let the tendons pass without friction.
The tibialis posterior and flexor digitorum
Preoperative Care and Patient longus were therefore transposed anteriorly,
Drawing well visible through the anterior approach and
ready to be sutured.
The patient was settled in supine position; a tour- 7. The tendon sutures were performed maintaining
niquet was placed at thigh level and inflated for the ankle dorsiflexed at 90 and the toes
the duration of the intervention to have a bloodless extended at 20 . The tibialis posterior was
operating field. Three surgical incisions were connected to the tibialis anterior tendon in end
drawn: one extended medial retromalleolar to to end with the Pulvertaft technique. The flexor
expose the tibialis posterior and flexor digitorum digitorum longus was sutured to the extensor
longus tendons up to their muscular junction, digitorum longus and extensor hallucis longus
another dorsal to ankle and dorsum of the foot in end to side. Both sutures were performed
level to expose the tibialis anterior, extensor checking a correct and balanced tension.
digitorum longus, and extensor hallucis longus
tendons, and a third, smaller one, centered on the
bony insertion of the tibialis anterior. Technical Pearls
1. If the tibialis anterior tendon is too short to be

Surgical Technique properly transposed, it is possible to remove
some of the proximal muscular tissue around it
1. The tibialis posterior and flexor digitorum to increase the free portion to be transferred.
longus tendons were identified and split from 2. The transosseous hole for the passage of the
distal to proximal up to their muscular junction tibialis anterior tendon should reach a width of
through the medial retromalleolar incision. 4–5 mm starting with a 2.5 mm drill which is
2. The tibialis anterior, extensor digitorum progressively increased. Before drilling it is
longus, and extensor hallucis longus tendons useful to place a Kirschner wire as a marker
were identified through the anterior incision. under fluoroscopy at the level of the third
3. The insertion of the tibialis anterior on the first cuneiform in order to identify the correct exit
cuneiform and the base of the first metatarsal point. The inlet and outlet holes must be wid-
bone were exposed through the small third ened and chamfered to avoid tendon lesions
medial incision. during its passage.
4. The tibialis anterior was dissected proximally 3. Ensure that the window in the interosseous mem-
and cut up to its muscular junction through the brane at the distal third of the leg is large enough
anterior approach. Then, it was extracted dis- to pass the tibialis posterior and flexor digitorum
tally through the small medial incision preserv- longus tendons without gliding problems.
ing its bony insertion. 4. The correct position to perform the sutures is
5. A 4–5 mm hole (according to tibialis anterior obtained by keeping the ankle dorsiflexed at
tendon diameter) was drilled with fluoroscopic 90 and the toes in extension of about 20 .
guidance transversally through the cuneiform The correct tension of the tendon transfers has
bones. The tibialis anterior was passed through to be checked before proceeding with the
this hole and extracted at the level of the third suture. A complete pROM of the ankle and
cuneiform, which has become therefore its new toes should be achieved checking the normal
insertion. Lastly, the tendon was passed under tenodesis effect which is present in a
the extensor retinaculum and pulled proximally. healthy limb.
5. All the tendon sutures should be resistant and After splint removal the patient starts physiother-
reliable. Experience suggests a Pulvertaft apy with no-load full range-of-motion exercises
suture with nonabsorbable 3/0 nylon thread. for 3 weeks and subsequent progressive weight
6. The tendon sutures have to be placed proxi- bearing. For all the non-weight-bearing period,
mally to the extensor retinaculum, to avoid any heparin prophylaxis is administered. Painkillers
impingement during active movements. and anti-edema drugs are prescribed as needed.
Intraoperative Images Outcome: Clinical Photos and Imaging
See Figs. 1, 2, and 3. The patient has been followed for 6 months with
periodic controls every month. He gradually
regained good ambulation without limping and
Postoperative Management with a good foot positioning during walking with-
out the need of orthosis. Active dorsiflexion of the
A below-knee splint keeping the ankle at 90 and ankle has been maintained at 90 and the toes at
supporting the toes has to be maintained for 0 . Pain was well controlled from the beginning
one month, and weight bearing is not allowed. with progressive disappearance. The patient
Fig. 1 Tibialis anterior and

posterior suture
Fig. 2 Tendon sutures

completed
Fig. 3 Position of ankle

and toes after performing all
the sutures
Fig. 4 Postoperative ankle

and toes extension
Fig. 5 Postoperative ankle

and toes flexion
resumed his previous daily life activities and job, References

with minimal residual functional limitation during
brisk walk or run. The rerouting of the tibialis De Marchi F, Malerba F, Montrasio Alfieri U, et al. Tibialis
posterior tendon transfer through the interosseal mem-
anterior is a safe and well-established procedure
brane in paralysis of the common peroneal nerve. Foot
that has shown no long-term effect of tendon Ankle Surg. 2000;6:19–25.
blood supply (Figs. 4 and 5). Emamhadi M, Naseri A, Aghaei I, et al. Soleus nerve
transfer to deep peroneal nerve for treatment of foot
drop. J Clin Neurosci. 2020;78:159–63.
Ferraresi S, Garozzo D, Buffatti P. Common peroneal
Avoiding and Managing Problems nerve injuries: results with one-stage nerve repair and
tendon transfer. Neurosurg Rev. 2003;26(3):175–9.
Garozzo D, Ferraresi S, Buffatti P. Surgical treatment of
1. Preoperative assessment: evaluate joint common peroneal nerve injuries: indications and results.
pROM; verify the absence of posterior capsule A series of 62 cases. J Neurosurg Sci. 2004;48:105–12.
and Achille’s tendon retraction; and confirm Giuffre JL, Bishop AT, Spinner RJ, et al. Partial tibial nerve
transfer to the tibialis anterior motor branch to treat
the absence of radiological signs of arthritis
peroneal nerve injury after knee trauma. Clin Orthop
and the absence of clinical and electromyo- Relat Res. 2012;470:779–90.
graphic motor recovery at least 1 year from Ho B, Khan Z, Switaj PJ, et al. Treatment of peroneal nerve
the injury injuries with simultaneous tendon transfer and nerve
exploration. J Orthop Surg Res. 2014;9:67.
2. Intraoperative management: identification and
Kim DH, Murovic JA, Tiel RL, et al. Management and
protection of neurovascular bundles; release of outcomes in 318 operative common peroneal nerve
adequate tendon length for the transfers; main- lesions at the Louisiana State University Health Sci-
tenance of the correct position of the foot and ence Center. Neurosurgery. 2004;54(6):1241–428.
Leclère FM, Badur N, Mathys L, et al. Nerve transfers for
ankle during tendon suture; verify the adequate
persistent traumatic peroneal nerve palsy: the
tension of the sutures at the end of the proce- Inselspital Bern experience. Neurosurgery.
dure; and provide an adequate hemostasis after 2015;77(4):572–9.
release of the tourniquet in order to prevent Lingaiah P, Jaykumar K, Sural S, et al. Functional evalua-
tion of early tendon transfer for foot drop. J Orthop
postoperative hematomas with following fibro-
Surg (Hong Kong). 2018;26(3):1–7.
sis and adhesions Molund M, Engebretsen L, Hvaal K, et al. Posterior tibial
3. Postoperative management: ensure appropriate tendon transfer improves function for foot drop after
immobilization followed by a personalized knee dislocation. Clin Orthop Relat Res. 2014;472(9):
2637–43.
physiotherapic protocol and full compliance
Nath RK, Lyons AB, Paizi M. Successful management of
and strict cooperation by the patient are foot drop by nerve transfers to the deep peroneal nerve.
required for optimal results J Reconstr Microsurg. 2008;24(6):419–27.
Samson D, Ng CY, Power D. An evidence-based algorithm
for the management of common peroneal nerve injury
associated with traumatic knee dislocation. EFORT
Open Rev. 2017;1(10):362–7.
Learning Points Terzis JK, Kostas I. Outcomes with microsurgery of com-
mon peroneal nerve lesions. J Plast Reconstr Aesthet
In young patients with chronic common peroneal Surg. 2020;73(1):72–80.
nerve palsy without degenerative arthritic signs Vigasio A, Marcoccio I, Patelli A, et al. New tendon transfer
for correction of drop-foot in common peroneal nerve
and preserved good passive joint mobility, tendon palsy. Clin Orthop Relat Res. 2008;466(6):1454–66.
transfers remain the most appropriate solutions. Werner BC, Norte GE, Hadeed MM, et al. Peroneal nerve
The technique described in this work represents dysfunction due to multiligament knee injury: patient
our first choice, having proved to be reliable and characteristics and comparative outcomes after poste-
rior tibial tendon transfer. Clin J Sport Med.
safe even in the long term. 2017;27(1):10–9.
Tibial Bone Defect Reconstruction
with Ilizarov and Free Flap 70
Vasileios D. Polyzois, Dimitrios F. Georgiou,
Aristeidis K. Koutsopoulos, and Dimitrios V. Polyzois
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 752
Alternative Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 752
Preoperative Medical Status, Evaluation, and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Treatment Strategy and Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Stage I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Stage II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 759
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760
Abstract old Caucasian male who sustained a high-

Infected distal tibial bone defects associated energy Gustillo Anderson IIIB/Tscherne
with compromised soft tissue envelope are Grade III injury of his right tibia in association
critical and frequently call for therapeutic with initial 4 cm of bone loss. Following his
amputation. We present the case of a 52-year- primary management (combined orthoplastic
procedures where performed) in another hos-
pital, he was referred to our center. Upon his
admission, the diagnosis of severe osteomyeli-
tis was established, and further osseous
V. D. Polyzois (*) · D. F. Georgiou · A. K. Koutsopoulos · debridement proved the only way to deal with
D. V. Polyzois
4th Department of Orthopaedics & Traumatology, KAT deep infection. This resulted in a total of 9.5 cm
General Hospital, Athens, Greece of distal tibial bone loss with resection of the

https://doi.org/10.1007/978-3-030-23706-6_95
752 V. D. Polyzois et al.
septic ankle joint. Latissimus dorsi free flap Treatment Plan

was transferred to provide coverage and ade-
quate blood supply to the injury site. Ilizarov The extensive distal tibial bone and soft tissue
bone transport technique was later applied, loss-associated septic complication require
following a proximal tibial corticotomy. Due aggressive debridement. This should be followed
to debridement of the obviously septic tibial by soft tissue transfer, thus cover the wound and
plafond, a distraction tibiotalar arthrodesis provide local blood supply for infection control as
became a necessity. This took place as soon well as to stabilize the soft tissue envelope. This
as the distally transported tibial shaft reached was the first (damage control) stage of treatment
the talar docking site. No autograft procedure after referral of the patient to our center. After a
of the docking site was performed. The patient period necessary for the wound to heal and control
was encouraged to go full weight bearing after infection, the second stage of reconstruction
a month from the initiation of this treatment, followed. A combined tibial bone transport was
stayed “in-frame” for 10 months, and returned performed, together with fusion of the ankle joint
to previous activities 2 months after removal of with replacement of the previous unilateral tibial
the external fixator. This combined ortho- fixator by an Ilizarov frame.
plastic approach resulted in a functional lower
extremity.
Alternative Treatment Options
Keywords
1. Therapeutic amputation/osseointegrated per-
Distal tibial bone defect · Ilizarov technique · cutaneous implants (Tsikandylakis et al. 2014)
Bone transport · Latissimus dorsi free flap · 2. Masquelet technique with free flap coverage
Tibiotalar arthrodesis (Masquelet et al. 2000; Giannoudis et al. 2011)
3. Ilizarov bone transport technique along with
soft tissue transport and grafting of the
The Clinical Scenario docking/arthrodesis site in a Papineau fashion
technique (Karargyris et al. 2014; Polyzois
A previously healthy 52-year-old Caucasian male et al. 2010, 2011)
sustained a Gustillo Anderson IIIB/Tscherne Grade 4. Ilizarov bone transport technique along with
III injury of his right distal tibia following a motor- soft tissue transport and flap surgery after the
cycle accident. The injury was consisted of a com- transport’s docking when the soft tissue gap is
plex distal third tibial shaft fracture associated with minimal (Polyzois et al. 2010)
bone loss, large soft tissue defect of the medial 5. Vascularized fibular flap plus free flap cover-
aspect of the tibia, and gross contamination. age, with the disadvantage of reduced mechan-
ical characteristics and danger of refractures.
Addressable possibly in rare pediatric cases
Reconstructive Requirements (Yajima et al. 1993; Medda et al. 2021)
6. Bilateral vascularized fibula graft (Miyamoto
1. A contaminated Gustillo Anderson IIIB/ et al. 2016) with increased morbidity of the
Tscherne Grade III fracture of the right distal donor sites and prolonged operating time
tibia with 4 cm bone loss was presented. Fol- 7. Titanium mesh cage and cancellous autograft
lowing thorough debridement, 9.5 cm of tibial alone or in combination with cancellous allo-
bone defect was detected. grafts plus free flap coverage, with the disad-
2. Large soft tissue defect of the medial and ante- vantage of intolerance in infected conditions
rior aspect of the right distal tibia and higher cost (Ostermann et al. 2002)
3. Osteomyelitis of the right distal tibia and septic 8. Multistage treatment protocol with extensive
arthritis of the right ankle joint initial bone and soft tissue debridement,
70 Tibial Bone Defect Reconstruction with Ilizarov and Free Flap 753
spanning external fixation, free flap coverage, and soft tissue were recorded. Therefore, exten-
and final stage autografting and tibiotalo- sive osseous debridement was necessary along
calcaneal fusion with intramedullary nailing, with further skin and underlying tissues debride-
with possible intolerance due to prior infection ment. This resulted in a total of 9.5 cm of distal
once again (Asomugha et al. 2016) tibial bone defect which included the plafond as
well (Fig. 3). The tibial stump was debrided in a
cone shape while the talar bed in a cup shape to
Preoperative Medical Status, assist in bone healing at the docking site during
Evaluation, and Imaging the next stage of treatment. The initial delta frame
was revised to a lateral unilateral external fixator
Initial management took place in another institu- to allow for attachment of the flap on the donor
tion, whereas he had three surgical procedures. site (Fig. 4). At the same time, the right decubitus
position was chosen with the extremities in a
1. On the day of injury, Doppler ultrasonography figure of four fashion. Plastic surgeons went
was used preoperatively in the emergency room ahead with two-team approach; the one team
to assess the main vessels. The blood flow was harvested left latissimus dorsi free flap, while the
documented as adequate. Under general anes- other prepared the recipient area and vessels.
thesia, he undergone washout debridement and Although LD flap may be associated with variable
application of a Delta frame bridging the prox- morbidity, it was considered a good choice due to
imal tibia and the hind foot (Fig. 1). Formerly, a the large dimensions and 3D geometry of the
4 cm distal tibia bone loss was reported (Fig. 2). wound. While perforator flaps (e.g., ALT flap)
The surgical team attempted to close the wound can bring stability and combat infection with min-
with limb shortening and tension sutures. Fixing imal donor site morbidity, LD flap is more versa-
the extremity in marked shortening reduced the tile for three-dimensional infected wounds. The
overlying soft tissue defect. Negative pressure right posterior tibial artery was dissected to pre-
wound VAC was applied too. Digital subtrac- pare for the end-to-side anastomosis regardless of
tion angiography was performed after damage the fact that all three main vessels of the extremity
control surgery to assess the extremity’s vascu- were found intact. This type of anastomosis pre-
larity which was proved not to be compromised serves distal perfusion while there is no change in
with all three main vessels intact. overall flap success when compared to end-to-end
2. About 2 weeks later, despite the antimicrobial anastomosis. The selection of posterior tibial ves-
treatment, the surgical team decided to go for sels as recipient is critical and was based:
repeat washout and debridement and implantation
of antibiotic impregnated beads due to clinical • Normal posterior tibial arterial flow and
and laboratory signs of ongoing deep infection. venous outflow based on ultrasound
3. A third attempt of debridement took place with parameters
the removal of the beads when the treating • Facilitates flap orientation for adequate wound
physicians faced a worryingly smelly local coverage
condition of the wound. • Tension-free anastomosis outside the zone of
injury and good coverage of vessels at the
Treatment Strategy and Surgical anastomotic site (mandatory to inset the prox-
Technique imal part of the flap above the vessels to avoid
compression)
Stage I
The flap was resurfaced with a split thickness
Thereafter, the patient was referred to our institu- skin graft, and standard protocol for lower limb
tion for further treatment. Upon his admission, anticoagulant therapy and flap monitoring was
clinical ankle septic arthritis, devitalized bone, applied.
Fig. 1 Delta type external fixation for damage control by the time of admission
Stage II
A waiting period of 30 days was followed to allow
The patient was postoperatively closely monitored
for settling of the flap and confirmation of the
by physical examination and handheld Doppler for
efficacy of the appropriate antimicrobial therapy
the first 7 days (flap checks every half an hour the
(Fig. 5).
day of the operation, every hour day 1 post op,
every 2 h day 2 post op, every 3 h day 3, and every We proceeded with the next stage of our
4 h day 4–7 post op). Anticoagulant regimen reconstruction that comprised application of an
included low molecular heparin and oral aspirin. Ilizarov frame and bone transport only after clin-
The limb was kept elevated, avoiding pressure at ical and laboratory confirmation of infection
the site of anastomosis and the flap area. The drain subsidence.
was removed from the donor area at day 11 when A typical Ilizarov bone transport frame was
drainage was less than 30 ml per day. Flap training applied (Fig. 6). The Ilizarov barrel consisted of
(patient in the standing position gradually for few two rings: one below the knee joint and proximal
minutes) started at day 7 to confirm the adequate to the corticotomy site and one on the tibial shaft
venous outflow. Recovery was uneventful and the slightly proximal to its mid-portion. The third
patient was discharged on day 11 post op. fixation level was in the hind foot and was
Fig. 2 Radiographs following initial treatment and initial spanning external fixation demonstrating a defect of approx-
imately 4 cm. The extremity was fixed in marked shortening to assist partial initial coverage of the wound
achieved by means of a footplate. Smooth unilateral tibiotalar arthrodesis and provides a

1.8 mm wires were used to fix the tibia in the closer to normal gait pattern.
center of the Ilizarov barrel while multiple
hydroxyapatite-coated half pins were utilized to
augment the fixation on the bone. Adequate Postoperative Management
space between the Ilizarov frame and the free
flap was provided. Close monitoring of the flap’s viability along with
Special attention was given to assure the accu- the extremity’s condition in total is of critical
rate driving-orientation of the transported tibial importance. The Ilizarov bone transport proce-
segment on the docking talar bed. A total of dure might overstress the flap and its vascular
9 cm of distraction gap at the proximal supply/drainage throughout the process. After
corticotomy site was obvious after about about another 100 days “in frame,” the docking/
100 days “in frame” (Fig. 7), that is, about arthrodesis site showed solid fusion radiographi-
90 days with the standard 1 mm distraction cally (Fig. 8). Clinical testing of the fusion site by
rhythm per day plus the initial 10-day latency removing the interconnecting threaded rods
following the proximal corticotomy. We decided between the distal tibial ring and the footplate
to leave the affected extremity 0.5 cm shorter. This verified the fusion’s adequate mechanical
slight length discrepancy is beneficial in cases of strength. The patient was encouraged to walk
Fig. 3 Resection of the devitalized and septic right distal tibia, together with the proximal articular surface of the talus
due to severe septic arthritis of the right ankle joint
Fig. 4 Replacement of the

initial delta frame.
Attachment of a lateral
unilateral spanning external
fixation to assist free flap
surgery with latissimus
dorsi and split thickness
skin graft
Fig. 5 Settling of the flap prior to the Ilizarov bone transport procedure
Fig. 6 Use of Ilizarov bone transport technique, demonstrating the 9,5 cm bone loss after ankle joint and tibial
debridement/resection and the proximal corticotomy
Fig. 7 The transported tibial segment ready to engage the talar docking site. 9 cm of “internal lengthening”
Fig. 8 200 days after referral, good healing of the docking/arthrodesis site, good bone formation at the proximal
distraction site
or larger bone and soft tissue defects resulting

from trauma, infection, or even tumors can be
addressed with the Ilizarov external fixator and
technique alone, or in combination with tradi-
tional flap surgery or advanced plastic micro-
surgical techniques.
2. Ilizarov’s technique is based on the distraction
histogenesis phenomenon, which is character-
ized by the nature’s ability to heal a fracture in
diastasis and the ability to elongate skin,
nerves, muscles, and vessels under gradual
distraction.
3. This technique involves application in simple
cases where extremity inequality needs to be
addressed. A low-energy corticotomy (iatro-
genic fracture) is performed in specific zones
of a tubular long bone after an external fixation
device is attached on the extremity. After an
initial latency period of about a week, the two
segments are being separated with a rhythm of
1 mm per day. New bone formation will take
Fig. 9 Final outcome. The patient able to go full weight place in the gap, by intramembranous
bearing 10 months after referral of his case
ossification.
4. It will take something between one and two
full weight bearing at this time with the assistance months per centimeter for the regenerate bone
of crutches. to fully consolidate.
5. Concerning alternative soft tissue reconstruc-
tion, the ALT flap is certainly a reasonable
Outcome: Clinical Photos and Imaging alternative. A vastus lateralis free muscle flap
could also be an alternative but could add an
Gradual consolidation of the regenerate bone additional functional deficit to the patient’s
proximally was documented with plain radio- already disturbed gait. A medial sural perfora-
graphs during the final stage of the treatment and tor flap or a propeller flap offers no option for
prior to frame removal (Fig. 8). Stress test of the large defects of this size. The SCIP flap with its
regenerate bone took place at about another short pedicle that is not preferred and the DIEP
100 days by removal of the proximal flap with its thick subcutaneous fat layer that
interconnecting threaded rods. After this 10-day does not facilitate insetting of the flap are also
dynamization period, the frame was definitively no viable options for large defects in the spe-
removed. The patient was encouraged to gradu- cific anatomic region.
ally return to daily activities with the use of a cane
for the first 2 months “out of frame” (Fig. 9).
Learning Points 1. This simple principle of bone lengthening can

be applied in the scenario of an isolated long
1. The Ilizarov technique has proven its efficacy bone defect with adequate soft tissue coverage
over the last decades in the management of of even where both bone and soft tissue loss
concomitant bone and soft tissue loss. Smaller coexist. In such cases, we pretty much go for
transportation of a bone segment rather than References

lengthening of the bone. The transported bone
segment will fill the bone void by taking its Asomugha EU, Den Hartog BD, Junko JT, Alexander
IJ. Tibiotalocalcaneal fusion for severe deformity and
place while forming regenerate bone in its
bone loss. J Am Acad Orthop Surg. 2016;24(3):125–34.
trailing end. In its leading end, it will reach Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou
the predetermined docking site, where healthy R. Masquelet technique for the treatment of bone
bone, able to provide union, exists. defects: tips-tricks and future directions. Injury.
2011;42(6):591–8. https://doi.org/10.1016/j.injury.
2. Ilizarov himself came up with tips and tricks to
2011.03.036. Epub 2011 May 4.
facilitate transport of the surrounding soft tis- Karargyris O, Polyzois VD, Karabinas P, Mavrogenis AF,
sues of the transported bone segment, to min- Pneumaticos SG. Papineau debridement, Ilizarov bone
imize the surface of the missing soft tissues. In transport, and negative-pressure wound closure for sep-
tic bone defects of the tibia. Eur J Orthop Surg
the following years, different strategies were
Traumatol. 2014;24(6):1013–7. https://doi.org/10.
applied, tested, and underwent comparison. 1007/s00590-013-1279-x. Epub 2013 Jul 18.
3. Of particular interest is the testing of the con- Masquelet AC, Fitoussi F, Begue T, Muller
cept of primary closure of the soft tissue gap by GP. Reconstruction of the long bones by the induced
membrane and spongy autograft. Chir Plast Esthet.
free flap surgery and use of the traditional
2000;45(3):346–53.
Ilizarov method for the management of bone Medda S, King MA, Runyan CM, Frino J. Vascularized
loss. On the other hand, we have the option of pedicled fibula for pediatric tibia reconstruction.
using Ilizarov bone transport and leaving the J Orthop Trauma. 2021;35(Suppl 2):S48–9.
Miyamoto S, Fujiki M, Setsu N, Kawai A. Simultaneous
soft tissue gap to be dealt subsequently/sec-
reconstruction off the bone and vessels for complex
ondarily by free flap as soon as the transported femoral defect. World J Surg Oncol. 2016;14(1):291.
segment reaches its docking site. https://doi.org/10.1186/s12957-016-1037-8.
4. Supporters of the first strategy mainly insist on Ostermann PAW, Haase N, Rubberdt A, Wich M,
Ekkernkamp A. Management of a long segmental
the beneficial coverage and improved vascu-
defect at the proximal meta-diaphyseal junction of the
larity of the injured extremity that the free flap tibia using a cylindrical titanium mesh cage. J Orthop
is providing. On the other hand, surgeons that Trauma. 2002;16(8):597–601.
favor the late closure present as their main Polyzois VD, Galanakos S, Zgonis T, Papakostas I,
Macheras G. Combined distraction osteogenesis and
argument the fact that the soft tissue gap is
Papineau technique for an open fracture management
significantly smaller or diminished after the of the distal lower extremity. Clin Podiatr Med Surg.
transport technique. Literature justifies both 2010;27(3):463–7. https://doi.org/10.1016/j.cpm.
strategies in the management of infection. In 2010.03.004.
Polyzois VD, Galanakos SP, Tsiampa VA, Papakostas ID,
the first case, muscle coverage, vascularity, and
Kouris NK, Avram AM, Papalois AE, Ignatiadis
subsequently more efficient antibiotic therapy IA. The use of Papineau technique for the treatment
are the main argument while the fact that an of diabetic and non-diabetic lower extremity pseudo-
open wound after meticulous and continuous arthrosis and chronic osteomyelitis. Diabet Foot Ankle.
2011;2. https://doi.org/10.3402/dfa.v2i0.5920.
debridement is the key to burn infection is the
Tsikandylakis G, Berlin Ö, Brånemark R. Implant survival,
main argument in the second case. adverse events, and bone remodeling of osseointegra-
tedpercutaneous implants for transhumeral amputees.
Clin Orthop Relat Res. 2014;472(10):2947–56. https://
Cross-References doi.org/10.1007/s11999-014-3695-6.
Yajima H, Tamai S, Mizumoto S, Inada Y. Vascularized
fibular grafts in the treatment of osteomyelitis and
▶ Femur Reconstruction with a Modified infected nonunion. Clin Orthop Relat Res. 1993;293:
Masquelet Technique 256–64.
Reconstruction of Plantar Heel Defect
71
Mohin A. Bhadkamkar and William C. Pederson
Contents
Preoperative Problems/Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 762
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 762
Outcome and Clinical Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 766
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
Abstract
This chapter describes the management of a

34-year-old female with recurrent breakdown
of her left heel. She has a history of
M. A. Bhadkamkar myelomeningocele which was closed at birth.
Baylor College of Medicine, Houston, TX, USA She is in fact continent and can walk with
e-mail: bhadkamk@bcm.edu minimal assistance. She is otherwise a healthy
W. C. Pederson (*) individual. The left heel developed an ulcer
Baylor College of Medicine, Houston, TX, USA approximately 5 years ago and has had several
Texas Children’s Hospital, Houston, TX, USA attempts at bone debridement and closure with
e-mail: micro1@ix.netcom.com; local tissue without success. When she
wcpeders@texaschildrens.org

https://doi.org/10.1007/978-3-030-23706-6_97
762 M. A. Bhadkamkar and W. C. Pederson
presented, she had a chronic wound on the left Preoperative Problems/Reconstructive

heel and protective sensation. There was Requirements
chronic hyperkeratotic tissue around the
wound and exposed granulating bone in the 1. Adequate debridement of surrounding scarred
base. Imaging did not show strong evidence and hyperkeratotic tissues.
of osteomyelitis of the calcaneus. The options 2. Management of bone – biopsy to rule out oste-
for reconstruction included local flaps versus omyelitis and adequate resection to obviate
microsurgical free-tissue transfer. These were future breakdown.
discussed with the patient, and it was felt best 3. Soft tissue-coverage of heel – The heel wound
to perform a medial plantar artery flap. This is too large for primary closure and requires
chapter describes the thought processes healthy tissue for coverage.
involved in this decision and how this wound 4. Stable flap for coverage – The patient needs to
was successfully managed with this flap. be able to ambulate and bear weight on the
heel, and the flap needs to be stable and not
Keywords shear with walking.
5. Contoured coverage: Coverage needs to be
Foot reconstruction · Heel reconstruction ·
well contoured to the foot so as to enable the
Medial plantar artery flap
patient to wear shoes and not disrupt the
patient’s natural ambulation biomechanics.
6. Protective sensation – As a weight-bearing
Clinical Scenario
surface, every effort should be made to recon-
struct the defect with sensation. Without pro-
Thirty-four-year-old female with a history of
tective sensation, the patient will be at a high
myelomeningocele presented with a heel wound
risk for future injury and possible failure of the
with exposed bone. She had experienced chronic
reconstruction.
breakdown of the wound over many years, having
previously failed three attempts at debridement
and closure. The patient had abnormal but protec-
Treatment Plan
tive sensation of her foot at the time of presenta-
tion (Fig. 1).
Given the patient’s reconstructive needs and prior
history, reconstruction was planned with a medial
plantar artery flap (Crowe et al. 2019; Shanahan
and Gingrass 1979). This particular flap was cho-
sen due to its ability to provide glabrous, sensate
tissue for the heel defect. The tissue is of similar
quality to the native heel tissue, delivering sensa-
tion and resistance to sheer forces (Scaglioni et al.
2018). In designing the flap, it is kept off the
weight-bearing surfaces of the metatarsal heads
and lateral foot. If this is adhered to, the donor site
can be skin-grafted and does not result in any
functional deficits of ambulation. Furthermore,
the medial plantar artery flap avoids free tissue
transfer and its associated challenges, as well as
any morbidity associated with a distant donor site.
Prior to definitive coverage, the wound should be
Fig. 1 View of left heel of patient with chronic wound, thoroughly debrided to nonscarred healthy tissue.
note hyperkeratotic changes around margins The bone must be biopsied to rule out
71 Reconstruction of Plantar Heel Defect 763
osteomyelitis, but debridement back to bleeding

cancellous bone is usually adequate. In the face of
bone which is very soft and not bleeding, the soft
tissue reconstruction should be delayed until
biopsy results are back. Broad-spectrum antibi-
otics should be given at the time of surgery, but
after bone biopsy is performed.
1. Reverse sural artery flap (Mahmoud 2017) Fig. 2 Sural artery flap after delay prior to placing on
(Fig. 2): posterior heel wound in a diabetic
(a) Not always reliable
(b) Usually a two-staged procedure
(c) Insensate
(d) Unstable
2. Free-muscle flap with skin graft (Crowe et al.
2019; Cho et al. 2018):
(a) Involves microsurgery, more difficult
(b) Risk of flap loss
(c) Insensate
(d) Unstable
(e) Has a tendency to break down over time
(Fig. 3)
3. Free fasciocutaneous flap (Sönmez et al. 2003)
(Fig. 4):
(a) Involves microsurgery
(b) Potential for flap loss
(c) Usually insensate Fig. 3 Patient 2 years after latissimus dorsi muscle flap
(d) Unstable in most cases and skin graft to heel defect. Note breakdown of skin over
weight-bearing surface
The patient undergoes a thorough examination of

the foot including palpation of the pulses and
Doppler examination to ascertain the quality of
blood flow. If the pulses are not palpable in the
posterior tibial artery and dorsalis pedis, vascular
imaging should be obtained. The type will depend
on the patient’s institution and it’s capabilities, but
presently CT angiography is usually preferred for
this. Plain films of the foot are obtained looking at
how much bone has been resected and for signs of
osteomyelitis. If there is any question about the
presence of bone infection, an MRI scan is essen- Fig. 4 Radial forearm fasciocutaneous free flap to plantar
tial. The bone may light up on the MRI due to foot
inflammation; however, the gold standard for the

diagnosis of osteomyelitis remains bone biopsy
and quantitative cultures. This scan can be useful
as a baseline, however, to use for comparison if
later scans are taken.
It is usually best to Doppler the medial plantar
artery in the plantar foot to evaluate its quality, as
well as flow in the first webspace with occlusion
of the posterior tibial artery. This gives an idea of
the quality of circulation in the dorsal system.
Fig. 5 Design of medial plantar artery flap in the arch of

Preoperative Care and Patient the foot, and the note flap does not cross any weight-
Drawing bearing area
The patient is placed supine, and a roll may be

placed under the contralateral hip to rotate the foot
outward. A tourniquet is placed on the thigh and
utilized for raising the flap. The foot and leg are
best fully exsanguinated to avoid venous oozing.
The flap is designed in the arch of the foot, cen-
tered over the area between the flexor hallucis
longus (FHL) and flexor digitorum longus (FDL)
to the second toe, along the axis of the medial
plantar artery (Fig. 5).
Surgical Technique
Fig. 6 Foot after wide debridement of skin, subcutaneous
1. The location of the medial plantar artery per- tissue, and bone. Flap has had skin incised as drawn in this
forator is identified using a Doppler and patient
marked. It generally arises approximately a
third of the way between the sustentaculum of
the calcaneus and the first metatarsophalangeal digital artery and lifted with the plantar fascia
joint, and courses toward the skin, between the and skin (see Fig. 6).
abductor hallucis and flexor brevis muscles. 3. The pedicle is then dissected toward its origin
The flap is designed on the same axis between as the medial plantar artery in the
the FHL and FDL to the second toe (see Fig. 5). intermuscular space. A pedicle length of up to
2. The flap is raised starting at the distal plantar 3–4 cm can usually be obtained. The lateral
aspect, and the skin and plantar fascia are first and medial aspects of the plantar fascia are
incised at the drawn distal edge of the flap. The divided and elevated with the skin toward the
plantar fascia must be harvested with the flap tarsal tunnel. There will be several sensory
as the perforators course through this structure. branches coming off the digital nerve which
The medial plantar artery is usually quite small should be preserved, if at all possible, to
and is identified in the space between the FHL improve the sensation of the flap. The more
and FDL tendons running with the common distal branches of the nerve will have to be
digital nerve to the first webspace. Once this is sacrificed, but the more proximal ones can be
identified, it is carefully dissected free from the saved and will innervate the skin (see Fig. 7).
Fig. 7 Flap being raised. Arrow points to sensory nerve in Fig. 8 Foot after incision of a trough for passage of the
pedicle of flap. Note other digital nerves to toes preserved pedicle and rotation of the flap into the defect
in the background
4. As the abductor hallucis is reached, the pedicle. The donor site is covered with a
neurovascular pedicle will go under this into splint-thickness skin graft of about 15/100000
the tarsal tunnel. The muscle usually needs to thick, which should be meshed without
be divided, and there will be a number of small expanding the mesh, as this follows the uneven
branches of the pedicle going into the muscle. contours of the muscles better. It must be
These must be carefully identified and divided dressed with a bolster, or a wound vacuum
between fine vascular clips while preserving device can be used as the graft is in a concave
the main pedicle coming off the posterior tibial surface. Poor take of the graft must be avoided
artery. at all costs to prevent a donor site problem
5. At the level of the edge of the abductor which may be as troublesome to the patient as
hallucis, the sensory nerves usually require the original heel wound. It is preferable to
intraneural dissection to preserve those going leave the bolster in place for 3 weeks without
to the flap. This should be done carefully with disturbing it to assure the best graft take
strong loupe magnification and microsurgical (Fig. 9).
instruments to avoid damaging these nerves
and rendering the flap insensate.
6. It is not possible to take this flap through a Technical Pearls
tunnel due to the septations in the plantar
skin, thus an incision is made from the pivot 1. The medial plantar artery flap should be
point of the pedicle to the heel wound, and designed so that the donor site avoids any
these skin edges are elevated a bit to allow weight-bearing area of the foot.
passage of the flap pedicle without tension 2. The medial plantar artery should be identified
once the skin is closed (see Fig. 8). at the distal margin of the flap first, between the
7. The tourniquet is let down, and the flap is FHL and FDL tendons running with the com-
placed in a warm moist sponge. The flap is mon digital nerve to the first webspace.
often pale in the beginning, but after 5– 3. The flap is elevated with the plantar fascia
10 min, it will pink up assuming the pedicle which must be divided distally and proximally.
hasn’t been damaged. The wounds are irrigated 4. The nerves innervating the flap come off the
and hemostasis is obtained. The flap is sutured medial plantar nerve proximally, not distally.
in place loosely and the tunnel for the pedicle In order to preserve the sensory innervation to
closed carefully to avoid pressure on the the flap, an intraneural dissection of these
Fig. 10 Patient about 3 months postop

Fig. 9 Patient after inset of flap and split-thickness skin
graft to donor site. There is a bolster of petroleum gauze
and cotton balls tied down over the graft
graft. After 3 weeks, the splint is removed and
the bolster (or vacuum wound device) removed
from the donor site. The foot is wrapped with a
nerves from the posterior tibial nerve in the compression bandage or compression socks, and
tarsal tunnel is usually necessary. ambulation is gradually instituted over the next
5. The donor site must be managed carefully, as 3 weeks. Full weight bearing is allowed only after
failure of take of the skin graft can lead to a a total of 6 weeks. At this point, healing of both
chronic wound of the plantar foot – but if the the flap and donor site is usually completed
graft takes, the donor site is usually very well enough to allow the shear forces of ambulation.
tolerated.
Outcome and Clinical Photos

This patient did very well and returned to full weight
See Figs. 6, 7, 8, and 9. bearing in about 6 weeks. At 3-year follow-up, she
had stable coverage with no further breakdown and
no further evidence of osteomyelitis. As she does not
Postoperative Management have full sensation due to the myelomeningocele,
she examines her foot daily to make sure there are
The patient’s foot is kept elevated to minimize no areas of breakdown (Figs. 10 and 11).
edema. Broad-spectrum antibiotics are given for
5–7 days. If there is a suspicion of osteomyelitis in
the calcaneus, guidelines from the infectious dis- Avoiding and Managing Problems
ease specialists should be followed, but in general,
once the wound is debrided and vascularized, soft Two primary issues arise with the medial plantar
tissue coverage is provided and oral or IV antibi- artery flap, potential loss of the flap, and poor
otics are maintained for 6–8 weeks. Ambulation is healing at the donor site. The course of the medial
allowed once all eschar is gone from the incision plantar artery should be marked with the Doppler
and the skin grafted donor site has healed prior to raising this flap. If this cannot be heard, an
completely. It is best not to “dangle” patients alternative for coverage of the wound should be
after this procedure, but rather keep the foot up chosen. In order to identify this vessel, which
for a total of 3 weeks in the elevated position. This distally can be quite small, the common digital
affords the best chance for healing of the skin nerve to the first webspace is identified and the
Fig. 11 Patient’s foot at 3 years postop

Fig. 13 View of patient’s foot 4 weeks s/p medial plantar
artery flap. Patient removed bolster and walked on foot
causing loss of most of the skin graft and dehiscence of the
posterior margin of the flap
graft fails, the wound must be carefully debrided

and regrafted, again with a 3-week period of eleva-
tion and support of the graft (Fig. 13).
Learning Points
1. Plantar heel wounds are best reconstructed

with like tissue, and the medial plantar artery
flap provides ideal tissue for this.
2. Other regional and free flaps are options but are
Fig. 12 Flap mid-way through dissection, digital nerves
prone to breakdown under the forces on the
are left in place, note clip on distal end of medial plantar
artery (arrow) heel with ambulation.
3. Meticulous care of the donor site is required to
maximize healing of the required skin graft.
vessel will be running either directly with this
vessel or very close to it. The nerve is left down,
and the vessel is harvested with the skin and the References
plantar fascia back to where it comes off the
posterior tibial artery under the abductor hallucis Cho EH, et al. Muscle versus fasciocutaneous free flaps in
(Fig. 12). lower extremity traumatic reconstruction: a multicenter
Poor take of the skin graft on the donor site is outcomes analysis. Plast Reconstr Surg. United States.
2018;141(1):191–9. https://doi.org/10.1097/
the worst potential problem with this flap. Overall, PRS.0000000000003927.
the best type of graft is a meshed but not expanded Crowe CS, et al. Strategies for reconstruction of the plantar
split-thickness graft. This is held down with a tie- surface of the foot: a systematic review of the literature.
on bolster or vacuum wound-care device. The foot Plast Reconstr Surg. 2019;143(4):1223–44. https://doi.
org/10.1097/PRS.0000000000005448.
must be elevated for 3 weeks postop, and in gen- Mahmoud WH. Foot and ankle reconstruction using the
eral, one should not remove the bolster for this time distally based sural artery flap versus the medial plantar
period. This usually leads to good graft take. If the flap: a comparative study. J Foot Ankle Surg. United
States. 2017;56(3):514–8. https://doi.org/10.1053/j. Shanahan RE, Gingrass RP. Medial plantar sensory flap for
jfas.2017.01.019. coverage of heel defects. Plast Reconstr Surg. 1979;64
Scaglioni MF, Rittirsch D, Giovanoli P. Reconstruction of (3):295–8. PMID: 382204. https://doi.org/10.1097/
the heel, middle foot sole, and plantar forefoot with the 00006534-197909000-00001.
medial plantar artery perforator flap: clinical experience Sönmez A, et al. Reconstruction of the weight-bearing
with 28 cases. Plast Reconstr Surg. United States. surface of the foot with nonneurosensory free flaps.
2018;141(1):200–8. https://doi.org/10.1097/ Plast Reconstr Surg. 2003;111(7):2230–6. https://doi.
PRS.0000000000003975. org/10.1097/01.PRS.0000062564.35426.07.
Plantar Weight-Bearing Area Defects
Reconstructed with Perforator Flap 72
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 770
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
Abstract
Extended defects of the sole of the foot

should be reconstructed with durable tissue
facilitating solid anchorage to deep tissue to
resist shearing. Ideally this tissue should pre-
A. Gravvanis (*) sent protective sensation and restore both
contour and function in order to achieve opti-
mal durability and ambulation.
G. E. Papanikolaou
A case of a 60-year-old woman who
Consultant Plastic Surgeon, Unit of Plastic, Reconstructive
Microsurgery and Aesthetic Surgery, Metropolitan sustained a devastating crush-avulsion injury
Hospital, Athens, Greece of her right foot following a motorcycle
https://doi.org/10.1007/978-3-030-23706-6_99
770 A. Gravvanis and G. E. Papanikolaou
accident is presented. The patient was presented 4. Circumferential skin defect

with devitalized skin of the whole circumfer- 5. Avulsion of the plantar aponeurosis
ence of her foot, 2 weeks after the accident. A 6. Requirement to provide durable and stable skin
thorough debridement was followed with recon- coverage of the sole of the foot (Ducic et al.
struction with a chimeric Anterolateral thigh 2006)
perforator flap with part of vastus lateralis mus-
cle that was anastomosed to the posterior tibial
Treatment Plan
vessels and reinnervated with coaptation to the
sural nerve. Recovery was uneventful, planter
Extensive foot defects are an indication for free
weight bearing began at 3 weeks, and accept-
tissue transfer. Moreover, the defect of the plantar
able gait recovery was noted by 3 months as
surface of the foot requires tissue with anatomic
evaluated clinically and by gait analysis.
and biomechanical characteristics that best simu-
This case report suggests the chimeric Ante-
late the original missing tissue. Therefore, the flap
rolateral thigh perforator flap to be a reliable
must be thick and easily contoured to the recipient
option in sole reconstruction and extended foot
area in order to permit less movement against the
defects.
underlying skeletal structures, resembling the sole
of the foot (Kuran et al. 2000).
Keywords
A plan for a chimeric free flap was established
Foot reconstruction · Sole reconstruction · in order to accommodate the extended defect. The
Anterolateral thigh flap · Chimeric flap lateral thigh area is an excellent donor area to
design chimeric flaps with minimal morbidity.
Ultrasound scanning (Fig. 2) showed that the lat-
The Clinical Scenario eral thigh skin thickness was suitable to resurface
the plantar aspect of the foot (Gravvanis et al.
A 60-year-old woman sustained a devastating 2013). Most importantly, the ALT flap can provide
crush-avulsion injury of her right foot following sensate skin for the weight-bearing area by coapta-
a motorcycle accident. The patient had no other tion of the lateral cutaneous nerve of the thigh for
major injuries, her wound was repaired by an reinnervation (Kuran et al. 2000; Sonmez et al.
orthopedic surgeon and she was discharged on 2003; Ducic et al. 2006; Santanelli et al. 2002).
day 3. The patient presented to the plastic surgery
outpatient department 2 weeks after the accident,
with devitalized skin of her right foot (Fig. 1a). Alternative Reconstructive Options
Thorough debridement revealed extensive soft
tissue loss of the heel, dorsum of the foot, exposed 1. Split-skin grafted latissimus dorsi muscle flap
medial malleolus and Achilles tendon insertion, could be an option for this extended defect with
necrosis of the plantar weight-bearing area, and the cost of considerable donor site morbidity
avulsion of the plantar aponeurosis (Fig. 1b, c). (Parmaksizoglu et al. 2011)
2. Other split-skin grafted muscle flaps, such as
rectus abdominis, serratus, and gracilis muscle
Preoperative Problem List: flaps with the main disadvantages of donor site
Reconstructive Requirements morbidity and limited size of flap insufficient
to fill the defect (Kuran et al. 2000; Sonmez
1. Extensive skin necrosis of the foot et al. 2003; Ducic et al. 2006)
2. Grossly contaminated wound (Gravvanis et al. 3. Local fasciocutaneous flaps (medial plantar flap,
2007) instep flap, and reverse sural flap) with the dis-
3. Heel weight-bearing soft tissue loss (Sonmez advantage of small flap size (Lofstrand and Lin
et al. 2003) 2018; Scaglioni et al. 2018; Hamdi et al. 2012)
72 Plantar Weight-Bearing Area Defects Reconstructed with Perforator Flap 771
Fig. 1 (a) The patient

presented to the plastic
surgery outpatient
department 2 weeks after
the accident, with
devitalized skin of her right
foot. (b) Thorough
debridement revealed
extensive soft-tissue loss of
the heel, exposed medial
malleolus, Achilles tendon
insertion, and (c) skin of the
dorsum of the foot
Fig. 2 Color Duplex Ultrasound indicated the skin from thickness and the thickness of the underlying vastus
the thigh area as the most appropriate donor site to match lateralis muscle as compared to the thickness of the con-
the three-dimensional foot defect, according to the skin tralateral healthy heel thickness
The use of skin flaps versus muscle skin-grafted Preoperative Evaluation and Imaging
flaps, and innervated versus non-innervated flaps
for the sole of the foot is still debatable. In fact, the 1. Color Doppler ultrasonography (Gravvanis
ideal result (i.e., restoration of glabrous plantar et al. 2007) was used preoperatively to accu-
skin with normal sensation) is presently rately assess the main vessels (anterior, poste-
unobtainable. Split-skin grafted muscle flaps rior tibial, and peroneal). Blood flow was
have been claimed to be more stable than assessed by standard Doppler measurements
fasciocutaneous flaps because they are easily of the peak systolic velocity (SV), mean veloc-
contoured to the recipient area and permit less ity (MV), and minimum diastolic velocity
movement against the underlying skeletal struc- (DV).
tures, resembling the sole of the foot (Sonmez Blood flow in anterior tibial and peroneal
et al. 2003). On the other hand, recurrent ulcerations vessels was evaluated as excellent, while the
and bulkiness are the main disadvantages of muscle posterior tibial vessels were injured at the level
flaps indicating the necessity for other reconstruc- of the medial malleolus. Nevertheless, blood
tive modality or adjunct (Kuran et al. 2000; Sonmez flow in the posterior tibial artery and vein was
et al. 2003). Patients who have undergone recon- normal 3 cm above the medial malleolus, as
struction with muscle flaps more often require addi- assessed by standard doppler measurements.
tional debulking procedures (Chowdary and Consequently, a decision to use posterior tibial
Murphy 1992) and they have to wear customized vessels, in end-to-side fashion, as recipients
shoes (Parmaksizoglu et al. 2011). was established.
Perforator flaps present the great advantage of 2. Handheld Doppler is not highly specific in
minimal donor site morbidity and there is identification of the dominant perforator but it
published data supporting the fact that even if is useful to map the perforators and accord-
the sensory protection of fasciocutaneous flaps is ingly outline the skin paddle for the ALT flap.
not considered, these flaps have superior proper- Further investigation with color Doppler pre-
ties, compared with split-skin grafted muscle flaps cisely identified the location of the dominant
(Sonmez et al. 2003). Significantly less pain and less ALT perforator(s).
ulceration were observed in the fasciocutaneous
group. Semmes-Weinstein monofilament tests
revealed poorer results with split-skin grafted mus- Preoperative Care and Patient
cle flaps, compared with fasciocutaneous flaps. Drawing
Whether or not to provide a sensate plantar
weight-bearing flap to reconstruct the foot remains 1. A plan for a chimeric Anterolateral thigh per-
controversial. Conflicting data exist regarding forator and vastus lateralis flap (ALT-VL flap)
non-innervated and reinnervated free flaps. Review was established. The patient was counseled
of the literature (Ducic et al. 2006) showed that regarding possible sequelae of ALT-VL flap
reinnervating a muscle flap with a sensory nerve harvest, including possible need to cover the
will permit reinnervation of the muscle and the flap donor site with a skin graft, visible scar,
overlying skin, but whether this provides a superior surgical wound dehiscence and infection, var-
result in durability and gait remains to be seen. A iable lateral thigh paresthesia, donor site pain,
superthin innervated ALT perforator flap was used and possible limited range of motion of the hip
to repair the dorsal foot and ankle of 12 patients and the knee (Kimata et al. 2000).
(Xie et al. 2016). In the transferred flap, protective 2. The patient was placed in the supine position,
sensibility existed in all cases, and the static the ipsilateral hip elevated and the leg inter-
two-point discrimination was 13–16 mm. The nally rotated. A bump was placed under the
authors concluded that innervated ALT perforator buttock to facilitate flap harvesting and the area
flap may be considered as an ideal strategy for foot proximally and distally to the thigh was pre-
and ankle reconstruction. pped and draped so that the entire anterior
thigh from the inguinal ligament to just below the skin paddle was preserved and traced
the knee was exposed. proximally for 10 cm.
3. A straight line from the anterior iliac spine to 8. The perforators to the skin paddle and to the
the lateral border of the patella was drawn and muscle were dissected towards the joining
a mark to the midpoint of this line was made. point to the LCFA, and then the vascular
The dominant perforator, according to the pedicle was dissected up to the origin from
color Doppler study, was located 2 cm lateral the profunda femoris artery.
to this point. 9. The chimeric flap (Fig. 3) was transferred and
4. An exploration incision was drawn at the inset to the recipient area.
thigh, 2 cm medial and parallel to the 10. End-to-side microvascular anastomoses were
aforementionedline. performed between LCFA and posterior tibial
5. An incision was also drawn at the distal tibia, artery and end-to-end between LCFV and
along the course of the posterior tibial artery. posterior tibial accompanying vein.
6. A prophylactic dose of a low molecular heparin 11. The lateral cutaneous nerve of the thigh was
was given the evening before surgery, and fur- sutured terminolateral to an epineural win-
ther doses were given thereafter every evening. dow of the posterior tibial nerve.
12. The skin paddle resurfaced the plantar aspect
of the foot and the Achilles tendon insertion
Surgical Technique (Fig. 4a), while the muscle component
reconstructed the medial malleolar area
1. After thorough debridement, the posterior tib- (Fig. 4b).
ial vessels were exposed proximal to the open 13. The proximal part of the VL muscle was inset
wound and 3 cm proximal to the medial above the micro-anastomoses, to avoid
malleolus were deemed to be of good quality wound closure tension that might compro-
for end-to-side anastomosis. mise anastomoses patency.
2. The flap harvest commenced with the medial
incision. The anterior flap was elevated first
and the subcutaneous dissection was extended Technical Pearls
medially.
3. Then the deep fascia was incised on the sur- 1. In the traumatized lower limb, it is important to
face of the rectus femoris and the incision was perform the microvascular anastomoses “out-
extended longitudinally. The flap was ele- side the zone of injury,” to ensure good arterial
vated deep to the deep fascia from medially inflow and adequate venous outflow.
to laterally, until the dominant perforator was 2. Preoperative color Doppler ultrasound study
identified. will facilitate the decision for the “healthy
4. The perforator was dissected through the zone” for microvascular anastomoses.
vastus lateralis muscle towards the 3. End-to-side arterial anastomoses preserves dis-
descending branch of the lateral circumflex tal blood supply to the traumatized lower limb.
femoral artery (LCFA). 4. Inset the proximal part of the flap above the
5. A muscular branch to the vastus lateralis mus- micro-anastomoses, to avoid wound closure
cle originating from the LCFA was identified tension that might compromise anastomoses
and dissected. patency.
6. At this point the dimensions of the ALT skin 5. Make the exploration incision in the donor
paddle and vastus lateralis muscle needed for thigh area first, and then identify the perfora-
the reconstruction were marked. tors. Thereafter, design the chimeric flap
7. The ALT skin paddle and the part of the VL (dimensions of skin paddle and muscle com-
were circumscribed and the branch of the ponent) that can cover effectively and recon-
lateral cutaneous nerve of the thigh entering struct the 3-dimensional defect.
Fig. 3 The chimeric flap consisted from a skin paddle 20 9 cm and a vastus lateralis muscle 15 6 cm. The lateral
cutaneous nerve of the thigh will be used for sensory re-innervation of the skin paddle
with protective sensation at the sole of her foot

and 17 mm static two-point discrimination was
achieved. The patient was able to ambulate wear-
ing a shoe (Fig. 5) and no recurred ulceration was
noticed. Most importantly, patient obtained nor-
The patient was postoperatively closely monitored
mal gait within 3 months after surgery (Fig. 5,
by physical examination and handheld Doppler for
insert).
the first 5 days. Anticoagulant regimen included
Moreover, the patient obtained a stable recon-
low molecular heparin and oral aspirin.
struction, and the skin component at the sole of the
Due to the circumferential defect, the foot was
foot had adhered to the underlying bones, permit-
not splinted and was kept elevated, avoiding pres-
ting little movement against the skeletal structure.
sure at the reconstructed heel, as well as medial
The muscle component provided good soft tissue
and lateral malleolar area. The drain was removed
coverage of the exposed bones at the malleolar
from the donor area at day 2. Recovery was
area, while the recovery of protective sensation
uneventful and the patient was discharged on
protected from recurrent ulcers. Stable sensate
day 11 post-op. The patient was allowed to ambu-
skin at the sole of the foot ensured almost normal
late in a cast shoe for 3 weeks after surgery.
gait (Figs. 4 and 5).
Even though a series of cases with long follow-
Outcome: Clinical Photos and Imaging up are required to document the value of the
method, the sensate chimeric ALT-VL flap both
No revision or regrafting was performed and dura- diminishes donor site morbidity and is ideally
ble coverage of the defect was achieved (Fig. 4). suited for most soft tissue reconstruction of the
At 20 months follow-up, the patient presented dorsal foot, heel, and plantar foot.
1. Color Doppler ultrasonography is an

extremely useful tool to study the vascular
anatomy of the lateral thigh area and design
chimeric flaps to reconstruct extended defects
(Gravvanis et al. 2007). Color Doppler is very
accurate in identifying recipient vessel
“healthy zone” where microanastomoses can
be performed safely.
2. Foot reconstruction with a free flap may require
additional debulking surgery (Chowdary and
Murphy 1992).
3. Patients who underwent free flap reconstruc-
tion of their foot sole defect usually require
customized shoes (Parmaksizoglu et al.
2011).
4. A superthin innervated ALT perforator flap
may be considered as an ideal strategy for
foot and ankle reconstruction (Xie et al.
2016).
5. Patient’s education for increased visual exam-
Fig. 4 (a) Plantar view 20 days postoperatively. The skin
paddle resurfaced the plantar aspect of the foot and the
ination and surveillance is essential to compen-
Achilles tendon insertion. (b) Dorsal view 20 days postop- sate for the decreased sensitivity of the
eratively. The muscle component reconstructed the medial reconstructed area (Ducic et al. 2006).
malleolar area and the proximal part of the VL muscle was
inset above the micro-anastomoses, to avoid wound clo-
sure tension
appearance at 3 months.
The patient was able to
ambulate wearing a regular
shoe and obtained almost
normal gait (insert)
Learning Points Fox CM, Beem HM, Wiper J, et al. Muscle versus
fasciocutaneous free flaps in heel reconstruction: sys-
temic review and meta-analysis. J Reconstr Microsurg.
1. Sensate Chimeric ALT-VL flap provides a 2015;31:59–66.
thick and durable tissue enough to resist shear- Gravvanis A, Tsoutsos D, Karakitsos D, et al. Blood per-
ing forces and bear the weight of the body. fusion of the free anterolateral thigh perforator flap: its
2. In obese patients fasciocutaneous flaps are beneficial effect in the reconstruction of infected
wounds in the lower extremity. World J Surg.
thick and could be precluded from their use in 2007;31:11–8.
resurfacing the foot sole. Nevertheless, super- Gravvanis A, Kateros K, Apostolou K, Karakitsos D,
thin sensate perforator flaps have been Tsoutsos D. Changes in donor site selection in lower
successfully used. limb free flap reconstructions by integrating duplex
ultrasonography in the preoperative design. Acta Chir
3. Sensate free flaps could offer early return to Plast. 2013;55(1):3–9.
daily activities and better recovery of protec- Hamdi MF, Kalti O, Khelifi A. Experience with the distally
tive sensation than nonsensate free flaps. It is based sural flap: a review of 25 cases. J Foot Ankle
still not possible to determine whether inner- Surg. 2012;51:627–31.
Kimata Y, Uchiyama K, Ebihara S, et al. Anterolateral
vated flap reconstructions are critical for either thigh flap donor-site complications and morbidity.
durability or ambulation. Plast Reconstr Surg. 2000;106:584–8.
4. Currently, there is no “gold standard” flap for Kuran I, Turgut G, Bas L, et al. Comparison between
the reconstruction of the weight-bearing sur- sensitive and nonsensitive free flaps in reconstruction
of the heel and plantar area. Plast Reconstr Surg.
face of the foot, since both fasciocutaneous and 2000;105:574–80.
muscle flaps show similar results regarding Lӧfstrand JG, Lin CH. Reconstruction of defects in the
recurrent ulceration, requirement for revision, weight-bearing plantar area using the innervated free
and the requirement for specialized footwear medial plantar (instep) flap. Ann Plast Surg. 2018;80:
245–51.
(Fox et al. 2015). Parmaksizoglu AF, Unal MB, Cansu E. The reconstruction
of foot soft tissue defects by tangential debulking of the
latissimus dorsi flap. J Reconstr Microsurg. 2011;27:
Cross-References 211–4.
Santanelli F, Tenna S, Pace A, et al. Free flap reconstruction
of the sole of the foot with or without sensory nerve
▶ Plantar Weight-Bearing Area Defects Recon- coaptation. Plast Reconstr Surg. 2002;109:2314–22.
structed with Muscle Flap Scaglioni MF, Rittirsch D, Giovanoli P. Reconstruction of
the heel, middle foot sole, and plantar forefoot with the
medial plantar artery perforator flap: clinical experience
with 28 cases. Plast Reconstr Surg. 2018;141:200–8.
References Sonmez A, Bayramicli M, Sonmez B, et al. Reconstruction
of the weight-bearing surface of the foot with non-
Chowdary RP, Murphy RX. Delayed debulking of free neurosensory free flaps. Plast Reconstr Surg.
muscle flaps for aesthetic contouring debulking of 2003;111:2230–6.
free muscle flaps. Br J Plast Surg. 1992;45:38–41. Xie S, Deng X, Chen Y, Song D, Li K, Zhou X, Li
Ducic I, Hung V, Dellon AL. Innervated free flaps for foot Z. Reconstruction of foot and ankle defects with a
reconstruction: a review. J Reconstr Microsurg. superthin innervated anterolateral thigh perforator
2006;22:433–42. flap. J Plast Surg Hand Surg. 2016;50(6):367–74.
Plantar Weight-Bearing Area Defects
Reconstructed with Muscle Flap 73
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 782
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 782
Abstract
The reconstructive strategy for the repair of

extended defects in the weight-bearing surface
of the foot must consider both contour and
function in order to achieve optimal durability
A. Gravvanis (*) and ambulation. Small defects can be
reconstructed by skin grafts or local flaps, but
extensive defects require free tissue transfer.
G. E. Papanikolaou
A case of a 14-year-old overweight male
Microsurgery and Aesthetic Surgery, Metropolitan who sustained a devastating crush-avulsion
Hospital, Athens, Greece injury of the sole of his foot is presented. A
https://doi.org/10.1007/978-3-030-23706-6_100
two-stage reconstruction procedure was under- 3. Avulsion of the plantar aponeurosis.

taken to resurface the plantar area. The first 4. Requirement to restore the contour of the sole
stage involved the transfer of a free latissimus and achieve optimal motor function of the foot
dorsi muscle flap covered with Integra artificial in terms of stability, durability, and ambulation
dermis. After 15 days, the silastic layer of the (Ducic et al. 2006).
Integra was peeled off and replaced with thick 5. Obesity is associated with increased pressure
split-thickness skin graft. and friction to the weight-bearing surface of
Recovery was uneventful at all two stages the foot (Gravvanis et al. 2011).
with satisfactory cosmetic and functional results.
Keywords Treatment Plan

Foot reconstruction · Heel reconstruction ·
The extensive defect of the plantar surface of the
Latissimus dorsi flap · Integra artificial dermis
foot requires a tissue transfer with anatomic and
biomechanical characteristics that best simulates
The Clinical Scenario the original missing tissue. Therefore, the flap
must be thick and easily contoured to the recipient
A 14-year-old overweight male sustained a dev- area in order to permit less movement against the
astating crush-avulsion injury of the sole of his underlying skeletal structures, resembling the sole
foot. He presented with a grossly contaminated of the foot (Kuran et al. 2000).
mangled foot, extensive soft-tissue loss of the A plan for a free muscle flap was established
plantar weight-bearing area, and avulsion of the because the skin thickness of the thigh and back
plantar aponeurosis (Fig. 1). area precluded the use of a perforator flap. Thus, the
operative strategy was to proceed with a spilt-skin
grafted latissimus dorsi muscle flap (Gravvanis
Preoperative Problem List: et al. 2011; Parmaksizoglou et al. 2011). To rein-
Reconstructive Requirements force the weight-bearing area of the heel, a decision
was made to resurface this part of the muscle flap
1. Extensive soft tissue loss of the plantar weight- with Integra artificial dermis.
bearing area (Sonmez et al. 2003).
2. Grossly contaminated mangled foot (Gravvanis
et al. 2007). Alternative Reconstructive Options
1. Free sensate or nonsensate fasciocutaneous flap

(i.e., ALT flap, scapular flap, radial forearm flap,
medial plantar flap), but the skin thickness of the
thigh and back area precluded the use of a per-
forator flap (Kuran et al. 2000; Sonmez et al.
2003; Ducic et al. 2006; Santanelli et al. 2002).
2. Other split-skin grafted muscle flaps, such as
rectus abdominis, serratus, and gracilis muscle
flaps with the main disadvantages of donor site
morbidity and limited size of flap insufficient
to fill the defect (Kuran et al. 2000; Sonmez
et al. 2003; Ducic et al. 2006).
Fig. 1 Grossly contaminated mangled foot, extensive
3. Local fasciocutaneous flaps (medial plantar
soft-tissue loss of the plantar weight-bearing area, and flap, instep flap, reverse sural flap) with the
avulsion of the plantar aponeurosis disadvantage of small flap size (Lofstrand and
73 Plantar Weight-Bearing Area Defects Reconstructed with Muscle Flap 779
Lin 2018; Scaglioni et al. 2018; Hamdi et al. tibial, and peroneal). Blood flow was assessed
2012). by standard Doppler measurements of the peak
systolic velocity (SV), mean velocity (MV), and
minimum diastolic velocity (DV).
Preoperative Evaluation and Imaging Blood flow in anterior tibial and peroneal
vessels was evaluated as excellent, while poste-
1. Near-Infrared-Spectroscopy (NIS) was used rior tibial vessels were avulsed at the level of the
to assess the perfusion of the avulsed plantar medial malleolus. Nevertheless, blood flow in
flap (Taylor and Simonson 1996). This nonin- the posterior tibial artery and vein was normal
vasive technique measures hemoglobin oxy- 6 cm above the medial malleolus, as assessed by
gen saturation and thus can be used for standard doppler measurements. Consequently,
monitoring of the tissue oxygenation. Mea- a decision to use as recipients the posterior tibial
surements were performed by using an vessels at this level was established.
InSpectra Tissue Spectrometer (Hutchinson
Technology Inc.). The probe was placed in Preoperative Care and Patient
the center of the avulsed plantar flap (Fig. 2), Drawing
with a 4 mm depth of light penetration. The
plantar surface of the left limb was used as 1. A plan for endoscopically assisted harvested
control. NIS showed that hemoglobin oxygen Latissimus Dorsi Muscle Flap was established.
saturation of the avulsed flap was significantly A vertical 5 cm incision was drawn in the
decreased 27 2%, as compared to the healthy midaxillary line. An additional 4 cm incision
left limb 93 2.1% (Fig. 2). Given that replan- above the iliac crest was drawn to facilitate the
tation of the avulsed flap was not technically access to the caudal part of the muscle.
feasible, debridement of the devitalized tissue 2. An incision was drawn along the course of the
was decided. posterior tibial artery.
2. Color Doppler Ultrasonography (Gravvanis 3. A prophylactic dose of a low-molecular-
et al. 2007) was used preoperatively to accu- weight heparin was given the evening before
rately assess the main vessels (anterior, posterior surgery, and further doses were given thereaf-
ter every evening.
Surgical Technique
1. After thorough debridement, the posterior tib-

ial vessels were exposed proximal to the open
wound and at 6 cm proximal to the medial
malleolus were deemed to be of good quality
with robust bleeding after division.
2. To harvest the flap, the patient was placed in a
lateral decubitus position.
3. A vertical 5 cm incision was placed in the
midaxillary line.
4. The dissection of the thoracodorsal vessels
and the division of the thoracodorsal nerve
Fig. 2 Near-Infrared-Spectroscopy (NIS) was used to were performed under direct visualization
assess the perfusion of the avulsed plantar flap: hemoglo-
bin oxygen saturation of the avulsed flap was significantly
without the use of endoscope.
decreased 27 2%, as compared to the healthy left limb 5. Then a 5-mm, 30 angled endoscope attached
93 2.1% (Fig. 2) to an endoretractor (KARL STORZ GmbH &
Co.KG, Germany) was inserted through the 9. The muscle flap was resurfaced with a split-
skin incision (Fig. 3). The superficial surface thickness skin graft.
of the muscle was initially dissected and was 10. To reinforce the weight-bearing area of the
followed by dissection of the undersurface. heel, a decision was made to resurface this
6. To complete the flap harvest, an additional part of the muscle flap with Integra artificial
4 cm incision above the iliac crest was used dermis (Fig. 5). The silastic layer of the Integra
to facilitate the access to the caudal part of the was peeled off 15 days later. It had taken 100%
muscle. The muscle was transected at its ori- and was well vascularized, and a thick split-
gin from the iliac crest and the spine. Large thickness skin graft was applied (Fig. 6).
perforators were ligated with an endoscopic
clip applier.
7. The muscle’s humeral insertion was divided Technical Pearls
under direct visualization, and then the pedi-
cle, 12 cm in length, was ligated (Fig. 4). 1. In traumatized lower limb, perform microvas-
8. The flap was transferred to the recipient area, cular anastomoses “outside the zone of injury.”
was inset to the defect and secured with
Vicryl 3-0 sutures. End-to-side microvascular
anastomoses were performed between poste-
rior tibial – thoracodorsal artery and end-to-
end between posterior tibial – thoracodorsal
vein using 9-0 Nylon sutures.
Fig. 4 Latissimus dorsi free muscle flap. A 5 5 cm

Integra artificial dermis was used to resurface the muscle
at the area of the reconstructed heel
Fig. 3 A vertical 5 cm incision was placed in the mid-

axillary line and a 5-mm, 30 angled endoscope attached to Fig. 5 Plantar view 10 days postoperatively. Complete
an endoretractor was inserted through the skin incision take of the Integra Artificial dermis was recorded
at about a week after surgery. At all other times,

the foot was kept elevated.
The drains were removed at day seven both
from the donor area and on day 2 from the leg.
Recovery was uneventful and the patient was
discharged on day 11 following the first operation.
The skin-grafting stage was a day case.
No revision or regrafting was performed. Durable

coverage of the defect was achieved (Fig. 7) and
Fig. 6 The silastic layer of the Integra was peeled off patient obtained normal gait within 3 months after
15 days later. The well-vascularized artificial dermis was
resurfaced with a thick split-thickness skin graft surgery. At 18 months follow-up, the patient was
able to ambulate wearing a regular shoe with an
orthosis in its base (Fig. 8). He was able to join
2. Preoperative Color Doppler Ultrasound study sport activities at his school and no recurrent
will facilitate the decision for the “healthy ulceration was encountered.
zone” for microvascular anastomoses. Split-skin grafted muscle flaps have been
3. End-to-side arterial anastomoses preserve dis- claimed to be more stable than fasciocutaneous
tal blood supply to the traumatized lower limb. flaps because they are easily contoured to the
4. Inset the proximal part of the flap (LD tendon) recipient area and permit less movement against
above the micro-anastomoses, to avoid wound the underlying skeletal structures, resembling the
closure tension that might compromise anasto- sole of the foot (Sonmez et al. 2003). On the other
moses patency. hand, recurrent ulcerations and bulkiness are the
5. Perform the dissection of the thoracodorsal main disadvantages of muscle flaps necessitating
vessels under direct visualization without the other reconstructive modalities and/or adjuncts
use of endoscope. (Kuran et al. 2000; Sonmez et al. 2003).
6. Perform first the dissection of the superficial In a previous case report using Integra to resur-
surface of the muscle and then the dissection of face a muscle flap (Moore et al. 2003), the authors
the undersurface.
7. An additional incision above the iliac crest
may be used to facilitate the access to the
caudal part of the muscle.
The patient was postoperatively closely moni-

tored by physical examination and handheld
Doppler for the first 5 days. Anticoagulant regi-
men included low-molecular-weight heparin and
oral aspirin.
Fig. 7 Postoperative appearance at 16 months. The dotted
The ankle was splinted in neutral position and lines indicate the weight-bearing area of the heel resurfaced
the patient was allowed to ambulate in a cast shoe with Integra
3. Patient education for increased visual exami-

nation and surveillance is essential to compen-
sate for the decreased sensitivity of the
reconstructed area (Ducic et al. 2006).
4. Integra is an expensive artificial dermal matrix
and its use in weight-bearing areas must be
reserved for specific cases such as in obese
patients (Gravvanis et al. 2011).
Learning Points
1. Free latissimus dorsi muscle flap provides a

thick and durable tissue enough to resist shear-
ing forces and bear the weight of the body.
2. Integra is an artificial dermis used as a template
for dermal regeneration in cases of full-
Fig. 8 At 18 months follow-up, the patient was able to thickness skin defects.
ambulate wearing a regular shoe with an orthosis in its 3. In obese patients, fasciocutaneous flaps are
base, and obtained almost normal gait (insert)
thick and could be precluded from their use in
applied artificial dermis over the latissimus dorsi resurfacing the foot sole.
muscle flap, 2 years after coverage of a tibial com- 4. Sensate free flaps could offer earlier return to
pound fracture. The aim was to improve the aes- daily activities and better recovery of protec-
thetic appearance of the limb (Moore et al. 2003). tive sensation compared to nonsensate free
The present clinical case is the first report using flaps, but it is still not possible to determine
Integra over a muscle flap acutely, aiming to that innervated flap reconstructions are critical
achieve durable skin coverage. Despite the recon- for either durability or ambulation.
struction being non sensate, Integra provides an 5. Currently, there is no “gold standard” flap for
additional layer of tissue over the muscle and the reconstruction of the weight-bearing sur-
increases the overall thickness of the reconstructed face of the foot, since both fasciocutaneous and
heel. Most importantly, Integra provides a perma- muscle flaps show similar results with respect
nent dermal replacement matrix overcoming the to recurrent ulceration, requirement for revi-
main structural deficit of split-skin grafted muscle sion, and the requirement for specialized foot-
flaps, and, thus, ensures more stable wound cover- wear (Fox et al. 2015).
age. Even though a case series with long follow-up
is required to assess the value of this reconstructive
method, Integra could be a sound adjunct to free Cross-References
muscle flaps in the reconstruction of foot weight-
bearing areas. ▶ Plantar Weight-Bearing Area Defects Recon-
structed with Perforator Flap

References
1. Latissimus dorsi muscle flap may require addi-
tional debulking surgery (Chowdary and Mur- Chowdary RP, Murphy RX. Delayed debulking of free
phy 1992). muscle flaps for aesthetic contouring debulking of
free muscle flaps. Br J Plast Surg. 1992;45:38–41.
2. Patients underwent muscle flap reconstruction
Ducic I, Hung V, Dellon AL. Innervated free flaps for foot
of their foot sole defect usually must wear reconstruction: a review. J Reconstr Microsurg.
customized shoes (Parmaksizoglu et al. 2011). 2006;22:433–42.
Fox CM, Beem HM, Wiper J, et al. Muscle versus medial plantar (instep) flap. Ann Plast Surg. 2018;80:
fasciocutaneous free flaps in heel reconstruction: sys- 245–9.
temic review and meta-analysis. J Reconstr Microsurg. Moore C, Lee S, Hart A, et al. Use of Integra to resurface a
2015;31:59–66. latissimus dorsi free flap. Br J Plast Surg. 2003;56:
Gravvanis A, Delikonstantinou I, Tsoutsos 66–9.
D. Reconstruction of the weight-bearing surface of Parmaksizoglu AF, Unal MB, Cansu E. The reconstruction
the foot with Integra-grafted latissimus dorsi muscle of foot soft tissue defects by tangential debulking of the
flap. Microsurgery. 2011;31:162–3. latissimus dorsi flap. J Reconstr Microsurg. 2011;27:
Gravvanis A, Tsoutsos D, Karakitsos D, et al. Blood per- 211–4.
fusion of the free anterolateral thigh perforator flap: its Santanelli F, Tenna S, Pace A, et al. Free flap reconstruction
beneficial effect in the reconstruction of infected of the sole of the foot with or without sensory nerve
wounds in the lower extremity. World J Surg. coaptation. Plast Reconstr Surg. 2002;109:2314–22.
2007;31:11–8. Scaglioni MF, Rittirsch D, Giovanoli P. Reconstruction of
Hamdi MF, Kalti O, Khelifi A. Experience with the distally the heel, middle foot sole, and plantar forefoot with the
based sural flap: a review of 25 cases. J Foot Ankle medial plantar artery perforator flap: clinical experience
Surg. 2012;51:627–31. with 28 cases. Plast Reconstr Surg. 2018;141:200–8.
Kuran I, Turgut G, Bas L, et al. Comparison between Sonmez A, Bayramicli M, Sonmez B, et al. Reconstruction
sensitive and nonsensitive free flaps in reconstruction of the weight-bearing surface of the foot with non-
of the heel and plantar area. Plast Reconstr Surg. neurosensory free flaps. Plast Reconstr Surg.
2000;105:574–80. 2003;111:2230–6.
Lӧfstrand JG, Lin CH. Reconstruction of defects in the Taylor DE, Simonson SG. Near infra-red spectroscopy to
weight-bearing plantar area using the innervated free monitor tissue oxygenation. New Horiz. 1996;4:420–5.
Lower Limb Transplantation
74
Pedro C. Cavadas
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
Abstract
Vascularized composite allotransplantation

(VCA) has emerged in recent years as a tech-
nically feasible and medically complex treat-
Electronic Supplementary Material: The online version ment to replace large segments of the upper
of this chapter (https://doi.org/10.1007/978-3-030-23706- limbs, face, abdominal wall, and penis. Lower
6_103) contains supplementary material, which is limb transplantation has only been reported in
available to authorized users. one case, described herein. A 22-year-old male
P. C. Cavadas (*) patient presented with bilateral transfemoral
Reconstructive Microsurgery, Clínica Cavadas, Valencia, amputation. Attempts at prosthetic fitting had
Spain been unsuccessful. Based on the author’s
e-mail: pcavadas@clinicacavadas.es

https://doi.org/10.1007/978-3-030-23706-6_103
786 P. C. Cavadas
positive previous experience in lower limb

replantation and transhumeral transplantation, a
bilateral transfemoral transplantation was
performed. The donor was a full HLA-
mismatched female multiorgan donor. The
immunosuppression (IS) therapy was standard
induction with alemtuzumab and triple therapy
with tacrolimus (Tac), mycophenolate mophetyl
(MMF), and prednisone. Surgical technique is
described in detail, including procurement after
cardiac arrest, intravascular rewarming and pre-
filling of the transplanted limbs, and sequential
revascularization. Although cytomegalovirus
(CMV) status was donor negative/recipient neg-
ative (D-/R-), the patient developed a primary
CMV infection coincident with an acute rejec-
tion at 3 months that responded to treatment.
Function improved steadily for 15 months,
with active knee and ankle flexion and exten-
sion. The patient was placed on a rehabilitation
regimen consisting of early walking between
parallel bars. At 15 months, the patient devel-
oped primary brainstem posttransplant lympho- Fig. 1 Bilateral AK amputation in a young patient unable
proliferative disease (PTLD) that required to use prostheses
immediate cessation of IS and amputation of
the transplanted limbs. Treatment with high-
dose methotrexate and radiation therapy achie-
ved complete remission. Seven years after limb
removal, the patient is alive and well.
At the present time, lower limb transplanta-
tion should be considered with extreme caution
because of the marginal risk/benefit ratio for
the patient.
Keywords
Lower limb transplantation · VCA ·

Vascularized composite allotransplantation ·
Immunosuppression · Posttransplant
lymphoproliferative disease · PTLD

Fig. 2 Bone level of amputation was 32 cm on the right
The recipient was a 22-year-old male with a bilat- and 41 cm on the left side
eral traumatic above-knee (AK) amputation
(Fig. 1). The femur stump was 32-cm-long on the EBV IgG+. HLA typing was A1 A24 B15 B44
right side and 41-cm-long on the left (Fig. 2). DRB1*1406 DRB1*15. After an extensive reha-
Blood group was O negative, CMV IgG-, and bilitation program, prosthetic fitting was not
74 Lower Limb Transplantation 787
Fig. 3 AngioCT showing

small-caliber femoral
arteries bilaterally
successful and the patient was wheelchair- 2. Lower limb transplantation had not been
confined. Tinel’s sign of the sciatic nerves was performed before, so no references were
located 10 cm above the amputation level. Femoral available.
arteries were patent but of very small caliber 3. Previous positive experience with one bilateral
(Fig. 3). There were remaining quadriceps and transhumeral transplantation patient and mul-
hamstring muscles in the stumps. The patient was tiple BK lower limb replantations by the author
a nonsmoker. The patient requested a lower limb made him consider bilateral AK transplanta-
transplantation. Institutional Review Board (IRB) tion in this case.
approval was obtained from the hospital and the 4. For basic ambulation, skeletal alignment and
Spanish organ procurement organization (ONT). stability, hip abduction (gluteus medius mus-
The donor was a 26-year-old female multiorgan cles), active knee extension (quadriceps mus-
donor with brain death. Blood group was O nega- cles), plantigrade feet, and protective plantar
tive, CMV, and EBV IgG-. HLA typing was A2, sensation are the minimum requisites. It
B44, BW4, DR15(2), DR17(3), DR51, DR52, seemed realistic to achieve these functions
DQ6(1), and DQ2. Cross-matching was negative. with a VCA in this patient.
5. The CMV negative and EBV positive
serostatus of the patient required a CMV and
Preoperative Problem List/ EBV negative donor to reduce the risk of CMV
Reconstructive Requirements infection and PTLD. This excluded many pos-
sible candidates.
1. The bilateral AK amputation level and the 6. The amount of allogenic tissue to be trans-
inability to use prostheses forced the patient planted was around 30% of the total body
to use a wheelchair all the time. weight. The hemodynamic intraoperative
788 P. C. Cavadas
management of this situation required careful Alternative Reconstructive Options

planning of volumes and temperature manage-
ment to avoid potentially lethal complications. There were no alternatives to provide two lower
limbs to the patient. Osseo-integrated AK pros-
theses were an option, but the patient refused them
Treatment Plan due to perceived negative results in other patients.
The risk is obviously less, and although the late
Surgery in VCA is just the beginning of the pro- results are mixed and difficult to interpret because
cess, and compared to the volume of medical of frequent conflict of interest (Hagberg and
aftercare, it is a minor component. Brånemark 2009), in retrospect would have been
This surgery was unprecedented. Never before a much safer option.
had a similar amount of allogenic tissue been Regarding VCA procurement, harvesting one
transplanted, and there was only one reported limb before cardiac arrest using exsanguination
case in the literature of a transknee bilateral and a high tourniquet (and the second limb after
replantation in a child with proportionally lower heart, lung, and liver procurement) would have
percentage of the body weight being reperfused been beneficial in that it reduces ischemia times,
(Bulic et al. 2017). and allows for a more relaxed insetting, and revas-
The plan was to have the recipient and the cularization of the first limb. However, the
donor patients in adjacent operating rooms to sequence was not performed this way due to non-
avoid transportation times. The procurement of medical, logistic, and organizational issues.
the lower limbs was planned after heart-lung pro- Quadriceps’ function in AK transplantation
curement because of political and logistic reasons. depends solely on the remaining proximal stump
To allow for the time constrains and associ- of muscle. Dissection of the cut proximal
ated stress, dissection of recipient’s structures branches of the femoral nerve and coaptation to
was planned 5 h before the beginning of the the nerve of the quadriceps of the transplanted
multiorgan procurement, and because of team- limb would be useful should the proximal stump
size limitations, only one surgical field was of quadriceps be minimal.
worked on.
Hemodynamic and systemic effects of the
amount of surgical injury were a prime concern Preoperative Evaluation and Imaging
during surgical planning, so sequential revascu-
larization was planned: first the right side, then the Evaluation of the donor is done from a standard
left one. The intravascular tree of the limbs was medical point of view, ruling out any contraindi-
filled with warm Hartman’s solution, and the cations for transplantation (active infection, pre-
veins were repaired first, followed by the arteries. vious malignant disease, renal disease, severe
The intended physiologic effect after clamp cardiovascular risk, previous sensitization to
release would be similar to a tourniquet release MHC antigens, ABO blood typing, HLA typing,
plus some hemodilution, instead of an acute rela- CMV and EBV serostatus, etc.) (KDIGO 2009).
tive hypovolemia. The boney structures in the stump were evalu-
In order to speed up the process, plate fixation ated through X-ray measurement of the length of
was chosen over intramedullary nailing because it remaining femurs (Fig. 2), and angioCT was used
can be performed rapidly under direct vision, to assess the superficial femoral vessels. These
without the need for the C-arm. Given the pre- were of small caliber, so the external iliac vessels
dicted limited ischemia times, an artery-last were planned as recipients (Fig. 3).
sequence of repairs was planned to reduce Muscle mass remaining was examined manu-
blood loss. ally by asking the patient to actively contract.
Repair of all other structures did not need spe- Tinel’s sign was explored in the sciatic nerves
cial planning. and found 10 cm proximal to the bone level.
No further explorations were necessary. the infrarenal aorta, to allow in situ cooling
Because of the nature of the procedure, full of the lower limbs.
medical transplantology screening was performed (b) The lower limbs were harvested with rapid
to the donor (HLA typing, CMV and EBV technique in a bloodless field. The bone
serostatus, ABO blood typing, etc.) was cut at 22 and 12 cm proximal to the
knee joint on the right and left sides respec-
tively, with extra length of schiatic nerve
Preoperative Care and Patient and muscles. The superficial femoral ves-
Drawing sels were dissected proximally up to the
common iliac vessels, avoiding inadvertent
The recipient patient was taken to the operating damage to the ureters.
room 5 h before the scheduled multiorgan pro- (c) The right leg was immediately transferred
curement of the donor next-door. to the recipient’s OR. The left limb was
Padding and general anesthesia preparation for submerged in crushed ice and saline in a
a lengthy procedure with invasive arterial pressure sterile plastic container and transferred to
monitoring and several large-bore IV accesses the recipient OR.
were provided. Induction therapy with 30 mg of (d) Cosmetic limb prostheses were affixed to
depleting anti-CD52 antibody alemtuzumab was the donor to reduce the cosmetic impact.
administered, along with prophylactic antibiotics. 3. Transplantation Procedure:
In the donor’s operating room, extra provision (a) The right leg was transplanted first. The
(30 l) of cold University of Wisconsin solution sequence of repairs was the same in both
was prepared for the in situ cooling and perfusion sides. Bone fixation was quickly performed
of the lower limbs, through the aortic catheter first with 4.5 mm locking plates and screws
(without infrarenal aorta clamping). placed laterally under direct vision, without
X-ray control.
(b) Hamstring muscles were then repaired. The
Surgical Technique sciatic nerve was repaired using epineural
interrupted 8/0 suture underloupe magnifi-
1. Recipient preparation: cation. The dorsal skin was closed. The
(a) Through fish-mouth incisions, longer on the quadriceps was sutured under tension
medial side, the remnant stump of quadri- with heavy absorbable material.
ceps muscle, hamstrings, and biceps femoris (c) Immediately before vascular repair, the left
was dissected and freed. The bone ends leg was brought to the surgical field and the
were minimally trimmed with a bone saw. bone fixation was performed to allow a
(b) The schiatic nerves were identified and semisimultaneous repair of some structures.
tagged. (d) The iliac artery of the VCA was then
(c) The external iliac artery and vein were dis- flushed with warm (37 °C) Ringer’s solu-
sected and prepared as recipients through a tion. The vascular tree of the limb was
limited ilioinguinal approach. filled with warm Ringer’s solution and
(d) Hemostasis was achieved and the wounds clamped (external iliac artery and vein).
temporarily closed with staples and the End-to-side anastomoses were performed
stumps wrapped with bandage waiting for to the recipient’s external iliac vessels
the limbs. using continuous 7/0 nylon with loupes.
2. Donor surgery: The vein clamps were released first and
(a) Upon aortic perfusion of cold Wisconsin then the arterial clamps, allowing revascu-
solution, and before heart, lung, and liver larization. The anesthesia team was warned
procurement, 30 l of this preservation solu- in advance, so they could transfuse packed
tion was infused without cross-clamping red cells to compensate for the
790 P. C. Cavadas
hemodilution. Ten minutes were allowed to (f) A total of 12 units of packed red cells,
assess the hemodynamic response. 6 units of fresh frozen plasma, and 3 units
(e) The same sequence of surgical maneuvers of platelets were transfused during and
was followed on the left side (Figs. 4 and 5). after surgery.
Reperfusion of the second limb was
performed 2 h after the first limb, and it
was also well tolerated by the patient. Total Technical Pearls
ischemia time was 3.5 h on the right side and
5.5 h on the left side. No fasciotomies was 1. Rapid technique is critical to avoid excessive
performed. A miniexternal fixator was ischemia time (known to induce ischemia
inserted in the tibia bilaterally for postoper- reperfusion injury, a proinflammatory stimulus
ative limb suspension. for acute rejection). Harvesting of in situ-
Fig. 4 The right limb

immediately before
trimming and repair of
structures. The VCA has not
yet been rewarmed
Fig. 5 Bone, muscles, and

the sciatic nerve have been
repaired in the right limb.
Immediately before
rewarming, vascular filling,
and anastomoses of the
right side, the left limb is
brought to the field. Fast
bone fixation by the surgeon
allowed for
semisimultaneous repair of
some structures in the left
side while the vascular
repairs were performed on
the right side
perfused lower limbs after cardiac retrieval for trough levels of 10–17 ng/ml during the first
requires extra attention to ligating hard-to-see month and 7–12 ng/ml thereafter, and tapering
vessels in order to avoid massive bleeding methylprednisolone (1 g on reperfusion, 250 mg
upon revascularization. for 2 days, 100 mg on POD3, 60 mg from POD
2. Fast bone fixation with plates and screws saves 4–14, and progressive reduction, thereafter). No
time and avoids the cumbersome need for CMV prophylaxis was instituted, given the D-/R-
C-arm, resulting in a more agile procedure. matching (KDIGO 2009). CMV and EBV replica-
Orthopedic training of the surgeon is tion in peripheral blood were monitored weekly.
mandatory. Passive range of motion of the ankle was allo-
3. Quadriceps muscle should be sutured under wed immediately. The knee was passively moved
maximal tension after the dorsal structures are after 5 days. Active motion of the knee was allo-
repaired. Distal muscle will be denervated, wed after 3 weeks. Dangling protocol was initi-
marginally perfused and nonfunctional, so rad- ated at 2 weeks.
ical debridement of distal muscle is advisable. At postoperative day (POD), 90 Tac was
4. Vascular repairs to the external iliac vessels changed for rapamycin in order to reduce nephro-
require standard vascular technique. The sur- toxicity and long-term risk of malignancy. Coin-
geon should be familiar with large-vessel cident with this, the patient developed CMV
surgery. primary infection (CMV syndrome) and skin
5. The sequence of management of vascular acute rejection (AR) (Fig. 6). IV valgancyclovir
clamps and the rewarming of the limbs was (Val) was started, and IV methyl prednisolone
important to avoid drastic relative hypo- (500 mg/day) was given for 5 days. Histology
volemia and hypothermia. Continuous com- revealed a Banff grade I acute rejection with pos-
munication with the anesthesia team is itive C4d staining. Donor-specific antibodies
paramount to avoid serious intraoperative (DSA) (flow cytometry) were negative. The AR
complications. was resistant to steroids. Intravenous immuno-
6. Fasciotomies are not needed if ischemia time is globulin (IVIg) was given for 7 days, and
less than 6 h. rapamycin was changed for Tac with rapid clinical
7. A single-pin external fixator is placed in the and histological resolution (Fig. 7). Neutropenia
midtibia for postoperative suspension of the occurred at POD 95 and responded to treatment
limbs. Pressure necrosis can result otherwise. with G-CSF. CMV replication became negative
See Figs. 4 and 5.
The patient was transferred to the ICU for 24 h.

Hourly clinical monitoring of the transplanted
legs was done for 5 days. No special wound care
was provided besides elevation using the mini-
Fig. 6 Steroid-resistant AR at 3 months, coincident with
external fixator. CMV infection and a change from Tac to rapamycin. Treat-
Immunosupression maintenance with mycophe- ment with IVIg and reintroduction of Tac solved the
nolate mophetyl (MMF) 1 g/12 h, tacrolimus (Tac) problem
792 P. C. Cavadas
Fig. 7 Clinical appearance

at 1 year, without signs of
rejection
Fig. 8 Bone consolidation

with good length symmetry
after 37 days of treatment. Val was stopped on day Chimerism tests were not performed in this
307 after verification of cellular CMV immunity patient.
(QuantiFERON-CMV).
A second AR occurred on POM 9, Banff
grade I, related to low through levels of Tac and Outcome, Clinical Photos, and Imaging
MMF reduction because of transient diarrhea (Tac
level 6.5 ng/ml and MMF level 3.4 mg/ml). Treat- At 15 months, the patient had full passive ROM in
ment with dose adjustment reversed the AR. both knees (0–140°), with active knee extension
Two episodes of deep abscess, unrelated to the (M4, MRC score). There was an extension lag of
bone fixation, developed within the left quadri- 30 and 45° on the right and left knees respectively,
ceps, at the muscular sutures. Acinetobacter spp. probably because of insufficient tension on the
and Enterococcus spp. were isolated. Treatment quadriceps repair and/or inadequate protection
with surgical debridement and intravenous with early splinting. There was active flexion of
aztreonam for 6 weeks was curative. Bone healing both knees. Foot (ankle) plantar flexion was M4
was confirmed on X-rays (Fig. 8). Renal function, on both feet, and active extension was M3. Tinel’s
blood pressure, and glucose levels remained nor- sign was advancing at plantar level (Cavadas et al.
mal. CMV replication and DSA were negative. 2013). The patient had fully incorporated the
Fig. 9 A 25-mm mass at

the brainstem in the sagittal
MRI. EBV PCR was
negative in blood but
positive in CSF. Stereotactic
biopsy confirmed the
diagnosis of B-cell
lymphoma (PTLD). This is
an exceedingly rare
complication in
transplantation with a
dismal prognosis.
Immediate reamputation of
the legs and interruption of
IS treatment were done
transplanted legs into his body image, despite the left eye remained and was treated surgically. At
gender mismatch. Walking between parallel bars the time of this writing, the patient is asymptom-
was improving, although there was mild hip flex- atic and continues in complete remission 7 years
ion to compensate for the knee extension lag after the diagnosis of PCNS PTLD.
(video 1). Function was improving steadily.
Clinically, the patient was stable with negative
CMVand EBV replication in peripheral blood. The Avoiding and Managing Problems
patient developed diplopia and strabismus of the
left eye with hypertropia. Trough levels of Tac Surgical complications in this unique case were
were 7 ng/ml. Brain MRI showed a 25-mm mass prevented by careful planning of ischemia times,
in the brainstem (Fig. 9). Positron emission tomog- sequence of repairs, volume and temperature
raphy (PET) showed no other metabolically signif- intraoperative management, and rapid technique.
icant locations. Toxoplasma and fungal antigens Every attempt should be made to reduce the
were negative. EBV polymerase chain reaction amount of bleeding and the potential pulmonary
(PCR) was positive in CSF. Stereotaxic biopsy complications associated with massive transfusion.
confirmed the diagnosis of primary CNS PTLD, The abscess formation on the left side was
with large pleomorphic lymphoid cells CD20+, most probably related to insufficient debridement
CD79a+, CD10 , BCL2 , BCL6 , TdT , and of distal vastus lateralis muscle bulk.
MUM1 . EBV PCR was negative in these cells, The extension lag of the knees was cumber-
although EBV protein LMP1 was positive. CMV some and limited the early ability to walk and was
and JC virus PCR were also negative. most probably due to insufficient tension of the
After discussing with the patient and his family quadriceps repair and the lack of splinting in
the extreme severity of the complication, the IS extension for the first postoperative 3 weeks.
therapy was abruptly interrupted and the legs Plans had been made to revise the quadriceps
reamputated. The patient was treated with high- suture secondarily to tighten and shorten the
dose methotrexate and stereotaxic radiotherapy repair, but the medical complications aborted all
with complete remission. The hypertropia of the planned secondary procedures.
794 P. C. Cavadas
The severe medical complication that precipi- AK levels. Its indication in bilateral AK ampu-
tated transplant removal is extremely infrequent in tees is not established.
EBV D-/R+ (Cavaliere et al. 2010) and most
probably unrelated to the transplanted organ
being a VCA (Cavadas et al. 2015). References
Bulic K, Antabak A, Dujmovic A, et al. Bilateral leg
Learning Points replantation in a 3-Month-Old Baby after a Knee
Level Crush Amputation-A 2-year follow-up. Ann
Plast Surg. 2017;78(3):304–6.
1. Lower limb transplantation is technically pos- Carty MJ, Zuker R, Cavadas P, et al. The case for lower
sible if close attention is paid to technical extremity allotransplantation. Plast Reconstr Surg.
details to reduce the surgical aggression. Oth- 2013;131(6):1272–7.
Cavadas PC, Thione A, Carballeira A, et al. Bilateral
erwise patient’s perioperative death is a very
transfemoral lower extremity transplantation: result at
real risk (Nasir et al. 2014). 1 year. Am J Transplant. 2013;13(5):1343–9.
2. Despite initial enthusiasm among the VCA Cavadas PC, Thione A, Blanes M, et al. Primary Central
community (because of brilliant early results nervous system posttransplant lymphoproliferative
disease in a bilateral transfemoral lower extremity
of hand-transplanted patients) prompted the
transplantation recipient. Am J Transplant.
consideration of lower limb transplantation 2015;15(10):2758–61.
(Cavadas et al. 2013; Carty et al. 2013), medium Cavaliere R, Petroni G, Lopes MB, et al. Primary central
and long-term complications of VCA are very nervous system post-transplant lymphoproliferative
disorder: an International Primary Central Nervous
significant and should be given heavy weight in
System Lymphoma Collaborative Group Report. Can-
the decision-making process of these patients. cer. 2010;116:863–70.
3. The main problem in modern transplantation Hagberg K, Brånemark R. One hundred patients treated
and VCA is not the surgical technique (rela- with osseointegrated transfemoral amputation prosthe-
ses – rehabilitation perspective. J Rehabil Res Dev.
tively well developed), but it is our still incom-
2009;46(3):331–44.
plete understanding of the immunologic Kidney Disease Global Outcomes (KDIGO) Transplant
processes involved and our limited and non- Work Group. KDIGO clinical practice guideline for
specific therapies. The Holy Grail of tolerance the care of kidney transplant recipients. Am
J Transplant. 2009;9(Suppl):S46–8.
is not any closer than it was 20 years ago.
Nasir S, Kilic YA, Karaaltin MV, et al. Lessons learned
4. Lower limb transplantation is clearly from the first quadruple extremity transplantation in the
contraindicated in BK levels and unilateral world. Ann Plast Surg. 2014;73(3):336–40.
Thigh Sarcoma Reconstruction
with Free Functional Latissimus Dorsi 75
Piggyback onto Rectus
Abdominis Flap
Steven Lo
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 797
Primary Reconstruction with Functional Rectus Abdominis Transfer . . . . . . . . . . . . . . . . . 799
Secondary Reconstruction with Free Functional Latissimus Dorsi Flap . . . . . . . . . . . . . . . 801
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 805
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
Abstract techniques described for poliomyelitis recon-

Lower limb sarcoma reconstruction often struction, such as hamstring transfers, or more
entails considerations centering around resto- recent techniques such as free functional mus-
ration of function and not simply defect filling. cle transfers. Here we describe a salvage case
Functional restoration after quadriceps resec- in a thigh sarcoma with quadriceps resection,
tion or femoral nerve loss may involve femoral nerve loss, and femoral artery and vein
resection with bypass. Primary reconstruction
with a pedicled functional rectus abdominis
flap was complicated by complete venous
S. Lo (*) occlusion of the lower limb and secondary
Canniesburn Plastic Surgery Unit, Glasgow, UK native thigh muscle necrosis at 2 months post-
University of Glasgow and The Glasgow School of Art, operatively. CT angiography indicated no
Glasgow, UK

https://doi.org/10.1007/978-3-030-23706-6_105
796 S. Lo
native recipient vessel branches in the thigh for

a second flap, and no obvious limb preserving
salvage option. Limb preservation was
achieved with a free functional latissimus
dorsi piggybacked to the preexisting trans-
posed deep inferior epigastric vessels in the
thigh from the rectus flap. The technique and
rationale are discussed, together with the algo-
rithm for lower limb functional reconstruction
in the West of Scotland sarcoma center.
Keywords Fig. 2 Tumor excision specimen over 6 kg in weight.

Taken en bloc with femoral vessels and nerve
Functional reconstruction · Quadriceps ·
Muscle transfer · Free functional muscle
relatively simple task of soft tissue coverage,
transfer · Sarcoma
centering around issues of vessel reconstruction
and unanticipated sequelae thereof, and loss of
the motors for extension of the knee. We present
The Clinical Scenario here both the primary reconstruction with func-
tional rectus abdominis transfer, major compli-
A 56-year-old previously fit and well man pre-
cation related to femoral vein bypass occlusion,
sented to the West of Scotland sarcoma service
and salvage with a free functional latissimus
with a huge myxoid liposarcoma of the right
dorsi (LD) transfer.
thigh, involving the femoral vessels, nerve, and
majority of the quadriceps muscle group (Figs. 1
and 2). This would entail a complex resection of
Preoperative Problem
the majority of the quadriceps, the femoral
List/Reconstructive Requirements
nerve, femoral vessels, and profunda femoris,
with the patient having undergone neoadjuvant
1. Tumor resection – This was performed in
radiotherapy. This posed a number of problems
conjunction with the sarcoma oncology and
for the plastic surgeon, unrelated to the
vascular surgeons. The extent of surgery was
the majority of the quadriceps muscles and the
entirety of the femoral triangle, femoral artery,
nerve, and vein. Given the extent and potential
morbidity of surgery together with involve-
ment of multiple critical structures, due con-
sideration was also given to ablative surgery
and formed part of the consent process for
primary surgery.
2. Vessel reconstruction – Both femoral artery
and vein were to be resected over the course of
20 cm, including the profunda femoris vessels.
The profunda femoris is a particularly impor-
tant issue, as it supplies the vascularity to the
preferred first line functional reconstructive
option – the long head of biceps femoris. Ves-
Fig. 1 Preoperative MRI showing extensive tumor sel reconstruction was planned with saphenous
involving femoral vessels and nerve vein harvest from the contralateral leg.
75 Thigh Sarcoma Reconstruction with Free Functional Latissimus Dorsi. . . 797
3. Soft tissue deficit – Sarcoma defects in the multidisciplinary team and with a focus on
medial thigh are notorious for the risk of restoring functional outcomes. The choice here
wound healing problems. In patients who have was to use a functional rectus abdominis trans-
had preoperative radiotherapy, a randomized fer, which is rarely described as a functional
trial found the thigh to have the highest wound transfer, and not the center’s first choice for
complication of all sites at 45% (O’Sullivan et al. functional defects in the lower limb (Grinsell
2002). This is of particular concern in patients at et al. 2012). The reasons for using a non-first-
risk of exposure of major vessels or bypass line option are outlined below.
grafts, with secondary hemorrhage or blowout
potential risks of flap reconstructive failure.
4. Functional restoration – With resection of the Treatment Plan
femoral nerve, this would result in a complete
loss of extension of the knee, equivalent to a The West of Scotland treatment algorithm for
four component quadriceps resection. The aims functional restoration of the knee has been previ-
in reconstruction in sarcoma surgery are moving ously described (Flowchart 1) (Lo et al. 2012; Lo
away from simple “hole filling” by ad hoc plas- and Lin 2013). For a four component or complete
tic surgeons, with the plastic surgeon now femoral nerve resection, the preferred option
playing a fully integrated role in the sarcoma would be a hamstring transfer with sartorius
QUADRICEPS
RESECTION
NO MAJOR SOFT TISSUE MAJOR SOFT TISSUE

DEFICIT DEFICIT
<2 HEADS LOSS ≥ 2 HEADS LOSS

INCOMPLETE QUADS
RESECTION COMPLETE QUADS
Funconal reconstrucon Pedicled Funconal
not absolutely indicated (if RESECTION
femoral nerve intact) Muscle Transfers
Free funconing muscle
Funconal reconstrucon flap in isolaon - for
funcon and so ssue Free funconing muscle
may be considered in A. Lateral – long head
context of prosthec cover biceps femoris cover (RF or LD) + augmentaon with
in smaller defects < 2 (Level IV Evidence Ihara, pedicled transfer
B. Medial – Sartorius
heads Innocen )
C. Central – Sartorius
Power remains 67% of (Level IV evidence
normal (Markhede and D. Subtotal– Sartorius + Murumatsu 2011 - poor
Stener 1981) long head biceps femoris outcomes with FFMT in
isolaon)
Flowchart 1 Treatment algorithm

798 S. Lo
centralization, with or without a free flap recon- Alternative Reconstructive Options

struction for soft tissue replacement. This more
conventional approach is described later. For this Functional muscle transfers for quadriceps recon-
particular patient, the specific problem of femoral struction, such as hamstring or sartorius transfers,
vessel resection without profunda reconstruction have been described for poliomyelitis for more than
obviated the use of the hamstrings as a first option. a century (Goldthwait 1897; Crego and Fisher
With no clear option for a free flap anastomosis in 1931). In the last couple of decades, these have
a critical site, other than to the reconstructed fem- been repurposed in the management of oncological
oral vessels, a plan was made for a local flap defects of the quadriceps, and supported more
option. The risk of a free flap to a reconstructed recently by the use of free functional muscle trans-
femoral vessel was thought to be too great, spe- fers (Pritsch et al. 2007; Ihara et al. 1999; Fischer
cifically related to the risk of femoral vein throm- et al. 2015). Objective data to support the actual
bosis rather than arterial thrombosis, with femoral functional role of these transfers is limited, and the
occlusion likely leading to flap loss and exposure author has recently completed three-dimensional
of critical structures. There are few data regarding (3D) gait analysis and electromyography to support
exact thrombosis rates of femoral vein reconstruc- the role of these functional transfers. The typical
tion, but the incidence of deep vein thrombosis in approach to quadriceps reconstruction using ham-
lower limb oncology patients has been reported at string and sartorius transfers is illustrated in Figs. 3,
22% (Yamaguchi et al. 2013) and for femoral vein 4, 5, 6, and 7.
reconstruction occlusion 38% (Park et al. 2018). Although well described as a FFMT, the LD
The initial treatment plan was therefore for an is no longer the author’s personal preference.
oblique rectus abdominis musculocutaneous The free functional rectus femoris transfer is
(ORAM) flap with segmental innervation for now the preferred first option for FFMT in the
functional reconstruction and soft tissue coverage. lower limb. It can be combined with the ante-
The option to tag and preserve motor components rolateral thigh (ALT) flap for extensive skin cov-
of the femoral nerve was also made to allow erage, but its main advantage is that it is a tubular
secondary free functional flap transfer once the muscle with fascial coverage, allowing it to
viability of femoral bypass was ensured. develop a gliding plane, and has an excellent
In this patient, following tumor resection, tendon for recipient site tenorrhaphy. The
major necrosis of the proximal residual thigh mus- major disadvantage of the LD flap is that it
cles including part of the hamstrings occurred at may scar down secondarily onto the wound bed,
approximately 2 months postoperatively, limiting final muscle excursion. Sacrificing a single
resulting in exposure of a desiccated, irradiated component of the quadriceps in harvesting a FFMT
section of femur and arterial conduit. On CT angi- rectus femoris does not significantly impact on the
ography imaging, it was found that the femoral function of the donor limb, as indicated by resec-
vein bypass had completely occluded resulting in tion studies of the quadriceps muscle group
no venous return from the leg. Notably on scans, (Markhede and Stener 1981).
no native arterial branches were noted in the prox-
imal thigh suitable for a salvage free flap due to
resection and vessel reconstruction. At this point, Preoperative Evaluation and Imaging
a consideration was made for proceeding with a
hip disarticulation. On further review of scans, the Primary surgery evaluation. In oncology patients
deep inferior epigastric vessels from the previ- undergoing muscle transfers, routine assessment of
ously turned down ORAM flap were thought to the donor muscles is not normally necessary unless
provide a possible attempt at salvage. Plan at this there is a preexisting abnormality of gait. In patients
stage was to perform a functional latissimus dorsi with congenital anomalies or viral-induced paraly-
transfer onto the existing ORAM flap, thus pro- sis, nerve conduction studies and electromyographic
viding soft tissue salvage, coverage of the arterial assessment may be useful in determining if the
bypass, and restoration of extension of the knee. potential donor muscles (e.g., long head biceps
Fig. 3 Hamstring transfer.

Typically only the long
head of biceps femoris is
taken. (Picture credit: Lee
et al. (2013))
femoris/sartorius) are viable options for transfer.

Standard imaging protocols are used for tumor Surgical Technique
assessment, including contrast-enhanced MRI
and CT. Primary Reconstruction with
Secondary surgery. Following thrombosis of Functional Rectus Abdominis Transfer
the femoral vein bypass, the patient underwent
MR angiography (Figs. 8, 9, and 10). Specific 1. Tumor resection carried out by the oncology
3D renders may occasionally be useful in preop- surgeons, with resection including most of the
erative planning. quadriceps, 20 cm length of femoral artery and
800 S. Lo
Fig. 4 Sartorius transfer. (Picture credit: Lee et al. (2013))
vein and femoral nerve. Tumor specimen 3. Template made for the defect using a sponge
weighed 6 kg. dressing (Fig. 11). The author’s preference is
2. Vessel reconstruction by vascular surgeons for an oblique rectus abdominis paddle as
with saphenous vein conduits for both femoral described by Taylor, as it provides greater
artery and vein. Note that the profunda femoris skin paddle length than vertical or horizontal
artery was not reconstructed. designs (Taylor et al. 1983). Care taken to
Fig. 5 Distal femur osteosarcoma in a different patient. Fig. 8 Patient after re-presentation with wound break-
Endoprosthesis in situ down and exposure of femur at 2 months after primary
surgery. Extensive areas of muscle necrosis in
devascularized segments of hamstring muscles
Fig. 9 Preoperative MR
angiogram showing
complete occlusion of
femoral vein conduit
Fig. 6 Long head biceps transfer raised
Fig. 7 After tenorrhaphy to residual rectus femoris muscle

Secondary Reconstruction with Free
preserve the thoracoabdominal innervation for Functional Latissimus Dorsi Flap
coaptation.
4. Flap was passed extra-abdominally to the 1. The ORAM flap was explored proximally
thigh, and coaptation to suitable motor and the deep inferior epigastric vessels
branches of the femoral nerve. Assessment of divided. As the ORAM was already in situ,
pedicle and nerve coaptation through range of the flap was thought to have revascularized
motion at hip joint carried out. (particularly the fasciocutaneous component)
802 S. Lo
Fig. 10 (a) Red arrow

shows deep inferior
epigastric vessels turned
down into thigh with rectus
abdominis flap. (b) Yellow
arrow shows long bypass
segment (circled blue) with A
occlusion of femoral vein
graft. No artery or vein
branches in thigh
Fig. 11 The primary surgery consisted of a turned down Fig. 12 Secondary surgery consisted of a free functional
oblique rectus abdominis musculocutaneous (ORAM) flap LD flap
with functional innervation to residual motor branches of
femoral nerve
in tension with the knee extended, to avoid
problems with secondary lag.
through surrounding tissue. The flap and mus- 5. Assessment of vascular pedicle and nerve
cle remained perfused after pedicle division. coaptation through range of motion at hip joint.
2. LD harvested as a musculocutaneous flap. This
preserves at least one gliding plane at the native
skin-muscle interface. A muscle-only flap with- Technical Pearls
out a skin paddle will likely develop scar adhe-
sions at the entire flap perimeter (Fig. 12). 1. CT or MR angiography in all patients: In a
3. Anastomoses performed, and nerve coaptation previous review of the center’s lower limb CT
to previously tagged motor branch of the fem- angiography data, approximately 50% cases
oral nerve (Figs. 13, 14, and 15). underwent a change in management plan
4. Muscle tensioning. The aim in muscle transfers based on findings from CT or MR angiography
for extension of the knee is to maintain the flap (Roditi et al. 2015).
Fig. 15 Coaptation of previously marked motor branch of

femoral nerve. LD sutured proximally to residual stump of
rectus femoris
flat muscle so that the deep fascial layer is at

the periphery, is preferable.
3. Tagging of residual motor nerves: To allow
secondary functional reconstruction. It is
important to routinely identify and tag one or
two resected nerve ends that are motor in
nature, to allow easy identification for second-
ary transfers. This was critical in this
Fig. 13 Illustration of free functional LD flap transfer patient’s case.
(Picture credit: Lo and Lin (2013)) 4. Avoid redundancy in venous conduit: The
vein is shorter or at the same length, but
never longer than the artery in order to avoid
kinking. The author’s preference is to have the
vein always marginally shorter than the artery.
5. Functional testing of the anastomoses: It is
critical in all forms of lower limb reconstruc-
tion and particularly functional restoration, that
the anastomoses and pedicle lengths are tested
through the range of expected joint motion.
This is to anticipate any problems with kinking
or compression by muscles when at the limits
of the functional range or if early physiother-
apy is envisaged. The nerve coaptation should
Fig. 14 LD flap in situ connected to the deep inferior
also be checked to ensure it is not tight at the
epigastric vessels from the turned down pedicle of the
previous ORAM flap limits of range of motion.
2. Tubing of functional transfers: Functional

transfers which are not typically tubular in Postoperative Management
nature (for example comparing LD with rectus
femoris) may not have a typical gliding surface Routine flap monitoring is performed. The phys-
and may be more prone to secondary scarring iotherapy protocol for functional quadriceps
to the wound bed. To minimize this, tubing of a reconstruction is as follows:
804 S. Lo
1. Straight leg brace for 6 weeks. the West of Scotland suggesting that they work
2. Mobilize from week 1 with walking aids. in principle like an “internal brace” (unpublished
3. Change to range of motion brace for following data).
6 weeks, graduating increase in ROM.
4. Assess straight leg raise at 6 weeks and intro-
duce isometric and straight leg raise exercises. Outcome, Clinical Photos, and Imaging
5. From West of Scotland 3D gait data, it has been
noted that the ankle plantarflexion or “push-off” The patient had no early postoperative flap-
is impaired in quadriceps reconstruction patients, related complications and can currently mobilize
and therefore physiotherapists are instructed to without a knee brace or walking aids. Late com-
work on calf strengthening exercises. plications included abdominal wall laxity at the
6. From week 12, all braces are discarded for site of his VRAM harvest, but without true bowel
patients with hamstring or sartorius transfers, herniation, managed conservatively. His 3D gait
if able to straight leg raise and patient is confi- analysis testing indicated a Gait Profile Score
dent. For patients on adjuvant chemotherapy, (GPS) of 9.05, which is at the upper end of our
the rehabilitation period is often significantly range GPS scores for functional quadriceps
extended until chemotherapy is complete due reconstruction patients (unpublished data –
to slower healing and overall weakness. patients with functional reconstruction mean
Hydrotherapy and light cycling can be intro- GPS 8.04, normal population GPS 5.4, and
duced. Specifically, for patients with FFMTs, patients without a functional reconstruction
reinnervation may take 6–9 months and longer GPS 10.2), with the rationale being that he has
duration of ROM brace may be required. No had a complete quadriceps loss (femoral nerve
specific muscle stimulation is used during this loss) and extensive secondary surgery. He also
time, with the expectation that passive stimu- underwent environmental simulation testing in
lation occurs during braced walking. the Motek Caren simulator. This is a virtual real-
7. Six months – patients undergo 3D gait analysis ity simulator with an active, tiltable treadmill,
and tailored physiotherapy including orthotics which we use to assess activities of daily living.
where applicable. Orthotics are more relevant This demonstrated that he is able to complete
in patients with endoprostheses, in which case shopping tasks with weighted bags in his hands
leg length disparity may be evident. and is capable of collision avoidance at normal
8. Baseline imaging at 6–12 months. Annual walking speeds (for example, sudden lateral tran-
imaging thereafter according to sarcoma sitions when walking in the street to avoid
follow-up protocols. bumping into other people). His Toronto Extrem-
ity Salvage Score was 66.6, again at the lower
It is important to emphasize to patients that range of scores for our patients. Post-op MRI
improvements can continue over a period of the confirms retention of muscle bulk in the trans-
first few years following surgery, not months, ferred LD at early and late follow-up (Fig. 16).
and that patients should be encouraged to persist He is currently year 6 post-op with no recurrence
in all physiotherapy exercises. Furthermore, the or metastases, and continues with clinical
aim in functional reconstruction is for a knee that follow-up in the Plastic Surgery clinic.
is stable in extension, with less emphasis placed
on knee flexion. This allows the patient to have
stability during “stance” in gait, thus allowing Avoiding and Managing Problems
relatively normal walking at the potential
expense of a knee that does not have full range 1. First choice for FFMT. Consideration in ret-
of flexion. With hamstring transfers, it has been rospect would be given for a FFMT rectus
noted that the knee can be relatively stiff but femoris, as it would provide a tubular muscle
stable in extension, with recent research from with excellent gliding planes, and a strong
Fig. 16 Fourteen months post-op. Free functional LD transfer with retention of muscle bulk (circled blue), with similar
appearance in scans at 6 years post-op
distal tendon. Furthermore, we frequently use recorded and performed by the plastic surgeon
this as a “flow through” configuration, and in conjunction with the oncology team, in
therefore the vascularity to the preexisting anticipation of any future free tissue transfer.
VRAM (in particular the muscle component Motor branches of nerves should likewise be
which may not revascularize through sur- identified and tagged for secondary functional
rounding tissues as the fasciocutaneous com- transfers where relevant.
ponent) can be preserved. 4. Importing a recipient pedicle into the thigh.
2. Vascular reconstruction of the profunda The deep inferior epigastric vessels from the
femoris. Wound breakdown in the proximal VRAM flap were used opportunistically in this
thigh, particular the hamstring compartment, case. However, they can be used as a planned
may have been related to the extensive femoral primary sequential flap, and we have used this
vessel resection but in particular loss of the on one other occasion.
profunda femoris. Connection of the profunda
femoris artery could be attempted if designed
with a suitable side branch of the saphenous Learning Points
vein. However, priority here is to maintain flow
to the distal limb and any such design would 1. The deep inferior epigastric vessels can be used
need to be carefully planned with the vascular as recipients for a free flap salvage in the thigh
surgeons. when no suitable local vessels exist.
3. Planning for a Plan B. With wound compli- 2. Always consider a functional reconstruction in
cations exceptionally high in major thigh the context of major motor nerve or muscle
reconstruction (45%), the primary surgical group resection. The plastic surgeon should
plan must be made with acknowledgment of a not consider their role to be just “hole filling,”
Plan B. Maintaining length of any residual but think of how best they can restore the
recipient pedicles in the limb should be function and quality of life of their patients.
806 S. Lo
3. Functional outcomes should be assessed where Lo S, Lin CH. Functional muscle transfer in lower limb
possible with validated outcome measures reconstruction. In: Levine G, Lee P, Wei FC, editors.
Reconstructive surgery of the lower extremity.
such as the TESS score and 3D gait analysis. Oxford, UK: Taylor & Francis Group; 2013. With
Our responsibility is to demonstrate to patients permission from publisher
and other clinicians that functional transfers Lo SJ, Yeo M, Puhaindran M, Hsu CC, Wei FC. A
have true added value in oncological resection. reappraisal of functional reconstruction of extension
of the knee following quadriceps resection or loss. J
4. Future directions in oncological resections Bone Joint Surg Br. 2012;94:1016–23.
may include nerve transfers for functional res- Markhede G, Stener B. Function after removal of various
toration, in conjunction with soft tissue hip and thigh muscles for extirpation of tumors. Acta
reconstruction. Orthop Scand. 1981;52:373–95.
O’Sullivan B, Davis AM, Turcotte R, Bell R, Catton C,
Chabot P, Wunder J, Kandel R, Goddard K, Sadura A,
Pater J, Zee B. Preoperative versus postoperative radio-
therapy in soft-tissue sarcoma of the limbs: a
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Park D, Cho S, Han A, Choi C, Ahn S, Min SI, Ha J, Min
Crego CH Jr, Fisher FJ. Transplantation of the biceps SK. Outcomes after arterial or venous reconstructions
femoris for the relief of quadriceps femoris paralysis in limb salvage surgery for extremity soft tissue sar-
in residual poliomyelitis. J Bone Joint Surg coma. J Korean Med Sci. 2018;33:e265.
Am. 1931;13-A:515–29. Pritsch T, Malawer MM, Wu CC, Squires MH, Bickels
Fischer S, Soimaru S, Hirsch T, Kueckelhaus M, Seitz C, J. Functional reconstruction of the extensor mechanism
Lehnhardt M, Goertz O, Steinau HU, Daigeler A. Local following massive tumor resections from the anterior
tendon transfer for knee extensor mechanism recon- compartment of the thigh. Plast Reconstr Surg.
struction after soft tissue sarcoma resection. J Plast 2007;120:960–9.
Reconstr Aesthet Surg. 2015;68:729–35. Roditi E, Roditi G, Lo S. Lower limb CT and MRI angi-
Goldthwait JE. The direct transplantation of muscles in the ography in the West of Scotland. In: Scottish Plastic
treatment of paralytic deformities. J Bone Joint Surg. Surgery Meeting 2016, Dunkeld; 2015.
1897;10:246–52. Taylor GI, Corlett R, Boyd JB. The extended deep inferior
Grinsell D, Di Bella C, Choong PF. Functional reconstruc- epigastric flap: a clinical technique. Plast Reconstr
tion of sarcoma defects utilising innervated free flaps. Surg. 1983;72:751–65.
Sarcoma. 2012;2012:315190. Yamaguchi T, Matsumine A, Niimi R, Nakamura T,
Ihara K, Shigetomi M, Kawai S, Doi K, Yamamoto Matsubara T, Asanuma K, Hasegawa M, Sudo
M. Functioning muscle transplantation after wide exci- A. Deep-vein thrombosis after resection of musculoskel-
sion of sarcomas in the extremity. Clin Orthop Relat etal tumours of the lower limb. Bone Joint J. 2013;95-
Res. 1999;358:140–8. B:1280–4.
Diabetic Foot Reconstruction Using
SCIP Flap 76
Contents
Preoperative Problem Lists: Reconstructive Requirement . . . . . . . . . . . . . . . . . . . . . . . . . 808
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Reconstructive Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 812
Intraoperative Images (Figures 8, 9, 10, and 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814
Outcome-Clinical Photo and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815
W. Tonaree
Department of Surgery, Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok, Thailand
H. P. Suh · J. P. Hong (*)
e-mail: joonphong@amc.seoul.kr

https://doi.org/10.1007/978-3-030-23706-6_106
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
Abstract admission. Despite the oral antibiotics from the

Worldwide, approximately 15% of patients primary care hospital, the symptoms were
with diabetes mellitus will develop foot ulcers aggravated.
during their lifetime. Limb salvage procedures At admission, there was no fever, but localized
can increase the 5-year survival rate and also heat sensation was noted on the left foot along the
improve the quality of life. Multidisciplinary fifth day and presented with wet gangrene
team approach is very important to manage the extending proximally on the plantar area with
wound in every medical aspect. Hyperglyce- cellulitis. The vascularity was accessed by palpat-
mia, nutritional status, infection, and underlying the dorsalis pedis and posterior tibial artery,
ing medical condition should be addressed and and both revealed good pulsation. Lab results
controlled. showed leukocytosis and high values of ESR
Diabetic foot ulcer should be debrided and CRP (Fig. 1).
under angiosome concepts. Computed tomog-
raphy angiography plays the role for vascular
status evaluation. Control of the infection and Preoperative Problem Lists:
wound bed preparation should be achieved Reconstructive Requirement
before soft tissue reconstruction.
Microsurgery in diabetic foot patients has 1. Severely infected left diabetic foot ulcer
91.7% success rate which is comparable to 2. Poorly controlled Type 1 diabetes mellitus
nondiabetic foot reconstruction. 3. Anticipated plantar defect after debridement
In this case, a patient who developed 4. The need for soft tissue coverage of the left
infected diabetic foot ulcer at the plantar sur- plantar area
face area is presented. After multiple debride-
ment sessions and also systemic medical
control by a multidisciplinary team, soft tissue Treatment Plan
coverage was performed using superficial cir-
cumflex iliac artery perforator flap. After the patient is admitted to the hospital,
debridement should be performed as soon as pos-
sible to control the infection, limit the ascending
Keyword
spread, preserve as much viable tissue possible,
Diabetic foot ulcer · Diabetic foot and ultimately reach the goal of limb preservation.
reconstruction · Foot reconstruction · Removal of infected necrotic tissue and identifying
Superficial circumflex iliac artery perforator the pocket and the dead space under the skin should
flap · SCIP be performed. Deep tissue culture should be done
during the debridement before starting empirical
antibiotics. If osteomyelitis is suspected, bone
Clinical Scenario debridement should be performed and if possible
perform predebridement and postdebridement
A 35-year-old male patient with the underlying biopsies as well as take histology samples. Addi-
diseases of type 1 diabetes mellitus for 10 years, tional debridements are also planned based on the
with diabetic nephropathy, developed an ulcer wound bed condition after the first debridement.
on the plantar area of the left foot 2 weeks before Empirical antibiotics should be given immediately
76 Diabetic Foot Reconstruction Using SCIP Flap 809
Fig. 1 Preoperative picture
after admission and changed specifically to bacte- perforator flap (SCIP) is considered as the first
rial culture results. choice in this patient.
Multidisciplinary approach will allow to
address multiple problems efficiently while
attending the wound management (Suh and Alternative Reconstructive Options
Hong 2019).
Preoperative vascular evaluation will be 1. Secondary wound healing with NPWT may
performed using computed tomographic angiog- provide a simpler closure solution but will not
raphy and duplex ultrasound to address the vas- provide padding over the defect allowing the
cular status of the foot and potential donor site of patient to use it functionally. It will take a
the flap. One can also consider to perform angio- longer time to heal, and the postoperative care
plasties skipping the diagnostic CT angiogram if trying to prevent ulcerations can be a challenge
the major arteries are not palpable. The flow will (Liu et al. 2017).
be addressed as adequate if the visual arterial flow 2. Free muscle flap with skin graft can be a good
velocity is more than 15 cm/second by the duplex option. In the recent papers, muscle flap with
ultrasonography. One should regard the condition skin graft has a comparable to fasciocutaneous
of the renal function as the dyes used for angio- free flap in terms of functional recovery and
grams can be detrimental (Suh et al. 2016). limb salvage (Cho et al. 2018). It is important
Wound bed preparation is frequently required as a surgeon to consider what works best in
prior to reconstruction through adequate debride- one’s hands. However, the disadvantages
ment, infection control, and adjunctive use of include the donor site functional morbidity
negative pressure wound therapy (NPWT). and also higher wound breakdown complica-
Depending on the site of the defect especially if tion when compared to the fasciocutaneous
the weight bearing region is involved and on the flap (Lee et al. 2019).
extent of the defect, free flap coverage may be 3. Acellular dermal matrix with skin graft may
needed. The flap should be well vascularized to add an additional layer of dermis but will still
fight against infection, thin enough to resist the lack adequate coverage to bear weight.
sheering forces and to allow using reasonable 4. Other fasciocutaneous free flaps, such as ante-
footwear. Based on the characteristics of the rolateral thigh free flap (ALT), can be combined
defect, the superficial circumflex iliac artery with vastus lateralis muscle to obliterate the
dead space. Also if we need the long pedicled

flap, thin ALT is a reasonable reconstructive
option (Hong 2006).
In patients with diabetic foot ulcer, it is important

to correct or address the general condition that is
closely related to surgical outcome. Controlling
the blood sugar level, evaluating renal insuffi-
ciency, correcting nutritional status, and improv-
ing infection are key considerations prior to
surgery. This is why multidisciplinary approach
is effective.
In addition to wound management, one must
consider the skeletal structure and the related
functional outcome. Evaluation starts by
obtaining a plain radiography confirming the
presence of osteomyelitis and Charcot foot. To
Fig. 2 Plain radiography showed osteolytic lesion at
prepare the wound for reconstructive surgery, second-fifth metatarsal bone
serial debridement was planned and instillation
of negative pressure wound therapy will be
performed and changed every 2 days (Figs. 2,
3, and 4).

Drawing
Multiple debridements were performed in conjunc-

tion to using instillation of NPWT. Due to the high
likelihood for microsurgical reconstruction,
detailed evaluation of the vascular status was
needed. As mentioned above, a SCIP flap was
planned as an ideal flap for this case. Using CT
angiogram allows not only to evaluate the overall
vascular status of the entire leg but also to see the
anatomy of the SCIP donor site. Frequently, preop-
erative computed tomography angiography will
allow the surgeon to evaluate for calcification in
the artery helping to determine the need for angio-
plasty and to select possible recipient sites for the
flap as well as evaluate the pattern of the superficial
branch of superficial circumflex iliac artery of the Fig. 3 Plain radiography showed osteolytic lesion at
SCIP flap. Further using of duplex ultrasonography second-fifth metatarsal bone
Fig. 4 Preoperative
computed tomography
angioplasty of the leg
showed good perfusion to
peripheral vessels
will help to understand local anatomy with regard epigastric artery within the superficial fat layer is
to the location of the superficial branch of superfi- performed and marked on the skin accordingly.
cial circumflex iliac artery and superficial circum- Alterations of the design can be made on the
flex iliac vein. It also provides additional table. For example, this patient had a unexpected
information on recipient arteries by measuring the dead space at the plantar surface after the debride-
artery velocity where flow velocity of more than ment. Thus, the flap was designed longer to oblit-
15 cm/second will be enough to provide adequate erate the dead space after the deepithelializing part
flow after anastomosis of the flap. Prior to surgery of the flap (Fig. 5).
during the final designing of the flap, duplex ultra-
sonography (NextGen Logiq-e with 12L_RS
probe, GE Healthcare, WI,USA), 8 MHz vascular Surgical Technique
setting, is used to trace the potential recipient sites
in addition to major axial arteries and superficial On the day of the surgery, a single injection of
veins. The duplex ultrasonography is performed at low-molecular weight heparin is given.
the SCIP donor site. Various information can be All the nonviable, infected soft tissue and
gathered here to aid the flap design. First, the bone were debrided. The fourth and fifth toes
anatomy and calcification of the vessels at both were amputated due to necrosis. Infected pocket
donor and recipient sites with the B-mode and was identified, and debridement and drainage of
then use color flow mode to check the flow velocity the infected fluid and pus were performed.
of the pedicle. If the flow velocity of the main Angiosome of the foot was considered during
branch is faster than 15 cm/second, it is considered the debridement which may enhance the wound
to be safe as a flap pedicle. Preoperative design marginal vascularity from healthy angiosome
using ultrasound to trace the superficial branch of territory surrounding the wound. After debride-
superficial circumflex iliac artery, superficial cir- ment, tissue culture was obtained again to deter-
cumflex iliac vein, and also superficial inferior mine any residual colonization which will be
Fig. 5 Preoperative SCIP

marking and flap design
Fig. 6 Diabetic foot ulcer

after multiple debridement
and instillation of negative
pressure wound therapy
considered for postoperative antibiotic therapy. 2. Superficial circumflex iliac artery perforator
The final defect size was 23 6 cm (Figs. 6 flap was designed at right groin with a
and 7). 24 8 cm skin island.
3. The incision was made initially at the inferior
border of the flap where the superficial fascia is
Reconstructive Technique easy to identify. One the layers between the
deep and the superficial fat is found; dissection
1. First the recipient vessels are explored. In this can begin from lateral to medial until the point
case, the medial plantar artery and vein were that vessels penetrate the deep fascia is shown
dissected and a good pulsation confirmed by the ultrasound exam.
under a 3.5 loupe magnification. For further 4. Meticulous dissection of the perforator in the
preparation of the recipient site, microscope superficial fascia plane is made and the
can be used. pedicle traced toward the source vessel
Fig. 7 Diabetic foot ulcer

after multiple debridement
and instillation of negative
pressure wound therapy
penetrating the deep fascia. Once the perfora-

tor is traced toward the SCIA, one can elevate Technical Pearls
the flap on this artery and vein or elevate on
the perforator. Usually, the accompanying 1. In diabetic patients, multidisciplinary team
vein will drain to the superficial vein, and if should be involved including endocrinologists,
this is the case, one does not need to anasto- vascular interventionists, orthopedic surgeons,
mose the accompanying vein. Rather the plastic surgeons, and nurses.
superficial vein will be easier to anastomose 2. All medical conditions should be addressed and
due to its bigger diameter. Thus, inclusion of controlled including strictly controlled blood
the superficial vein within the SCIP flap sugar level (if HbA1c is above 6.5%, blood
assured good venous drainage as well as allo- glucose level above 200 mg/dl was significantly
wed easier anatomosis. associated with increasing rate of wound dehis-
5. Prior to dividing the pedicle, one should check cence and reoperation rate) (Endara et al. 2013)
the status of the recipient site to make sure and nutrition (prealbumin >15 mg/dl).
there is a good pulse. The flap is elevated and 3. Components of reconstruction for diabetic
the superficial vein anastomosed first in end-to- foot:
end fashion with the medial plantar vein, and a. Debridement using angiosome concept and
then the medial branch of the SCIA anasto- infection control.
mosed in an end-to-side fashion to the medial b. Adequate vascularity to the foot is essential.
plantar artery. If the distal pulses are diminished, one must
6. The flap covered the defect, and the distal part consider preoperative vascular angioplasty or
of the flap was de-epithelialized to obliterate bypass surgery prior to any reconstruction.
the dead space underneath the plantar skin at c. Wound coverage with well-vascularized
the first metatarsal joint area. tissue.
7. A silastic drain and two Jackson-Pratt drains d. Provide good functional outcome; bone and
were placed, and sutured subcutaneously with tendon abnormalities should be corrected if
3–0 Vicryl, and the skin was stapled. needed.
8. A Jackson-Pratt drain was placed at SCIP 4. Negative pressure wound therapy with instilla-
donor site which was then closed primarily. tion is a good option for promoting healthy
Incisional negative pressure wound therapy environment of the wound and stimulating
was performed as a dressing. angiogenesis and granulation. It provides
better clinical outcomes than other standard Postoperative Management

wound cares (Kim et al. 2015, 2014).
5. Preservation of major vessels of the foot is A splint is applied to maintain the right foot and
very important in diabetic patients to prevent ankle position (neutral position) to minimize any
further ischemic change. This is why the tension to the anastomosis area. Adequate hydra-
authors strongly advocate using end-to-side tion is maintained. If fluid collection or hematoma
anastomosis to the artery to preserve distal is suspected underneath the flap, gentle manual
perfusion to the foot. In the case of severe compression of the flap is needed to drain the
calcification, one should search for an artery fluid. The patient starts wheelchair ambulation
segment spared from calcification, use a on day 4–5 after compression of the flap using
branch from the major vessel, or use a flow bandages (Suh et al. 2019). Tolerable weight bear-
through anastomosis. ing is then performed.
Postoperative use of intravenous prostaglandin
E1 to maximize peripheral artery dilation is con-
Intraoperative Images (Figures 8, 9, 10, tinuously used for 5 days. Also, low-molecular-
and 11) weight heparin can be considered. However,
Fig. 8 Superficial
perforator flap, sized
24 8 cm
Fig. 9 Superficial
perforator flap, sized
24 8 cm
view of the foot
view of the foot
when the patient underwent angioplasties prior to showed good contour and good functional out-
reconstruction, the authors did not discontinue the come. The patient can have a normal shoe fitted
anticoagulant therapy. Oral aspirin was given for to the foot (Figs. 12 and 13).
2 weeks (Jin et al. 2019). ESR and CRP were
monitored for detecting occult infection and
inflammation. Antibiotics were given 2–6 weeks Avoiding and Managing Problems
depending on the final bacterial biopsy culture to
control the infection and osteomyelitis. 1. Debridement and infection control is the critical
At the SCIP donor site, incisional negative step and should be promptly performed when
pressure therapy was applied for 5 days after the patient is in a stable medical condition.
primary closure (Peter Suh and Hong 2016). 2. Antibiotic therapy should be changed
according to the pathogen to reduce the chance
Outcome-Clinical Photo and Imaging of bacterial resistance to the antibiotic.
3. During the postoperative period, if flap ische-
Off-loading footwear was used until all of the mia is suspected and the anastomosis is patent,
wound was healed. Compression garment was angiography and vascular intervention should
maintained for 6–12 months for reducing the be performed to detect any proximal arterial
swelling and shearing force to the flap. The flap occlusion.
pictures
pictures
4. In patients with severe atherosclerosis, com- 2. Limb salvage in diabetic foot patients results in
pression garment should be applied after 10– significant increase of the 5-year survival rate
14 days to minimize the flap complication from to 86.8% (Oh et al. 2013).
arterial insufficiency. 3. Components of reconstruction for diabetic
5. If the ESR and CRP are increased during post- foot include debridement using angiosome
operative period, deep infection or osteomye- concept and infection control, adequate vas-
litis should be suspected and managed. Proper cularity to the foot, wound coverage with
imaging might be helpful to investigate the well-vascularized tissue, and good functional
infected site.
outcome.
Learning Points
1. In the diabetic foot ulcer patient, multi- Cross-References

disciplinary team approach is crucial to obtain
the best possible general condition of the ▶ Thin Free Flap for Resurfacing of the Arm and
patient prior to surgery. Forearm
References instillation: review of evidence and recommendations.

Wounds. 2015;27(12):S2–S19.
Cho EH, Shammas RL, Carney MJ, Weissler JM, Bauder Lee ZH, Abdou SA, Daar DA, Anzai L, Stranix JT, Thanik V,
AR, Glener AD, et al. Muscle versus Fasciocutaneous et al. Comparing outcomes for Fasciocutaneous versus
free flaps in lower extremity traumatic reconstruction: a muscle flaps in foot and ankle free flap reconstruction.
multicenter outcomes analysis. Plast Reconstr Surg. J Reconstr Microsurg. 2019;35(9):646–51.
2018;141(1):191–9. Liu S, He CZ, Cai YT, Xing QP, Guo YZ, Chen ZL, et al.
Endara M, Masden D, Goldstein J, Gondek S, Steinberg J, Evaluation of negative-pressure wound therapy for
Attinger C. The role of chronic and perioperative glu- patients with diabetic foot ulcers: systematic review and
cose management in high-risk surgical closures: a case meta-analysis. Ther Clin Risk Manag. 2017;13:533–44.
for tighter glycemic control. Plast Reconstr Surg. Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction
2013;132(4):996–1004. using free flaps increases 5-year-survival rate. J Plast
Hong JP. Reconstruction of the diabetic foot using the Reconstr Aesthet Surg. 2013;66(2):243–50.
anterolateral thigh perforator flap. Plast Reconstr Peter Suh HS, Hong JP. Effects of incisional negative-
Surg. 2006;117(5):1599–608. pressure wound therapy on primary closed defects
Jin SJ, Suh HP, Lee J, Hwang JH, Hong JPJ, Kim after superficial circumflex iliac artery perforator flap
YK. Lipo-prostaglandin E1 increases immediate arte- harvest: randomized controlled study. Plast Reconstr
rial maximal flow velocity of free flap in patients under- Surg. 2016;138(6):1333–40.
going reconstructive surgery. Acta Anaesthesiol Scand. Suh HP, Hong JP. The role of reconstructive microsurgery
2019;63(1):40–5. in treating lower-extremity chronic wounds. Int Wound
Kim PJ, Attinger CE, Steinberg JS, Evans KK, Powers KA, J. 2019;16(4):951–9.
Hung RW, et al. The impact of negative-pressure Suh HS, Oh TS, Lee HS, Lee SH, Cho YP, Park JR, et al. A
wound therapy with instillation compared with stan- new approach for reconstruction of diabetic foot
dard negative-pressure wound therapy: a retrospective, wounds using the Angiosome and Supermicrosurgery
historical, cohort, controlled study. Plast Reconstr concept. Plast Reconstr Surg. 2016;138(4):702e–9e.
Surg. 2014;133(3):709–16. Suh HP, Jeong HH, Hong JPJ. Is early compression therapy
Kim PJ, Attinger CE, Crist BD, Gabriel A, Galiano RD, after perforator flap safe and reliable? J Reconstr
Gupta S, et al. Negative pressure wound therapy with Microsurg. 2019;35(5):354–61.
Femur Reconstruction with a Modified
Masquelet Technique 77
Andreas Gravvanis and Efstathios Balitsaris
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 825
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 825
Abstract
Femoral bone defect associated with infection

presents a reconstructive challenge. A case of a
35-year-old Caucasian male who sustained a
composite and contaminated Gustilo IIIB injury
A. Gravvanis (*) of his left distal femur, following a motorcycle
Plastic, Reconstructive and Aesthetic Surgery, road accident, is presented. The femoral bone
Metropolitan Hospital of Athens, Athens, Greece defect was approximately 10 cm and managed
E. Balitsaris with a new strategy, consisting of a two-stage
Department of Plastic Reconstructive, Microsurgery and
Aesthetic Surgery, Metropolitan Hospital, Athens, Greece

https://doi.org/10.1007/978-3-030-23706-6_131
820 A. Gravvanis and E. Balitsaris
procedure. The first stage involved the infection involved the infection control with Masquelet
control with implantation of a temporary technique, whereas the second stage involved
cement spacer. The second stage consisted of a bone reconstruction with free fibula flap in addi-
free fibula transfer and bone autograft place- tion to morcellized cancellous autologous bone
ment. This modified Masquelet technique, graft.
adding a vascularized bone flap at the second
stage of the reconstruction, resulted in a stable
reconstruction capable of withstanding high Alternative Reconstructive Options
forces while allowing early mobility of the
patient. 1. The Masquelet technique (Masquelet et al.
2000; Masquelet 2003).
Keywords
2. Vascularized fibular flap (Yajima et al. 1993)
with the disadvantage of insufficient mechan-
Femoral bone defect · Masquelet technique · ical strength and reported stress fracture inci-
Temporal cement spacer · Free fibula flap · dence rate of 7–16%.
Bone autograft 3. Osteocutaneous “double-barrel fibular flaps”
(Dautel et al. 2001) or double vascularized
fibula graft with hydroxyapatite (Matsuo
The Clinical Scenario et al. 2008) with significant limitations due
to the limited available bone length plus the
A healthy 35-year-old Caucasian male sustained a short vascular pedicle.
Gustilo IIIB of his left femur, grossly contami- 4. Bilateral vascularized fibula flap (Miyamoto
nated, following a motorcycle road accident. The et al. 2016) with significant increase of the
injury consisted of a distal third shaft fracture of morbidity and operative time.
his left femur, associated with large skin defect of 5. Combined allografts with vascularized fib-
the middle and distal thigh. ula (Capanna method) (Capanna et al. 2007;
Weichman et al. 2015). The allograft offers
immediate structural strength, and the osse-
Preoperative Problem List: ous flap ensures bone-healing, but with the
Reconstructive Requirements disadvantage of increased cost and intoler-
ance in contaminated and/or infected
1. Grossly contaminated Gustilo IIIB fracture of wounds.
the femur with bone defect >5 cm 6. Recycled autografts (Tanzawa et al. 2008).
2. Large skin defect of the middle and distal thigh 7. Recycled or devitalized autograft and a
3. Requirement to prevent early stress fracture, vascularized fibula (Ogura et al. 2015).
nonunion, or delayed union that needs 8. Segmental prostheses (Cipriano et al. 2015).
reoperation 9. Vascularized periosteal flaps used alone or in
combination with allografts (Saad et al. 2017;
Diaz-Gallardo et al. 2017). The periosteum is
Treatment Plan thin and pliable, with high osteogenic and
angiogenic properties, having minimal
The extensive defect of the femur requires thor- donor site morbidity and making it an ideal
ough debridement and a tissue transfer that will graft for small bone defects.
ensure sufficient mechanical strength, fast 10. Ilizarov’s distraction osteogenesis and free
healing, and tolerance to infection. Therefore, a twin-barreled vascularized fibular bone graft
two-stage procedure was planned. The first stage (Lai et al. 2007).
77 Femur Reconstruction with a Modified Masquelet Technique 821
11. A three-stage treatment protocol, combining a (Fig. 1). Imaging of the femur with Computed
two-stage Masquelet technique with a third Tomography (CT) confirmed the size of the
stage of a free fibula flap, in patients with defect.
large defects and not enough cancellous auto- 2. Digital subtraction angiography (DSA) con-
graft (Ma et al. 2017). firmed the existence of superficial and deep
femoral vessels at the traumatized limb, but
smaller branches such as lateral and medial
Preoperative Evaluation and Imaging circumflex femoral vessels were absent due
to the primary injury. DSA showed normal
Upon admission, the patient underwent thorough vascular anatomy at the contralateral
debridement of all devitalized tissues followed lower limb.
by external fixation for damage control, and mus- 3. Color Doppler Ultrasonography (Gravvanis
cle repair resurfaced by split-thickness skin et al. 2013) was used preoperatively to accu-
grafts. rately assess the main vessels (anterior, poste-
rior tibial, and peroneal). Blood flow was
1. Radiograph following the debridement and assessed by standard Doppler measurements
external fixation showed that the femoral of the peak systolic velocity (SV), mean
bone defect was approximately 10 cm velocity (MV), and minimum diastolic
velocity (DV).

Drawing
Stage 1:
1. A plan for the infection control involved was
made, using the first stage of the Masquelet
technique. Preparations for acquiring a poly-
methyl methacrylate (PMMA) cement spacer
with antibiotic were made, as well as the proper
locking compression plate.
2. A vertical incision line was drawn at the ante-
rolateral side of the thigh, at the edge between
the split-thickness skin grafts and the
nonwounded area.
Stage 2:
1. Six weeks later and without any signs of infec-
tion, the second stage of the modified
Masquelet technique was planned to involve
the free fibula flap and the morcellized bone
autograft.
2. An incision was drawn on the previous incision
at the thigh.
Fig. 1 Radiograph following the debridement and exter-
nal fixation for damage control. The femoral bone defect 3. An incision was drawn along the post-
was approximately 10 cm eriolateral edge of the contralateral fibula
Fig. 2 Modified Masquelet

technique. (a) First stage: A
polymethyl methacrylate
(PMMA) cement spacer
with antibiotic was
implanted at the site of the
bone, and fixation was
performed with locking
compression plate. (b)
Second stage: The thigh-
recipient site was prepared,
and the cement spacer was
carefully removed
preserving the formed
“induced membrane.” (c)
The fibula flap was
impacted into the femur and
stabilized with locked nails.
(d) The remaining space
within the “induced
membrane” was filled with
morcellized cancellous
autologous bone graft
4. An incision 2 cm in length was also drawn over 5. A prophylactic dose of a low-molecular heparin
the anterior iliac spine for the cancellous bone was given the evening before surgery, and fur-
autograft harvesting. ther doses were given thereafter every evening.
Surgical Technique Intraoperative Images
Stage 1: See Figs. 1 and 2.

1. An incision was made through the skin and
muscle of the thigh until the full bone defect
was visualized. Postoperative Management
2. Thorough debridement of the devitalized bone
tissue was performed until proper bleeding was Stage 1: The patient was postoperatively closely
seen at both sides of the femur fracture. monitored by physical examination and blood
3. A polymethyl methacrylate (PMMA) cement tests for signs of infection.
spacer with antibiotic was implanted at the site Stage 2: The circulation of the left fibula was
of the bone, and fixation was performed with confirmed using color Doppler ultrasonography.
locking compression plate (Fig. 2a). Rehabilitation started on the tenth postoperative day.
Stage 2: Given the long bone defect, to avoid early frac-
1. Careful dissection through the previous thigh ture and/or nonunion, the patient was strictly
incision was made, and the cement spacer was advised for nonweight bearing activities for
carefully removed preserving the formed 8 weeks, followed by partial weight bearing for
“induced membrane” by the orthopedic team another 4 weeks. At all other times, the limb was
(Fig. 2b). kept elevated. The drains were removed at day
2. Concurrently, the plastic surgery team 7 from the recipient area and on day 2 from the
harvested the right fibula osseous flap. donor area.
3. The flap was shaped as a single barrel Low-molecular heparin doses were given dur-
vascularized bone 10 cm in length, with a ing the rehabilitation time.
peroneal pedicle 14 cm long. Six months postoperatively, the patient was
4. The fibula was impacted into the femur and allowed to full weight-bearing activities with the
stabilized with locked nails (Fig. 2c). use of external support.
5. The superficial femoral vessels were dissected
as recipient at the midthigh area.
6. The right great saphenous vein was harvested Outcome: Clinical Photos and Imaging
as a graft to elongate the fibula’s pedicle, and
end-to-side anastomoses were performed with Bone scan obtained 20 months postoperatively
the superficial femoral artery and vein. showed complete bone union (Fig. 3a). At that
7. The remaining space within the “induced time, the patient was able to walk without any assis-
membrane” was filled with morcellized cancel- tance, despite a slight leg length discrepancy
lous autologous bone graft (Fig. 2d). (Fig. 3b).
The bone defect was close to the knee joint,
and the patient presented 0 –70 range of motion.
Technical Pearls The reduced range of motion was managed with
Thomson procedure in a later stage.
1. In traumatized lower limb, perform microvas- Patient’s both thighs were fractured in the
cular anastomoses “outside the zone of injury,” accident; therefore, direct comparison of weight-
using the great saphenous vein as a graft to bearing capacity was not very indicative. Never-
elongate the pedicle. theless, quantitative technique relying on pressure
2. End-to-side arterial anastomoses preserve dis- sensor grids revealed that the average intensities
tal blood supply to the traumatized lower limb. and the max intensity were not statistically differ-
3. Preoperative Color Doppler Ultrasound study ent between the 2 limbs.
will facilitate the decision for the “healthy No donor-site morbidity including valgus
zone” for microvascular anastomoses. ankle deformity developed.
Fig. 3 (a) Radiograph following 20 months after the Plain radiograph following 36 months after the second
second stage. (b) The patient was able to walk without stage. (d) CT scan following 36 months after the second
any assistance, despite a slight leg length discrepancy. (c) stage showed fibula flap survival and bone union
Plain radiograph and CT scan following 5 cm in length and is associated with soft tissue
36 months after the second stage showed fibula defect and/or infection.
flap survival and bone union (Fig. 3c, d). 2. The decision-making process should consider
the amount of bone and/or soft tissue loss,
the patient’s health status, and willingness to
Avoiding and Managing Problems comply with prolonged treatment and
rehabilitation.
1. Post-traumatic segmental defects of the distal 3. Massive allografts (Capanna method) present
femur pose a reconstructive challenge that is intolerance in contaminated and/or infected
significantly increased as the defect exceeds wounds.
Learning Points reconstructive technique for intercalary defects of

long bones: the association of massive allograft with
vascularized fibular autograft. Long-term results and
1. The Masquelet technique has been used in the comparison with alternative techniques. Orthop Clin
clinical setting for more than 2 decades as a North Am. 2007;38:51–60. https://doi.org/10.1016/j.
method for reconstruction of bone defects with ocl.2006.10.008. PMID: 17145294.
good results. Cipriano CA, Gruzinova IS, Frank RM, Gitelis S, Virkus
WW. Frequent complications and severe bone loss
2. Polymethyl methacrylate (PMMA) spacer con- associated with the repiphysis expandable distal femo-
trols the infection and is always encapsulated ral prosthesis. Clin Orthop Relat Res. 2015;473:831–8.
with a thick fibrous membrane called “induced https://doi.org/10.1007/s11999-014-3564-3. PMID:
membrane” (Mauffrey et al. 2016). 24664193.
Dautel G, Duteille F, Merle M. Use of osteocutaneous
3. The “induced membrane” delivers growth and “double-barrel fibular flaps” in limb reconstruction:
osteoinductive factors, promoting the vasculari- four clinical cases. Microsurgery. 2001;21(7):340–4.
zation and the corticalization of the cancellous PMID: 11754435.
Diaz-Gallardo P, Knörr J, Vega-Encina I, Corona PS,
bone graft, treating femur nonunions success-
Barrera-Ochoa S, Rodriguez-Baeza A, Mascarenhas
fully (Pelissier et al. 2004). The vascularized VV, Soldado F. Free vascularized tibial periosteal
fibula flap has the advantage of fast healing and graft with monitoring skin island for limb reconstruc-
tion: Anatomical study and case report. Microsurgery.
tolerance to infection but has the disadvantage of
2017;37(3):248–51. https://doi.org/10.1002/micr.
insufficient mechanical strength. 30011. PMID: 26621668.
4. The combination of vascularized bone and Gravvanis A, Petrocheilou G, Tsoutsos D,
cancellous bone, possibly contributes long- Delikonstantinou I, Karakitsos D. Integrating imaging
techniques in lower limb microsurgical reconstruction:
standing sufficient mechanical strength in focusing on ultrasonography versus computed tomog-
long bone defects. raphy angiography. In Vivo. 2013;27(3):371–5.
5. Potentially the use of antibiotic-impregnated Lai D, Chen CM, Chiu FY, Chang MC, Chen
TH. Reconstruction of juxta-articular huge defects of
cement spacer at the first stage and the use of
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vascularized bone at the second stage reduce Ilizarov’s distraction osteogenesis. J Trauma.
the likelihood of infection. 2007;62(1):166–73. PMID: 17215750.
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two-stage technique and the requirement for union. Arch Orthop Trauma Surg. 2017;137(4):
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wide resection of malignant bone tumors of the lower Minato H, Tomita K. Histological examination of frozen
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Part V
Breast/Trunk
Composite Axillary Defect After
Sarcoma Resection: Reconstruction 78
with Anterolateral Thigh Flap
Shimpei Miyamoto
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 830
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 834
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 834
Abstract free anterolateral thigh flap. The patients pre-

Reconstruction of composite axillary defects sented with a recurrent malignant peripheral
presents a challenging problem. This case illus- neural sheath tumor at the axillary region and
trates composite axillary reconstruction with the underwent radical resection of the tumor. The
resultant defect included bony thoracic wall and
overlying skin. The defect of bony thoracic wall
was reconstructed with a synthetic material.
S. Miyamoto (*) Because ipsilateral latissimus dorsi flap had
Department of Plastic and Reconstructive Surgery, been used previously, a free anterolateral thigh
Graduate School of Medicine, The University of Tokyo, flap with the iliotibial tract was harvested from
Tokyo, Japan
e-mail: shimiyam555@gmail.com;
ipsilateral thigh without a positional change.
miyamos-tky@umin.ac.jp The vascular pedicle was hooked up to the

https://doi.org/10.1007/978-3-030-23706-6_63
830 S. Miyamoto
thoracodorsal vessels. The flap and the iliotibial

tract were used to cover the synthetic material.
The patient was extubated immediately after the
operation and no respiratory problem occurred.
The flap survived without a vascular compro-
mise and the wounds healed uneventfully. Post-
operatively, his vital capacity reduced by 34%.
Four years after the operation, the patient was
free of disease and his affected arm was useful.
Keywords
Anterolateral thigh flap · Axillary sarcoma ·

Chest wall reconstruction · Iliotibial tract ·
Axillary reconstruction
A 44-year-old man presented to our institution

with a malignant peripheral neural sheath tumor
(MPNST) of his left axilla that had recurred mul-
tiple times. He had a history of two resections at
another hospital. At the time of the second opera-
tion, he underwent full-thickness thoracic wall
resection including the fourth rib and reconstruction Fig. 1 Preoperative patient’s appearance
with a pedicled latissimus dorsi musculocutaneous
flap and a skin graft. Seven years after the second 2. Lack of the ipsilateral latissimus dorsi muscle
operation, the tumor recurred at the left axilla and which had been previously used.
the excisional biopsy revealed recurrence of the 3. Tumor resection was performed with the
MPNST; however, the patient refused further treat- patient in lateral decubitus position. This posi-
ment. Eleven years after the second operation, he tion limited the donor sites which make a
presented to our institution again. two-team approach possible.
At the time of presentation, the tumor had
invaded the thoracic wall and the previously trans-
ferred latissimus dorsi muscle (Figs. 1 and 2). The Treatment Plan
radical resection of the tumor required another
full-thickness thoracic wall resection including The tumor resection was planned to include
three ribs followed by robust reconstruction of 14 12 cm bony thoracic wall and 18 10 cm
the thoracic wall. overlying skin. Three ribs (fifth to seventh) would
be resected. If the tumor was found to adhere to
the lung, the portion of the lung would have to be
Preoperative Problem List: resected simultaneously. The use of synthetic
Reconstructive Requirements material was planned to reconstruct the bony tho-
racic wall. A free anterolateral thigh (ALT) flap
1. Requirement to reconstruct a large composite including the iliotibial tract was chosen to recon-
axillary defect including bony thoracic wall struct the overlying skin and cover the synthetic
and overlying skin. material. The flap was planned to be harvested
78 Composite Axillary Defect After Sarcoma Resection: Reconstruction with Anterolateral Thigh Flap 831
The requirement of the synthetic material for skel-

etal reconstruction in this case is controversial.
Four ribs (fourth to seventh) were resected in
this case; however, the number of resected ribs is
not the only factor that influences the thoracic wall
stability (Arnold and Pairolero 1996; Losken et al.
2004). The iliotibial tract alone when sutured
under tension might provide enough stabilization
without causing flail segments.
The color doppler ultrasonography was performed

on the patient’s left thigh. The presence and the
location of the skin perforators of the ALT flap
were evaluated. In this patient, a dominant
musculocutaneous perforator was found and
marked at the point slightly cephalad to the mid-
point of the thigh. This examination was performed
with the patient in right lateral decubitus position in
Fig. 2 Preoperative 3D-CT of the patient. Green portion
indicates the recurrent tumor order to mark the exact location of the skin
perforators.
from the ipsilateral thigh permitting two-team

approach (Miyamoto et al. 2016a). Preoperative Care and Patient
Drawing
Alternative Reconstructive Options The patient was placed in right lateral decubitus
position. The whole upper limb and lower limb
1. The superiorly based pedicled rectus abdominis were prepped and draped to facilitate the change
musculocutaneous flap. This flap can be har- of the limb position.
vested without a positional change. The disad- The design of the ALT flap was made to
vantages are resultant abdominal wall weakness include the marking of the skin perforator at the
and limited freedom of flap inset. Microvascular anterior cranial quarter of the skin island (Fig. 3).
supercharging of the deep inferior epigastric This flap design enables a large portion of the
vessels may be necessary (Chang et al. 2004). iliotibial tract to be incorporated into the flap.
2. The free rectus abdominis musculocutaneous
flap or deep inferior epigastric artery perforator
flap. These flaps also can be harvested without a Surgical Technique
positional change. The disadvantages are resul-
tant abdominal wall weakness and lack of fas- 1. The tumor resection was performed by the
cial support of the flap (Tukiainen et al. 2003). orthopedic surgeons and the thoracic surgeons.
3. The free or pedicled omental flap. The disad- The size of the defect was as planned, and the
vantages are requirement of laparotomy and adhering portion of the lung was resected
positional change to harvest the omentum. Fur- simultaneously (Fig. 4).
thermore, skin graft is necessary to cover the 2. The ALT flap was harvested from the ipsilat-
omentum (Watkins and Thomas 1985). eral thigh with the patient in lateral decubitus
832 S. Miyamoto
Fig. 3 Drawing the flap at the left thigh. Left side is

cranial. Note the location of the used perforator (arrow) at Fig. 5 Intraoperative view of the harvested flap
the anterior cranial quarter of the skin island
5. The thoracodorsal vessels were dissected and

used as recipient vessels. The flap artery was
anastomosed to the thoracodorsal artery in an
end-to-end fashion. Two comitant veins were
anastomosed to the thoracodorsal vein and its
branch in an end-to-side fashion and with a
venous coupler, respectively.
6. The bony thoracic wall was reconstructed
using the synthetic material (GORE-TEX soft
tissue patch, WL Gore & Associates.inc, DE)
(Fig. 6). After flap revascularization, the
iliotibial tract of the flap was sutured to the
Fig. 4 Intraoperative view after tumor resection thoracic wall covering the synthetic material
(Fig. 7). The skin defect was closed using the
skin island of the flap (Fig. 8).
position without a positional change. First inci- 7. The donor site of the ALT flap was closed with
sion was made the anterior border of the flap a split-thickness skin graft from the buttock
and the flap was raised from the anterior to the (Fig. 9).
posterior including the fascia lata. The skin
perforator was found around the intramuscular
septum between the rectus femoris and the Technical Pearls
vastus lateralis muscles.
3. The intramuscular septum was widely opened, 1. The design of the ALT flap was made to
and the skin perforator was retrogradely dis- include the marking of the skin perforator at
sected up to its origin. This perforator was of the anterior cranial quarter of the skin island.
the musculocutaneous type and coursed through 2. The ALT flap can be harvested even with the
the vastus lateralis muscle. The origin of the patient in lateral decubitus position (Miyamoto
perforator was the oblique branch of the lateral et al. 2016a, b).
circumflex femoral artery (Wong et al. 2009). 3. The anterior approach is advisable to find the
4. After completing dissection of the vascular skin perforator of the ALT flap. Care must be
pedicle, lateral incision was made and maxi- taken not to mistake the rectus femoris for the
mum size of the iliotibial tract was harvested. vastus lateralis muscle because differentiation
Then, the vascular pedicle was clamped and of the muscles is more difficult in lateral
transected (Fig. 5). decubitus than in supine position.
Fig. 6 Intraoperative view of the thoracic wall reconstruc- Fig. 9 Appearance of the donor site immediately after
tion with the synthetic material operation
The patient was extubated immediately after the

operation. No respiratory problem occurred. The
chest drain was removed on the second postoper-
ative day. The flap survived without a vascular
compromise and the wounds healed uneventfully.
The patient underwent adjuvant radiation therapy

Fig. 7 Intraoperative view of revascularization of the flap.
Arrows indicate the vascular pedicle (60Gy/30fr) because the surgical margin was pos-
itive. Four years after the operation, the patient
was free of disease and his affected arm was
useful. The range of motion of his left shoulder
joint was full (Fig. 10). Although paradoxical
breathing was not found, the results of his post-
operative spirogram revealed moderate restrictive
impairment (Fig. 11). His vital capacity reduced
from 4.06‘ preoperatively to 2.66‘ 5 months post-
operatively and the vital capacity also reduced
from104.1% to 68.7%.
Fig. 8 Appearance immediately after operation 1. Preoperative color doppler ultrasonography of

the donor site should be performed with the
patients in lateral decubitus position. The loca-
Intraoperative Images tion of the skin perforator can shift depending
on the patient’s position. The intramuscular sep-
See Figs. 4, 5, 6, 7, 8, and 9. tum between the rectus femoris and vastus
834 S. Miyamoto
patient’s appearance at
a b
30-months follow-up
Learning Points
1. The ALT flap is highly versatile for reconstruc-

tion of composite axillary defects after sar-
coma resection. It can be tailored to the
requirements of the individual’s defect. Flap
harvesting in lateral decubitus position enables
a two-team approach.
2. The bony thoracic wall can be reconstructed
with the iliotibial tract alone which can be
incorporated to the ALT flap if the size of the
defect is small. If the size of the defect is large,
combined use of a synthetic material becomes
necessary to avoid paradoxical breathing.
Fig. 11 Postoperative CT at 4-years follow-up References

lateralis muscles should also be confirmed and Arnold PG, Pairolero PC. Chest-wall reconstruction: an
marked using the ultrasonography because dif- account of 500 consecutive patients. Plast Reconstr
Surg. 1996;98(5):804–10.
ferentiation of the muscles during flap harvest is
Chang RR, Mehrara BJ, Hu QY, Disa JJ, Cordeiro
sometimes difficult in lateral decubitus position. PG. Reconstruction of complex oncologic chest wall
2. The branches of the subscapular arterial system defects: a 10-year experience. Ann Plast Surg.
are commonly used as recipient vessels in this 2004;52(5):471–9; discussion 479.
Losken A, Thourani VH, Carlson GW, Jones GE,
type of reconstruction. Care must be taken for
Culbertson JH, Miller JI, et al. A reconstructive algo-
the arm position not to compress the vascular rithm for plastic surgery following extensive chest
pedicle during early postoperative days. wall resection. Br J Plast Surg. 2004;57(4):295–302.
Miyamoto S, Fujiki M, Kawai A, Chuman H, Sakuraba M. defects. Ann Surg. 2003;238(6):794–801; discussion
Anterolateral thigh flap for axillary reconstruction after 801–2.
sarcoma resection. Microsurgery. 2016a;36(5):378–83. Watkins RM, Thomas JM. The role of greater omentum in
Miyamoto S, Fujiki M, Sakisaka M, Kawai A. Combined reconstructing skin and soft tissue defects of the groin
use of the latissimus Dorsi musculocutaneous flap and and axilla. Br J Surg. 1985;72(11):925–6.
the anterolateral thigh flap to reconstruct an extensive Wong CH, Wei FC, Fu B, Chen YA, Lin
shoulder defect in an NF-1 patient. Plast Reconstr Surg JY. Alternative vascular pedicle of the anterolateral
Glob Open. 2016b;4(4):e670. thigh flap: the oblique branch of the lateral circum-
Tukiainen E, Popov P, Asko-Seljavaara S. Microvascular flex femoral artery. Plast Reconstr Surg. 2009;123
reconstructions of full-thickness oncological chest wall (2):571–7.
Anterolateral Thigh (ALT) Free Flap
Reconstruction of a Complex Chest 79
Wall Defect
Christian M Asher, Mwango Bwalya, Navid Ahmadi,

Aman S Coonar, and Charles M. Malata
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 838
Illustrated Case Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 840
Radiological Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 841
Intraoperative Sequence for the ALT Flap Harvest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 843
Recipient Vessel Exposure: The Internal Mammary Vessels . . . . . . . . . . . . . . . . . . . . . . . 846
Skeletal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847
Microsurgery: Anastomoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 849
Microanastomoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850
C. M. Asher
Department of Plastic & Reconstructive Surgery,
Addenbrooke’s Hospital, Cambridge University Hospitals
NHS Foundation Trust, Cambridge, UK
M. Bwalya
Department of Cardiovascular Science, UCL, London, UK
N. Ahmadi · A. S. Coonar
Royal Papworth Hospital, Royal Papworth Hospital NHS
C. M. Malata (*)
Addenbrooke’s Hospital, Cambridge University Hospitals
NHS Foundation Trust, Cambridge, UK
School of Medicine, Anglia Ruskin University, Cambridge
& Chelmsford, UK
e-mail: charles.malata@addenbrookes.nhs.uk

https://doi.org/10.1007/978-3-030-23706-6_64
838 C. M. Asher et al.
Postoperative Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850

Contributing Factors to Case Complexity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855
Abstract Keywords
The objective of chest wall reconstruction is to ALT · Anterolateral thigh-free flap · Chest wall
protect intrathoracic structures through the res- defects · Clinical scenarios · Reconstructive
toration of a semirigid thoracic skeleton, pro- challenges · Flap outcomes · Technical pearls ·
vide robust soft tissue, and in some cases, Vascular pedicle · Surgical indications
obliterate intrathoracic dead space, all without
limitation on the normal physiological excur-
Introduction
sion of the chest wall during ventilation
(Sanna et al., J Vis Surg 3:95, 2017a). Pedicled The objective of chest wall reconstruction is to
(locoregional) flaps provide adequate soft tissue protect intrathoracic structures through the resto-
cover, can obliterate dead space and keep the ration of a semirigid thoracic skeleton, provide
surgical field regional (Dingman and Argenta, robust soft tissue, and in some cases, obliterate
Ann Thorac Surg 32(2):202–208, 1981; intrathoracic dead space, all without limitation on
Pairolero and Arnold, J Thorac Cardiovasc the normal physiological excursion of the chest
Surg 90(3):367–372, 1985; Azarow et al., wall during ventilation (Sanna et al. 2017a). Ped-
Surg Clin North Am 69(5):899–910, 1989). icled (locoregional) flaps provide adequate soft
These are either advanced (locally) or trans- tissue cover and can obliterate dead space and
posed some distance; however, they are often keep the surgical field regional (Dingman and
limited by their size, reach, or unavailability. Argenta 1981; Pairolero and Arnold 1985;
Free tissue transfer into extensive defects con- Azarow et al. 1989). These are either advanced
stitutes the ultimate reconstructive tool when (locally) or transposed some distance; however,
adjacent and locoregional tissues have been they are often limited by their size, reach, or
unavailability. Free tissue transfer into extensive
involved in previous reconstruction, have been
defects constitutes the ultimate reconstructive tool
disturbed and compromised by the effects of
when adjacent and locoregional tissues have been
disease, surgery, and radiotherapy, or where
involved in previous reconstruction, have been
robust soft tissue coverage is required to restore
disturbed and compromised by the effects of dis-
form, function, and protect vital underlying ease, surgery, and radiotherapy, or where robust
structures and organs (Gottlieb and Krieger, soft tissue coverage is required to restore form,
Plast Reconstr Surg 93(7):1503–1504, 1994; function, and protect vital underlying structures
Janis et al., Plast Reconstr Surg 127(Suppl and organs (Gottlieb and Krieger 1994; Janis et al.
1S), 2011). We illustrate an interdisciplinary 2011).
approach to complex chest wall reconstruction The anterolateral thigh (ALT) free flap is a
highlighting peri-operative considerations and reliable reconstructive option for soft tissue
technical pearls to optimize patient outcomes. coverage in large and complex defects of the
79 Anterolateral Thigh (ALT) Free Flap Reconstruction of a Complex Chest Wall Defect 839
chest wall. Indications for use include recon- 1995). A pertinent advantage of the ALT flap
struction following therapeutic tumor ablation, in chest wall reconstruction is that it can be
palliative oncological resection of advanced or harvested at the same time as resection surgery
recurrent malignancies, radiation-induced with a two-surgeon approach (Wei et al. 2002;
ulceration, postoperative sternal wound dehis- Shahzad et al. 2013).
cence, recalcitrant sternal infections, and tho- Harvesting vascularized fascia and muscle
racic trauma (Press et al. 1988; Wei et al. 2002; with the ALT enables dead space obliteration,
Tukiainen et al. 2003a; Di Candia et al. 2010; even in thin patients following radical resections,
Nasajpour and Steele 2011; Di Candia et al. improved delivery of antibiotics to the recipient
2012; Kim et al. 2019; Miyamoto et al. 2021). site, protection of the vascular pedicle/perfora-
First described by Song et al. in 1984, the ALT tors, and facilitates more efficient and safer flap
free flap is supplied by musculocutaneous or harvest while reenforcing flap inset at the recip-
septocutaneous perforators arising from the ient site (Di Candia et al. 2010; Salo and
descending branch of the lateral femoral cir- Tukiainen 2020).
cumflex artery. It is “notorious” for vascular Ultimately, success of free flap-based chest
variation, their incidence, and use well wall reconstruction is determined by the pres-
described within the literature, further advanc- ence of undamaged, reliable, and readily acces-
ing its popularity (Koshima et al. 1989; Kimata sible recipient vessels for the microvascular
et al. 1998; Lee et al. 2015; Smith et al. 2017; anastomoses. The internal mammary vessels
Cormack and Lamberty 1995). (ipsilateral or contralateral) are ideal for centrally
The ALT flap offers great versatility for use based reconstructions while the thoracodorsal-
in simple and complex chest wall reconstruc- subscapular vascular axis provides reliable ves-
tions. It is a donor of pliable tissue up to sels of adequate length for the microvascular
15 x 30 cm with direct donor site closure, reconstruction of lateral chest wall defects (Salo
wider if grafted, and a long vascular pedicle and Tukiainen 2020). Alternative local recipient
length (Bégué et al. 1990; Wei et al. 2001; sites include the deltopectoral vessels; however,
Lakhiani et al. 2012). It can be raised as a cuta- thoracic vasculature can be compromised by
neous, fasciocutanenous, or a musculocutan- local disease, divided as part of tumor ablation
eous flap (Di Candia et al. 2010; Di Candia (be it a therapeutic or a debulking procedure),
et al. 2012; Seder and Rocco 2016; Groth et al. compromised by previous surgery, or rendered
2020) and in a chimeric fashion (Koshima et al. unsuitable by previous radiation or infection.
1993) allowing it to be tailored to almost any Extrathoracic anastomoses are described includ-
defect with minimal donor site morbidity coming branches of the external carotid, subclavian
pared to flaps raised from other sites (Di Candia artery, and the inferior epigastric artery with or
et al. 2010; Di Candia et al. 2012; Kimata et al. without bridging venous grafts or venous loops
1998; Marsh and Chana 2010; Kuo et al. 2009). (Di Candia et al. 2010; Threlfall et al. 1982;
Though vascular variation is described (Wei Tukiainen et al. 2003b; Hussain and Malata
et al. 2002; Kim et al. 2019; Koshima et al. 2010).
1989; Kimata et al. 1998), the perforators are We present a complex chest wall reconstruc-
readily mapped on the skin perioperatively with tion case (on several fronts), illustrating a system-
a handheld (pencil) Doppler while the location atic approach to perioperative management and
of the most dominant perforator has a consistent illustrate the versatility of ALT free flap for chest
anatomical location (Cormack and Lamberty wall reconstruction.
Illustrated Case Report
A B C
Preoperative images of a 73-year-old Visible telangiectasia, tissue atrophy, The angiosarcoma and skin were
woman with a fixed ulcerated, and lateral rotation of the breast adherent to the underlying tissues
fungating, mal-odorous radiation- mound due to tethering (indrawing by following adjuvant radiotherapy to
induced angiosarcoma of the right the tumor) the site of a previous wide local
lateral breast with indrawing and excision of a lobular breast
distortion of the breast carcinoma
D
Intraoperative images showing the palpable margin of tumor and involved skin
marked (dashed line)
A 5 cm margin beyond the area of induration creating a defect that would on
estimate be 20x18cm
E
The midline was marked with identification of the second rib costal cartilage to
guide internal mammary vessel preparation intraoperatively
F
Close-up image showing an exophytic, fungating mass eroding into and
contracting the underlying tissue, distorting the contour of the breast. The post-
radiation telangiectasia and tissue atrophy are visible
including the pectoralis minor muscle, the inter-

Radiological Investigations
costal muscles and abutted the ribs. There was,
however, no pleural involvement.
CT and MRI scans were performed to assess local
involvement and stage the disease. The
angiosarcoma had invaded the chest wall
G
CT scan demonstrating involvement of the chest wall on
the right side. The tumor invades the soft tissues and
abuts the ribs. There was no evidence of bony infiltration,
pulmonary or other distant metastases identified on the
remainder of the scans
H
MRI scan illustrating the soft tissue extent of the tumor
which did not extend into the pleura
Intraoperative Sequence for the ALT

Flap Harvest
I The reconfirmed ALT flap margins on the left thigh

(purple ink) for reconstruction of the 20 x18cm chest wall
defect. The septum between rectus femoris and vastus
lateralis is typically found along the vertical axis between
the anterior superior iliac spine (ASIS) and the lateral
patella (dashed black line). The most dominant perforator
is found within 3cms, inferolateral to the midpoint of this
line. Cross-hatchings are to guide/ align subsequent
donor site closure.
A handheld pencil Doppler (8 MHz) is used to identify
the main perforators, typically within a 2 cm radius of the
junction between the proximal and middle third of the
vertical axis (circled blue crosses). The flap outlines are
extended medially toward the midinguinal point to
facilitate exposure of the pedicle.
J
The flap was raised and included fascia and a cuff of vastus
lateralis, the latter providing substance to obliterate dead
space following oncological resection on the chest wall
and negating the need for intramuscular dissection.
K
A well-perfused flap prior to pedicle division and
transfer. The flap is secured to surrounding tissues with
silk sutures (or staples) to prevent accidental avulsion of
the pedicle prior to division and inset in the chest wall
defect.
L
The therapeutic tumor resection (20 cm x 18 cm)
included a 5 cm margin (solid blue line) from the
indurated, irregular, and unstable borders of the tumor
(interrupted line). The inferolateral relation of the tumor
and site of previous radiotherapy to the second rib costal
cartilage is illustrated.
M
Following sterile prep, the excision margin is redefined.
N
En bloc resection was performed, including the antero-
lateral segments of the 4 underlying ribs (ribs 2–5).
O
The resected mass viewed in isolation (O). It includes
irradiated tissue. The central yellowish-brown
discoloration is due to the betadine swab used to cover it
during the resection to prevent bacterial contamination of
the thoracic cavity.
P
There was no macroscopic evidence of tumor on the
under surface confirming complete resection. (P)
Q
The lateral thoracic defect prior to reconstruction: This is
full thickness, exposing lung, diaphragm, and
pericardium with covering fat and mediastinum (under
the lung).
Recipient Vessel Exposure: The

Internal Mammary Vessels
R
The internal mammary vessels as viewed from inside the
chest cavity. This is an unusual view for plastic surgeons.
It clearly shows the internal mammary artery (pale) with
its two venae comitantes on either side (bluish tinge)
encased in prepleural perivascular fat. The vessel pedicle
was mobilized by the cardiothoracic surgeons; therefore,
there was no need to dissect the vessels from the
superficial aspect of the ribs. Please note the pericardium,
with overlying small blood vessels superomedial to the
diaphragm. The axis of the heart is positioned
superomedial in relation to the liver and lung and covered
anteriorly by mediastinal fat.
Skeletal Reconstruction
S
Skeletal reconstruction involved a trilamellar construct, the
methylmethacrylate-mesh “sandwich” (Figures S,T,U).
With chest drains inserted deep to the mesh, the first or
base layer, polypropylene mesh is inset. This is trimmed to
size and tightly secured with interrupted 0 ethibond sutures
to the residual rib/thoracic skeleton/cage.
T
The second layer is the methylmethacrylate cement.
It is placed onto the mesh and molded to form. Cold
saline is continuously dripped onto the cement as it
“sets.” This prevents undue heat transfer and thermal
injury to the underlying vital structures like the lung,
heart, and liver. Care needs to be taken as very cold water
can induce cardiac dysrhythmia and therefore should not
be allowed to accumulate inside the chest. During this
phase, the right lung is deflated again to avoid thermal
injury.
U
The third and most superficial layer of the skeletal
reconstruction is another layer of Marlex mesh.
Both mesh layers were secured to the rib/ thoracic
“remnant” using both interrupting and running O
ethibond sutures. Care should be taken to avoid injury to
the vascular pedicle directly or through compression.
It is crucial to leave sufficient space between the chest
wall and the mesh “’sandwich” to allow some movement
of the vascular pedicle and prevent kinking.
Microsurgery: Anastomoses
V. i
The recipient internal mammary vascular pedicle is
shown coming from under the chest wall prior to
anastomoses (V.i).
V.ii
Note the adequate space between the mesh sandwich and
the cut edge of the chest wall (V.ii).
W
Both recipient and donor vessels are in view prior to the
microanastomoses, resting on a green visibility
background, raised (by swabs) to a more superficial
position to facilitate microsurgery in a horizontal plane.
The ALT artery (arrow) is longer and narrower than
the vein (with a ligaclip on it, none on the artery). The
ALT is secured to the chest wall with silk sutures for
stability during the microanastomoses. This is crucial in
chest wall reconstruction because of the continuous
ventilatory excursion of the thorax. It is important to keep
the mesh-sandwich isolated from the environment by
swabs soaked in antiseptic to prevent bacterial
colonization during the microanastomoses.
The flap included a cuff of vastus lateralis,

Microanastomoses
providing adequate soft tissue cover for the resec-
tion, muscle to contribute obliteration of dead
A continuous, hand sewn, end-to-end (EEA)
space, while also protecting the supplying perfo-
venous anastomosis of ALT vein to IMV was
rators, eliminating the need for skeletonization.
performed while ALT artery was anastomosed
EEA to the IMA with interrupted sutures. Both
microanastamoses were performed with a 9/0 Postoperative Follow-up
monofilament nylon.
The ischemia time from flap division to com- There were no complications such as
pletion of the last anastomosis was 105 minutes, reexploration, partial or total flap failure, return
and the total operation time from knife-to-skin to to theater, or readmission. The patient was
the last suture was 540 minutes. discharged home on the 13th day.
3 months postoperative image comparison

A robust reconstruction with primary healing enabled by the transfer of well vascularized tissue into a hostile (irradiated)
bed
3 months post-operative image comparison

3 months post-operative image comparison

The donor was mostly closed primarily. The 18 cm width centrally in a thin woman necessitated the central portion to be
grafted. The skin was harvested from the same thigh to avoid exposing another leg during surgery, thus minimizing
additional heat loss and loss of efficiency repreparing and redraping. A small area of unhealed skin graft is visible at the
proximal aspect of grafted thigh. This is common and due to the movement of the underlying muscle (with inevitable
telescoping). The contour of the leg was not significantly affected, and both donor and graft recipient site healed.
reconstruct the bony defect (Sanna et al.

Contributing Factors to Case
2017b; Wells and Coonar 2018).
Complexity
(d) Prior radiation damage: The tumor was
thought to be due to the extensive previous
The patient herein presented posed several chal-
irradiation for lobular breast cancer after
lenges which contributed to its complexity:
breast-conserving surgery by means of wide
local excision. The tissues within this previ-
(a) Resection size and extent: This was a full ously irradiated surgical filed were atrophic,
thickness defect from skin to parietal pleura firm, and scarred, had lost their normal tissue
(depth) as shown in the postresection image planes (making dissection difficult), and pro-
(Q). vided a poorly vascularized source of tissue
(b) Large segmental bony defect: caused by the with poor healing potential.
resection of multiple ribs (second to fifth rib) (e) Tumor morphology: This was a large, exo-
(P, Q). phytic tumor, ulcerated and fungating through
(c) Skeletal reconstruction: This was required due the skin increasing the risk of infection. It was
to the high risk of flail chest if a suitably sized tethered to underlying muscle, and the borders
skeletal reconstruction was not undertaken to were indeterminate. The resection needed to
be extensive to reduce the risk of incomplete risk of compromised ventilation postopera-

margins and the reconstruction robust enough tively, additional abdominal morbidity would
to allow the normal function of the chest wall not be acceptable if a suitable alternative were
and viscera. available.
(f) Tumor histology: Sarcoma and radiation- (i) Decision-making to avoid the abdomen and
induced malignancy represent histologically the back: A robust, vascularized flap (in the
aggressive malignancies, and the true extent form of a free tissue transfer) was therefore
of infiltration is macroscopically difficult to needed in the face of previous radiation without
determine. They require wide margins of resec- increasing operative time as has been empha-
tion (David and Marshall 2011). There is sized by other authors (Press et al. 1988).
potential for repeated local recurrences if not (j) Potential iatrogenic injury of recipient vessels:
completely resected (Pantelides et al. 2013) Extensive resection of the right chest wall with
hence the need of 5 cm margin used in this case. a 5 cm margin resulted in the defect being
(g) Older age group with comorbidities: This within centimeters of the sternum. Joint surgi-
was an elderly relatively frail female. The cal planning included planning approach to
extent of the planned surgery, previous sur- avoid damage to the recipient site vessels. In
gery, and thoracic radiation posed a signifi- case of inadequate flow of the recipient vessels,
cant anesthetic risk. the contingency plan was the use of the contra-
(h) Donor sites: In this case, the patient possessed lateral vessels through tunneling or extra-
limited surplus tissues suitable to reconstruct thoracic vessels including those arising from
the defect. The ipsilateral latissimus dorsi the external carotid (Di Candia et al. 2010).
(LD) flap could not be relied on because of
previous axillary surgery, and the vascular ped-
icle may have been compromised by the inci- Technical Pearls
dence of this tumor. It was unclear
preoperatively if tumor resection would involve The resection margins in aggressive chest malig-
sacrifice of the TDAvascular axis. Furthermore, nancies are extensive in order to achieve clear
the LD flap would have also been within the oncological margins (David and Marshall 2011).
previously irradiated field to a variable degree; In this case, the wide resection also excised a
therefore, avoidance of its use primarily would portion of the previously operated and irradiated
minimize intraoperative challenges and risk of tissues, optimizing the recipient site.
delayed wound healing (as there was no room Soft tissue reconstruction on a mobile, convex
for error in terms of avoiding flap failure/ surface must be robust, particularly to withstand
wound breakdown). Use of the contralateral the cyclical mechanics and pressures of ventila-
LD, as a free flap (Tan et al. 2016), would entail tion and coughing. The choice of reconstruction in
serial changes in patient position on the operat- this case introduced fresh, well vascularized tissue
ing table with attendant increase in operative into a suboptimal surgical field. It allowed a two-
time, risk of infection through exposure of vital surgeon team approach reducing operative time
organs, and damage to them and the flap while and allowed closure of the donor site, largely
precariously attached peripherally at the donor primarily, with neither donor- nor reconstruction-
site prior to transfer. A regionally based recon- limiting function. Enough donor tissue was avail-
struction was therefore not ideal primarily. The able to close the defect. Although a small skin
abdominal tissues are a reliable source of tissue graft was required for the donor site, the outcome
for chest wall reconstruction (Azarow et al. was satisfactory.
1989); however, dissection through harvest of Recipient vessel selection, microanastomosis
rectus abdominis poses risk of weakness to the technique, and pedicle placement are equally
abdominal wall. In the context of this patient important in microsurgery and complex chest
undergoing a thoracic resection and preexisting wall reconstruction. The caliber of the ALT artery
(descending branch of the lateral circumflex fem- restoration of both form and function of the
oral artery) ranges between 1.5 mm and 2.5 mm patient’s thoracic cavity. It is important all
with slightly larger veins, a reasonable match for involved teams are familiar with one another’s
the internal mammary vessels (IMA 0.9 mm to surgical approach, operative aims, and require-
2.5 mm 2.7 mm IMV) (Arnez et al. 1995; Murray ments. The versatility of the two operative teams
et al. 2012). During dissection, no diathermy was in this illustrated case allowed for oncological
used during recipient vessel dissection. Vessel resection and flap harvest to occur simulta-
dissection was performed by the senior author neously. Furthermore, contingency plans were
with loupe magnification, which avoids inadver- formulated including if the recipient vessels of
tent traction injury through an unmagnified field. the ipsilateral IMA/IMV vessels were injured/
The flap was harvested with a pedicle with resected during oncological resection.
enough length not to be under tension when inset This case should be assessed and managed
and anastomosed at the recipient site and the chest within the multidisciplinary team (MDT) setting,
wall at maximum convexity on ventilation. offering the gold standard care, particularly for
The inclusion of muscle is useful in complex complex cases. Patient wishes should be care-
reconstruction. The muscle is well vascularized, fully considered. Both contrast-enhanced CT
and its inclusion reduces both operative time and and MRI were useful for staging and to deter-
the need for extensive perforator dissection, lim- mine the extent of soft tissue involvement. This
iting risk of iatrogenic perforator vessel injury facilitates operative planning including deter-
during harvest, division, or transfer from shearing mining the extent of resection, reconstructive
forces. Its volume contributes to three- requirements, and may identify opportunity for
dimensional reconstruction and elimination of neoadjuvant/adjuvant therapy (Shahzad et al.
any dead space underneath the flap and the 2013; Sanna et al. 2017b).
reconstructed chest wall. Inclusion of muscle
may not be as necessary in patients with a higher
BMI with surplus subcutaneous tissue at the References
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Anterolateral Thigh Flap for Poland’s
Syndrome 80
George E. Papanikolaou, Steven Lo, and Andreas Gravvanis
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 859
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
Abstract
Poland’s syndrome is a rare congenital malfor-

mation characterized by unilateral absence of
G. E. Papanikolaou
the sternal portion of pectoralis major muscle,
Microsurgery and Aesthetic Surgery, Metropolitan ipsilateral brachysyndactyly, and occasionally
Hospital, Athens, Greece other anomalies of the anterior chest wall and
S. Lo breast. The current theory on the etiology of
Canniesburn Plastic Surgery Unit, Glasgow, UK Poland’s syndrome is subclavian artery hypo-
University of Glasgow and The Glasgow School of Art, plasia, caused by kinking of the artery during
Glasgow, UK the sixth week of gestation: the stronger the
A. Gravvanis (*) interaction, the more severe the pathology.

https://doi.org/10.1007/978-3-030-23706-6_65
858 G. E. Papanikolaou et al.
A case of a male patient with Poland’s

anomaly who was reconstructed with a free
anterolateral thigh perforator flap is presented.
The flap was used successfully as an autolo-
gous filler to recreate the anterior axillary line
and correct the chest contour deformity. The
use of the free anterolateral thigh perforator
flap is an excellent choice as autologous filler
to correct mild and moderate deformity in male
Poland’s syndrome, carrying low morbidity
and leaving both minimal scarring and func-
tional sequelae.
Keywords
Poland’s syndrome · ALT flap · Chest wall

reconstruction · Autologous reconstruction
The clinical scenario: A 16-year-old healthy

male presented with unilateral breast and chest
wall asymmetry (Fig. 1). The sternal head of the
left pectoralis major muscle was absent with an
associated ill-defined anterior axillary fold. Inter-
estingly, the clavicular head of pectoralis major
was hypertrophic exaggerating the chest wall
anomaly. The breast was hypoplastic and the
nipple-areola complex was small and displaced
superolaterally. No hand anomaly was present.
The latissimus dorsi muscles were symmetric
and well developed. The patient was psycholog-
ically disturbed by the aesthetic appearance of
his chest and requested surgical correction of the
deformity.
Fig. 1 Preoperative left anterior (a), left three-quarters

Preoperative Problem List: (b), and left lateral (c) view of male Poland syndrome
patient demonstrating chest wall deformities, poorly
Reconstructive Requirements defined anterior axillary line, hypertrophy of the clavicular
head, and absence of the sternal head of pectoralis major
1. The anterior axillary fold is deficient due to the muscle
absence of the sternal head of the left pectoralis
major muscle (Fox and Hamilton 2010; Poland 3. Young and athletic male patient expressing
1841; Seyfer et al. 2008; Fokin and Robicsek concern about his cosmetic appearance and
2002; Urschel 2009). seeking surgical correction.
2. Chest wall asymmetry associated with hypo- 4. Requirement to reconstruct an aesthetic disor-
plastic left breast, small and superiorly der of the anterior chest wall with no functional
displaced nipple-areola complex (Baas et al. impact, where the chosen surgical treatment
2018; Foucras et al. 2003). should have minimal morbidity, scarring, and
80 Anterolateral Thigh Flap for Poland’s Syndrome 859
functional sequelae (Gravvanis et al. 2009; 3. Autologous fat injection, which needs to be
Gautam et al. 2007). combined with other reconstructive tech-
niques, requires adequate fat reserves, and
must be performed in more than one lipofilling
Treatment Plan sessions (Delay et al. 2010; Yang and Lee
2011; Pinsolle et al. 2008).
Given that the patient was a rugby player involved Since this patient had insufficient fat
in many other sporting activities, a surgical pro- reserves to allow for numerous sessions this
cedure was planned that would result in minimal technique was excluded.
donor site morbidity, least scarring, and maximum 4. Other free or pedicled perforator flaps (i.e.,
patient satisfaction. The treatment plan in this TDAP, DIEP, SIEA, TUG, and omentum flap)
male patient aimed to restore the abnormal mus- with acceptable donor site morbidity (Gautam
cular contour, redefine the anterior axillary line, et al. 2007; Liao et al. 2005; Dos Santos Costa
and correct the chest wall deformity (Seyfer et al. et al. 2010; Huemer et al. 2012).
2010).
Two options were proposed to the patient: free
anterolateral thigh perforator flap (Wei et al. 2002) Preoperative Evaluation and Imaging
and pedicled thoracodorsal artery perforator flap
(Hamdi et al. 2008). Both are associated with The volume deficit of the left chest wall was
negligible donor site morbidity but with a long estimated by templating the chest contour defect.
scar on the thigh area and the back, respectively. The thickness of the defect was estimated
After thorough discussion about all alternative 1.5–1.9 cm at various sites of the left chest. The
options, advantages and disadvantages, risks, lateral thigh skin thickness was estimated by
and possible complications, we decided to pro- pinch test 1.6 cm and was considered reasonable
ceed with free transfer of the anterolateral thigh match. Although the use of CT scan preopera-
perforator flap. The ALT flap was used as an tively could provide more precise, scientific cal-
autologous filler to replace the pectoralis major culation of the lost volume of chest wall, it was not
muscle absence and recreate an aesthetic pleasant proposed to avoid patient’s exposure to radiation.
chest contour. The desired size of the flap (7 14 cm) was
estimated preoperatively by templating the chest
contour defect, and a color Doppler ultrasonogra-
Alternative Reconstructive Options phy was used to locate the cutaneous perforators
of the ALT flap.
1. Use of customized chest prosthesis, with or
without latissimus dorsi muscle transposition
(Chavoin et al. 2018; Saour et al. 2008; Marks Preoperative Care and Patient
et al. 1991). Drawing
The main drawbacks include seroma forma-
tion, implant displacement and/or fracture, and The patient was placed in the supine position. The
potential capsular formation. thorax and the entire leg were prepped and draped.
2. Endoscopically assisted latissimus dorsi muscle The subglandular/subcutaneous breast pocket was
transposition, which is associated with high marked. Afterwards, a straight line was marked
functional shoulder deficit, and therefore could between the anterior superior iliac spine and the
be restrictive in young patients with sport activ- lateral edge of the patella. The midpoint of this
ities (Hester and Bostwick 1982; Gravvanis line was identified and a 3 cm radius circle was
et al. 2007). outlined. Perforators, which are usually located
within this area, were detected by color Doppler humeral tuberosity (Fig. 2b). The lateral circum-
ultrasonography. flex femoral artery and vein were anastomosed
in end-to-end fashion to the thoracodorsal artery
and vein. The upper corner of the flap
Surgical Technique (2 2 cm) was not de-epithelialized and was
inset at the axillary incision as a skin paddle for
1. A horizontal 5 cm incision was made at the flap monitoring (Fig. 2c).
lower axillary crease and was used both for the
recipient vessels and the subglandular pocket
dissection. Technical Pearls
2. The thoracodorsal vessels were dissected free
from the thoracodorsal nerve and were divided 1. The same axillary incision was used both for
proximal to the origin of the serratus branch. the recipient vessels and the subglandular
With the aid of a lighted retractor, a sub- pocket dissection.
glandular/subcutaneous pocket was dissected 2. The initial incision for the ALT harvest must be
as marked preoperatively, using the same axil- made medially and centered above the rectus
lary incision. The lower border of the femoris muscle.
pectoralis major muscle’s clavicular head was 3. The septum is approached by elevating the
also dissected. deep fascia for medial to lateral until the dom-
3. A tandem team raised the ALT flap simulta- inant perforator was noticed.
neously by a standard dissection technique. A 4. Respect and preserve musculocutaneous per-
medial incision above the rectus femoris mus- forators, if no septocutaneous perforators are
cle was made and deepened down to the sub- visible.
fascial plane. The dissection was continued 5. The dimensions of the skin flap must primarily
beneath the deep fascia and extended laterally fit the chest wall defect and secondarily allow
until the dominant perforator was encountered. the direct closure of the donor area.
An intramuscular route of the perforator, 6. Use key sutures on the chest wall and on the
through vastus lateralis, was identified. The flap for better inset and orientation.
dissection proceeded laterally toward the intra- 7. Leave a small skin paddle for flap monitoring
muscular space between rectus femoris and and remove it at a second stage.
vastus lateralis muscle to identify the main
descending branch of the lateral circumflex
femoris artery (LCFA). The flap template was Intraoperative Images
subsequently marked and centered over the
dominant perforator. The deep fascia was See Fig. 2a–c.
incised laterally, and the flap was elevated
from lateral to medial until the perforator was
encountered. Elevation of the flap was com-
pleted by dissection of the perforator to the Postoperative Management
LCFA origin. The pedicle length was 14 cm.
The donor area was closed directly. The patient was postoperatively closely moni-
4. The flap was de-epithelialized and sutured tem- tored by physical examination and handheld
porarily on the chest wall, to mold and orientate Doppler for the first 5 days. Anticoagulant regi-
the flap for the best possible contour (Fig. 2a). men included low molecular heparin and oral
Key sutures were marked on the chest and on aspirin. The patient was allowed to ambulate at
the flap. Flap inset was performed with PDS 2–0 the second postoperative day.
sutures, with the upper border of the flap sutured The drains were removed at the third day both
to the caudal border of the clavicular head of from the chest and the leg. Recovery was unevent-
pectoralis major, toward the crest of the greater ful and the patient was discharged on day 4.
Fig. 2 (a) Intraoperative view demonstrating the chest skin and PDS 2–0 sutures were used to secure its
de-epethilialized perforator flap overlying the chest wall position at the marked areas (c) The upper corner of the flap
before implantation. The key sutures were marked on the (2 2 cm) was inset at the axillary incision for flap
chest and on the flap (b) The flap was buried under the monitoring
reconstruction and did not wish for further sym-

metrizing procedures.
The thigh area is an ideal donor site since the
Three months postoperatively the patient was
scar could be easily covered with a conventional
noted to have a well-developed anterior axillary
fold, significantly improved chest contour, and swimming suit. The ALT perforator flap can
reasonable symmetry with the controlateral breast ensure negligible donor site morbidity and
(Fig. 3). Although the skin paddle was well hid- acceptable thigh scarring in a male patient [14,
den in the axilla, this was removed at a second 17]. The use of a dermo-adiposal perforator flap
stage under local anesthetic. No donor site prob- as a filler in our case resulted in well-defined
lems were reported by the patient during sporting anterior axillary fold and addressed the chest
activities, and functional evaluation demonstrated contour deformity.
full range of motion at the knee joint without In conclusion, the free anterolateral thigh per-
muscle weakness. Although lipofilling was pro- forator flap is an excellent choice as autologous
posed for further definition, the patient was satis- filler to correct mild to moderate deformity of
fied with the aesthetic outcome of his male Poland’s syndrome.
flap without running the risk to compromise its

vascular supply.
3. The incorporation of vastus lateralis muscle
could provide more volume to the transferred
flap. Its use as chimeric flap could restore the
volume deficit in particular areas of the chest,
planned with the aim of CT scan preoperatively
(Gravvanis et al. 2009; Wei et al. 2002).
4. If no adequate symmetrization is achieved,
lipofilling could be performed in a secondary
session (Pinsolle et al. 2008).
Learning Points
1. In cases of mild to moderate Poland’s syn-

drome deformity the ALT flap offers an excel-
lent reconstructive option with low morbidity
and high aesthetic and functional result.
2. The ALT flap is a dermo-adiposal flap and does
not show atrophy over time. Improvements in
aesthetic definition can be addressed at a sec-
ond stage with lipofilling, with the added
advantage that the perforator flap provides a
well-vascularized environment for autologous
fat grafts.
3. Perforator flaps remains soft, pliable, and nat-
ural looking throughout patient’s life and
changes as the patient ages.
References
Fig. 3 (a) Postoperative left anterior (b) Left three- Baas M, Burger EB, Sneiders D, et al. Controversies in
quarters (c) Left lateral view of male Poland syndrome Poland syndrome: alternative diagnoses in patients
patient demonstrating well-developed anterior axillary with congenital pectoral muscle deficiency. J Hand
fold, significantly improved chest contour, and reasonable Surg Am. 2018;43(2):186.e1–186.e16.
symmetry with the controlateral breast Chavoin JP, Taizou M, Moreno B, et al. Correcting Poland
syndrome, with a custom-made silicone implant: con-
tribution of three-dimensional computer-aided design
Avoiding and Managing Problems reconstruction. Plast Reconstr Surg. 2018;142(2):190e-
119e.
Delay E, Sinna R, Chekaroua K, et al. Lipomodelling of
1. If no septocutaneous perforators are visible,
Poland’s syndrome: a new treatment of the thoracic
musculocutaneous perforators must be recog- deformity. Aesthet Plast Surg. 2010;34(2):218–25.
nized and preserved. Usually one perforator is Dos Santos Costa S, Blotta RM, Mariano MB, et al. Aes-
enough to preserve skin paddle viability thetic improvements in Poland’s syndrome treatment
with omentum flap. Aestetic Palst Surg. 2010;34(5):
(Gravvanis et al. 2007; Wei et al. 2002).
634–9.
2. The subglandular/subcutaneous pocket should Fokin AA, Robicsek F. Poland’s syndrome revisited. Ann
be dissected wide enough to accommodate the Thorac Surg. 2002;74(6):2218–25.
Foucras L, Grolleau-Raoux JL, Chavoin JP. Poland’s syn- breast and chest wall reconstruction in a Poland anom-
drome: clinic series and thoraco-mammary reconstruc- aly patient. Ann Plast Surg. 2005;55(4):422–6.
tion. Report of 27 cases. Ann Chir Plast Esthet. Marks MW, Argenta LC, Izenberg PH, et al. Management
2003;48(2):54–66. of the chest-wall deformity in male patients with
Fox JP, Hamilton CG. Poland syndrome: evaluation and Poland’s syndrome. Plast Reconstr Surg. 1991;87(4):
treatment of the chest wall in 63 patients. Plast Reconstr 674–8.
Surg. 2010;126(3):902–11. Pinsolle V, Chichery A, Grolleau JL, et al. Autologous fat
Gautam AK, Allen RJ Jr, LoTempio MM, et al. Congenital injection in Poland’s syndrome. J Plast Reconstr
breast deformity reconstruction using perforator flaps. Aesthet Surg. 2008;61(7):784–91.
Ann Plast Surg. 2007;58(4):353–8. Poland A. Deficiency of the pectoral muscles. Guys Hosp
Gravvanis A, Tsoutsos D, Karakitsos D, et al. Blood per- Rep. 1841;6:191–3.
fusion of free anterolateral thigh perforator flap: its Saour S, Shaaban H, McPhail J, McArthur P. Customised
beneficial effect in the reconstruction of infected silicone prostheses for the reconstruction of chest
wounds in the lower extremity. World J Surg. wall defects: technique of manufacture and final out-
2007;31(1):11–8. come. J Plast Reconstr Aesthet Surg. 2008;61
Gravvanis A, Lo S, Shirley R. Aesthetic restoration of (10):1205–9.
Poland’s syndrome in a male patient using free ante- Seyfer AE, Saour S, Shaaban H, McPhail J, et al.
rolateral thigh perforator flap as autologous filler. Customised silicone prostheses for the reconstruction
Microsurgery. 2009;29(6):490–4. of chest wall defects: technique of manufacture and
Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical final outcome. J Plast Reconstr Aesthet Surg.
technique in pedicled thoracodorsal artery perforator 2008;61(10):1205–9.
flaps: a clinical experience with 99 patients. Plast Seyfer AE, Fox JP, Hamilton CG. Poland syndrome: eval-
Reconstr Surg. 2008;121(5):1632–41. uation and treatment of the chest wall in 63 patients.
Hester TR Jr, Bostwick J 3rd. Poland’s syndrome: correc- Plast Reconstr Surg. 2010;126(3):902–11.
tion with latissimus muscle transposition. Plast Urschel HC Jr. Poland syndrome. Semin Thorac
Reconstr Surg 1982; 69(2): 226–233. Cardiovasc Surg. 2009;21(1):89–94.
Huemer GM, Puelzl P, Schoeller T. Breast and chest wall Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-
reconstruction with the transverse musculocutaneous tissue flap? An experience with 672 anterolateral thigh
gracilis flap in Poland syndrome. Plast Reconstr Surg. flaps. Plast Reconstr Surg. 2002;109(7):2219–26.
2012;130(4):779–83. Yang H, Lee H. Successful use of squeezed-fat grafts to
Liao HT, Cheng MH, Ulusal BG, et al. Deep inferior correct a breast affected by Poland syndrome. Aesthet
epigastric perforator flap for successful simultaneous Plast Surg. 2011;35(3):418–25.
Abdominal Wall Reconstruction
81
Roisin T. Dolan, Calum S. Honeyman, and Henk P. Giele
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 868
Surgical Technique and Intraoperative Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869
PMP Tumor Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869
AW-VCA Retrieval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870
Vascular Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870
Postoperative Monitoring for AW-VCA Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870
Postoperative Monitoring for AW-VCA Acute Cellular Rejection . . . . . . . . . . . . . . . . . . . . 871
R. T. Dolan (*)
Oxford Reconstructive, Plastic, Hand and Innovation
Collaboration, Department of Plastic, Reconstructive and
Hand Surgery and Nuffield Department of Surgery, Oxford
University Hospitals NHS Foundation Trust, Oxford, UK
e-mail: rdolan@svcpc.ie
C. S. Honeyman · H. P. Giele
Oxford Reconstructive, Plastic, Hand and Innovation
Collaboration, Department of Plastic, Reconstructive and
Hand Surgery and Nuffield Department of Surgery, Oxford
University Hospitals NHS Foundation Trust, Oxford, UK

https://doi.org/10.1007/978-3-030-23706-6_68
866 R. T. Dolan et al.

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 872
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 872
Abstract previous PMP debulking surgery 7 years ago.

Large abdominal wall defects resulting from He presented with recurrent PMP-related com-
trauma, abdominal wall tumors, necrotizing plications to include extensive peritoneal
infections, or complications from previous sur- deposits extending through the right anterior
geries present a significant reconstructive chal- abdominal wall, intestinal and renal obstruction,
lenge. Reconstructive goals are fourfold: requiring JJ stent placement, respiratory and
1. restoration of the anatomy and integrity of intra-abdominal sepsis with psoas abscess for-
the musculofascial anterior abdominal wall 2. mation (Figs. 1 and 2).
provision of stable soft tissue coverage 3. and He was reviewed by the regional transplant
4. provision of dynamic muscle support. multidisciplinary team. Due to widespread dissem-
Several options have been described to ination of the disease process, multivisceral organ
reconstruct large complex abdominal wall transplantation (MVT) to include stomach and the
defects, including component separation, tis- small and large intestine was recommended.
sue expansion, use of absorbable and non-
absorbable mesh, acellular dermal matrices,
pedicled thigh flaps, and vascularized or non-
vascularized rectus fascia grafts.
Abdominal wall-vascularized composite allo-
transplantation (AW-VCA) was first described
by Levi et al. in 2001. Since then, 40 full-
thickness AW-VCAs have been performed in
38 patients in seven international units. Herein,
the case of a 39-year-old male presenting with
recurrent Pseudomyxoma Peritoni (PMP) invol-
ving his anterior abdominal wall is discussed.
Following PMP tumor resection, he underwent
multivisceral organ transplantation and concom-
itant AW-VCA for reconstruction of the abdom-
inal wall defect.
Keywords
Complex abdominal wall defects · Abdominal

wall transplantation

Fig. 1 Contrast CT thorax, abdomen, and pelvis demon-
A 39-year-old man presented for management
strating extensive mixed morphology peritoneal malig-
of recurrent Pseudomyxoma Peritoni (PMP). nancy causing extrinsic compression of the stomach with
His past medical history was significant for a intestinal and renal obstruction
81 Abdominal Wall Reconstruction 867
Since PMP disease extended into the right

anterior abdominal wall and suprapubic region
in the context of previous laparotomies/scar
tissue and raised intra-abdominal pressure from
MVT, a concomitant abdominal wall transplant/
vascularized composite allograft (AW-VCA) was
recommended (Fig. 3). Retrieving the entire ante-
rior abdominal wall, as part of multivisceral pro-
curement, allows “like-for-like” reconstruction,
with no donor site morbidity for the recipient.

The reconstructive goal for this patient is 1. to

restore the anatomy and integrity of the mus-
culofascial anterior abdominal wall in the con-
text of a large full-thickness tumor resection
defect; 2. prevention of visceral eventration;
and 3. provision of dynamic muscle support.
Definitive reconstruction will serve to mechani-
cally protect the abdominal viscera, maintain a
sterile environment, and avoid large fluctuations
Fig. 2 Sagittal view contrast CT thorax, abdomen, and
pelvis demonstrating extensive peritoneal deposits with in temperature and fluid levels. Reconstruction
extension in the anterior abdominal wall will also restore contribution to respiratory
Fig. 3 Preoperative
clinical photograph
demonstrating significant
PMP disease extension into
the right anterior abdominal
wall extending to the
suprapubic region
support and the ability to raise abdominal pres- Treatment Plan

sure for defecation, urination, and coughing
(Honeyman et al. 2020; Giele et al. 2016; Molitor Surgical planning for this patient required consid-
et al. 2018; Avashia et al. 2015; Berli et al. 2013). eration of the following:
Reconstructive requirements:
1. Preoperative patient optimization. Optimiza-
1. Consider comorbidity profile of the patient. tion maximizes chances of successful recon-
This patient has significant preoperative struction. This patient had significant
nutritional and fluid challenges in the context multidisciplinary input from gastroenterology
of malabsorption from PMP disease and renal medicine and transplant-specific nutritionists
obstruction. A history of recurrent sepsis to allow correction of metabolic and nutritional
means he is likely to be catabolic and will deficiencies and plan for anticipated postoper-
need significant nutritional optimization +/ ative challenges. Control of sepsis (intra-
blood products to aid wound healing. Preop- abdominal infection/Systemic Inflammatory
erative anesthetic evaluation is essential in Response) is key to preventing catabolism
this cohort of patients. If a long aesthetic and the development of early surgical site
cannot be tolerated, it is important to plan infections which could compromise wound
for a temporizing procedure (intraperitoneal healing.
packing, Silo technique, and negative pres- 2. Anatomical defect: Reconstruction of this
sure wound therapy) to avoid an open complex (>15 cm diameter, full-thickness
abdomen. superficial & musculofascial layers) defect
2. Consider defect size and location. This will be a involving abdominal wall subunits I-III and
large (>15 cm) full thickness (superficial and partially IV-VI as described by Hurwitz &
musculofascial layers) midline defect extending Hollins (Hurwitz and Hollins 1994) can be
from the xiphisternum to the pubic symphysis. achieved in one-stage using an abdominal
Reconstruction of skin, subcutaneous tissue, and wall transplant/vascularized composite allo-
fascia layers is required to restore abdominal graft (AW-VCA).
wall integrity. Post-MVT edema will increase
the size of this defect further (Honeyman et al.
2020; Giele et al. 2016). Alternative Reconstructive Options
3. Consider the “hostile” abdomen. It is impera-
tive to examine the patient for previous surgi- Options are limited in the context of a large,
cal scars (laparotomy, laparoscopy, stomas, complex, full-thickness defect. Basic principles
and drain sites). Scar tissue from multiple pre- of abdominal wall reconstruction involve recon-
vious abdominal surgeries or irradiation is struction of 1. the myofascial layer and 2. soft
likely to hamper local tissue advancement and tissue coverage. Large myofascial defects can be
restrict the degree of tissue undermining that reconstructed with prosthetic (mesh) materials,
can be safely achieved due to compromise of bioprosthetic (acellular dermal matrices) mate-
local blood supply and denervation. Review- rials, or autologous tissue. Meshed materials
ing copies of previous operation notes is allow continued drainage of the abdominal cavity
imperative. and are a good scaffold for granulation tissue
4. Consider placement of stomas. Complex intra- formation which allows for delayed skin grafting.
abdominal surgeries often require fashioning of Nonabsorbable polypropylene meshes are associ-
defunctioning colostomy and urostomies to ated with lower rates of fistula and hernia forma-
allow the intestinal and urogenital systems to tion (Lak and Goldblatt 2018). Acellular dermal
recover. This should be considered in the preop- matrix (ADM) tends to form fewer adhesions with
erative plan to avoid interference with planned bowel than prosthetic materials and incorporate
tissue advancement. into native tissue by regeneration (Garvey et al.
2017). However, ADMs generally lose integrity pretransplant workup. It is possible for transplant
when used as large bridge grafts and are associ- recipients to be presensitized by alloantigens after
ated with higher rates of abdominal hernia forma- pregnancy, previous transfusions, and previous
tion. Autologous tissue options in large defects transplants, but the majority of DSAs develop
would be restricted to free tissue transfer options after transplantation has occurred. The clinical
such as latissimus dorsi myocutaneous flap or significance of DSAs in VCA remains poorly
anterolateral thigh fasciocutaneous flap (+/ fas- defined (Selvaggi et al. 2009).
cia lata) (Roubaud and Baumann 2018).

Preoperative Evaluation and Imaging Drawing
Consent for AW-VCA is obtained from donor The defect and planned marginal resection are
families. Pretransplant counseling is provided defined preoperatively (Fig. 3). A large
for all patients awaiting an AW-VCA especially AW-VCA will be required for this defect, and the
focusing on possible skin tone mismatch/pres- transplant-retrieval surgeons are informed.
ence of tattoos. Another important preoperative
consideration is the mean weight of the donor,
which can be up to 40% more than the recipient. Surgical Technique and Intraoperative
Standard pretransplant contrast-computed tomo- Images
graphy gives an indication of recipient abdomi-
nal capacity. It also allows to aid surgical PMP Tumor Resection
planning by imaging potential recipient vessels
for AW-VCA namely the inferior epigastric, Resection of stomach, small and large bowel, and
deep circumflex iliac, and internal mammary affected anterior abdominal wall was performed.
vessels (Figs. 1 and 2). This resulted in a large full-thickness defect
Measurement of donor-specific antibodies encompassing the majority of the entire anterior
(DSAs) and non-DSAs forms part of the routine abdominal wall (Fig. 4).
Fig. 4 Post-tumor
resection anterior
abdominal wall defect
AW-VCA Retrieval time for muscle-containing transplants ranges from

4 to 6 h.
The donor AW-VCA is retrieved as part of routine
multiorgan transplant procurement. Full thickness
Technical Pearls
AW-VCA comprises peritoneum, posterior rectus
sheath, both rectus abdominis muscles, anterior
1. Dissection of the recipient deep inferior epigas-
rectus sheath, overlying fat, skin, and parts of the
tric vessels may be difficult as recipient patients
internal and external obliques and transversus
commonly have extensive scarring and previ-
abdominis. The AW-VCA is most commonly
ous laparotomies which can compromise and
retrieved using a longitudinal elliptical incision
distort abdominal wall vascular anatomy.
over both rectus abdominus muscles (Fig. 5).
2. Prolonged cold ischemia time and recipient
instability during transplantation can be
addressed using a temporary “banking” of the
Vascular Anastomosis AW-VCA using remote revascularization. This
technique involves anastomosis of the donor
Using the microsurgical technique employed by
inferior epigastric vessels to the recipient-
the Bologna, Oxford, and Groningen teams, the
radial forearm vessels prior to in situ transfer
donor inferior epigastric (DIEA&V) vessels are
and reanastomosis to recipient-inferior epigas-
dissected to their origin at the external iliac vessels
tric vessels (Giele et al. 2016).
and anastomosed end to end with the recipient
inferior epigastric vessels (Figs. 6 and 7). We
estimate an average time to revascularization of Postoperative Management
1 h and one additional hour of operative time to
perform definitive closure, extending the case Postoperative Monitoring for AW-VCA
overall by 2 h after completion of visceral Ischemia
transplantation.
An important operative challenge is reducing AW-VCA postoperative monitoring is similar to
the inherent AW-VCA cold-ischemia time standard free flap monitoring protocols which
sustained while waiting for completion of the comprise visual inspection of flap color, warmth,
multivisceral transplant. Acceptable cold ischemia and capillary refill.
Fig. 5 AW-VCA
demonstrating 14 cm
diameter skin paddle with
rectus muscle and deep
inferior epigastric donor
vessels
Postoperative Monitoring for AW-VCA erythema, rash, or edema (Gerlach et al. 2016).
Acute Cellular Rejection All units perform AW-VCA skin biopsies in
response to these changes or if there is suspected
Clinical skin changes on the AW-VCA may indi- or biopsy-proven organ transplant ACR. The cur-
cate acute cellular rejection (ACR) such as rent Oxford protocol consists of protocol-driven
endoscopies, mucosal biopsies, monitoring of
stoma output, serum citrulline, and calprotectin
levels (Venick 2021). Intestinal graft endoscopies
are performed three times a week for the first
3 months, then twice a week for the next 3 months,
and subsequently at an interval of one endoscopy
every 2 weeks until stoma closure, and then once a
year for routine checkups. In addition, intestinal
endoscopies were performed in response to clini-
cal episodes of suspected rejection (increased
stoma output).
This patient developed graft-versus-host disease

on day 17 which presented clinically as a wide-
spread confluent macular rash but spared the
abdominal wall transplant skin paddle (Fig. 8).
He was treated with methylprednisolone and
plasma exchange, and the rash was improving.
Fig. 6 The microscopic approach, employed by Bologna, Unfortunately the patient deceased at day 18 post-
Oxford, and Groningen, uses the donor and recipient infe-
rior epigastric vessels, anastomosed in an end-end fashion. operatively following an arrest from respiratory
(Image by Emily O’Hanlon) sepsis.
Fig. 7 Clinical photograph

demonstrating AW-VCA in
situ inset onto the recipient
deep inferior epigastric
vessels. Stoma in situ
through the lower anterior
abdominal wall
Fig. 8 Clinical photograph

Day 18 postoperatively
demonstrating graft versus
host disease sparing the
AW-VCA
At Oxford, there are no reported cases of Intes- rejection which tends to precede ACR of the
tinal Transplant ACR without preceding transplanted organs.
AW-VCA skin ACR (concordant rejection). 2. AW-VCA can assist the diagnosis of graft-ver-
Over one-third [37% (7/19)] of AW-VCA had sus-host-disease as the development of wide-
biopsy-confirmed ACR presenting as a visible spread macular rash tends to spare the
skin rash. There is no evidence that the presence AW-VCA skin paddle.
of a VCA increased the frequency of intestinal
rejection episodes.
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jamcollsurg.2016.11.017.
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Friend PJ, Giele H, Vaidya A. Abdominal wall trans-
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1. AW-VCA allow real-time immunosurveillance 1111/ajt.13693.
Giele H, Vaidya A, Reddy S, Vrakas G, Friend P. Current
following MVT. Development of rashes/color state of abdominal wall transplantation. Curr Opin
changes on the AW-VCA allows early skin Organ Transplant. 2016;21(2):159–64. https://doi.org/
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Honeyman C, Dolan R, Stark H, Fries CA, Reddy S, Olomouc Czech Repub. 2018 Sep;162(3):184–9.
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Abdominal Wall Reconstruction
Postsarcoma Excision 82
Shameem Haque and Shadi Ghali
Contents
Clinical Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876
Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877
Alternative Reconstructive Options (Table 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
Abstract
The management of patients with complex

abdominal wall defects involves a multi-
disciplinary team approach.
Compared with conventional ventral hernia
S. Haque
The Royal Free University Hospital, London, UK
repair, there are several considerations particu-
e-mail: shameem.haque@nhs.net lar to oncological abdominal wall defects,
S. Ghali (*)
these include the management of irradiated
Plastic Surgery Clinic, The Royal Free University soft tissues, as well as the presence of bacterial
Hospital, London, UK contamination and the management of soft
e-mail: shadi.ghali@nhs.net

https://doi.org/10.1007/978-3-030-23706-6_69
876 S. Haque and S. Ghali
tissues following previous resections with or 33 years, she became pregnant and a healthy boy
without reconstructions. was delivered by caesarean section with no evi-
This chapter describes the management of a dence of recurrent disease at that time.
complicated patient with a massive abdominal Prior to her 34th birthday, she developed a
wall defect resulting from the resection of a localized abdominal wall recurrence at the edge
recurrent tumor, which had been excised at mul- of her previous radiation field and the tumor his-
tiple previous attempts at tumor clearance as well tologically appeared to have a higher mitotic
as being reconstructed previously, and had also index. This was resected and reconstructed with
been treated over the years with adjuvant che- a pedicled VRAM flap and Prolene mesh in an
motherapy, radiotherapy, and immunotherapy. outside institution. In the same year, a restaging
With the advance of new biomaterials CT scan demonstrated a cardiac/ right ventricle
developed to reinforce and reconstruct the mass, which was resected, confirming a metastatic
abdominal wall, as well as the use of traditional deposit leading to cardiac radiation therapy as
workhorse flaps, we present this extreme case. well as chemotherapy and immunotherapy for
In this chapter the alternative forms of recon- paraspinal tumor deposits.
struction are also discussed and the thought On presentation to our abdominal wall unit, CT
processes, which go into planning a case such imaging revealed multiple tumors in her right
as this one, are highlighted? flank, the tumor appeared to encase the right
colon, right kidney, and extending into abdominal
rectus muscle and abdominal wall and adjacent to
Keywords
small bowel. This was palpable below her VRAM
Abdominal wall reconstruction · Anterolateral skin paddle (Fig. 1a, b).
thigh flap · Chimeric flap · Biological mesh

Clinical Scenarios Reconstructive Requirements
Case 1 1. The tumor was determined to be unresectable by

other centers, due to the potential size of the
This 35-year-old lady, normally fit and well, non- abdominal wall defect following palliative resec-
smoker, and nondrinker initially presented 10 years tion with the associated surgical morbidity. This
earlier at the age of 25 years with a right abdominal was weighed up against the patient’s young age
soft tissue tumor, originally classified as a malig- and long palliative course as well as the patient’s
nant peripheral nerve sheath tumor/spindle cell determination to continue with treatment.
sarcoma not otherwise specified. 2. Irradiation usually results in difficulty in
Following initial resection as well as subse- distinguishing anatomic planes, extensive soft
quent resections for local recurrences, she was tissue fibrosis, reduced tissue pliability, and pro-
treated with adjuvant proton beam therapy. longed healing time. This results in a high like-
Three years later at the age of 30 years, she devel- lihood of wound healing problems in relation to
oped right-sided lung metastases which was operating in the field of previous proton beam
resected, followed 2 years later (32 years) with a therapy and was also an important consideration.
scalp metastases which was resected, and 1 year 3. Reconstructive requirements included
later (33 years) she developed a mass in her right recontouring of deeper musculofascial compo-
thyroid gland and right base of skull both of which nents with biological mesh. This mesh pos-
were resected and treated with adjuvant radiother- sesses a number of attributes over and above
apy. Later that same year, a left lung metastasis synthetic mesh (Table 1), namely it can be
was resected and the following year a small bowel placed as an underlay/interposition mesh with-
mesenteric deposit was removed. At the age of out fear of dense bowel adhesions developing
82 Abdominal Wall Reconstruction Postsarcoma Excision 877
Fig. 1 (a) Preoperative images (anterior view). The annotated in white broken line. (b) Preoperative images
VRAM flap reconstruction and midline laparotomy scar (posterior view). The VRAM flap reconstruction is visible.
are both visible. There is also caesarean section scar below Approximate proton beam therapy field annotated in white
the underwear. Approximate proton beam therapy field broken line
Table 1 Advantages/disadvantages of synthetic and biological mesh

Mesh Advantages Disadvantages
Synthetic Reduced hernia recurrence rate compared to Risk of visceral adhesions, bowel erosion, fistula, and
primary closure obstruction
Inert Remains as a foreign body (no tissue remodeling)
Strength maintained after implantation Infection or exposure often requires removal
Relatively inexpensive Implantation in contaminated field associated with
high rate of infection
Radiation can theoretically increase the risk of
complications such as bowel adhesion and extrusion
May be contraindicated in contaminated wounds
Biosynthetic More resistant to mesh infection Relatively expensive compared with synthetic
Documented revascularization Some materials may stretch over time
Often does not need to be removed when Variable recipient host responses (encapsulation and
exposed to or contaminated with bacteria resorption) for some types
Less risk of adhesion to bowel High incidence of hernia recurrence and seroma for
Can be used in high-risk surgical fields and some types
can be placed directly over bowel Long-term data not available for some materials.
and is resistant to contamination because of its 5. A large flap would be required to cover the area
ability to revascularize and incorporate (Butler of skin irradiated below the original VRAM
and Prieto 2004; Butler et al. 2010). The Ven- flap, in order to cover the underlying biological
tral Hernia Working Group have previously mesh.
stratified different patient risk groups and
have made recommendations for the use of
different mesh materials (Table 2) (Ventral Treatment Plan
Hernia Working et al. 2010).
4. The potential excision of the whole right Given the patients reconstructive history with a
hemi-abdominal wall was planned including VRAM flap as well as her potential need for
musculature and overlying irradiated skin pos- further reconstructions should further tumor exci-
sibly including excision of the previous sions be deemed possible, an ipsilateral pedicled
VRAM reconstruction. anterolateral thigh (ALT)/vastus lateralis
Table 2 Combined CDC and VHWG (Ventral Hernia Working et al. 2010) wound classification and recommended mesh
type (Boukovalas et al. 2018)
Classification Definition Mesh indicated
CDC Class 1 Surgical incision – sterile Synthetic
(clean) Few medical comorbidities
VHWG Grade 1
CDC Class II Controlled violation of the GI tract Biologic/synthetic
(clean-contaminated) Previous wound infection
VHWG Grade 3
CDC Class III (contaminated) Gross spillage of GI tract Biologic
VHWG Grade 3/4 Significant medical comorbidities
CDC Class IV Chronic infection Biologic
(dirty)
VHWG 4
Abbreviations: CDC, Centers for Disease Control and Prevention; GI, gastrointestinal; VHWG, Ventral Hernia Working
Group
(VL) chimeric flap was planned. In designing the arteriovenous (AV) loop composed of the long
flap, as large a skin paddle as deemed possible saphenous vein disconnected distally and
would be designed while still being able to connected to the superficial femoral artery
achieve primary closure of the donor site. This proximally could be used. This would involve
was planned as it was judged that the skin paddle three microanastomosis and would ensure cov-
would always be smaller than the defect and any erage of the upper part of the wound (Butler
residual mesh could be covered with the vastus et al. 2013).
lateralis component of the chimeric flap and skin 4. If a larger flap was required, the same pedicle,
grafted if required. The flap was raised after the the lateral femoral circumflex vessels, also sup-
extent of the defect was determined following plies the anteromedial thigh flap through
excision, and while the mesh was being inset. medial perforator vessels, the tensor fascia
lata flap via the transverse branch, and the
rectus femoris muscle through a separate
Alternative Reconstructive Options branch. Therefore a subtotal thigh flap can be
(Table 3) designed using these other components if a
particularly large defect is encountered (Lin
Specific to this patient’s reconstruction, there and Butler 2010). Of note also, vascularized
were a number of considerations with respect to fascia lata was historically the mainstay for
the reconstruction and alternatives: reconstructing fascial defects of the abdominal
wall; however, this technique has largely been
1. Her ipsilateral latissimus dorsi muscle and supplanted by the use of biological mesh.
overlying skin were both rigid due to the pre- 5. This lady was only 35 years old and would
vious proton beam therapy. inevitably develop future recurrences. There-
2. The aim was to keep the original VRAM and fore while a local fasciocutaneous flap from
base it on a new superior blood supply through the left side of the abdominal wall, outside of
its superior scar to reduce morbidity in such a the proton beam field or the contralateral
huge resection. remaining VRAM would provide a good recon-
3. If the VRAM needed to be removed struction, this would be detrimental to the over-
intraoperatively, a pedicled ALT/vastus all integrity of the anterior abdominal wall and
lateralis flap would not reach the defect. In would therefore be saved as a “last resort” or
this case, a free ALT/VL flap connected to an indeed be saved for any future recurrence(s).
Table 3 Thigh and torso-based pedicled flaps used in abdominal wall reconstruction flap
Flap Characteristics
ALT flap Large surface area
Minimal donor site morbidity
Will reach periumbilical area but has been reported to reach to costal margin
Can reach ipsilateral posterior iliac spine posteriorly and the contralateral fossa laterally
Associated fascia may not be reliable for fascial reconstruction
TFL flap Large skin paddle able to reach periumbilical area
Associated with some skin necrosis
Strong fascia for reconstruction
Rectus femoris Provides a long cylindrical muscle approximately 6 cm wide and can support a large skin island
flap
Combined thigh Subtotal thigh flap that may include rectus femoris TFL, vastus lateralis, and or ALT.
flap Bilateral pedicle thigh flap may contract the entire abdominal wall
Fascial aspect may be used to repair fascial defects but less reliable than mesh (may tear) so used in
combination with mesh
Latissimus dorsi Arc of rotation of the flap allows coverage of superolateral abdominal wall defects
flap
position. The ipsilateral hip was elevated

slightly with a sandbag, and the leg internally
rotated. The abdomen and thigh were prepped
The patient’s ipsilateral thigh was examined for
and draped so that the entire abdomen and
any previous scars or trauma and the pliability of
circumferential thigh were exposed to just
her skin and soft tissues determined. Preoperative
below the knee.
handheld Doppler signals from the territory of her
3. A straight line from the anterior superior iliac
anterolateral thigh perforators were determined to
spine to the superolateral border of the patella
ensure their presence and to also determine the
was drawn and the midpoint mark determined.
most distal dominant perforator to aid in flap
The dominant perforator, according to the
design.
color Doppler study, was located 3 cm lateral
to this point and all of the distal perforators
were marked to aid flap design as distal as
Preoperative Care and Patient possible to increase the reach of the flap.
Drawing 4. An exploratory incision was made 3–4 cm
medial and parallel to the aforementioned line.
1. The plan was to carry out a chimeric ante-
rolateral thigh perforator/vastus lateralis
(ALT/VL) flap. The patient was counselled Surgical Technique
and the potential for harvesting a vein graft
and converting to a free flap and/or the need Intraoperatively, the tumor was found to invade
for a further flap from her contralateral abdo- the abdominal wall with a clear plane without
men were discussed as well as the need for a invasion of the right colon or liver. The resultant
split skin graft to cover any muscle flaps. The triangular skin defect measured approximately
complications and limitations of the aforemen- 25 25 35 cm with one side based at the
tioned options were all discussed (Kimata et al. midline, one side based above the inguinal liga-
2000). ment, and one side based at the margin of the old
2. Following general anesthesia and spinal anal- VRAM flap. The abdominal wall defect deep to
gesia, the patient was placed in the supine this comprised the whole of the right hemi-
abdominal wall from the midline to the quality of overlying skin given the previous
mid-axillary line, and from the iliac crest and proton beam therapy and immunotherapy
right lower ribs. injection sites.
1. The deeper musculofascial defect was 2. The pedicled ALT/VL flap was dissected with
reconstructed with a large biological mesh a muscular branch to the vastus lateralis to raise
(bovine acellular dermal matrix [Surgimend a chimeric flap in order to increase the surface
4 mm mesh 25 40cm, Integra Lifesciences, area of the flap and provide vascularized tissue
NJ]). This was inset with interrupted 0 PDS to the biological mesh. The flaps were tunnel-
sutures, by placing the mesh in the intraperito- ing underneath the rectus femoris muscle
neal space and tensioned up against the poste- (Fig. 3) and passing subcutaneously over the
rior abdominal wall (Fig. 2). The resulting inguinal ligament.
large triangular area of Surgimend was 3. The vastus lateralis muscle was placed over the
exposed in the right flank due to the poor Surgimend medially in the right lower
image depicting the extent
of abdominal wall
resection, reconstructed
with a large biological mesh
(Surgimend 4 mm mesh
25 40 cm/Integra
Lifesciences, NJ).
Approximate dimensions
25 25 35 cm
image – pedicled ALT/VL
flap tunneled underneath
the rectus femoris muscle
abdomen, and the ALT flap laterally extending

into the right flank (Fig. 4). Technical Pearls
4. Parts of the ALT flap both in the subcutaneous
tunnel and underneath lateral abdominal pli- 1. In order to maximize flap reach, the skin pad-
dle is designed as distal on the anterior thigh as
able skin were de-epithelized and buried dis-
possible. In general, a pedicled ALT will reach
tally at the mid-axillary line in order to fill the
the periumbilical area but has been reported to
dead space (Fig. 4).
reach the costal margin. Conversion to a free
5. The previous VRAM flap, maintaining its new
flap aided by a long saphenous vein loop is
superior blood supply through its superior scar,
more reliable (Butler et al. 2013).
covered the right upper quadrant of exposed
2. The exploratory incision in the donor thigh
biological mesh. There was no requirement for medial to the marked line is important in
conversion to a free ALT/vastus lateralis flap order to explore the perforators (usually in the
and arteriovenous loop as the flap had adequate subfascial plane).
reach. 3. Once the perforators to the ALT skin paddle are
6. The upper midline fascia and Scarpa’s layers identified, these can be dissected back to the
were closed over closed suction drains. Below lateral femoral cutaneous artery (LFCA) and
the umbilicus, the vastus lateralis muscle was the distal pedicle is used to supply the vastus
inset to the linea alba and the donor site closed lateralis muscle, allowing a degree of separa-
in layers over a closed suction drain (Fig. 5). tion and maneuvering for inset of the flap.
image – pedicled ALT/VL
flap tunneled
subcutaneously,
de-epithelialized and inset
at the mid-axillary line and
to the inferior aspect of the
VRAM flap. ALT/VL flaps
completely covering the
Surgimend biological mesh
4. To improve flap reach, the chimeric flap is subcutaneous spaces is essential to eliminate
passed underneath rectus femoris muscle to deep collections (Garvey et al. 2014).
emerge medial to the muscle and then tunneled
subcutaneously.
5. Blunt dissection medial to the rectus fem- Intraoperative Images
oris muscle and superiorly, up to the pro-
funda femoris artery (PFA) aids flap Figures 2, 3, 4, and 5.
mobilization.
6. Tension on the pedicle can be determined by
palpating the pedicle up to the PFA with the hip Postoperative Management
in the supine position and also with varying
degrees of flexion. Postoperatively the flaps (old VRAM and new
7. Other than clinical determination of skin pad- ALT) were monitored clinically and the patient
dle viability in terms of capillary refill and was nursed at a 45 incline (the angle at which
color, de-epithelization of the most distal least tension was placed on the pedicle, deter-
region of the flap gives the surgeon another mined intraoperatively as outlined). The patient
opportunity to determine flap viability and was commenced on postoperative antibiotic pro-
debride on table accordingly. phylaxis as this is associated with a decreased
8. The placement of closed suction drains infection rate following ventral hernia repairs
between the mesh and the flaps and in the (Ventral Hernia Working et al. 2010).The patient
Fig. 5 Completion of
reconstruction: final flap
inset and warning not to
apply pressure to the
subcutaneous tunnel
was nursed on the surgical high dependency unit

and anticoagulated with low molecular weight Outcome: Clinical Photos and Imaging
heparin and mechanical calf compression was
applied (flowtrons). The deep drains to the mesh Despite her delayed wound healing, this lady had
were removed within 5 postoperative days and the a successful outcome in terms of successful
subcutaneous drains just before discharge on day abdominal wound tissue coverage and reasonable
12 (once mobilizing and below 50 cc/24 h for two abdominal wall function (Fig. 7).
consecutive days).
At the 3-week postoperative mark, the patient
had some breakdown at the junction of irradiated Avoiding and Managing Problems
skin and also at the lateral aspect of the wound
(Fig. 6a). She was treated with two operative 1. In complex cases, it is important to commence
debridements as well as negative pressure VAC operative involvement from the start in order to
therapy for 4 weeks in total in order to expedite prevent poorly designed incisions by the onco-
wound healing (Fig. 6b). The area of necrosis logical surgeon. This is especially true in the
included the area of undermined skin previously presence of old reconstructions and/or
exposed to proton beam therapy had result. This distorted anatomy, which can compromise
was anticipated by planning the inset of the vastus reconstructive efforts and outcomes.
lateralis under this area so that once debrided, the 2. Previous abdominal wall irradiation is an indi-
negative pressure dressings were placed on this cation for the use of biological mesh in onco-
muscle rather than the mesh. logical abdominal wall reconstruction as this is
Fig. 6 (a) Area of necrosis in undermined irradiated skin. (b) Area of granulation following debridement of necrotic soft
tissues and negative pressure dressing therapy
Fig. 7 Final outcome

3 months postoperatively
associated with more favorable outcomes (But- future reconstructions which least compromise
ler et al. 2005). the patient’s long-term outcomes.
3. In the case of compromised wound healing, it
is important to maximize reconstructive out-
comes with debridement and appropriate Learning Points
wound healing efforts to maximize function
and minimize complications and facilitate any 1. It is important to plan these complex proce-
adjuvant therapies. dures in a multidisciplinary setting in order to
4. With patients who have had multiple surgical understand the potential defect dimensions and
interventions, remember to plan ahead for composition, and in order to plan the
reconstruction(s) and to adequately counsel the Butler CE, Prieto VG. Reduction of adhesions with com-
patient of the potential implications, complica- posite AlloDerm/polypropylene mesh implants for
abdominal wall reconstruction. Plast Reconstr Surg.
tions, and limitations of each reconstruction. 2004;114(2):464–73.
2. When designing the ALT/VL flap for abdomi- Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdomi-
nal wall reconstruction, aim to design skin nal, and chest wall reconstruction with AlloDerm in
paddles as distally as possible on the anterior patients at increased risk for mesh-related complica-
tions. Plast Reconstr Surg. 2005;116(5):1263–75; dis-
thigh in order to improve flap reach on the cussion 76–7.
anterior abdominal wall. Butler CE, Burns NK, Campbell KT, Mathur AB, Jaffari
3. It is important, when transferring a pedicled MV, Rios CN. Comparison of cross-linked and non-
ALT/VL flap to the abdomen, to tunnel it cross-linked porcine acellular dermal matrices for
ventral hernia repair. J Am Coll Surg. 2010;211(3):
underneath the rectus femoris muscle and 368–76.
bluntly dissect the pedicle to the profunda Butler CE, Baumann DP, Janis JE, Rosen MJ. Abdominal
femoris artery in order to maximize flap reach. wall reconstruction. Curr Probl Surg. 2013;50(12):
4. Try and use previous reconstructions to your 557–86.
Garvey PB, Martinez RA, Baumann DP, Liu J, Butler
advantage in order to minimize the complexity CE. Outcomes of abdominal wall reconstruction with
of your own reconstruction. acellular dermal matrix are not affected by wound
5. In this patient, a wound healing complication contamination. J Am Coll Surg. 2014;219(5):
was expected and therefore the muscle was 853–64.
Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H,
inset securely over the mesh in areas of most Nakatsuka T, et al. Anterolateral thigh flap donor-site
tension, and biological mesh was planned from complications and morbidity. Plast Reconstr Surg.
the outset as it is more resistant to infection 2000;106(3):584–9.
(Garvey et al. 2014). Lin SJ, Butler CE. Subtotal thigh flap and bioprosthetic
mesh reconstruction for large, composite abdominal
wall defects. Plast Reconstr Surg. 2010;125(4):
1146–56.
References Ventral Hernia Working G, Breuing K, Butler CE,
Ferzoco S, Franz M, Hultman CS, et al. Incisional
Boukovalas S, Sisk G, Selber JC. Abdominal wall recon- ventral hernias: review of the literature and recommen-
struction: an integrated approach. Semin Plast Surg. dations regarding the grading and technique of repair.
2018;32(3):107–19. Surgery. 2010;148(3):544–58.
Total Vaginal Reconstruction After
Total Pelvic Exenteration 83
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 892
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 893
Abstract
Delayed total vaginal reconstruction can be

performed in selected patients after total pelvic
exenteration (TPE). Currently, several options
are available for repairing vaginal defects,
A. Gravvanis (*)
including the use of various loco-regional perfo-
Plastic, Reconstructive and Aesthetic Surgery, rator flaps. A case of a secondary vaginal recon-
Metropolitan Hospital of Athens, Athens, Greece struction in a 29-year-old patient who was
G. E. Papanikolaou referred to us 3 years following TPE is presented.
Consultant Plastic Surgeon, Unit of Plastic, Reconstructive The patient presented with good prognosis
Microsurgery and Aesthetic Surgery, Metropolitan and had been disease free for 3 years. The
Hospital, Athens, Greece

https://doi.org/10.1007/978-3-030-23706-6_70
operative challenge was to create a new vaginal

space and accommodate an adequately sized yet
nonbulky neovagina. This was achieved with
the transfer in one stage of the bilateral TUG
flaps using only the skin paddles for
reconstructing the neovagina and sparing the
gracilis muscles for future neoanal myoplasty.
Postoperative course was uneventful achieving
a functional neovaginal circumference and
length with patient’s satisfactory sexual activity.
Keywords
Pelvic exenteration · Pelvic reconstruction ·

Vaginal defect · Vaginal reconstruction ·
Gracilis myocutaneous flap Fig. 1 The patient presented with a laparotomy scar at the
middle line, and two permanent ostomies. Note the preser-
vation of the vulva
The Clinical Scenario 2. Reestablish normal sexual activity and body

image considering patient’s desire for sexual
A 29-year-old patient was referred to us 3 years life (McArdle et al. 2012; Crosby et al. 2011).
following total pelvic exenteration (TPE) for the 3. The presence of the two ostomies precluded
treatment of recurrent cervical carcinoma. The the abdominal region as a potential donor site
patient had received prior radiotherapy followed (Qiu et al. 2013; Wang et al. 2007).
by chemotherapy. The TPE included total resec- 4. Pre-reconstruction radiotherapy of the lower
tion of the vagina with preservation of the vulva, abdomen and sigmoidostomy excluded the use
hysterectomy, and bilateral salpingo- of bowel conduit for vaginal reconstruction.
oophorectomy, resection of the rectum followed 5. Use of a thin, pliable, and sensate flap that can
by urinary diversion and sigmoidostomy. be accommodated in a narrow space (Kiiski
Given that the patient presented with good et al. 2019; Kaartinen et al. 2015).
prognosis and had been disease free for 3 years 6. The flap should be bulky enough to obliterate
and considering her desire for sexual life after the dead space and eliminate the fistulas
having received sexual counseling from experts, formation.
the decision to proceed with vaginal reconstruc- 7. Promote rapid wound healing, reducing at the
tion was made. same time the morbidity (Jurado et al. 2009).
Preoperative clinical examination and imaging
showed total absence of the vagina with scarring
and soft tissue contracture at the pelvic floor, but Treatment Plan
with integrity of the perineum and the external
genital organs (Fig. 1). The patient presented with good prognosis and
had been disease free for 3 years. Moreover, she
desired to have an active sexual life after having
Preoperative Problem List/ received sexual counseling from experts. The
Reconstructive Requirements delayed scenario exhibited the additional chal-
lenge of the creation of the vaginal space that
1. Delayed creation of a neovaginal space that had been rendered more demanding due to scar-
had been rendered constricted due to scarring ring and previous radiotherapy. The challenge of
and radiotherapy (Gravvanis et al. 2015; reconstruction of an adequately sized yet non-
McArdle et al. 2012). bulky vagina had to be met, thus to avoid
83 Total Vaginal Reconstruction After Total Pelvic Exenteration 889
jeopardizing the flap viability due to compression Preoperative Evaluation and Imaging
(Pusic and Mehrara 2006).
Therefore, a decision was made to proceed Clinical examination of the external genital
with the use of the bilateral transverse upper organs showed preservation of the vulva and the
gracilis musculocutaneous (TUG) flaps. The pres- clitoris, with concomitant absence of the vaginal
ervation of the medial cutaneous nerve of the orifice due to the previous total vaginectomy. The
thigh, branch of the obturator nerve that supplies perineal area was integral with no signs of herni-
the proximal median thigh skin, will ensure the ation or fistula. Abdominal inspection revealed
sensory rehabilitation of the neovagina. the presence of a midline scar and the presence
of two permanent ostomies resulted from the pre-
vious total pelvic exenteration (Fig. 1).
Alternative Reconstructive Options The patient received preoperative sexual
counseling regarding the resumption of sexual
1. Abdominal-based pedicled flaps such as the activity from specialized expert and was informed
transverse (TRAM) and vertical (VRAM) rec- about all the possible postoperative complications.
tus abdominis myocutaneous flaps, and the Both thighs were examined in order to evaluate
deep inferior epigastric artery perforator flap the presence of any disease and to verify the
(DIEP), with the disadvantages of donor site vascular status of the patient.
morbidity (dysfunction of the ostomies and
increased abdominal herniation risk), inade-
quate flap size for circumferential total vaginal Preoperative Care and Patient
reconstruction, and longer operative time Drawing
(Cortinovis et al. 2018; Qiu et al. 2013; Weiwei
et al. 2009; Wang et al. 2007). The patient was marked in an upright position.
2. Visceral flaps such as sigmoid loop and jeju- The axis of the gracilis muscle was drawn and
num flap are mainly used in gender extended between the pubic tubercle and the
reassignment surgery and in congenital vagi- medial tibial tuberosity. An elliptical horizontally
nal atresia. Disadvantages of these flaps are oriented skin paddle of 6 cm in vertical height and
also the need for vaginal stenting, the exces- 20 cm in length was outlined over the proximal
sive mucous production, and the risk of meta- two-thirds of the muscle, with the upper border
chronous colon cancer in the neovagina located at the groin-thigh crease and the posterior
(Özkan et al. 2018; Bistoni et al. 2016; distal end of the cutaneous part of the flap between
McArdle et al. 2012; Sahakitrungruang and the middle and lateral thirds of the posterior thigh
Atittharnsakul 2010). The microsurgical (Fig. 2).
option with the use of free jejunum flap was The patient was placed in dorsal lithotomy
excluded mainly due to previous intraab- position. The operative field from umbilicus
dominal surgery, radiation, and sigmoido- down to the knee was prepped and draped.
stomy that would increase significantly the
overall operational risk.
3. Bilateral thigh-based flaps, such as Singapore Surgical Technique
flap (pudendal thigh fasciocutaneous flap) and
anterolateral thigh flap (ALT flap). The Singa- 1. The scar and the whole soft tissue contracture
pore flap presents an increased risk of apical were removed from the perineal area down to
flap necrosis that was further increased due to the vulvar area. A new vaginal space was
perineum radiation. The ALT flap has great arc created (Fig. 3).
of rotation, but it is very difficult to reach the 2. The skin flap is incised at its lower border
vagina and inset the flap without pedicle and down to the muscular fascia. The sartorius
perforator compression (Wong et al. 2009; muscle is identified and retracted superiorly.
Woods et al. 1992; Wee and Joseph 1989). Then, the gracilis muscle can be identified
the proximal median thigh skin is preserved

in order to provide sensory rehabilitation of
the neovagina.
7. The rest of the skin flap paddle was incised
and elevated at its superior and posterior bor-
ders, avoiding shearing of the cutaneous
aspect of the flap off the muscle.
8. The proximal gracilis muscle is dissected and
through a separate short distal incision the
tendinous insertion is divided, resulting in a
20 cm long muscle thus finalizing the flap
harvest.
9. A tunnel is dissected under the labia, and only
Fig. 2 Preoperative drawing of the two TUG flaps the skin paddles are pulled through (Fig. 4).
10. The anterior and posterior parts of the skin
island are de-epithelialized, and the neo-
vagina is shaped into a pouch by suturing
the skin flaps together, starting from the ante-
rior wall (Fig. 5).
11. The posterior part of the neovagina is sutured
and secured to the Cooper’s ligaments and the
fascial structures behind the pubic bone, and
its proximal end is sutured to the introitus.
Fig. 3 Creation of the new vaginal space
and dissected distally all the way near the

knee joint. The minor pedicle is ligated, and
the muscle tendon is identified.
3. The anterior border of the skin island is
incised, and the incision is carried out to the
muscular fascia.
4. The flap is elevated from distal to proximal on
the thigh, taking care to preserve the small
musculocutaneous perforators that provide
the blood supply of the skin paddle.
5. The vascular pedicle (medial circumflex fem-
oral vessels) of the flap is identified entering
the proximal third of the gracilis muscle in the
space between the adductor longus and
adductor magnus muscles, and dissected free
from the surrounding tissues to its source
vessels (deep femoral vessels).
6. The medial cutaneous nerve of the thigh, Fig. 4 Skin flaps raised and brought to the defect under
branch of the obturator nerve that supplies the labia, while gracilis muscles were left in the thigh
Fig. 6 The proximal end of the neovagina is sutured to the

introitus. The rest of the wounds were closed directly, and
drains were placed
4. The vascular pedicle is dissected to its source

vessels to increase pedicle length and prevent
kinking.
5. One or two large perforators to the muscle are
ligated distally.
Fig. 5 The two flaps were sutured together in a conic 6. Preserve the medial cutaneous nerve of
shape to form the anterior and posterior wall of the the thigh, branch of the obturator nerve
neovagina
in order to provide sensibility to the
neovagina.
12. The muscles were not inserted behind the 7. The gracilis muscles were not inserted behind
neovagina, but after the division of their distal the neovagina but were left in their original
end were left in their original position in the position in order to ensure adequate mobiliza-
thigh. At the closure of the donor site the tion of the skin paddle.
muscle’s distal end was loosely sutured to 8. The muscle’s distal end is loosely sutured to
the adductor longus muscle. the adductor longus muscle.
13. Donor sites are closed directly, and suction
drains are placed at the donor and the recipi-
ent sites (Fig. 6). Intraoperative Images
See Figs. 3, 4, 5, and 6.

Technical Pearls
1. Flap harvesting starts with distal skin incision Postoperative Management

and continued until muscle fascia to secure the
circulation of the skin paddle through the small The patient was postoperatively monitored
musculocutaneous perforators. through physical examination and Doppler for
2. The deep fascia must be included to the flap in the first 5 days. She remained in bed rest for
order to preserve skin blood supply. 1 day, avoiding sitting for 1 week.
3. Fascia is opened over gracilis muscle and The suction drains were removed when the
muscle is dissected all the way near knee fluid secretion was less than 30 cc, and about
joint. 4 days postoperatively.
The wounds healed uneventfully resulting in a

satisfactory neovagina. Magnetic resonance imag-
ing at 2 years follow-up demonstrated insignifi-
cant volume regression over time and the vaginal
depth remained stable, without evidence of orifice
constriction.
The preservation of the medial cutaneous nerve
of the thigh, branch of the obturator nerve that
supplies the proximal median thigh skin, ensured
the sensory rehabilitation of the neovagina. See
Figs. 7 and 8. Interestingly, the patient reported
entirely satisfactory sexual relations approximat-
ing pre-exenteration frequency, authorizing the
effectiveness of the method in the woman’s psy-
chological well-being.
1. The deep fascia must be included to the skin

flap in order to preserve the small Fig. 7 Two years postoperatively. The wounds healed
musculocutaneous perforators and provide uneventfully in a satisfactory neovagina
adequate tissue bulk (Kaartinen et al. 2015).
2. To ensure adequate mobilization of the skin
paddle the gracilis muscles must be divided at
their distal end and loosely sutured to the
adductor longus muscle.
3. The gracilis muscles are spared as a lifeboat in
case of wound dehiscence, partial necrosis, or
fistula formation in the posterior wall, as well
as in case of potential neoanus dynamic anal
myoplasty in the future (Pusic and Mehrara
2006; Mirhashemi et al. 2002; Pirro et al.
2005).
Learning Points Fig. 8 MRI demonstrated insignificant volume regression

over time and stable vaginal depth, without evidence of
orifice constriction
1. Secondary total vaginal reconstruction
requires careful patient selection for achieving cutaneous nerve of the thigh, branch of the
optimal outcomes. Interestingly, less than 50% obturator nerve, and this is an important aspect
of the patients undergo immediate vaginal for the woman’s psychological well-being. In
reconstruction after pelvic exenteration (Kiiski the literature, the reported postreconstructive
et al. 2019; Mirhashemi et al. 2002). satisfactory sexual activity ranges from 14%
2. The sensory rehabilitation of the neovagina is to 85% (Løve et al. 2013; Crosby et al. 2011;
feasible through preservation of the medial Ratliff et al. 1996).
3. The proposed modification of TUG flaps with- Mirhashemi R, Averette HE, Lambrou N, et al. Vaginal
out gracilis muscle insertion in the neovagina reconstruction at the time of pelvic exenteration: a
surgical and psychosexual analysis of techniques.
addresses effectively and prudently technical Gynecol Oncol. 2002;87(1):39–45.
problems encountered in secondary post-total Özkan Ö, Özkan Ö, Çinpolat A, et al. Vaginal reconstruc-
pelvic exenteration vagina reconstruction, and tion with the modified rectosigmoid colon: surgical
safeguards the success of the method. technique, long-term results and sexual outcomes.
J Plast Surg Hand Surg. 2018;52(4):210–6.
Pirro N, Sielezneff I, Malouf A, et al. Anal sphincter
reconstruction using a transposed gracilis muscle with
References a pudendal nerve anastomosis: a preliminary anatomic
study. Dis Colon Rectum. 2005;48(11):2085–9.
Bistoni G, Alamouti R, Martinez Alcaide S, et al. Versatil- Pusic AL, Mehrara BJ. Vaginal reconstruction: an algo-
ity of the free jejunum flap in vaginal reconstruction. rithm approach to defect classification and flap recon-
Clin Case Rep. 2016;4(3):240–3. struction. J Surg Oncol. 2006;94(6):515–21.
Cortinovis U, Sala L, Bonomi S, et al. Rectus abdominis Qiu SS, Jurado M, Hontanilla B. Comparison of TRAM
myofascial flap for vaginal reconstruction after pelvic versus DIEP flap in total vaginal reconstruction after
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Crosby MA, Hanasono MM, Feng L, et al. Outcomes of 1020e–7e.
partial vaginal reconstruction with pedicled flaps fol- Ratliff CR, Gershenson DM, Morris M, et al. Sexual
lowing oncologic resection. Plast Reconstr Surg. adjustment of patients undergoing gracilis
2011;127(2):663–9. myocutaneous flap vaginal reconstruction in conjunc-
Gravvanis A, Kakagia D, Haidopoulos D, et al. Secondary tion with pelvic exenteration. Cancer. 1996;78(10):
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1319–20. struction after abdominoperineal resection with near
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Oncol. 2009;16(1):121–7. reconstruction with the deep inferior epigastric perfo-
Kaartinen IS, Vuento MH, Hyöty MK, et al. Reconstruc- rator flap: a preliminary report. Plast Reconstr Surg.
tion of the pelvic floor and the vagina after total pelvic 2007;119(6):1785–90.
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Kiiski J, Räikkönen K, Vuento MH, et al. Transverse 701–9.
myocutaneous gracilis flap reconstruction is feasible Weiwei L, Zhifei L, Ang Z, et al. Vaginal reconstruction
after pelvic exenteration: 12-year surgical and oncolog- with the muscle-sparing vertical rectus abdominis
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Løve US, Sjøgren P, Rasmussen P, et al. Sexual dysfunc- 2009;62(3):335–40.
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Penile Reconstruction with a Free
Radial Artery Forearm Flap (FRAFF) 84
for Bladder Exstrophy
Marlon E. Buncamper, Karel Claes, and Stan Monstrey
Contents
Preoperative Considerations: Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . 896
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 896
The Anterolateral Thigh (ALT) Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897
Abdominal Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 898
Groin/Superficial Circumflex Iliac Artery Perforator (SCIP) Flaps . . . . . . . . . . . . . . . . . . . . 898
Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
Preoperative Care and Patient Drawings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905
Abstract
Reconstruction of a functional phallus for a cis

male who has undergone multiple surgeries for
reconstruction of his urogenital system
demands a thorough knowledge of all recon-
M. E. Buncamper · K. Claes · S. Monstrey (*) structive and microsurgical techniques. It also
Department of Plastic Surgery, Ghent University Hospital, requires close cooperation between the urolo-
Ghent, Belgium
e-mail: marlon.buncamper@uzgent.be;
gist and plastic surgeon as each case is
Karel.Claes@uzgent.be; Stan.Monstrey@ugent.be different.

https://doi.org/10.1007/978-3-030-23706-6_71
896 M. E. Buncamper et al.
A one-stage phalloplasty reconstruction Preoperative Considerations:

with a free radial forearm flap in a 22-year- Reconstructive Requirements
old cis patient, with a history of bladder
exstrophy reconstruction as a child, is 1. Studies have shown that the mean erectile
described. The classical tube-within-a-tube penile length is 14.15 cm and has a circumfer-
design was altered as there was no need for ence of 12.23 cm, meaning that the neophallus
a reconstruction of the urethra. The glans of should either add 10 cm to the micropenis or
the penis was integrated into the base of the replace the whole penis and measure at least
neophallus for erogenous sensation. For a 14 cm in length (Wessells et al. 1996).
more pleasing aesthetic result, the corona 2. The patient should be able to expose himself
was also fashioned during the initial without fearing that his neophallus does not
procedure. resemble a normal male penis.
After having assessed that tactile sensation 3. Since the patient is able to achieve an orgasm,
was present along the length of the neo- the phallus should also allow erogenous stim-
phallus 15 months postoperatively, an erec- ulation (Selvaggi et al. 2007a; Vriens et al.
tile prosthesis was placed by the urologist. 1996).
All procedures were uneventful and produced 4. The ability to have penetrative sexual inter-
a functionally and aesthetically pleasing course was of great importance to the patient,
neophallus. so the phallus should be able to accommodate
an erectile prosthesis (Hoebeke et al. 2003).
5. The final result should be achieved in the
Keywords
fewest possible operations.
Genital surgery · Bladder exstrophy · Free 6. No urethral reconstruction was required as the
radial forearm flap · Phalloplasty patient was satisfied with his urostomy.
7. There should be minimal surgical morbidity at
the donor site (Hage and de Graaf 1993).
Clinical Scenario 8. Surgeons should be aware of potential changes
in anatomy due to prior operations and
A 22-year-old cis male patient was referred to scarring.
the urogenital team for penile reconstruction. He
had undergone multiple operations for bladder
exstrophy. These included bladder reconstruc- Treatment Plan
tion, osteotomies to adapt the pelvic ring and a
Mitrofanoff procedure to achieve urinary conti- There were many options for phalloplasty in this
nence with a continent urostomy. The patient’s patient that could have addressed his reconstructive
main complaint was that he felt ashamed to needs, but after ample consultation and discussion,
expose himself in front of his peers and had a free radial forearm flap (FRFF) was selected. The
shunned social situations where there was the free radial forearm flap is still the gold standard for
remote possibility of him having to undress. phalloplasty in gender confirming surgery and
Though he was able to achieve an orgasm by other penile reconstructive surgeries.
erogenous stimulation of his penile stump, nor- The reasons that the FRFF is considered the
mal sexual intercourse, by vaginal penetration, method of choice (Morrison et al. 2016; Hage and
was impossible due to the insufficient length of de Graaf 1993; Monstrey et al. 2009) are:
his penis. This resulted in a lack of confidence
when in contact with girls of his age. The patient 1. It is a one-stage operation.
was a nonsmoker, with a BMI of 22. 2. It is a reliable flap that is easy to harvest.
84 Penile Reconstruction with a Free Radial Artery Forearm Flap (FRAFF) for Bladder Exstrophy 897
3. It is the most frequently used flap for tactile sensation is an absolute requirement before
phalloplasty and the effectiveness has been placement of a prothesis. This necessitates one of
proven in large series (Morrison et al. 2016). the sensory nerves of the flap being coaptated to a
4. Due to the flap thinness and pliability, the tube- nerve in the pubic area, the ilioinguinal nerve
within-a-tube technique can always be applied, being the nerve of choice. The glans of the patient,
should urethral reconstruction in one stage be which allowed for orgasm, would be incorporated
needed. at the base of the neophallus. Friction when pen-
5. The aesthetic result is deemed equal or superior etrating or when masturbating could then result in
to phalloplasties with other flaps. an orgasm. One branch of the penile dorsal nerve
6. The possibility of incorporating at least two can be coaptated to give erogenous sensation
sensory nerves is always present, while studies along the flap.
show that the innervation of these nerves gives
the greatest sensitivity.
7. It allows for safe and effective accommodation Alternative Reconstructive Options
of an erectile prosthesis making penetrative
sexual intercourse possible (Lumen et al. The Anterolateral Thigh (ALT) Flap
2008; Morrison et al. 2016).
8. Surgical morbidity is acceptable (Selvaggi In 2006, Felici described the Antero Lateral Thigh
et al. 2007b). (ALT) as an alternative free flap to the free radial
9. The radial forearm flap has a long pedicle forearm flap for phallic reconstruction. In that
allowing easy bridging of the distance from same year, Mutaf published his work using the
the pubic area to the groin. ALT as a pedicled flap for phallic reconstruction
(Felici 2006; Mutaf 2006; Rubino et al. 2009).
The major drawback of the radial forearm flap Due to the increased risks when performing a
phalloplasty is that it remains a microsurgical free flap as opposed to a pedicled flap, the pedi-
operation that requires surgical expertise with cled option has gained favor.
close postoperative monitoring and the potential The ALT flap advantages as an alternative to
of anastomotic revision. The almost circumferen- the FRFF are:
tial donor site on the forearm, which in gender
reaffirming surgery is deemed an unwelcome stig- 1. Since described in 1965, it has become one of
mata, was not a major concern for this cis male the most commonly used flaps in reconstruc-
patient. tive surgery and is deemed safe and reliable
The tube-within-a-tube design was abandoned (Morisson et al. 2014).
as no urethral reconstruction was required. Only a 2. It is a one-stage operation.
distal urethral opening was created to a short 3. In the well-chosen patient, it can be shaped into
blind-ending urethra. an aesthetically acceptable phallus.
As the goal was also to allow for penetrative 4. If required, it can be combined with another
and pleasurable sexual intercourse, the technique for urethral reconstruction, and in
phalloplasty would need stiffening. This can some cases, if very thin, it can allow for recon-
only be achieved by the incorporation of an erec- struction of the urethra with the tube-within-a-
tile prosthesis. In this patient, the proximal part of tube technique.
the prothesis could be placed within the sheets of 5. Sensory innervation can be achieved by
the retained cavernous bodies to prevent disloca- branches of the lateral femoral cutaneous nerve
tion and malpositioning. In order to limit compli- (Selvaggi et al. 2007b; Morrison et al. 2014).
cations due to erosion of the radial artery forearm 6. Its proximity to the pubic area makes a pedi-
flap by friction caused by the erectile prothesis, cled transfer possible.
7. It allows for safe and effective accommodation Abdominal Flap

of an erectile prosthesis making penetrative
sexual intercourse possible. Flaps based on the epigastric vessels have been used
8. There is always plenty of tissue in the ALT, for penile reconstruction before free flap
insuring more padding around the prosthesis. phalloplasties. Of these, the abdominal phalloplasty
9. The donor site is easily concealed under cloth- flap centered on the suprapubic area is the most
ing making it less conspicuous. common.
The advantages of using the abdominal flap as
Despite all the advantages of using an ALT flap alternative to the FRFF are:
as an alternative to the FRFF for phallus recon-
struction, the disadvantages are: 1. No microsurgery is required.
2. The donor site is easily concealed making it
1. Though the aesthetic results of the ALT are less conspicuous.
adequate, the aesthetic results of the FRFF are
deemed superior. The disadvantages when compared to the
2. There is often only one nerve to be coaptated FRFF are:
making it necessary to choose either for erog-
enous or protective tactile sensation. 1. The aesthetic results of the abdominal flap are
3. Innervation of the nerves of the FRFF are deemed poor when compared to those of the
superior to those of the ALT (Selvaggi FRFF (Morrison et al. 2016).
et al. 2007). 2. It is usually a two-step procedure.
4. Due to the anatomical variations in the pelvic 3. Nerve innervation is not possible, making the
region in bladder exstrophy, the pedicle of the placement of a prosthesis more likely to result
ALT may not be long enough for transfer, in complications.
necessitating conversion to a free flap, mitigat- 4. The variability in vascular anatomy makes this
ing all the advantages of a pedicled flap (Mor- an unreliable flap.
rison et al. 2016). 5. The flap is bulky making sexual penetrative
5. The girth of the neophallus, especially after intercourse unlikely.
placing the prosthesis, is far more than with a 6. The presence of abdominal scars in patients
FRFF, which may make penetration difficult with bladder exstrophy precludes the use of
(Morrison et al. 2016). this flap.
6. Due to anatomical variations, an ALT
phalloplasty always necessitates preoperative
CT angiography for the identification and loca- Groin/Superficial Circumflex Iliac
tion of the perforators (Sinove et al. 2013) Artery Perforator (SCIP) Flaps
The main theoretical advantage of the ALT In 2006, Koshima described penile reconstruction
phallus above the FRFF phallus is avoiding the by means of bilateral perforator flaps based on the
conspicuous forearm donor site scar and not hav- superficial circumflex iliac artery, a branch of the
ing the need for a microsurgical intervention. femoral artery, allowing it to be used as either a
Hence it is often described as the flap of choice pedicled or free flap (Koshima et al. 2006).
in bladder exstrophy penile reconstruction. How- This flap has gained in popularity, especially
ever, since the aim of the operation is to recon- for urethral reconstruction or as a salvage flap in
struct a penis that is as functionally and failed phalloplasty.
aesthetically as pleasing as possible, it is our opin- The advantages to using the SCIP flap as alter-
ion that the obvious choice remains the FRFF. native to the FRFF are:
1. It is a one-stage procedure. Preoperative Care and Patient

2. It is a thin and pliable flap deemed safe and Drawings
reliable.
3. An acceptable aesthetic result can be obtained Preoperatively, the genital area, the left forearm,
for the neophallus. and the right upper leg were shaved. The patient
4. It can be combined with a second SCIP flap for was placed supine with the left arm on an arm
urethral reconstruction. board at 90 of abduction at the shoulder. A well-
5. Its proximity to the pubic area makes pedicled padded tourniquet was applied proximally on the
transfer possible. left upper arm.
6. It allows for a safe and effective accommoda- There are various perforators supplying the skin
tion of an erectile prosthesis making penetra- of the forearm, either piercing the antebrachial fas-
tive sexual intercourse possible. cia as they pass through the muscle or through the
7. The donor site can be closed primarily and is septum. Their position is predictable, making pre-
easily concealed, making it less conspicuous. operative Doppler localization unnecessary.
The flap design measures 14 cm in breadth by
The disadvantages of the SCIP when compared 16 cm in length. The most distal outline of the flap
to the FRFF are: was positioned on the distal forearm starting at the
wrist crease. The lateral border was placed at the
1. Nerve innervation is not possible, making the border of the ulnar bone. The rest of the flap was
placement of a prosthesis more likely to result drawn around the volar and radial aspects of the
in complications. wrist. A lazy s-line was drawn from the proximal
2. The pedicle may be too short necessitating border of the flap extending to the cubital fossa.
microsurgical conversion (Koshima et al. In the left groin, the femoral artery was palpated
2006). and marked. The urologist started by marking all
3. The presence of abdominal and groin scars visible scar tissue on the penile stump except for
in patients with bladder exstrophy makes the skin of the glans. He designed his excision
this an unreliable flap due to anatomical pattern so that the base of the neophallus could be
changes. inset around the base of the penile stump (Fig. 1).
Preoperative Evaluation
Clinical examination revealed a penile stump of

4.5 cm (micropenis) covered with scar tissue with
the remanence of a glans and cavernous bodies.
The patient’s nondominant left hand had no visi-
ble scarring.
An Allen’s test was performed at the left wrist
to assess the palmar arch and exclude any poten-
tial vascular insufficiency on the radial side of
the hand following FRRF. The amount of sub-
cutaneous fat on the upper leg was evaluated.
Both the estimated bulk of the resulting
phalloplasty and visible scars in the right groin Fig. 1 Preoperative view of the penile stump, abdominal
area and abdomen precluded selection of the scars from previous operations and urostomy in the right
ALT flap. groin
Perioperative antibiotic prophylaxis was The flap was then dissected from distally to
administered (Toia et al. 2012). proximally. Where the pedicle travels under the
brachioradialis muscle, retractors are used for better
exposure. Again, care was taken to avoid damaging
Surgical Technique the superficial branch of the radial nerve where it
exits underneath the brachioradialis muscle.
This operation was performed simultaneously by The pedicle was then followed until it
the urology and plastic surgery teams. reached the cubital fossa where it joined with
The urologist started with excision of the the ulnar artery. The venous system was
scared skin and tissue of the penile stump, expos- followed proximally to where the deep and the
ing both penile cavernous bodies. superficial systems coalesce. The tourniquet was
Both cavernous bodies were released as far deflated and hemostasis achieved. Blood flow to
back as possible, removing any scar tissue that the fingers and flap was checked. With the flap
still remained and held them. On the dorsum of the still attached to the forearm by its pedicle, the
penile stump, a branch of the dorsal penile nerve phallus was formed by wrapping the flap on
was dissected and marked. A branch of the itself. To create the illusion of a glans, a small
ilioinguinal nerve was dissected and marked for crescent shaped skin flap, 1 cm in breadth,
coaptation to the nerves of the neophallus. encircling the whole circumference of the phal-
The tourniquet on the left arm was inflated. The lus, was incised at the distal one-third of the flap
plastic surgeon started by making an incision in (Fig. 2). This flap was sutured onto itself to
the wrist crease at the site of the radial artery. The create a corona. A skin graft was applied on the
radial artery and its concomitant veins were iden- remaining proximal defect as described in the
tified, divided, and ligated. Norfolk technique (Fig. 3).
The proximal outline of the flap was then In the left groin, where the recipient vessels
incised to the level of Scarpa’s fascia where with were marked, an incision was made and dissection
scissors, both the medial cutaneous nerve and a of the common femoral and the femoral artery
second cutaneous nerve branch were identified. past its bifurcation into the deep femoral artery is
These will later serve for sensory coaptation. made visible. Vessel loops are placed around the
The lazy s-incision was made to the level of the three branches of the femoral vessel in preparation
subcutis. This was followed by sharp dissection of for clamping. The greater saphenous vein was
the cephalic vein and any other superficial veins
that flowed directly into the cephalic vein, with
the identified sensory nerves dissected up to the
cubital fossa.
The ulnar aspect of the flap was first raised
subdermally. This dissection is superficial to the
muscular fascia, ligating all perforators up to the
medial border of the flexor carpi radialis (FCR)
muscle.
The flap was then dissected subdermally from
its most radial aspect until the cephalic vein was
reached. Care was taken to dissect free the super-
ficial branches of the radial nerve. Dissection then
proceeded deep to the antebrachial fascia and the
paratenon was left intact on the surface of the Fig. 2 Norfolk design of the coronaplasty, with the neo-
flexor carpi radialis. phallus still attached
Fig. 3 Coronaplasty with the Norfolk technique and the

phallus still attached
Fig. 5 Final perioperative result of the phalloplasty
Fig. 4 Microscopical nerve coaptation of the flap nerve to

the ilioinguinal nerve
also dissected over a distance of 6 cm and

clamped and ligated in preparation for the flap.
The pedicle was ligated and transferred to the
recipient site in the pubic area. Fig. 6 The forearm donor site covered with split skin
The radial artery was microscopically anasto- grafts
mosed to the common femoral artery in an end-to-
side fashion, and the cephalic vein was also The denuded penile stump was incorporated
microscopically anastomosed end-to-end to the into the base of the neophallus but the glans was
greater saphenous vein. One forearm nerve was left exposed (Fig. 5). Pulsation of the radial artery
coaptated, microscopically with four single was confirmed with the handheld Doppler and a
stitches Ethylon 9.0 to the dorsal penile nerve for suture was placed at the most distal point where
erogenous sensation. The second nerve was also the signal was heard.
coaptated with four single stitches Ethylon 9.0 to The donor site defect was covered using split-
the ilioinguinal nerve for protective sensation thickness skin grafts taken from the anterior sur-
(Fig. 4). face of the right thigh (Fig. 6). The arm was
splinted to immobilize it, reducing pain and Intraoperative Images

improving skin graft take. The donor site on the
right thigh was dressed with an alginate dressing
and sterile gauze. As the patient had a functioning
urostomy and no urethral reconstruction, no type Postoperative Management
of urinary diversion catheter was required.
The phallus was placed on a bed of gauze, ensur-
ing that it remained at an angle of at least 45 to
Technical Pearls the thighs and pointed slightly to the right. The
patient was positioned to allow a maximum 30
1. First ligate the distal end of the radial artery, angle at the hip.
this will aid in identifying the borders of flap For the first postoperative night, the patient
later on during dissection. remained in the postanesthesia care unit (PACU).
2. Identify the two sensory nerves in the proxi- The flap was monitored each hour for changes
mal part of the flap. in capillary refill, color, Doppler signal, and
3. Dissect the sensory nerves, the cephalic vein, temperature.
and other superficial veins proximally, all the Pain control was achieved using a combination
way to the cubital fossa. of intravenous and intramuscular analgesia.
4. Ligate the nerves and mark them with a clip. Fractioned heparin was administered subcutane-
5. Start by dissecting the flap from its ulnar ously and continued throughout the hospital stay.
border towards the flexor carpi radialis The next morning, the patient was transferred to
(FCR) muscle, preserving all the perforators the ward where a low-fiber diet was started. Flap
traveling radially from the FCR. monitoring was decreased in frequency in the
6. Then dissect the flap from its most radial course of the first 3 days, to three times daily, up
margin. to discharge.
7. Always leave paratenon intact on the under- On the fifth day, the forearm splint was removed
lying tendons to assure take of the skin and the split skin grafts inspected. Bedrest was
grafts. observed for 7 days after which the patient gradu-
8. The pedicle is elevated from distal to proximal. ally ambulated with help of a physiotherapist. The
9. Once the junction of brachioradialis and the patient was discharged from hospital on the 13th
FCR is reached, perforators do not have to be postoperative day, with minimal home care.
preserved.
10. Beyond this point, retractors should be used
for better exposure. Outcome
11. The tourniquet may safely remain inflated for
2 h. The patient was seen for regular follow-up at the
12. When fashioning the phallus, the pedicle outpatient clinic. His recovery was uneventful and
should remain attached. he was able to pursue his daily activities within
13. The recipient vessels should be controlled with 3 months. At 14 months, tactile sensation at the tip
both vessel loops and 90 Satinsky clamps. of the phallus was reported.
14. The radial artery should be anastomosed so that An aesthetically pleasing result was achieved
it enters at an angle of no greater than 90–125 . (Figs. 6–7). The patient was able to achieve
15. The radial artery should be anastomosed first, orgasm by rubbing his exposed glans at the base
followed by the vein. of his phallus (Fig. 8). He had not tried penetrative
16. Once adequate circulation to the flap is sex. The donor scar on his left arm healed well
established, then the nerves are coaptated. leaving a not too conspicuous scar (Figs. 9–10).
The age at which phallic reconstruction is

performed is debatable. Early reconstruction
may aid in the psychological stresses that these
boys experience, but this must be weighed up
against the maturity necessary to deal with the
physical and sexual consequences of the
phalloplasty, regardless of the method used.
Reconstruction after the age of 18 (the major-
ity) makes flap design easier as no care has to be
taken to incorporate predictions in phallic
growth. Bear in mind that the penis, that the
phallus is replacing, is formed by genital tissues,
demonstrating a more exponential growth during
puberty.
Most patients have a nonfunctional urethra due
to urinary diversion, precluding the need for ure-
thral reconstruction. This does simplify the recon-
structive process in comparison to reconstructing
a phallus in a patient who wants to void through
Fig. 7 Dorsal aspect of the neophallus at 14 months his new neophallus. Therefore, some plastic sur-
geons prefer a pedicled anterolateral thigh (ALT)
flap above the standard radial forearm flap in this
The patient had complete hand function with a full specific group of patients.
range of motion and no loss of sensation. Preserving and incorporating any useful glan-
One month later, the erectile prosthesis was dular, penile, and cavernous tissue as the basis of
placed in the phallus. This procedure and the the newly reconstructed phallus is very important
subsequent convalescence period were also as this will later on facilitate sexual stimulation
uneventful. and pleasure.
If alternative flaps are being used, a preopera-
tive workup including CT angiography for map-
Avoiding and Managing Problems ping of the perforators is recommended. This will
assess the thickness of the flap and any changes in
Reconstructive phalloplasty in cases of bladder the normal anatomy due to the underlining anom-
exstrophy requires the collaboration of surgical alies or prior surgery. As in any free flap, aim to
specialties. These patients have had multiple minimize the ischemic period by shaping the phal-
reconstructive operations at birth, including lus while it is still attached and perform nerve
some form of urinary diversion by a urologist. coaptation following microvascular anastomosis.
Though the actual penile reconstruction is typ- Ensure the pedicle is well placed and that there are
ically performed by the plastic and reconstructive no kinks when the position of the recipient leg is
surgeon, it is imperative that the urologist be part changed.
of the decision-making process and operative Complications of the radial forearm phalloplasty
team as, in the long term, the urologist’s role include the general complications of any surgical
may be the most important for patients. Assessing intervention and include minor wound healing
the specific needs and feasibility of the needs of problems in the groin (Monstrey et al. 2009; Mor-
each patient together with the urologist will yield rison et al. 2016). Other complications are related to
greater patient satisfaction in the long run. the free tissue transfer. The total flap failure rate in
Fig. 8 Ventral aspect of the neophallus, with penile glans incorporated at the base, at 14 months
Fig. 10 Ventral aspect of donor site at 14 months

postoperative
the literature is low (<1–1.69%) with a somewhat

higher anastomotic revision rate (7.8–12%). About
5.43–7.3% of the patients demonstrate some degree
of skin slough or partial flap necrosis (Monstrey
et al. 2009; Morrison et al. 2016). This is higher in
smokers, in patients who insist on a large-sized
penis, and also in patients having undergone anas-
Fig. 9 Dorsal aspect of donor site at 14 months tomotic revision.
No major or long-term problems such as func- superficial circumflex iliac artery perforator (SCIP)
tional limitation, nerve injury, chronic pain/edema flaps. J Reconstr Microsurg. 2006;22(3):137–42.
Lumen N, Monstrey S, Selvaggi G, Ceulemans P, De
or cold intolerance, poor donor scaring have been Cuypere G, Van Laecke E, Hoebeke P. Phalloplasty: a
recorded (Monstrey et al. 2009; Morrison valuable treatment for males with penile insufficiency.
et al. 2016). Urology. 2008;71(2):272–6.
Overall our experience is that the appearance Monstrey S, Hoebeke P, Selvaggi G, et al. Penile recon-
struction: is the radial forearm flap really the standard
of the donor site is acceptable to patients who technique? Plast Reconstr Surg. 2009;124:510–8.
view it as a worthwhile trade-off for the creation Morrison SD, Son J, Song J, Berger A, Kirby J, Ahdoot M,
of a phallus. The use of full thickness skin grafts Lee GK. Modification of the tube-in-tube pedicled
and dermal substitutes may contribute to a better anterolateral thigh flap for total phalloplasty: the mush-
room flap. Ann Plast Surg. 2014;72(Suppl 1):S22–6.
forearm scar (Selvaggi et al. 2007). Morrison S, Shakir A, Vyas K, Kirby J, Crane C, Gordon
K. Phalloplasty: a review of techniques and outcomes.
Learning Points Mutaf M, Isik D, Bulut Ö, Büyükgüral B. A true non-
microsurgical technique for total phallic reconstruction.
Ann Plast Surg. 2006;57:100–6.
1. Reconstruction of the neophallus in boys with Rubino C, Figus A, Dessy LA, Alei G, Mazzocchi M,
bladder exstrophy should be treated on an indi- Trignano E, Scuderi N. Innervated island pedicled ante-
vidual case basis, as there is not one technique rolateral thigh flap for neo-phallic reconstruction in
that suits all. female-to-male transsexuals. J Plast Reconstr Aesthet
Surg. 2009;62(3):e45–9.
2. The need for urethral reconstruction deter- Selvaggi G, Monstrey S, Ceuleman P, T’Sjoen G, De
mines the reconstructive options. Cuypere G, Hoebeke P. Genital sensitivity after sex
3. Various flap choices are available. reassignment surgery in transsexual patients. Ann
4. Penetrative functionality can be achieved by Plast Surg. 2007a;58:427–33.
Selvaggi G, Monstrey S, Hoebeke P, et al. Donor site
the placement of an erectile prosthesis. morbidity of the radial forearm free flap after
5. Adequate aesthetic and functional result can be 125 phalloplasties in gender identity disorder. Plast
achieved. Reconstr Surg. 2007b;118:1171–7.
Sinove Y, Kyriopoulos E, Ceulemans P, Houtmeyers P,
Hoebeke P, Monstrey S. Preoperative planning of a
pedicled anterolateral thigh (ALT) flap for penile recon-
References struction with the multidetector CT scan. Handchir
Mikrochir Plast Chir. 2013;45:217–222.
Felici N. A new phalloplasty technique: the free ante- Toia F, D'Arpa S, Massenti MF, Amodio E, Pirrello R,
rolateral thigh flap phalloplasty. J Plast Reconstr Moschella F. Perioperative antibiotic prophylaxis in
Aesthet Surg. 2006;59:153–7. plastic surgery: a prospective study of 1,100 adult
Hage JJ, de Graaf FH. Addressing the ideal requirements patients. J Plast Reconstr Aesthet Surg. 2012;65(5):
by free flap phalloplasty: some reflections on refine- 601–9.
ments of technique. Micro-surgery. 1993;14:592–8. Vriens J, Acosta R, Soutar D, Webster M. Recovery of
Hoebeke P, De Cuypere G, Ceulemans P et al. Obtaining sensation in the radial forearm free flap in oral recon-
rigidity in total phalloplasty: experience with 35 struction. Plast Reconstr Surg. 1996;98:64–9.
patients. J Urol. 2003;169:221–3. Wessells H, Lue T, Mcaninch J. Penile length in the flaccid
Koshima I, Nanba Y, Nagai A, Nakatsuka M, Sato T, and erect states: guidelines for penile augmentation.
Kuroda S. Penile reconstruction with bilateral J Urol. 1996;156(3):995–7.
Areola-Sparing Mastectomy and Deep
Inferior Epigastric Perforator Flap 85
Reconstruction
Jack F. C. Woods, Lylas Aljohmani, and Philip Blondeel
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 920
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 920
Abstract
Breast cancer is the most commonly diagnosed

malignancy in women worldwide. Great pro-
gress has been made in the management of
J. F. C. Woods (*) · L. Aljohmani these patients over the last few decades. Cur-
Department of Plastic & Reconstructive Surgery, rently, gold standard postmastectomy recon-
St Vincent’s University Hospital, Dublin, Ireland struction involves microsurgical techniques
e-mail: aljohmal@tcd.ie
using perforator-based free flaps, although
P. Blondeel many alternative approaches may be used for
Ghent University Hospital, Ghent, Belgium
e-mail: phillip.blondeel@ugent.be particular reasons. While many free flap options

https://doi.org/10.1007/978-3-030-23706-6_73
908 J. F. C. Woods et al.
for breast reconstruction have been described, considered the “Gold Standard” procedure in autol-
the deep inferior epigastric perforator (DIEP) ogous breast reconstruction (Blondeel et al. 2012).
flap is most used, which provides a favorable It is the most popular free flap employed in breast
donor site in the majority of patients and is a reconstruction worldwide and outcomes continue
robust, repeatable, and reliable procedure pro- to improve with research and training.
viding good tissue and a long pedicle. However, The deep inferior epigastric artery originates
each patient is unique and certain cases can from the external iliac artery immediately above
present significant challenges to the reconstruc- the inguinal ligament, passing along the medial
tive surgeon. Various techniques and approaches border of the abdominal inguinal ring and punctur-
can help in the management of these complex ing the transversalis fascia before entering the rec-
cases. In this chapter, a complex patient is tus sheath below the arcuate line, ascending
described who had bilateral areola-sparing mas- between the rectus abdominis muscle and the pos-
tectomies and wanted to pursue autologous terior lamella of its sheath and continuing in one of
reconstruction despite having limited donor site many types of branching patterns as it proceeds
tissue available. The treatment plan and surgical superiorly. There are most commonly two branches
technique are outlined, as well as some technical in which the lateral branch is dominant (Blondeel
pearls and learning points, covering the general et al. 1998). The branches anastomose above the
approach to the patient as well as perforator umbilicus with the superior epigastric artery and
choice, recipient vessel access, microsurgical lower intercostal arteries. A varying number of
technique, de-epithelialization, flap perfusion, fascial perforators come from these branches and
flap inset, management of the donor site, and they have variable lengths of intramuscular course.
adjunctive procedures. Some approaches to Ongoing research and innovation by clinicians
potential problems or complications and their and academics have allowed for refinements in the
management are discussed. technique of DIEP flap breast reconstruction sur-
gery and have improved the reconstructive journey
and outcomes for patients. Various novel ideas
Keywords
have been pursued, such as using advanced preop-
DIEP flap · Breast reconstruction · Areola erative imaging methods and intraoperative angi-
sparing · Outcomes ography techniques to improve safety and
decision-making, while ongoing investigation into
the efficacy of nerve coaptation for sensory recov-
Introduction ery and vascularized lymph node transfer into post-
adenectomy axillae may become accepted stan-
In modern times, there have been positive devel- dards in the future. In addition to technical
opments for breast cancer patients with a myriad of improvements, there have been advances in patient
reconstructive options available to them, including care with enhanced recovery after surgery (ERAS)
microsurgical techniques. Work by Taylor (Boyd protocols, shared decision-making, and early dis-
et al. 1984) investigating the vascular supply of the charge. In this challenging case, a modern
superior and deep epigastric arteries as well as the approach to breast reconstruction is described,
development of microsurgical techniques and including technical tips and innovations that
increased interest in perforator flaps led to the first improve results and outcomes for patients.
descriptions of the deep inferior epigastric artery
perforator flap (Koshima and Soeda 1989). Its
application as a tool for breast reconstruction was Clinical Scenario
suggested in the early 1990s by Robert Allen
(Allen and Treece 1994) and since then it has A 47-year-old woman, with a significant family
been refined and popularized by Blondeel and history of breast cancer, presented after biopsy
others (Blondeel 1999), such that it is now and radiological investigation with multifocal
85 Areola-Sparing Mastectomy and Deep Inferior Epigastric Perforator Flap Reconstruction 909
Fig. 1 Preoperative images of a 47-year-old woman with Fig. 3 Preoperative view of the anterior chest
a multifocal breast cancer of her left breast. She had a
positive family history for breast cancer

The patient described above posed several chal-

lenges which contributed to the complexity of the
case:
1. The possible need for adjuvant treatment:

• The long-term adverse outcomes of adju-
vant irradiation to autologous flaps after
immediate postmastectomy reconstruction
are significant, where it can lead to fat and
flap necrosis, volume loss, need for revision
surgery, and to poorer patient-reported out-
comes. As such, when adjuvant radiation is
considered a possibility, a delayed-
immediate approach by the use of “baby-
sitter” implants or tissue expanders can be
Fig. 2 Scar from previous biopsy can be visualized on the
employed, followed by subsequent autolo-
upper pole of the left breast. Markings are in place for
sentinel node biopsy. Note the relatively modest abdominal gous flap reconstruction (Otte et al. 2016).
pannus Any capsular fibrosis that develops at the
early stage is correctable during the autolo-
gous reconstruction.
left breast cancer. There was no evidence of dis- 2. Size and volume of donor site:
ease close to her nipple-areolar complex. She had • In selection of potential candidates for
no significant past medical history and had no DIEP flap breast reconstruction it is impor-
previous operations to her chest or abdomen. tant to consider the availability and volume
Her preoperative status can be seen in Fig. 1–3. of the putative donor site, as well as the
contralateral breast in a unilateral recon- abdominal tissue, whether to preserve some

struction setting (size, ptosis, projection, of her native areolar tissue in the resection to
and chest wall). In cases where great dispar- improve the ultimate reconstructive out-
ity between donor site and preoperative or come, and the decision to proceed in multiple
desired breast size exists, implant-based or stages. With these decisions, there are poten-
alternative flap options exist (Myers et al. tial pitfalls for patient understanding and
2021). However, the gold standard remains expectation. These issues may be mitigated
the use of an abdominal donor site. While by involving the patient entirely in the pro-
some patients may have true contraindica- cess. Shared decision-making requires sig-
tions for a DIEP flap reconstruction, volume nificant patient education and consultation
deficiency at the donor site may be consid- time. While this process can be onerous, it
ered only as a relative contraindication, as ultimately leads to greater trust and under-
techniques exist to assist in the delivery of standing for all stakeholders.
volume restoration, including the use of 5. Secondary surgery:
bipedicled or stacked DIEP flaps for unilat- • It is a significant challenge to achieve high-
eral cases or adjunctive fat grafting in bilat- quality results for patients with one-stage
eral cases. These challenges were faced reconstructions. The plan to complete this
with the patient presented above, who had patient’s reconstructive journey over multi-
a low body mass index and significant ple stages was important from both a poten-
donor and recipient volume disparity. tial oncological and aesthetic perspective.
3. Aesthetic result desired: Secondary surgery may involve corrections
• The outcomes of surgery for post- to the abdominal donor site or adjunctive
mastectomy breast reconstruction are procedures to the reconstructed breast, such
highly emotive topic for patients. There as mastopexy, lipofilling, scar revision, or
can be significant discrepancy in outcomes nipple reconstruction. Allowing the patient
between the patient expectation or experi- to heal and recover before assessing for
ence and the opinions of the medical team. issues including volume and projection
In an increasingly litigious healthcare envi- gives the opportunity to plan the appropriate
ronment, it is imperative that patients are secondary surgery, as in this patient with
offered the opportunities for informed and lipofilling.
open discussion of all options with their
associated risks and implications. Setting
goals and expectations for the reconstruc- Treatment Plan
tive journey is an important facet of care,
particularly when faced with challenging In this patient’s case, after a multidisciplinary
cases such as the one presented, where nat- team (MDT) discussion, there was a shared deci-
ural limitations in the patient’s physique sion to proceed with bilateral mastectomy (areola-
make it difficult to meet preconceived sparing mastectomies) and a left sentinel lymph
desires or expectations. One aspect that node biopsy. She was planned for a staged breast
can improve the aesthetic result is, where reconstruction as outlined below.
oncologically appropriate, the preservation
of some native areolar tissue such that a 1. First Stage
more natural look is achieved subsequent A staged autologous reconstruction was
to nipple reconstruction at a later stage. performed in this case as it was unknown
4. Decision-making: whether this woman would need radiotherapy
• Three issues were important for decision- postoperatively. She had placement of “baby-
making in this patient: whether to continue sitter” implants to preserve her native breast
with a DIEP flap given her limited skin. While she ultimately received
chemotherapy and hormone-based therapy, she rupture/rippling/animation/visibility or palpa-

did not require adjuvant treatment with radio- bility/implant illness/implant-associated lym-
therapy. Baby-sitter implants may be used in phoma); possible need for multiple revision
two situations: operations
• Patients who are unsure or undecided regard- • Latissimus dorsi and implant or extended
ing their ultimate reconstructive choice latissimus dorsi
• Patients who may require radiotherapy or – Advantages – Donor site on back is prefer-
other adjuvant therapies which might inter- able to some patients
fere with the optimal results of an autolo- – Disadvantages – Likely insufficient tissue,
gous reconstruction which would require an implant, with asso-
2. Second Stage ciated risks; shoulder weakness; animation;
Three months following her bilateral mas- seroma
tectomy, she had the second stage of her recon- • Gracilis-based free flap
struction. For this stage, the patient had a – Advantages – Consistent anatomy; favor-
removal of her implants and a delayed- able donor site
immediate type of reconstruction. Bilateral – Disadvantages – Sacrifices muscle and may
DIEP free flaps were raised and inset to the lose volume as these atrophies; risk of
internal mammary vessels, with access through lymphedema; medial thigh numbness
the previous areola-sparing mastectomy scars. • Profunda artery perforator free flap
• The steps of this procedure are outlined in – Advantages – Long pedicle; thick tissue;
the section “Surgical Technique” below. favorable donor site
3. Third Stage – Disadvantages – Inconsistent dominant per-
Nine months following the bilateral autolo- forator location; seroma; narrow flap width
gous free DIEP flap reconstruction, the patient may limit volume
had a third stage of her reconstruction with • Gluteal artery perforator free flap
modified CV flap nipple reconstructions and – Advantages – Good tissue volume in
bilateral lipofilling to improve volume and selected patients
shape. A total of 400 ml of fat was harvested – Disadvantages – Technically challenging;
from both flanks and thighs for this procedure short pedicle; seroma; donor site discomfort
and was processed with centrifugation before • Lumbar artery perforator free flap
lipofilling. The majority of the DIEP flap skin – Advantages – Good mimic for the shape
paddles were excised to improve the aesthetic and feel of breast tissue
results, with the remainder contributing to the – Disadvantages – Short pedicle; technically
CV flap nipple reconstruction. Results from challenging; donor site scar; higher revision
this can be seen in Fig. 7–9. rates than DIEP flap
Alternative Reconstructive Options Preoperative Evaluation and Imaging
There were potential alternative options for this In preparation for a DIEP flap breast reconstruction,
patient that were considered and discussed with there are some key considerations preoperatively:
the patient during the counseling process.
1. Imaging
• Implant-based only • The advances in radiological imaging tech-
– Advantages – No further procedure; no niques have proved invaluable to microvas-
donor site cular surgeons. Angiographic CT scanning
– Disadvantages – Implant-associated potential has allowed for preoperative visualization
risks (capsular contracture/displacement/ of flap vasculature and intramuscular course
as well as giving an indication of domi- 1. Medication

nant vessels. This facilitates clearer pre- • Antibiotics: These may be administered
operative planning as well as reduction in according to local antimicrobial guidelines
operative time, with associated cost bene- to cover potential pathogens, typically
fits (Uppal et al. 2009). While it does gram-positive bacteria such as staphylococ-
require an exposure of the patient to radi- cus or streptococcus. In the described case,
ation, it may be combined with a staging the antibiotic used was one dose of 1.2
scan for oncological patients. Magnetic grams of amoxicillin/clavulanic acid.
resonance imaging (MRI) and ultrasound • Anti-emetics and analgesia.
(US) are alternative modalities; however, • Muscle relaxant.
MRI provides less spatial resolution and 2. Equipment
US is less sensitive (Rozen and Ashton • A warming blanket is placed from the hips
2009). down to the feet and is used to maintain core
2. Donor site evaluation temperature at 37 C.
• A pinch test is performed to assess the • Two intravenous lines and an arterial line
donor site volume and whether the abdo- are placed by the anesthesiologist.
men will close satisfactorily after the flap is • Antithrombotic stockings and a spontaneous
harvested. pneumatic compression machine are used.
• The donor site is assessed for the presence • An indwelling urinary catheter is sited with
of previous scars or hernias. a temperature probe.
3. Patient body mass index (BMI) 3. Positioning
• The patient’s height and weight are used to • The patient is positioned with hips and
calculate a BMI. One potential upper limit knees flexed, by placing two pillows under
at which DIEP flap reconstruction might not the knees.
be offered would be for patients with a • A soft head ring is used to prevent develop-
BMI > 35. ment of occipital pressure ulceration.
4. Doppler • A urinary catheter is placed with a temper-
• The position of the best perforator(s) are ature probe.
confirmed and marked, guided by the pre- • The shoulders are abducted at 90 degrees at
operative imaging, using a handheld pencil the start of the operation until the mastec-
doppler (8 MHz). This is typically tomy and/or lymph node surgery is com-
performed when the patient attends for pre- plete, after which they are moved in to the
operative assessment 2 days before their patient’s side in a sterile fashion. If the
operation and rechecked at the beginning reconstruction is in a delayed setting such
of the operation. as in this patient, the arms are placed in by
5. Consent the patient’s side and well wrapped with soft
• Fully informed consent is solicited from the protection. This avoids potential ulnar nerve
patient when they present for their preoper- neuropathic symptoms.
ative review, taking time to ensure that all 4. Marking
relevant information is understood by the • Marking is completed with a pinch test to
patient. confirm viability of abdominal wound clo-
sure, with the apices of the markings at the
anterior superior iliac spines, and the border
Preoperative Care and Patient of the umbilicus is marked.
Drawing • Markings are also made on the chest wall
including the midlines and breast footplate.
There are several steps that may be routinely taken 5. Draping
in preparation for a DIEP flap on the day of • The patient is draped using sterile technique
surgery: in a standard fashion. Rather than using skin
clips to secure drapes, other tools such as a 7. Significantly sized lateral and medial row
microbial sealant device may be used. perforator vessels were preserved.
8. Incisions were made to the fascia, keeping a
small cuff of between 2 and 5 mm around the
Surgical Technique perforators.
9. Intramuscular dissection proceeded in a lon-
The steps of the surgical technique followed in gitudinal fashion, along clefts in the muscle
this case are as follows: tissue, to identify the main pedicle of the deep
Flap raise: inferior epigastric artery (DIEA) and venae
comitantes (DIEVs), dividing intramuscular
1. At the commencement of the abdominal flap branches as required. The rectus fascia was
raise, the midline was marked superiorly and incised toward the origin of the inferior epi-
inferiorly by temporary surgical clips and a gastric vessels at an early stage to allow for
3-0 silk suture placed on the superior edge of greater exposure. The fascia is freed from the
the umbilicus. underlying muscle along its edges in order to
2. The abdominal flaps were incised and avoid catching the muscle fibers during later
de-epithelialization of the majority of the closure.
flaps was performed at this stage, leaving a 10. Crossing segmental motor nerves were pre-
circle of skin which included the marked per- served where possible.
forator sites for subsequent doppler 11. At least two viable perforators were included
monitoring. with each flap, as checked with intraoperative
3. The umbilicus was incised circumferentially handheld doppler.
down to the fascia, without total 12. The communications with superior epigastric
skeletonization in order to preserve intact vessels were ligated and the pedicle was
vascularization. followed into the groin in the perivascular
4. At the lower abdominal incision, superficial fat at a submuscular level, ligating any unnec-
inferior epigastric arteries and veins were essary branches but preserving crossing
inspected. More than one superficial vein mixed segmental nerves, until the pedicle
may be present. The veins were dissected for was circumferentially free throughout its
2 cm of length and had a surgical clip placed course.
on them in case of flap requirement for addi- 13. The flaps were then divided in the midline
tional venous drainage. and separated completely from the fascia,
5. The incisions were continued down to the taking care to preserve the perforator entry
fascia circumferentially. Beveling was points.
performed at the sub-Scarpa’s fascia level to 14. Once the recipient vessels had been pre-
include this deep fat with the flaps on their pared, the DIEA and DIEV vessels were
borders, which helps to reduce potential con- carefully separated using blunt artery for-
tour step-off in the reconstructed breast and to ceps and double ligated in the groin before
reduce dog-ears laterally at the donor site. sterile weighing and transfer of the flap to the
6. Suprafascial dissection proceeded around the recipient site.
midline along the anterior rectus fascia up to 15. Bilateral salpingo-oophorectomy was then
the xiphisternum to enable mobilization of completed by the gynecology surgeons
upper abdominal tissue for later closure of before abdominal wound closure.
the donor site. The flaps were then raised
using monopolar diathermy from laterally to Chest preparation:
medially until encountering the border of the
rectus fascia, whereby bipolar diathermy was 1. The vertical trans-areolar mastectomy inci-
used to proceed with caution close to perfo- sions were reopened and the implants were
rating vessels. removed with capsulotomies. If greater access
is required, the scar may be extended laterally 6. An interrupted end-to-end hand-sewn arterial
or inferiorly. anastomosis of the DIEA to the IMA was
2. Access to the recipient vessels was gained by performed using a 9-0 monofilament nylon
dissection through the pectoralis major muscle, suture.
in the congruent direction of the muscle fibers, 7. Flow tests were performed to confirm success-
onto the fourth rib. ful anastomoses.
3. Perichondrial flaps were lifted and cartilage 8. The ischemia time from flap division to com-
was removed from the medial 3 cm of the rib pletion of the last anastomosis on each side was
up to the sternocostal joint. 43 min for the left breast and 48 min for the
4. The perichondrium was then lifted to reveal the right breast.
internal mammary artery (IMA) and vein
(IMV) wrapped in pre-pleural perivascular fat. Flap inset and wound closure:
5. The operating microscope was used to com-
plete recipient vessel preparation, ensuring to 1. The flap was inset after completion of
avoid excessive handling and heat exposure de-epithelialization, retaining a vertical
and ensuring that any clips on branches were ellipse of skin including a doppler-identified
placed transversely to preserve usable vessel perforator site for monitoring, which was
length. marked with a 6-0 nylon suture. Further infor-
6. Flow was checked in the recipient vessels to mation on flap inset is described in the section
ensure they are adequate for anastomosis. below.
7. A pediatric feeding tube was placed at the 2. The skin island was incised to allow for inset
medial aspect of the excised rib with a tempo- to native breast skin edges, which was then
rary suture and this was connected to closed with 3-0 monocryl sutures and
low-pressure suction to maintain a clear surgi- Dermabond skin glue.
cal field while allowing for regular irrigation of 3. The abdominal donor site was closed in
the vessels and preventing desiccation. layers.
4. The wound was washed and hemostasis was
Microsurgical anastomosis: ensured.
5. The rectus abdominis muscles were repaired
1. The DIEP flaps were placed in large saline- with 2-0 vicryl figure-of-eight sutures and the
soaked gauze swabs and secured in position fascia repaired with 0-looped nylon in two
with skin clips and silk sutures before micro- layers.
vascular anastomoses were completed. 6. One suction drain was placed on each side,
2. The contralateral abdominal flap was used for exiting through the lateral hair-bearing area of
each breast and the flap turned 180 degrees to the mons pubis.
allow the pedicle to lie appropriately without 7. The operating table was maneuvered in con-
tension for anastomosis. junction with the anesthesiologists to allow
3. In the chest, the IMA and IMV were ligated the patient to be flexed at the hips and knees
distally and vascular clamps applied and remove tension from the wound closure.
proximally. 8. High lateral tension was maintained by skin
4. Flow was checked to ensure it was satisfactory clips to mitigate lateral dog-ears and Scarpa’s
and the pedicle was placed carefully to ensure fascia was repaired with 2-0 vicryl interrupted
there was no twist or kink. sutures.
5. Microvascular anastomoses were performed 9. Skin closure was performed with 3-0 mono-
with an operating microscope. A venous anas- cryl buried dermal and running subcuticular
tomosis was performed using a 2.5 mm coupler sutures.
between one DIEV vena comitans and one 10. An umbilicoplasty was performed using an
IMV vena comitans. inverted V incision on the abdominal skin,
Fig. 4 Postoperative images of a 47-year-old woman after Fig. 5 DIEP flap monitoring skin paddles can be visual-
completion of bilateral free DIEP flaps ized within the areola-sparing mastectomy scar
ensuring its position in the midline and at the

level of the iliac crest.
11. Closure of the umbilical wound was com-
pleted with 4-0 monocryl buried dermal and
5-0 vicryl rapide half-buried mattress sutures.
Total skin-to-skin operative time was 8 h. There

were no complications such as reexploration, par-
tial or total flap failure, return to theater, or
readmission. The patient was discharged home on
the sixth postoperative day. Results after comple-
tion of the second stage can be seen in Fig. 4–6.
Technical Pearls
DIEP flaps are the most commonly performed

autologous breast reconstruction where microsur- Fig. 6 The volume result is insufficient at this stage
gical technical expertise is available. As such,
over the last 30 years there have been refinements surgeons advocate relying on the single best
in technique and improvements in outcome. Some perforator, which is most commonly found in
technical pearls that may be of value are the medial row and near to the umbilicus, and
highlighted below: this may simplify flap dissection. However,
increasing fat necrosis can occur if fewer per-
1. Perforator choice: Selection of perforators is forators are included. In addition, a single per-
critical in DIEP flap harvest. Variable numbers forator has a higher risk of insufficient inflow
of perforating vessels can be included in each or outflow and inclusion of more than one
flap, typically from one to four in total. Some perforator may help to prevent twisting of the
pedicle in transfer. If including more than one 3. Microanastomosis technique: Typical micro-
perforator, this is best done in series rather than surgical techniques in DIEP flap breast recon-
parallel, to limit muscle dissection and struction involves the end-to-end anastomosis
damage. of the DIEA to the IMA and either one or two
2. Recipient vessel access: With a nipple- or DIEV to one or two IMV. For end-to-end anas-
areola-sparing mastectomy, appropriate visuali- tomosis, innovation has led to the development
zation of the recipient site may be challenging. of a coupler device as an alternative to hand-
If necessary, extending the wound laterally or sewn anastomosis. It has been demonstrated
inferiorly can help to improve this situation, that this is superior to hand-sewn anastomosis
without compromising the overall result. The with regard to flap loss, return to theater, failure
most commonly used recipient vessels for rate, and operative time (Fitzgerald O’Connor
DIEP flap breast reconstruction are the internal et al. 2016). The use of a coupler device for
mammary vessels. While use of the thora- venous anastomosis is now standard practice in
codorsal and circumflex scapular vessels have DIEP flap breast reconstruction in most
been described, these are technically more centers.
demanding and appropriate positioning or shap- 4. De-epithelialization: There are many advan-
ing of the flap can be difficult. Standard access tages to maintaining a de-epithelialized dermis
requires removal of the medial cartilaginous with the DIEP flap in the setting of breast
portion of the third or fourth rib to provide a reconstruction. It helps to maintain structural
wide exposure of the IMV. IMV perforator integrity and shape of the flap, as well as pre-
anastomosis and rib-sparing techniques have serving subdermal vessels and lymphatic chan-
been described, with the argument that it may nels to improve drainage and reduce swelling.
reduce postoperative pain and improve chest De-epithelialization of the peripheries of the
wall deformity. While IMV perforators may be flap can be done at an early point in the oper-
a safe alternative, they need to be carefully ation when it is still in situ at the abdomen,
assessed for size and flow and the oncological leaving only small areas to refine around the
surgeon must be willing to preserve them appro- skin paddle before inset. This allows for better
priately. In addition, postoperative pain is more hemostasis and less manipulation of the flap
typically located not at the chest but at the after microsurgical anastomosis, protecting the
abdominal donor site. The chest wall deformity pedicle in the process.
does not appear to be an issue with appropriate 5. Intraoperative flap perfusion: There are an
placement and shaping of the flap. Using the increasing variety of tools available to aid
fourth rib for access can further reduce this decision-making in autologous flap reconstruc-
potential risk and allows for more proximal tion. Indocyanine green is a dye that can be
access to be available in the event of inadvertent used for fluorescent angiography to rapidly
damage to the recipient vessels. Furthermore, assess areas of reduced perfusion in a flap,
standard access is quicker to perform and helping to select regions to be excised and
quicker to learn, with greater recipient vessel minimize partial or total loss or areas of fat
length in the case of potential revision anasto- necrosis as well as being used to detect patency
mosis and broader access may also reduce of microvascular anastomosis and viability of
ischemia time. When the recipient vessels mastectomy skin flaps. An alternative tool that
access is complete, there is benefit in using has been investigated for this purpose is
suction connected to a pediatric feeding tube dynamic infrared thermography.
that is sited at the medial aspect of the wound 6. Flap inset: Creation of a three-dimensional
bed with a temporary suture, allowing mainte- breast from a flat portion of abdominal tissue
nance of a clean surgical field with irrigation is achieved using the three-step principle
and prevent vessel desiccation, without the need described by Blondeel (Blondeel et al. 2009).
for an assistant holding a suction device. This is undertaken by first defining the breast
footprint at the correct position on the chest wall natural look from the patient’s rostral view-
in the pre-pectoral plane. The inframammary point. The majority of techniques also describe
fold is placed 2–3 cm higher than in the pre- suturing the umbilical skin dermis to the rectus
morbid breast, depending on the laxity of the fascia or stalk plication.
mastectomy skin flap balanced with the tension 8. Nipple-areola complex (NAC) reconstruction:
from the lateral abdominoplasty skin flap clo- It is important to consider the final result of the
sure. In the second stage, the flap is then molded reconstructive journey for patients even at the
into a drop shape like conus. A wedge of skin is earliest stage, with the NAC often being com-
removed at the site where the umbilicus was pleted at the final stage. Many options exist for
incised and this is closed in three layers. At the NAC reconstruction, including three-
peripheries of the chest wall pocket, sutures are dimensional tattooing and various described
placed at three locations: 1. from Scarpa’s fascia grafts and local flaps. If deemed oncologically
to just below the pectoralis tendon laterally; sound, it can be beneficial to preserve as much
2. along the lateral border of the pocket as deter- specialized tissue as possible, as in the case of
mined by the lateral edge of the inframammary the areola-sparing mastectomy in this
fold, which encourages the fullness more medi- described clinical scenario. This allows poten-
ally and leaves a natural lazy-S contour laterally; tial for use of this tissue for local flap recon-
and 3. along the medial edge of the struction at a secondary stage and greater
inframammary fold, which allows the flap to likelihood of a natural appearing result.
bunch up at the site of the meridian and gives
it a more natural fullness. The flap position is
then evaluated and any excess fullness or poorly Postoperative Management
vascularized areas are carefully removed. The
third stage involves assessing the breast enve- The postoperative period provides an opportunity
lope and draping the mastectomy skin in an for clinicians to keep patients comfortable, maxi-
appropriate position over the skin paddle to cre- mize safety, control costs, and improve outcomes.
ate as natural a ptosis as possible. Once this has The development and study of ERAS protocols
been decided and marked, the excess flap skin is has been a significant improvement in this regard
de-epithelialized and the border of the skin pad- for care of patients after autologous breast recon-
dle incised carefully to allow for skin inset. In struction (Batdorf et al. 2015). A multimodal
the setting of a delayed reconstruction where the approach with multidisciplinary involvement is
projecting mastectomy skin envelope has not key. In addition to pre- and perioperative steps,
been maintained, lower pole projection can be focusing on postoperative issues can include:
improved by de-epithelializing the lower pole
chest wall skin, preserving dermis and subcuta- • Medication
neous fat as a platform for the flap to sit on – Analgesia: including paracetamol, nonste-
(Blondeel 1999). roidal anti-inflammatories, remifentanil,
7. Umbilicoplasty: During flap harvest it is clonidine, and patient-controlled analgesia
important to preserve vascularity to the umbi- with opiates in selected cases.
licus, avoiding complete skeletonization of the – Anti-emetics: This may include cyclizine,
umbilical stalk. When insetting the umbilicus, ondansetron, metoclopramide, prochlorper-
many techniques have been described (Joseph azine, or levomepromazine.
et al. 2016). Most techniques involve an inci- – Anti-thrombotics: This is typically in the
sion around the umbilicus initially and form of low molecular weight heparin
describe the use of an inverted V or U in the prophylaxis unless intravenous heparin is
abdominal flap for umbilical reinsertion. This specifically indicated in cases of
creates a superior hooding and breaks up the coagulopathies.
circumferential scar while allowing a more
– Intravenous fluids: Crystalloids +/ colloid

bolus to maintain urine output >50 ml per
hour and a mean arterial pressure
> 60 mmHg.
– Oxygen: Supplementary O2 should be pro-
vided via nasal prongs at least for the first
night to maintain oxygen saturations.
• Patient positioning
– The patient should be maintained at least
30 degrees upright and with both hips and
knees flexed, typically using two pillows
behind the knees.
• Flap monitoring
– Color, temperature, capillary refill time, and
doppler probe.
– Half-hourly observations for the first 2 h,
then hourly for the first 24 h by a health care
professional who is trained in flap monitor- Fig. 7 Postoperative images of a 47-year-old woman after
ing. Observations every 2 h on day two, the final stage reconstruction of the breasts with a free
DIEP flaps
every 3 h on day three, and every 4 h for
each day afterward that the patient remains
in hospital.
• Drain management
– Drain removal is often delayed until outputs
have decreased sufficiently, but they may be
removed safely at an earlier stage. There is
emerging evidence they may be removed
safely at an earlier stage without increasing
the risk of seroma (Miranda et al. 2014).
• Feeding
– The patient may have sips of clear fluids
overnight on the first night. After clinical
review the following morning, the patient
will be allowed to proceed with a light diet
and progress gradually. If opiate analgesia
has been used, laxatives are prescribed.
• Multidisciplinary input
– Physiotherapy
– Clinical nurse specialist
– Pain team Fig. 8 Lipofilling and nipple-areola complex reconstruc-
tion have been completed with satisfactory results six
months postoperatively

session of lipofilling and there is a natural ptosis
This patient in this case was satisfied with her to the breasts with an increased volume in com-
result. The clinical images of her outcome can be parison to her preoperative state. The donor site
seen in Fig. 7–9. There is satisfactory long-term has healed well with no significant dog-ears and
volume retained in both breasts despite only one she has no functional limitations.
– Low threshold for early reoperation if con-

cerns are present at the end of the procedure
• Venous congestion – this may occur
intraoperatively or early in the postoperative
period.
– Ensure no twisting or kinking of the vessels,
which can be assisted by marking one sur-
face of the veins in situ before division at
the donor site.
– A microsurgical clamp can be placed on one
of the two (typically the smaller) venae
comitantes while still in situ in the abdomen
to check if there is sufficient drainage
through the other that would be suitable
for a single anastomosis.
– Check the superficial inferior epigastric
vein, which is preserved at the start of the
Fig. 9 Oblique views of the reconstructions can be seen operation. If this is pregnant at an early
stage then it should be considered for a
Avoiding and Managing Problems supercharging anastomosis at the time. A
vein graft may be required and the use of
There are many problems that can occur during intravenous heparin may be considered if a
and after a DIEP flap breast reconstruction. Some vein graft is used.
of the major and more important complications – If inspecting a case of venous congestion
can be prevented or mitigated by good under- for salvage, the pedicle needs to be carefully
standing and careful management on behalf of examined, flow checked, and thrombolytic
the surgeon. In a more general sense, always agents such as urokinase or tissue plasmin-
ensuring that the set-up of the operating field is ogen activator need to be considered and
appropriate and the employment of two surgical carefully handled.
teams can significantly reduce potential compli- • Hematoma – this may occur in the early post-
cations and operative time. operative period and can significantly compro-
Problems that may be encountered during or mise flap perfusion.
after DIEP flap surgery, with suggestions for pre- – Check and recheck hemostasis after the
vention and management, include the following: chest pocket has been prepared; meticulous
hemostasis is essential. Mean arterial pres-
• Anastomotic concerns – this may relate to the sure should be >60 mmHg while hemosta-
arterial or venous anastomosis. sis is reviewed.
– Good positioning and set-up at the start, • Donor site issues – this may include wound-
with use of suction and background healing problems, dog-ears, hernias, or
– Use a coupler for the vein, aiming for a size seromas.
of 2.5 mm – Ensure the operating table is flexed at the
– If atherosclerosis is present, use an inside- hips and following closure of the rectus
out suturing technique sheath to take tension off the wound
– Check inflow after the recipient vessels closure.
have been clamped and clipped – Progressive tension sutures in closing the
– Perform flow tests after anastomosis and upper abdominal flap.
redo the anastomosis if there are any – High lateral tension to help mitigate
concerns dog-ears, using surgical skin clips to hold
the position while sutures are placed to vascularized matrix to accept subsequent fat
Scarpa’s fascia. transfer for volume augmentation.
– Hernia prevention by performing nerve- • Areola-sparing mastectomy: The decision to
sparing flap dissection and robust rectus preserve native tissue in nipple- or areola-
sheath repair. The use of prophylactic sparing mastectomies should be made at a
mesh does not seem to reduce hernia rates, multidisciplinary level according to accepted
provided that good surgical technique is guidelines. If it is possible to be safely preserved
used in wound closure. then it can improve the functional and aesthetic
• Deep venous thrombosis/pulmonary embolism. outcomes of reconstruction for patients. Access
– Early mobilization and physiotherapy may be more challenging than with standard
– Good perioperative hydration skin-sparing or classical mastectomies and
– Low molecular weight heparin wounds may have to be extended in order to
– Thromboembolic deterrent stockings and visualize the recipient site appropriately.
spontaneous pneumatic compression devices • Patient involvement in decision-making:
When a reconstructive journey is undertaken
it is important to have patient understanding
Learning Points and commitment to the process. Careful
counselling pre- and perioperatively will
• Staged reconstruction: Staged autologous breast allow for appropriate decision-making with
reconstruction should be considered if certain the patient. Shared decision-making tech-
factors are significant enough to risk putting a niques allow for goal and expectation setting
patient at increased morbidity. The most com- that will lead to improved outcomes.
mon factors for this include the potential need
for adjuvant irradiation and fully informed
patient choice, although other patient medical Cross-References
concerns may also deter patients from undergo-
ing immediate reconstruction. The delayed- ▶ Breast Reconstruction with PAP Flap
immediate option of a baby-sitter implant ▶ Combined Autologous Breast and Lymphedema
allows for preservation of mastectomy skin Reconstruction with a Predesigned DIEP and
flaps in these settings (Otte et al. 2016). Lymph-Node Flap
• Donor site volume: There are situations where ▶ SIEA Flap for Breast Reconstruction
DIEP flap breast reconstruction is absolutely ▶ Stacked Free Flaps for Breast Reconstruction
contraindicated, such as for patients where flap
vascularity may be compromised by significant
abdominal scarring or where general health References
such as severe obesity, uncontrolled diabetes,
debilitating cardiovascular disease, or uncon- Allen RJ, Treece P. Deep inferior epigastric perforator flap
for breast reconstruction. Ann Plast Surg. 1994;32(1):
trollable coagulopathies may preclude
32–8.
it. However, particularly for very slender Batdorf NJ, Lemaine V, Lovely JK, Ballman KV, Goede
women, disparity in abdominal tissue volume WJ, Martinez-Jorge J, Booth-Kowalczyk AL, Grubbs
must only count as a relative contraindication. PL, Bungum LD, Saint-Cyr M. Enhanced recovery
after surgery in microvascular breast reconstruction.
The donor site is typically well accepted by
J Plast Reconstr Aesthet Surg. 2015;68(3):395–402.
patients with low morbidity. If there are con- Blondeel PN. One hundred free DIEP flap breast recon-
cerns regarding potential flap volume, this can structions: a personal experience. Br J Plast Surg.
be remedied either by use of stacked flaps or a 1999;52(2):104–11.
Blondeel PN, Beyens G, Verhaeghe R, Van Landuyt K,
bipedicled flap in a unilateral reconstruction or
Tonnard P, Monstrey SJ, Matton G. Doppler flowmetry
by staged lipofilling as in the described clinical in the planning of perforator flaps. Br J Plast Surg.
scenario, whereby the flap acts as a 1998;51(3):202–9.
Blondeel PN, Hijjawi J, Depypere H, Roche N, Van Miranda BH, Amin K, Chana JS. The drain game: abdom-
Landuyt K. Shaping the breast in aesthetic and recon- inal drains for deep inferior epigastric perforator breast
structive breast surgery: an easy three-step principle. reconstruction. J Plast Reconstr Aesthet Surg.
Plast Reconstr Surg. 2009;123(2):455–62. 2014;67(7):946–50.
Blondeel PN, Morrison CM, Allen RJ. The deep inferior Myers PL, Nelson JA, Allen RJ. Alternative flaps in autol-
epigastric artery perforator flap. In: Neligan P, editor. ogous breast reconstruction. Gland Surg. 2021;10(1):
Plastic surgery. 3rd ed. London: Elsevier; 2012. 444–59.
Boyd JB, Taylor GI, Corlett R. The vascular territories of Otte M, Nestle-Krämling C, Fertsch S, Hagouan M,
the superior epigastric and the deep inferior epigastric Munder B, Richrath P, Stambera P, Abu-Ghazaleh A,
systems. Plast Reconstr Surg. 1984;73(1):1–16. Andree C. Conservative mastectomies and immedi-
Fitzgerald O’Connor E, Rozen WM, Chowdhry M, Patel ate-DElayed AutoLogous (IDEAL) breast recon-
NG, Chow WT, Griffiths M, Ramakrishnan VV. The struction: the DIEP flap. Gland Surg. 2016;5(1):
microvascular anastomotic coupler for venous anasto- 24–31.
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DIEP Flap Reconstruction in a Slim
Patient 86
Efstathios Balitsaris, Vasilios Venizelos, and Andreas Gravvanis
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 926
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 932
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933
Abstract
Breast reconstruction after modified radical

mastectomy is always a challenge for plastic
E. Balitsaris (*)
surgeons. The widespread use of free flaps and
Department of Plastic Reconstructive, Microsurgery and especially the use of the DIEP flap, which is
Aesthetic Surgery, Metropolitan Hospital, Athens, Greece considered the “Gold Standard” (Blondeel
V. Venizelos 1999), made the choice about the preferred
Department of Breast Surgery, Metropolitan Hospital, reconstruction method easier.
Athens, Greece Challenging cases include slim patients
A. Gravvanis (BMI near the low end of the natural range),
Plastic, Reconstructive and Aesthetic Surgery, with the contralateral healthy breast of medium

https://doi.org/10.1007/978-3-030-23706-6_74
924 E. Balitsaris et al.
volume or more (cup size B) and without limitations should be identified. The plastic
ptosis. If the patient does not need or want any surgeon should go through all the possible
operation on the healthy breast, achieving the alternatives, explain all the details about the
desirable esthetic outcome and symmetry steps of each procedure, and give all the
needs to be attended with caution. The objec- information needed about complications,
tives are to ensure symmetry with a well- reoperations, revision surgeries, scars,
vascularized flap, avoiding complications at esthetic outcome, overall cost, and time
the donor site from over resection. management. A detailed and straightfor-
ward conversation is mandatory.
2. Implant-based breast reconstruction:
Keywords
• Delayed implant-based breast reconstruc-
DIEP flap · Breast reconstruction · Slim tion after modified radical mastectomy is
patient · Symmetry not considered the first choice of treatment,
even if the mastectomy is not followed by
radiation therapy. In cases after radiation
Clinical Scenario therapy (as in this case), the skin quality
has significant disadvantages. The skin
A 42-year-old woman presented with radical mas- envelope and soft tissue deficiency, the atro-
tectomy of the left breast, 1 year after completion phy, and the lack of elasticity and expansion
of chemotherapy and 6 months after completion ability of the radiated skin require enough
of post mastectomy radiation therapy. The patient tissue transfer to cover the implant. On the
preferred no intervention on the nonptotic right other hand, in slim patients with low BMI
breast and requested breast reconstruction with and low volume of autologous tissue trans-
optimal symmetry. Her BMI was 20.2, and the fer availability, Immediate Implant-based
cup size of the right breast was B. There was no Breast Reconstruction (IBBR) should be
history of other illnesses and previous operations. considered in cases that autologous tissue
Her preoperative status can be seen in Fig. 1a–c. transfer is not possible or does not meet the
patient’s desire. Complications such as
wound healing problems, fat necrosis, par-
Preoperative Problem List/ tial mastectomy flap failure, capsular con-
Reconstructive Requirements tracture formation, implant infection, and
higher rates of reoperations and revision
Critical issues in this case that need to be attended surgeries are identified in IBBR and should
are the following: be explained to the patient.
3. Donor site volume availability:
1. Patient’s desires and expectations: • In order to choose the type of breast recon-
• The patient requires breast reconstruction struction that meets patient’s needs and
that approaches as near as possible the pre- preferences, it is important to examine
mastectomy condition and with maximum donor site volume availability according to
symmetry, with no intervention at the con- the contralateral breast’s size, shape, degree
tralateral breast. The expected ideal self- of ptosis, and projection. Even though the
image after the reconstruction needs to be DIEP flap is considered the flap that meets
addressed with caution, and a thorough con- best these requirements, it could be a diffi-
versation needs to be done about the limita- cult judgment in slim patients. All donor
tions of the requested result. The intended sites could be found of insufficient volume
goals after the reconstruction and the and with high risk of wound-healing com-
expected esthetic outcome are delicate sub- plications after flap removal. Moreover, in
jects for the patient that has decided to go an effort to recruit more volume from the
through breast reconstruction. The natural donor site, the plastic surgeon could face
86 DIEP Flap Reconstruction in a Slim Patient 925
Fig. 1 (a) Preoperative left lateral view. (b) Preoperative right lateral view. (c) Preoperative front view
zones of flap with poor blood supply, with with skin and soft tissue deficiency, the
subsequent partial flap necrosis and/or fat quality of the remaining skin after radiation
necrosis. Although hybrid reconstruction therapy, the volume limitations of the cho-
with a combination of an implant could be sen flap (slim patient), and the desired ideal
offered, alternatives such as bipedicled flap, symmetrical esthetic outcome without inter-
stacked DIEP flaps (Haddock et al. 2019), vention on the contralateral breast. All alter-
or fat transfer in a second stage should be native options were discussed in multiple
considered. Low volume at the donor site consultations, giving all the time needed
should not be a true contradiction (Kantak for proper education and evaluation as to
et al. 2015). conclude at the end of the process in a
4. Decision-making: shared decision which would meet the
• In this case, we had to address four major reconstructive goals and patient’s needs
issues: the type of the previous mastectomy and expectations.
Treatment Plan – Disadvantages: short vascular pedicle and

diameter discrepancy with recipient ves-
Following the consultation process, patient and sels. Low flap volume, less skin available,
surgical team decided to proceed with DIEP flap asymmetry in thigh contouring, possible
reconstruction. The decision about the use of a need for double flap, and low risk for
single-pedicled, a bipedicled, or two-stacked lymphedema
DIEP flaps would be made intraoperatively, • Profunda Artery Perforator-Free Flap
according to the flaps’ blood perfusion status. The – Advantages: no donor site morbidity, long
evaluation of flap’s blood perfusion would be made and wide vascular pedicle.
using clinical criteria, ultrasonic hand doppler – Disadvantages: need for CTA due to vari-
probe and fluorescence imaging (FI). A possible able location of the dominant perforator.
second stage of fine tuning of the contouring and According to perforator’s location, skin
volume of the breast, using lipofilling, in addition paddle may have to be orientated lower,
to nipple reconstruction and scar revision in donor thus more visible scar. Less skin is avail-
and recipient sites, was agreed. able, as compared to DIEP flap, with prob-
able need for stacked flaps. Asymmetry in
thigh contouring may arise.
Alternative Reconstructive Options • Gluteal Artery Perforator-Free Flap
– Advantages: could have enough volume in
Alternative options for reconstruction were pre- certain body types.
sented, and advantages/disadvantages were – Disadvantages: short pedicle and challeng-
discussed thoroughly. ing pedicle dissection. Dense fat and diffi-
culties in flap shaping. Intraoperative
• Implant-Based Breast Reconstruction Without change of position, less tolerable post-
Tissue Transfer surgery recovery. Asymmetrical deformity
– Advantages: No donor site visible under clothing may arise.
– Disadvantages: multiple stages using tissue • Lumbar Artery Perforator-Free Flap
expander, high rates of implant-associated – Advantages: similar skin thickness and soft
complications (infection, exposure, wound tissue with breast.
healing problems, and rupture) that could – Disadvantages: very short pedicle that
lead to failure rate up to 70%, according to requires lengthening with vein graft. Chal-
the literature. Capsular contracture, displace- lenging flaps rise, because of anatomical
ment, rippling, animation, visibility, or pal- inconsistency. Visible scar and asymmetri-
pability that cannot be avoided and will lead cal deformity that can be noticed.
to multiple revision operations. Low possi- • Free Flap Plus Implant
bility for achieving symmetry, implant ill- – Advantages: no need for second flap
ness, ALCL, poor esthetic outcome, time – Disadvantages: implant-associated compli-
consuming, and possible higher cost cation (infection, capsular contracture, etc.),
• Latissimus Dorsi Flap higher risk of partial or total flap loss
– Advantages: no need for microsurgical
expertise
– Disadvantages: lower flap volume, less skin Preoperative Evaluation and Imaging
availability, and necessity for implant. Sig-
nificant donor site morbidity associated with A meticulous evaluation of the patient’s overall
muscle weakness, seroma, and visible scar clinical status and especially the donor site is
• Gracilis-Free Flap important, as part of the preoperative assessment,
– Advantages: concealed scar, negligible that can decrease the complication rate and the
donor site morbidity operation time. Here are some key elements:
1. Imaging 1. Days before the operation:

• Preoperative CT angiography is favored by • Smoking is not considered a true contradic-
many reconstructive surgeons. It provides tion, but we encourage patients to quit
detailed information about the location and smoking or decrease the amount of ciga-
size of the perforators and their course rettes some weeks before surgery.
through the muscles (Fitzgerald O’Connor • Shower with an antibacterial soap before
et al. 2016; Kiely et al. 2021). It facilitates surgery is a way of preventing infection. It
the preoperative marking of the perforators will be used after surgery too.
on the abdomen’s skin and plays a key role in 2. Drawing: Markings
the identification of the dominant perforator. • Patients’ drawing begins at the breast
• 3D imaging of the patient’s normal breast is (Fig. 2).
another tool in plastic surgeon’s armamen- • The breasts’ meridians and the
tarium. A close estimation of the normal inframammary folds are marked. The new
breast’s volume and the needed flap’s vol- inframammary fold is marked 1 cm higher
ume can be done, to achieve symmetry. A than the contralateral breast because the
mirror image of the normal breast can be tension of the abdominal flap after donor
simulated using 3D imaging. Creating a site closure is expected to lower it.
model of the simulated breast using a 3D • The footprint of the new breast is marked
printer can be a useful and handful tool according to the contralateral breast.
trying to estimate the exact volume and • The skin between the mastectomy scar and
shape of the needed flap. the new inframammary fold, centered at the
2. Donor Site Evaluation breast meridian, is marked to be
• A careful clinical examination of the de-epithelialized. It matches the breast
patient’s abdomen, including a pinch test, footplate except the upper pole, so that the
is essential. It gives important information
about possible existence of hernias and pre-
vious operations and about the volume of
the flap that can be harvested without com-
plications at the abdomen’s closure site.
• A 3D printed model of the flap can be made
by using the CTA. The maximum volume of
the flap that can be harvested can be calcu-
lated and printed.
3. Doppler
• The pencil doppler is the workhorse tool for
the preoperative marking of the perforators.
4. Patient Body Mass Index (BMI)
• A BMI calculation is performed. In this
case, the patient’s BMI was 20,2. Height ¼
168 cm Weight ¼ 56Kg

Drawing
Some basic considerations and instructions at the

preoperative time and preparation include the
following: Fig. 2 Preoperative markings
new breast will be seen as a single esthetic and the dermal flap of the upper pole is ele-
unit, avoiding the patchwork-like appear- vated to create a pocket.
ance. Moreover, we remove most of the 2. Pectoralis major muscle is divided parallel to
irradiated anelastic skin, minimizing its muscle fibers at the level of the third rib.
wound closure complications and maximiz- 3. 3 to 4 cm of rib cartilage is removed close to the
ing the esthetic outcome. The upper mastec- sternocostal joint, leaving most of the peri-
tomy skin, to be elevated and cover the chondrium intact.
upper part of the de-epithelialized DIEP 4. Perichondrium is divided, and the internal mam-
flap, is also marked. mary vessels are revealed and prepared, preserv-
• The umbilicus border is marked. ing the maxim vessel length. Major attention is
• Drawing is continued by marking the perfo- given not to traumatize the pleura under the
rators using a handheld pencil doppler device vessels. Final preparation of the vessels is
and the findings from the CTA which we use made under microscope before the anastomoses.
to calculate the distance between each perfo-
rator from the umbilicus. Flap Raise:
• An elliptical line is drawn connecting the
left and right anterior superior iliac spine 1. Skin incision at the lower flap is made, and
and passing just above the superior border dissection proceeds down to the muscle
of the umbilicus. This is the superior border fascia.
of the flap. 2. The SIEV are identified, dissected for 2 cm
• At the midline, a point measured 6–8 cm inferiorly, and ligated with a surgical clip.
above the vaginal cleft is marked and a 3. An incision around the umbilicus is made,
second elliptical line between the left and and dissection continuous down to the muscle
right anterior superior iliac line is drawn, fascia.
passing through that point. This is the infe- 4. Skin incision at the superior mark of the flap
rior point of the flap. is made, and dissection proceeds down to the
• The vertical width of the flap and the verti- fascia, beveling superiorly under the Scarpa’s
cal width of the breast skin to be resected fascia, in order to include maximum volume
should be measured. In slim patients, the of the flap.
most inferior point can be drawn closer to 5. Dissection of the flap proceeds from the lateral
the umbilicus and the inferior elliptical line side of the flap with the largest perforators seen
can be moved superiorly, so that the flaps’ in CTA, preferably at the contralateral side of
width is enough without risking wound- the breast to be reconstructed.
healing complications at the donor site 6. The flap is elevated from the muscle fascia,
closure. and the largest perforators are preserved.
• 3D imaging and 3D printed model’s mea- 7. The muscle fascia around the chosen perforator
surements can be very helpful in correct (s) is cut, leaving a circular cuff around them.
markings of the abdomen. 8. The muscle fascia is incised toward the deep
inferior epigastric vessels and the perforator
(s) is/are dissected intramuscular and sub-
Surgical Technique muscular until the main pedicle is identified.
9. The superior/proximal end of the deep infe-
The basic steps during the surgical procedure in rior epigastric vessels is carefully ligated,
this patient include the following: making sure all perforators chosen/dissected
Breast and recipient site preparation: are connected to the pedicle.
10. The pedicle is then dissected until there is
1. An incision is made at the superior border of adequate length and vessel diameter/size for
the breast skin that will be de-epithelialized, artery and vein anastomoses.
11. The controlateral side of the flap is then dis- The veins are anastomosed first, followed by
sected, and the largest perforator is identified the arteries.
and preserved. 2. Flow is checked by patency test (milking test),
12. The flap is skeletonized, and the perforators clinical examination of the flap, and the use of
of that side are temporarily occluded with hand doppler.
microsurgical clamps.
13. Thereafter, flap perfusion is evaluated by Flap inset and wound closure:
clinical criteria (capillary refill, color, and
temperature), by intraoperative doppler, and 1. The flap is placed at the recipient site covering
by indomethacin green ICG fluorescent the footprint of the marked new breast and
imaging. creating a cone to achieve projection. The
14. In this case, the flap was based on 2 medial upper part is de-epithelialized, placed inside
row perforators. When flap dissection was the created pocket under the upper pole mas-
completed, clinical evaluation showed excel- tectomy skin flap, and secured/anchored with
lent perfusion of all 4 zones. Moreover, this sutures.
was verified by ICG imaging (Fig. 3). The 2. The abdominoplasty flap superior to the umbi-
evaluation gave us confidence that there is no licus is elevated.
need for bipedicled flap or stacked flaps; 3. The rectus fascia is closed (nylon loop suture).
therefore, a decision for single pedicle DIEP 4. The operating table is flexed and the
flap was made. abdominoplasty flap is secured.
15. Then, the temporarily clamped perforators on 5. The neoumbilicus is marked and dissected.
the contralateral side were ligated. 6. Drains in donor and recipient site are placed,
16. Deep inferior epigastric vessels are ligated. and closure of all wounds is made in standard
The flap is transferred to the chest and secured fashion.
onto the recipient site.
Microsurgical anastomosis: Technical Pearls
1. Under the microscope, preparation of the ves- Technical details during surgery that can maxi-
sels and anastomoses is completed in standard mize flap survival, optimize the esthetic outcome,
fashion using interrupted sutures (9–0 nylon). and minimize potential pitfalls and operating time
have been reported by many experienced micro-
surgeons. When it comes to preparing for a DIEP
flap in a slim patient, some of those pearls are as
follows:
1. Preoperative CT angiography is valuable to

identify the dominant perforator.
2. Including more than one perforator from the
medial row, and close to the middle of the flap,
can be rewarding when trying to maximize
flap’s vascularization and volume.
3. If the recipient site vessels are the left internal
mammary vessels, consider access more prox-
imal than the fourth rib, because there is
reduced risk of finding two small veins than a
Fig. 3 ICG imaging with SPY camera, showing adequate large one. Especially in radiated breast, this can
DIEP flap blood perfusion be time saving at the final dissection of the
recipient vein and the anastomosis with a large guide doppler use can be very helpful. Numer-
deep inferior epigastric vein. ous methods and devices are described in liter-
4. The use of indocyanine green (ICG) fluores- ature to assess flap’s blood perfusion, and
cence angiography is an excellent intraoperative significant progress is made, but none of them
tool for evaluating flap perfusion (Hembd et al. can be more reliable and can replace clinical
2020). In slim patients, where flap volume is of monitoring until know.
great importance, it can help deciding whether a • Administrating low-molecular-weight heparin
single pedicled DIEP flap is adequate or a double prophylaxis after surgery and early ambulation
pedicled or stacked DIEP flaps are necessary. can reduce the risk of VTE without increasing
5. Marking the patient in standing position is the risk of hematoma.
mandatory. Mark the footprint of the new • Maintaining normotension in arterial blood
breast first, putting the new inframammary pressure, administrating restrictive fluid resus-
fold 1–2 cm higher, because it is expected to citation (crystalloids<6 ml/Kg/h) (Anker et al.
be lowered when the abdominal flap will be 2018), keeping the patient normovolemic with
pulled down for closure. urine output >50 ml/h, and avoiding vasoac-
6. Use internal sutures making the flap like conus tive drugs can improve flap perfusion, lower
to achieve maximum projection. the risk of interstitial edema and venous con-
7. Anchoring the flap with 3 sutures at the upper gestion, help early patient’s mobilization,
pole can reduce risk of pedicle movement lower hospital stay, and reduce the risk of
when the patient will stand up and will enhance wound-related complications such as wound
the esthetic outcome. dehiscence and fat necrosis. Encouraging the
patient to drink more than 1,5Lts of water daily
can reduce fluid administration to minimum,
Postoperative Management lowering the risk of pitfalls.
• Removing drains at an early stage according to
A careful approach and management of the post- outputs without prolonging hospital stay.
operative period is mandatory for patient’s safety • Pain management with minimum use of opioid
and flap survival. Critical issues about postopera- analgesia.
tive management are the following:
• Warming the patient before the end point of Outcome, Clinical Photos, and Imaging
anesthesia and removal of endotracheal tube.
Excessive hypothermia (Chen et al. 2022) and The stages and final outcome of this case are
postoperative shivering can lead to vasospasm shown in Figs. 4, 5, 6, and 7. The patient found
and decreased blood perfusion to the flap, the result very satisfying and meeting all needs,
increased risk of arterial thrombosis, partial or preferences, and expectations. Despite the limita-
total flap loss, and surgical site infection. tions of a slim patient and after one session of
• Keeping the patient’s hips and knees flexed, lipofilling, symmetry in both volume/size and
and body elevated at 30 degrees upright. shape was achieved and a natural looking breast
• Clinical monitoring of the flap (color, temper- was created without donor site complications. The
ature, capillary refill time, and doppler) every patient was able to continue her working out
30 min for the first 2 h, every 1 h for the first activities without any concerns in donor site. Vol-
24 h, every 2 h on day 2, every 3 h on day ume assessment, using Vectra XT (by Canfield),
3, and tapering. Having educated and experi- showed that the right healthy breast was approx-
enced nursing stuff is crucial in early detection imately 37 cc larger than the reconstructed right
of problems in flap viability. Placing a small breast (Figs. 4a, b). Nevertheless, the skin enve-
suture (nylon 9–0) over the perforator(s) to lope and conus showed some differences 3 months
Fig. 4 (a) Postoperative result using 3D VECTRA imag- approximately 37 cc larger than the left. (b) Oblique view
ing after completion of the first stage (3 months post-op). of the postoperative result using 3D VECTRA imaging
The volume of the right breast was estimated after completion of the first stage (3 months post-op)
Fig. 5 (a) Preoperative marking of nipple reconstruction. (b) Preoperative markings for lipofilling
post-op, and the patient desired further reinjected to the upper mastectomy flap and the
improvement. medial-lower part of the DIEP flap.
Six months post-op, patient was planned for Three years post-op, volumetric analysis dem-
nipple reconstruction (Fig. 5a) and flap shaping. onstrated that the reconstructed breast was 40 cc
Given the mild differences in terms of volume and larger (Fig. 7); nevertheless, the patient looked
shape among the 2 breasts, flap shaping with very symmetric in terms of footprint, conus, and
lipofilling was planned (Fig. 5b). skin envelope. The contour of the abdomen was
250 cc were harvested from patients inner good also, and the scar was linear well-hidden in
thighs, inner knees, and flags, purified, and the underwear (Fig. 6a–c).
Fig. 6 (a) Final result at 3 years postoperatively, following 1 session of lipofilling and medical tattooing of the
reconstructed nipple and areolar. (b) Right oblique view. (c) Left oblique view
height is a significant risk factor for overall

donor-site morbidity. Therefore, the criterion
to choose DIEP flap in a slim patient is the
feasibility to close the abdomen without ten-
sion. This might compromise the reconstructed
skin envelope, but usually the contralateral
breast is small or moderate size in the slim
patient.
• Regarding the conus, we use internal sutures
making the flap like conus to achieve maxi-
mum projection. Further projection and vol-
ume can be achieved with lipofilling in a
second stage.
Fig. 7 Final result using 3D VECTRA XT imaging. The
• Likewise, special attention not to create con-
reconstructed breast is calculated approximately 39 cc
larger tour deformities and irregularities, from the fat
harvesting in the slim patient, is required.
• Meticulous preoperative study of the CT angi-
ography will facilitate the dominant perfora-
Avoiding and Managing Problems tor selection. In the slim patient, a second
perforator dissection will ensure better flap
• Slim patient presents significant challenges in perfusion.
autologous breast reconstruction. Donor site • In the case that the second perforator is in a
selection is critical to ensure optimum healing different row with subsequent significant mus-
and the best possible esthetic outcome. cle morbidity, the dissection of a bipedicle flap
• Analyzing the breast into 3 anatomical fea- is the solution (Xu et al. 2009).
tures: footprint, conus, and skin envelope
(Blondeel et al. 2009), the latter is the most
critical for the decision-making. On the one Learning Points
hand, there is a requirement for adequate flap
dimensions (height, length, and thickness) to • Low body weight and low BMI are not a
reconstruct the breast, and on the other, there is contradiction for unilateral delayed DIEP flap
a demand not to produce healing problems and breast reconstruction, after modified radical
contour deformities in the donor site. Flap mastectomy.
• A significant number of alternatives are pre- Blondeel PN. One hundred free DIEP flap breast recon-
sent, but we do not consider that any of them structions: a personal experience. Br J Plast Surg.
1999;52(2):104–11. https://doi.org/10.1054/bjps.
can be equivalent to the “Gold Standard.” 1998.3033. PMID: 10434888.
• Concerns about donor site volume availability Blondeel PN, Hijjawi J, Depypere H, Roche N, Van Landuyt
are present and should be taken into account K. Shaping the breast in aesthetic and reconstructive
before decision-making, in relation to the con- breast surgery: an easy three-step principle. Part II – breast
reconstruction after total mastectomy. Plast Reconstr
tralateral breast volume, degree of ptosis, and Surg. 2009;123(3):794–805. https://doi.org/10.1097/
patients’ needs and preferences. PRS.0b013e318199ef16. PMID: 19319042.
• Bipedicled and stacked DIEP flap are a consid- Chen K, Beeraka NM, Sinelnikov MY, Zhang J, Song D,
erable backup plan, in case that single-pedicle Gu Y, Li J, Reshetov IV, Startseva OI, Liu J, Fan R, Lu
P. Patient management strategies in perioperative,
DIEP flap cannot provide enough volume. intraoperative, and postoperative period in breast
• ICG fluorescence imaging is a reliable tool, in reconstruction with DIEP-Flap: clinical recommenda-
addition to clinical examination, for taking the tions. Front Surg. 2022;9:729181. https://doi.org/10.
correct intraoperative decision. 3389/fsurg.2022.729181. PMID: 35242802; PMCID:
PMC8887567.
• 3D imaging and 3D printed models are useful Fitzgerald O’Connor E, Rozen WM, Chowdhry M, Band B,
tools for preoperative evaluation and measure- Ramakrishnan VV, Griffiths M. Preoperative computed
ments, to achieve maximum symmetry. tomography angiography for planning DIEP flap breast
• Lipofilling in a second stage can contribute to reconstruction reduces operative time and overall compli-
cations. Gland Surg. 2016;5(2):93–8. https://doi.org/10.
refinements of the breast volume and contour. 3978/j.issn.2227-684X.2015.05.17. PMID: 27047777;
• Adequate consultation and shared decision PMCID: PMC4791353.
between patient and surgeon are essential. Haddock NT, Cho MJ, Teotia SS. Comparative analysis of
• Great results in reconstructive microsurgery come single versus stacked free flap breast reconstruction: a
single-center experience. Plast Reconstr Surg.
after detailed planning and meticulous execution. 2019;144(3):369e–77e. https://doi.org/10.1097/PRS.
0000000000005906. PMID: 31461004.
Hembd AS, Yan J, Zhu H, Haddock NT, Teotia
Cross-References SS. Intraoperative assessment of DIEP flap breast
reconstruction using indocyanine green angiography:
reduction of fat necrosis, resection volumes, and post-
▶ Areola-Sparing Mastectomy and Deep Inferior operative surveillance. Plast Reconstr Surg.
Epigastric Perforator Flap Reconstruction 2020;146(1):1e–10e. https://doi.org/10.1097/PRS.
▶ Breast Reconstruction with PAP Flap 0000000000006888. PMID: 32590635.
▶ Combined Autologous Breast and Lymph- Kantak NA, Koolen PG, Martin C, Tobias AM, Lee BT,
Lin SJ. Are patients with low body mass index candi-
edema Reconstruction with a Predesigned dates for deep inferior epigastric perforator flaps for
DIEP and Lymph-Node Flap unilateral breast reconstruction? Microsurgery.
▶ SIEA Flap for Breast Reconstruction 2015;35(6):421–7. https://doi.org/10.1002/micr.
▶ Stacked Free Flaps for Breast Reconstruction 22407. Epub 2015 Mar 28. PMID: 25821046.
Kiely J, Kumar M, Wade RG. The accuracy of different
modalities of perforator mapping for unilateral
DIEP flap breast reconstruction: a systematic
References review and meta-analysis. J Plast Reconstr Aesthet
Surg. 2021;74(5):945–56. https://doi.org/10.1016/j.
Anker AM, Prantl L, Strauss C, Brébant V, Heine N, bjps.2020.12.005. Epub 2020 Dec 10. PMID:
Lamby P, Geis S, Schenkhoff F, Pawlik M, Klein 33342741.
SM. Vasopressor support vs. liberal fluid administration Xu H, Dong J, Wang T. Bipedicle deep inferior epigastric
in deep inferior epigastric perforator (DIEP) free flap perforator flap for unilateral breast reconstruction:
breast reconstruction – a randomized controlled trial. seven years’ experience. Plast Reconstr Surg.
Clin Hemorheol Microcirc. 2018;69(1–2):37–44. 2009;124(6):1797–807. https://doi.org/10.1097/PRS.
https://doi.org/10.3233/CH-189129. PMID: 29660924. 0b013e3181bf81cf. PMID: 19952636.
Breast Reconstruction with PAP Flap
87
Jian Farhadi and Barbara Pompei
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 936
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942
Abstract
Nowadays, breast reconstruction with autolo-

gous flaps is a well-accepted reality. While
abdominal flaps are probably the most com-
J. Farhadi (*) monly performed, not all patients are good
Plastic Surgery Group, Zürich, Switzerland candidates for that type of autologous re-
University of Basel, Basel, Switzerland construction, because of lack of abdominal
e-mail: jian@farhadi.com; tissue, previous surgeries, or inadequate perfora-
info@plasticsurgery-group.com tors. Alternative autologous options have been
B. Pompei developed to face this problem. In the last
Plastic Reconstructive and Aesthetic Unit, Lugano, decade the profunda artery perforator (PAP)
Switzerland

https://doi.org/10.1007/978-3-030-23706-6_76
936 J. Farhadi and B. Pompei
has progressively gained importance as alterna- The possible need for a symmetrization proce-
tive option to DIEP flaps. The chapter describes dure to the contralateral breast was also discussed
in detail the characteristics of PAP flap, from the with the patient.
origin to the surgical technique and recent
updates. In addition to that, as PAP flap cannot
be considered an easy flap for a microsurgeon Treatment Plan
who approaches it for the first time, particular
care has been taken to explain tips and tricks that The first step of the treatment plan is a detailed and
can help in patient selection, surgical planning, standardized consultation with the patient, in
and flap harvesting, with the aim of shortening order to identify the best reconstructive option.
the learning curve and avoiding pitfalls. Body habitus, cup size, medical history, lifestyle,
and personal preferences are taken into account
Keywords before deciding for the most appropriate autolo-
Pap flap · Autologous reconstruction · Breast gous approach.
reconstruction The use of abdominal flaps based on the per-
forators of the deep inferior epigastric artery
(DIEP flap) can be currently considered the first
The Clinical Scenario choice when it comes to autologous breast recon-
struction. However not all patients are suitable for
A 52-year-old woman presented with an in situ reconstruction with DIEP flaps, because of lack of
ductal carcinoma (DCIS) to the upper external abdominal tissue, previous surgeries, or inade-
quadrant of the right breast. The breast was a C quate perforators. For this reason, during the last
cup, with a grade II ptosis (Regnault classifica- decade, alternative autologous options have been
tion) (Fig. 1a). Comparing MRI and mammogram developed when the abdominal area cannot not
images with the original breast volume, cancer be used.
extension resulted to be not compatible with The profunda artery perforator (PAP) flap for
breast conserving surgery. Indication for nipple breast reconstruction was first introduced in 2010
sparing mastectomy and immediate autologous by Allen et al. (2012) as a variation of the posterior
reconstruction was then given. thigh myocutaneous flap described previously
(Hurwitz and Walton 1982; Angrigiani et al. 2001).
The PAP flap is based on the muscul-
Preoperative Problem List: ocutaneous or more frequently on septocutaneous
Reconstructive Requirements perforators of the profunda femoris artery, which
supplies the upper posterior compartment of the
Following patient’s wish to avoid breast implants, thigh. The artery typically gives off three main
an autologous-based reconstruction was agreed. perforators: While the first one supplies the
During the examination, not enough tissue was adductor and the gracilis muscles, the PAP flap
found in the abdominal area in order to match the is based on the second and third perforators that
volume of the contralateral breast. supply a more posterior area of the thigh under the
On the opposite, the tissue of the medial- buttock crease (the so-called “banana roll”). Clin-
posterior thigh was found abundant enough to ical observation and preoperative imaging suggest
guarantee a cosmetically pleasing reconstruction that it is possible to find at least one suitable
(Fig. 1b). Pinch test was used to check skin laxity perforator in 98% of thighs, with average diameter
of the area, in order to obtain a tension-free clo- of 1.9 mm (Hunter et al. 2015).
sure and to avoid lower migration of the scar. This flap presents many advantages:
After discussing available options with the
patient, the indication for a posterior artery perfo- • It provides a good amount of soft and pliable
rator flap (PAP flap) autologous reconstruction tissue even in slender patients, without affect-
was eventually given. ing buttock contour.
87 Breast Reconstruction with PAP Flap 937
Fig. 1 Preoperative images of the breast area of the patient (a) and of the donor site (b)
• The scar is quite well concealed by the gluteal DIEP flap can hardly be considered an option for
crease. these patients.
• The good pliability of the posterior thigh tissue With regards to the surgical approach herein
allows for a satisfying three-dimensional shap- presented, TUG flap and IGAP flap can be consid-
ing of the breast. ered in case of inadequate profunda artery perfora-
• Muscle saving dissection (majority of cases) tors that are found during dissection (Hunter et al.
allowing for quicker recovery. 2015). Both flaps can be suitable for the same
• The lower number of lymphatic vessels in the cohort of patients, bringing approximately the
area of flap dissection should reduce the risk of same volume as PAP flap to the reconstruction.
seroma, when compared with TUG flap When compared to TUG flap, PAP flap pedicle
dissection. offers a more central perfusion of the flap with a
• Appropriate pedicle length (average 9.9 cm) longer skin paddle, ideal for salvage reconstruction.
that allows for different recipient sites (Allen Differently from DIEP, SGAP, IGAP, and
et al. 2012). TUG, thanks to the septal nature of the majority
of perforators, PAP flap often allows a harvesting
When it comes to PAP flap, the upper poste- with no muscle dissection, with a consequent
rior compartment of the thigh is evaluated; the minor muscle-related donor site morbidity and
pinch test of the adipose roll under the buttock lower risk of seroma formation (Haddock et al.
crease gives an approximation of the available 2012; Hunter et al. 2015).
tissue that can be harvested with the flap. In
addition to this, also the tension of the wound
closure is also evaluated with the pinch test. Preoperative Evaluation and Imaging
Complications and postoperative behavior also
have to be discussed with the patient, as every- During the first consultation with the patient, the
day activity can be limited with the harvesting of upper medial and posterior thigh area is examined,
tissue from this area. in order to evaluate both the presence of sufficient
tissue for a breast reconstruction and the degree of
skin laxity. As a matter of fact, the reconstruction
Alternative Reconstructive Options has to provide not only a cosmetically pleasing
result, but also a tension-free closure, in order to
The PAP flap is often offered to patients that, for minimize the risk of donor site complications.
various reasons, cannot be offered breast recon- After the consultation, preoperative images are
struction with an abdominal-based flap (lack of collected; typically computed tomographic angiog-
tissue, previous abdominal surgery, and previ- raphy (CTa) was the imaging of choice to guide
ously harvested DIEP flap); if this is the case, identification and selection of the perforators
branching from the profunda femoris artery

(Haddock et al. 2012).
Initially, when PAP flap was first described,
magnetic resonance (MRI) or computed tomo-
graphic angiography (CTa) were performed in
order to obtain detailed mapping of the perforators
from the profunda artery (Allen et al. 2012). Once
main perforators were identified with preoperative
imaging, the position of skin perforators was con-
firmed with the use of a handheld doppler
(Haddock et al. 2012). Haddock et al. report that,
in their experience, they were able to find sufficient
size perforators (1.9 0.5 mm) in 98.8% of pos-
terior thigh preoperative imaging. Interestingly in Fig. 2 Modified approach with patient in lithotomy
position
addition to this, the study showed that those perfo-
rators could be more commonly found in the prox-
imity of the adductor magnus at approximately has to be made. This allows for more flexibility in
3.8 cm from the midline and 5.0 cm below the the harvesting, limiting the tension of the skin
gluteal fold (Haddock et al. 2012). closure.
In his practice, the senior author has progres- The original positioning of the patient, as well
sively limited the use of preoperative imaging as, as the surgical technique have been modified from
in his experience, CTa perforators mapping did the initial approach. When Allen started
not often correspond to the actual findings during performing the PAP flap (Allen et al. 2012), he
the dissection. However, the use of updated 3D opted for a prone position of the patient. This type
imaging might open new interesting scenarios for of positioning, while allowing for a good expo-
the preoperative accurate localization of profunda sure of the pedicle, required, at the same time,
artery perforators. intraoperative turning of the patient to gain access
to the mastectomy site. Not long after, the position
of the patient was converted to supine with the
Preoperative Care and Patient lower limbs placed in “frog-leg” position,
Drawing resulting in a much more time-saving procedure.
As a matter of fact, with this arrangement, two
The original marking described by Allen (2012) surgical teams could work at the same time, one
was made with the patient in standing position: on the mastectomy site for chest preparation and
The superior incision margin was drawn 1 cm one on the harvesting of the flap. Same approach
inferior to the gluteal fold, while the second line is also shared by the senior author, with the only
of incision was drawn approximately 7 cm below variation of the legs placed in lithotomy position,
the previous one. The skin paddle was designed when necessary (Fig. 2).
with an elliptical shape, trying to maintain the
incision within the lateral and medial extension
of the gluteal fold. Surgical Technique
The senior author has partially modified his
marking from the originally described in order to The patient is placed supine “frog-leg” position
achieve a better cosmetic outcome with less scar (Allen et al. 2012), allowing for a two-team
migration and to improve the position of the ped- approach, shortening operative times.
icle with regard of the skin island. The superior The gluteal crease defines the superior border
incision is outlined along the gluteal crease, while of the flap, while the inferior one is defined by
the pinch test defines where the inferior marking pinch test. The horizontal extension of an
elliptical flap is then designed in order to be technique, the dissection is carried out from cau-
concealed along the gluteal crease itself, in the dal to cranial in order to preserve TUG pedicle in
attempt not to extend laterally or medially to that case of poor PAP perforators (Fig. 3). In addition
landmark. Although CTa is helpful for identifica- to this, it is suggested to follow the perforators
tion of perforators, the senior author has currently down to their origin on the profunda femoris as
stopped performing it as sometimes misleading, standard approach, as by experience the diameter
for this reason perforators are not marked preop- of PAP perforators is usually quite small. Similar
eratively on the skin paddle. to the dissection in SGAP flaps, the use of one or
In the original description of the flap more self-retainer is essential in case of intra-
harvesting technique (Allen et al. 2012), Allen muscular dissection, in order to create the right
used to perform a medial to lateral dissection tension between muscle fibers and to progres-
starting from the medial portion of the thigh, sively expose the pedicle, avoiding direct trac-
posterior to the adductor longus muscle. Follow- tion on it (Fig. 3b).
ing this approach, after the first medial incision, When it comes to PAP flap the closure of the
the gracilis muscle fascia is opened, and the donor site is of primary importance. Being con-
muscle is pulled anteriorly in order to expose stantly under tension, wounds in the posterior
the adductor magnus muscle. The dissection is thigh region are prone to delay in healing and
then carried out posteriorly, opening the adductor dehiscence. While quilting the dead space in the
magnus fascia, until a suitable perforator is visu- area where the flap has been harvested might
alized. Once the perforator is identified, the dis- create discomfort in the first few postoperative
section is carried out following the perforator days (from pulling sensation to mild pain), it also
until the appropriate diameter is reached; if reduces the risk of seroma and helps with the
required by the size of the perforator, the dissec- healing of the superficial plane onto the deep
tion can be continued until the origin on the one. After the positioning of a suction drain, a
profunda vessels. multilayer closure is performed in order to dis-
The senior author has modified this approach. tribute the tension:
When the flap is harvested from medial to lateral,
as originally described, the option of using alter- • 2–0 PDS suture is used for deep quilting in
native flap pedicle (TUG or IGAP pedicle) as order to reduce the dead space
bailout in case of inappropriate PAP perforators • Barbed sutures are then used for more superfi-
is not available anymore. In this modified cial layers
Fig. 3 (a) Intraoperative dissection. (b) The use of self-retainers is essential in order to get a good exposure of the pedicle
during the intramuscular dissection
Technical Pearls A subcutaneous injection of low molecular

weight heparin is given to the patient once a day,
1. Patient selection has a very important role starting from 6 hours after surgery.
when it comes to PAP flap: Skin laxity is a The drain is kept in place at least for 48 h and is
key element to achieve an easy closure and, not removed before the output is lower than 30 cc
as a consequence, a good cosmetic outcome. in 24 hours. The patient is not mobilized until the
PAP perforators can be found quite low in the second postoperative day, in order to allow for the
upper posterior compartment of the thigh, and swelling around the thigh to start decreasing. Com-
because of this location, the patient might end pressive garments are applied on the patient imme-
up with an unpleasant low riding scar, if the diately after surgery and kept for at least 6 weeks.
tissue results to be too tight.
2. As mentioned before, the majority of PAP per-
forators tend to be septocutaneous, however Outcome: Clinical Photos and Imaging
musculocutaneous perforators can still be
found. When this happens, muscle relaxation No complications were observed in the postopera-
is essential for an optimal dissection, in order tive time. The flap volume allowed reaching both a
to avoid muscle contraction that may jeopar- pleasant result on the reconstructed side and a good
dize the integrity of the vessel. match with the contralateral breast (Figs. 4 and 5).
3. The pedicle dissection has to be carried on as While no discomfort was reported regarding
deep down as possible, as at this level the the breast area, the patient described the donor
vessel caliber offers a better match with the site as sore for a few days after the surgery. Ten-
recipient vessels in the chest. sion around the thigh scar can also be common in
the early postoperative period. No long-term
issues or limitations in the range of movement of
Intraoperative Images the leg were reported.
Symmetrization mastopexy to the left breast
Figure 3a, b The pictures show the course of the was performed 6 months after the first surgery
perforators with respect of the adductor magnus only to reach an even level between the two nipple
muscle. In picture 3A you can see the adductor areola complexes; no volume modifications were
magnus muscle in the background, partially needed. Overall, the patient was quite satisfied
retracted to show the course of an intramuscular regarding both the breast reconstruction and the
perforator; a second septal perforator is visible on donor site cosmetic outcome. Although admitting
the anterior surface of the muscle. Gracilis muscle an initial concern about an asymmetry between
lies aside, on the left-hand side. Picture 3B shows the thighs, eventually the patient referred not to
in details the intramuscular course of the perfora- notice major discrepancy between them. No cau-
tor inside the adductor magnus muscle. dal migration of the thigh scar was observed in
this case.
Follow-up appointments are, usually, carried
Postoperative Management on until 6–12 months after surgery in order to
plan, if needed, ancillary procedures once the
After surgery, the flap is monitored every hour for healing process is completed.
the first 24 hours, both clinically (flap color, cap-
illary refill time, and temperature) and with a
handheld doppler where the skin perforator is Avoiding and Managing Problems
identified. Close monitoring of the flap is essential
in order to immediately decode possible issues 1. When selecting patients, excess of tissue in
that might require revision surgery. Less frequent the upper posterior thigh (“banana roll”) is
doppler checks are carried on for the first 3 days. not sufficient condition to perform a PAP
Fig. 4 (a) Postoperative image after right breast recon- upper-outer pole of the right breast and good symmetry is
struction with PAP flap and left breast symmetrization achieved. (b. c) Postoperative image of the donor site that
mastopexy; monitoring skin paddle is visible in the right shows a cosmetically pleasing outcome
Fig. 5 (a) An example of a bilateral breast reconstruction with PAP flap. (b, c) Donor site outcome
flap, as it is essential to also have tissue laxity, 2. If the length of the pedicle is insufficient for
in order to avoid donor site complications. If tension-free anastomoses, it is advisable to use
the tissue is too firm the patient does not artery and vein graft. It is preferable to harvest
represent a good candidate for this type of the grafts from the DIEA system and to per-
reconstruction. form the pedicle grafting on a side table.
1. Because of its complexity, PAP flap harvesting Allen RJ, et al. Breast reconstruction with the profunda
artery perforator flap. Plast Reconstr Surg. 2012;129
has a longer learning curve compared with
(1):16e–23e.
other flaps, for this reason only skilled micro- Angrigiani C, et al. The adductor flap: a new method for
surgeons should approach this type of breast transferring posterior and medial thigh skin. Plast
reconstruction. Reconstr Surg. 2001;107:1725–31.
2. PAP flap represents a better option than TUG Haddock NT, et al. Predicting perforator location on pre-
operative imaging for the profunda artery perforator
flaps when it comes to secondary breast recon- flap. Microsurgery. 2012;32:507–11.
struction cases. As a matter of fact, thanks to Hunter JE, et al. Evolution from the TUG to PAP flap for
the position of the perforators, PAP flap offers breast reconstruction: comparison and refinements of
a much bigger skin island than TUG. technique. J Plast Reconstr Aesthet Surg. 2015;68(7):
960–5.
3. The flap PAP pedicle is usually longer than the Hurwitz DJ, Walton RL. Closure of chronic wounds of the
one in TUG flap, this allows for more flexibil- perineal and sacral regions using the gluteal thigh flap.
ity of the inset. Ann Plast Surg. 1982;8:375–86.
Breast Reconstruction with Lumbar
Artery Perforator Flap 88
Tasneem Belgaumwala, T. Roggio, and Venkat Ramakrishnan
Contents
Preoperative Problem List – Reconstruction Requirements . . . . . . . . . . . . . . . . . . . . . . . 944
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 944
Intraoperative Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 947
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 948
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 950
Abstract
This case illustrates the use of a lumbar artery

T. Belgaumwala (*) perforator (LAP) flap for immediate breast
St. Andrew’s Centre for Plastic Surgery and Burns, reconstruction. The patient previously had a
Broomfield Hospital, Chelmsford, UK left mastectomy and autologous breast recon-
Guy’s and St. Thomas, NHS Trust, London, UK struction with a deep inferior epigastric artery
e-mail: tasneem.belgaumwala@nhs.net perforator (DIEP) flap and was planned for right
T. Roggio · V. Ramakrishnan mastectomy. The total operative time was 6 h.
St. Andrew’s Centre for Plastic Surgery and Burns, The patient’s postoperative recovery was
e-mail: plasticsurgery@ramakrishnan.co.uk uneventful, and she was discharged from the

https://doi.org/10.1007/978-3-030-23706-6_77
944 T. Belgaumwala et al.
hospital on the fifth postoperative day. The late The LAP flap offers an autologous recons-
postoperative result was aesthetically pleasing tructive option with good aesthetic results in an
with no palpable areas of fat necrosis. The back appropriately selected patient. The flap can be
donor area healed uneventfully with no wound harvested from the ipsilateral back in the prone
dehiscence or seroma. There was good bilateral position after which the mastectomy is performed
breast symmetry in the long term after nipple in supine position while the pedicle graft is being
reconstruction and areolar tattooing. harvested for pedicle lengthening if required. The
LAP pedicle dissection is done until a sizeable
Keywords caliber of vessels is obtained and a vascular ped-
icle graft is used to increase pedicle length.
Immediate breast reconstruction · Autologous
reconstruction · LAP flap
The Clinical Scenario The first choice of flap for autologous breast recon-
struction is the deep inferior epigastric artery per-
A 50-year-old patient, who had previously under- forator (DIEP) flap. Previous DIEP flap for breast
gone left mastectomy with autologous reconstruc- reconstruction or an abdominoplasty precludes the
tion with DIEP flap, presented to us for with subsequent use of the abdominal pannus. In such
cancer in the contralateral breast (Fig. 1a, b). cases, other sites are examined. Alternative autolo-
The primary reconstructive aim was to match the gous donor sites available include medial thighs
previous left-sided reconstruction, while the sec- (TUG/PAP flaps) (Pollhammer et al. 2016), flanks
ondary aim was to limit donor site morbidity. On (LAP flaps) (Hamdi and Antoniazzi 2020;
examination it was seen that there was a good Opsomer et al. 2018), and buttocks (sGAP/iGAP
thickness of pannus in the lower back but not flaps) (Kitcat et al. 2012).
enough tissue in the upper thighs as a donor area Flaps from the medial thigh usually lack bulk
for autologous flap reconstruction. and may require bilateral flaps to recreate the breast
mound. Alternatively, lipotransfer may be done as
an adjunct, but it still leaves a deficit in the upper
Preoperative Problem List – pole of the breast. SGAP flaps require a more
Reconstruction Requirements tedious intramuscular dissection and the quality of
fat obtained is not as soft and pliable as in the flanks.
1. Breast reconstruction using autologous tissue For patients who will require radiotherapy, an
2. Previous use of abdominal pannus for breast implant reconstruction may not be appropriate.
reconstruction so DIEP flap unavailable Also, if a previous autologous reconstruction has
3. Need to match the volume and ptosis of previ- been done for the contralateral breast, is very
ously reconstructed right breast difficult to achieve a similar result. Multiple future
4. Use of single donor site (if possible) procedures are likely to be required for expander/
5. Single procedure for reconstructing breast implant exchange (Pu et al. 2018; Kitcat et al.
requiring no/minimal revision 2012). There is also a risk of Anaplastic Large
Cell Lymphoma (ALCL), albeit very low (Collett
et al. 2019; Sheena et al. 2020).
Treatment Plan
The decision was to proceed with a LAP flap Preoperative Evaluation and Imaging
reconstruction from the back, as the patient had
adequate tissue in the lower back but not in the The patient was examined initially in the standing
thighs. She was counselled regarding the proce- position to determine the breast size/symmetry,
dure and its complications accordingly. and degree of ptosis. The thigh, lumbar, and
88 Breast Reconstruction with Lumbar Artery Perforator Flap 945
Fig. 1 (a) Preoperative photographs of patient to show breast size, (b) previous breast reconstruction, and flank
donor area
gluteal donor sites were assessed. On pinching the slightly, the iliac crest was first marked. The max-
flanks and asking the patient to bend forwards, the imum width of the skin paddle was then deter-
volume of tissue available and the degree of mined. In prone position, the perforator markings
medial laxity can be determined. The area was were done and confirmed with the Doppler. The
examined for scars. Preoperative CT angiography skin paddle was centered around these with the
is done to assess perforator location and caliber. width of it being limited by ease of primary donor
Perforator mapping is done by measuring the dis- site closure (Fig. 2). This was determined by the
tance from the iliac crest and the midline. The pinch test. Anteriorly the markings may be
presence of the DIEA/|V must be noted for the merged with the previous abdominoplasty/DIEP
use of lengthening the pedicle. scar staying just short of the midline in the poste-
Preoperatively, a hand-held Doppler may be rior aspect.
used to confirm site the skin perforators. Following induction of anesthesia, the patient
was placed in the prone position with the arms by
the side, taking care to protect all pressure points.
Drawing
Surgical Technique
The patient was marked preoperatively in the
standing position. The breast footprint and breast 1. The flap harvest is performed first with the
meridian were marked bilaterally. If the patient patient in prone position.
has significantly ptotic breasts, a Wise pattern 2. Flap dissection was carried out in a lateral to
skin resection is marked. medial approach.
An ipsilateral LAP flap was designed. The 3. After incising the lateral skin, extra subcuta-
markings of the LAP flap were also done in the neous fat was harvested anteriorly to increase
standing position. With the patient bent forward flap bulk. Additional flap volume was also
Fig. 2 Preoperative CT
angiogram showing the
lumbar artery perforators
obtained by beveling inferiorly to include a used to reposition the inframammary fold and
gluteal extension. the lateral breast fold if required.
4. Once the erector spinae was reached, the 11. The recipient vessels were then prepared. If
medial part of the thoracolumbar fascia was preserved during mastectomy, the internal
opened to expose the perforators. The 4th mammary artery perforators (IMAp) are a
lumbar artery perforator was found to be the good caliber match to the LAP vessels. Oth-
best and flap was raised on that. erwise, the thoracodorsal (TDA/V) vessels or
5. Care is taken to identify and preserve the internal mammary vessels (IMA/IMV) can be
sensory nerves (nervi clunium superiores) used as recipients with the use of pedicle
for reinnervation in case a sensate flap is lengthening grafts.
attempted. 12. The anastomosis was done to the 2nd internal
6. Dissection was carried down in the subfascial mammary perforator vessels.
plane followed by the intermuscular plane 13. Before flap inset, the pedicle was examined to
between quadratus lumborum and the para- ensure there was no twist or kink on it. It is
spinal muscles. imperative to ensure that there is no tension
7. The perforator was carefully dissected to a on the pedicle while positioning the flap in the
suitable length and caliber, ligating all mus- breast pocket.
cular branches. The final bit of pedicle dissec- 14. Final flap contouring and de-epithelization
tion may be done with the aid of an operating was done, and the flap was inset.
microscope. 15. The total surgical time was 6 h.
8. The donor area was closed with quilting
sutures and placement of a drain to prevent
seroma formation. Technical Pearls
9. The patient was turned to supine decubitus,
following which the mastectomy was 1. A two-team approach is essential to ensure
performed. If the pedicle length is not ade- parallel operating at multiple sites and reduce
quate, an interposition vascular graft can be operative time. Process mapping (breaking
harvested simultaneously and a bench anas- the surgery into multiple steps) makes it sim-
tomosis can be performed. pler to allocate tasks to each team member
10. After the mastectomy finished, hemostasis of (Sharma et al. 2019). The interposition pedi-
the mastectomy skin flaps and breast pocket cle graft is harvested at the same time as the
was achieved. At this point, sutures can be mastectomy and the pedicle lengthening is
done concurrent with the recipient vessel caliber LAP vessels and the larger
dissection. IMA/V. In case of unavailability of the DIEP
2. Harvesting an ipsilateral flap allows the flap pedicle due to previous harvest, thoracodorsal
to be placed as such without need for pedicle or the lateral circumflex femoral ped-
contouring. icle are used.
3. Do not recruit tissue into the flap too aggres- 12. Dermal release at the edge of the skin paddle
sively, particularly at the superior border. This aids in suturing of the skin and avoids the step
risks creating excessive dead-space, which off from mastectomy to flap skin.
leads to seroma and infection. 13. Avoid aggressive denuding over the iliac crest
4. The preoperative CT angiogram guides the to prevent seroma formation. Undermining
choice of perforators, the 3rd or the 4th per- only the caudal area for closure mimics a
forator is ideal in size and position. lower body lift while reducing tension over
5. Meticulous hemostasis at each stage is essen- the donor area.
tial. Careful ligation of the muscular branches 14. Immediate use of a compression garment is
is imperative as once these branches retract it essential to further reduce the risk of a
is difficult to ligate them. seroma.
6. Try to obtain maximum pedicle length by
dissecting up to the transverse process of the
vertebra. Deeper dissection beyond this point Intraoperative Photos
risks injury to spinal nerves.
7. Shaping of the flap is rarely required as the See Fig. 3a-c.
beveling in the superior flap provides the
upper pole fullness, while the gluteal exten-
sion provides the projection and volume. Postoperative Management
8. Use of venous couplers decreases anasto-
motic time and minimizes the risk of using The patient was monitored closely postopera-
vein grafts. tively by physical examination and regular mon-
9. The internal mammary perforators (IMAp) itoring of the skin island. Temperature, color,
are generally a good caliber match for the turgor, and capillary refill were monitored hourly
flap vessels. Use of the IMAp also decreases for the first 24 h, followed by 2 hourly and 4 hourly
the need for vascular grafts, as a shorter ped- for the next 24 and 48 h respectively. The blood
icle length is required. They may be dissected pressure and urine output were similarly observed
down to the intercostal membrane for better to ensure the patient was adequately hydrated.
caliber of vessels (Fattah et al. 2010). This A Bair hugger was used for the first 24 h to
aids in more aesthetic placement of the flap as avoid hypothermia and promote vasodilatation.
the major bulk of tissue in breast reconstruc- Clear fluids were started orally once the patient
tion is required in the lower pole. was fully awake, along with supplementary intra-
10. If the internal mammary vessels (IMA/IMV) venous fluids. Use of compression devices and
are used, this may require resection of a por- low molecular weight heparin were continued
tion of the 3rd/4th rib, to increase the recipient during the hospital stay.
length available. The IMA is also smaller The patient gradually began mobilizing on day
inferiorly so there is less chance of a signifi- 1 with the reconstruction supported in a soft bra.
cant size discrepancy with the flap vessels. Drains were kept in place for the next few days,
11. Our practice today is the use of a bridging and removed once the patient had been mobilized
pedicle graft of the DIEA/V vessels as a rou- and drain output was low. Often, the donor area
tine. This helps to lengthen the pedicle and drain may remain for a few extra days to decrease
allows a better inset of the flap. Further, it acts the risk of donor site seroma. The patient was
as an “caliber reducer” between the small discharged on the fifth postoperative day.
Fig. 3 (a) Intraoperative photographs showing flap markings, (b) position of patient for flap harvest and (c)
harvested flap
3. Resist the temptation to elevate the superior

flap aggressively to avoid donor area seroma
formation.
The patient had an uneventful hospital stay with no
4. Restrict the skin paddle width depending on
postoperative complications. At reassessment a fort-
laxity of the flank to avoid donor site dehis-
night after the surgery, all wounds had healed, and
cence. If the tissue obtained from a single flap
she was able to carry out most activities of daily
seems inadequate, plan for bilateral (stacked)
living. Her 2-month postoperative result was satis-
LAP flaps.
factory with a good symmetry to the contralateral
5. Hematoma and seroma rates in the donor area
breast and an acceptable donor scar (Fig. 4a, b).
can be reduced by meticulous hemostasis,
There was no obvious asymmetry of the contour of
especially while ligating/clipping the muscular
the back. She later underwent local flap nipple recon-
branches.
struction and tattooing of the areola (Fig. 5a, b).
6. Interposition grafts may be harvested from the
previous abdominoplasty or DIEP donor area
scar. Alternative pedicle graft options are the
contralateral thoracodorsal pedicle or the lat-
eral circumflex pedicle, although these may
1. Patient selection is critical to ensure a good
mean an added incision.
aesthetic outcome and minimize donor site
complications. It is important to ensure that
there is sufficient tissue and laxity in the flanks
available for LAP flap reconstruction prior to Learning Points
surgery. Clinical examination will determine
whether a unilateral or stacked LAP recon- 1. The LAP flap has many advantages in breast
struction is appropriate. reconstruction. It is a useful alternative in
2. Appropriate planning and patient counselling patients where the abdominal or thigh tissue
are essential. Always explain that a vascular is inadequate or unavailable. It does not require
interposition graft may be required, as the ped- much coning or contouring as flap planning
icle length can be short and may not reach the and beveling provides the contour of the breast
desired recipient vessels for anastomosis. according to the desired shape for reconstruc-
Patients should be warned regarding the risks tion. The scar is relatively hidden in the lower
of donor site complications, such as delayed back in swimwear.
healing, seroma, infection, numbness, and con- 2. Patient selection is crucial to optimize out-
tour asymmetry. comes and reduce donor site morbidity.
Fig. 4 (a) Early postoperative photographs of patient to show breast symmetry and (b) well healed donor area
Fig. 5 (a) Late postoperative photographs of patient after nipple reconstruction and (b) Late postoperative result showing
minimal donor area asymmetry and well healed donor area
3. Flap volume and width should be limited to cell lymphoma in textured breast implants. Plast
avoid donor site complications. Where more tis- Reconstr Surg. 2019;143(3S):30S–40S.
Fattah A, Figus A, Mathur B, et al. The transverse
sue is required, stacked flaps can be performed. myocutaneous gracilis flap: technical refinements.
4. The most concerning donor complication of J Plast Reconstr Aesthet Surg. 2010;63:305–13.
LAP flaps is contour asymmetry. This may be Hamdi M, Antoniazzi E. Lumbar artery perforator flap for
mitigated by careful placement of the scar pre- breast reconstruction. In: Breast reconstruction – mod-
ern and promising surgical techniques. Cham: Springer
operatively and offering contralateral liposuc- Nature; 2020. p. 209–18.
tion at a later time to symmetrize the back. Kitcat M, Molina A, Meldon C, et al. A simple algorithm
5. The use of interposition pedicle grafts is encour- for immediate postmastectomy reconstruction of the
aged to increase pedicle length and matching small breast – a single surgeon’s 10-year experience.
Eplasty. 2012;12:e55.
the donor and recipient pedicle caliber. Opsomer D, Stillaert F, Blondeel PN, et al. The lumbar
artery perforator flap in autologous breast reconstruc-
tion: initial experience with 100 cases. Plast Reconstr
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▶ Breast Reconstruction with PAP Flap Pu Y, Mao TC, Zhang YM, Wang SL, Fan DL. The role of
▶ Secondary Breast Reconstruction with Vertical postmastectomy radiation therapy in patients with
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Posteromedial Thigh Flap (vPMT) analysis. Medicine. 2018;97(6):e9548.
▶ SIEA Flap for Breast Reconstruction Sharma HR, Rozen WM, Mathur B, et al. 100 steps of a
▶ Stacked Free Flaps for Breast Reconstruction DIEP flap – a prospective comparative cohort series
demonstrating the successful implementation of pro-
cess mapping in microsurgery. Plast Reconstr Surg
Glob Open. 2019;7:e2016.
References Sheena Y, Smith S, Dua S, Morgan M, Ramakrishnan
V. Current risk estimate of breast implant-associated
Collett DJ, Rakhorst H, Lennox P, et al. Current risk anaplastic large cell lymphoma in textured breast
estimate of breast implant-associated anaplastic large implants. Plast Reconstr Surg. 2020;145(2):446e.
Secondary Breast Reconstruction
with Vertical Posteromedial Thigh 89
Flap (vPMT)
Mario F. Scaglioni and Vendela Grufman
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 952
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 957
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 958
Abstract A skin-sparing mastectomy was planned for

In this chapter, an alternative option of breast a 37-year-old female patient with a ductal car-
reconstruction with free autologous tissue from cinoma in situ (DCIS) and an autologous
the abdomen is presented. reconstruction was desired. A two-stage pro-
cedure with initial expander implantation
followed by reconstruction with free autolo-
gous tissue was arranged. The use of an
abdominal flap was precluded due to the
patient’s wishes and paucity of abdominal tis-
M. F. Scaglioni (*) · V. Grufman
Department of Hand- and Plastic Surgery, Luzerner sue. Furthermore, the donor site morbidity of a
Kantonsspital, Lucerne, Switzerland gluteal flap was not acceptable to the patient.
e-mail: Mario.scaglioni@gmail.com

https://doi.org/10.1007/978-3-030-23706-6_79
952 M. F. Scaglioni and V. Grufman
As an alternative, a thigh-based free flap 3. Missing nipple areola complex (Muruci et al.
was therefore chosen; 3 months after the initial 1978).
stage, reconstruction was conducted with the 4. Scar in the upper lateral quadrant (Toth and
free posteromedial thigh flap (PMT). The flap Lappert 1991).
was harvested in a vertical manner (vPMT)
with a longitudinally oriented ellipse along
the posteromedial aspect of the thigh. Treatment Plan
The recovery periods were uneventful after
both procedures and the aesthetic result in After an interdisciplinary tumor board review, the
terms of volume and symmetry to the contra- decision was made to perform a two-stage proce-
lateral breast was excellent. dure, especially as uncertain nodal status and
unfavorable size ratio of tumor to breast were
Keywords present. A plan for skin-sparing mastectomy
Breast reconstruction · Autologous (SSM) and sentinel node biopsy (SNB) was set
reconstruction · Posteromedial thigh · PMT and conducted through the gynecological depart-
flap · Profunda femoris artery ment. The nipple could not be spared because of
the proximity to the DCIS. Furthermore, the deci-
sion was made to excise a small skin paddle in the
The Clinical Scenario area where the MRI showed signs of reaction of
the subcutis. Following the SSM, an expander
A 37-year-old female Caucasian patient underwent implantation was conducted.
staging for a large ductal carcinoma in situ (DCIS) The postoperative pathology report showed a
of the left breast. The tumor measured 6.5 complete resection of the DCIS without an inva-
4.6 5.6 cm. Furthermore, three axillary lymph sive component. The sentinel node biopsy was
nodes were radiologically enlarged and showed negative. Consequently, no further adjuvant ther-
signs of malignancy. Yet, repeated biopsies always apy was needed.
showed negative results. There were no abnormal- The patient preferred reconstruction of the
ities seen in the right breast. Magnetic resonance breast with autologous material. Breast recon-
imaging (MRI) was conducted, where a close rela- struction using either pedicled or free abdominal
tion between the mass and the subcutis was noted, flaps indicates a first choice when using autolo-
indicating a possible infiltration of the skin. Her gous tissue (Blondeel 1999). However, in patients
anamnesis showed no familial predisposition to lacking abdominal tissue, a thigh flap can be an
breast cancer or report of prior illnesses. excellent alternative (Allen et al. 2012; Park et al.
Clinical examination revealed a thin patient 2015; Scaglioni et al. 2017, 2018). Hence, a
(BMI 19.5 kg/m2) with a small-sized breast and fasciocutaneous vertical posteromedial thigh flap
no surplus of abdominal tissue. There were no scars (vPMT) was performed 3 months after initial
in the breast nor thigh area indicating prior surgery. operation. Furthermore, nipple reconstruction
was discussed and decided to be conducted at a
later time.
1. Lack of volume with intact skin envelope as a
result of skin-sparing mastectomy (SSM) (Yano When discussing breast reconstructive options
et al. 2007). with the patient, the team outlined various alter-
2. Requirement to reconstruct breast symmetri- natives with advantages and disadvantages. The
cally to contralateral healthy side (Giacalone reconstructive alternatives depend primarily on
et al. 2002). the type of mastectomy performed and may be
89 Secondary Breast Reconstruction with Vertical Posteromedial Thigh Flap (vPMT) 953
classified in several ways, such as reconstruction provides a reliable delineation of vascular anat-
type and reconstruction time point. In the end, the omy for the donor area and delivers a preoperative
fact that the patient selects the preferred tech- roadmap for flap elevation (Lee et al. 2013).
nique, clearly understanding its nature, leads to
the best aesthetic results and maximizes satisfac-
tion in outcome (Saulis et al. 2007). Preoperative Care and Patient
Drawing
1. Implant-based reconstruction: either immediate
reconstruction or two-stage procedure with The patient in this clinical scenario had no routine
placement of an expander followed by a perma- medication. Nevertheless, it is important to go
nent implant. The implant-based reconstruction through a possible medication list with the patient
has become the most common method of breast prior to intervention. An example of a drug that
reconstruction worldwide (Albornoz et al. 2013). should be considered temporarily paused is
2. Autologous reconstruction with gluteal perfo- tamoxifen (Kelley et al. 2012).
rator flap: either SGAP (superior gluteal artery Preoperatively markings were conducted: A
perforator) or IGAP (inferior gluteal artery per- line is drawn from the perineum to the distal inser-
forator), depending on the patient’s and sur- tion of semitendinosus muscle. This line represents
geon’s preference, distribution of adipose the mid-line of the adductor magnus muscle. The
tissue as well as where adequate perforators perforators are typically found in proximity of this
can be found. Drawbacks include the relatively line, usually 8–10 cm distal to the groin crease. A
short vascular pedicle and the necessity of hand-held Doppler probe is used to detect the loca-
intraoperative position change resulting in a tion of the audible perforators which are conse-
lengthy procedure. Furthermore, dissection is quently marked with an “x” (Fig. 1). The borders
technically tedious and preoperative imaging is of the breast are bilaterally outlined, approximating
a necessity (Allen 1998). the planned pocket for the flap (Fig. 2).
3. Autologous reconstruction with muscular flap: Intraoperatively, the patient was placed in a
transverse upper gracilis flap (TUG) (Yousif supine position, the right hip abducted and the
et al. 1992). The disadvantage is the relatively knee flexed. This “frog-leg” position for flap
short pedicle length and the increased donor harvesting is advocated by Allen et al. (2012).
site morbidity resulting from muscle harvest. The complete lower right extremity is circumfer-
entially prepped and draped.

Surgical Technique
The thigh region was evaluated for adequate vol-
ume. Even in relatively thin patients, there is 1. The first stage was conducted by the gyneco-
typically excess subcutaneous tissue accessible logical surgeons.
in this region. A vertical pinch test is performed 2. For the second stage (3 months after initial
preoperatively to ensure primary closure without operation), the expander is removed after
excessive tension. incision of the mastectomy scar. No capsular
In order for the flap harvest to be safer and formation is visible intraoperatively.
more time-efficient, it is crucial that the preoper- 3. Recipient vessel preparation: Internal mam-
ative investigation includes a proper study of the mary vessels (IMA and IMV) are used as
vascular anatomy of the thigh, a perforator map- recipients. A partial rib sparing technique at
ping. Assessment of the perforator location, the level of the third rib was performed, in
course, and size was consistently carried out order to obtain large-caliber vessels. The dis-
with a surface hand-held Doppler probe and com- section of the IMA was conducted according
puted tomography angiography (CTA). CTA to Haddock and Teotia (2017): In a first step,
Fig. 1 Preoperative drawings donor site
under constant protection of the dorsal peri-

chondrium, with a surgical elevator. As a last
step, the dorsal perichondrium is incised, a
perichondral flap elevated, and the dissection
of the IMA and IMV carried out after visual-
ization. This is normally performed under
loupe magnification.
4. Flap dissection is commenced with an inci-
sion performed along the anterior border of
the marked skin paddle.
5. The subcutaneous tissue is dissected using a
monopolar electrocautery needle. Slight
superior and inferior bevelling (a couple of
cm in each direction) can be carried out in
order to include more subcutaneous tissue.
The aim is to display the gracilis muscle
investing fascia. At this stage, a disposable
Fig. 2 Preoperative outlining of breast pocket
self-retaining retractor system is installed to
properly visualize the operating field.
the pectoralis major muscle is split from the 6. In a next step, the fascia is opened and dissec-
sternocostal – to the bone/cartilage junction. tion proceeds to the subfascial plane of the
In a next step, the perichondrium on top of the gracilis muscle, extending posteriorly onto the
rib cartilage is incised and dissected from the adductor magnus. Hereby the septum between
cartilage, paying special attention to the ele- gracilis and adductor magnus is exposed, on
vation of the dorsal perichondrium. The cra- the upper border of the latter. In doing so,
nial half (up to 50%) of the cartilage is then septocutaneous perforators can usually be
removed, after prior incision with a scalpel identified posterior to the gracilis muscle.
7. If this is not the case, the deep fascia over the Irrigation with lidocaine (1%) is used to treat
adductor magnus muscle is incised, in search intraoperative vascular spasms (Notodihardjo
for musculocutaneous perforators. After the et al. 1998). Two suction drains (Ch 10 or 12)
perforators have been localized, further eleva- are placed inferolaterally and fixated.
tion of the deep fascia follows. Septocutaneous 14. Shaping the flap: The patient is brought into
perforators within the septum between the the sitting position intraoperatively to per-
adductor magnus and the semimembranosus form correct shaping of the flap. The main
muscle should not be overlooked. goal is to achieve symmetry with the contra-
8. As soon as sizable perforators are selected lateral breast. It is possible to try out different
(>1 mm), either septo- or musculocutaneous, flap positions, before selecting the final one
a retrograde intramuscular dissection is giving the best aesthetic result.
conducted and pedicle dissection is followed
through until desirable length is achieved. The The flap is then attached to the pectoral fascia with
chosen “frog-leg” position intraoperatively Vicryl 2–0 or 3–0 sutures. De-epithelialization is
allows for stretching the gracilis and adductor performed, except for the area of the monitor
magnus for easier intramuscular perforator dis- island. Here, the skin is closed with Monocryl ®
section. At this stage, a further self-retaining 4–0 intradermally.
retractor is used to spread the fibers of the
muscle to facilitate visualization of the perfo- Summary of operation
rator and the vascular pedicle. The vascular 1. Preoperative markings – Detect the perforators
pedicle can be dissected up to an average of (PFA) using hand-held pencil Doppler
8–13 cm in length. 2. Preparation at recipient site:
9. As a last step, the posterior incision of the skin Preparing recipient vessels: Internal mammary
paddle is completed, being attentive of enclos- vessels
Evaluation of mastectomy skin envelope
ing the chosen perforators. At this point in the
3. Incision along anterior border of skin paddle of
operation, the flap size can again be evaluated vPMT with bevelling of the subcutaneous fat
according to defect size and volume loss. 4. Flap elevation:
10. Before the flap is completely elevated, an Expose the septum between gracilis and adductor
intraoperative indocyanine green angiography magnus
Choose sizeable perforators
(LA-ICG) is usually performed. This offers the Intramuscular dissection of the perforator
reassurance of sufficient flap perfusion. (deroofing technique)
11. Now the pedicle is divided. Complete flap harvest
12. The donor site is closed primarily in layers 5. Anastomosis
with (undyed) Vicryl 2–0 and 4–0 Monocryl Venous – Coupler devise
Arterial – Interrupted nylon suture
intradermal suture, after placement of two
6. Flap inset/shaping with the patient in the seated
suction drains (Ch 10 or 12). position
13. Vessel anastomosis: The vascular pedicle of 7. De-epithelialization and skin closure
the flap is aligned to the recipient vessels. 8. Closure of donor site area primarily
These are ligated distally and clamped prox-
imally. After transection, the recipient vessels
are irrigated with heparinized saline. The
anastomosis of the vein is performed with a Technical Pearls
vascular coupling device. The arterial anasto-
mosis is subsequently completed, after 1. The skin paddle is elevated from anterior along
approximation of vessels ends using a double the posterior border of the gracilis muscle.
opposing clamp, with interrupted 9–0 nylon 2. The septum between gracilis and adductor
sutures. After removal of the clamps, the per- magnus muscle needs to be exposed by retrac-
fusion and the venous outflow is evaluated. tion of the gracilis muscle.
3. The septum is approached by elevating the To prevent thromboembolic events, low-dose

fascia from anterior to posterior. intravenous heparin (10,000 IE/24 h) is com-
4. Septal perforator should be quickly visualized, menced 6 h postoperatively and continued for
otherwise continue the dissection posteriorly in 5 days. Subcutaneous unfractionated heparin is
order to identify muscular perforator. then given until full weight-bearing of the lower
5. The perforator needs to be freed and dissected extremity is achieved.
out to the profunda femoris in order to achieve An antibiotic therapy with a cephalosporin of
longer pedicle and larger vessels caliber. the first generation is given intravenously until the
6. Leaving the flap attached posteriorly until drains have been removed.
complete perforator dissection guarantees an
easier dissection without risk of pedicle
detachment and injury due to traction. Outcome, Clinical Photos, and Imaging
The postoperative recovery period was unevent-

Intraoperative Images ful. 3 months postoperatively the patient pre-
sented with satisfactory scars and a pleasant
See Figs. 3 and 4. aesthetic result, as seen in Figs. 5, 6, and 7.
The volume of the left breast shows a minor
surplus laterally, especially seen in the frontal
Postoperative Management view. The transition of the upper pole is not as
smooth as can be achieved, with minor contour
After completion of surgery, the patient is admit- deformities.
ted to the recovery unit for the following 24 h. The Reconstruction of the nipple areola complex
patient is placed in a supine position on bed rest, is now scheduled 6 months after the initial oper-
with the hip slightly abducted and the knee flexed ation (SSM). Simultaneously other corrections
on the operated side. Mobilizing commences after are going to be performed: lipofilling of the
3 days and patient ambulation is usually achieved upper and lower lateral quadrants on the right
after 5 days. side; scar correction. Initially the plan was to
Flap monitoring is conducted at an hourly basis remove the monitor island flap. However, this
for the first 24 h. The flap is clinically evaluated may lead to an even more bulky appearing breast.
and tested with a handheld Doppler probe. Usu- Hence the right side is ameliorated to achieve
ally flap monitoring is continued 2–4 hourly after symmetry.
the first 24 h until discharge.
Fig. 3 Flap elevated

medially with perforator
dissected intramuscularly
Fig. 4 Complete elevation of the PMT flap
Fig. 6 Postoperative result after 3 months in the

lateral view
2. Flap monitoring is of utmost importance, espe-

cially in the first 24 h after completion of the
anastomosis. The flap salvage outcome corre-
lates significantly with the time of presentation
of compromise (Chen et al. 2007). When there
is even a small doubt of flap viability, an oper-
ative revision is conducted without hesitation.
3. Another point which needs to be stressed is the
prevention of kinking of the pedicle. This is
Fig. 5 Postoperative result after 3 months in the often underestimated during flap inset. When
frontal view the flap is draped into position, a smooth, gen-
tle curve of the pedicle should be achieved.
Avoiding and Managing Problems 4. Although not likely, the risk of distortion to the
outer labia with labial spreading is feasible.
1. As with all microvascular breast reconstruc- The inferior migration of scar tissue follows
tions, there is a risk of vascular compromise gravity and displays a disastrous complication,
and the possibility for fat necrosis of the trans- which is very difficult to correct.
ferred tissue. One of the major concerns of the 5. The vertical design allowed the preservation of
vPMT-flap is the viability of the distal part of the lymphatic bundle running along the super-
the skin paddle. By viewing the anatomical ficial femoral vein, avoiding lymphatic impair-
studies focused on the perforasome of the pro- ment of the extremity.
funda femoris perforators, it is obvious though,
that the vascular territory of the perforators
includes the entire medial thigh (Ahmadzadeh Learning Points
et al. 2007). By using indocyanine green angi-
ography (LA-ICG) intraoperatively, the flap – The vPMT flap is an alternative option of
viability can be tested, and less perfused areas breast reconstruction when abdominal tissue
can be excised. is missing.
presentation of the first signs of vascular compromise

dictates the salvage outcome of free flap transfers. Plast
Reconstr Surg. 2007;120(1):187–95.
Giacalone PL, Bricout N, Dantas MJ, Daurés JP, Laffargue
F. Achieving symmetry in unilateral breast reconstruc-
tion: 17 years’ experience with 683 patients. Aesthet
Plast Surg. 2002;26(4):299–302.
Haddock NT, Teotia SS. Five steps to internal mammary
vessel preparation in less than 15 minutes. Plast
Reconstr Surg. 2017;140(5):884–6.
Kelley BP, Valero V, Yi M, Kronowitz SJ. Tamoxifen
increases the risk of microvascular flap complications
in patients undergoing microvascular breast reconstruc-
tion. Plast Reconstr Surg. 2014. Plast Reconstr Surg.
2012;129(2):305–14.
Lee GK, Fox PM, Riboh J, Hsu C, Saber S, Rubin GD,
Chang J. Computed tomography angiography in micro-
surgery: indications, clinical utility, and Pitfalls.
Eplasty. 2013;13:e42.
Muruci A, Dantas JJ, Noguerira LR. Reconstruction of the
Fig. 7 Postoperative result after 3 months in the oblique nipple-areola complex. Plast Reconstr Surg. 1978;61:
view 558–60.
Notodihardjo HW, Ogawa Y, Kusumoto K. The blood flow
– The reconstructed breast should be small to patterns of microsurgical procedures in rats with topical
and systemic vasodilators. Scand J Plast Reconstr Surg
medium size. Hand Surg. 1998;32(3):249–54.
– The vertical shape of the flap allows inclusion Park JE, Alkureishi LW, Song DH. TUGs into VUGs and
of more tissue and avoidance of injury to lym- friendly BUGs: transforming the Gracilis territory into
phatic structures of the upper medial thigh. the best secondary breast reconstructive option. Plast
Reconstr Surg. 2015;136(3):447–54.
– The resulting scar is well hidden with low Saulis AS, Mustoe TA, Fine NA. A retrospective analysis
morbidity. of patient satisfaction with immediate postmastectomy
breast reconstruction: comparison of three common
procedures. Plast Reconstr Surg. 2007;119(6):
1669–76.
References Scaglioni MF, Chen YC, Lindenblatt N, Giovanoli P. The
vertical postero medial thigh (vPMT) flap for autolo-
Ahmadzadeh R, Bergeron L, Tang M, Geddes CR, Morris gous breast reconstruction: a novel flap design. Micro-
SF. The posterior thigh perforator flap or profunda surgery. 2017;37(5):371–6.
femoris artery perforator flap. Plast Reconstr Surg. Scaglioni MF, Eder M, Giovanoli P. The use of inverted-L
2007;119:194–200. posteromedial thigh (L-PMT) flap for autologous
Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm breast reconstruction: a case report. Microsurgery.
shift in U.S. breast reconstruction: increasing implant 2018;38(5):558–62.
rates. Plast Reconstr Surg. 2013;131:15–23. Toth BA, Lappert P. Modified skin incisions for mastec-
Allen RJ. The superior gluteal artery perforator flap. Clin tomy: the need for plastic surgical input in preopera-
Plast Surg. 1998;25(2):293–302. tive planning. Plast Reconstr Surg. 1991;87(6):
Allen RJ, Haddock NT, Ahn CY, Sadeghi A. Breast recon- 1048–53.
struction with the profundal artery perforator flap. Plast Yano K, Hosokawa K, Masuoka T, Matsuda K, Takada A,
Reconstr Surg. 2012;129(1):16e–23e. Taguchi T, Tamaki Y, Noguchi S. Options for immedi-
Blondeel PN. One hundred free DIEP flap breast recon- ate breast reconstruction following skin-sparing mas-
structions: a personal experience. Br J Plast Surg. tectomy. Breast Cancer. 2007;14(4):406–13.
1999;52(2):104–11. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK,
Chen KT, Mardini S, Chuang DCC, Lin CH, Cheng MH, Sanger JR. The transverse gracilis musculocutaneous
Lin YT, Huang WC, Tsao CK, Wei FC. Timing of flap. Ann Plast Surg. 1992;29:482–90.
SIEA Flap for Breast Reconstruction
90
Gerald Duff and Colin Morrison
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 960
Intraoperative Images (Figs. 3, 4, 5, and 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 962
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 963
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 966
Abstract
A 52-year-old woman presented to our depart-

ment for delayed left breast reconstruction,
following left breast mastectomy and chemo-
G. Duff (*) and radiotherapy for inflammatory carcinoma
Department of Plastic Surgery, St. Vincent’s University almost 10 years ago. Following discussion
Hospital, Dublin, Ireland with the patient about the reconstructive
C. Morrison options, it was agreed to proceed with free
Department of Plastic, Reconstructive and Aesthetic
Surgery, Surgical Professional Unit, St. Vincent’s
University Hospital, Dublin, Ireland

https://doi.org/10.1007/978-3-030-23706-6_80
960 G. Duff and C. Morrison
autologous tissue from the abdominal area. CT

angiography revealed bilateral dominance of
the superficial systems, so the decision was
made to reconstruct the breast with superficial
inferior epigastric artery perforator (SIEA)
flap. The flap was performed without intra- or
postoperative complication, and the patient is
well and happy with cosmesis over 5 years
later.
This is a flap that is relatively easy to raise,
the donor defect is minimal, and in this way it
is advantageous to the other abdominal flaps.
Some authors have also reported reduced hos-
pital stay in relation to other abdominal free
flaps.
However, it is not always anatomically fea-
sible, and there are special technical consider- Fig. 1 Preoperative appearance of left chest post
ations that require certain experience in the mastectomy
handling of the flap. The unreliable vascular
territory, which varies widely, makes the use of
this flap challenging, and possibly this is the Preoperative Problem List /
reason that the earlier plastic surgeons sought Reconstructive Requirements
different solutions, the TRAM and subse-
quently the DIEP flap. However, with improved 1. Reconstruction of left breast needed.
preoperative and intraoperative imaging tools, 2. Need for healthy skin and subcutaneous tissue
this flap offers an attractive solution. Maybe in transfer.
the future, minimally invasive delay techniques, 3. History of chemotherapy may have bearing on
which result in a wider and more reliable perfu- quality of blood vessel walls and make anasto-
sion pattern, will improve the appeal of this moses challenging.
elegant flap.
Keywords
Treatment Plan
Breast reconstruction · SIEA flap · Free flap Single-stage free flap reconstruction from an
abdominal donor site. DIEAP flap would be the
most commonly used option in our unit. Preopera-
The Clinical Scenario tive evaluation of the patient’s abdominal wall
would be carried out to assess perforator quantity
Our patient was a 52-year-old woman who pre- and caliber. This was then reviewed by a consultant
sented to our service for consideration of autolo- radiologist and plastic surgeon to plan surgery.
gous reconstruction of her left breast. Her history
was of previous left mastectomy for inflammatory
ductal carcinoma. She had undergone neo- Alternative Reconstructive Options
adjuvant chemotherapy and subsequent mastec-
tomy and axillary lymph node clearance. She DIEAP flap – Most reliable flap option and con-
was otherwise fit and well with no history of sidered gold standard. Requires incision of rectus
note (Fig. 1). sheath and dissection through rectus muscle
90 SIEA Flap for Breast Reconstruction 961
(Vanschoonbeek et al. 2016; Coroneos et al. scan were located with Doppler probe and
2015). marked (Fig. 2).
Transverse upper gracilis flap – Can be
conformed to breast shape. Small skin paddle, high
donor site morbidity (Taylor and Daniel 1975). Surgical Technique
Pedicled Latissimus dorsi flap with implant –
Requires prosthesis, intraoperative repositioning, 1. IV antibiotics given at induction. A two-team
donor site seroma, and animation issues among approach was utilized to minimize
disadvantages. operative time.
2. For the chest, the mastectomy scar was excised
and sent for histology. The superior mastec-
Preoperative Evaluation and Imaging tomy skin flap was elevated, and access to the
internal mammary vessels was gained via split-
The patient underwent radiological assessment of ting of pectoralis major and excision of the
the abdominal wall. CT angiography revealed fourth costal cartilage.
bilateral dominance of the superficial systems, so 3. For the abdomen, the umbilicus was isolated.
the decision was made to reconstruct the breast 4. The inferior aspect of the skin paddle was
with SIEA flap. Data in the literature has shown incised, and the superior epigastric vessels
that preoperative CTA may significantly improve were identified and dissected. The flap was
flap success (Henry et al. 2017). then raised from superiolateral to inferomedial
at the level of the rectus sheath.
5. The vessels were dissected back to their ori-
Preoperative Care and Patient gin. Once the recipient vessels were prepared
Drawing and ready, the pedicle was clamped and
divided.
Patient was positioned supine and the abdominal 6. The abdomen is closed in layers over two
midline was marked. The skin paddle was redivac drains, and the neoumbilicus was
marked, and the perforators on the CTA fashioned.
Fig. 2 Preoperative marking of flap

7. The microsurgical anastomoses were operation. Low-molecular-weight heparin subcuta-

performed and the flap was revascularized. neous injections were commenced the evening
The flap was inset with a Jackson-Pratt drain. after surgery. Intravenous antibiotics were contin-
ued until the access cannulae expired and were
continued orally until the drains were removed.
Technical Pearls Drains were maintained until output was less than
30 ml in two consecutive 24-h periods (Fig. 7).
• The pedicle enters the flap at the inferior aspect
of the flap, so unlike the DIEAP flap, conforma-
tion options of flap are limited (Park et al. 2016). Outcome, Clinical Photos, and Imaging
• The skin paddle cannot cross the midline.
Angiosome is highly variable (Holm et al. Our patient experienced uneventful and fast
2008). recovery. One year postoperatively, the patient
• The flap is raised from superior to inferior. presented with a satisfactory functional and aes-
thetic result. She subsequently underwent nipple
reconstruction and contralateral symmetrizing
Intraoperative Images (Figs. 3, 4, 5, reduction (Figs. 8 and 9).
and 6)
• Preoperative abdominal angiography aids in

Postoperative Management operative planning and may reveal the feasibil-
ity of using a SIEA flap (Henry et al. 2017).
The patient was managed under the departmental • Do not cross the midline to avoid perfusion
free flap protocol. The patient was monitored in a issues.
high dependency unit for 48 h. Flap observations • Chemotherapy affects the quality of vessels,
were performed at set intervals for 5 days post and they must be handled with care.
Fig. 3 The raised SIEA flap before pedicle division

Fig. 4 The raised flap

showing the pedicle vessels
Fig. 5 The raised flap before pedicle division
Disadvantages
Learning Points
• Short pedicle (Garza et al. 2018)
Advantages of the SIEA flap include • Pedicle enters on one side of flap
• Vessel diameter mismatch (Gregoric et al. 2011)
• Ease of dissection • Increased incidence of seroma (Moradi et al.
• Rectus sheath left intact 2011)
Fig. 6 The raised flap before pedicle division from below
Fig. 7 The flap day 7 postop
• Higher rate of arterial thrombosis leading to flaps (Hadad et al. 2013). Some authors have
reexploration (Vanschoonbeek et al. 2016) also reported reduced hospital stay in relation to
• Incur higher hospital total charges, are associ- other abdominal free flaps.
ated with longer lengths of stay, and experience However, it is not always anatomically feasi-
more immediate complications compared with ble, and there are special technical considerations
pedicled TRAM (Kwok et al. 2019) that require certain experience in the handling of
the flap. The unreliable vascular territory, which
In summary, this is a flap that is relatively easy varies widely, makes the use of this flap challeng-
to raise, the donor defect is minimal, and in this ing, and possibly this is the reason that the earlier
way it is advantageous to the other abdominal plastic surgeons sought different solutions, the
Fig. 8 Result after 5 years

Fig. 9 Abdomen after 5 years
TRAM and subsequently the DIEP flap. However, Garza RM, Shenaq D, Song DH, Park JE. Superficial infe-
with improved preoperative and intraoperative rior epigastric artery flap salvage technique using deep
inferior epigastric artery graft. Plast Reconstr Surg
imaging tools, this flap offers an attractive solu- Glob Open. 2018;6(1):e1528.
tion. Maybe in the future, minimally invasive Gregoric M, et al. Delaying the superficial inferior epigas-
delay techniques, which result in a wider and tric artery flap: a solution to the problem of the small
more reliable perfusion pattern, will improve the calibre of the donor artery. J Plast Reconstr Aesthet
Surg. 2011;64(9):1181–6.
appeal of this elegant flap. Hadad I, et al. Augmented SIEA flap for microvascular
breast reconstruction after prior ligation of bilateral
deep inferior epigastric arteries. J Plast Reconstr
Cross-References Aesthet Surg. 2013;66(6):845–7.
Henry FP, Butler DP, Wood SH, Jallali N. Predicting and
planning for SIEA flap utilisation in breast reconstruc-
▶ Areola-Sparing Mastectomy and Deep Inferior tion: an algorithm combining pre-operative computed
Epigastric Perforator Flap Reconstruction tomography analysis and intra-operative angiosome
assessment. J Plast Reconstr Aesthet Surg. 2017;70
(6):795–800.
Holm C, Mayr M, Höfter E, Raab N, Ninkovic
References M. Interindividual variability of the SIEA angiosome:
effects on operative strategies in breast reconstruction.
Coroneos CJ, Heller AM, Voineskos SH, Avram R. SIEA Plast Reconstr Surg. 2008;122(6):1612–20.
versus DIEP arterial complications: a cohort study. Kwok AC, Simpson AM, Ye X, Tatro E, Agarwal
Plast Reconstr Surg. 2015;135(5):802e–7e. JP. Immediate unilateral breast reconstruction using
abdominally based flaps: analysis of 3,310 cases. J Taylor GI, Daniel RK. The anatomy of several free flap
Reconstr Microsurg. 2019;35(1):74–82. donor sites. Plast Reconstr Surg. 1975;56:243.
Moradi P, et al. SIEA flap leads to an increase in abdominal Vanschoonbeek A, Fabre G, Nanhekhan L, Vandevoort
seroma rates compared to DIEP flap for breast recon- M. Outcome after urgent microvascular revision of
struction. Eur J Plast Surg. 2011;34(2):87–91. free DIEP, SIEA and SGAP flaps for autologous breast
Park JE, Shenaq DS, Silva AK, Mhlaba JM, Song reconstruction. J Plast Reconstr Aesthet Surg. 2016;69
DH. Breast reconstruction with SIEA flaps: a single- (12):1598–608.
institution experience with 145 free flaps. Plast
Reconstr Surg. 2016;137(6):1682–9.
Superior Gluteal Artery Perforator
Flap for Immediate Breast 91
Reconstruction
Tasneem Belgaumwala and P. Roblin
Contents
Preoperative Problem List: Reconstruction Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 970
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 970
Intraoperative Photos (Figs. 4 and 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 975
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 976
Abstract
This case illustrates the use of a superior glu-

T. Belgaumwala (*) teal artery perforator (SGAP) flap for bilateral
St. Andrew’s Centre for Plastic Surgery and Burns, immediate breast reconstruction. A 45-year-
Broomfield Hospital, Chelmsford, UK old female was undergoing bilateral nipple
Guy’s and St. Thomas’ NHS Trust, London, UK sparing risk reducing mastectomy for BRCA
e-mail: tasneem.belgaumwala@nhs.net mutation. The total operative time was 10 h.
P. Roblin The patient’s postoperative recovery was
Guy’s and St. Thomas’ NHS Trust, London, UK uneventful, and she was discharged from the
e-mail: paulroblin@doctors.org.uk

https://doi.org/10.1007/978-3-030-23706-6_81
970 T. Belgaumwala and P. Roblin
hospital on the sixth postoperative day. The Preoperative Problem List:

late postoperative result was esthetically pleas- Reconstruction Requirements
ing with no palpable areas of fat necrosis. The
buttock donor area healed uneventfully with no 1. Breast reconstruction using autologous tissue
wound dehiscence or seroma. There was good 2. Aim to get symmetry of size and shape
bilateral breast symmetry in the long term with bilaterally
no donor site contour deformity. 3. Use of single donor site (if possible)
4. Single procedure for reconstructing breast
Keywords requiring no/minimal revision
Breast reconstruction · Autologous
reconstruction · SGAP flap
Treatment Plan
The decision was to proceed with a bilateral

SGAP flap reconstruction for this patient. In
this case, the patient had limited abdominal tis-
A 45-year-old patient presented to us for bilateral
sue and a previous abdominal scar. On examina-
risk reducing mastectomy and autologous recon-
tion of other donor sites, the SGAP flap was the
struction (Fig. 1). She had previously undergone
best choice for obtaining the optimal result. With
splenectomy and caesarean section and did not
an SGAP, it is important that the tissue is soft and
have adequate volume in the lower abdomen. On
has sufficient height for allowing an optimal
examination of alternative donor areas, she had
breast reconstruction. She was counseled re-
adequate tissue in the gluteal region and recon-
garding the procedure and its complications
struction was planned using a SGAP flap (Fig. 2).
accordingly.
The reconstructive aim was obtaining bilateral
The SGAP flap offers an autologous recon-
breast symmetry and volume with a well-
structive option with good esthetic results in an
concealed donor site.
appropriately selected patient. The flap may be
harvested in lateral position simultaneously
while the mastectomy is being performed, or in
the prone position once the mastectomy and the
recipient vessel preparation have been completed.
The gluteal donor area is well hidden in
swimwear.
The first choice of flap for autologous breast

reconstruction in most cases is the deep inferior
epigastric artery perforator (DIEP) flap. Alterna-
tive autologous donor sites available include
medial thighs (TUG/PAP flaps), flanks (LAP
flaps), and buttocks (sGAP/iGAP flaps). (Kitcat
et al. 2012; Pollhammer et al. 2016). All these
options have advantages and disadvantages
Fig. 1 Preoperative photographs of patient to show breast which must be taken into consideration by the
size and buttock donor area patient when they make their choice of
91 Superior Gluteal Artery Perforator Flap for Immediate Breast Reconstruction 971
Fig. 2 Preoperative
photographs of patient to
show breast size and
buttock donor area
reconstruction options. Previous DIEP flap

for breast reconstruction or an abdominoplasty Preoperative Evaluation and Imaging
precludes the subsequent use of the abdominal
pannus. Reasons for opting for SGAP flap The patient was examined initially in the standing
may be a younger, slimmer patient, pre- position to determine the breast size/symmetry,
vious abdominal surgery/previous DIEP, and and degree of ptosis. The abdominal, thigh, lum-
patient’s choice of donor site (Granzow et al. bar, and gluteal donor sites were assessed. On
2006). pinching the upper gluteal region, the volume of
Flaps from the medial thigh usually lack bulk tissue available is assessed, in particular for the
and may require bilateral flaps to recreate the height which can be obtained (which is correlated
breast mound. Alternatively, lipotransfer may be with the height of the breast), as well as the soft-
done as an adjunct, but it still leaves a deficit in the ness of fat can be determined. A Preoperative
upper pole of the breast. LAP flaps require a MRA examination is performed to assess perfo-
change in position and have a very short pedicle rator location and caliber. The perforators are
which usually necessitates an interposition vascu- mapped on the buttock with the patient in prone
lar graft for lengthening the pedicle, adding to the position (MRI scan is performed in prone posi-
overall procedure time. A DIEP flap has potential tion) by measuring the vertical distance up from
abdominal donor site problems. the coccyx as the fixed bony landmark and the
Implant reconstruction may not be appropriate lateral distance from the midline.
for patients requiring postoperative radiotherapy Preoperatively, a handheld Doppler may be
due to the higher rates of implant complications used to confirm site of the skin perforators (Fig. 3).
and capsular contracture. It can be difficult to
match a contralateral autologous reconstruction if
it had been done previously. Multiple future pro- Preoperative Care and Patient
cedures are likely to be required for expander/ Drawing
implant exchange (Pu et al. 2018; Kitcat et al.
2012). There is also a risk of Anaplastic Large The patient was marked preoperatively in the
Cell Lymphoma (ALCL), albeit very low (Collett standing position. The breast footprint was
et al. 2019; Sheena et al. 2020). marked bilaterally, and height and width of the
3. The internal mammary vessels (IMA/IMV)

were used as recipient vessels. The third or
fourth costal cartilage is removed and the
vessels dissected. The choice of costal carti-
lage is defined by which one lies most central
in the breast. The vessels were exposed from
rib to rib to give the maximum length.
4. Following the preparation of the recipient
vessels, the patient was turned to the prone
position to raise the flap.
5. The edges of the flap were incised down to the
muscle layer and the flap raised in a subfascial
plane from the superolateral to position in an
inferomedial direction in line with the muscle
fibers.
Fig. 3 Preoperative MR angiogram showing the lumbar 6. The perforators entering the gluteus maximus
artery perforators
muscle were identified, and the most suitable
one as identified on the scan was chosen
breast was marked. If the patient has ptotic depending on position and course.
breasts, a Benelli type incision for moderate or a 7. The muscle was split in the direction of the
Wise pattern skin resection for more marked pto- fibers, and perforator dissection was contin-
sis is marked. In this case, the patient wished to ued taking care to ligate the muscular
preserve the nipples so a “batwing”-type incision branches. Dissection was facilitated with use
was marked. of self-retaining retractors which were pro-
Bilateral SGAP flaps were designed. The gressively opened and moved to broaden the
markings of the SGAP flap were done in prone space during dissection (Zoccali et al. 2019).
position. The maximum width of the skin paddle 8. Once the sacral fascia was reached and
was then determined. In prone position, the per- incised, the rest of the dissection was contin-
forator markings were confirmed with the Dopp- ued under the microscope. Maximum possi-
ler. The skin paddle was centered around these ble pedicle length was obtained by following
with the height of it being limited by ease of the vessels up to their origin.
primary donor site closure, aiming to match the 9. The donor area was closed in layers over a
height of the breast. Some of the height is obtained drain.
by chamfering the skin paddle. 10. Simultaneously, the pedicle was dissected
Following induction of anesthesia, the patient and flap shaping was done on a separate
was placed in the supine position with the arms by bench.
the side, taking care to protect all pressure points. 11. The patient was turned back into supine position
and the flap inset and the shape or size adjusted
if necessary. The flap was then removed and the
Surgical Technique anastomosis undertaken to the previously dis-
sected internal mammary vessels.
1. A skin-sparing mastectomy was performed 12. Prior to anastomosing the vessels, the pedicle
by the breast surgeons. was examined to ensure there was no twist or
2. After the mastectomy, hemostasis was carried kink on it.
out and the breast pocket redefined. Sutures 13. The flap was inset and final flap contouring
are used to reposition the inframammary fold and de-epithelization was performed.
and the lateral breast fold if required. 14. The total surgical time was 10 h.
Technical Pearls 5. The preoperative MR angiogram guides the

choice of perforators, and close liaison with
1. To reduce the ischemia time, while the donor the radiologist is imperative in identifying the
site is being closed and patient is being turned optimal perforator.
supine, flap shaping and pedicle dissection 6. Meticulous hemostasis at each stage is essen-
can be performed on a side table. tial. Careful ligation of the muscular branches
2. Although it is possible to harvest the flap in is important as once these branches retract it is
lateral position, only the ipsilateral side can difficult to ligate them.
be used as the donor site. In this unit, we now 7. Try to obtain maximum pedicle length by
only harvest the flap with the patient in the dissecting up to the origin of the vessels, but
prone position. For bilateral reconstructions, also this often leads to an artery that has a
flaps have to be harvested with the patient diameter that matches that of the recipient
prone. This is also the method we now always artery.
use for unilateral reconstructions as this is 8. Shaping of the flap is rarely required as the
more comfortable for the operating surgeon beveling in the inferior aspect of the flap pro-
and allows for an easier dissection. vides the projection and volume.
3. The contralateral flap to the mastectomy side 9. Use of venous couplers decreases anasto-
is harvested. This is because the laterally motic time and minimizes the risk of using
placed perforating vessels will lie medially vein grafts. There can often be a relatively
near the internal mammary vessels thus large size mismatch with the vein, and
reducing the problems that may be encoun- the coupler is a good solution for this
tered with a short flap pedicle length. In addi- problem.
tion, chamfering is usually more effectively 10. Dermal release at the edge of the skin paddle
carried out inferiorly and allows for a better aids in suturing of the skin and avoids the
recreation of the upper pole of the breast with step-off from mastectomy to flap skin.
the flap being rotated 180 degrees. 11. The flap is cut to shape (sculptured) and not
4. To facilitate closure of the donor site, the shaped. It is usually not possible to shape
tissue inferiorly and superiorly is dissected these flaps so the dimensions of the flap
in a suprafascial plane. This is limited as harvested should match those of the breast.
much as possible to reduce the risk of an
excessive dead-space, which could lead to
seroma formation and infection. Intraoperative Photos (Figs. 4 and 5)
photographs showing
technique of flap harvest
with self-retaining
retractors and the final
harvested flap with pedicle
length obtained
photographs showing
technique of flap harvest
with self-retaining
retractors and the final
harvested flap with pedicle
length obtained
healed, and she was able to carry out most activ-

ities of daily living. Her 2-month postoperative
result was satisfactory with a good symmetry and
The patient was monitored closely postopera-
acceptable, symmetrical donor site scars (Figs. 6
tively by physical examination and regular mon-
and 7). There was no obvious asymmetry of the
itoring of the flow coupler. Initially, the flap was
contour of the buttock.
monitored hourly for the first 24 h, followed by
2 hourly and 4 hourly for the next 24 and 48 h,
respectively. The blood pressure and urine output
were similarly observed to ensure the patient was
adequately hydrated. A Bair hugger was used for
1. Patient selection is critical to ensure a good
the first 24 h to avoid hypothermia and promote
esthetic outcome and minimize donor site com-
vasodilatation. Clear fluids were started orally
plications. It is important to ensure that there is
once the patient was fully awake, along with sup-
sufficient tissue and laxity in the gluteal area
plementary intravenous fluids. Use of compres-
available for SGAP flap reconstruction prior to
sion devices and low-molecular-weight heparin
surgery.
were continued during the hospital stay.
2. Appropriate planning and patient counseling
The only restriction for the patient was to avoid
are essential. Patients should be warned
full hip flexion of the hip for the first few days (this
regarding the risks of donor site complications,
depends on the tension of the buttock closure).
such as delayed healing, seroma, infection,
The patient gradually began mobilizing on day
numbness, flattening of the buttock, and con-
1 with the reconstruction supported in a soft bra.
tour asymmetry.
Drains were kept in place for the next few days,
3. Resist the temptation to elevate the superior
and removed once the patient had been mobilized
flap aggressively to avoid donor area seroma
and drain output was low. Once the drain was
formation.
removed, the patient wore compression garment
4. Only harvest what is required for the vertical
for the buttocks. The patient was discharged on
height of the skin paddle to avoid donor site
postoperative day 6.
dehiscence and to minimize flattening of the
buttock.
Outcome and Clinical Photos 5. Hematoma rates in the donor area can be
reduced by meticulous hemostasis, especially
The patient had an uneventful hospital stay with while ligating/clipping the muscular branches.
no postoperative complications. At reassessment 6. The use of lateral perforators ensures a longer
a fortnight after the surgery, all wounds had pedicle length which obviates the need for
interposition vascular grafts. This helps to Learning Points

facilitate the ease of the anastomosis.
7. The flap is shaped and cut to size prior to the 1. The SGAP flap has many advantages in breast
anastomosis. Once the anastomosis has been reconstruction. It is a useful alternative in
completed, the flap is then placed into the patients where the abdominal or thigh
pocket once and not removed. This is impor- tissue is inadequate or unavailable. It does
tant due to the fact that a high proportion of not require much coning or contouring as
these cases for immediate reconstruction have flap planning and beveling provides the
a relatively limited access for the mastectomy contour of the breast according to the
and anastomosis. desired shape for reconstruction. The scar is
relatively hidden in the lower buttock in
swimwear.
2. Patient selection is crucial to optimize out-
comes and reduce donor site morbidity.
3. Where flap volume is limited, stacked flaps can
be performed.
4. The most concerning donor complication of
SGAP flaps is contour asymmetry. This may
be mitigated by careful placement of the scar
preoperatively and offering contralateral
liposuction at a later time to symmetrize the
back. The concave contour deformity can be
revised with open revision or more recently
with subcutaneous scar release and fat
transfer.
5. The tedious pedicle dissection is essential to
avoid the use of pedicle grafts and ensure
Fig. 6 Early postoperative photographs of patient to show matching vessel caliber to the recipient
breast symmetry and well-healed donor area vessels.
Fig. 7 Early postoperative

show breast symmetry and
well-healed donor area
Cross-References Kitcat M, Molina A, Meldon C, et al. A simple algorithm

for immediate postmastectomy reconstruction of the
small breast-a single surgeon’s 10-year experience.
▶ Bilateral Breast Reconstruction with the Free Eplasty. 2012;12:e55.
Fasciocutaneous Infragluteal Flap (FCI) Pollhammer MS, Duscher D, Schmidt M, Huemer
▶ Breast Reconstruction with PAP Flap GM. Recent advances in microvascular autologous
▶ Secondary Breast Reconstruction with Vertical breast reconstruction after ablative tumor surgery.
World J Clin Oncol. 2016;7(1):114–21.
Posteromedial Thigh Flap (vPMT) Pu Y, Mao TC, Zhang YM, Wang SL, Fan DL. The
▶ SIEA Flap for Breast Reconstruction role of postmastectomy radiation therapy in patients
▶ Stacked Free Flaps for Breast Reconstruction with immediate prosthetic breast reconstruction: a
meta-analysis. Medicine. 2018;97(6):e9548.
Sheena Y, Smith S, Dua S, Morgan M, Ramakrishnan
V. Current risk estimate of breast implant-
References associated anaplastic large cell lymphoma in tex-
tured breast implants. Plast Reconstr Surg. 2020;
Collett DJ, Rakhorst H, Lennox P, et al. Current risk 145(2):446e.
estimate of breast implant associated anaplastic large Zoccali G, Mughal M, Giwa L, Roblin P, Farhadi J. Breast
cell lymphoma in textured breast implants. Plast reconstruction with superior gluteal artery perforator
Reconstr Surg. 2019;143(3S):30S–40S. free flap: 8 years of experience. J Plast Reconstr
Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast recon- Aesthet Surg. 2019;72(10):1623–31.
struction with gluteal artery perforator flaps. J Plast
Reconstr Aesthet Surg. 2006;59:614–21.
Superior Gluteal Artery Perforator
(SGAP) Flap in Delayed Autologous 92
Breast Reconstruction
Shine Singh, Laura Kearney, and Peter Ceulemans
Contents
Preoperative Problem List /Reconstructive Requirements: . . . . . . . . . . . . . . . . . . . . . . . . 978
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 978
Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 978
Preoperative Evaluation /Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 979
Patient Positioning and Markings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 980
Outcome: Clinical Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 981
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 983
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 983
Abstract
The use of autologous flaps in breast recon-

S. Singh (*) struction is well-established. The deep inferior
Registrar in Plastic Surgery, St. Vincent’s University
Hospital, Dublin, Ireland
epigastric artery perforator (DIEAP) flap
e-mail: Shine.singh@nhs.net remains the gold standard, however not all
L. Kearney
patients are suitable for abdominal tissue trans-
Specialist Registrar in Plastic Surgery, St. Vincent’s fer. Alternative autologous options include
University Hospital, Dublin, Ireland flaps such the transverse upper gracilis
e-mail: laurakearney@rcsi.ie (TUG), profunda artery perforator (PAP), infe-
P. Ceulemans rior gluteal artery perforator (IGAP), and
Plastic Surgeon, Villa Medici, Mechelbaan, Belgium

https://doi.org/10.1007/978-3-030-23706-6_132
978 S. Singh et al.
superior artery perforator (SGAP), each with • Desire to achieve symmetry without secondary
its own advantages and disadvantages. symmetrizing surgery
We describe a 65-year-old lady who • Minimal donor site morbidity – contour defor-
underwent delayed left breast reconstruction mities, visible scarring, seromas
using the SGAP flap. The patient had an • Appropriate preoperative imaging
uneventful post-operative course with a good
aesthetic result. The SGAP flap is therefore a
safe and reliable alternative when a DIEAP flap Treatment Plan
is not possible.
Following consultation, a superior gluteal artery
Keywords perforator (SGAP) flap was planned. Allen and
Tucker first described the SGAP flap for autolo-
Breast reconstruction · Perforator flap · gous breast reconstruction in 1995. Both the supe-
Buttock tissue · Gluteal flap rior and inferior gluteal arteries are terminal
branches of the internal iliac artery. As the supe-
rior gluteal artery passes the greater sciatic fora-
Clinical Scenario men, it divides into a superficial and deep branch.
The deep branch travels in between the gluteus
A 65-year-old lady was referred for secondary medius muscle and the iliac bone. The superficial
breast reconstruction. She had undergone a simple branch goes on to supply the gluteus muscle and
left mastectomy for ductal carcinoma in situ the overlying fat and skin in this region. Perforat-
5 years previously. No adjuvant chemotherapy or ing vessels can be separated from the underlying
radiotherapy was required. The patient now muscle and fascia and form the basis of the SGAP
wished to pursue delayed breast reconstruction. flap. Typically there are 4–5 perforators arising
Her preference was for complete autologous from this vessel, with a pedicle length between
reconstruction and to avoid any surgery to the 3 cm to 8 cm. A large SGAP can be adequately
healthy contralateral breast. perfused on one of these perforators (Gagnon and
In addition to the patients’ preference, her body Blondeel 2006; Blondeel 1999).
habitus, cup size, comorbidities, lifestyle, and Although there was initial enthusiasm for glu-
overall expectations were carefully considered teal based perforator flaps, this has not translated
before deciding on the most appropriate autolo- into a popular alternative choice for autologous
gous approach. reconstruction. This is likely due to the perceived
On clinical examination, the contralateral right demanding perforator dissection, the potential
breast was of medium size. The patient had a body need to reposition the patient intra-operatively
mass index of 23, with minimal autologous donor and quoted longer operating times; on average
site tissue in both the abdominal and thigh areas. 7 h 12 min for SGAP flaps, in comparison to
There were no scars or abnormalities noted in her averages of 4 h 36 min to 6 h 28 min for DIEAP
buttock region. flaps (Baumeister et al. 2010). However, the
SGAP offers several unique advantages and
should not be overlooked as a real and valuable
Preoperative Problem List / option in autologous breast reconstruction.
Reconstructive Requirements:
• Patient preference for complete autologous Advantages

reconstruction
• Lack of sufficient excess tissue in the abdomen • Substantial donor site tissue: even in thin
or thigh (precluding DIEAP or TUG flaps) patients the SGAP flap provides an average of
92 Superior Gluteal Artery Perforator (SGAP) Flap in Delayed Autologous Breast Reconstruction 979
451 g of tissue, sufficient for even moderate to 2. TUG Flap – suitable for small volume breast
large breast reconstruction (Gagnon and reconstruction. However, the patient had asked
Blondeel, 2006). to avoid any symmetrizing surgery. In addi-
• Vascular reliability: the SGAP flap provides a tion, the vessels, while of similar length to a
reliable anatomical basis and safe blood sup- SGAP flap, 6–8 cm, tend to be of smaller
ply. The perforators have an average length of diameter, artery 1.2 mm, vein 2.8 mm
3 to 8 cm and a diameter of 1 to 1.5 mm. The (Baumeister et al. 2010). Hair-bearing skin in
superior gluteal artery measures 3.5 mm on the inguinal region can also restrict the size of
average and the vein ranges from 2 to 4 mm. skin paddle harvest.
Both vessels are a good size match for the 3. PAP flap – The PAP flap is based on the
internal mammary vessels. musculocutaneous perforators or more fre-
• Excellent aesthetic result: the nature of the fat quently the septocutaneous perforators of the
in the gluteal region and the high fat-to-skin profunda femoris artery, which supplies the
ratio allows creation of a youthful breast with upper posterior compartment of the thigh.
good projection and volume and little if any The artery typically gives off three main per-
ptosis (Guerra et al. 2004; Opsomer 2020). forators, with the PAP flap based on the second
• Low rates of fat necrosis: the rates of fat necro- and third perforators that supply a posterior
sis reported in SGAP flaps are extremely low, area of the thigh under the buttock crease (the
3.7–10%, compared to DIEAP flaps, 13–29% so-called “banana roll”). The dissection is con-
(Baumeister et al. 2010). This is thought to be sidered as technically challenging as the SGAP
because gluteal fat seems to be more resistant and overall results in autologous flaps of lower
to ischemia, probably because it is used to poor volumes.
vascularization during sitting (Blondeel 1999). 4. IGAP – while the SGAP flap is based on per-
• Well- concealed donor site: although it can lead forators of the superior gluteal artery, the IGAP
to a visible groove in the upper buttock, mainly flap is based on perforators of the inferior glu-
noticeable on a lateral view, generally patient teal artery that supply the lower gluteal fold.
satisfaction is high, with a donor site scar that is Advantages over the SGAP flap include a lon-
well-concealed in normal underwear. ger pedicle length and maintaining upper but-
tock fullness. However, the resultant scar,
while well concealed in the lower gluteal
Alternative Reconstructive Options fold, can produce a contour deformity of the
lower buttock. This, along with potential hypo-
1. Extended Latissimus Dorsi (ELD): The esthesia of the posterior buttock due to the
latissimus dorsi is a pedicled myocutaneous proximity of posterior cutaneous nerve of the
flap based on the thoracodorsal vessels. It is thigh and temporary pain on sitting, mean that
rotated from the back to the chest, useful in the the SGAP is used preferentially.
setting of previous radiation and reconstruction
of large skin and soft tissue mastectomy
defects. The latissimus dorsi (LD) flap is typi- Preoperative Evaluation /Imaging
cally combined with an implant, although an
extended LD has been described. This involves With such technically demanding dissection,
a more aggressive harvest of subcutaneous tis- pre-operative imaging is essential. MRA is used
sue, eliminating the need for an implant, for the instead of CTA to avoid exposing patients to
reconstruction of small- to -medium-sized ionizing radiation or iodinated intravenous con-
breasts. The main disadvantages are a high trast and due to improved accuracy of MRA
seroma rate, extensive donor site scar, and images. Although CTA lacks the finer detail of
potential contour deformities. MRA, it is less costly and more readily available.
980 S. Singh et al.
Perforating vessels of 1-mm diameter and their

course can reliably be visualized. Preoperative
knowledge of a larger vessel diameter, pedicle of
sufficient length for insetting, central location of
the vessel on the flap, and a pattern of arborization
suggesting perfusion of the tissue to be trans-
ferred, all provide an invaluable road map for
flap design (Vasile et al. 2010).
The presence of septal perforators can be
favorable, as this avoids tedious muscular dissec-
tion and helps in preserving buttock shape. How-
ever it is worth noting that even septocutaneous
perforator dissection may be tedious as they can
be enveloped in thick fascia. Fig. 1 Preoperative patient marking. The perforators iden-
tified on MRA are confirmed by hand held Doppler device
and illustrated in red
Patient Positioning and Markings

can be closed without undue tension. Once the
The patient is placed in a lateral decubitus posi- flap harvest was complete and the donor closed,
tion, with the hips in flexion and the arm of the the patient was positioned supine for flap
affected side lying free. This allows simultaneous anastomosis.
exposure of the donor site for flap harvest and
recipient site for preparation of the internal mam-
mary vessels, the recipient vessels of choice. In Surgical Technique
bilateral cases, patients are positioned prone.
A line is drawn from posterior superior iliac 1. Skin incisions are made and subcutaneous tis-
spine (PSIS) to meet the apex of greater trochan- sue is dissected to the fascia of gluteus maximus
ter. The point approximately one third from the using a monopolar electrocautery needle.
posterior iliac spine (PSIS) along this line repre- 2. Beveling of the subcutaneous tissue is
sents where the SGA exits the pelvis. A line is performed 2–3 cm inferiorly to recruit more
then drawn between the PSIS and the coccyx. The tissue.
position of the piriformis is located by joining the 3. Once the fascia of the gluteus maximus is
middle of the PSIS-coccyx line to the superior reached, it is incised and elevated with the
edge of the greater trochanter. Perforators can be flap, in a lateral to medial direction.
identified superior to this line, usually at the junc- 4. The perforators are identified running in the
tion of the proximal and middle thirds and medial direction of the gluteus muscle fibers and are
to this (Fig. 1). again approached from a lateral to medial
Three perforators were marked with a Doppler direction.
ultrasound probe and these correlated to MRA 5. Lateral perforators provide extra length,
findings. Once marked, the skin paddle can be whereas the medial perforators are usually
customized to almost any orientation as long as larger. A pedicle length of 7–9 cm is usually
the outline contains a perforator. The preference is possible.
to avoid oblique incisions due to associated con- 6. The flap can be raised on either lateral or
tour deformity. medial perforators. This flap was raised on a
A horizontally orientated elliptical shaped skin single large perforator which was adequate in
paddle was designed around marked perforators. providing a good vascular supply.
The length of the skin paddle is usually 20–28 cm 7. The perforator was then dissected through the
and the width is, on average 10 cm, but 12–14 cm muscle by dividing it in the line of its fibers.
8. Dissection continues until the perforator makes microvascular anastomosis easier and
reaches the superior gluteal artery. safer.
9. Careful dissection and ligation of all side 8. The donor site should be closed meticulously.
branches is performed. The gluteus maximus muscle is re-approxi-
10. Before attempting to ligate the tributaries of mated with absorbable sutures and a large suc-
superior gluteal vein, it is very important to tion placed over the muscle and brought out
assure adequate exposure and visualization of laterally. The superficial fascia system is iden-
the superior gluteal vein leaving the pelvis. tified and carefully approximated before final
11. Once the flap is harvested, the donor defect is skin closure.
closed with a large suction drain in place. 9. The incidence of seroma in the donor site can
12. The patient is then positioned supine to com- be decreased significantly with the use of a
plete the microsurgical anastomosis. large suction drain and compression garments.
Leave the suction drain in place for 10 days or
more and ask patients to wear compression
Technical Pearls garments for 6 weeks.
1. Avoid beveling superiorly and medially to

reduce the chances of a contour deformity. Intraoperative Images
Similarly, orientation of the skin paddle should
be transverse rather than oblique. See Figs. 2 and 3.
2. Avoid undermining over the iliac crest and
trochanter because this interrupts important
periosteum-to-skin ligaments. Outcome: Clinical Photographs
3. The fascia of the gluteus maximus is elevated
along with the flap. This allows the surgeon to The patient had an uncomplicated recovery and a
enter the optimal, relatively bloodless, dissec- satisfactory cosmetic outcome. The buttock scar
tion plane. settled well and was easily concealed by
4. Use muscle relaxant to completely paralyze the underwear.
gluteus maximus and avoid any sudden con- At 6 months the patient had a nipple recon-
traction, which can result in perforator damage. struction with a local flap and areolar tattooing.
5. When the deepest portion of the gluteus
maximus is reached, the anterior fascia of the
muscle is opened and the sub-gluteal fat pad is
exposed, unveiling an intricate vascular net-
work. Wide exposure is essential to carefully
identify and ligate venous side branches of
superior gluteal vein. Although tedious,
dissecting into the sub-gluteal fat can gain an
extra 2–3 cm of pedicle length.
6. Avoid excessive, prolonged traction on the
piriformis muscle when exposing the superior
gluteal vessels. This traction can be transmitted
to the sciatic nerve, which lies caudal to the
piriformis muscle. Otherwise patients can expe-
rience significant symptoms for some time fol-
lowing surgery. Fig. 2 The SGAP flap dissected off the gluteus maximus
7. Use a venous coupler device. This accom- muscle from lateral to medial. The first large perforator is
modates vessel caliber discrepancies and identified emerging from between the muscle fibers
982 S. Singh et al.
Fig. 3 The perforating vessel has been separated from the

surrounding fibers of the gluteus maximus muscle. Careful
dissection yields a pedicle length of up to 9cm
Fig. 5 Patients contralateral right breast for comparison
• It is vital to give necessary time for careful

preoperative patient counselling in terms of
expectations of overall result and potential
issues with this particular donor site.
• Despite careful technique, donor site contour
defects can occur. Fat grafting can be used to
correct these and simultaneous revisions of any
dog ears, with liposuction of the lateral tro-
chanteric region and contouring of the upper
buttock (Lotempio and Allen 2010).
• The nature of the gluteal fat means it can create a
youthful breast reconstruction with little ptosis.
However, this can sometimes make it difficult to
match the contralateral side. Secondary proce-
Fig. 4 Left lateral view of patient showing final result of
delayed SGAP reconstruction. A satisfactory breast size dures such as liposuction of the flap may be
and shape was achieved. required to achieve this.
• Preoperative MRA imaging allows the option
The final result is a breast of comparable volume, of performing an IGAP if no SGA perforators
shape and projection (Figs. 4 and 5). can be identified.
1. The DIEP remains the first choice for the vast Baumeister S, Werdin F, Peek A. The sGAP flap: rare
exception or second choice in autologous breast recon-
majority of autologous breast reconstruction.
struction? J Reconstr Microsurg. 2010;26:251–8.
2. Various perforator flaps can be used as a sec- Blondeel PN. The sensate free superior gluteal artery per-
ond choice but each donor site has its forator (S-GAP) flap: a valuable alternative in autolo-
disadvantages. gous breast reconstruction. Br J Plast Surg. 1999;52:
185–93.
3. Although technically demanding, the SGAP is
Gagnon AR, Blondeel PN. Superior gluteal artery perfora-
a real and valuable alternative option, particu- tor flap. Semin Plast Surg. 2006;20(2):79–88. https://
larly for the reconstruction of medium- to doi.org/10.1055/s-2006-941714.
large-size breasts (Yaghoubian and Boyd Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL,
Allen RJ. Breast reconstruction with gluteal artery per-
2011).
forator (GAP) flaps: a critical analysis of 142 cases.
Ann Plast Surg. 2004;52:118–25.
Lotempio MM, Allen RJ. Breast reconstruction with
Cross-References SGAP and IGAP flaps. Plast Reconstr Surg.
2010;126(2):393–401.
Opsomer D, Vyncke T, Ryx M, Stillaert F, Van Landuyt K,
▶ Bilateral Breast Reconstruction with the Free Blondeel P. Comparing the lumbar and SGAP flaps to
Fasciocutaneous Infragluteal Flap (FCI) the DIEP flap using the BREAST-Q. Plast Reconstr
▶ Breast Reconstruction with PAP Flap Surg. 2020;146(3):276e–82e.
Vasile JV, Newman T, Rusch DG, Greenspun DT, Allen
▶ Secondary Breast Reconstruction with Vertical
RJ, Prince M, Levine JL. Anatomic imaging of gluteal
Posteromedial Thigh Flap (vPMT) perforator flaps without ionizing radiation: seeing is
▶ SIEA Flap for Breast Reconstruction believing with magnetic resonance angiography.
▶ Stacked Free Flaps for Breast Reconstruction J Reconstr Microsurg. 2010;26(1):45–57.
Yaghoubian A, Boyd JB. The SGAP flap in breast recon-
▶ Superior Gluteal Artery Perforator Flap for
struction: backup or first choice? Plast Reconstr Surg.
Immediate Breast Reconstruction 2011;128(1):29e–31e.
Stacked Free Flaps for Breast
Reconstruction 93
Warren M. Rozen, Harmeet K. Bhullar, Tasneem Belgaumwala,
and Venkat Ramakrishnan
Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986
Preoperative Problem List: Reconstruction Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 987
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 987
Surgical Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988
Intraoperative Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 991
W. M. Rozen (*) · H. K. Bhullar

Department of Plastic and Reconstructive Surgery,
Peninsula Health, Frankston, VIC, Australia
Faculty of Medicine, Peninsula Clinical School, Central
Clinical School, Monash University, Frankston, VIC, Australia
e-mail: warrenrozen@plasticsurgeyvictoria.com.au
T. Belgaumwala
St. Andrew’s Centre for Plastic Surgery and Burns,
Guy’s and St. Thomas, NHS Trust, London, UK
e-mail: tasneem.belgaumwala@nhs.net
V. Ramakrishnan
St. Andrew’s Centre for Plastic Surgery and Burns,
e-mail: plasticsurgery@ramakrishnan.co.uk

https://doi.org/10.1007/978-3-030-23706-6_82
986 W. M. Rozen et al.

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 993
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 993
Abstract Background
The gold standard for autologous breast recon-
struction has been the use of abdominal free The gold standard for autologous breast recon-
tissue transfer in the form of Deep Inferior Epi- struction has been the use of abdominal free
gastric Artery perforator (DIEP) flap. Thin tissue transfer in the form of Deep Inferior
patients with low body mass index (BMI) or Epigastric Artery Perforator (DIEP) flap
with paucity of tissue in the abdominal pannus (Pollhammer et al. 2016). Thin patients with
pose a reconstructive challenge. Alternative low body mass index (BMI) or with paucity of
donor sites and reconstructive options include tissue in the abdominal pannus pose a recon-
medial thighs, back, gluteal region, and implant structive challenge. Alternative donor sites and
reconstruction (Mohan AT, Zhu L, Vijay- reconstructive options include medial thighs,
asekaran A, Saint-Cyr M, Clin Plastic Surg 47: back, gluteal region, and implant reconstruction
611–619, 2020). We present a case to illustrate (Mohan et al. 2020). Stacking of flaps ensures
the use of stacked DIEP flaps for breast recon- that the flap orientation and bulk resemble the
struction. Immediate reconstruction was done breast footprint and mound as closely as possi-
postmastectomy and axillary clearance for inva- ble (Patel et al. 2016). We present a case to
sive lobular carcinoma left breast. The flaps were illustrate the use of stacked DIEP flaps for breast
divided in the midline and stacked side by side reconstruction.
with anastomoses done in parallel (independent
pedicles). The total reconstruction time was
5.5 h. The patient’s postoperative recovery was
uneventful, and she was discharged from the
hospital on the fourth postoperative day. Since
both flaps were harvested from the abdomen, the
donor site morbidity is restricted to a single site,
aiding speedy postoperative recovery. Using
both DIEA pedicles ensures that all zones of the
abdomen can be safely used avoiding complica-
tions of fat necrosis, particularly in patients
requiring postoperative radiation therapy.
Stacking of the flaps ensures that the flap orien-
tation and bulk resemble the breast footprint and
mound as closely as possible. The late postoper-
ative result was esthetically pleasing with no
palpable areas of fat necrosis. The abdomen
healed uneventfully with no abdominal wound
dehiscence or seroma. There was no delay in
receipt of adjuvant treatment.
Keywords
Breast reconstruction · DIEP flap · Stacked Fig. 1 Preoperative photographs of patient to show breast
flap · Low BMI size and abdominal donor area
93 Stacked Free Flaps for Breast Reconstruction 987
3. Use of single donor site (if possible)

requiring no/minimal revision
5. Preferably no requirement of contralateral
symmetrizing procedures
Treatment Plan
The decision was to go ahead with either a

bipedicled or a stacked DIEP flap as a single
pedicle would be unreliable to perfuse the entire
abdominal pannus. She was counseled regarding
the procedure and its complications accordingly.
1. Stacked bilateral Transverse Upper Gracilis

(TUG) flaps – donor areas both thighs, pro-
longed recovery, and increased donor area com-
Fig. 2 Preoperative photographs of patient to show breast plications. Not preferred unless abdominal
size and abdominal donor area
tissue is too inadequate or the abdomen is
scarred by multiple previous surgeries restricting
The Clinical Scenario the available volume.
2. Flaps from the gluteal and lumbar region –
A 47-year old patient was diagnosed with multi- requires change of position during harvest and
focal invasive lobular carcinoma left breast for closure, so parallel operating is not possible. Ped-
which she was on neoadjuvant chemotherapy icle length obtained is short and needs extension
and was to undergo mastectomy and axillary using grafts increasing time under anesthesia.
node clearance. She was referred to the plastic 3. Implant-based reconstruction – not ideal for
and reconstructive services for consideration of patients in need of postoperative radiation ther-
autologous breast reconstruction. On preoperative apy as higher complications of capsular con-
examination in the clinic, it was noted that she did tracture. Requires multiple surgeries to change
not have adequate tissue in the hemiabdomen expander to permanent implants followed by
matching the right breast even though it was a implant exchange every decade or earlier if
small-moderate-sized breast (C cup size) (Figs. 1 there are complications (Pu et al. 2018).
and 2). She had not undergone any abdominal
procedures in the past. The only way for safely
using all four zones of the abdominal pannus was Preoperative Evaluation and Imaging
harvesting both DIEA pedicles.
The patient was examined initially in the stand-
ing position to determine the breast size and
Preoperative Problem List: symmetry, degree of ptosis, if any, and any obvi-
Reconstruction Requirements ous skin tethering. The thigh, lumbar, and gluteal
donor sites can also be assessed. In the supine
1. Breast reconstruction using autologous tissue position, scars of previous surgery, if any, are
2. Inadequate tissue in hemiabdomen for volume noted, as are abdominal laxity and rectus
replacement divarication. The pinch test is also done to
The patient was placed in supine position with

the arms out and a pillow below the knees and
protection of all pressure points. Both the breasts
and abdomen were prepared and draped.
Surgical Steps
1. The breast surgeon performed a circumareolar

mastectomy with axillary clearance done
through a separate axillary incision.
2. While the mastectomy was being performed,
the flap harvest was begun from the contra-
lateral side of the abdomen.
Fig. 3 Preoperative CT angiogram of patient demonstrat-
ing the perforator on the left side of the abdomen 3. After incising the lower edge of the flap, the
superficial inferior epigastric vein (SIEV) was
identified and dissected for a few centimeters
assess approximate volume of alternative donor to use in case the superficial system was dom-
sites, namely medial thigh, lower back, and inant or there is no superficial-deep venous
buttock. crossover seen after the anastomosis.
Preoperative CT angiogram is routinely done to 4. The upper incision was then taken and an
visualize the best perforators for flap raising, course extension of the subscarpal fat was recruited
of the perforators, dominance of superficial venous in the supraumbilical region which minimally
system, and presence of midline crossover. Addi- increases flap volume, but helps matching the
tionally, an estimate of flap volume can be obtained thickness of the superior and inferior abdom-
and any incidental hernias as well as presence of inal flaps. This aids in abdominal closure as
rectus divarication can be confirmed (Fig. 3). well as producing an esthetically pleasing
abdomen.
5. The flap was then raised using monopolar
Preoperative Care and Patient cautery, lateral to medial and inferior to supe-
Drawing rior, stopping short of the chosen perforator.
Closer to the perforator, dissection was done
On the day of surgery, before induction, the breast using bipolar cautery.
markings were done in standing position. The 6. Once the suprafascial tissue around the per-
breast footprint and breast meridian were marked forator was cleared, an opening was made in
bilaterally. If the patient has significantly ptotic the rectus fascia superolateral to the perfora-
breasts, a wise pattern skin resection is marked. If tor and extended inferolaterally.
contralateral breast symmetrization is to be done 7. The perforator was isolated with minimal har-
at the same time, the breast reduction markings are vest of the sheath and muscle splitting as
done in standing position. In supine position, the opposed to muscle-cutting approach.
planned abdominal pannus was marked, taking 8. A cranial extension of either of the pedicles is
care to include the chosen perforators. The pannus taken so that anastomosis in series can be
is marked from upper umbilicus as the upper limit considered.
and lower limit are kept approximately 12 cm 9. Once adequate pedicle length and caliber
below this, just above or below the lower abdom- were attained, the pedicle was divided.
inal crease. Perforator position may be confirmed 10. The flap can be divided in the midline early
by hand-held Doppler in case a preoperative CT on to enable encircling the perforator and to
angiogram is not available. start contouring and de-epithelization of the
first flap while the contralateral flap is being in series with the secondary pedicle being
harvested. anastomosed to the cranial continuation of
11. The second flap was raised in a similar man- the primary pedicle, or in parallel to different
ner. The total combined weight of both flaps sets of recipient vessels (Fig. 4). If the anas-
before contouring was 583 g. The abdominal tomosis is done in series, the first anastomo-
donor site was closed after insertion of a sis can be done on a separate bench while the
drain, with few sutures on the Scarpa’s recipient vessels are being prepared (Patel
fascia followed by barbed intradermal suture. et al. 2016; Murray et al. 2015).
Any excess flap is discarded after contouring. 15. The flaps were stacked side by side with both
12. After the mastectomy was done, vessel dis- the medial edges of the flap forming the bulk
section was carried out with the preference of of the lower pole. Other options for flap
vessels being intercostal perforators, if pre- stacking are as folded flaps, coned flaps, or
served during mastectomy, followed by the divided and folded flaps (Patel et al. 2016;
thoracodorsal and internal mammary vessels. Murray et al. 2015) (Fig. 5).
13. Once hemostasis of the mastectomy skin flaps 16. Before flap inset, both pedicles are examined
and pocket is ensured, a few sutures are taken to ensure there is no twist or kink on them.
to reposit the inframammary fold if breached It is also very imperative to ensure that
and the lateral breast fold is recreated. there is no tension on either of the pedicles
14. The anastomosis was done in series – the while positioning the flaps in the breast
medial flap was anastomosed to the lateral pocket.
row perforator artery and vein of the lateral 17. Final flap contouring and de-epithelization
flap in series, and the lateral flap was anas- were done, and flaps were inset.
tomosed to the thoracodorsal artery and vein. 18. The total surgical time from incision to
Other options for vessel anastomosis can be patient being taken off table was 5 h.
Fig. 4 Illustration of
various configurations of
anastomosis. (Permissions
from Journal of
Reconstructive
Microsurgery)
A C
Asymmetric Symmetric Asymmetric Symmetric
B D
Asymmetric Symmetric
Fig. 5 Illustration of various configurations of shaping and stacking abdominal flaps. (Permissions from Gland Surgery
Journal)
4. Proper visualization of the perforator is the

Technical Pearls key – length of fascial incision is not a priority
if it jeopardizes the visualization of the perfo-
1. Clinical examination of the patient is an rator during dissection.
important indicator for the need for 5. Encircle the perforator early on during the dis-
bipedicled/stacked flap reconstruction. Once section taking a small cuff of fascia if necessary
decided, appropriate planning is essential. to avoid tethering or shear during dissection.
Preoperative imaging with CT angiogram of 6. If the perforator is paramuscular, ensure that
the abdomen has a significant impact on adequate fascia has been left medially for
decrease in surgical time as it can be decided closure of the sheath.
which are the best perforators on either side to 7. Muscle splitting, rather than cutting the mus-
be used (Smit et al. 2009). cle, in the plane of the perforator ensures
2. A two-team approach plays a crucial role reduced complication of abdominal bulging
where each team is working on a different postoperatively. It helps reduce postoperative
area simultaneously, with each member of pain as well.
the team having a designated role, rather 8. In case of a paramuscular perforator, ensure
than a single surgeon doing the entire surgery. adequate rectus sheath is left medially to
Process mapping (breaking the surgery into enable closure of the sheath over the mesh.
multiple steps) also makes it simpler to allo- 9. Dissecting superficial veins on both sides
cate tasks to each team member (Sharma et al. ensures additional venous drainage options
2019). if the flap is superficial venous dominant.
3. Meticulous hemostasis at each stage is essen- These also provide a source of vein grafts if
tial to avoid postoperative complications. pedicle lengthening is required.
10. Use of venous couplers decreases anasto-

motic time and the apprehension of use of
vein grafts.
11. When anastomosis is done in series, it is
essential to ensure that after the final anasto-
mosis is done, and before placing the flap into
the mastectomy pocket, there is no flip or
twist in the intraflap anastomosis.
12. Use of internal mammary perforator vessels
decreases the need for vein grafts as shorter
pedicle length is required. They may be dis-
sected down to the intercostal membrane for
better caliber of vessels. The perforator vein
may be used for anastomosis of the superficial Fig. 7 Flaps after division, stacking, and bench
vein if alternative vessels are being used for anastomosis
anastomosis.
13. Anchoring sutures may be taken between the
flap, and the pectoral is epimysium to keep
the flap in place and avoid traction on the
pedicle.
14. Dermal release at the edge of the skin paddle
aids in suturing of the skin adages and avoids
the step off from mastectomy to flap skin.
Intraoperative Photos
See Figs. 6, 7, and 8. Fig. 8 To show projection of flaps after coning sutures

tively by physical examination and Doppler mon-
itoring of both skin islands. Temperature, color,
turgor, and capillary refill were monitored hourly
for the first 24 h, followed by 2 and 4 h for the next
24 and 48 h, respectively. The blood pressure and
urine output were similarly observed. A Bair hug-
ger was used for the first 24 h to avoid hypother-
mia. Clear fluids were started orally once the
patient was fully awake along with supplementary
intravenous fluids to ensure adequate hydration.
Use of compression devices and standard mea-
sures to avoid venous thromboembolism were
Fig. 6 Postmastectomy defect with planning of placement continued during the hospital stay. The patient
of stacked flaps gradually began mobilizing the next day after a
supportive bra had been put on. Drains were kept

in place for the first 48 h, and removed once the
patient had been mobilized, and drain output was
low. The patient was discharged on the fourth
postoperative day and was seen again 2 weeks
later.
The patient had an uneventful hospital stay with-

out experiencing any postoperative complica- Fig. 9 1-year postoperative outcome – breast
tions. At the reassessment a fortnight after the
surgery, all wounds had healed and she was able
to carry out most activities of daily living. Two
months postoperative, result was satisfactory with
a good symmetry to the contralateral breast and
pleasing abdominal scar.
There was no abdominal weakness or bulging.
She was then offered nipple reconstruction and
tattooing of the areola to restore as much similarity
to the contralateral breast as possible. The aim is to
restore the breast appearance in order to achieve a
symmetry in bra cleavage (Figs. 9 and 10). Fig. 10 1-year postoperative outcome – abdominal
donor area
Avoiding and Managing Problems scar is too low, the lower incision may not
coincide with it. This is done to reduce the
1. If there are no suitable perforators on the CT tension on the skin closure and avoid wound-
angiogram, it is easier and more time efficient healing problems.
to proceed with a planned Ms-TRAM on that 3. Coning sutures are taken under the flap to
side, rather than dissecting multiple small per- improve flap projection (Patel et al. 2016;
forators through the rectus muscle. In this case, Chae et al. 2017), else the flaps will sit flat in
try to limit the fascial harvest to minimum to the pocket or migrate laterally over time. The
decrease donor site morbidity. The additional use of pocket control sutures also minimizes
disadvantage of using Ms-TRAM as opposed lateral migration (Senchenkov and Lemaine
to DIEP flap is the decrease in pedicle length, 2015; Blondeel et al. 2009). Reconstitution of
which may necessitate the need for pedicle the inframammary fold helps prevent inferior
lengthening using vascular grafts. migration/ptosis of the flaps. It also prevents
2. If the abdomen has scars from previous surgery further downward pulling of the
(Parrett et al. 2008), the skin incisions need to inframammary fold during abdominal closure
be planned accordingly. The paddle may have (Senchenkov and Lemaine 2015).
to be skewed or the division of the flap may not 4. It is important to incorporate only subscarpal
be in the midline in such cases. This is usually fat in the superior flap as the Scarpa’s layer
needed in case of a high appendicectomy or a contributes to strength of abdominal closure
lower paramedian incision. Sometimes, a and if not approximated can lead to wound-
higher Cesarean section scar may necessitate healing complications. A slight down curve
shifting the skin paddle more cranially. If the toward the umbilicus at the upper incision
and an upward crescent at the lower midline References

incision decrease tension at the site most liable
to breakdown. Blondeel PN, Hijjawi J, Depypere H, Roche N, Van
Landuyt K. Shaping the breast in aesthetic and
5. Shaping the flap before the anastomosis helps
reconstructive breast surgery: an easy three-step
determine the pedicle lie and keeps the entire principle. Part II – breast reconstruction after total
construct more stable during the anastomosis. mastectomy. Plast Reconstr Surg. 2009;123(3):
This is more applicable if anastomosis is being 794–805.
Chae MP, Rozen WM, Patel NG, Hunter-Smith DJ,
done in series as the bench anastomosis is done
Ramakrishnan V. Enhancing breast projection in autol-
with a stable construct and the chance of the ogous reconstruction using the St Andrew’s coning
pedicle flipping over itself and introducing a technique and 3D volumetric analysis. Gland Surg.
twist is decreased. 2017;6(6):706–14.
Mohan AT, Zhu L, Vijayasekaran A, Saint-Cyr
6. The advantage of a stacked flap over a
M. Autologous breast reconstruction in low body
bipedicled flap is the increase in projection mass index patients: strategies for maximizing skin
and the liberty of contouring. The quantity envelope and breast volume. Clin Plast Surg.
and distribution of fat in the abdominal pannus 2020;47:611–9.
Murray A, Wasiak J, Rozen WM, Ferris S, Grinsell
dictate what configuration is most appropriate
D. Stacked abdominal flap for unilateral breast
while planning the stacking of the flaps. reconstruction. J Reconstr Microsurg. 2015;31(3):
7. Hematoma and seroma rates in the abdomen 179–86.
can be reduced by meticulous hemostasis and Parrett BM, Caterson SA, Tobias AM, Lee BT. DIEP
flaps in women with abdominal scars: are complica-
limited raising of the upper abdominal flap,
tion rates affected? Plast Reconstr Surg. 2008;121(5):
restricted only to the midline, just enough to 1527–31.
allow abdominal closure without tension. The Patel NG, Rozen WM, Chow WT, Chowdhry M, Fitzger-
use of incisional vacuum-assisted closure ald O’Connor E, Sharma H, Griffiths M, Ramakrishnan
VV. Stacked and bipedicled abdominal free flaps for
(VAC) devices after layered closure of the
breast reconstruction: considerations for shaping.
abdominal incision may help prevent wound- Gland Surg. 2016;5(2):115–21.
healing problems (Siegwart et al. 2020). Pollhammer MS, Duscher D, Schmidt M, Huemer
GM. Recent advances in microvascular autologous
breast reconstruction after ablative tumor surgery.
World J Clin Oncol. 2016;7(1):114–21.
Learning Points Pu Y, Mao TC, Zhang YM, Wang SL, Fan DL. The role of
postmastectomy radiation therapy in patients with
1. A premeditated decision for using a stacked immediate prosthetic breast reconstruction: a meta-
flap can lead to a more esthetic result with analysis. Medicine. 2018;97(6):e9548.
Senchenkov A, Lemaine V. Optimizing shape and projec-
fewer donor site complications.
tion in low-volume bilateral microvascular breast
2. Stacked flaps are technically challenging but can reconstruction: technical tips. J Plast Reconstr Aesthet
be made easier with teamwork and process map- Surg. 2015;68(9):1313–4.
ping. The use of preoperative CT angiograms Sharma HR, Rozen WM, Mathur B, Ramakrishnan V. 100
steps of a DIEP flap-a prospective comparative cohort
cannot be undermined in such circumstances.
series demonstrating the successful implementation of
3. Stacked flaps are more reliable in vascularity process mapping in microsurgery. Plast Reconstr Surg
and lead to fewer complications of fat necrosis. Glob Open. 2019;7(1):e2016.
They also need fewer secondary revision sur- Siegwart LC, Sieber L, Fischer S, Maraka S, Kneser U,
Kotsougiani-Fischer D. Influence of closed incision
geries and symmetrizing procedures.
negative-pressure therapy on abdominal donor-site
4. Stacked DIEP flaps offer the advantage of two morbidity in microsurgical breast reconstruction.
flaps from the same donor site, thus restricting Microsurgery. 2020. https://doi.org/10.1002/micr.
the donor area morbidity and surgical time, as 30683
Smit JM, Dimopoulou A, Liss AG, Zeebregts CJ,
opposed to stacked TUG or SGAP/LAP flaps.
Kildal M, Whitaker IS, et al. Preoperative CT angiog-
5. The knowledge of various orientations of flap raphy reduces surgery time in perforator flap recon-
stacking and options for pedicle anastomosis struction. J Plast Reconstr Aesthet Surg. 2009;62(9):
helps obtain a more esthetic result. 1112–7.
Partial Mastectomy Reconstruction
with Pedicled Thoracodorsal Artery 94
Perforator Flap
Gabriele Giunta and Moustapha Hamdi
Contents
The Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 996
Preoperative Problem List: Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . 996
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 996
Alternative Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 998
Preoperative Evaluation and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 998
Preoperative Care and Patient Drawing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999
Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1000
First Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1000
Second Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
Technical Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002
Intraoperative Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002
Postoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002
Outcome-Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002
Avoiding and Managing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1004
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1004
Abstract
Partial breast reconstruction is required in most

of the cases of partial mastectomies to avoid
G. Giunta post Breast Conserving Therapy (BCT) breast
Department of Plastic, Reconstructive & Aesthetic deformity or in those cases of partial or total
Surgery, University Hospital Brussels, Vrije Universiteit
Brussel (VUB), Brussels, Belgium
free flap failure for breast reconstruction, as a
salvage procedure.
M. Hamdi (*)
Department of Plastic and Reconstructive Surgery,
There are two main categories of surgical
Brussels University Hospital, Brussels, Belgium techniques in partial breast reconstruction:
e-mail: moustapha.hamdi@uzbrussel.be

https://doi.org/10.1007/978-3-030-23706-6_83
996 G. Giunta and M. Hamdi
volume displacement and volume replace- deep inferior epigastric veins (DIEv). However,
ment. Among the volume replacement tech- after 48 h, the flap presented venous congestion
niques, pedicled perforator flaps are the first and a revision was required (Fig. 2). During the
choice. exploration, the ipsilateral superficial inferior epi-
This case illustrates a salvage partial breast gastric vein (SIEV) of the flap was found
reconstruction in a woman who underwent congested, due to superficial venous system dom-
previous left mastectomy and immediate inance. So the SIEV was anastomosed to the sec-
DIEP flap breast reconstruction. Due to mas- ond deep inferior epigastric vein comitans
sive liponecrosis of the flap, the patient devel- (DIEVc) of the flap by an interpositional vein
oped a soft-tissue deficiency in the lower pole. graft (Bartlett et al. 2018) (Fig. 3). The flap par-
The patient underwent a two-stage proce- tially recovered; however, a deformity in the
dure. The first stage involved the restoration of breast contouring was noticed during the 6 months
the missing tissues with a thoracodorsal artery postoperatively control (Fig. 4). Due to a partial
perforator (TDAP) flap. The TDAP flap pro- fat necrosis of the flap, there was a parenchyma
vides good number of soft tissues, sparing the deficiency in the lower poles of the breast with
latissimus dorsi muscle and minimizing the scars contraction. A volume replacement tech-
seroma formation rate. A contralateral breast nique was required to correct this partial breast
symmetrization was also performed. defect. So the patient was planned for a local
After 3 months, the patient received second- pedicled perforator to improve the result of the
ary procedures to refine the breast reconstruc- reconstruction of the left breast.
tion. Lipofilling of the medial poles, revision of
the horizontal scar and the nipple areola com-
plex reconstruction were performed. The Preoperative Problem List:
recovery was uneventful. At 1 year follow-up Reconstructive Requirements
the patient showed a satisfactory aesthetic
result and no impairment at the donor site. 1. Partial failure of a previous Diep flap (Lie et al.
2013).
2. Lack of tissues in the lower quadrants of the
Keywords
breast (Karanas et al. 2002; de Weerd et al.
Oncoplastic Surgery · Partial Breast 2005).
Reconstruction · Partial Mastectomy · Volume 3. Requirement of a volume replacement tech-
Replacement Techniques, TDAP flap nique to provide loco-regional tissues in the
left breast (Hamdi et al. 2007b; Hamdi and
Van Landuyt 2006).
A 56-year-old patient presented with a breast can- Treatment Plan

cer in the left breast in 2005. She underwent a
tumorectomy and a sentinel lymph node biopsy Lack of breast tissues up to 30% in large breast
(SLNB). Unfortunately pathological examination will determinate volumetric deformities and a
revealed that the surgical margins were positive. local pedicle flap is indicated in this situation
Taking into account the pathology and the previ- (Losken and Hamdi 2017).
ous surgery, a left skin sparing mastectomy and an Due to the massive liponecrosis, the flap has
immediate autologous breast reconstruction was shrunk and subsequent tissues deficiency in the
planned (Fig. 1). A contralateral deep inferior lower pole with heavily scarred skin was evident.
epigastric artery perforator (DIEP) flap was According to the classification by Lie, the
harvested and anastomosed to the left internal patient developed an IV grade DIEP flap fat
mammary artery (DIEa) and to one of the two necrosis that required a second local flap to
94 Partial Mastectomy Reconstruction with Pedicled Thoracodorsal Artery Perforator Flap 997
Fig. 1 Surgical marking of

the left skin sparing
mastectomy and of the right
DIEP flap
Fig. 2 DIEP flap venous congestion 48 H postoperatively Fig. 3 Interpositional vein graft between the SIEV and the
DIEVc
address the defects (Lie et al. 2013). Pedicled procedure in patients with unsatisfactory out-
non–breast locoregional flaps are both used in comes, after full or partial failure of microsurgical
primary or secondary partial breast reconstruction autologous breast reconstruction or a total failure
or even in those cases of tertiary breast reconstruc- of prosthetic reconstruction (Hamdi et al. 2011).
tion. Tertiary breast reconstruction is a salvage In this patient in accordance to the grade of the
Fig. 4 Six months

postoperative result. The
patient developed
liponecrosis of the lower
part of the DIEP flap
liponecrosis and the localization of the defect, a are required. In this patient, the superior gluteal
2-stage procedure was planned. artery perforator (SGAP) flap or the transverse
The first surgical stage involved the release of musculocutaneous gracilis (TMG) flap could
the scar tissues and the replacement of the tissues have been proposed (Hamdi et al. 2010).
deficiency with a small left pedicled thoracodorsal 2. The latissimus Dorsi muscle (LD) flap with the
artery perforator (TDAP) flap and the breast sym- increased risk of donor site morbidity (Karanas
metrization (Hamdi et al. 2008a). et al. 2002).
In the second stage, performed after 3 months, 3. The lateral intercostal artery perforator
breast lipofilling and the Nipple Areola Complex (LICAP) flap: Another volume replacement
(NAC) reconstruction were planned to refine the technique that suits mainly the lateral breast
breast reconstruction. quadrants (Hamdi et al. 2006).
4. Advancement of abdominal skin flap and
definitive small implant (Georgeu et al. 2009).
1. Second free flap: a second free flap can be Preoperative Evaluation and Imaging
planned after a partial or total failure of previ-
ous free flap reconstruction. The patient should Any previous breast and axillary surgery should
be informed about potential complications; pri- be taken into account when planning a tertiary
mary and secondary antithrombotic blood tests partial breast reconstruction with local pedicled
flaps. Furthermore patient details such as the lax- cause false negative and false positive, during the
ity of the skin, the fat distribution, and of course preoperative mapping the patient is positioned in
the location of the defect to be reconstructed are the lateral surgical decubitus with 90o of shoulder
fundamental factors in the decision-making pro- abduction and 90o of elbow flexion. The lateral
cess of partial breast reconstruction with flaps. decubitus permits the skin stretching that allows
The thoracodorsal artery perforator (TDAP) the perforators to enter the skin with a more per-
flap is based on the perforators arising from the pendicular route (Hamdi et al. 2007a). Angio-CT
vertical or horizontal branches of the scan can be also employed to identify the
thoracodorsal vessels, up to 2–3 musculo- TD perforator. Two perforators from the
cutaneous perforators from the vertical branch thoracodorsal artery were found and considered
are present. The proximal perforator can be reliable to harvest the TDAP flap (Fig. 5).
found in the subcutaneous plane obliquely
8–10 cm distal to the posterior axillary fold and
2–3 cm posterior to the anterior border of the Preoperative Care and Patient
muscle, while the second perforator usually lies Drawing
2–4 cm distally to the first one. Perforators preop-
erative mapping was performed with a unidirec- The surgical marking was performed the day
tional hand-held Doppler (8 Hz) ultrasonography before surgery. The anterior border of the
in the planned flap area. To avoid the background latissimus dorsi muscle is identified and marked
signal from the thoracodorsal vessels, that could in standing position. Then, as previously reported,
Fig. 5 A skin paddle

measured 21 10 cm was
outlined at the lateral
thoracic area centered on
the identified perforators
the patient was positioned in the lateral decubitus 2. Then the patient was positioned and prepped
for the perforator detection and the flap marking. again in lateral position for the TDAP flap
The TDAP flap was designed horizontally ori- harvesting. The flap dissection was
ented, under the bra line, to include the identified performed under loupe magnification.
perforators. The pinch test is used to verify the 3. The flap harvesting began with skin incision
skin laxity and excess of subcutaneous tissues in in the antero-inferior border of the flap to
the lateral thorax and back in order to estimate the identify the anterior border of the latissimus
flap width. The size of the flap was of 21 10 cm dorsi muscle.
(Fig. 5). The anterior border of the flap was 4. Then the distal border of the flap was incised
marked to reach the lateral border of the up to the deep fascia and the dissection was
inframammary fold, over the anterior border of performed with a postero-anterior approach
the latissimus dorsi muscle, also in way to include along the LD in a suprafascial plane. The
possible septocutaneous branches arising from the dissection continued accurately until the
thoracodorsal artery. All the previous scars in the marked perforator vessels were identified.
breast were marked. The main perforator was chosen: it had a
visible pulsation and was adequate in caliber
(>0.5 mm), so the dissection continued along
Surgical Techniques the perforator course up to the main pedicle.
The perforator originated from the
First Stage descending branch of the TD vessels and
usually is preferred over the ones from the
1. The patient was positioned and draped in transverse branch. The cleavage plane on the
supine position. The breast skin was incised latissimus dorsi, in which the perforator lies,
along the previous scars. The mastectomy was developed.
flaps were raised, the scars released, and the 5. The perforator had an intramuscular course,
DIEP flap was detached. The flap had shrunk so the dissection was performed within the
because of the massive liponecrosis. (Fig. 6). muscle. Wide exposure is crucial in perforator
Fig. 6 Intraoperative view. The DIEP flap has undergone massive fat necrosis
dissection within the LD. Muscle fibers were way that the anterior border of the flap filled
spread, maintaining their longitudinal integ- the medial part of the defect.
rity and any nerve to the muscle was carefully 8. The donor site was closed primarily in three
preserved. The dissection should be layers and a drain was placed and the patient
performed close to the vessels, all the muscu- was returned again to the supine position.
lar branches identified were ligated with sur- 9. The skin island of the DIEP flap was
gical clips or coagulated with bipolar cautery. de-epithelialized and the flap was buried.
6. The dissection of the main pedicle was 10. The TDAP flap was partially de-epithelialized
performed until the required pedicle length and buried, except for a small skin paddle used
was achieved. When the pedicle dissection to recreate the areola and provide soft tissue
was completed, the flap was dissected anteri- along the previous vertical scar.
orly from the serratus and the latissimus dorsi 11. A contralateral breast reduction was also
fascia. Intercostal perforators, found anteri- performed to achieve breast symmetry.
orly on the anterior border of the LD, were
ligated.
7. Then, the TDAP flap was completed dis- Second Stage
sected from the donor site and connected
only to the vascular pedicle. The flap was The second surgical stage was performed
advanced and transposed into the defect in 3 months later (Fig. 7).
Fig. 7 3 months
postoperative result after
the first stage
Fig. 8 Second stage:

Lipofilling of the upper and
lower medial quadrants
1. Lipofilling of the upper and lower medial their dissection will take more time because
quadrants was performed to improve the breast of their longer intramuscular course.
contouring (Fig. 8).
2. Scar revision of the medial horizontal scar and
the excision of the vertical skin paddle of the Intraoperative Images
TDAP flap were performed.
3. Furthermore the nipple areola complex was
reconstructed.
Technical Pearls
Standard perforator flap monitoring is performed
1. The initial identification of the anterior border during the first 5 days. Clinical monitoring
of the LD muscle allows repositioning the included checking color, temperature, capillary
anterior border of the flap intraoperatively. refilling, and perforator Doppler monitoring. The
2. A posterior approach is chosen in harvesting a patient received Low-molecular-weight heparin
pedicled TDAP flap. (LMWH) during the relative immobilization
3. A perforator is considered suitable to raise the time. The arm is held in 45° abduction and arm
flap when it is visibly pulsatile and it has a stretching is limited for a week. Physiotherapy can
diameter greater than 0.5 mm. be started afterwards and the majority of the
4. The largest perforator is most commonly found patients require between 9–14 sessions of shoul-
in the sixth intercostal space, from 0.8 to der physiotherapy (Hamdi et al. 2008b).
3.5 cm from the anterior border of the LD
muscle.
5. Perforators along the same row can both be Outcome-Clinical Photos and Imaging
included in the flap, without sacrificing any
muscle fibers. The patient was discharged home in stable condi-
6. Distal perforators will provide longer flap ped- tion, after the removal of the drains, in average
icle than the proximal perforators; however, 3–5 days post-op after the first stage, while the day
after surgery of the second stage. The patient Avoiding and Managing Problems
presented with a satisfactory aesthetic and stable
result at 12 months follow-up. The fat grafting 1. Previous axillary or thoracic surgery with dam-
performed in the second stage allowed obtaining age to the thoracodorsal vessels is an absolute
volume adjustments and improving the projection contraindication for a latissimus dorsi muscle
or contour irregularities due to partial fat necrosis flap or thoracodorsal artery perforator
or flap contractures (Delay et al. 2018) (Fig. 9). (TDAP flap).
No wound healing complications were detected at 2. When the perforators are not considered suit-
the donor site (Fig. 10). able in caliber, the TDAP flap can be converted
Fig. 9 The result of the partial breast reconstruction with the TDAP flap after 12 months
Fig. 10 1 year follow up. The donor site with the resulted scar. The LD muscle contouring was preserved
as a muscle sparing LD, preserving a small cuff inferior epigastricperforator flap loss in breast recon-
of muscle attached to the perforators, preserv- struction. Ann Plast Surg. 2005;54:590–4.
Delay E, Guerid S, Meruta AC. Indications and controver-
ing the muscle innervation. sies in lipofilling for partial breast reconstruction. Clin
3. Flap contractures, pathologic scarring and vol- Plast Surg. 2018;45(1):101–10. Epub 2017 Sep 18.
ume loss are common sequelae and may need Georgeu GA, Caulfield R, Niranjan N. Salvage of total loss
secondary procedures, such as lipofilling or of DIEP and skin envelope in breast reconstruction with
tissue expansion. J Plast Reconstr Aesthet Surg.
scar revision. 2009;62(10):1299–302. https://doi.org/10.1016/j.bjps.
4. Seroma is the most common donor site com- 2007.12.066. Epub 2008 Jun 16.
plication, however it can be treated mainly Hamdi M, Van Landuyt K. Pedicled perforator flaps in
conservatively. Seroma may occur when the breast reconstruction. In: Spear SI, Willey SC, Robb
GL, et al., editors. Surgery of the breast: principles and
donor site is closed under tension. Three lay- art. Philadelphia: Lippincott-Raven; 2006. p. 833–44.
ered donor site closure prevents the seroma. Hamdi M, Van Landuyt K, de Frene B, Roche N,
Blondeel P, Monstrey S. The versatility of the inter-
costal artery perforator (ICAP) flaps. J Plast Reconstr
Learning Points Aesthet Surg. 2006;59(6):644–52.
Hamdi M, Van Landuyt K, Van Hedent E, Duyck
P. Advances in autogenous breast reconstruction: the
1. Accurate patient selection is mandatory in par- role of preoperative perforator mapping. Ann Plast
tial breast reconstruction with pedicled flaps. Surg. 2007a;58(1):18–26.
2. Non-breast locoregional flaps such as the Hamdi M, Wolfli J, Van Landuyt K. Partial mastectomy
reconstruction. Clin Plast Surg. 2007b;34(1):51–62.
Latissimus dorsi (LD) flap or perforator flaps Hamdi M, Van Landuyt K, Hijjawi JB, Roche N, Blondeel P,
are the first choice in partial breast Monstrey S. Surgical technique in pedicled thoracodorsal
reconstruction. artery perforator flaps: a clinical experience with
3. Perforator mapping and a correct flap drawing 99 patients. Plast Reconstr Surg. 2008a;121(5):1632–41.
Hamdi M, Decorte T, Demuynck M, Defrene B,
are the keystone in volume replacement Fredrickx A, Van Maele G, De Pypere H, Van
techniques. Landuyt K, Blondeel P, Vanderstraeten G, Monstrey
4. The use of local pedicled perforator flaps has S. Shoulder function after harvesting a thoracodorsal
allowed surgeons to replace large breast artery perforator flap. Plast Reconstr Surg.
2008b;122(4):1111–7; discussion 1118–9.
defects reducing the donor site morbidity, spar- Hamdi M, Andrades P, Thiessen F, et al. Is a second free
ing the underlying muscle and the motor inner- flap still an option in a failed free flap breast reconstruc-
vations and minimize seroma formation rate. tion? Plast Reconstr Surg. 2010;126:375–84.
5. Secondary procedures may be often required to Hamdi M, Casaer B, Andrades P, Thiessen F, Dancey A,
D’Arpa S, Van Landuyt K. Salvage (tertiary) breast
improve the final result and achieve breast reconstruction after implant failure. J Plast Reconstr
symmetry at long-term follow-up. Aesthet Surg. 2011;64(3):353–9.
Karanas YL, Santoro TD, Shaw WW, Da Lio AL. Use of
the Latissimus Dorsi Flap for recontouring and aug-
mentation after TRAM flap breast reconstruction. Ann
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approach for intraoperative salvage of venous conges- review of 17,096 DIEP flaps in 693 articles including
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de Weerd L, Woerdeman LA, Hage JJ. The lateral Losken A, Hamdi M. Partial breast reconstruction – tech-
thoracodorsal flap as a salvage procedure for partial niques in oncoplastic surgery. Thieme Medical Pub-
transverse rectus abdominis myocutaneous or deep lishers; 2017.
Bilateral Breast Reconstruction
with the Free Fasciocutaneous 95
Infragluteal Flap (FCI)
Contents
Clinical Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1006
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
Alternative Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
Preoperative Care and Flap Marking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1008
Intraoperative Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1009
Outcome: Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1011
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1011
Abstract
Breast cancer is still one of the leading causes

of deaths among women in the Western civili-
zation. With an increasing efficiency of breast
Z. Jandali · B. Merwart (*) · L. P. Jiga cancer therapy and hence steadily increasing
Department of Plastic, Aesthetic, Reconstructive and Hand survival rates, the number of patients who need
Surgery, Evangelisches Krankenhaus, Medical Campus, postmastectomy breast reconstruction is on
e-mail: zaher.jandali@evangelischeskrankenhaus.de;
the rise.
dr@jandali.de; Worldwide, most breast reconstructions are
benedikt.merwart@evangelischeskrankenhaus.de; still implant based. But recent studies on
dr.lucian.jiga@evangelischeskrankenhaus.de; BIA-ALCL have caused a major concern
lucian.jiga@evangelischeskrankenhaus.de

https://doi.org/10.1007/978-3-030-23706-6_84
regarding the future use of silicone prosthesis

for postmastectomy reconstruction. Not least
because of this matter, autologous breast
reconstruction is becoming more and more
popular.
Free perforator flaps are nowadays the gold
standard for autologous breast reconstruction,
the abdominal wall being mainly considered as
primary donor site (e.g., DIEP, SIEA) in
patients with adequate tissue volume (Yu
et al. 2013).
However, in athletic patients lacking
abdominal fat pads, either the gluteal or the
thigh regions can be considered as donor
areas using several well-described flaps (e.g.,
SGAP, IGAP, FCI, PAP, and TUG).
Among the multiple different options the
free facsciocutaneous infragluteal flap
(FCI-flap) is an excellent choice for patients
who cannot get breast reconstruction with a
DIEP-flap. Compared to other gluteal-based
flaps, like the SGP/IGAP, for example, the
consistent septocutaneous perforators make Fig. 1 Implant-based postmastectomy reconstruction in
the dissection relatively easy. Additionally, combination with pedicled myocutaneous LD flaps, of
both breasts 6 years prior to presentation
the scar is well hidden in the gluteal crease.
Here an otherwise healthy female is pre-
sented, in whom the fasciocutaneous infragluteal mastectomy, with no further need of adjuvant
flap (FCI-flap) was opted to simultaneously radio- or chemotherapy. Immunohistochemistry
reconstruct both breasts. The healing of the for the estrogen receptor was positive, hence she
patient was uneventful. The aesthetic result was was on oral antihormone therapy with a selective
very pleasing. estrogen receptor modulator (Tamoxifen). Due to
a BRCA1/2 gene mutation the patient additionally
had a prophylactic mastectomy on the right side.
Keywords
The implant-based postoncology reconstruction
Breast cancer · Autologous breast left her with an unsightly result with a clear breast
reconstruction · Gluteal flaps · Infragluteal asymmetry, no NAC reconstruction and different
flap · Microsurgery patterns of the cutaneous part of the LD muscle. In
addition, the patient suffered from chronic pain
due a capsular contracture (Baker Type III).
Clinical Scenario The patient was proposed for prosthesis
explantation and resection of the capsular fibrosis
A 52-year-old patient was presented to the clinic with simultaneous bilateral autologous breast vol-
with a capsular contracture after an implant-based ume reconstruction followed by separate nipple
postmastectomy reconstruction in combination areola reconstruction. Because the patient was
with pedicled myocutaneous latissimus dorsi very thin, with a BMI of 20 kg/m2, the lower
(LD) flaps of both breasts, 6 years prior (see abdomen was not available as a donor site.
Fig. 1). She initially suffered from invasive breast Another reconstruction with foreign body mate-
cancer on the left side, which was treated with a rial was not an option for the patient.
95 Bilateral Breast Reconstruction with the Free Fasciocutaneous Infragluteal Flap (FCI) 1007
Preoperative Problem List: disadvantage of a relatively short perforator

Reconstructive Requirements compared to the FCI-flap and the need of
back-table surgery with perforator pedicle
1. Type III capsular contracture on both breasts lengthening using vascular grafts, which
(Lardi et al. 2017) makes the surgery very challenging.
2. Wish for autologous reconstruction of both 2. Breast reconstruction through fat grafting, with
breasts the disadvantage of the need for multiple pro-
3. Not a suitable candidate for a reconstruction cedures. Furthermore, many patients will have
using a DIEP flap a problem with the “breast free” interval until
4. The LD muscle has already been used and can the final volume is reached (Mestak et al.
therefore not serve as a backup 2013).
Treatment Plan Preoperative Evaluation and Imaging
The treatment plan was a two-stage reconstruc- CT angiography is routinely performed prior to
tion. The first stage involved removing the surgery in all patients undergoing autologous
implants and simultaneously reconstructing both breast reconstruction with free perforator flaps to
breasts with autologous tissue. Because the DIEP show the exact anatomy of the perforators. For a
flap, which is regularly the first choice for autolo- better visualization of the perforators, the CT
gous breast reconstruction, was not an option, the should be done in a prone instead of a supine
second-best choice was the fasciocutaneous position. Immediately before the operation the
infragluteal flap (FCI), due to its several advan- presence and location of the perforators is always
tages as compared with other flap options from the verified with an acoustic ultrasound Doppler. In
thigh and buttock. Studies show that even thin cases where the patient had adjuvant radiation
patients offer enough tissue to perform a breast therapy, an additional CT angiography of the
reconstruction with an adequate volume (Papp recipient area can be helpful to confirm the suit-
et al. 2011). The second stage involved the recon- ability of the recipient vessels.
struction of the nipple areola complex with a
SKATE-flap for the nipple and full thickness
skin grafts for both areolas. The skin grafts were Preoperative Care and Flap Marking
harvested from both upper eyelids, respectively,
the left groin area (Henderson et al. 2018). To mark the outlines of the flap, the patient is
placed in a prone position, with a pillow put
underneath the pelvis so it is slightly flexed,
Alternative Treatment Plan similar to the position of a buttocks lift. The
first line is drawn in the gluteal crease. The skin
1. Autologous breast reconstruction with a differ- island of the flap should be placed over this initial
ent type of free flap: Other gluteal-based flaps line with its surface 50% above and 50% below
like the superior gluteal artery perforator flap the crease. A hand-held acoustic 8Mhz ultra-
(SGAP) (Hunter et al. 2016) or the inferior sound Doppler is then used to mark the perfora-
gluteal artery perforator flap (IGAP) tors, which usually lie in the middle third of the
(Pollhammer et al. 2016), which, compared to gluteal crease. A pinch test can be used to deter-
the FCI flap, involve dissecting the gluteus mine the maximum width of the flap and to
muscle, thigh-based flaps like the transverse confirm primary closure of the donor site.
musculocutaneous gracilis flap (TMG), and When the flap does not exceed the size of
the profunda artery perforator flap (PAP) or 20 cm width and 10 cm in height, a tension-free
the lumbar artery perforator flap that has the primary closure is usually possible (Fig. 2).
9. The first incisions were made along the lateral

borders of the flap. Then the tensor fasciae
latae (TFL) muscle and the fascia lata were
approached.
10. Once these structures were identified they
were spared and used to guide the dissection
towards the gluteus muscle fascia which was
opened at the dorsal margin of the distal por-
tion of the TFL muscle. Through beveled
incision of the gluteal fat pad cranially, cau-
dally, medially, and laterally one can obtain
Fig. 2 Patient in a standing position. The outlines around more flap volume. Nevertheless, over-
the infragluteal crease show the incision, the vertical mark-
ings show the perforator. The small circles show the thinning of the wound edges should be
beveled area avoided. The fat and the bursa above the
ischium should always be preserved (Papp
et al. 2011).
Surgical Technique 11. The dissection then proceeded from lateral to
medial over the fibers of the gluteus muscle
1. In more time-consuming cases like this one a until its medial border was reached. At this
two-team approach is preferred since it sig- point careful dissection using bipolar cautery
nificantly reduces operative time. must be employed to find the most distal
2. At the beginning of the operation the patient segment of the perforators entering the fat
was placed in a supine position. pad of the flap at this level. Usually two to
3. After excising both of the skin islands of three good caliber perforators are present.
the previous myocutaneous LD flaps, Once the perforator entry points were identi-
the implants were removed and a total fied the dissection proceeded cranially under-
capsulectomy was performed. neath the gluteus maximus muscle which can
4. The width of the second and third and fourth be carefully lifted to facilitate vessel expo-
intercostal space on both sides was then sure. The vessels are accompanied by the
checked. Since it was less than a finger’s posterior femoral cutaneous nerve and usu-
width it was decided to not use a rib-sparing ally curl around the lower border of the
approach (Darcy et al. 2011). gluteus muscle. The nerve can be micro-
5. The pectoralis major muscle was divided in surgically dissected and taken with the flap
the line of its fibers from the lateral margin of when a sensate reconstruction is planned. The
the sternum about 4–5 cm laterally above the nerve can then be coapted to the sensate nerve
third rib on both sides. branch of an intercostal perforator.
6. After removing the periosteum with a 12. Then the nerve and the vessels were sepa-
rasparatorium, a 4 cm wide piece of the rib rated. Medial and lateral branch of the nerve
was excised to expose internal mammary should always be preserved to avoid
arteries and veins. On both sides they were dysesthesia and sitting problems (Fansa and
suitable for microsurgical anastomosis. Heitmann 2019).
7. The wounds on the chest were temporarily 13. Once the flap supplying vessels were identi-
closed with staples and a sterile dressing fied, the gluteus maximus muscle was ele-
was put on. vated, the ischiocrural muscles were held
8. The patient was then changed to a prone laterally and medially, and the vessels were
position, with a pillow put underneath the further followed to the infrapiriform foramen.
pelvis so it was slightly flexed, similar to the Usually the perforators converge proximally
position of a buttock lift. into one or two major branches leading to the
inferior gluteal artery (Fansa and Heitmann dissection and should always be followed to
2019). identify the perforators which travel from
14. The supplying vessels were clamped. underneath the muscle turning superficially in
15. The donor sites were closed in a multilayer its proximity.
closure, starting with the superficial fascia 3. The use of a pillow facilitates adequate expo-
and ending with vertical and longitudinal sure for flap harvesting and is particularly use-
self-absorbing sutures at the dermal level. ful for an optimal approach to the most
Negative pressure drains were inserted on proximal deep part of the pedicle.
each side. 4. Do not forget to extract the pillow when the
16. The patient was again turned to supine posi- donor site must be closed, it facilitates a
tion and attention was focused on the tension-free wound approximation.
recipient site. 5. When approaching the proximal part of the
17. The flaps were then anastomosed end to end pedicle, detailed exposure of the surrounding
to the internal mammary artery using nerve anatomy is mandatory to avoid possible
8–0 S&T suture material. For the venous lesions of the important sensory branches lead-
anastomoses to the internal mammary vein, ing to the ischial fat pad.
2.5 mm couplers were used on both sides.
18. Both flaps showed good perfusion right away.
19. After a waiting time of about 15 min both Intraoperative Imaging
flaps were partially de-epithelialized. The
de-epithelialized parts were sutured to the See Figs. 3, 4, and 5.
pectoralis major muscle using 2–0 Vicryl
sutures. Once the flaps were in place, wounds
were closed with intracutaneous running Postoperative Management
sutures with Monocryl 3–0.
20. Immediately following surgery, compression Postoperatively the patient was closely moni-
garment was put on that the patient should tored. In the first three days the flaps were evalu-
wear 8 weeks postoperatively. ated hourly in respect of their color, turgor, and
21. Six months later the nipple areola complex temperature. The examination was completed by
was reconstructed. acoustic Doppler ultrasound. The intervals were
22. To reconstruct the nipple SKATE-flaps were then raised to 2 and 3 h after 3 and 5 days,
utilized on both sides. respectively.
23. The areola on the right side was reconstructed
with full thickness skin grafts from both
upper eyelids, with an advantage of an addi-
tional blepharoplasty for the patient. The skin
graft for the left areola was harvested from the
left groin region.
Technical Pearls
1. Always dissect from lateral to medial above the

gluteus maximus muscle and underneath its
fascia as for the S-GAP, otherwise you risk
Fig. 3 Outlines of the flap. The transverse marking shows
injuring the perforators. the infragluteal crease, the vertical marking shows the
2. The medial margin of the gluteus maximus localization of the perforator. First incisions are made
muscle is a trustful path indicator for the along the lateral borders of the flap
Fig. 4 Flap partially elevated. The gluteus maximus mus-

cle is held cranially. The flap is held medially to expose the
supplying vessels
Fig. 5 The flap raised and only attached to the supplying

vessels. Pedicle length ranges from 5–15 cm
Fig. 6 Three months postoperative bilateral breast recon-
struction with FCI flaps
The patients are mobile as soon as they can stand

up. Since it is important to get up, not sitting on the
operated side, physical therapists usually assist the Twelve months postoperatively the patient pre-
patients when they get up for the first time. sented with annoying “dog ears” in both lateral
Drains are removed with regards to the amount parts of the donor area. These were corrected by
of fluid, usually when they reach a volume of less simple excision.
than 20 ml within 24 h. Usually compression of
the flap is not started before the third week
postoperatively. Avoiding and Managing Problems
1. In most cases there is a caliber mismatch

Outcome: Clinical Photos and Imaging between the FCI perforator and the IMA. This
makes the arterial anastomosis challenging and
See Figs. 6, 7, and 8. is one of the main disadvantages of the FCI
After all reconstructive stages, the patient flap. This can sometimes require vein grafts to
experienced uneventful and fast recovery. The successfully revascularize the flap.
flap showed good perfusion at all times. Both 2. Even though the surgery can also be performed
posterior thighs showed initial dysesthesia that in lateral position, prone/supine position is a lot
receded within 6 months postoperatively. easier.
Fig. 7 Three months after reconstruction of the NAC,

9 months after breast reconstruction with double FCI flap
Learning Points
1. The fasciocutaneous infragluteal flap (FCI) is a

suitable flap for breast reconstruction of small- to
medium-sized breast. When used for bilateral Fig. 8 View of the donor area from posterior, 3 months
reconstruction this is not an issue since the sym- after harvesting FCI flaps from both infragluteal folds
metry can be achieved by the surgical procedure.
2. By subcutaneous beveling cranial, caudal, and especially be considered when doing a unilat-
lateral, the volume of the flap can be increased. eral reconstruction.
3. If possible, the medial and lateral part of the
posterior femoral cutaneous nerve should be
preserved. Hurting these branches can lead to References
dysesthesia and sitting problems (Windhofer
et al. 2002; Papp et al. 2011). Darcy CM, Smit JM, Audolfsson T, et al. Surgical tech-
nique: the intercostal space approach to the internal
4. Due to more septa running through the adipose mammary vessels in 463 microvascular breast recon-
tissue the FCI flap is a lot firmer, compared to structions. J Plast Reconstr Aesthet Surg. 2011;64:
tissue from the lower abdomen. Therefore, 58–62.
shaping of the flap is not as easy as compared Fansa H, Heitmann C. Breast reconstruction with autolo-
gous tissue. 2019. https://doi.org/10.1007/978-3-319-
to a DIEP flap. 95468-4.
5. Due to the fibrous septa within the flap tissue, Henderson JT, Lee TJ, Swiergosz AM, et al. Nipple-areolar
descent is not as prominent over time, this must complex reconstruction: a review of the literature and
introduction of the rectangle-to-cube nipple flap. infragluteal free flap: a ten year experience. Ann Past
Eplasty. 2018;18:e15. Surg. 2011;66(6):587–92.
Hunter C, Moody L, Luan A, et al. Superior gluteal artery Pollhammer M, Duscher D, Schmidt M, et al. Recent
perforator flap: the beauty of the buttock. Ann Plast advances in microvascular autologous breast recon-
Surg. 2016;3:191–5. struction after ablative tumor surgery. World J Clin
Lardi AM, Ho-Asjoe M, Junge K, et al. Capsular contracture Oncol. 2016;7(1):114–21.
in implant based breast reconstruction – the effect of Windhofer C, Brenner E, Moriggl B, et al. Relationship
porcine acellular matrix. Gland Surg. 2017;6(1):49–56. between the descending branch of the inferior gluteal
Mestak O, Mestak J, Bobac M, et al. Breast reconstruction artery and the posterior femoral cutaneous nerve appli-
after a bilateral mastectomy using the BRAVA expan- cable to flap surgery. Surg Radiol Anat. 2002;24(5):
sion system and fat grafting. Plast Redonstr Surg Glob 253–7.
Open. 2013;8:e71. Yu SC, Kleiber GM, Song DH. An algorithmic approach to
Papp C, Windhofer C, Michlits W. Augologous breast total breast reconstruction with free tissue transfer.
augmentation with the deepithelialized fasciocutaneous Arch Plast Surg. 2013;40(3):173–80.
Breast Sarcoma Case: ALT and LTP
Flaps in the Management of Bilateral 96
Asynchronous Breast Angiosarcoma
Steven Lo
Contents
Preoperative Problem List/Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . . . 1015
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015
Primary Treatment in Breast Angiosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015
Recurrence in Breast Angiosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1016
Primary Reconstruction with ALT Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017
Recurrence and Secondary Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017
Outcome, Clinical Photos, and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Abstract carcinoma algorithms, and should mandate

Greater clarity is needed in the surgical man- the involvement of a tertiary sarcoma center
agement of breast sarcoma. Breast sarcoma experienced in the management of such cases.
should not be managed according to breast This case centers around the management of a
patient with primary breast angiosarcoma, ini-
tially treated in a non-sarcoma center with
mastectomy and latissimus dorsi (LD) flap
reconstruction, but with incomplete surgical
S. Lo (*)
Canniesburn Plastic Surgery Unit, Glasgow, UK margins. The patient’s further management
was discussed through the National Scottish
University of Glasgow and The Glasgow School of Art,
Glasgow, UK Sarcoma Network MDT, and surgical care

https://doi.org/10.1007/978-3-030-23706-6_85
1014 S. Lo
transferred to the specialist sarcoma unit in confirmed primary angiosarcoma. Incomplete

Glasgow. A radical extended neo-mastectomy margins were further treated at the same center
was performed on the right side, and recon- with nipple areola complex (NAC) excision,
struction with an anterolateral thigh (ALT) superomedial and lateral margin excision, and
flap at 1 week, once definitive pathology con- latissimus dorsi (LD) with subpectoral implant.
firmed clear margins. Treatment goals are Pathology on the second-stage surgery indicated
aimed at primary clearance of sarcoma, with involvement at multiple margins in the NAC and
angiosarcoma showing a clear survival benefit superomedial specimens.
with a negative margin excision, with positive Studies in angiosarcoma show a clear survival
margins having a 6-month mean survival ver- benefit with a negative margin excision, with pos-
sus negative margin 42 months. Subsequent itive margins having a 6-month mean survival
metastasis to the contralateral breast was later versus negative margin 42 months (Jallali et al.
treated with paclitaxel followed by radical 2012). This was discussed at the National Scottish
mastectomy and lateral thigh perforator (LTP) Sarcoma MDT and it was therefore considered
flap. The supporting rationale, current evi- entirely appropriate to proceed with further sur-
dence, data from the West of Scotland breast gery, as adjuvant radiotherapy or treatment with
sarcoma audit, and recent Scottish Sarcoma paclitaxel would be non-curative. The patient’s
Network guidelines on breast sarcoma are care was transferred to the tertiary plastic surgery
discussed in the context of this case. center at this stage. This case, however, posed a
number of problems. Firstly, as the implant was in
Keywords a subpectoral plane directly adjacent to the chest
wall, there was risk of tumor seeding to the chest
Breast sarcoma · Angiosarcoma · ALT · LTP ·
wall. However, complete chest wall resection
Chest wall
would likely to be highly morbid. An MRI and
PET scan was therefore requested to assess for
chest wall disease, and if negative, postsurgical
irradiation could be considered. Secondly, the
incomplete margins would necessitate an
A 26-year-old female presented as a national
extended radical neo-mastectomy involving skin
referral having undergone treatment for a primary
up to the clavicle and below the inframammary
angiosarcoma of the right breast elsewhere. Pre-
fold (IMF). Typical options for reconstruction
vious surgery included biopsy, followed by nip-
were not available, as the LD had already been
ple-sparing mastectomy and implant (Fig. 1), and
used, and the patient was very slim making a deep
specialist international review of pathology which
inferior epigastric perforators (DIEP) impossible.
Alternative sites were considered for chest wall
resurfacing with the requisite for a large surface
skin area. An anterolateral thigh (ALT) or lateral
thigh perforator (LTP) flap were considered as
possible options, with transverse musculo-
cutaneous gracilis (TMG) or similar flaps not pro-
viding sufficient skin. Thirdly, theoretical planes
of contamination may be associated with LD
transfer in the presence of incompletely excised
angiosarcoma. Consideration was given to dis-
cuss adjuvant radiotherapy to both chest wall
and back donor site after definitive surgery. We
present here both the further oncological manage-
Fig. 1 MRI breasts in prone position showing large mass ment at the tertiary sarcoma center, together with
in right breast subsequent clinical course.
96 Breast Sarcoma Case: ALT and LTP Flaps in the Management of Bilateral Asynchronous Breast. . . 1015
Preoperative Problem List/ have universally found low positive findings

Reconstructive Requirements of 0–2.3%, consistent with recently published
series with a 0% positive node rate (Lo et al.
1. Tumor resection and pathology margin con- 2021; Zelek et al. 2003; Barrow et al. 1999;
trol methods – This was performed by the Pencavel et al. 2011).
sarcoma center with guidance from further MRI
and PET imaging. This did not indicate any 18F-
fluorodeoxyglucose (FDG)-avid disease in the Treatment Plan
chest wall, and therefore rib resection was
deemed unnecessary. The extent of surgery was Primary Treatment in Breast
to include an extended neo-mastectomy includ- Angiosarcoma
ing up to the clavicle, below the IMF, up to the
midline, and including the LD implant pocket A treatment algorithm at Canniesburn Regional
and pectoralis major/minor. Given the critical Plastics Unit for breast sarcoma has been adopted
importance of clear margins, it was decided in as the Scottish Sarcoma Network (Glasgow Cen-
discussion with the sarcoma pathologists not to ter) Breast Sarcoma Guidelines (Flowchart 1)
proceed with frozen sections, and instead await (Lo et al. 2021). Breast angiosarcoma is managed
definitive pathology prior to reconstruction. in a subsection of these guidelines, as it has a
2. Flap choice – Both LD and DIEP were not significantly poorer prognosis than other breast
available as reconstructive options. The recon- sarcomas, with higher rates of multifocal disease
struction here was for chest wall resurfacing (65%), local recurrence (82–90%), and is notori-
rather than for aesthetic reasons. A robust bed ously difficult to determine tumor margins both
would be required for possible adjuvant radio- radiologically and clinically (Jallali et al. 2012).
therapy, precluding the use of a skin grafted As margins in angiosarcoma have a critical bear-
muscle flap. An ALT or LTP flap were planned. ing on prognosis, a radical mastectomy is advo-
3. Secondary aesthetic restoration – In the cated – as angiosarcoma can be multicentric and
absence of normally available flap options, aes- commonly involves the deep margin (Jallali et al.
thetics would be more of challenge to restore, 2012). Margin control methods may also be
particularly with the subsequent large skin defect employed, and previously frozen section was
which would exceed that typically seen even used at time of surgery, but now more commonly
with a radical mastectomy. Discussions with the a delayed reconstruction is performed in cases
patient included options to improve later appear- where the pathology is likely to be hard to inter-
ance. It was emphasized that fat transfer would pret. Each case should be discussed on an individ-
not be used in this patient. Although studies ual basis with an expert sarcoma pathologist.
suggest that it may be safe in breast carcinoma, Following these principles, a review of the incom-
no such studies exist in more aggressive pathol- plete excision rate for breast angiosarcoma in the
ogies such as angiosarcoma. The unit’s research West of Scotland sarcoma center was 0% which is
work centers around adipocytokines – growth among the best in the world (Lo et al. 2021). This
factors associated with fat, and adipocyte- is in contrast to data collected by the Royal
derived stromal cells (ADSCs), and how these Marsden, who noted a 46% overall incomplete
directly and indirectly promote tumor growth excision rate, although a third of these patients
(Wang et al. 2021; Huang et al. 2019). It was had been managed at peripheral hospitals where
for these reasons that fat transfers are not advo- there was a 100% positive margin (Jallali et al.
cated in this group of patients. 2012). Positive margins have significant impact
4. Lymph node excision – Limited data exists on local recurrence and survival, which are 3 and
elective lymph node clearance in breast sar- 6 months, respectively, with negative margins
coma, but the consensus is that in the absence improving this to 23 and 42 months. It is therefore
of clinical or radiological disease, lymph node of paramount importance in angiosarcoma to
clearance is not mandatory. Previous studies obtain a negative margin resection.
1016 S. Lo
Flowchart 1 Treatment
algorithm. Scottish Breast sarcoma
Sarcoma Network
guidelines for breast
sarcoma Discuss at Sarcoma MDT
Staging CT + Breast MRI
Centralize surgery at Sarcoma
Centre
Breast Lymph nodes
Involved nodes
<3cm and > Grade 2 Node
Angiosarcoma without distant
Grade 1 >3cm negave
mets
Radical
Mastectomy or
WLE or mastectomy + No LN
radical LN clearance
mastectomy margin clearance
mastectomy *
control**
* Radical mastectomy here refers to resecon of breast, overlying skin, pec major but not lymph nodes ** Margin control refers to methods
to assess the margin such as frozen secon or delaying reconstrucon unl definive pathology
Recurrence in Breast Angiosarcoma are not generalizable to angiosarcoma given the

different clinical and aesthetic priorities in these
There are limited data to guide treatment of local groups. No comments can be therefore be made
recurrence in breast angiosarcoma. Data regarding on optimal modes of reconstruction other those
locoregional spread to lymph nodes from Memo- which are descriptive and related to personal
rial Sloan Kettering in 1772 patients including preference.
breast sarcoma found only 46 cases of lymph
node metastases (2.3%) (Fong et al. 1993). With-
out surgical treatment, mean survival was Preoperative Evaluation and Imaging
5.9 months, but with lymphadenectomy, this was
16.3 months and included the only long-term sur- Primary surgery evaluation. Standard imaging
vivors. In local recurrence in the chest wall in protocols are used for tumor assessment, includ-
breast angiosarcoma, data from a multicenter ing contrast-enhanced MRI breasts and CT stag-
study in the Netherlands, found that in those that ing. Of note, MRI breasts in the prone position
did not undergo further surgery had a mean sur- may be helpful to delineate cases that may have
vival of only 6 months, compared to 34 months in chest wall involvement. All cases of breast sar-
the operative group, although this may be affected coma are discussed at the National Scottish Sar-
by bias with those not eligible for surgery poten- coma MDT, and pathology and imaging are
tially have a more unfavorable prognosis (e.g., re-reviewed by national experts in these fields. In
age and distant metastases) (Seinen et al. 2012). cases where surgery may be morbid or extensive,
PET scan may be used on a case-by-case basis,
to help determine whether surgery is likely to be
Alternative Reconstructive Options futile – for example with metastases not seen on
staging CT, or to help define the extent of surgery –
DIEP flaps may be used for chest wall resurfacing as in the case of subtle skin involvement in
in breast sarcoma, although are seldom used by angiosarcoma. Genetic testing is also used in
the author, given the preference to spare the abdo- cases with a strong family history, as in this case
men for salvage. There are no data comparing as her family history included a number of primary
reconstructive flap options in angiosarcoma breast cancers, although no genetic component was
given its rarity. Data from studies in breast cancer identified.
Secondary surgery for recurrence: All cases

are reviewed at National Sarcoma MDT and con-
sensus opinion gathered from sarcoma experts.
PET scan is more commonly used in cases of
locoregional recurrence, to ensure that any further
surgery is not done in the presence of metastases.
Surgical Technique
Primary Reconstruction with ALT Flap
1. Tumor resection carried out by sarcoma sur-

geons, with radical neo-mastectomy including
previous LD flap, implant pocket including
posterior capsulectomy, implant, and total
breast skin up to clavicle and below IMF.
Tumor specimen and implant seroma fluid
sent for analysis. A thoracodorsal arteriove-
nous (AV) shunt was created to maintain flow
in a long length of thoracodorsal artery and
vein, in case this was required for
microanastomoses at a later date (Figs. 2, 3,
4, 5, and 6).
2. Wound was dressed and formal pathology
Fig. 2 Radical neo-mastectomy removing previous recon-
awaited prior to reconstruction at 1 week later. struction and extending beyond IMF and normal limits of
3. Template made for the defect using a sponge breast skin. The marked points on the breast (marked with
dressing. 15 25 cm ALT flap was raised in a inked “X”) indicate areas of incomplete excision as
described in pathology report
standard manner. The patient’s leg skin was
supple and allowed primary closure (Fig. 7).
4. Flap anastomoses to internal mammary vessels.
The tail of the ALT flap was de-epithelialized
and folded to provide some degree of lower pole
fullness (Figs. 8 and 9).
Recurrence and Secondary

Reconstruction
The patient unfortunately presented with a contra-

lateral breast metastasis, a few months following
surgery (Fig. 10). In view of this, adjuvant radio-
therapy was not commenced as previously Fig. 3 Implant pocket. Implant seroma was sent for cytol-
planned. Pathology suggested this was an identi- ogy which reported no atypical or malignant cells
cal tumor to the primary, rather than a new pri-
mary. The decision at National Sarcoma MDT was given to salvage surgery as discussed by Seinen
to treat with paclitaxel for a period of 6 months et al. (2012). Repeat scans showed no further
and review disease progression. In the absence of disease progression. The patient was counselled
disease progression, consideration would be regarding the limited but beneficial data regarding
1018 S. Lo
Fig. 6 Reverse showing implant capsule and marked mar-

gins for pathology
Fig. 4 Chest wall defect. Note that the capsule was

excised in its entirety including the posterior capsule on
the chest wall. Also note the slim abdomen on the patient, Fig. 7 ALT flap 15 25 cm
not suitable for DIEP transfer
12, and 13). Given that the patient already had
metastatic disease, the rationale for operation
differed from the first surgery (i.e., not with
curative intent). Therefore it was decided to
proceed with primary reconstruction in lieu of
waiting for definitive pathology.
2. Ketorolac was given peri-operatively in-line
with limited data suggesting it may reduce
escape of tumor cells from dormancy during
surgery or general anesthetics (Chen et al.
2019; Panigrahy et al. 2019).
3. An LTP flap was raised from the left thigh but
oriented to provide a similar scar to the other
Fig. 5 Radical neo-mastectomy specimen thigh’s ALT donor site (Fig. 14). An LTP flap
was chosen instead of ALT, as a smaller skin
surgery for local recurrence, and proceeded to paddle was required, and more fat could be
resection with reconstruction. harvested from the peri-trochanteric fat. The
flap was folded into a crescent shape and
1. A mastectomy was performed on the contralat- inset for breast reconstruction (Figs. 15, 16,
eral breast, with a more limited skin excision and 17). Microanastomoses performed to inter-
and partial pectoralis major resection (Figs. 11, nal mammary vessels.
Fig. 10 Recurrence (metastasis) in contralateral breast
Fig. 8 De-epithelialized tail of flap folded for lower pole

projection
Fig. 11 Left mastectomy
Fig. 9 Flap in situ
Technical Pearls Fig. 12 Reverse showing partial pectoralis major

resection
1. MRI breasts in prone position. May be help-

ful in determining proximity to chest wall. may be given to remote flaps, such as ALT,
2. Consider remote flaps in breast sarcoma. LTP, or SGAP (superior gluteal artery perfora-
The recurrence rates in breast sarcoma, and in tor), in younger patients, in order to preserve
particular angiosarcoma can be as high as salvage options of LD and abdominal
two-thirds (Seinen et al. 2012). Consideration advancement.
1020 S. Lo
Fig. 15 LTP flap
Fig. 13 Mastectomy defect

Fig. 16 Rolled into a crescentic shape
Fig. 14 LTP flap raised to provide similar scar to other

thigh, and thus thigh contours were similar post-op Fig. 17 Rolled LTP viewed from front
3. Goals of surgery are oncological and not at an early stage and manage related
aesthetic. Primary efforts are aimed at expectations.
obtaining clear margins. This may involve 4. Never forget that no reconstruction is an
margin control methods such as frozen section option. Although breast reconstructive surgeons
or delayed reconstruction after formal pathol- have progressed the specialty immeasurably, it
ogy. Oncological resection must never be must be remembered that mastectomy and pri-
compromised for aesthetic reasons. It is impor- mary closure may be entirely appropriate, partic-
tant to emphasize goals of surgery with patients ularly in elderly patients. One must consider the
high recurrence rate and available salvage

options if this patient returns with recurrence. In
contradistinction, this does not mean that one
should attempt to remove a tumor with the goal
of primary closure. Breast angiosarcoma man-
dates the involvement of a plastic surgeon to
facilitate closure in conjunction with the breast
or sarcoma surgeons.
5. DIEP flaps may increase chest wall defect
size. With extensive chest wall defects, DIEP
flaps may increase the vertical height of the
chest defect upon abdominal closure. This
should be taken into consideration when plan-
ning major chest wall defect resurfacing. Fig. 18 Postoperative result, awaiting symmetrization
surgery and tattooing
Postoperative Management complete clearance at all margins. The breast

implant seroma sample likewise did not show
Routine flap monitoring is performed. Careful any cytologically atypical or malignant cells. Nip-
observation with instructions to monitor for comple reconstruction and limited liposuction of con-
partment syndrome in the thigh were given, as the tour abnormalities was done at a later date under
ALT flap included a wide skin paddle with relatively local anesthetic (Fig. 18). She is currently
tight primary closure. In cases involving resection of awaiting further symmetrization surgery and con-
ribs (not in this particular case), the management of sideration of asymmetric implants. There are
chest drains should be explicitly emphasized to increasing data regarding tumor release from dor-
junior staff. Where a concomitant lung resection is mancy with the use of general anesthetics and
required or lung injury has occurred, the potential major surgery, and therefore current practice is
for leak into the pleural space and under the flap gradually taking this into consideration when
increases significantly. A leak test should always be patients request revisional surgery (Chen et al.
performed with saline in the chest cavity and 2019; Panigrahy et al. 2019). This includes mini-
Valsalva procedure, as injuries may occur from mizing return to theater, performing revision sur-
sharp rib ends or from needle puncture during gery under local anesthetic where feasible, and
mesh insetting. In these cases, flap compromise or use of ketorolac peri-operatively if general anes-
surgical emphysema may occur postoperatively. thesia is required. Post-op staging confirms no
Expedited examination for critical complications further disease recurrence or metastases at
and chest drain blockage should be followed by follow-up approximately 3 years from initial sur-
placing the chest drain on low pressure suction. gery. No further adjuvant therapies were given
Postoperatively, low pressure wall suction is rou- after the 6-month course of paclitaxel.
tinely used at 10 to 20 cm H20 or more recently,
a digital chest drain solution such as the Thopaz
system. Avoiding and Managing Problems
1. WLE versus mastectomy. The correct choice

Outcome, Clinical Photos, and Imaging of primary oncological resection will reduce
unnecessary repeat surgeries and minimize
The patient had no early postoperative flap-related the risk of incomplete margins which may
complications for either the primary surgery or for adversely affect patient prognosis (Barrow
the salvage surgery to the contralateral breast. et al. 1999). Most major sarcoma centers advo-
Definitive pathology on both occasions confirmed cate aggressive surgical management with
1022 S. Lo
radical mastectomy rather than WLE. Strik- Learning Points

ingly, in the West of Scotland sarcoma center,
it was found that WLE was associated with an 1. The management of breast sarcomas should be
incomplete excision rate of 87.5% versus 10% centralized to a tertiary sarcoma center.
with mastectomy ( p ¼ 0.0001, Odds ratio 61) 2. Remote flaps preserve salvage options of LD
(Lo et al. 2021). Institut Gustav-Rouissy, and abdominal advancement, which is relevant
France, recommend WLE in only very partic- given the very high rate of recurrence in breast
ular cases – those that are both <3 cm and angiosarcoma.
Grade 1 (Zelek et al. 2003). 3. Treatment goals are oncologic, not aesthetic.
2. Breast sarcoma cases should be referred Never compromise oncologic margins for
early to a specialist sarcoma center. Data aesthetic gain.
indicate an incomplete excision rate for breast 4. Fat transfer should not be used in breast sar-
sarcomas of 0% in the West of Scotland sarcoma patients – existing data relates to breast
coma center compared to 50% in peripheral cancer only.
units ( p ¼ 0.0002, Odds ratio 43), and for
angiosarcoma, the figures were 0% and
62.5%, respectively (Lo et al. 2021). The References
Royal Marsden group likewise found that the
Barrow BJ, Janjan NA, Gutman H, Benjamin RS, Allen P,
positive margin rate was higher in peripheral
Romsdahl MM, Ross MI, Pollock RE. Role of radio-
units than in sarcoma center (61% vs. 9.5%, therapy in sarcoma of the breast – a retrospective
p < 0.001), and with an associated improved review of the M.D. Anderson experience. Radiother
disease free survival (58% vs. 37%) (Pencavel Oncol. 1999;52(2):173–8.
Chen Z, Zhang P, Xu Y, et al. Surgical stress and cancer
et al. 2011). Centralization of breast sarcoma
progression: the twisted tango. Mol Cancer.
management is advocated, but suggest this 2019;18(1):132. https://doi.org/10.1186/s12943-019-
should be done in close collaboration with the 1058-3.
referring breast team in order to develop strong Fong Y, Coit DG, Woodruff JM, Brennan MF. Lymph node
metastasis from soft tissue sarcoma in adults. Analysis
interprofessional links. The Scottish Sarcoma
of data from a prospective database of 1772 sarcoma
Network Breast Sarcoma guidelines were patients. Ann Surg. 1993;217(1):72–7.
inspired by the case presented here, as this Huang JY, Wang YY, Lo S, et al. Visfatin mediates malig-
case highlighted the need for clear national nant behaviors through adipose-derived stem cells
intermediary in breast cancer. Cancers. 2019;12(1):29.
guidelines on the care of breast sarcoma
https://doi.org/10.3390/cancers12010029.
(Lo et al. 2021). Jallali N, James S, Searle A, et al. Surgical management of
3. Planning for a Plan B. Given the very high radiation-induced angiosarcoma after breast conserva-
recurrence rates in angiosarcoma, planning tion therapy. Am J Surg. 2012;203(2):156–61. https://
doi.org/10.1016/j.amjsurg.2010.12.011.
must always take into consideration salvage
Lo S, Foster N, Campbell L, et al. A need for clarity on
options. surgical management of breast sarcoma: Scottish sar-
4. Do not assume that further surgical treat- coma network guidelines and regional audit. J Plast
ment of recurrence is futile. Although it is Reconstr Aesthet Surg. 2021;74(6):1180–92. https://
doi.org/10.1016/j.bjps.2020.10.072.
acknowledged that the data in breast sarcoma
Panigrahy D, Gartung A, Yang J, et al. Preoperative stim-
are limited, evidence points towards significant ulation of resolution and inflammation blockade erad-
increases in patient survival when surgical treat- icates micrometastases. J Clin Invest. 2019;129(7):
ment is used for regional lymph node spread or 2964–79. https://doi.org/10.1172/JCI127282.
Pencavel T, Allan CP, Thomas JM, Hayes AJ. Treatment
local recurrence. These data should be shared
for breast sarcoma: a large, single-Centre series. Eur
with patients during the consent process, to J Surg Oncol. 2011;37(8):703–8. https://doi.org/10.
allow a patient to make an informed decision. 1016/j.ejso.2011.04.006.
Seinen JM, Styring E, Verstappen V, et al. Radiation- biological mechanisms, and therapeutic potential. Can-
associated angiosarcoma after breast cancer: high cer Lett. 2021;498:229–39. https://doi.org/10.1016/j.
recurrence rate and poor survival despite surgical treat- canlet.2020.10.045.
ment with R0 resection. Ann Surg Oncol. 2012;19(8): Zelek L, Llombart-Cussac A, Terrier P, et al. Prognostic
2700–6. https://doi.org/10.1245/s10434-012-2310-x. factors in primary breast sarcomas: a series of patients
Wang YY, Hung AC, Lo S, Yuan SF. Adipocytokines with long-term follow-up. J Clin Oncol. 2003;21(13):
visfatin and resistin in breast cancer: clinical relevance, 2583–8.
Intraoperative Perforator Avulsion
in Free Flap Breast Reconstruction 97
Randy De Baerdemaeker and Assaf A. Zeltzer
Contents
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026
Alternative Autologous Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1027
Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1027
Imaging Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1027
Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1028
Outcome Clinical Photos and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1032
Patient Consent
The patient provided written consent for use of her
images and data.
Disclosure
The authors have no conflict of interests to declare in
relation to the content of this chapter.
R. De Baerdemaeker
Surgery, Brussels University Hospital (VUB), Brussels,
Belgium
e-mail: randy.debaerdemaeker@uzbrussel.be
A. A. Zeltzer (*)
Department of Plastic, Reconstructive & Aesthetic Surgery
Belgium
e-mail: assaf.zeltzer@uzbrussel.be

https://doi.org/10.1007/978-3-030-23706-6_86
1026 R. De Baerdemaeker and A. A. Zeltzer

Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
Abstract Preoperative Problem List:

Perforator avulsion is a rare, feared and highly Reconstructive Requirements
morbid complication in free flap transfer.
Intraoperative and postoperative pedicle anas- 1. Requirement to reconstruct a left breast
tomosis avulsions have been described, but 2. Requirement to treat upper limb lymphedema
poor literature exists on true perforator traction
tear and salvage.
This chapter describes a case of an Treatment Plan
intraoperative perforator avulsion in free flap
breast reconstruction combined with free Left unilateral breast reconstruction using a free
vascularized lymph nodes transfer and deep inferior epigastric artery perforator (DIEaP)
lymphovenous anastomosis. flap combined with free vascularized lymph nodes
The description of the intraoperative manage- transfer (VLNT) from the groin to the left axilla
ment of this complication and salvage procedure and left arm lymphovenous anastomosis (LVA) in
is included. An analysis of the intraoperative a two-team approach.
course that led to the complication was also
conducted to reduce chance of this complication
happening again and to diminish second victim
phenomenon among the operating staff.
Keywords
Pedicle avulsion · Free flap · Perforator flap ·

Breast reconstruction · Second victim
A 48-year-old female smoker underwent a left

breast total mastectomy and axillary lymph node
dissection in 2013 for stage II cancer. She required
postoperative radiotherapy and chemotherapy. In
2016, after completion of her oncologic treat-
ments, she was scheduled for a left unilateral
breast reconstruction using a free deep inferior
epigastric artery perforator (DIEaP) flap com-
bined with free vascularized lymph nodes transfer
(VLNT) from the groin to the left axilla and left
arm lymphovenous anastomosis (LVA) (Fig. 1). Fig. 1 Preoperative picture with markings
97 Intraoperative Perforator Avulsion in Free Flap Breast Reconstruction 1027
Alternative Autologous Reconstructive Preoperative Evaluation and Imaging

Options
Clinical Evaluation
If the abdominal donor site is not available
for flap harvest, other flaps for breast reconstruc- (a) Standard workup for any patient scheduled for
tion may be considered such as transverse free flap surgery (medical history, allergies,
myocutaneous gracilis (TMG) flap, superior glu- medication, hypercoagulability risk factors,
teal artery perforator (SGaP) flap, inferior glu- previous surgeries, smoking status, evaluation
teal artery perforator (IGaP) flap, and lumbar of donor sites, . . .) was done.
artery perforator (LaP) flap. Harvesting lymph (b) Patients with lymphedema who have failed
nodes in continuity with one of these flaps has nonsurgical measures are clinically staged.
not been successfully described. In most of the Stage 0, 1, and 2 patients with pitting edema
alternative donor site locations, lymph nodes are are potential candidates for reconstructive sur-
not standard available or the risk of donor site gery (Stage 2 and 3 patients with non-pitting
lymphedema is too high (Dayan and Allen edema are candidates for liposuction or resec-
2019). tion techniques, respectively).
They can, however, all be combined with a (c) Volumetric measurements
second separate free vascularized lymph node The optoelectric volumetry (or infrared
flap from the inguinal area if available or also perometry) is a frame connected to a computer
from alternative donor sites, e.g., lateral thoracic and is used to scan the limb calculating volume
nodes, submental nodes, supraclavicular nodes, and circumference. It is fast, reproducible, and
and the more recently described intra-abdominal accurate, and therefore the method of choice.
nodes (Schaverien et al. 2018). (d) Quality of life
There have also been reports of using a pedi- Although there is often a correlation, it has
cled latissimus dorsi myocutaneous flap coupled been observed that there is sometimes a dis-
with lateral thoracic lymph nodes for the treat- crepancy between the measurements or imag-
ment of lymphedema along with breast recon- ing evaluation of lymphedema and the
struction (Inbal et al. 2017). This represents subjective evolution of the lymphedema per-
another approach for combining breast recon- ception by patients after (surgical) treatment.
struction with lymphedema surgery. However, For that reason, there is an emphasis on qual-
this approach may not always be feasible as ity of life evaluation in all of our patients,
often the lateral thoracic nodes have been besides the objective evaluation (perometer,
removed during the axillary dissection. The con- scintigraphy, etc.).
tralateral latissimus dorsi myocutaneous flap can
also be harvested as a free flap in conjunction
with the lateral thoracic nodes and transferred to Imaging Techniques
the index breast in the setting that the lateral
thoracic nodes on the index breast were removed. The ideal imaging study for lymphedema would
Similar to the combined abdominal free flap and provide information regarding the anatomy and
lymph node approach, combing the pedicled function of the lymphatic vessels, lymph nodes,
latissimus dorsi flap with the lateral thoracic and interstitial tissues.
nodes has proven to be efficacious in improving All patients undergo lymphoscintigraphy to
patients’ lymphedema symptoms, but larger confirm lymphedema. Indocyanine green lym-
studies are needed to decipher whether one phography (ICG) is performed to identify the
modality is superior to the other (Inbal et al. presence of functional lymphatic vessels. If lym-
2017). phatic vessels are present, LVS is recommended.
In patients with impaired lymphatic channels, simultaneous access to the inguinal, abdominal, tho-
VLNT is recommended. Presence or absence of racic, axillary region and the arm to prepare the flaps
scarring directs us to the placement of the node and the recipient sites for the autologous breast
flap. The protocol described here is named the reconstruction, VLNT, and simultaneous LVA. The
Brussels Approach to Upper Limb Lymphedema two operating teams work individually with their
Surgery protocol (BALLS protocol) (Zeltzer et al. own set of coagulation, suction, and instruments.
2018). Given the large exposure, it is recommended placing
For autologous free flap breast reconstruction, the patient on a heated mattress, with adequate
the use of different preoperative pressure point relief. For monitoring the patient, it
imaging modalities has become the standard of is routine to place one peripheral intravenous line, a
care. The computed tomographic angiogram bladder catheter, blood pressure monitoring, and
(CTA) is routinely used for perforator mapping temperature monitoring.
and the findings are confirmed with the handheld The microscope is placed besides the head of
Doppler. the patient on the ipsilateral side of the
reconstruction.

Drawing Surgical Techniques
The vascularized lymph node transfer will be With a two-team approach, the recipient sites for
based on the superficial circumflex iliac artery. both the DIEaP flap and free lymph nodes transfer
Patients planned for this procedure undergo per- were prepared. The harvest of the flaps at the
forator mapping using preoperative computed donor site began with the dissection of the left
tomographic scans, as described extensively for groin free VLNT flap based on the superficial
DIEaP flap breast reconstruction. The design of circumflex iliac vessels.
the abdominal flap should be adapted accordingly The flap was first incised superiorly and laterally
and the perforator selected taking the side of the and the superficial circumflex iliac pedicle and the
harvested nodes in account for an effective micro- SIEV on the left side are localized first. The flap is
surgical anastomosis in both anterior thorax elevated from lateral to medial making sure that blue
(internal mammary vessels) and the axilla. Thus dye cannot be seen in the harvested nodes (which
the preoperative CT scanner is important in the can very often be palpated in the flap, the lymph
selection of the side of the donor site for groin nodes should not be visualized directly nor skele-
nodes by confirming the number of functional tonized as this will devascularize the nodes and
lymph node units per groin in the Golden Triangle impair their function). Care was taken not to harvest
(Zeltzer et al. 2017) (Fig. 1). any nodes caudal of the circumflex pedicle and
Different techniques for reverse lymphatic medial to the femoral artery. Dissection of the
mapping have been suggested as a means of iden- venous structures was carried out medial to the
tifying and avoiding the groin nodes responsible femoral artery making sure that the veins were skel-
for draining the lower extremity. Twelve hours etonized of any lymphatic tissue. The venous drain-
prior to surgery and just before start of surgery, age of the flap is by the SCIV. Alternatively, the
1 cc of patent blue is injected in the web spaces of SIEV can be included in the flap and used for extra
the toes. All blue-dyed structures are strictly drainage, which was not necessary in this case.
avoided during flap harvest. If the targeted nodes After the VLNT was harvested, the DIEaP flap
for the flap are blue, the flap harvest should be was being harvested in the usual fashion.
aborted. Patients should be well informed of this At this point, the VLNT flap was not separated
eventuality. from the DIEaP flap.
The patient is positioned on the back with the Dissection of bilateral superficial inferior epi-
ipsilateral arm in 90 abduction on a table to allow gastric vein (SIEV) was performed as a standard
Fig. 2 Dissection of cranial limb of the DIE over a short distance before carrying the dissection caudally
procedure. The DIEaP flap was then entirely ele-

vated on a single right dominant medial row per-
forator. When the perforator is followed through
the fascia and rectus abdominis muscle, the cra-
nial limb of the DIE is dissected over a short
distance (10–15mm), before carrying the dissec-
tion caudally until the external iliac vessels are
visualized (Fig. 2).
The leading surgeon turned briefly to check on
the progress of the recipient sites, and after that
point, the connected flap composed of the DIEaP
flap and the free vascularized lymph node transfer
(VLNT) from the groin, unsecured to the patient,
slipped to the left side of the patient, avulsing the Fig. 3 Microanastomosis of the avulsed perforator
attached to the flap to the cranial limb of the DIE pedicle,
DIE perforator subfascially prior to the junction
with the clipped distal perforator visible above
with the DIE vessels.
A high-risk salvage was attempted, starting
with the harvest of the right DIE pedicle up to as the avulsion injury was too severe to permit
the external iliac vessels and separation of the their primary repair. Slight compensation maneu-
DIEaP flap and the VLNT groin flap. On a side vers were necessary to accommodate size
table, a microscopic evaluation of the vessels discrepancy (Fig. 3).
was conducted. Extensive avulsion injury of the Intra-flap dissection and harvest of the left SIEV
vein on both sides was seen. Lesser damage was was performed followed by its anastomosis to the
found to the arteries. A debridement of the zone right SIEV, and a vascular interposition graft.
of injury was performed and afterwards the anas- The flap was then positioned on the patient and
tomosis of the flap perforators directly to the the DIE vessels were then anastomosed to the
cranial limb of the DIE vessels was performed, anterograde limb of the internal mammary vessels
Fig. 4 Schematic overview of the salvage procedure
and the SIEV to the retrograde limb of the internal upper limb mobility. Furthermore, a healthy bed
mammary vein (Fig. 4). of tissue at the recipient site is needed for
The separate free VLNT was connected to the vascularized lymph node transfer so that the
thoraco-dorsal vessels. Separating the two flaps lymphatic vasculature can regenerate. Obvi-
eased the salvage procedure and the correct inset ously also the recipient vessels for a lymph
of the VLNT in the axilla. node transfer to the axillary region require dis-
Due to this intraoperative complication, the section of the axilla and removal of scar tissue.
lymphovenous anastomosis was rescheduled, to • The DIEaP vessels are anastomosed with the
be performed during another operating time in internal mammary vessels. The superficial cir-
which the symmetrization procedure of the con- cumflex iliac artery flap vessels are anasto-
tralateral breast will be performed, as well as the mosed to either the serratus branch, a side
nipple reconstruction and donor site scar correc- branch of the thoraco-dorsal vessels, or the
tions if necessary. thoraco-dorsal vessels themselves. This
depends on the available donor vessels and
the size of the recipient vessels. It is preferred
Technical Pearls to place the breast reconstruction flap medial
on the chest wall and the lymph node flap
• Axillary scar tissue removal is a critical step for lateral in the apex of the axilla. For this reason,
the reduction of arm volume. Wide removal of it is preferred to perform this operation using a
scar tissue from the axilla is required to improve separate flap and a separate set of anastomoses
for the breast flap and the VLNT. Performing for the first 5 days with flap monitoring protocol.
an additional anastomosis for the lymph nodes Clinical monitoring involves checking color, tem-
is an area of considerable debate if the flap is perature, capillary return, and Doppler signal
harvested in continuity with the flap for autol- evaluation. The monitoring is performed each
ogous breast reconstruction. Often harvesting half an hour during the day of the surgery, every
the flap in conjunction with the DIEaP pro- hour for the next 24 hours, every 2 hours in the
vides adequate perfusion of the lymph nodes second postop day, every 3 hours during the
that should be confirmed with intravascular postop day 3, every 8 hours in the postop day
ICG angiography. In the setting that the nodes 4, and then once per day. Low molecular weight
are perfused well without signs of arterial heparin (LMWH) is administered according to the
insufficiency or venous congestion, perhaps risk factors during the hospitalization. As with any
an additional anastomosis is not necessary. microvascular breast reconstruction, there are
While some routinely perform an additional risks of complications. Every effort should be
arterial and venous anastomosis to maximize made to avoid donor site lymphedema as
perfusion to the lymph nodes, others do not. described. A prolonged duration of drains, com-
Some believe only an additional venous anas- pressive bandage on the donor site, repeated aspi-
tomosis is necessary as the fluid absorbed by ration, or percutaneous drainage might be
the lymph nodes is returned to the systemic necessary to prevent/manage recipient or donor
circulation via the pedicle vein. Outcomes on site complications like seroma or lymphocele.
whether an additional set of anastomoses are Patients are scheduled for postop antibiotics and
needed to maximize a patient’s postoperative anticoagulants, and are instructed not to lift
lymphedema remain to be elucidated. weight during 6 weeks postoperatively nor to lift
• Dissection of bilateral superficial inferior epi- their arms above shoulder height or compress the
gastric vein (SIEV) is performed as a standard arm against the thorax.
procedure. An analysis of the intraoperative course that led
• When the perforator is followed through the to the intraoperative complication was also
fascia and rectus abdominis muscle, the cranial conducted to reduce chance of this complication
limb of the DIE is dissected over a short dis- happening again and to diminish second victim
tance (10–15mm). This might be used as a safe phenomenon among the operating staff (Scott et al.
zone where the pedicle can be manipulated. 2009).
• Stay calm and focused on the procedure in case In this particular case we think that switching
an intraoperative complication occurs. from operating site from the leading surgeon
• Salvage is possible using supermicrosurgical (recipient and donor site), shifting in surgical role
techniques. at the donor site (first assistant to leading surgeon to
• The surgeon must first excise the zone of first assistant again), and abrupt retracting gesture
trauma. Depending on the nature of the injury, by a junior assistant led to the complication.
an appropriate technique to repair the avulsion In general, patients can be treated with a
can be selected (Cereceda-Monteoliva et al. chimeric flap using a combined abdominal flap
2018). For double vessel avulsion, repairing for breast reconstruction and inguinal lymph
the artery first allows the vein to fill and node flap for lymphedema treatment. This
become more prominent for repair. approach was first described by Saaristo et al.
(2012) and two more studies demonstrated sim-
ilar findings confirming the technique (Nguyen
Postoperative Management et al. 2015, De Brucker et al. 2016). Studies have
demonstrated that vascularized lymph node
The postoperative period went uneventful with transfer can be combined with microvascular
complete survival of both DIEaP and VLNT breast reconstruction. Rates of seroma formation
flaps. The patient was postoperatively monitored and wound healing complications in the
vascularized lymph node transfer–DIEaP flap Avoiding and Managing Problems

group were higher than in the isolated
vascularized lymph node transfer group (20% 1. Organize surgery in a way that the two operat-
versus 8%). Patients undergoing combined pro- ing teams can work individually with their own
cedures may need to be made aware of these set of coagulation, suction, and instruments.
increased risks. However, one study comparing 2. Know and communicate your role at any
the benefits of performing a simultaneous autol- time, especially when switching operating
ogous breast reconstruction with the inguinal fields and operating roles.
node transfer to performing an isolated inguinal 3. Pay attention to younger assistants and other
lymph node transfer found that patients under- operating staff joining the team. They might
going the simultaneous VLNT with the autolo- not be aware of established routines and need
gous free flap breast reconstruction had superior to be supervised at all time.
outcomes (Akita et al. 2017). 4. Independently of its size, bilateral dissection
of the SIEVs on both sides is performed. They
can be used to increase outflow or as vascular
Outcome Clinical Photos and Imaging interponates.
5. Follow the perforator through the fascia and
One-year postoperative results (Fig. 5) after muscle, always dissect the cranial limb or side
lymphovenous anastomosis that was performed branches over a short distance. They might be
together with the symmetrization procedure of used as a safe zone where the pedicle can be
the contralateral breast (mastopexy) and the ipsi- manipulated or as a salvage point for anasto-
lateral nipple reconstruction and donor site scar mosis in case intra-flap anastomoses are
correction. needed or if disasters happen.
Fig. 5 One-year postoperative pictures

6. Use routine movements. 2. Subfascial perforator avulsion is a rarer com-

7. Work efficiently and focused. plication with higher morbidity rates. Manage-
8. Secure the flap at all times. ment of those types of injury is directly related
9. Do not avulse the pedicle. to prevention during harvest.
10. Stay calm and focused on the procedure in 3. This case is presented with the goal to empha-
case an intraoperative complication occurs. size that complications do occur in microsur-
Salvage is possible. geries and may often be dramatic ones. A
11. Train in supermicrosurgery. proper combination of team work, positive
12. If available, ask an experienced colleague for attitude, not panicking, analyzing logically
advice or technical support. the issue, and trusting your surgical skills for
13. Communicate complications and their impact the salvage of a flap is necessary.
with the patient and their relatives. 4. An analysis of the intraoperative course that
14. Regardless the outcome of the case, analyze leads to an intraoperative complication has to
what went wrong when and why. be conducted to reduce chance of this compli-
15. Be aware of the second victim phenomenon. cation happening again and to diminish second
When patients experience unexpected events, victim phenomenon among the operating staff.
some health professionals become “second
victims.” These caregivers feel as though
they have failed the patient, second-guessing
Cross-References
clinical skills, knowledge base, and career
choice. Every day healthcare professionals
▶ Deep Inferior Epigastric Artery Perforator
practice their art and science within enor-
(DIEaP) Flap Harvest After Full Abdominoplasty
mously complex environments and some-
times experience unexpected patient
outcomes. Many within healthcare systems
References
suffer alone after events. It is imperative that
an improved understanding of effective and Akita S, Tokumoto H, Yamaji Y, et al. Contribution of
immediate surveillance and support strategies simultaneous breast reconstruction by deep inferior
be developed to mitigate the suffering among epigastric artery perforator flap to the efficacy of
vascularized lymph node transfer in patients with breast
second victims (Scott et al. 2009).
cancer-related lymphedema. J Reconstr Microsurg.
2017;1(212):571–8.
Branford OA, Davis M, Schreuder F. Free flap survival
Learning Points after traumatic pedicle avulsion in an obese diabetic
patient. Br J Plast Surg. 2008;04:002.
Cereceda-Monteoliva N, et al. Salvage of free flaps follow-
1. Perforator avulsion is a rare, feared and highly ing vascular pedicle avulsion using supermicrosurgery
morbid complication in free flap transfer. techniques: a case report and a review of the literature.
Intraoperative and postoperative pedicle anas- www.ePlasty.com. Interesting Case. March 26, 2018.
Dayan JH, Allen RJ Jr. Neurotized diagonal profunda
tomosis avulsions have been described, but artery perforator flaps for breast reconstruction. Plast
poor literature exists on true perforator traction Reconstr Surg Glob Open. 2019;7(10):e2463. https://
tear and salvage. doi.org/10.1097/GOX0000000000002463.
As per the literature, anastomoses avulsions eCollection 2019 Oct.
De Brucker B, Zeltzer A, Seidenstuecker K, Hendrickx B,
can and have occurred intra- or postoperatively Adriaenssens N, Hamdi M. Breast cancer-related
secondary to hematomas, traumatic abrupt lymphedema: quality of life after lymph node transfer.
movements from the patient, or iatrogenic Plast Reconstr Surg. 2016;137(6):1673–80.
manipulation/positioning errors (Branford Gahankari D, Malyon A, Weiler-Mithoff EM. Avulsion of
vascular anastomosis in free-flap breast reconstruction.
et al. 2008,Gahankari et al. 2001; Martano Br J Plast Surg. 2001;54:167.
and Malata 2012, Salgado et al. 2002, Wei Inbal A, Teven CM, Chang DW. Latissimus dorsi flap with
et al. 2001) vascularized lymph node transfer for lymphedema
treatment: technique, outcomes, indications and review Lymphedema. Semin Plast Surg. 2018;32(1):28–35.
of literature. J Surg Oncol. 2017;115(1):72–7. https:// https://doi.org/10.1055/s-0038-1632401. Epub 2018
doi.org/10.1002/jso.24347. Epub 2016 Dec 12. Apr 9.
Martano A, Malata CM. Accidental latissimus dorsi flap Scott SD, Hirschinger LE, Cox KR, et al. The natural
pedicle avulsion during immediate breast reconstruc- history of recovery for the healthcare provider “second
tion: Salvage by conversaion to free flap. J Plast victim” after adverse patient events. Qual Saf Health
Reconstr Aesthet Surg. 2012;65(8):1107. Care. 2009;18:325–30. https://doi.org/10.1136/qshc.
Nguyen AT, Chang EI, Suami H, Chang DW. An algorith- 2009.032870.
mic approach to simultaneous vascularized lymph node Wei FC, Demirkan F, Chen HC, et al. The outcome of
transfer with microvascular breast reconstruction. Ann failed free flaps in head and neck and extremity recon-
Surg Oncol. 2015;22(9):2919–24. struction: what is next in the reconstructive ladder?
Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Plast Reconstr Surg. 2001;108:1154e–60.
Hartiala P, Suominen EA. Microvascular breast recon- Zeltzer AA, Anzarut A, Braeckmans D, et al. The
struction and lymph node transfer for postmastectomy vascularized groin lymph node flap (VGLN): anatom-
lymphedema patients. Ann Surg. 2012;255(3):468–73. ical study and flap planning using multi-detector CT
Salgado CJ, Smith A, Kim S, et al. Effects of late loss of scanner. The golden triangle for flap harvesting. J Surg
arterial inflow on free flap survival. J Reconstr Micro- Oncol. 2017;116(3):378–83.
surg. 2002;18:579e–84. Zeltzer AA, Anzarut A, Hamdi M. A review of lymph-
Schaverien MV, Badash I, Patel KM, Selber JC, Cheng edema for the hand and upper-extremity surgeon.
MH. Vascularized Lymph Node Transfer for J Hand Surg [Am]. 2018:1–9.
Deep Inferior Epigastric Artery
Perforator (DIEaP) Flap Harvest After 98
Full Abdominoplasty
Gabriele Giunta and Assaf A. Zeltzer
Contents
Preoperative Problem List – Reconstructive Requirements . . . . . . . . . . . . . . . . . . . . . . 1036
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1036
Alternative Autologous Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1038
Thigh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1038
Lower Back/Buttock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1038
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1041
Patient Consent
The patient provided written consent for use of her
images and data.
G. Giunta
Surgery, University Hospital Brussels, Vrije Universiteit
Brussel (VUB), Brussels, Belgium
e-mail: gabriele.giunta@uzbrussel.be
A. A. Zeltzer (*)
Department of Plastic, Reconstructive & Aesthetic Surgery
Belgium
e-mail: assaf.zeltzer@uzbrussel.be

https://doi.org/10.1007/978-3-030-23706-6_87
1036 G. Giunta and A. A. Zeltzer
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043
Abstract biopsy. She also received adjuvant hormonal

The deep inferior epigastric artery perforator therapy. One year later, she presented at the
(DIEaP) flap represents the gold standard for consultation for a secondary unilateral breast
autologous breast reconstruction. Due to the reconstruction.
preoperative computed tomography angiogra- A full abdominoplasty, with wide undermining
phy (CTA), previous abdominal surgeries are of the proximal abdominal wall and umbilical
no longer contra-indication for DIEaP flap transpositioning and bilateral breast reduction,
harvesting; however, previous abdominoplasty had been performed elsewhere 10 year earlier. In
with umbilical transposition is still considered accordance to this absolute contraindication for
an absolute contra-indication for a DIEaP-flap. DIEaP flap reconstruction, an autologous breast
This case reports a DIEaP flap-based breast reconstruction with a free lumbar artery perforator
reconstruction in a patient who had undergone (LaP) flap was planned (Zeltzer et al. 2018)
a full abdominoplasty 10 years before and, tak- (Figs. 1 and 2).
ing this into account, the patient was planned for
a lumbar artery perforator (LaP) flap reconstruc-
tion. Surprisingly the preoperative CTA map- Preoperative Problem List –
ping identified a good caliber DIEa perforator in Reconstructive Requirements
the peri-umbilical region on the right hemi-
abdomen. A classical flap harvest and one arte- 1. Requirement to reconstruct a relatively large
rial and one venous anastomosis to the internal right breast
mammary vessels were performed. However, 2. Availability of abdominal tissue but presence
due to venous congestion, the flap was revised of previous full abdominoplasty with navel
twice: the first time intra-operatively and the transposition (Zeltzer et al. 2018)
second time 12 h postoperatively. The flap 3. Preoperative computed tomography angiogra-
fully recovered and the patient was discharged phy mapping to identify perforators in scarred
at day 8 postoperatively. tissues (Parrett et al. 2008; Masia et al. 2010;
The flap edges showed some superficial Mahajan et al. 2012; Hamdi et al. 2014;
necrosis that was treated with conservative Ngaage et al. 2019)
treatment, while the donor site healed unevent-
fully. The patient underwent secondary aes-
thetic procedures 4 months later. Treatment Plan
Keywords According to the patient’s past history of
Breast reconstruction · Abdominoplasty · abdominoplasty, which represents an absolute
DIEaP flap · CT-angiography · DIEaP flap contraindication for DIEaP flap, a plan for an
contraindications autologous breast reconstruction with free lum-
bar artery perforator (LaP) flap was initially
decided.
The Clinical Scenario The routinely preoperative computed tomogra-
phy angiography (CTA) mapping showed nice
A 50-year-old patient with a multifocal inva- lumbar perforators and also an unexpectedly
sive ductal carcinoma [pT1cN0 (sn)(i-) grade good caliber deep inferior epigastric artery perfo-
II ER+/PR+] of the right breast received rator at the periumbilical region. This perforator
modified mastectomy and sentinel node originated from the right hemi-abdomen and
98 Deep Inferior Epigastric Artery Perforator (DIEaP) Flap Harvest After Full Abdominoplasty 1037
Fig. 1 Preoperative
front view
Fig. 2 Preoperative back

view (lumbar donor)
during its subcutaneous course crossed the mid- Preoperative Evaluation and Imaging
line. So in accordance to the preoperative scan, the
plan was changed and a reconstruction based on The past medical history was taken into consider-
the ipsilateral DIEaP flap was planned. ation and the patient was evaluated to check if she
The surgical plan was to identify the perfora- had any contraindication to free perforator flap
tor through the previous abdominoplasty scar, reconstruction.
without the incision of the upper marking of the Nowadays the preoperative CTA is a standard
flap. If the DIEa perforator had not been consid- in surgical planning when a free flap breast recon-
ered suitable to raise a DIEaP flap, the “lifeboat” struction is indicated (Masia et al. 2010; Ngaage
LaP flap would have been harvested from an et al. 2019).
extension of the exploratory lower incision The back and the abdomen were evaluated to
(scar which was already present from her previ- determine the presence and the course of the main
ous abdominoplasty). fasciocutaneous perforators (SGaP vs LaP).
The CTA mapping showed that the right DIEA
perforator detected in the periumbilical region
Alternative Autologous Reconstructive was in continuity to the right iliac vessels. Fur-
Options thermore, a left superficial inferior epigastric vein
(SIEV) crossing the old abdominoplasty scar was
Thigh detected (Fig. 3).
The upper medial thigh is a consistent option for

autologous breast reconstruction. Preoperative Care and Patient
This region is considered as the second most Drawing
common donor site in breast reconstruction in
those patients in which the abdomen is not avail- The amount of tissues available for the DIEaP flap
able and/or who required small breast reconstruc- was evaluated by the “pinch” test. The dominant
tion. (Patel and Ramakrishnan 2017) perforator and the other accessory perforators,
These free flaps can be harvested from the detected with the CTA, were marked with an indel-
thigh tissues: ible pen. A hand Doppler is used to check their
location. The superior border of the flap was
1. TMG (transverse musculocutaneous gracilis) marked just above the transposed umbilicus and
flap gently descended laterally towards the anterior
2. PaP (profunda artery perforator) flap superior iliac spines to avoid dog-ears in donor
site closure. The lower border was marked in cor-
respondence to the previous abdominoplasty scar.
Lower Back/Buttock Furthermore, the right lumbar perforator was
marked and after the pinch test, the LaP flap was
If the abdominal and thigh donor sites are not designed around the chosen perforator and in con-
available, the lower back/buttock region provides tinuity with the DIEaP flap drawing (Figs. 4 and 5).
some flaps that can be employed in autologous
breast reconstruction.
These free flaps can be harvested from the Surgical Technique
lower back/buttock tissues:
The inferior skin incision of the DIEaP flap was
1. LaP (lumbar artery perforator) flap (Hamdi made. On the left side the superficial inferior
et al. 2016) epigastric vein (SIEv) was identified and it could
2. IGaP (inferior gluteal artery perforator) flap be dissected distally through scar tissues. The
3. SGaP (superior gluteal artery perforator) flap DIEA perforator on the right hemi-abdomen was
Fig. 3 CT-angiography reconstruction of the perforator vessel on the right hemi-abdomen with view of the perforator
originating from the right DIEA pedicle
Fig. 4 Preoperative
markings DIEaP
frontal view
Fig. 5 Preoperative
markings LaP lateral view
identified through the lower incision. The main A few minutes after the vascular anastomoses,
pedicle consisted of two venae comitantes and one because of an initial venous congestion, an addi-
artery and it was considered pulsatile and found tional venous anastomosis of the left SIEV to a side
suitable in caliber and patency. Other smaller per- branch of the DIEv in the pedicle was performed
forators on the left side were encountered and then (Zeltzer et al. 2011). Twelve hours postoperatively,
sacrificed due to the right dominant perforator. the flap was again congested and a flap revision
After the evaluation of the reliability of the was required. An avulsion of the anastomosed
perforator, a standard flap harvest was performed. SIEv to the side branch of the DIEv was seen. A
The upper skin incision was made up to the mus- venous interposition graft from the second DIEv,
cular fascia and the lateral to medial dissection of that was not used, was harvested to bridge the left
the flap till to the chosen perforator and the sub- SIEv to the side branch of the DIEv.
fascial perforator dissection up to the deep inferior
epigastric vessels origin.
The DIEaP flap was anastomosed to the inter- Technical Pearls
nal mammary vessels: the DIEa and one of the
two deep inferior epigastric veins (DIEv) were 1. The dissection of the SIEV was performed by
anastomosed. During the flap insetting, the zones blunt dissection to identify the vein through the
I and II were preserved and also a part of zone III scarred tissues. Once the left SIEV was identi-
containing the SIEv was spared (Patel and fied, bipolar dissection was used to dissect the
Ramakrishnan 2017). The final weight of the SIEV as long as possible before clipping it
flap was 803 g. distally.
Outcome-Clinical Photos and Imaging
After the revision, the flap fully recovered and the

patient was discharged home at day 8 postopera-
tively. The abdominal scar healed without any
complication.
The flap edges showed some dehiscence that
healed with conservative treatment. Secondary aes-
thetic procedures were performed 4 months postop-
eratively. The flap was advanced towards the
midline and the lipofilling of the medial and the
superior border of the right breast was performed.
Furthermore, the inframammary fold was impro-
Fig. 6 Intraoperative view with anastomosis of DIE ped-
icle to the IM vessels (green arrow), SIEv with interposi-
ved. The immediate postoperative result can be
tion graft to side branch of DIEv (blue arrow) seen in Fig. 7.
2. Suprafascial dissection of perforator: Once the

perforator was identified through the old scar,
the flap was elevated from lateral to medial
1. CTA is recommended when vascular anatomy
with monopolar electrocautery in the plane
is not predictable, especially in cases of previ-
above the muscular fascia up to the identified
ous abdominal scars. CTA can accurately map
perforator.
the perforators and also help in perforator
3. Intramuscular dissection of perforator: The
choice in flaps both from scarred and unscarred
muscular fascia is then opened for several cen-
abdominal wall (Ngaage et al. 2019).
timeters with the microscissors. The dissection
2. Intraoperatively a venous congestion was
of the perforator was performed with bipolar
detected after the vascular anastomoses. The
forceps, micro-De Bakey forceps and Q-tips.
arterial and venous anastomoses were evalu-
The motor branches of the intercostal nerves
ated and were both patent, while the left SIEV
can be identified traversing the pedicle and
was congested and when unclamped it showed
they were spared. The deep inferior epigastric
dark venous bleeding. This means that the
vessels were dissected during their intramuscu-
superficial system was the main venous return
lar course up to the posterior surface of the
in the flap. Then an anastomosis between the
rectus muscle. Then the vessels were followed
SIEV and a side branch of the anastomosed
caudally to their origin and then ligated (Fig. 6).
DIEV was performed (Liu et al. 2007).
3. However, after 12 h, the flap was again
congested and then revised. The congestion
was due to an excessive tension along the
anastomosis between the SIEV and the DIEV.
The patient was postoperatively monitored for the
The anastomosis was released and vein graft
first 5 days with flap monitoring protocol. Clinical
and was used to bridge the gap between the two
monitoring involves checking color, temperature,
vessels and decrease tension.
capillary return, and Doppler signal evaluation.
The monitoring is performed every 30 min during
the day of the surgery, every hour for the next 24 h, Learning Points
every 2 h in the second postop day, every 3 h during
the postop day 3, every 8 h in the postop day 4, and 1. The preoperative computed tomography angi-
then once per day. Low molecular weight heparin ography (CTA) has a primary role in the surgi-
(LMWH) is administered according to the risk cal planning of perforator flap breast
factors during the hospitalization. reconstruction. CTA identifies the most
Fig. 7 Postoperative view

after one session of
corrections of the
reconstructed breast
suitable perforators, showing the perforator alternative plan B, previous abdominoplasty

anatomy and their course from the subcutane- is no longer an absolute but a relative contra-
ous tissue up to the main vessel. indication in DIEaP flap harvesting.
2. Due to the preoperative CTA, previous abdom- 4. The flap was based on a right periumbilical
inal scars and/or liposuctions of the abdomen perforator which was detected during the
are no longer a contra-indication for DIEP flap CTA. The first hypothesis of the nature of this
harvesting. (Mahajan et al. 2012; Parrett et al. perforator is that this is due to repermeation or
2008; Masia et al. 2010; Hamdi et al. 2014; regeneration of the vessels during the scarring
Dragu et al. 2010). Nevertheless previous full (Ribuffo et al. 2001). There are scarce studies
abdominoplasty with umbilical transposition is regarding the anatomical changes in perfora-
still considered an absolute contraindication tors following abdominal scars (Ngaage et al.
for a DIEaP-flap harvesting. 2019). During the scar healing, vascular endo-
3. However, some authors reported a DIEP flap thelial growth factor and basic fibroblast
harvesting after an abdominoplasty (Broyles growth factor increased their expression, allo-
et al. 2012; Rozen et al. 2012; Di Candia wing vasodilation and angiogenesis (Kim et al.
et al. 2012) This is the first case report of a 2017; Ngaage et al. 2019). The second hypoth-
DIEaP flap harvesting in a patient who had esis of the perforator origin is the possibility
undergone a previous full abdominoplasty that during the previous surgery, the upper
with umbilical repositioning. This case shows abdominal flap was only mobilized on the
that with correct perforator mapping and an midline.
5. Venous congestion is suspected in case of brisk breast reconstruction. Plast Reconstr Surg.
capillary refill or red/purple coloration of the 2016;138(2):343–52.
Kim SY, Lee KT, Mun GH. The influence of a Pfannenstiel
flap. Other intraoperative findings of venous scar on venous anatomy of the lower abdominal wall
congestion of the flap are the evidence of a and implications for deep inferior epigastric artery per-
dilated SIEV or brisk bleeding during the forator flap breast reconstruction. Plast Reconstr Surg.
deepithelialization of the flap (Bartlett et al. 2017;139(3):540–8.
Liu TS, Ashjian P, Festekjian J. Salvage of congested deep
2018). inferior epigastric perforator flap with a reverse flow
venous anastomosis. Ann Plast Surg. 2007;59(2):
214–7.
Cross-References Mahajan AL, Zeltzer A, Claes KE, et al. Are Pfannenstiel
scars a boon or a curse for DIEP flap breast reconstruc-
tions? Plast Reconstr Surg. 2012;129:797–805.
▶ Intraoperative Perforator Avulsion in Free Flap Masia J, Kosutic D, Clavero JA, et al. Preoperative com-
Breast Reconstruction puted tomographic angiogram for deep inferior epigas-
tric artery perforator flap breast reconstruction.
J Reconstr Microsurg. 2010;26:21–8.
Ngaage LM, Hamed R, Oni G, et al. The role of CT
References angiography in assessing deep inferior epigastric per-
forator flap patency in patients with pre-existing
Bartlett EL, Zavlin D, Menn ZK, et al. Algorithmic abdominal scars. J Surg Res. 2019;235:58–65.
approach for intraoperative salvage of venous conges- Parrett BM, Caterson SA, Tobias AM, et al. DIEP flaps in
tion in DIEP flaps. J Reconstr Microsurg. 2018;34(6): women with abdominal scars: are complication rates
404–12. affected? Plast Reconstr Surg. 2008;121:1527–31.
Broyles JM, Howell LK, Rosson GD. Succesfull DIEP flap Patel NG, Ramakrishnan V. Microsurgical tissue transfer in
for breast reconstruction in a patient with prior breast reconstruction. Clin Plast Surg. 2017;44(2):
abdominoplasty. Plast Reconstr Surg. 2012;129:874e– 345–59. https://doi.org/10.1016/j.cps.2016.12.002.
5e. Epub 2017 Feb 13.
Di Candia M, Asfoor AA, Jessop ZM, et al. Previous Ribuffo D, Marcellino M, Barnett GR, et al. Breast recon-
multiple abdominal surgeries: a valid contraindication structions with abdominal flaps after abdominoplasties.
to abdominal free flap breast reconstruction? Eplasty. Plast Reconstr Surg. 2001;108:1604–8.
2012;12:e31. Rozen WM, Whitaker IS, Ting JWC, et al. Deep inferior
Dragu A, Unglaub F, Wolf MB, et al. Scars and perforator- epigastric artery perforator flap harvest after
based flaps in the abdominal region: a contraindication? abdominoplasty with the use of computed tomographic
Can J Surg. 2010;53:137–42. angiography. Plast Reconstr Surg. 2012;129:198e–200e.
Hamdi M, Larsen M, Craggs B, et al. Harvesting free Zeltzer AA, Andrades P, Hamdi M, et al. The use of a
abdominal perforator flaps in the presence of previous single set of internal mammary recipient vessels in
upper abdominal scars. J Plast Reconstr Aesthet Surg. bilateral free flap breast reconstruction. Plast Reconstr
2014;67:219–25. Surg. 2011;127:153e–4e.
Hamdi M, Craggs B, Brussaard C, et al. Lumbar artery Zeltzer AA, De Baerdemaeker RA, Hendrickx B, et al.
perforator flap: an anatomical study using multidetector Deep inferior epigastric artery perforator flap harvest
computed tomographic scan and surgical pearls for after full abdominoplasty. Acta Chir Belg. 2018;1:1–6.
Perineal Reconstruction for a Complex
Perineal Defect 99
Aileen Egan, Eamon Francis, and Colin Morrison
Contents
Preoperative Planning/Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
Defect Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
Options for Reconstruction Available/Precluded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
Intraoperative Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1047
Small and/or Superficial Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1048
Large and Complex Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1049
Surgical Technique and Intraoperative Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1050
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1052
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1053
Abstract
A. Egan (*) · E. Francis The need for perineal reconstruction can occur
Department of Plastic, Reconstructive and Aesthetic in a variety of settings, including congenital
Surgery, St. Vincent’s University Hospital, Dublin, Ireland
defects, post-traumatic, post-infectious, and fol-
e-mail: aileenfegan@rcsi.com; francise@tcd.ie
lowing oncologic resection. Respecting the
C. Morrison
variation in male and female anatomy, there
Department of Plastic, Reconstructive and Aesthetic
Surgery, Surgical Professional Unit, St. Vincent’s are a number of well-described methods of
University Hospital, Dublin, Ireland

https://doi.org/10.1007/978-3-030-23706-6_121
1046 A. Egan et al.
reconstruction. They may not, however, be Three weeks later, the patient underwent com-
encountered in large volumes in many practices. pletion proctectomy with further EndoSponge®
The challenge includes the provision of an temporization dressing. The defect at this stage
aesthetic as well as a functional reconstruction. involved a dead-space cavity of 1474cm
This may involve a skin and pelvic cavity (length height width), with significant radio-
defect, vaginal defect of variable degree, and therapy skin changes peripherally. The patient
the necessity to maintain continence. subsequently underwent reconstruction of this
The perineal region has a rich vascular supply, perineal defect with a pedicled anterolateral
meaning there are several local or regional flap (ALT) flap.
reconstructive options. Nevertheless, healing by
secondary intention, with negative-pressure
wound therapy (NPWT) and split-thickness Preoperative Problem List:
skin grafting, is also possible, with free tissue Reconstructive Requirements
transfer a further consideration, particularly
with massive defects. Preoperative Planning/Workup
Below we outline a stratagem and discus-
sion, centered on a complex post-oncological In this case, the patient had an established defect
resection for a male patient. following major oncological resection, which was
refractory to other interventions.
Keywords A single-stage procedure was required which
recruited healthy vascularized tissue of sufficient
Perineum · Oncologic resection ·
bulk to obliterate the cavity and promote healing
Reconstruction · Anterolateral Thigh (ALT) ·
of the irradiated wound bed.
Pedicled Flap
Defect Composition
The perineal defect consisted of a dead-space
A 52-year-old man, with a history of colorectal
cavity of 1474cm (length height width),
cancer treated with surgery and radiotherapy, pre-
with significant radiotherapy skin changes periph-
sented with a non-healing perineal wound.
erally (Fig. 1).
One year previously the patient had undergone
a low anterior resection with primary anastomo-
sis. The postoperative course was complicated by
Options for Reconstruction
an anastomotic leak, requiring him to undergo an
Available/Precluded
emergent Hartmann procedure and loop
ileostomy. Following this, the patient developed
A previous laparotomy scar and the presence of a
a pre-sacral collection.
stoma on both sides of the abdomen precluded any
This was initially drained via a pelvic drainage
of the abdominal-based reconstructive options,
catheter inserted by interventional radiology. How-
leading to consideration of the thigh or buttocks
ever, a number of months later, the patient had
as available donor sites (Fig. 2).
ongoing perineal discharge secondary to a persis-
tent collection. Examination under anesthetic
(EUA) was performed with EndoSponge® inser-
tion. After 3 weeks of this management, referral to Intraoperative Requirements
the plastic surgery service was made to determine
suitability for perineal reconstruction. It is useful to consider the following:
99 Perineal Reconstruction for a Complex Perineal Defect 1047
Fig. 1 Perineal defect post-completion proctectomy. Post-radiation skin changes visible (left); and demonstration of the
large cavity (right)
• Intraoperative diagnostic equipment, e.g.,

indocyanine green dye, Doppler probe (posi-
tioning/access for personnel/screening/
pathology)
Treatment Plan
Surgical planning for this patient required consid-

eration of the following:
– Disease-free status following colorectal can-

cer; follow-up ongoing with colorectal and
oncology teams
– Previous radiation therapy to perineal area
– Other co-morbidities (nil of note)
– Presence of previous colostomy and ileostomy
on anterior abdominal wall
– Risk of bladder injury and potential diversion/
suprapubic catheter insertion
– Optimization of metabolic and nutritional sta-
tus pre- and postoperatively
– Prolonged operative time
Fig. 2 Anterior abdominal wall demonstrating midline – Positioning and potential for repositioning
laparotomy scar and bilateral stomata intraoperatively
• Discussion with anesthetic colleagues regard-

The aims of surgical perineal reconstruction
ing surgical plan, timeframe, and positioning,
include:
including positioning of intravascular monitor-
ing or access – Dead space obliteration
• Availability of a high-dependency or intensive- – Import of healthy, well-vascularized, non-
care bed postoperatively irradiated tissue (flap reconstruction)
1048 A. Egan et al.
– Choosing an acceptable donor site

– Maintaining integrity of the abdominal wall
– Cosmetic acceptability
– Providing protective sensation
– Allowing sexual intercourse (in event of vagi-
nal reconstruction)
Challenges of reconstruction include:
– Ideally to be carried out as a single-stage

procedure
– Robust and reliable to facilitate early recovery
– Minimizing complications
– Including bulk to fill the dead space Fig. 3 Areas of perineum for consideration of reconstruc-
– Minimizing donor-site morbidity tion, from (Niranjan 2006)
Small and/or Superficial Defects

– Local flaps are generally limited in their size
In consideration of any perineal defect, for either and vascularity, particularly in cases where a
male or female patients, it is prudent to consider wound bed has previously been irradiated.
the relevant anatomy and resultant defect. – Regional flaps provide skin and subcutaneous
Notwithstanding the advances in surgical prac- tissue based on known vascular perforators. As
tices for colorectal malignancy and increasing lapa- shown above, the internal pudendal artery
roscopic, laparoscopic-assisted, and robotic surgery, gives off multiple branches including the pos-
primary closure, with or without mesh augmenta- terior labial arteries, which supply design of
tion, will occasionally not be feasible, and herein both the Lotus Petal and Singapore flaps.
enters the skills of the reconstructive surgeon. – The Singapore flap, described by Wee and
A number of classification systems have been Joseph in 1989 (Wee and Joseph 1989), can
described in an attempt to aid reconstructive deci- be raised either uni- or bilaterally, depending
sion making (Westbom and Talbot 2019; Moraru on the defect.
and Scripcariu 2017; Vranckx and D’Hoore – The Lotus Petal flap (Yii and Niranjan 1996),
2012), with the majority reverting to options for reported in 1996, illustrated a multi-vector
superficial versus deep defects (John et al. 2013). adipocutaneous flap which became popular
Alternatively, a more recent publication by Merici for vulvovaginal reconstruction. A thinner,
et al. described a “subunit approach” (Mericli more aesthetically considered refinement was
et al. 2016). described by Warrier et al. in 2004 (Warrier
It is worth bearing in mind that in the absence et al. 2004).
of Level 1 evidence, the current literature suggests – The Gluteal Fold flap is another of those based
that autologous myocutaneous flap reconstruction on perforators of the internal pudendal vessels,
of irradiated perineal defects is superior to pri- often designed as a V-Y advancement, and also
mary closure (Howell et al. 2013) (Fig. 3). has the advantage of bilaterality. This has been
Below, we will outline a series of options for widely described, with some modifications, in
perineal reconstruction, which can be used alone addition to its retaining of sensation (Coltro
or in combination with one another, according to et al. 2015; Hurwitz et al. 1981)
the clinical scenario. As with all procedures, sur- – Monstrey et al. also described their use of the
geons’ experience and preferences may dictate the Pudendal Thigh Fasciocutaneous Island flap
chosen reconstruction (Fig. 4). (Monstrey et al. 2001)
Fig. 4 Perforator blood

supply to perineal region
(Niranjan 2006)
Large and Complex Defects for perineal defects in 2000 by Luo et al.
(2000). Indeed, more extensive defects have
Larger defects can require muscle and soft tissue been reconstructed using chimeric ALT-VL
bulk, potentially from more than one site. (vastus lateralis) pedicled flaps, as described
Some may wish to consider them in terms of by Wong et al. (2009). Even further still,
their donor region: mega-chimeric ALT-VL-Rectus femoris flap
in a case report by Kosutic et al. (2019) high-
Abdominal lights the importance of patient-specific nature
– Transverse Rectus Abdominus Myocutaneous of the surgical planning in these cases.
Flap (TRAM) – Gracilis.
– Vertical Rectus Abdominus Myocutaneous – Tensor Fascia Lata.
Flap (VRAM)
– Oblique Rectus Abdominus Myocutaneous
Flap (ORAM) Preoperative Evaluation and Imaging
– Omentum
Preoperative multidisciplinary team discussion to
Gluteal involve all relevant parties in the patient’s care is
– Inferior Gluteal Artery Perforator Flap (IGAP) advisable.
– Inferior Gluteal Artery Myocutaneous Flap Preoperative consultation with the patient for
(IGAM) (Boccola et al. 2010) formal clinical examination and explanation of
available reconstruction options, including con-
Thigh sent for surgery and anticipated risks and benefits.
– Anterolateral thigh (ALT) was first described Preoperative imaging may be useful in some
in 1984 as a free flap by Song et al. (1984), and settings, such as in the form of CT angiography;
1050 A. Egan et al.
however, this is usually a guide only, as the sur- – Dissection of the pedicle to main profunda
gical course may deviate. artery maximized pedicle length.
Most importantly, preoperative marking of rel- – Tunnel created subcutaneously to allow inset
evant perforators using a Doppler probe, either of the flap to the perineum.
before or during surgery. – Donor site at right thigh was primarily closed
with a drain.
– Flap was de-epithelialized distally to allow
Preoperative Care and Patient roll-up and inset into the perineal cavity, with
Drawing the remaining proximal skin paddle inset to
close the external skin defect.
In this case, the patient was prepared for surgery in – Two pelvic drains were placed (Fig. 6).
the supine position, with the right thigh having
been selected as the donor site. Cavity dimensions
were taken (Fig. 5). Technical Pearls
The anterolateral thigh flap markings were car-
ried out in standard fashion: – Draw additional oblique line from ASIS to
mid-patella. Along this line center a 15 cm
– Line drawn from the anterior superior iliac incision equidistant from the main perforator;
spine (ASIS) to the proximal lateral border of if the perforator is not good when explored or if
the patella, with midpoint marked injured you can then elevate an AMT flap.
– Circle of radius 2 cm marked around this mid- – The 15 cm incision is extended curvilinearly
point to locate the most common perforating by 2 cm proximally and distally once the per-
vessels forator is confirmed as suitable.
– Skin paddle designed according to template – The donor site can be closed primarily if it is
and incision line marked medially at this level 8 cm at its width centrally; beyond this it is
unlikely. The more distal the skin defect, the
more challenging closure becomes.
Surgical Technique and Intraoperative – To help close a donor site primarily you can
Images longitudinally incise the Tensor Fascia Lata
(TFL) along the full length of the wound, in
– Flap dissection carried out medially to later- addition to mobilizing the soft tissues, but cau-
ally, identifying and protecting perforating ves- tion should be exercised as the perforators from
sels using vessel loops. rectus femoris can/will be sacrificed.
a b
Fig. 5 (a) Preoperative marking of the right anterolateral the right anterolateral thigh using handheld Doppler probe
thigh donor site as described, drawing line from ASIS to to identify perforating vessels to the skin within a circle of
lateral border of the patella. (b) Preoperative marking of 6 cm diameter at midpoint of primary line
a b
c d
Fig. 6 (a) Flap dissection carried out medially to laterally, the pedicle turned through approximately 90 degrees. The
identifying and protecting perforating vessels using vessel proximal skin paddle was designed to recreate the skin
loops. (b) Partial intramuscular course of the pedicle neces- defect. The distal portion of the flap was de-epithelialized
sitated short intramuscular dissection to access main vas- to allow folding inward to fill the cavity. (d) Flap appear-
cular supply. (c) Flap was tunneled subcutaneously, with ance following inset
– The distal runoff should not be divided until

the flap itself is ready to be disconnected, as it Postoperative Management
can be made chimeric by including it and
vastus lateralis to increase bulk to fill any Postoperatively, these patients are often managed
dead space. in a high-dependency setting, or on a dedicated
– The pedicle to ALT flap is highly variable and ward to facilitate close monitoring and attentive
should be dissected carefully; particular atten- positioning.
tion should be paid to the oblique branch, Ideally, the patient should be nursed laterally,
which is typically higher than midpoint perfo- side-to-side, avoiding pressure on the perineal
rators but can still supply the flap and provide area. (Further limitations may be required in the
adequate pedicle length in free tissue transfer. case of other donor sites.)
– If tunneling the flap, caution not to avulse the Placement of a pillow between the patient’s
perforator or kink it at inset when using the thighs in order to avoid excessive compression
ALT as a pedicled flap; transpose over rectus on the flap or at bony prominences of the knees
femoris and gracilis. while laterally positioned.
1052 A. Egan et al.
Drains are ideally left in situ until draining less – Infection and abscess formation
than 30 ml on two consecutive days once the – Seroma
patient has been mobilizing. – Dehiscence
The patient can mobilize as soon as tolerated to – Delayed healing
facilitate postoperative recovery; however, they – Sinus formation
must avoid sitting directly for longer than a few – Flap loss or necrosis (partial or complete)
seconds, ideally.
Sutures are removed between 2 and 3 weeks Therefore, all efforts should be made to
postoperatively, pending healing status. address these intraoperatively in the first instance.
Close clinical monitoring will assist in early
detection or suspicion of such problems, and pro-
Outcome-Clinical Photos and Imaging mpt management is imperative to avoid
compromising the reconstruction.
Following an uneventful postoperative course,
our patient was discharged home on postoperative
day 7. The photographs below demonstrate very Learning Points
satisfactory healing of both donor and flap
(Fig. 7). – Multidisciplinary management is essential
from start to finish in these cases.
– Identification of required tissues for the recon-
Avoiding and Managing Problems struction will guide decision regarding
reconstruction.
As described across the literature, complication – Patient-specific procedure can provide well-
rates following perineal surgical procedures vary vascularized tissue, with or without bulk.
widely – between 14% and 80% (Moraru and – Occasionally, more than one mode of recon-
Scripcariu 2017). The most common reasons for struction may be required, for very large or
complications and wound issues include: complex defects.
Fig. 7 (a) Donor site

6 weeks postoperatively. (b) a b
Flap appearance at 6 weeks
– Importance of having a “lifeboat” procedure in reconstruction. Plast Reconstr Surg. 2000;105(1):

the event of perforator injury. 171–3.
Mericli AF, Martin JP, Campbell CA. An algorithmic ana-
tomical subunit approach to pelvic wound reconstruc-
tion. Plast Reconstr Surg. 2016;137(3):1004–17.
References Monstrey S, Blondeel P, Van Landuyt K, Verpaele A,
Tonnard P, Matton G. The versatility of the pudendal
Boccola MA, Rozen WM, Ek EW, Teh BM, Croxford M, thigh fasciocutaneous flap used as an island flap. Plast
Grinsell D. Inferior gluteal artery myocutaneous island Reconstr Surg. 2001;107(3):719–25.
transposition flap reconstruction of irradiated perineal Moraru DC, Scripcariu V. Updates in pelviperineal recon-
defects. J Plast Reconstr Aesthet Surg. 2010;63(7): struction options after abdominoperineal resection. J
1169–75. Surg. 2017;13:115–22.
Coltro PS, Ferreira MC, Busnardo FF, Olivan MV, Ueda T, Niranjan NS. Perforator flaps for perineal reconstructions.
Grillo VA, et al. Evaluation of cutaneous sensibility of Semin Plast Surg. 2006;20(2):133–44.
the internal pudendal artery perforator (IPAP) flap after Song YG, Chen GZ, Song YL. The free thigh flap: a new
perineal reconstructions. J Plast Reconstr Aesthet Surg. free flap concept based on the septocutaneous artery. Br
2015;68(2):252–61. J Plast Surg. 1984;37(2):149–59.
Howell AM, Jarral OA, Faiz O, Ziprin P, Darzi A, Vranckx JJ, D’Hoore A, editors. 7 Reconstruction of per-
Zacharakis E. How should perineal wounds be closed ineum and abdominal wall. Selected Topics in Plastic
following abdominoperineal resection in patients post Reconstructive Surgery. Chapter 7. 2012. https://doi.
radiotherapy-primary closure or flap repair? Best evi- org/10.5772/31520
dence topic (BET). Int J Surg (London, England). Warrier SK, Kimble FW, Blomfield P. Refinements in the
2013;11(7):514–7. lotus petal flap repair of the vulvo-perineum. ANZ J
Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a Surg. 2004;74(8):684–8.
reliable, sensate flap for the closure of buttock and peri- Wee JT, Joseph VT. A new technique of vaginal recon-
neal wounds. Plast Reconstr Surg. 1981;68(4):521–32. struction using neurovascular pudendal-thigh flaps: a
John HE, Jessop ZM, Di Candia M, Simcock J, Durrani AJ, preliminary report. Plast Reconstr Surg. 1989;83(4):
Malata CM. An algorithmic approach to perineal recon- 701–9.
struction after cancer resection – experience from two Westbom CM, Talbot SG. An algorithmic approach to
international centers. Ann Plast Surg. 2013;71(1):96– perineal reconstruction. Plastic Reconstruct Surg –
102. Global Open. 2019;7(12):e2572.
Kosutic D, Tsapralis N, Gubbala P, Smith Wong S, Garvey P, Skibber J, Yu P. Reconstruction of
M. Reconstruction of critically-sized perineal defect pelvic exenteration defects with anterolateral thigh-
with perforator flap puzzle technique: a case report. vastus lateralis muscle flaps. Plast Reconstr Surg.
Case Rep Plastic Surg Hand Surg. 2019;6(1):38–42. 2009;124(4):1177–85.
Luo S, Raffoul W, Piaget F, Egloff DV. Anterolateral thigh Yii NW, Niranjan NS. Lotus petal flaps in vulvo-vaginal
fasciocutaneous flap in the difficult perineogenital reconstruction. Br J Plast Surg. 1996;49(8):547–54.
Breast Reconstruction Using
a Transverse Upper Gracilis Flap 100
Tasneem Belgaumwala and N. Pantelides
Contents
Preoperative Problem List: Reconstruction Requirements . . . . . . . . . . . . . . . . . . . . . . . 1056
Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1056
Alternative Reconstruction Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1057
Intraoperative Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1060
Outcome and Clinical Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1061
Learning Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1061
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1063
Abstract
This case illustrates the use of a transverse

T. Belgaumwala (*) upper gracilis (TUG) flap for breast reconstruc-
St. Andrew’s Centre for Plastic Surgery and Burns, tion. The patient previously had a right breast
Broomfield Hospital, Chelmsford, UK reconstruction with a deep inferior epigastric
Guy’s and St. Thomas’ NHS Trust, London, UK artery perforator (DIEP) flap and underwent a
e-mail: tasneem.belgaumwala@nhs.net contralateral risk reducing mastectomy with
N. Pantelides immediate reconstruction. The total operative
St. Andrew’s Centre for Plastic Surgery and Burns, time was 3.5 h. The patient’s postoperative
e-mail: n.pantelides@nhs.net recovery was uneventful, and she was

https://doi.org/10.1007/978-3-030-23706-6_130
1056 T. Belgaumwala and N. Pantelides
discharged from the hospital on the fifth post- while the secondary aim was to limit donor site
operative day. The late postoperative result was morbidity.
aesthetically pleasing with no palpable areas of
fat necrosis. The thigh donor area healed
uneventfully with no wound dehiscence or Preoperative Problem List:
seroma. There was good bilateral breast sym- Reconstruction Requirements
metry in the long term after nipple reconstruc-
tion and areolar tattooing. 1. Breast reconstruction using autologous tissue
2. Previous use of abdominal pannus for breast
reconstruction so DIEP flap unavailable
Keywords
3. Need to match the volume and ptosis of previ-
Breast reconstruction · Autologous ously reconstructed right breast
reconstruction · TUG flap · Low BMI 4. Use of single donor site (if possible)
requiring no/minimal revision
A 60-year-old patient, who had previously under- Treatment Plan

gone right mastectomy and deep inferior epigas-
tric artery perforator (DIEP) flap breast The decision was to proceed with a TUG flap
reconstruction, presented to us for left risk- reconstruction from the right thigh, as the patient
reducing mastectomy and autologous reconstruc- had adequate thigh tissue and in order to avoid an
tion (Fig. 1). Since she had previously undergone intraoperative change of position. She was
a DIEP flap, the abdominal donor site was no counseled regarding the procedure and its compli-
longer available. On examination of alternative cations accordingly.
donor areas, she had adequate tissue in the upper The TUG flap offers an autologous reconstruc-
medial thigh area, and reconstruction was planned tive option with good aesthetic results in an appro-
using a transverse upper gracilis (TUG) flap priately selected patient. The flap can be
(Fig. 2). The primary reconstructive aim was to comfortably harvested from the contralateral
match the previous right-sided reconstruction, thigh in the supine position while the mastectomy
Fig. 1 Preoperative
show breast size, previous
breast reconstruction, and
thigh donor area
100 Breast Reconstruction Using a Transverse Upper Gracilis Flap 1057
Fig. 2 Preoperative
show breast size, previous
breast reconstruction, and
thigh donor area
is being performed. The septocutaneous pedicle may also be appropriate. However, if the patient
dissection is easier compared with the perforator has an autologous reconstruction for the contralat-
dissection of many alternative flaps, and there is eral breast, it can be difficult to achieve a similar
no functional deficit from gracilis muscle harvest. result using implant-based reconstruction. Multiple
If the tissue obtained from a unilateral TUG is future procedures are likely to be required for
inadequate, stacked TUG flaps may be used to expander/implant exchange (Pu et al. 2018; Kitcat
reconstruct a single breast, or the unilateral TUG et al. 2012). There is also a risk of Anaplastic Large
flap may be augmented with primary or secondary Cell Lymphoma (ALCL), albeit very low (Collett
lipomodeling (Pantelides et al. 2022). et al. 2019; Sheena et al. 2020).
Alternative Reconstruction Options Preoperative Evaluation and Imaging
The deep inferior epigastric artery perforator The patient was examined initially in the standing
(DIEP) flap is considered the gold standard for position to determine the breast size/symmetry
autologous breast reconstruction but is not avail- and degree of ptosis. The thigh, lumbar, and glu-
able in all patients. For patients who have under- teal donor sites were assessed. On the medial
gone an abdominoplasty, or if the DIEP flap has thigh, the pinch test was used to assess the volume
previously been used, this option is no longer of tissue available and the degree of medial upper
available. Furthermore, some slim patients with thigh laxity. The area was examined for scars to
low body mass index (BMI) may have inadequate exclude previous operations.
skin and fat in the abdominal pannus and scars Preoperatively, a hand-held Doppler may
from previous abdominal operations may jeopar- be used to site the skin perforators in the
dize the blood supply of the lower abdomen medial thigh but is not necessary as there are
(Pollhammer et al. 2016; Mohan et al. 2020). reliable and consistent skin perforators present
Alternative autologous donor sites available 8–12 cm distal to the pubic symphysis (Arnez
include medial thighs (TUG/PAP flaps), flanks et al. 2004).
(LAP flaps), and buttocks (sGAP/iGAP flaps)
(Kitcat et al. 2012).
Flaps from the gluteal and lumbar region Preoperative Care and Patient
require a change of position during flap harvest Drawing
and closure so parallel operating is not possible.
The pedicle length obtained is short and needs The patient was marked preoperatively in the
extension using grafts (Opsomer et al. 2018), standing position. The breast footprint and breast
increasing time under anesthesia. meridian were marked bilaterally. If the patient
For some patients, particularly those who will has significantly ptotic breasts, a Wise pattern
not require radiotherapy, an implant reconstruction skin resection is marked.
A contralateral TUG flap was designed, for Scarpa’s fascia to preserve lymphatics in the
ease of pedicle orientation, as discussed later. femoral triangle and prevent lymphedema.
The markings of the TUG flap were also done 4. The long saphenous vein was identified and
in the standing position. With the thigh abducted preserved. A medial tributary of the long
and externally rotated, the adductor longus mus- saphenous vein, which lies along the inferior
cle was palpated and the gracilis muscle drawn edge of the skin paddle, was harvested to
on posterior to this. The upper border of the flap some length. This can be used as a vein graft
was marked 2 cm below the groin crease. The if needed later to increase the pedicle length.
anterior limit of the flap is just medial to the 5. Once the medial border of the long saphenous
anterior midline of the thigh while posteriorly vein was crossed and the adductor fascia was
it is marked just short of the posterior midline. identified, the dissection changed to a deeper
A crescent-shaped flap was marked, centered subfascial plane such that the fascia of the
over the gracilis muscle, with the width of it adductor longus was incorporated into
being limited by ease of primary donor site clo- the flap.
sure (Fig. 3). This was determined by the 6. Continuing in the subfascial plane, at the
pinch test. medial border of adductor longus, the septum
Following induction of anesthesia, the patient between adductor longus and gracilis was
was placed in the supine position with the arms seen. The septum was opened and the gracilis
out, taking care to protect all pressure points. Both pedicle and obturator nerve were identified.
breasts and the right leg were prepared and 7. The inferior border of the flap was incised,
draped. and the inferior thigh was undermined in the
sub-Scarpa’s plane to recruit more fat into
the flap.
Surgical Technique 8. The posterior dissection was then performed.
The posterior skin was incised, and the flap
1. The breast surgeon performed a circumareolar raised from posterior-to-anterior in a sub-
mastectomy. fascial plane, taking care to recruit all the fat
2. While the mastectomy was carried out, the available. The dissection was continued over
flap was harvested from the contralateral the muscles of the posterior thigh (semi-
thigh. membranosus and semitendinosus) until the
3. After incising the anterior edge of the flap, the posterior border of the gracilis was reached.
flap was raised initially from anterior-to-pos- Care must be taken to identify the gracilis
terior. This initial portion, medial to adductor muscle from posteriorly to avoid elevating
longus was raised immediately below the the fat/fascia off it.
photograph showing
position of patient for flap
harvest
9. At this point, the gracilis muscle was trans- the surgery into multiple steps) makes it sim-
ected inferiorly and superiorly taking great pler to allocate tasks to each team member
care to achieve adequate hemostasis at the (Sharma et al. 2019).
cut edge of the muscle on either side. It is 2. Harvesting a contralateral TUG flap ensures
important to harvest all the fascia surrounding that the flap pedicle is orientated toward the
the muscle in order to recruit all the perfora- medial chest recipient vessels once the flap
tors supplying the skin. has been coned, for ease of anastomosis.
10. The final part of the flap raise is pedicle dissec- 3. Including the medial tributary of the long
tion: the pedicle was dissected proximally up to saphenous vein may provide a source of
the point that it enters the profunda femoral vein grafts if pedicle lengthening is required.
vessels. Self-retaining retractors were used to 4. Do not recruit tissue into the flap too aggres-
hold the muscular septum open for easy access sively, particularly at the inferior border. This
to the pedicle. Once adequate pedicle length and risks creating excessive dead-space, which
caliber was attained, the pedicle was divided. leads to seroma and infection.
11. After the mastectomy finished, hemostasis of 5. Meticulous hemostasis at each stage is essen-
the mastectomy skin flaps and breast pocket tial. This is especially important at the cut
was achieved. At this point, sutures can be edges of the gracilis muscle since it retracts
used to reposition the inframammary fold and once it is divided. Dissection and hemostasis
the lateral breast fold if required. may be made easier by the infiltration of 1%
12. The recipient vessels were then prepared. If lidocaine as it minimizes the muscular con-
preserved during mastectomy, the internal traction and negates the need for muscular
mammary artery perforators (IMAp) are a paralysis (Haeney et al. 2005).
good caliber match to the gracilis vessels. 6. Try to obtain maximum pedicle length by
Otherwise, the internal mammary vessels dissecting to the point where the pedicle joins
(IMA/IMV) can be used as recipients. the profunda femoris. This also ensures a better
13. The TUG flap was shaped on a side operating caliber of gracilis vessels and decreases vessel
table (Figs. 4, 5, and 6). The flap was coned to size mismatch, particularly if the internal mam-
recreate the breast mound and give adequate mary recipients are chosen.
projection, before being positioned on the 7. Shaping the flap before the anastomosis
chest and secured for anastomosis. helps determine the pedicle lie and keeps
14. The anastomosis was done to the internal the entire construct more stable during the
mammary perforator vessels in the second anastomosis. It may be possible to increase
intercostal space. pedicle length by means of interposition vas-
15. Before flap inset, the pedicle was examined to cular grafts as a bench anastomosis while
ensure there was no twist or kink on it. It is recipient vessel dissection is being carried
imperative to ensure that there is no tension out.
on the pedicle while positioning the flap in the 8. Since a crescent of tissue is obtained, it may
breast pocket. be shaped into a cone by bringing the tips of
16. Final flap contouring and de-epithelization the ellipse together to recreate a breast
was done, and the flap was inset. mound. Alternatively, it can be partially
17. The total surgical time was 3.5 h. coned or laid as a crescent in the lower pole,
depending on the shape and width of the
contralateral breast.
Technical Pearls 9. Use of venous couplers decreases anasto-
motic time and minimizes the risk of using
1. A two-team approach is essential to ensure vein grafts.
parallel operating at multiple sites and reduce 10. The IMAp vessels are generally a good caliber
operative time. Process mapping (breaking match for the flap vessels. Use of the IMAp
also decreases the need for vein grafts, as a

shorter pedicle length is required. They may
be dissected down to the intercostal membrane
for better caliber of vessels (Fattah et al. 2010).
This aids in more aesthetic placement of the
flap as the major bulk of tissue in breast recon-
struction is required in the lower pole.
11. If the IMA/IMV is used, this may require
resection of a portion of the third/fourth rib,
to increase the recipient length available. The
IMA is also smaller inferiorly so there is less
chance of a significant size discrepancy with
the flap vessels. Fig. 5 Intraoperative photograph showing harvested flap
12. Anchoring sutures may be taken between the
gracilis muscle and the pectoralis epimysium
to hold the pedicle in place and avoid
traction.
13. Dermal release at the edge of the skin paddle
aids in suturing of the skin and avoids the step
off from mastectomy to flap skin.
14. It may be possible to reconstruct the nipple
primarily in certain cases if the center of the
crescent coincides with the summit of the
breast mound and is at the same level as the
contralateral nipple.
Intraoperative Photos
Fig. 6 Intraoperative photograph showing possible flap

placement and coning options to increase projection

tively by physical examination and regular mon-
itoring of the skin island. Temperature, color,
turgor, and capillary refill were monitored hourly
for the first 24 h, followed by 2 and 4 h for the next
24 and 48 h, respectively. The blood pressure and
urine output were similarly observed to ensure the
patient was adequately hydrated. A Bair hugger
Fig. 4 Intraoperative photograph showing harvested flap was used for the first 24 h to avoid hypothermia
and promote vasodilatation. Clear fluids were for anastomosis. Patients should be warned
started orally once the patient was fully awake, regarding the risks of donor site complications,
along with supplementary intravenous fluids. Use such as delayed healing, seroma, infection,
of compression devices and low molecular weight numbness, and lymphedema.
heparin were continued during the hospital stay. 3. Resist the temptation to make the superior inci-
The patient gradually began mobilizing on sion in the groin crease as the scar migration
day 1 with the reconstruction supported in a and stretch postoperatively may lead to labial
soft bra. Drains were kept in place for the first spreading.
48 h, and removed once the patient had been 4. Restrict the skin paddle width up to a maxi-
mobilized and drain output was low. Often, the mum of 8–9 cm depending on laxity of the
thigh donor area drain may remain for a few extra thigh to avoid donor site dehiscence. If the
days to decrease the risk of donor site seroma. tissue obtained from a single flap seems inad-
The patient was discharged on the fifth postop- equate, plan for bilateral (stacked) TUG flaps.
erative day. 5. The flap must not extend beyond the posterior
midline due to the risk of injury to the posterior
cutaneous nerve of the thigh.
Outcome and Clinical Photos 6. It is essential to avoid dissecting in the deep
plane lateral to the long saphenous vein as this
The patient had an uneventful hospital stay with may give rise to lymphedema due to inadver-
no postoperative complications. At reassessment tent harvest of the inguinal lymph nodes.
a fortnight after the surgery, all wounds had 7. Hematoma and seroma rates in the donor area
healed, and she was able to carry out most activ- can be reduced by meticulous hemostasis,
ities of daily living. Her 2-month postoperative especially at the cut edges of the gracilis
result was satisfactory with a good symmetry to muscle.
the contralateral breast and a discrete donor scar 8. Loss of volume of the muscle component with
(Figs. 7 and 8). There was no obvious asymmetry time must be accounted for, and the flap
of the contour of the thighs. She later underwent requirement should be adjusted accordingly.
local flap nipple reconstruction and tattooing of
the areola (Fig. 9).
Learning Points
Avoiding and Managing Problems 1. The TUG flap has many advantages in breast
reconstruction. It is a useful alternative in
1. Patient selection is critical to ensure a good patients where the abdominal tissue in inade-
aesthetic outcome and minimize donor site quate or unavailable. It can be coned or used as
complications. It is important to ensure that a crescent according to the desired shape for
there is sufficient tissue and laxity available reconstruction. The scar is relatively hidden in
for TUG flap reconstruction prior to surgery. the medial thigh.
Clinical examination will determine whether a 2. Patient selection is crucial to optimize out-
unilateral or stacked TUG reconstruction is comes and reduce donor site morbidity.
appropriate and whether lipomodeling may be 3. Flap volume and width should be limited to
required. avoid donor site complications. Where more
2. Appropriate planning and patient counseling is tissue is required, stacked flaps can be
essential. Always explain that a vein graft may performed.
be required, as the pedicle length can be short 4. The most concerning donor complication of
and may not reach the desired recipient vessels TUG flaps is lymphedema. While very rare,

photograph of patient to
show breast symmetry

photograph of patient to
show well-healed thigh
donor area
this can be devastating for patients and care 5. Harvesting some fat from bilateral outer
must be taken anteriorly not to harvest the thighs and lipofilling the upper part of the
inguinal lymphatics (Saint-Cyr et al. 2012). pectoralis major muscle may help increase
Fig. 9 Late postoperative

photograph after nipple
reconstruction and nipple-
areola complex tattooing
the volume of reconstruction as well as pre- cell lymphoma in textured breast implants. Plast
vent hollowing of the upper pole of the Reconstr Surg. 2019;143(3S):30S–40S.
Dayan E, Smith ML, Sultan M, et al. The diagonal upper
reconstructed breast. A modest amount of gracilis (DUG) flap a safe and improved alternative to
projection can be achieved by primary the TUG flap. Plast Reconstr Surg. 2013;132:33–4.
lipofilling of the gracilis muscle. Fattah A, Figus A, Mathur B, et al. The transverse
6. The knowledge of various orientations of flap myocutaneous gracilis flap: technical refinements.
J Plast Reconstr Aesthet Surg. 2010;63:305–13.
stacking and options for pedicle anastomosis Haeney JA, Stanley PR, Ramakrishnan VV. Lidocaine
helps obtain a more aesthetic result in stacked facilitates safe and simple intramuscular dissection.
TUG flaps if used for unilateral breast Plast Reconstr Surg. 2005;116(4):1183–4.
reconstruction (Pantelides et al. 2022; Dayan Kitcat M, Molina A, Meldon C, et al. A simple algorithm
for immediate postmastectomy reconstruction of the
et al. 2013; Park et al. 2015). small breast – A single surgeon’s 10-year experience.
Eplasty. 2012;12:e55.
Mohan AT, Zhu L, Vijayasekaran A, Saint-Cyr
Cross-References M. Autologous breast reconstruction in low body mass
index patients: strategies for maximizing skin envelope
and breast volume. Clin Plast Surg. 2020;47:611–9.
▶ Bilateral Breast Reconstruction with the Free Opsomer D, Stillaert F, Blondeel PN, et al. The lumbar
Fasciocutaneous Infragluteal Flap (FCI) artery perforator flap in autologous breast reconstruc-
▶ Breast Reconstruction with PAP Flap tion: initial experience with 100 cases. Plast Reconstr
Surg. 2018;142:1e–8e.
▶ Secondary Breast Reconstruction with Vertical Pantelides N, Jica R, Patel N, Morgan M, Ramakrishnan V.
Posteromedial Thigh Flap (vPMT) Unilateral breast reconstruction using double transverse
▶ SIEA Flap for Breast Reconstruction upper gracilis (TUG) flaps. J Plast Reconstr Aesthet Surg.
▶ Stacked Free Flaps for Breast Reconstruction 2022;75(3):1164–70. Available online 14 Nov 2021
Park JE, Alkureishi LWT, Song DH. TUGs into VUGs and
friendly BUGs: transforming the gracilis territory into
the best secondary breast reconstructive option. Plast
References Reconstr Surg. 2015;136(3):447–54.
Pollhammer MS, Duscher D, Schmidt M, Huemer
Arnez ZM, Pogorelec D, Planinsek F, et al. Breast recon- GM. Recent advances in microvascular autologous
struction by the free transverse gracilis (TUG) flap. Br breast reconstruction after ablative tumor surgery.
J Plast Surg. 2004;57:20–6. World J Clin Oncol. 2016;7(1):114–21.
Collett DJ, Rakhorst H, Lennox P, et al. Current risk Pu Y, Mao TC, Zhang YM, Wang SL, Fan DL. The role of
estimate of breast implant-associated anaplastic large postmastectomy radiation therapy in patients with
immediate prosthetic breast reconstruction: a meta- demonstrating the successful implementation of pro-
analysis. Medicine. 2018;97(6):e9548. cess mapping in microsurgery. Plast Reconstr Surg
Saint-Cyr M, Wong C, Oni G, et al. Modifications to Glob Open. 2019;7:e2016.
extend the transverse upper gracilis flap in breast recon- Sheena Y, Smith S, Dua S, Morgan M, Ramakrishnan
struction: clinical series and results. Plast Reconstr V. Current risk estimate of breast implant-
Surg. 2012;129:24e–36e. associated anaplastic large cell lymphoma in tex-
Sharma HR, Rozen WM, Mathur B, et al. 100 Steps of a tured breast implants. Plast Reconstr Surg. 2020;
DIEP flap – A prospective comparative cohort series 145(2):446e.
Index
A Anatomosis, 813
Abbe flap, 49 Anesthesia, 374
Abdominal flap, 898 Angio-CT scan, 383
Abdominal wall reconstruction Angiography, 548
alternative reconstructive options, 868–869 Angioplasties, 809
anatomical defect, 868 Angiosarcoma, 1015, 1016, 1022
clinical scenario, 866–867 Anterior abdominal wall, 867
outcome, clinical photos and imaging, 871–872 defect, 869
PMP tumor resection, 869 Anterior fibula osseocutaneous flap, 156
postoperative management, 870–871 Anterior mandible, 380
preoperative care and patient drawing, 869 Anterior skull base, 40, 42
preoperative evaluation and imaging, 869 Anterior skull base reconstruction, with intracranial free
pre-operative patient optimization, 868 flaps
preoperative problem list/reconstructive requirements, alternative reconstructive options, 31–32
867–868 clinical scenario, 30
surgical technique and intra-operative images, 869–870 intraoperative images, 33
treatment plan, 868 outcome, clinical photos and imaging, 34
vascular anastomosis, 870 postoperative management, 33–34
Abdominal wall reconstruction post-sarcoma excision preoperative care and patient drawing, 32
alternative reconstructive options, 878 preoperative evaluation and imaging, 32
clinical scenarios, 876–877 preoperative problem list/reconstructive requirements,
outcome, 883–884 30–31
postoperative management, 882 surgical technique, 32–33
preoperative care and patient drawing, 879 treatment plan, 31
preoperative evaluation and imaging, 879 Anterior superior iliac spine (ASIS), 147
preoperative problem list/reconstructive requirements, Anterior tibial artery (ATA), 537–539
876–877 Anterolateral thigh (ALT) flap, 4, 7, 8, 31–33, 101, 103,
surgical technique, 879–883 106, 107, 111, 112, 114, 116, 145, 146, 342, 725,
treatment plan, 877–878 727, 729, 730, 736, 737, 739, 830–832, 859, 860,
Abdominal wall vascularized composite 862, 1017, 1049
allotransplantation (AW-VCA), 867, 869–872 advantages, 897–898
Ablative surgery, 360 alternative reconstructive options, 859
Acellular dermal matrix (ADM), 809, 868 avoiding and managing problems, 862
Adequate hydration, 814 clinical photos and imaging, 861
Adjuvant radiation therapy, 833 clinical scenario, 858
Aesthetic balance, 180 disadvantages, 898
Aggressive debridement, 443 imaging, 859
Allen test, 426, 482, 580 intraoperative images, 860
Allograft, 520–521 patient drawing, 859
Alloplastic reconstruction, 361 postoperative management, 860
Ameloblastoma mandible, 184 preoperative care, 859
Anastomosis, 48, 49, 51, 132, 373, 408, 597 preoperative evaluation, 859
Anastomotic concerns, 919 reconstructive requirements, 858
Anatomical snuffbox, 549, 554 surgical technique, 860

https://doi.org/10.1007/978-3-030-23706-6
1066 Index
Anterolateral thigh (ALT) flap (cont.) Bell’s palsy, 256

technical pearls, 860 Bell’s phenomenon, 244
treatment plan, 859 Bilateral breast reconstruction, with FCI flaps
Anterolateral thigh (ALT) free flap, 217, 333, 809 autologous breast reconstruction, 1007
advantages in chest wall reconstruction, 839 clinical outcomes, 1010
description, 839 clinical scenario, 1006
intraoperative sequence, 841–843 disadvantages, 1010
microanastomoses, 850 fat grafting, 1007
recipient vessel exposure, 846 intraoperative imaging, 1009
Anterolateral thigh perforator (ALT) flap., 80 postoperative patient management,
Anterolateral thigh perforator and vastus lateralis flap, 772 1009–1010
Antibiotic(s), 115, 399, 815 preoperative care and flap marking, 1007
prophylaxis, 365, 374, 383 preoperative evaluation and imaging, 1007
therapy, 406, 815 preoperative problem list, 1007
Anticipated soft tissue, 594 requirements, 1007
Anticoagulant medication, 548 surgical technique, 1008–1009
Antithrombotic therapy, 548, 551 technical pearls/instructions, 1009
Apert syndrome, 584 Bilateral electromyography, 279
Arm and forearm replantation Bilateral thigh-based flaps, 889
clinical scenario, 604 Bilateral vascularized fibula flap, 820
outcomes, 610 Biological mesh, 876–878, 880, 881, 883
postoperative management, 609–610 Bipolar cautery, 484, 485
preoperative care and patient drawing, 607 Bladder exstrophy, 896, 898, 899, 903
preoperative evaluation and imaging, 607 Blood coagulation analysis, 548
preoperative problem list, 605 Body mass Index (BMI), 912
surgical techniques, 607–608 Bone autograft, 821, 822
treatment plan, 605–606 Bone flap alternatives, 314
Arteriography, 726 Bone free flaps, 371–376
Arterovenous (AV) loop, 878 Bone non-union
Artery-only ear replant, 131 alternative reconstructive options, 396
Arthrodesis, 446 antibiotics and thromboprophylaxis, 399
Arthrogryposis, 584 clinical scenario, 394
Arthroplasty procedures, 517 DCIA iliac crest flap, 396
Aryepiglottic transition, 208, 209 drains, 398
Atherosclerosis, 816 fibula osseocutaneous flap, 396
Auriculotemporal nerve, 217 flap monitoring, 399
Autologous breast reconstruction, 1007, 1038 medial femoral condyle flap, 396
Autologous fat injection, 859 medical therapy, 396
Autologous reconstruction, 944, 953, 970, 971, 1056 mobilization, 399
Avascular necrosis (AVN), 467 nutrition and oral intake, 399
Avascular necrosis of the lunate (AVNL) oral hygiene, 399
alternative reconstruction options, 482 outcome, clinical photos and imaging, 399
avoiding and managing problems, 488 postoperative management, 398–399
outcomes, 487 preoperative care and patient drawing, 397
postoperative management, 487 preoperative evaluation and imaging, 396–397
preoperative evaluation and imaging, 482, 483 preoperative problem list/reconstructive
preoperative problem list/reconstructive requirements, requirements, 394–395
478, 480 surgical technique, 397–398
surgical technique, 483–486 treatment plan, 395
technical pearls, 486–487 Bony reconstruction, 370
treatment plan, 480–481 fibula osteocutaneous free flap, 371
Avulsion, 1030, 1031, 1033 iliac crest free flap, 371
injuries, 421 plate and soft tissue flap, 372
Axillary system, 388 Brachial flap (BF), 585
Brachial plexus injury, 652, 659, 660
alternative reconstructive options, 642–643
B available donor nerves, 641
Becker Flap (BPF), 578 clinical outcomes, 647
Becker’s ulnar perforating flap, 578 clinical photos and imaging, 647
Index 1067
clinical scenario, 638 preoperative evaluation and imaging, 961

elbow flexion, 641, 652 preoperative problem list/reconstructive
finger flexion, 652 requirements, 960
follow-up, 647, 648 surgical technique, 961–962
free muscle transplantation, 654 treatment plan, 960
imaging, 654 Breast reconstruction, with PAP flap
intraoperative images, 659 alternative reconstructive options, 937
nerve-based reconstruction, 654 clinical scenario, 936
patient position, 645 intraoperative images, 940
patient selection, 640 outcome-clinical photos and imaging, 940
postoperative management, 647, 659 post-operative management, 940
pre-operative care, 655 preoperative care and patient drawing, 938
preoperative care and patient markings, preoperative evaluation and imaging, 937–938
644–645 preoperative problem list, 936
pre-operative evaluation, 654 surgical technique, 938–939
preoperative evaluation and imaging, 643–644 treatment plan, 936–937
preoperative marking, 645 Breast sarcoma
preoperative problem list, 639 clinical presentation, 1014
problem management, 647 DIEP flaps, 1016
reconstructive problems/requirements, 640 outcomes, clinical photos and imaging, 1021
shoulder abduction, 652 postoperative monitoring, 1021
shoulder abduction and external rotation, 642 preoperative evaluation and imaging, 1016–1017
supra and infraclavicular approaches, 646 preoperative problem list, 1015
surgical reconstruction technique, 645–647 recurrence in, 1016
surgical technique, 657, 658 surgical technique, 1017
technical features, 647 treatment algorithm, 1015
timing of surgery, 640–641
Brachial plexus lesion
improve grip function, 628 C
improve thumb opposition, 629 Calvarial bone radionecrosis
outcome, clinical photos and imaging, 634 alternative reconstructive options, 21–22
postoperative management, 633–634 clinical photos and imaging, 25
preoperative evaluation and imaging, 627–628 clinical scenario, 20
preoperative problem list/reconstructive intraoperative images, 25
requirements, 626 postoperative management, 25
reanimation of shoulder, 629 preoperative care and patient drawing, 22–23
surgical technique, 629–633 preoperative evaluation and imaging, 22
treatment plan, 626–627 preoperative problem list, 20–21
wrist joint stabilization, 629 surgical technique, 23–24
Brachioradialis tendon, 581 treatment plan, 21
Breast, 858 Calvarial bone reconstruction, 16
Breast-cancer related lymphedema, 666, 667 Capanna method, 824
Breast reconstruction, 924, 932 Capillary refilling, 436, 452
alternative reconstructive options, 952–953 Cefotaxime, 374
clinical scenario, 952 Cephalic vein transposition, 382, 389, 390
outcome, clinical photos and imaging, 956–958 Cephalograms, 174, 179
postoperative management, 956 Cephalosporin, 140
preoperative care and patient drawing, 953–954 Cerebrospinal fluid (CSF) leakage, 33
preoperative evaluation and imaging, 953 Cervical lymph nodes, 713–714
preoperative problem list, 952 Cervical non-union, 305
surgical technique, 953–955 Charcot joint, 461
treatment plan, 952 Cheek reconstruction, 155
Breast reconstruction, SIEA flap Cheng’s Lymphedema Grading, 675
alternative reconstructive options, 960–961 Chest wall defect, 1014, 1018, 1021
clinical scenario, 960 Chest wall reconstruction, 838
intraoperative images, 962–964 anterolateral free flap (see Anterolateral thigh (ALT)
outcome, clinical photos and imaging, 962–966 free flap)
postoperative management, 962–964 contributing factors to complexity, 853–854
preoperative care and patient drawing, 961 en-bloc resection, 845
1068 Index
Chest wall reconstruction (cont.) clinical photos and imaging, 670–671

intra-operative images, 840 clinical scenario, 666–667
post-operative follow up, 850–853 intraoperative images, 670
preoperative image, 840 postoperative management, 670
skeletal reconstruction, 847–850 preoperative care and patient drawing, 667–669
subfascial flap harvest, 855 preoperative evaluation and imaging, 667–668
therapeutic tumor resection, 844 preoperative problem list, 666
Chimeric antero-lateral thigh flap, 211 surgical technique, 667–669
avoiding and managing problems, 213 treatment plan, 666
intraoperative images, 211 Common digital artery (CDA), 432
outcome, 213 Common digital nerve (CDN), 432
postoperative management, 211 Comorbidities, 371
preoperative care and patient drawing, 209 Complete brachial plexus lesion, see Brachial plexus
preoperative evaluation and imaging, 209 lesion
preoperative problem list and reconstructive Complete peroneal nerve palsy
requirements, 209 alternative reconstructive options, 744
reconstructive options, 209 clinical photos and imaging, 747
surgery, 210 clinical scenario, 744
treatment plan, 209 intraoperative images, 747
Chimeric flap(s), 210, 214, 362, 363, 370–372, 375, 376, postoperative management, 747
382, 770, 773, 774, 878, 880, 882 preoperative care and patient drawing, 746
Circular saw injury of hand preoperative evaluation and imaging, 745
flap anastomosis, 568 preoperative problem list, 744
flap elevation, 568 surgical technique, 746
flap thinning procedure, 569 treatment plan, 744
initial debridement, 567 Complex hand trauma, 432
intraoperative imaging, 567 Complex neck allotransplantation, 237–238, 240
outcome photos and imaging, 570 alternative reconstructive options, 235
patient history, 564 clinical photos and imaging, 239
postoperative management, 570 clinical scenario, 234
preoperative care and flap marking, 566–567 postoperative management, 239
preoperative evaluation and imaging, 566 preoperative care and patient drawing, 236–237
preoperative problem list, 565 preoperative evaluation and imaging, 235–236
recipient vessel preparation, 568 preoperative problem list, 234–235
reconstruction of vital structures, 568 surgical technique, 237
surgical technique, 567–569 treatment plan, 235
treatment plan, 565–566 Complex tissue allotransfer, 238
Circumareolar mastectomy, 1058 Composite axillary defect, sarcoma resection
Circumferential thumb defect alternative reconstructive options, 831
alternative reconstructive options, 557 clinical scenario, 830–831
avoiding and managing problems, 560 intraopeartive images, 833
outcome, clinical photos and imaging, 559 outcome, 833–834
postoperative management, 559 postoperative management, 833
preoperative care and patient drawing, 557 preoperative care and patient drawing, 831–832
preoperative evaluation and imaging, 557 preoperative evaluation and imaging, 831
preoperative problem list/reconstructive preoperative problem list, 830
requirements, 556 surgical technique, 831–832
surgical technique, 557, 559 treatment plan, 830
technical pearls, 559 Composite facial nerve defect, 339
treatment plan, 556 Composite fasciocutaneous fibula reconstruction, 198
Cocaine abuse Composite free radial forearm flap, 122–124
hard palate necrosis due to, 62 Composite scalp reconstruction, 16
palatal defects in, 65 Compound osteo-muscular flap, 443
Colon cancer, 370 Compression garment, 815
Color Doppler, 105 Computed tomography-angiography (CTA), 105, 546,
sonography, 546–548, 553, 557 937, 953, 1038, 1042
ultrasonography, 174 Computer-aided design and manufacturing (CAD/CAM),
Combined autologous breast and lymphedema 315, 387
reconstruction, DIEP and lymph-node flap Condylar prostheses, 185
alternative reconstructive options, 666–667 Congenital hand malformation (brachysyndactyly), 583
Index 1069
Contralateral C7, 653, 658 recipient vessel access, 916

Contralateral flap, 973 reconstructive requirements, 909, 910
Contralateral radial free forearm flap (cRFFF), 575, 579 treatment plan, 910, 911
Contralateral scapula, 362 umbilicoplasty, 917
Conventional radiograph, 726 wound closure, 914
Cook-Swartz doppler signal, 387 Deep inferior epigastric perforator (DIEP) flap
Corpectomy, 304, 309 reconstruction, in slim patient, 929–930, 932
Corticocancellous VBG, 485 alternative reconstructive options, 926
Cosmetic reconstruction, 407 breast and recipient site preparation, 928
Cranioplasty fixation discs, 20 clinical scenario, 924
Cranioplasty with autologous osseous grafts, 13 decision-making, 925
Cross-facial nerve graft (CFNG), 257, 268–270 donor site volume availability, 924–925
Crush injury, 406, 442, 544, 553, 556 flap inset and wound closure, 929
CT angiogram, 809 flap raise, 928–929
CT angiography, 596, 599 free flap plus implant, 926
Cutaneous free flaps, 81 gluteal artery perforator free flap, 926
gracilis free flap, 926
implant-based breast reconstruction, 924
D implant-based breast reconstruction without tissue
Debridement, 479, 553, 808–810, 813, 816 transfer, 926
Debulking procedure, 137, 560, 691 latissimus dorsi flap, 926
Decision-making process, 824 lumbar artery perforator free flap, 926
Deep circumflex iliac artery (DCIA) flap, 163, microsurgical anastomosis, 929
361, 371 outcome, clinical photos and imaging, 930–932
Deep circumflex iliac artery (DCIA) iliac crest patient’s desires and expectations, 924
flap, 396 postoperative management, 930
Deep inferior epigastric artery perforator (DIEaP) flap, preoperative care and patient drawing, 927–928
889, 936, 944, 986, 987, 992, 996, 1000, preoperative evaluation and imaging, 926–927
1027–1030, 1057 preoperative problem list/reconstructive requirements,
autologous breast reconstruction, 1038 924–925
avoiding/managing problems, 1041 profunda artery perforator free flap, 926
clinical scenario, 1036 surgical technique, 928–929
CTA, 1042, 1043 treatment plan, 926
flap edges, 1041 Deep inferior epigastric vein comitans (DIEVc), 996
lower back/buttock tissues, 1038 Deep inferior epigastric veins (DIEv), 996, 1040
postoperative management, 1041 De-epithelialisation, 916
preoperative care/patient drawing, 1038 De-epithelialized perforator free flap, 84
preoperative evaluation/imaging, 1038 Deep tissue culture, 808
reconstructive requirements, 1036 Deep venous thrombosis, 140
surgical techniques, 1040 Dental rehabilitation, 361
technical pearls, 1041 Dermo-adiposal perforator flap, 861
treatment plan, 1038 Descending genicular artery (DGA), 481, 482, 526–529
Deep inferior epigastric donor vessels, 870 Diabetic foot reconstruction
Deep inferior epigastric perforator flap (DIEP flap), 666, alternate reconstructive options, 809
668–671, 908, 1016, 1021 avoiding and managing problems, 815
alternative reconstructive options, 911 outcome-clinical photo and imaging, 815
avoiding, 919 postoperative management, 814, 815
chest preparation, 914 preoperative care/patient drawing, 810, 811
de-epithelialisation, 916 preoperative evaluation and imaging, 810
flap inset, 917 reconstructive technique, 812, 813
flap raise, 913 requirements, 808
intra-operative flap perfusion, 916 surgical techniques, 811–813
managing problems, 919 technical pearls, 813, 814
microanastomosis, 916 treatment plan, 808, 809
microsurgical anastomosis, 914 Diabetic foot ulcer, 808, 812, 813, 816
nipple-areola complex, 917 Diaphyseal dissection, 538
perforator choice, 915 Distal femur osteosarcoma, 801
postoperative management, 917, 918 Distal fibular osteotomy, 192
preoperative care, 912 Distally based flaps, 740
preoperative evaluation, 911, 912 Distal nerve transfers, 654
1070 Index
Distal radioulnar joint (DRUJ), 515 outcome, clinical photos and imaging, 388, 389
Distal tibial bone defect pectoralis major regional flap, 382
antimicrobial treatment, 753 postoperative management, 387, 388
clinical scenario, 752 preoperative/reconstructive requirements, 380, 381
delta type external fixation, 753 preoperative care, 383
ilizarov bone transport technique (see Ilizarov bone preoperative evaluation and imaging, 382–386
transport technique) recipient sites, 387
Masquelet technique, 752 recipient vessels, 388
outcomes of treatment, 759 reconstruction, 372
postoperative management, 754 soft tissue free flap, 382
reconstructive requirements, 752 tracheostomy, 383
replacement of delta frame, 753, 756 treatment plan, 381
treatment plan, 752 type of defects, 381
treatment strategy and surgical technique, 753–754 Drains, 374
Distraction osteogenesis, 820 Draping, 912
Donor site(s), 385, 387 Dual innervation, of free gracilis muscle transfer, 256
closure, 364 Dual-phase CT angiography, 382
drawing, 362, 372 Duplex ultrasonography, 596, 598, 811
evaluation, 372 Duplex ultrasound, 5
Donor-specific antibodies (DSA), 792, 869 Dynamic reanimation, 278
Donor vessels, 730–731 Dysphagia, 208
Doppler, 912
ultrasonography, 753
Dorsal finger defect E
avoiding and managing problems, 552 Ear amputation, 130
outcome, clinical photos and imaging, 551, 552 Ear replantation
postoperative management, 551 clinical scenarion, 130
preoperative care and patient drawing, 548 outcomes, 133
preoperative evaluation and imaging, 546–548 postoperative management, 133
preoperative problem list/reconstructive preoperative care and patient drawing, 131
requirements, 545 preoperative evaluation and imaging, 131
reconstructive options, 545, 546 preoperative problem list-reconstructive
surgical technique, 548–550 requirements, 130
technical pearls, 550 surgical techniqies, 131
treatment plan, 545 treatment plan, 130
Dorsal intercalated segment instability (DISI), 468 EIP (extensor indicis proprius), 585
Dorsalis pedis flap Electrocautery, 549
alternative reconstructive options, 407 Elliptical flap, 939
avoiding and managing problems, 410 Emergency all-in-one reconstruction, 432
intraoperative images, 408 Empirical antibiotics, 808
outcome-clinical photos and imaging, 410 En-bloc resection, 517, 845
postoperative management, 410 Endoscopically-assisted latissimus dorsi muscle
preoperative care and patient drawing, 407 transposition, 859
preoperative evaluation and imaging, 406 Endoscopic flap inset, skull base reconstruction
preoperative problem list/reconstructive alternative reconstructive options, 40
requirements, 406 clinical scenario, 38
surgical technique, 407, 408 outcome, clinical photos and imaging, 42
technical pearls, 408 postoperative management, 41–42
treatment plane, 407 preoperative care, 40
Dorsal/plantar metatarsal artery system, 426 preoperative evaluation and imaging, 40
Double-barrel fibular flaps, 820 preoperative problem list/reconstructive requirements,
Double free flap 38–39
chimeric flaps, 382 surgical technique, 40
donor sites, 385, 387 treatment plan, 39
fibula free flap, 382 End-to-side anastomosis, 269
fibula intraflap osteotomies, 383 End-to-side arterial anastomoses, 823
IID, 380 ENT, 383
locoregional flap, 381, 382 Epineurial nerve coaptation, 558
mandibular symphysis, 380 Epiphora, 256
Index 1071
Epiphyseal artery injury, 541 preoperative problem list/reconstructive

EPL (extensor pollicis longus) tendon transfer, 585 requirements, 820
Escharotomy, 574 surgical technique, 823
Estlander flap, 49 treatment plan, 820
Extended latissimus dorsi (ELD), 979 Fibula bone flap, 387
Extensive peritoneal deposits, 867 Fibula bone mimetism, 180
Extensor digitorum communis (EDC), 654 Fibula flap, 822
Extensor digitorum longus, 746 Fibula free flap, 320, 321, 382
Extensor hallucis longus, 746 Fibula intraflap osteotomies, 383
External carotid system, 388 Fibula osseocutaneous flap, 396
Extremity lymphedema, 674, 675, 679 Fibula osteocutaneous flap, 200
Eyelid ectropion, 256 Fíbula osteocutaneous free flap, 361, 371
Fibular bone, 158
Fibular flap, 101
F Fibular segmentation, 179
Face lift incision, 257 Fibula wedge osteotomy, 315
Facial aesthetic subunit Finger reconstruction of free ulnar artery perforator flap
allotransplantation, 343 patient history, 616
postoperative management, 346 postoperative management, 622
Facial contour, 201 preoperative care and patient drawing, 618
Facial dissection, 247 preoperative evaluation and imaging, 618
Facial nerve, 332, 334, 338 reconstructive requirements, 616–618
function, 257 surgical techniques, 618–619
reconstruction, 145, 146, 242, 244, 249 First dorsal metatarsal artery (FDMA), 455
tumors, 277 First metacarpal bone, 442, 443
Facial palsy, 243 First plantar metatarsal artery (FPMA), 455
Facial paralysis, 243, 266, 267 Flap anastomosis, 388, 568, 1017
microsurgical procedures, 279 Flap control, 114, 364, 374
non-microsurgical options, 279 Flap debulking surgery, 555
patient history, 276 Flap dissection, 954
postoperative management, 282 Flap dyspragia, 595
preoperative care and patient drawing, 279–280 Flap elevation, 597
preoperative problem list, 276–278 Flap harvesting, 107, 113
static and dynamic facial reanimation methods, 279 Flap inset, 345, 917
surgical techniques, 280–282 Flap monitoring, 957
treatment plan, 278 Flap prelamination, 137–139
Facial reanimation, in congenital facial palsy, see Moebius Flap thinning procedure, 569
syndrome Flexor carpi radials (FCR), 469
Facial reanimation, 147 Flexor carpi ulnaris, 580
Facial rejuvenation, 180 Flexor digitorum longus (FDL), 746, 764, 765
Fascial radial forearm free-flaps (FRFFF), 217 Flexor digitorum profundus (FDP), 432, 632
Fasciocutaneous flaps, 382, 575, 581 Flexor digitorum superficialis (FDS), 432
Fasciocutaneous free flap, 809 Flexor hallucis longus (FHL), 764, 765
Fasciocutaneous infragluteal flap (FCI), bilateral breast Flexor pollicis brevis (FPB), 585
reconstruction with, see Bilateral breast Flexor pollicis longus (FPL), 632
reconstruction, with FCI flaps Flexor tenolysis, 555
Fast bone fixation, 791 Fluorescence angiography, 546
Fat grafting, 982 Foot drop, 744
FDG-PET/CT scan, 383, 386 Forehead flap
Femoral bone defect, 821 chimeric paramedian-pericranial, 64
Femur reconstruction, with modified Masquelet for nasal cover, 64
technique, 824 paramedian, 62, 63
alternative reconstructive options, 820–821 rib graft and, 65
clinical scenario, 820 Free antelorateral thigh flap, 146, 149, 150, 729–730
intraoperative images, 822–823 Free deep inferior epigastric artery perforator flap
outcome, clinical photos and imaging, 823–824 (DIEP), 5
post-operative management, 823 Free fasciocutaneous anterolateral thigh (ALT) flap, 13
preoperative care and patient drawing, 821–822 Free fibula flap, 111, 112, 157, 158, 180, 192, 317, 320,
preoperative evaluation and imaging, 821 820, 821
1072 Index
Free fibula flap reconstruction of cervical spine, 303 surgical technique, 456, 457
clinical scenario, 304–305 technical pearls, 457, 459
outcomes, 310 treatment plan, 453
postoperative management, 310 Functional reconstruction, 798, 803, 804
preoperative care and patient drawing, 307–308
preoperative evaluation and imaging, 306
preoperative problem list and reconstructive G
requirements, 305 Gait profile score (GPS), 804
surgical technique, 308–309 Giant cell tumor, 518
treatment plan, 305 Glenoid fossa, 541
Free flap, 960, 962, 964 Glossectomy, 79, 80, 387
Free functional muscle, 626, 632, 633 Gluteus maximus, 981
Free functional muscle transfer (FFMT), 266, Gracilis flap, 244, 246, 249, 250, 254
278, 798 Gracilis free flap, 926
Free functioning gracillis transfer (FFMT), 343 Gracilis muscle, 248, 266–272, 1059
Free latissimus dorsi musculocutaneous flap, 4 Gracilis muscle flap, 633
Free medial femoral condyle (MFC) flap, for salvage Great auricular nerve (GAN), 145
arthrodesis Great-toe transfer, 425, 426
clinical photos and imaging, 533 Groin flap (GF), 585
flap harvest, 529–530
flap inset and osteosynthesis, 530
postoperative management, 533 H
preoperative imaging, 527–528 Hamstring transfer, 799
preoperative marking, 528 Handheld Doppler examination, 383, 444, 727
reconstructive requirements, 526 Haptic-assisted surgery planning (HASP), 315
treatment plan, 526–527 Head and neck, 394
Free muscle flap, 809 Hematomas, 271, 284, 919
Free muscle transfer (FMT), 632, 633 Hemiglossectomy, 100–102, 104, 370, 371
Free osseocutaneous fibula flap, 155 defects, 79, 80
Free radial artery forearm flap (FRAFF), for bladder Hemiglossectomy defect reconstruction
exstrophy PAP flap, 81
abdominal flap, 898 SCIP perforator free flap, 78
ALT flap, 897–898 Henley retractor, 483
clinical scenario, 896 Herbert type B2 scaphoid fracture, 466
intraoperative images, 902 Homogeneously thinned flap, 559
outcome, 902 Humpback deformity, 466, 474
postoperative management, 902 Humural tuberosity, 860
preoperative care and patient drawings, 899–900 Hyperbaric oxygen therapy (HBOT), 424, 609
preoperative considerations/reconstructive Hypermetabolism, 386
requirements, 896 Hypokalemia, 370
preoperative evaluation, 899 Hypopharynx reconstruction, 214
SCIP flap, 898–899 Hypothyroidism, 370
surgical technique, 900–902
treatment plan, 896–897
Free radial forearm fasciocutaneous flap, 22 I
Free radial forearm flap, 21, 25 ICG-lymphography, 671
Free serratus anterior flap, 5 IgA nephropathy, 234
Free style approach, 597 Iliac crest free flap, 371
Free thoracodorsal artery perforator flap, 5 Iliac flap, 101
Free vascularized joint transfer Iliotibial tract, 830–832
alternative reconstructive options, 454, 455 Ilizarov bone transport technique, 752
avoiding and managing problem, 461, 462 flap setting prior to, 754, 757
intraoperative images, 459 post-operative management, 755
outcome, clinical photos and imaging, 460, 461 uses of, 754
postoperative management, 459, 460 Immobilization, 459
preoperative care and drawing, 455, 456 Immunosupression, 791
preoperative evaluation and imaging, 455 Implant-based breast reconstruction, 924
preoperative problem list/reconstructive requirements, Implant based postmastectomy reconstruction, 1006
452, 453 Implant-based reconstruction, 953
Index 1073
Implant reconstruction, 1057 Knee, 724–726, 729–733

Implant surgery, 175, 179 reconstruction, 736
Indocyanine green (ICG) lymphography, 690, 691, Kuhnt-Szymanowski procedure, 278
697, 1028 K-wires, 428
Infection in right thumb, 424
Inferior epigastric vessels, 871
Inferior gluteal artery perforator (IGAP) flap, 937, L
979, 1027 Laparotomy, 137
Infragluteal flap, see Fasciocutaneous infragluteal flap Large segmental bony defect, 853
Infraorbital nerve, 372 Laryngeal reconstruction, 227
Infrapatellar defects, 737 Laryngectomy, 234
Infraspinatus, 373 Lateral antebrachial cutaneus nerve (LACN), 122–124
Integra, 780, 782 Lateral arm flap, 579
Integra Dermal Regeneration Template, 409, 426 Lateral circumflex femoral artery (LCFA), 6, 738, 860
Intensive care unit, 374 Lateral circumflex femoral artery tree (LCFA),
Intercostal nerve, 549, 653 147, 148
Intercostal neurovascular bundle, 546 Lateral femoral condyle (LFC), 467, 470, 478, 481, 482,
Inter-incisal distance (IID), 380 485, 486
Internal mammary artery perforators Lateral femoral cutaneous artery (LFCA), 881
(IMAp), 947, 1059 Lateral femoral cutaneous nerve (LFCN), 148
Internal mammary vessels, 389, 846, 947, 972 Lateral femoral osteochondral graft, 493, 494, 496,
Intramuscular dissection, 107 504, 509
Intramuscular septum, 832, 833 Lateral femoral trochlea flap, 500
Intraoperative assembled cutting guide, 315 Lateral intercostal artery perforator (LICAP) flap, 998
Intra-operative flap perfusion, 916 Lateral thoracic axillary lymph nodes (LTLN), 700,
Intraoperative management, 749 703–705
Intraoperative perforator avulsion, in free flap breast Latissimus dorsi, 13, 146, 382
reconstruction flap, 365, 579, 854, 926, 979
alternative autologous reconstructive options, 1027 free flap, 753
clinical scenario, 1026 muscle, 363, 371–375, 444, 858
intraoperative images, 1031 muscle flap, 778–780, 782, 998
outcome-clinical photos and imaging, 1032 muscle segment, 363
postoperative management, 1031–1032 myocutaneous, 101
preoperative care and patient drawing, 1028 Latissimus dorsi (LD)-based breast reconstruction, 666
preoperative evaluation and imaging, 1027–1028 Leeching, 57
preoperative problem list, 1027 Leech therapy, 48
surgical techniques, 1028–1029 Left fibula osseocutaneous flap, 155
treatment plan, 1027 Ligaclips, 105
Intravenous prostaglandin E1, 814 Lingual/inferior alveolar nerves, 103
Ipsilateral and healthy vessels, 387 Lipofilling, 861
Ischemia, 815 Liposarcoma, 345
time, 605 Lip switch flap, see Abbe flap
Load-reduction procedures, 482
Local flap nipple reconstruction and tattooing, 1061
Locoregional axial pattern fasciocutaneous flaps, 595
J
Locoregional flap, 381, 382
Jackson-Pratt drainage, 597, 813
Locoregional metastasis, 382
Jaw atrophy, 172
Loupe magnification, 549
Low body mass index (BMI), 1057
Lower limb lymphedema
K clinical outcomes, 706
Karapandzic flap, 49 clinical scenario, 700
Kienböck’s disease intra-operative images and outcomes, 701
Lichtman stage IIIa, 492, 494, 496 post-operative care, 703
stages, 495 post-operative management, 705–706
wrist arthroscopy, 496 pre-operative evaluation and imaging, 702–703
See also Avascular necrosis of the lunate (AVNL) reconstructive options, 701–702
Kirschner-wire fixation, 544, 553, 556 surgical techniques, 703–705
Kissing-flap procedure, 484 treatment plan, 700
1074 Index
Lower limb transplantation M

clinical case, 787 Magnetic resonance angiography, 105, 546
intraoperative images, 790 Magnetic resonance imaging (MRI), 147, 595
outcomes, clinical photos and imaging, 793 Malar proeminence deficiency, 343
postoperative management, 791–792 Malignant peripheral neural sheath tumor (MPNST), 830
preoperative care and patient drawing, 789 Mandible defect, 110
preoperative evaluation and imaging, 789 Mandible reconstruction, 370–372, 374–376
preoperative problem list, 788 Mandibular bone reconstruction, 154
surgical techniques, 789–791 Mandibular pseudo-prognathism, 172
treatment, 788 Mandibular reconstruction, 186, 194
Lower lip, 371 Mandibular reconstruction, VSP
sensibility restoration, 372 alternative reconstructive options, 314–315
Lower lip reconstruction, total, see Total lower lip clinical scenario, 314
reconstruction in house vs. external planning, 317
Low molecular weight heparin (LMWH), 244, intraoperative images, 320
1031, 1041 osseous defect, 314
LTP flap, 1014, 1018 outcome, clinical photos and imaging, 321
Lumbar artery perforator (LaP), 1038 postoperative management, 320
Lumbar artery perforator (LAP) flap, breast preoperative care and patient drawing, 317
reconstruction, 944, 1027 preoperative evaluation and imaging, 315–317
alternative reconstruction options, 944 preoperative problem list/reconstructive requirements,
appropriate planning and patient counselling, 948 314
clinical scenario, 944 recipient vessels, 314
intraoperative photos, 947 soft tissue defect, 314
outcome and clinical photos, 948–949 surgical technique, 320
patient selection, 948 treatment plan, 314
postoperative management, 947 workflow, 316–317
preoperative care and patient drawing, 945 Mandibular soft tissue, 381
preoperative evaluation and imaging, 944–945 Mandibular symphysis, 380
preoperative problem list/reconstruction Mandibulectomy, 370, 371
requirements, 944 Mangled extremity severity score system, 605
surgical technique, 945–946 Marlex mesh, 848
Lunate reconstruction, 486 Masquelet technique, 752, 820–822
Lunate revascularization, 478, 480 Masseteric nerve, 256, 258, 259, 262
Lymphadenectomy, 383 Masseter nerve, 268
LYMPHA technique, axillary clearance surgery transfer, 145–147, 149, 150
alternative reconstruction options, 684 Masseter nerve-innervated gracilis, 278
clinical scenario, 684 Massive facial defect
intraoperative images, 685 alternative reconstructive options, 155
outcome, clinical photos and imaging, 685 clinical photos and imaging, 158–159
postoperative management, 685 clinical scenario, 154
preoperative care and patient drawing, 684 intraoperative images, 157
preoperative evaluation and imaging, 684 postoperative management, 158
preoperative problem list, 684 preoperative care and patient drawing, 156
surgical technique, 685 preoperative evaluation and imaging, 156
treatment plan, 684 preoperative problem list, 154
Lymphatic-venous by-pass, 685 surgical technique, 156–157
Lymphedema, 350, 352, 690, 691, 1061 treatment plan, 154–155
donor site, 711 Mastectomy, 1018, 1022
lymphology grade III, 710 scar, 667
mild to moderate, 711 Mastoidectomy, 144
moderate to severe, 711 Matev technique, 426
surgical management of, 710 Mathes and Nahai classification, 247
treatment, 711 Maxillary reconstruction
Lymph node(s), 145 avoiding and managing problems, 178, 179
excision, 1015 chimeric scapula tip and latissimus dorsi free flap, 361
transfer, 666, 667 conventional non-vascularized bone transplants, 173
Lymphorrhea, 597 fibula osteocutaneous free flap, 361
Lymphovenous anastomosis, 676, 700 fibular augmentation, 176
Index 1075
harvested fibula, 176 surgical technique, 426, 428

implant placement, 175 technical pearls, 428
implants coverage, 178 treatment plane, 425
intraoperative images, 176 Methicillin resistant staphylococcus aureus (MRSA), 525
intraoral fibula exposure, 178 Methylmethacrylate-mesh sandwich, 847
microsurgical jaw resections, 173 Meticulous hemostasis, 947, 948, 973, 1059
ostectomies, 176 Metronidazol antibiotics, 374
outcome-clinical photos and imaging, 177 Microanastomoses, 106, 383, 385, 850
postoperative management, 176 Microanastomosis technique, 916
post-operative radiograph, 177 Microstomia, 48, 49
preoperative care and patient drawing, 174 Microsurgery, 424, 610
pre-operative evaluation and imaging, 173, 174 Microsurgical anastomosis, 914
pre-operative problem list, 173 Microsurgical flap reconstruction, 13
reconstructive procedure, 175 Microsurgical instruments, 55
restored superior alveolar ridge, 177 Microsurgical replantation, 47, 51
scapula tip free flap, 366 Microsurgical thumb reconstruction, 425
second-stage implant surgery and vestibuloplasty, 175 Microsurgical toe transfer, 618
side-table shaping, 176 Microvascular anastomoses, 823
superior alveolar ridge exposition, 176 Microvascular ear reconstruction
surgical technique, 364 alternative reconstructive options, 137
treatment plan, 173 avoiding and managing problems, 140
Maxillary reconstruction, VSP intraoperative images, 138
clinical scenario, 323 outcome, clinical photos and imaging, 140
intraoperative images, 327 postoperative management, 140
outcome, clinical photos and imaging, 327 preoperative care and patient drawing, 137
preoperative evaluation and imaging, 323–327 preoperative evaluation and imaging, 137
preoperative problem list/reconstructive preoperative problem list/reconstructive
requirements, 323 requirements, 136
surgical techniques, 327 surgical technique, 138, 139
Maxillary sinus, 292 technical pearls, 139
Maxillomandibular relation, 180 treatment plan, 136
Medial femoral condyle (MFC), 396, 467, 482 Microvascular reconstruction of soft tissue defects of
Medial femoral condyle (MFC) flap, for salvage the scalp
arthrodesis clinical photos and imaging, 8
clinical photos and imaging, 533 clinical scenario, 4
flap harvest, 529–530 postoperative management, 8
flap inset and osteosynthesis, 530 preoperative care and patient drawing, 6
postoperative management, 533 preoperative evaluation and imaging, 5–6
preoperative imaging, 527–528 preoperative problem list, 4
preoperative marking, 528 surgical technique, 6–7
reconstructive requirements, 526 Midface reconstruction, 296
treatment plan, 526–527 alternative reconstructive options, 289–290
Medial plantar artery flap, 762, 764, 766, 767 intraoperative images, 292
Medial plantar flap (MPF), 585 outcome, 292
Medial retromalleolar incision, 746 postoperative management, 292
Medial subfascial approach, 386 preoperative care and patient drawing, 290
Medial sural artery perforator (MSAP) flap, 101–107, 585 preoperative evaluation and imaging, 290
Medical therapy, 396 preoperative examination, 288
Medication, 912 reconstructive requirements, 288–289
Mental nerves, 371, 372 surgical technique, 291
Metacarpal lengthening, 425, 426 treatment plan, 289
Metacarpophalangeal joint Mini wrap-around technique, 407, 408
alternative reconstructive options, 425 Mobile tongue, 383
avoiding and managing problems, 429 Mobilization, 115, 365, 374
outcome-clinical photos and imaging, 429 Modified Allen’s test, 156
postoperative management, 429 Modified Kirchmayer-Kessler technique, 568
preoperative evaluation and imaging, 426 Moebius syndrome, 276
preoperative problem list/reconstructive alternative reconstructive options, 268
requirements, 424 avoiding and managing problems, 271–272
1076 Index
Moebius syndrome (cont.) Nerve transfer, 626, 627, 630

clinical scenario, 266 Nipple-areola complex (NAC), 917
intraoperative images, 271 No mass was palpated, 594
outcome, clinical photos and imaging, 271 Non-microsurgical techniques, 425
postoperative management, 271 Non-microvascular attachment, 130
preoperative care and patient drawing, 268–269 Nonsensate fasciocutaneous flap, 778
preoperative problem list, 266 Non-union, 394, 396, 397
surgical technique, 269–270 Non-vascularized bone grafts (NVBG), 305, 467
treatment plan, 266–268 Non-vascularized cancellous bone grafts, 480
Monopolar electrocautery, 485 Nutrition, 114, 374, 375
Motek Caren simulator, 804 assessment, 382
MR angiogram, 382
Multidisciplinary approach, 809
Multidisciplinary team (MDT), 910 O
approach, 816 Oberlin procedure, 646, 647
Multidisciplinary treatment, 100 Oblique rectus abdominis (ORAM) flap, 798, 801, 802
Multi-visceral organ transplantation, 866 Obturator nerve, 259
Muscle coverage, 180 Omental lymph node flap, 676
Muscle flap reconstruction, foot sole defect, 778 Oral aspirin, 599, 815
disadvantages of, 781 Oral cavity, 381, 388
latissimus dorsi, 778, 779, 781 Oral competency, 382
postoperative appearance, 781 Oral reconstruction, 106
postoperative management, 781 Oral tongue cancer, 100
preoperative care, 779 Orbital floor reconstruction, 362, 367
preoperative evaluation and imaging, 779 alloplastic reconstruction, 361
reconstructive Requirements, 778 bone grafts, 361
surgical technique, 779–780 Orbitomaxillary reconstruction, 199
Muscle positioning, 259 Orocutaneous fistula, 350, 351, 354
Muscle transfers, 798, 802 Orthopantomogram, 174, 179
Musculocutaneous flap, 382 Orthopantomography, 396
Musculocutaneous thoracodorsal artery perforator, 549, Orthoplastic, 732
554, 558 Osseocutaneous free fibula flap, 157
Musculo-fascial defect, 880 Osseointegrated prosthesis, 136
Mycophenolate mophetyl (MMF), 791 Osseointegration, 179
Myxofibrosarcoma, 594 Osseous defect, 314, 394
Osseous flap, 373
Ostectomies, 176
N Osteoarticular distal radius allograft, 520
Nasal reconstruction Osteocartilaginous bone grafts, 481
collapsed and contracted, 62 Osteochondral femoral condyle flap, 499
deformed and failed, 62 Osteochondral flaps from distal femur, 493, 499, 508
design, 71 Osteocutaneous fibula free flap, 383
partial/subtotal, 65 Osteocutaneous reconstruction
of saddle nose deformity, 62 alternative reconstructive options, 296
total, 62 clinical findlings, 295
Nasolabial fold compensatory procedures, 279 intraoperative images, 298
Neck dissection, 371 outcome, 299
Necrosis postoperative management, 298
cartilage grafts due to, 62 preoperative care and patient drawing, 297–298
partial, 67, 69, 75 preoperative evaluation and imaging, 296–297
partial flap, 76 reconstructive requirements, 295
subtotal septum, 62 surgical technique, 297–298
Necrotic tissue, 406 treatment plan, 296
Negative pressure wound therapy (NPWT), 424, 809, 810, Osteolysis, 385
812, 813 Osteolytic lesions, 383
Neotongue, 381, 386 Osteomyelitis, 20, 524, 527, 530, 815, 816
Nerve coaptation, 259, 550 Osteoradionecrosis (ORN), 20, 395, 396
Nerve conduction velocity (NCV), 654 alternative reconstructive options, 163
Nerve grafting, 634 indications, 162
Index 1077
outcome, 167 intraoperative images, 1002

preoperative care and patient drawing, 165 outcome-clinical photos and imaging, 1002–1003
preoperative evaluation and imaging, 164 postoperative management, 1002
preoperative problem list-reconstructive preoperative care and patient drawing, 999–1000
requirements, 162 preoperative evaluation and imaging, 996
surgical technique, 165–166 preoperative problem list, 996
treatment plan, 163 surgical techniques, 1000–1002
Osteosynthesis, 201, 383, 457, 459, 479 treatment plan, 996–998
Osteotomy(ies), 173, 200, 363, 373, 408, 428, 472, Passive elbow motion, 599
485, 486 Passive range of motion (pROM), 744
Pectoralis major myocutaneous flap, 101, 112
Pectoralis major regional flap, 382
P Pedicle, 1029–1031, 1033
Palmar finger defect Pedicled flaps, 578
alternative reconstructive options, 553 Pedicled latissimus dorsi flap, 595
avoiding and managing problems, 556 Pedicled muscle flaps, 737
outcome, clinical photos and imaging, 555 PEG placement, 388
postoperative management, 555 Penrose drain, 472, 486, 559
preoperative care and patient drawing, 553 Percutaneous endoscopic gastrostomy, 380
preoperative evaluation and imaging, 553 Percutaneous transluminal angioplasties
preoperative problem list/reconstructive (PTA), 209
requirements, 553 Perforator avulsion, 1033
surgical technique, 554 Perforator choice, 915
technical pearls, 555 Perforator flap(s), 107, 579, 736–738
treatment plan, 553 Perforator flap, foot reconstruction
Palmaris longus tendon, 121–124 advantages, 772
Palmar reconstruction, 575 anterolateral thigh perforator and vastus lateralis
Panorex, 382 flap, 772–773
Parascapular flaps, 382 latissimus dorsi muscle flap, 770
Parotidectomy local fasciocutaneous flaps, 770
avoiding and managing problems, 150, 151 postoperative appearance, 775
with facial nerve resection, 144 postoperative management, 774
intraoperative images, 148 preoperative evaluation and imaging, 772
LCFA, 148 problem management, 775
outcome, clinical photos and imaging, 149 reconstructive requirements, 770
postoperative management, 149 surgical technique, 773
preoperative care and patient drawing, 147 treatment plan, 770
preoperative evaluation and imaging, 147 Perforator pedicle, 9
preoperative problem list/reconstructive Perforator pedicled propeller flaps, 595
requirements, 144 Periauricular defects, 146, 148–150
reconstructive options, 145, 147 Perineal reconstruction
surgery, 147, 148 clinical history, 1046
treatment plan, 144 complications and wound issues, 1052
Partial breast reconstruction, 997–999 defect composition, 1046
Partial glossectomy, 101 intraoperative requirements, 1046
Partial glossectomy reconstruction, innervated lateral options, 1046, 1048, 1049
forearm flap outcome, 1052
alternative reconstruction options, 92–93 postoperative management, 1051, 1052
clinical photos and imaging, 96 preoperative care and patient drawing, 1050
clinical scenario, 92 preoperative evaluation and imaging, 1049
post-operative management, 96 preoperative planning/workup, 1046
preoperative care and patient drawing, 93–94 surgical technique and intraoperative images, 1050
preoperative evaluation and imaging, 93 treatment planning, 1047, 1048
preoperative problem list, 92 Periprosthetic joint infection (PJI), 724–726, 731–733
surgical technique, 94–95 Peritoneal malignancy, 866
treatment plan, 92 Peroneal nerve, 193, 541
Partial mastectomy reconstruction, TDAP flap Peroneal system, 382
alternative reconstructive options, 998 Phalloplasty, 896–899, 903
clinical scenario, 996 Pharyngo-esophageal reconstruction, 209
1078 Index
Pinch test, 1007 Pseudomyxoma peritoni (PMP), 866, 867, 869

Plain radiography, 810 pT3N3bM0, 375
Plantar heel defect Pulmonary function testing (PFT), 227
avoiding and managing problems, 766–767 Pulvertaft suture, 747
clinical scenario, 762
free fasciocutaneous flap, 763
free muscle flap, with skin graft, 763 Q
intra-operative images, 766 Quadriceps, 796–798, 804
outcome and clinical photos, 766 function, 788
post-operative management, 766 Quality of life, 1028
preoperative care and patient drawing, 764
preoperative evaluation and imaging, 763–764
preoperative problems/reconstructive R
requirements, 762 Radial forearm flap (RFF), 121–124, 137–139
reverse sural artery flap, 763 Radial forearm flow-through flap
surgical technique, 764–765 alternative reconstruction options, 433, 434
treatment plan, 762–763 avoiding and managing problems, 437, 438
Popliteal fossa, 481 intraoperative images, 436
Popliteal vessels, 737 outcome/clinical photos, 437
Porous polyethylene, 137 postoperative management, 436, 437
Positron emission tomography–computed tomography preoperative care and patient drawing, 434
(PET–CT), 147, 382 preoperative evaluation, 434
Post anesthesia care unit (PACU), 902 preoperative problem list/reconstructive requirements,
Posterior interosseous flap (PIF), 578 432
Posterior superior iliac spine (PSIS), 980 surgical technique, 434, 435
Posteromedial thigh (PMT) flap, 957 technical pearls, 435, 436
Postoperative antibiotic therapy, 812 treatment plan, 432
Postoperative complications, 389 Radial forearm free flap (RFFF), 63–65, 101, 103, 104,
Postoperative intravenous prostaglandin E1, 599 106, 107, 227
Postoperative management, 749 Radiation-induced fibrosis, 162
Postoperative radiation therapy, 594, 599 Radical neck dissection, 381
Postoperative radiotherapy, 360, 366, 381 Radical neo-mastectomy, 1014, 1017
Postradiotherapy, 382 Radiocarpal arthrodesis, 517
Postransplant lymphoproliferative disease (PTLD), 793 Radioscapholunate (RSL) arthrodesis, 484
Preauricular incision, 269 Radiotherapy, 371, 375, 381, 383
Prefabricated free flap, 138 Range of motion (ROM), 480
Preoperative assessment, 749 Rapid prototyping (RP) technology, 317
Preoperative computed tomography angiography, 810 Recipient sites, 387
Preoperative evaluations, 599 Recipient vessel(s), 382, 395
Preoperative imaging, 597 access, 916
Preoperative vascular evaluation, 809 identification, 130
Pressure dressing, 250 Reconstructive challenge, 838
Process mapping, 946 Reconstructive surgery, 725
Profunda artery perforator (PAP) flap, breast Rectus abdominis myocutaneous flaps, 101
reconstruction, 81, 979 Rectus femoris (RF), 148
alternative reconstructive options, 937 Renal obstruction, 866
clinical scenario, 936 Replantation, 55
intraoperative images, 940 Retracting scar, 574
outcome-clinical photos and imaging, 940 Reverse lymphatic mapping, 703
post-operative management, 940 Reverse radial free forearm flap (rRFFF), 578
preoperative care and patient drawing, 938 Reverse sural artery flap, 763
preoperative evaluation and imaging, 937–938 Revision amputation, 606
preoperative problem list, 936 Right side maxillectomy, 360
Profunda femoris artery (PFA), 882
Profunda femoral artery perforator (PAP) flap, 79, 101 S
Proper digital nerve (PDN), 432 Salvage laryngectomy, 217
Prophylactic antibiotics, 46–47 Sarcoma, 854
Proximal ulnar free flap, 618 Scalp burn, 4
Index 1079
Scalp reconstruction, 7 SIEA flap, for breast reconstruction

Scalp squamous cell carcinoma alternative reconstructive options, 960–961
outcomes, 16 clinical scenario, 960
postoperative management, 16 intraoperative images, 962–964
preoperative problems, 13 outcome, clinical photos and imaging, 962–966
surgical techniques, 14–15 postoperative management, 962–964
Scaphoid hemiresection and arthrodesis of the radiocarpal preoperative care and patient drawing, 961
joint (SHARC), 484 preoperative evaluation and imaging, 961
Scaphoid nonunion, 466, 467 preoperative problem list/reconstructive
Scaphoid non-union advanced collapse (SNAC) requirements, 960
alternative reconstructive options, 468 surgical technique, 961–962
avoiding and managing problems, 474, 475 treatment plan, 960
outcomes, 473 Sigmoidostomy, 888
postoperative management, 473 Silicone vs. pyrocarbon PIP joint arthroplasty, 455
preoperative evaluation and imaging, 468 Skin graft, 409–410, 594
preoperative problem list/reconstructive requirements, Skin incision, 737
466, 467 Skin-sparing mastectomy (SSM), 952
surgical technique, 469–472 Skin-tension release, 381
technical pearls, 472 Skull base resection, 199
treatment plan, 467 Slim patient, DIEP flap reconstruction in, see Deep inferior
Scapula flap, 101 epigastric perforator (DIEP) flap reconstruction, in
Scapular/parascapular flaps, 146 slim patient
Scapula tip, 365 Soft tissue component, 374
free flap, 362, 397 Soft tissue coverage, 565
Schwannomas, 277 Soft tissue dead space, 371
SCIP free flap Soft tissue debridement, 606
disadvantage, 81 Soft-tissue defect, 394, 442, 448, 724, 725, 729, 731, 733
for intraoral reconstruction, 79 Soft tissue fibrosis, 381
procedure, 443 Soft tissue flap, 199, 361
for tongue reconstruction (see Tongue reconstruction, Soft tissue free flap, 296, 382
SCIP flap for) Soft tissue reconstruction, 145, 854
Secondary lymphedema, 684, 685 alternate options, 594, 595
Secondary wound healing, 809 myxofibrosarcoma, 594
Second free flap, 998 outcome-clinical photo and imaging, 599
Second victim, 1032–1034 postoperative management, 598, 599
Semmes-Weinstein monofilaments test, 551 preoperative care/patient drawing, 596, 597
Sensate extended lateral arm flap (s-ELAF), 725, 727 preoperative evaluation and imaging, 595, 596
Sensate flap, 121, 122 preoperative problems, 594
Sentinel lymph node biopsy (SLNB), 996 surgical techniques, 596, 597
Sentinel node biopsy (SNB), 952 treatment plan, 594
Septal perforators, 159 Soft-tissue reconstruction, in exposed total knee arthroplasty
Septocutaneous vessels, 383 clinical scenario, 724
Seroma, 9, 1004 donor vessels, 730–731
Serratus anterior-rib flap free ALT flap, 729–730
alternative reconstruction options, 443 intraoperative images, 731
avoiding and managing problems, 448 outcome, clinical photos and imaging, 732
intraoperative images, 447 postoperative management, 731
outcome/clinical photos, 447 preoperative evaluation and imaging, 726–727
postoperative management, 447 preoperative problem list/reconstructive
preoperative care and patient drawing, 444 requirements, 724–725
preoperative evaluation, 444 treatment, 725–726
preoperative problem list/reconstructive Specimen of Maxillectomy, 364
requirements, 442 SPECT-CT, 671
surgical technique, 444–446 Speech and language therapy (SALT), 260
technical pearls, 446, 447 Splint, 814
treatment plan, 442, 443 Squamous cell carcinoma (SCC), 370, 380, 394
Serratus muscle flap (SMF), 579 Stacked free flaps, for breast reconstruction
Serratus muscles, 371 alternative reconstruction options, 987
Shoulder flexion, 373 avoiding and managing problems, 992–993
1080 Index
Stacked free flaps, for breast reconstruction (cont.) intraoperative images, 981
clinical scenario, 987 outcome, clinical photographs, 981–982
intraoperative photos, 991 patient positioning and markings, 980
outcome and clinical photos, 992 pre-operative evaluation/imaging, 979–980
postoperative management, 991–992 preoperative problem list/reconstructive
preoperative care and patient drawing, 988 requirements, 978
preoperative evaluation and imaging, 987 surgical technique, 980–981
preoperative problem list, 987 treatment plan, 978–979
surgical steps, 988–989 Superior gluteal artery perforator (SGAP) flap, 998, 1027
treatment plan, 987 Supermicrosurgery, 696
Staged soft tissue reconstruction, 13 Supermicrosurgical lymphaticovenular anastomosis
Standard perforator flap monitoring, 1002 clinical scenario, 690
Sternocleidomastoid muscle (SCM), 145 outcomes, 696
STFF, 373 postoperative management, 695–696
Stress test, 759 preoperative care and patient drawing, 692–693
Subclavian system, 388 preoperative evaluation and imaging, 691
Subfascial flap harvest, 855 preoperative problem list, 690
Subglandular/subcutaneous breast pocket, 859 surgical techniques and intraoperative images, 693
Submandibular incision, 186 treatment plan, 690
Superficial circumflex iliac artery (SCIA), 567, 597, Supermicrosurgical skill, 131
598, 811 Superolateral genicular artery (SLGA), 467, 481
Superficial circumflex iliac artery perforator (SCIP) flap, Super-thin ALT, 585
350, 353, 585, 586 Sural nerve, 193
advantages, 898 harvest, 258
anatomical characteristics, 600 Symmetrisation surgery, 1021
CT angiography, 596 Synthetic mesh, 876, 877
CT scan, 596
diabetic foot reconstruction, 809
direct anchoring pattern, 596 T
disadvantages, 899 T4aN0M0, 370
donor site, 599 Taiwan lymphoscintigraphy staging, 675
map and design, 596, 597 Temporal hollowing, 244
pedicle course, 597, 599 Temporalis muscle transfer, 244
perforator pathway, 597 Temporary lymphatic expansion (TLE) maneuver, 694
Superficial circumflex iliac vein (SCIV), 596–598, 811 Temporary vascular shunts, 605, 606, 613
Superficial fascia, 597 Temporomandibular joint reconstruction, with fibula
Superficial inferior epigastric artery, 811 free flap
Superficial inferior epigastric vein (SIEV), 988, 996, 1029, alternative reconstructive options, 185
1038, 1040 clinical photos and imaging, 192
Superficial peroneal nerve, 192 clinical scenario, 184
Superficial temporal artery (STA), 217 intraoperative images, 191–192
Superficial vein, 596, 597 postoperative management, 192
Superior gluteal artery perforator (SGAP) flap, for preoperative care and patient drawing, 186
immediate breast reconstruction, 974 preoperative evaluation and imaging, 185–186
alternative reconstruction options, 970–971 preoperative problem list, 184–185
clinical scenario, 970–971 surgical technique, 186–191
intraoperative photos, 973 treatment plan, 185
outcome and clinical photos, 974–975 Temporoparietal adipofascial free flap, in laryngotracheal
postoperative management, 974 reconstruction
preoperative care and patient drawing, 971–972 alternative reconstructive options, 227
preoperative evaluation and imaging, 971–972 intraoperative images, 228–230
preoperative problem list/reconstruction outcome, 230
requirements, 970 postoperative management, 228
surgical technique, 972 preoperative care and patient drawing, 227
treatment plan, 970 preoperative evaluation and imaging, 227
Superior gluteal artery perforator (SGAP) flap, in delayed preoperative problem list/reconstructive
autologous breast reconstruction requirements, 226
alternative reconstructive options, 979 surgical technique, 227–228
clinical scenario, 978 treatment plan, 226
Index 1081
Temporoparietal fascia (TPF), 217 secondary first metacarpal bone lengthening, 434
Temporoparietal free flap skin graft, 433
alternative reconstructive options, 217 titanium prosthesis, 443
avoiding and managing problems, 222 vascularized free composite flaps, 443
outcome, 222 Thyrocervical system, 388
postoperative management, 222 Tibialis anterior, 746
preoperative care and patient drawing, 217–218 Tibialis posterior, 746
preoperative evaluation and imaging, 218 Tibial tuberosity reconstruction
preoperative problem list/reconstructive ALT flap, 737
requirements, 216 free flap transfer, 737
surgical technique, 218 intraoperative images, 739
technical pearls, 218–219 patient history, 736
treatment plan, 216–217 pedicled muscle flaps, 737
Tendon transfers, 744–746, 749 postoperative management, 739
Tension-free anastomoses, 941 preoperative care and patient drawing, 737
Teratocarcinoma, 144 preoperative evaluation and imaging, 737
Teres major, 371–374, 376 preoperative problem list, 736
Teres major muscle, 366 surgical technique, 737
Tetanus prophylactics, 47 Tibiotalar arthrodesis, 755
Therapeutic amputation, 752 Tinel’s sign, 628
Thigh sarcoma Tissue expansion, of forehead skin, 76
clinical presentation, 796 Toe flaps, 455
outcome, clinical photos and imaging, 804 Toe transfer, 432, 433, 435
postoperative management, 803–804 Tolerable weight bearing, 814
preoperative evaluation and imaging, 798–799 Tomography angioplasty, 811
preoperative problem, 796–797 Tongue cancer, 92, 94
treatment algorithm, 797–798 Tongue reconstruction, 370–373
Thoracoacromial trunk, 389 advantages, 103
Thoracodorsal artery and vein, 704 ALT flap, 103, 104
Thoracodorsal artery perforator, 548–550 ALT myocutaneous flap, 101
Thoraco-dorsal artery (TDA), 444 avoiding and managing problems, 107
Thoracodorsal artery perforator flap (TDAP), 5, 146, 370, chemotherapy, 100
371, 373, 374 Cheng’s classification, 101
Thoracodorsal artery perforator (TDAP) flap, partial chimeric flap, 106
mastectomy reconstruction clinical photos, 106, 107
alternative reconstructive options, 998 disadvantages, 103
clinical scenario, 996–998 dysphagia, 100
intraoperative images, 1002 hypertension, 100
outcome-clinical photos and imaging, 1002–1003 imaging, 106, 107
postoperative management, 1002 intraoperative images, 106
preoperative care and patient drawing, 999–1000 long intramuscular dissection, 106
preoperative evaluation and imaging, 998–999 medial sural artery, 106
preoperative problem list, 996 microsurgical techniques, 100
surgical techniques, 1000–1002 mobilization, 100
treatment plan, 996–998 MSAP flap, 101, 104
Thoracodorsal nerve, 372, 374 multidisciplinary treatment, 100
Thoracodorsal perforator skin flaps, 372 oral tongue cancer, 100
Thoracodorsal vessels, 832 outcome, 106, 107
Thromboprophylaxis, 115, 374, 399 PAP flap, 104
Thrombotic prophylaxis, 388 partial/hemiglossectomy, 100
Thumb reconstruction, 406, 407, 414, 424, 426, 432, partial glossectomy, 101
616, 618 patient drawing, 105
Thumb/skin defect plastic surgeons, 106
allograft bone, 443 postoperative management, 106
free/regional flap, 434 preoperative care, 105
hand functionality, 433 preoperative evaluation and imaging, 104, 105
metacarpal shaped spacer bone cement, 443 radiotherapy, 100
non-vascularized autologous bone graft, 443 resection, 101
reverse island radial flap, 443 RFF flap, 103, 104
1082 Index
Tongue reconstruction (cont.) Total roots avulsion, 654, 660

surgical technique, 105, 106 Tracheostomy, 81, 115, 308, 371, 380, 383, 388
thin/ultrathin flap, 103 Transverse cervical vessels, 382, 389, 390
tissue bulk, 100 Transverse musculocutaneous gracilis (TMG) flap, 998
treatment plan, 101, 102 Transverse myocutaneous gracilis (TMG) flap, 1027
Tongue reconstruction, SCIP flap for Transverse sensate thoracodorsal artery perforator
advantages, 80 flap, 546
clinical outcomes, 85 Transverse upper gracilis (TUG) flap for breast
postoperative management, 84 reconstruction, 937, 979, 987
preoperative care and patient drawing, 81–82 clinical scenario, patient, 1056
preoperative evaluation and imaging, 81 outcomes, 1061
preoperative problem list/reconstructive postoperative management, 1060–1061
requirements, 79 pre-operative care and patient drawing, 1057
problem management and avoidance, 88 preoperative evaluation and imaging, 1057
surgical technique, 81–82 preoperative problems, 1056
surgical treatment plan, 82–84 surgical technique, 1058
technical considerations/pearls, 82–84 treatment plan, 1056
tracheostomy, 81 Trapezius, 101
Total laryngectomy, 234 Traumatic common peroneal nerve palsy, 744
Total lower face reconstruction, with double free flaps Traumatic injury, 478
alternative bone flaps, 112 Traumatic pseudomeningocele of C7 segment, 638, 644
clinical scenario, 110 Trimmed toe technique, 425
flap harvesting, 113–114 Trismus, 381
free bone flap and pectoralis major myocutaneous flap, Tube-within-a-tube design, 897
for external skin coverage, 112 Tumor resection, 185, 371
intraoperative images, 114–116 Two-point discrimination test, 552
one flap vs. two flaps strategy, 111 Type 1 diabetes mellitus, 808
operation flow and surgical sequence, 112
outcome, 115–117
postoperative management, 114–115 U
preoperative care and patient drawing, 112 Ulnar artery, 596
preoperative evaluation and imaging, 112–113 Ulnar forearm flap, 101
preoperative problem list and reconstructive Ulnar free flap, 617
requirements, 110–111 Ulnar perforators, 617
surgical team, 112 Umbilicoplasty, 917
treatment plan, 111 Upper extremity, 600
Total lower lip reconstruction Upper extremity reconstruction, free proximal fibula flap
alternative reconstructive options, 121–122 alternative reconstructive options, 536–537
clinical scenario, 120 clinical scenario, 536
flap sculpture and aesthetic lip component, 124 postoperative management, 540
innervated composite free radial forearm flap, 122–124 preoperative care and patient drawing, 537
outcome, clinical photos and imaging, 124–126 preoperative evaluation and imaging, 537
postoperative management, 124 reconstructive requirements, 536
preoperative care, 122–123 surgical anatomy, 537–538
preoperative evaluation and imaging, 122 surgical technique, 538–540
preoperative problem list/reconstructive treatment plan, 536
requirements, 120 Upper lip amputation
treatment plan, 120–121 clinical case, 54
Total pelvic exenteration (TPE), 888, 889, 892 intraoperative images, 57
alternative reconstructive options, 889 outcome, clinical photo and imaging, 58
imaging, 889, 892 postoperative management, 57–58
intraoperative images, 891 preoperative care and patient drawing, 56
managing problems, 892 preoperative evaluation and imaging, 56
postoperative management, 891 preoperative problem list, 54
preoperative care, 889 surgical techniques, 56
reconstructive requirements, 888 treatment plan, 55
surgical technique, 889, 890 Upper lip replantation
technical pearls, 891 Abbe flap, 49
treatment plan, 888 amputate, replantation of, 47–48
Index 1083
clinical scenario, 46 treatment plan, 675

Estlander flap, 49 Vascularized thoracic lymph node flap, 676
Karapandzic flap, 49 Vascular pedicle, 839, 848, 849, 854
leech therapy, 48 Vasculo-nervous pedicles (VNP), 432
preoperative problem list, 46 Vasodilator, 436
prophylactic antibiotics, 46–47 Vasospasm, 549, 551
rabies prophylactics, 47 Vastus lateralis (VL), 38, 148, 209–212, 343, 383
surgical technique, patient management and outcome, muscle flap, 39–41
49–50 Vastus lateralis motor nerve (VLMN), 333
tetanus prophylactics, 47 Vein grafts, 383, 387, 389, 390
Uterus cancer, 370 Venous congestion, 133, 919, 1043
Venous thromboembolism, 599
Vertical partial laryngectomy (VPL), 226
V Vertical posteromedial thigh flap (vPMT), 952, 957
VAC®-therapy, 567 Vessel anastomosis, 955
Vaginal reconstruction, 888, 889 Vessel avulsion, 1031
Valsalva manoeuvre, 193 Vessel-depleted neck, 381, 382, 388–390
Valsalva procedure, 1021 Vessel reconstruction, 796
Vascularity, 808 Vestibuloplasty, 175
Vascularized bone, 527 Virtual surgical planning (VSP), 113, 114, 117, 174
Vascularized bone grafts (VBGs), 467, 480, 482, 485 mandibular reconstruction, 314–323
Vascularized composite allotransplantation (VCA), maxillary reconstruction, 323–327
788, 790 Visceral flaps, 889
Vascularized fibula, 820 Volume replacement technique, 996, 998
Vascularized fibular flap, 172, 752, 820 Volumetric measurements, 1028
Vascularized free corticocancellous, 481 VRAM flap reconstruction, 877
Vascularized groin lymph node flap, 676
Vascularized lymph nodes transfer (VLNT), 700, 702–703,
1027–1032
W
characteristics, 710
Watertight repair, 31–33, 35
combination with, 711
WLE, 1022
lymphaticovenous bypass, 711
Wound bed preparation, 809
on lymphoscintigraphy, 716
Wound closure, 550
submandibular, 714
Wound debridement, 545
treatment plan, 711
Wrap-around procedure, thumb reconstruction
Vascularized lymph vessel transfer (VLVT), 351, 352
Vascularized medial femoral condyle periosteal flap in
outcome-clinical photos and imaging, 419
radius reconstruction
postoperative management, 419
clinical scenario, 513–514
preoperative care and patient drawing, 416–417
CT angiogram, 520
preoperative evaluation and imaging, 416
outcome, clinical photos and imaging, 521
preoperative problem list, 414–415
postoperative management, 521
surgical techniques, 417
preoperative evaluation, 519
treatment plan, 416
reconstructive requirements, 515
Wrist arthrodesis, 530
Wrist pain syndrome, 466
treatment plan, 515–517
Wrist reconstruction, 478
Vascularized nerve graft (VNG), 333, 338
Wuchereria bancrofti, 674
Vascularized periosteal flaps, 820
Vascularized submental lymph node (VSLN) transfer
outcomes, 679 Z
postoperative management, 678–679 Z and Reverse Z shape thumb, 584
preoperative care and patient drawing, 677 Z-plastys, 575
preoperative evaluation and imaging, 676–677 Z-shape thumb correction, 585
surgical technique, 677 Zygomaticus major muscle, 147

Clinical Scenarios in Reconstructive Microsurgery: Andreas Gravvanis Despoina D. Kakagia Venkat Ramakrishnan

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Clinical Scenarios in Reconstructive Microsurgery: Andreas Gravvanis Despoina D. Kakagia Venkat Ramakrishnan

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Andreas Gravvanis

With 912 Figures and 10 Tables

ISBN 978-3-030-23705-9 ISBN 978-3-030-23706-6 (eBook)

© Springer Nature Switzerland AG 2022

The evolution of Plastic Reconstructive Surgery resulted in the “Reconstruc-

Athens, Greece Andreas Gravvanis, MD, PhD, FEBOPRAS

Part I Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1 Microvascular Reconstruction of Soft Tissue Defects of the

2 Composite Defect of Scalp and Calvarial Bone Following

3 Reconstruction of Calvarial Bone Radionecrosis and

4 Anterior Skull Base Reconstruction with Intracranial Free

5 Endoscopic Insetting of Free Flaps in Skull Base

6 Upper Lip Replantation with Arterialized Venous Flap,

7 Upper Lip Amputation: Microsurgical Replantation and

8 Salvaging a Failed Total Nasal Reconstruction Using Radial

9 SCIP Flap for Tongue Reconstruction . . . . . . . . . . . . . . . . . . 77

10 Reconstruction of Partial Glossectomy with Innervated

11 Tongue Reconstruction with Medial Sural Artery

12 Total Lower Face Reconstruction with Double

13 Total Lower Lip Reconstruction with Innervated Radial

14 Ear Replantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

15 Ear Reconstruction Using Microvascular

16 Periauricular Reconstruction After Total

17 Reconstruction of a Massive Facial Defect

18 Mandible Reconstruction in Osteoradionecrosis . . . . . . . . . . 161

19 Atrophic Maxilla with Fibula Flap and Implant-Supported

20 Reconstruction of Temporomandibular Joint with

21 Orbital Reconstruction with Free Fibula Flap . . . . . . . . . . . . 197

22 Hypopharynx Reconstruction with a Chimeric

23 TPFF Augmentation of Primary Pharyngeal Closure

36 Reconstruction of Total Maxillectomy and Orbital Floor with a

37 Reconstruction of Mandible and Hemiglossectomy with a

38 Double Free Flap Reconstruction in the

39 Management of Bone Nonunion in Mandible Free Flaps with a

Part II Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

40 Complex Thumb Reconstruction Using Free

41 Free “Wrap-Around” Great Toe Flap for Thumb

42 Combined Osteodistraction and Free “Mini Wraparound”

43 First Toe-to-Hand Transfer and the Forearm Radial Flap as

44 Serratus Anterior-Rib Flap for the Reconstruction of

45 Free PIP Joint Transfer for Functional Finger

46 Treatment of Scaphoid Nonunion Using the

47 Treatment of the Avascular Necrosis of the Lunate

59 Adult Immediate Brachial Plexus Reconstruction . . . . . . . . . 637

60 Brachial Plexus Secondary Reconstruction with

Part III Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

61 Combined Autologous Breast and Lymphedema

62 Submental Lymph Node Transfer to the Lower

63 LYMPHA Approach for Axillary Clearance

64 Supermicrosurgical Lymphaticovenular Anastomosis

65 Lateral Thoracic Artery Lymph Nodes (LTLN) for Lower

66 Free Transfer of Cervical Lymph Nodes to a Lower Limb

Part IV Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721

67 Soft-Tissue Reconstruction in Exposed Total Knee

68 Tibial Tuberosity Coverage Using Venous Supercharged

69 Complete Peroneal Nerve Palsy: Functional Reconstruction

70 Tibial Bone Defect Reconstruction with Ilizarov and

Part V Breast/Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827

78 Composite Axillary Defect After Sarcoma Resection:

84 Penile Reconstruction with a Free Radial Artery

98 Deep Inferior Epigastric Artery Perforator (DIEaP) Flap

99 Perineal Reconstruction for a Complex

100 Breast Reconstruction Using a Transverse Upper