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Second Edition


Regional and Free Flaps for

Head and Neck Reconstruction:
Flap Harvest and Insetting
Mark L. Urken, MD, FACS Keith E. Blackwell, Mo
Professor Prafessor
Department of OtominolaryngoloiJ'f---Haad and Neck Surgery Diviaion af Head and Neck Surgery
Albert Einstein College of Medicine Department af Surgery
Chief of Head and Neck Surgical Oncology David Geffen School of Medicine
Continuum Cancer Cantars of New Yorlt University of Caltfornia, Loa Angeles
Division of Head and Neck Surgery Director
Department of OtDiaryngology Head and Neck Surgery SaJVica
Beth Israel Medical Center Department of Surgery
New York. New York Ronald Reagan UCLA Medical Center
Loa Angelea, California
Mack L. Cheney, MD
Professor Jeffrey R. Harris, MD FRCS (C)
Department of Otolaryngology-Head and Neck Surgery Associate Prafessor
HalYard Medical School Department of Surgery
Director of Facial Plastic and Reconatructive Surgery Division of Otolaryngology-Head and Neck Surgery
Department of Otolaryngology-Head and Neck Surgery University of AI berta
MassachusettJ Eya and Ear Infirmary Chief
Boii1Dn, MaaaachusetiB Department of Otolaryngology-Head and Neck Surgery
University of Alberta Hospital
Neal Futran, MD, DMD EdmoniDn, Alberta
Profassor and Chair of OtDiaryngology-HNS Canada
Director af Head and Neck Surgery
Univeraity of Wuhington
Seatlla, W11hington Forewsrdby
Tessa Hadlock, MD Shan R. Baker, MD
Facial Ne!Ve Center
Department of OtDiaryngology-Head and Neck Surgery Illustrator
MaaaachuaetiB Eye and Ear Infirmary Sharon Ellis
Aaaociate Professor New York. New York
HalYard Medical School
BolltDn, MaaaachusetiB

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Library of Congress Cataloging-in-Publication Data

Atlas of regional and free flaps fur head and neck reconstruction: flap harvest and insetting I Mark L Urken ... [et al.); illustrator,
Sharon Ellis. - 2nd ed.
Includes bibliographical references and index.
ISBN 978-1-60547-972-9
1. Head-smgery-Atlases. 2. Neck-surgery-Atlases. 3. Flaps (Smgery)-Atlases. 4. Surgery, Plastic-Atlases. I. Urken,
Mark L, 1954-
[DNLM: 1. Head-surgery-Atlases. 2. Neck-surgery-Atlases. 3. Surgery, Plastic-Atlases. 4. Surgical Flaps-Atlases.
WE 17]
RD52l.A846 2012
617 .5' 100223-dc23

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the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings
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9 8 7 6 5 4 3 2 1

To Laura, for the countless ways that she has enriched my life and whose endless
love and devotion provide the fuel for all of my professional endeavors.
To Gabrielle, Grant and Hannah who provide me with indescribable joy on a daily
basis and are the source of great pride for the remarkable individuals that they have
To the Board of Directors of the Thane Foundation that has provided generous
support and placed their faith in me to fight thia cruel disease in novel ways that could
not be accomplished without them.
To the Levy, Lane, Dawson and Plaut families who have always gone the extra mile
to provide their extraordinarily generous suppon that was critical to achieving success
in ao many of the initiatives of the Thane foundation.
To Elliot, for his friendship and suppon, and for putting his faith in me to help him
to combat a devutating illness, and which he has done with grace and courage.
Finally, to my fellows and residents, who have endured long hours in the operating
room and helped to provide the highest level of patient care.
Marie L Urletm
To Paul.
Mack L Cheney
To Paul Ward, MD and Mark Urken, MD for their mentonhip and teaching, and to
my wife Julie and son Ryan, for their support and understanding.
Keith E. BlacktJJell
To aU my friends and fim:Wy for their ongoing support and especially to Jody,
Jacbon, and Mackenzie who continue to show me what is truly important in life.
Jeffrey R. Harrit
For Bruce, who I am so fortunate to share life with, and our children, Rob, Kent,
McKenzie, and Forrest.
'lbsa A . Haillock
To my wonderful wife Margi, and children Alaandra, Jordan, and Evan, whose love,
devotion, and constant suppon have allowed me to pursue this endeavor, and have
enriched my life beyond compare.
Neal Furran


Keith E. Blackwell, MD Jeffrey R. Harris, MD FRCS (C)

Professor Associate Professor
Division of Head and Neck Surgery Deparbnent of Surgery
Department of Surgery Division of Otolaryngology-Head and Neck Surgery
David Geffen School of Medicine University of Alberta
University of California, Los Angeles Chief
Director Department of Otolaryngology-Head and Neck Surgery
Head and Neck Surgery Service University of Alberta Hospital
Department of Surgery Edmonton, Alberta
Ronald Reagan UCLA Medical Center Canada
Los Angeles. California
Arjun S. Joshi, MD
Mack L. Cheney, MD Assistant Professor
Professor Division of Otolaryngology-Head and Neck Surgery
Department of Omlaryngology-Head and Neck Surgery The George Washington University
Harvard Medical School Attending Physician
Director of Facial Plastic and Reconstructive Surgery Daparbnent of Surgery
Department of Omlaryngology-Head and Neck Surgery The George Washington University Hospital
Massachusetts Eye and Ear Infirmary Wahingmn, DC
Boston, Massachusetts
Robin W. Lindsay, MD
Neal D. Futran, MD, DMD Assistant Professor
Professor and Chalr of Otolaryngology-H NS Daparbnent of Surgery
Direcmr of Head and Neck Surgery Uniformed Services University of the Health Sciences
University of Washington Facial Plastic and Reconstructive Surgeon
Seattle, Washington Daparbnent of Otolaryngology-Head and Neck Surgery
National Naval Medical Centar
Allan M. Goldstein, MD Bethesda, Maryland
Associate Professor of Surgery
Harvard Medical School Mark L. Urken, MD, FACS
Associate Visiting Surgeon Professor
Department of Pediatric Surgery Department of Otorhinolaryngology-Head and NeckS urgery
Massachusetts General Hospital Albert Einstein College of Medicine
Boston, Massachusetts Chief of Head and Neck Su11ical Oncology
Continuum Cancer Centers of New York
Tessa A. Hadlock, MD Division of Head and Neck Surgery
Diracmr Department of Otolaryngology
Facial Nerve Centar Beth Israel Medical Canter
Department of Omlaryngology-Head and Neck Surgery New York, New York
Massachusetts Eye and Ear Infirmary
Associata Professor
Harvard Medical School
Boston, Massachusetts


D esearch in vascular surgery was markedly enhanced of the 1980s and 1990s brought many more surgical
~s a result of the work of Carrell and Guthrie in innovations and new microsurgical flap designs includ-
the early 1900s in which they performed replantations ing such important ones as the scapular flap, fibula oste-
and transplantations of several composite tissues. Hepa- ocutaneous :flap, and the radial forearm flap.
rin was discovered in 1916. The ability to control blood A number of regional flaps were coming into use
cloning was an essential step forward in the develop- for head and neck reconstruction at the same time as
ment of microvascular surgery, as was the use of the the emergence of clinical microvascular surgery. Most
operating microscope that was initiated by Nylen and important was the pectoralis major myocutaneous :flap.
Holmgren for ear and eye surgery in the early 1920s at The use of microsurgical tissue transfer for reconstruc-
the Karolinska Medical School in Stockholm, Sweden. tion of the head and neck was undoubtedly delayed
Jacobson and Suarez in 1960 wt:re the first to use the somewhat by the popularity of the pectoralis major
operating microscope to perform anastomoses of 3-mm myocutaneous flap and the belief that it represented the
arteries using 7-0 braided silk. Thus was bom microvas- answer to virtually all of the reconstructive challenges
cular surgery. Technical improvements in microsurgi- in head and neck reconstruction. The failure of the pec-
cal instruments, suture, and the operating microscope, toralis major flap to reliably transfer vascularized bone
including coaxial illumination, motorized zoom, and for mandibular reconstruction and the difficulties in
binocular viewing enabled multiple surgeons to simul- tubing this flap to reconstruct the pharyngoesophageal
taneously begin to investigate experimental extremity segment led to renewed interest in the role of free tissue
replantations throughout the world. transfer as a potential solution.
Success with replantations led to efforts to perform It was in the 1970s that otolaryngologists who per-
reconstructive microvascular surgery. During the 1960s, formed reconstructive surgery, like myself, became
Buncke experimented with replanting and transplant- interested in microvascular surgery. As a 2nd year house
ing tissues in laboratory animals. He developed many officer in the Department of Otolaryngology, Maxillo-
important principles and techniques and is considered facial Surgery at the University of Iowa, William Panje,
by some to be the founding father of microvascular sur- MD, traveled to New York to take a 1-week surgical
gery. The first reported experimental microsurgical skin course to learn the techniques of microvascular surgery.
flap transplantation was reported by Krizek and associ- When he returned from the course, he was kind enough
ates. Abdominal skin baaed on the superficial epigastric to teach me the techniques. We dissected donor :flaps
vascular pedicle was successfully transferred in dogs. in cadavers and practiced anastomosing 1-mm blood
During the decade of the 1970s, there were numer- vessels in rats. Once we were consistently successful in
ous advances in experimental microsurgical tissue trans- anastomosing these small blood vessels, we attempted
fer and later in the decade, the emergence of clinical the transfer of a free groin flap based on the superficial
microvascular surgery. Although human tissue transfer circu.m:fla iliac artery and ~in to the anterior floor-of-
was accomplished as early as 1957, when Sam and Sei- mouth in order to repair a defect resulting from removal
denberg reconstructed an esophagus with a free jejunal of a large squamous cell carcinoma. The vascular pedi-
segment, it was not unti11972 that the first human free cle was only 3 em in length. Much to our delight, the
skin flap transfer ofscalp tissue using microvascular sur- flap survived and it was reported in 1975 as the world's
gery was reported by Harii and colleagues. A year later, first successful intraoral microsurgical flap. Bill and I
Daniel and Taylor reported the successful transfer of a were in our 3rd year of residency at the time. We contin-
groin flap. The first revascularized fibular transfer was ued to perform other microsurgical reconstructive cases
reported byTaylor and colleagues in 1975. The decades together during our senior year of residency at Iowa.


In 1977, I completed my residency and began an a highly illustrated and in-depth discussion of both
academic career in the Department of Otolaryngol- normal and abnormal anatomy of donor sites, the most
ogy-Head and Neck Surgery at the University of common designs of flaps, and their major applications
Michigan. At this time, there was concern among some for head and neck reconstruction. The book details the
head and neck surgeons that otolaryngologists were not surgical techniques of dissecting and transferring flaps,
being trained to perform microvascular surgery and potential pitfalls when harvesting flaps, and preopera-
that this aspect of head and neck reconstruction would tive and postoperative surgical care. The Adas provides
be lost to our specialty. Dr. Krause, Chairman of the a comprehensive review of flaps used for head and
Department of Otolaryngology in Michigan, convened neck reconstruction and is divided into two pans. Part
an impromptu meeting of young academic otolaryngol- I discusses regional flaps including muscle and mus-
ogists with an interest in head and neck reconstruction culocutaneous and fascial and fasciocutaneous flaps.
at the fall meeting of the AAO-HNS in 1978. Attend- An additional chapter explores the palatal island flap.
ees concluded that the most effective way of securing Part II deals with a large selection of microsurgical flaps
microvascular surgery as pan of the expertise of otolar- and nerve graft donor sites. Photogmphs of detailed
yngologists was to teach young academic otolaryngolo- flap dissections in fresh cadavers are supplemented with
gists the techniques of microvascular surgery and the beautiful anatomic illustrations. New to this edition and
anatomy of the various donor flaps. These individuals of great value is the inclusion of detailed cadaveric dissec-
could, in turn, teach fellows and house officers in their tions that show the insetting and orientation of flaps to
respective residency programs. The first microvascular reconstruct some of the most common defects encoun-
training course for otolaryngologists was directed by tered by reconstructive surgeons. The book is a valuable
myself and Charles J. Krause, MD, in 1979 at the Uni- and timeless contribution to the medical literature.
versity of Michigan. In 1989, I published the first text Microvascular surgery has revolutionalized head
book solely devoted to microsurgical aspects of head and neck reconstruction over the last three decades.
and neck reconstruction. Surgeons can replace missing segments of the mandi-
Dominant among these early surgical leaders is Mark ble and maxilla with vascularized bone grafts in which
L. Urken, MD, who has had a prominent role in teach- osteointegrated dental implants can be incorporated.
ing microvascular surgery to otolaryngologists through Patients undergoing partial or total glossectomy are
courses he conducts, the fellowship progmm he directs, reconstructed with innervated musculocutaneous flaps.
and textbooks he has written and edited. Young leaders Sophisticated techniques in transplanting skin, muscle,
such as those who have contributed to the second edi- bone, mucous membrane, and nerve enable the head
tion of this outstanding adas continue to innovate and and neck surgeon to repair patients suffering from
expand the clinical applications of microsurgical recon- great deformities and dysfunction as a result of soft tis-
struction of the head and neck. sue and bony defects of the head and neck. The level
The second edition of the Atlas of Regional and Free of functional and aesthetic restoration of such patients
Flaps for Head and Neck Reconstruction represents the was not possible before the development of microvas-
culmination of the experience and knowledge in micro- cular surgery. This Atlas clearly provides an insight to
vascular and regional flap reconstruction of the head the impressive gains made in head and neck reconstruc-
and neck gained over the last 30 years. The contem- tion by enumerating and carefully describing the many
porary head and neck surgeon must have a thorough microsurgical and regional flaps available to the con-
understanding of the anatomy of microvascular and temporary head and neck surgeon. It will be an invalua-
regional flaps and their applications for head and neck ble resource for both the beginning and the experienced
reconstruction. They must also be familiar with the head and neck surgeon.
donor site morbidity resulting from their use. Micro-
vascular surgery requires specialized surgical skills and Shan R. Baker, MD
detailed understanding of anatomy. This atlas provides Universi'ljl of Michigan
n head and neck surgery, there are very few develop- high frequency. In addition, the more widespread use of
I ments that have had as great an impact as the abil-
ity to transport healthy tissue from regional and distant
radiation and chemotherapy as the primary modalities
for treating many upper aerodigestive tract malignancies
sites for the purpose of restoring patient form and func- has introduced a new set of treatment-related problems
tion following ablative surgery. The impact of free tis- that can only be managed through the introduction of
sue transfer has been monumental in promoting wound healthy, nonirradiated tissue to replace the damaged
healing despite scarring, radiation damage, and salivary sttuctures in the :field of radiation. Osteoradionecrosis
contamination. The ability to reliably transport healthy and pharyngoesophageal stenosis are examples of such
tissue into a head and neck defect following an exten- problems.
sive resection has greatly streamlined the ablative and The writing of the second edition of this book was
reconsuuctive program for both the patient and the sur- therefore motivated by the recognition that many of
geon; this simplification has dramatically decreased the the basic skill sets in flap harvest and utilization are no
incidence of prolonged hospitalizations and the need for longer a part of the mainstream of head and neck surgi-
multiple surgical procedures to achieve a suboptimal cal education. Understanding what can be done is vitally
final result. Finally, the predictable nature of Bap trans- important in order to ensure that clinicians are able to
fers permined the development of a myriad of smgical make the proper choices in advising patients as to what
and restorative refinements in our approaches to man- their best options are for managing their particular dis-
aging defects in the head and neck. The degree of detail ease process.
involved in contemporary treatment planning is a direct It was important, in the design of this edition, to
result of the ability to transfer well-vascularized hard- thoroughly present the full range of both regional and
and soft-tissue components, with varying thicknesses free tissue transfers that are utilized in contemporary
and the potential for both sensory and motor recovery. head and neck reconstruction. This involved the elimi-
The inclusion of dental implants as a part of the com- nation of certain donor sites from the first edition, in
prehensive restorative process has permitted significant particular the masseter muscle and lateral thigh flap
advances in function and quality oflife and has justified chapters. In their place, several new donor sites have
patient expectations for recovery levels that far more been included, which are the submental flap, paramed-
closely approximate their predisease state of Mrmaky. ian forehead flap, anterolateral thigh flap, posterior tib-
Advances in the treatment of head and neck cancer ial flap, ulnar forearm flap, serratus anterior flap (with
continue to demand modification of the approaches nb), and the radius osteocutaneous flap. In addition to
that we take in the management of patients afilicted defining the anatomy and flap harvest techniques of
with these devastating illnesses. With the evolution of these new donor sites, the authors felt that the demon-
nonsurgical "organ sparing'' strategies, as wclJ. as tran- stration of flap insetting techniques, in a variety of dif-
soral resections, with or without robotics, the art of ferent clinical situations, would be helpful to the reader
head and neck reconstruction is no longer a part of the in order to understand the methods for using the tissue,
mainstream of head and neck residency ttaining. This is once it was successfully harvested. This book does not
problematic with respect to the experience level of the cover all of the issues related to defect analysis, which is
next generation of surgeons who are no longer skilled the subject of the book titled, Multidisciplinary Head and
in the transfer of even basic regional flaps and may Neik Rubmt:ruet:Um: A Dejeet 0Nnt8d Approach, which
not be familiar with the more sophisticated free tissue is considered a companion text for this second edition.
transfers that are currently employed in centers that are The inclusion of descriptions of new donor sites that
performing head and neck reconsuuctive surgery with are presented in detail in this edition is a reflection of


the evolution of the field of reconstructive surgery and introduced into the gracilis chapter to highlight its role
a plea to surgeons to avoid complacency in using just a in facial reanimation surgery.
limited range of techniques that they have grown com- There are three new chapters added to the section of
jorrable in performing. Failure to continue to expand the Fascial and Fasciocutaneous Free Flaps. Both the ulnar
range of donor sites stifles the creativity and the drive and anterolateral thigh flaps have a proven track record
to do more for our patients and to continue to push in head and neck surgery, while the posterior tibial is a
the envelope, which is the process that led to the many relatively new but promising source of thin skin from
advances that have dramatically changed our manage- a remote part of the body. Reconstructive techniques
ment of head and neck cancer over the past three dec- for pharyngoesophageal reconstruction and lengthening
ades. of the thoracic trachea are demonstrated with extensive
Chapters 1 through 4 provide the reader with the cadaveric dissections.
anatomy and harvest techniques for the most important While the fibula, iliac crest, and scapular compos-
regional muscle and musculocutaneous flaps that are ite flaps are the mainstay of reconstructive surgery for
still vitally important in the head and neck surgeon>s defects of the maxillomandibular skeleton, there are two
armamentarium of reconstructive options. Along with new donor sites introduced in this edition: the radius
the latissimus dorsi donor site, which is covered in osteocutaneous and the serratus anterior/rib flaps. The
Chapter 20 as a free flap, these four donor sites provide technique for closure of the abdominal wall with a syn-
immediately available soft tissue that can be transferred thetic mesh following harvest of the iliac crest-internal
without microvascular surgical skills. The sternocleido- oblique osteomusculocutaneous flap is presented in
mastoid muscle flap is not a reliable carrier for the over- this edition of the atlas. In addition, the techniques for
lying cervical skin, but its use in airway reconstruction, insetting of these flaps for restoration of both mandib-
in particular in the management of invasive thyroid can- ular and maxillary defects are demonstrated in detail.
cer, is demonstrated through the illustrations that have In particular, the selection of side of harvest and its
been added in this revised chapter. impact on the location of the skin flap as well as the
In the section on regional cutaneous and fascia- vascular pedicle has been extensively covered through
cutaneous flaps, Chapters 5 through 8, there are two numerous cadaver dissections. Other vitally important
new donor sites that are presented, the submental and surgical problems have been presented in these revised
paramedian forehead. These flaps are vitally important chapters, such as the management of the missing con-
sources of color-matched skin that play a very significant dyle and the creation of a double-barreled fibular flap
role in contemporary reconstruction of facial defects. reconstruction of the mandible. Reconstruction of the
For total and subtotal defects of the cheek, the posterior palatomaxillary complex with the scapular tip, the fib-
scalp flap remains an excellent technique, which, when ula, and the iliac-internal oblique flaps is demonstrated
coupled with pre-expansion, provides a large surface in great detail in the relevant chapters.
area of skin to restore virtually the entire side of the The chapters on the free jejunal autograft and
face. Finally, the deltopectoral flap, although less com- the gastroomental flap have been extensively revised
monly used, was maintained as a part of this second through step-by-step cadaver dissections of the harvest
edition because there are still circumstances where this technique. In addition, the most common application of
is the donor site of choice for resurfacing cervical skin these visceral flaps for reconstructing the laryngophar-
defects. The technique of the island deltopectoral flap is yngectomy defect is presented in a detailed step-by-step
highlighted in this revised chapter and represents a use- fashion.
ful strategy for a single-stage transfer of color-matched Very little has changed in the harvest of the medial
skin from the upper chest. antebrachial and sural nerves other than the intro-
The palatal island flap, presented in Chapter 9, has duction of endoscopic, minimally invasive techniques.
emerged as the primary reconstructive option for full- These donor sites continue to be a very important part
thickness palatal defects with dimensions that are con- of head and neck reconstruction, particularly in the
ducive to this technique. In particular, the surface area management of facial nerve disorders. With advances
of the remaining palatal mucoperiosteum must be suf- in cross-face nerve grafting techniques and the use of
ficient to provide coverage of the defect with overlap of innervated free muscle to restore dynamic facial anima-
the edges of the bone. tion, the need for nerve grafts has grown substantially.
The rectus abdominus and gracilis flaps, Chapters Chapter 28, on recipient vessel selection, has been
10 and 11, have very important roles in contemporary significantly altered with the introduction of surgical
head and neck reconstructive surgery. In addition to dissections that demonstrate the harvest of the thora-
the conventional method of harvest, the rectus abdomi- coacromial artery and cephalic vein as well as the inter-
nus perforator flap has been added to this edition. A nal mammary artery and vein. These recipient vessels
more detailed description of flap insetting has been play a very important role in expanding the opportunity

to apply free tissue transfer to patients who have under- the diversity in reconstructive options has become a
gone prior surgery and radiation and present the chal- true creative endeavor. A mastery of different donor site
lenges inherent in the vessel-depleted neck. Finding options provides the surgeon with the confidence to find
suitable recipient vessels that permit the performance a solution for virtually every reconstructive problem,
of free tissue transfer is vital to the decision to offer life- regardless of the complexity of the defect or the tech-
preserving and quality-of-life enhancing surgery. niques that had been previously utilized in a particular
I will end this preface in a similar way to my ending patient.
of the preface in the first edition. While my coauthors In addition, there is a growing appreciation that one
and I have attempted to provide detailed photographs donor site may not suffice in the most complicated
of dissections and illustrations for the performance of defects. We have often resorted to the use of multiple
innumerable surgical techniques in this edition, they are free flaps or the combination of a free flap and a regional
not a replacement for each surgeon to go to the labora- flap to achieve the final result. Once again, expertise
tory to painstakingly practice these techniques prior to with many different flaps allows the surgeon to combine
attempting them in the operating room. While the lack flaps as the situation dictates.
of availability of appropriate laboratories in one's own This book was conceived, in large part, out of the
institution may serve as a barrier, the expansion of sur- requests of participants at an annual reconstructive
gical courses that provide hands on harvesting experi- course that my colleagues and I have given at Mount
ence allows ample opportunity to expand one's range of Sinai Medical Center over the past several years. The
surgical skills. The field of head and neck reconstruction course has in many ways mirrored the evolution of head
continues to be a dynamic and exciting career choice. and neck reconstruction with an ever-increasing cur-
However, it is imperative to never lose sight of the fact riculum that reflects the expansion of available recon-
that surgery is a discipline that requires that each surgeon structive options and an ever-increasing enrollment that
reaches the requisite level of skill and experience prior reflects the growing interest and enthusiasm for this dis-
to embarking on a surgical technique in a live patient. cipline. We realized that there was no single book that
provided the head and neck surgeon with a detailed
description of the anatomy and harvesting techniques
PREFACE FROM THE FIRST EDITION for the major regional and free flap donor sites currently
employed in head and neck reconstruction. We chose
The most attractive and challenging feature of head and the medium of fresh cadaver dissections to provide the
neck reconstruction is the complexity of the anatomy most realistic portrayal of the step-by-step details that
and function of this region. The range of tissue types would give the resident and attending surgeon a thor-
that must be duplicated is arguably greater than any ough understanding of each donor site. Since attention
other site in the body. Therefore, it is no surprise that a to detail is so vital to successful surgery, the descriptions
growing desire to achieve a higher level of rehabilitation in this book reflect that detail as closely as possible.
has caused dissatisfaction with conventional regional A thorough understanding of anatomy is the cor-
cutaneous and musculocutaneous flaps. The ability to nerstone of all surgery, and reconstructive surgery is
transfer flaps that are thinner, are more pliable, contain certainly no exception. With an understanding of the
vascularized bone, and have both motor and sensory intricate details of a donor site, the surgeon can creatively
potential has driven the era of free flap surgery. How- mold the tissue to fit the needs of the patient and the
ever, the availability of free tissue transfer must not particular defect. Each chapter includes details of nor-
mean the abandonment of conventional techniques. mal donor site anatomy as well as anatomic variations.
Regional donor sites provide a valuable source of tis- In every section of the book, the most important designs
sues that were ideal for many types of reconstruction. of each flap are presented as are the major applications
There are many different factors that enter into the to which that flap has been applied. With the tools of
decision regarding the optimum reconstruction for a anatomy and surgical technique, the surgeon's imagina-
particular patient and a particular defect. The adage, tion is the only limitation to solving a particular problem.
simpler is better, certainly applies to the selection of a Chapters 23 and 24 detail the anatomy and harvest
donor site. However, the desire for simplicity by using a of nerve grafts from the sural and medial antebrachial
regional flap must be weighed against the quality of the nerves. With an emphasis on restoring function to the
end result that can be achieved when free tissue from a head and neck, sensory and motor reinnervation are key
distant site is utilized. components and the head and neck surgeon will find it
Contemporary head and neck reconstruction involves valuable to be well versed with these two donor sites.
a thorough appreciation of both regional and free flaps. By providing a discussion of anatomy, flap design
This book covers a spectrum of donor sites and spans and utilization, anatomic variations, preoperative and
the innovations in technique from the 1960s through postoperative care, potential pitfalls, and harvesting
the early 1990s. The art of head and neck surgery with techniques for each donor site, this book is oriented

toward the resident as well as the practicing head and donor sites will undoubtedly be introduced that further
neck surgeon. However, it is not meant as a substi- expand the range of tissue that is available. There will
tute for the essential painstaking learning processes of certainly be new techniques that may totally revolu-
working in a microsurgical laboratory and in a cadaver tionize this discipline. It is imperative that the surgeon
dissection laboratory to master the techniques before approaches these innovations with an open mind.
applying them in clinical practice. Flexibility will permit change to occur and offer new
Just as the oncologic management of head and neck hope to our patients.
neoplasms will continue to evolve, so too will the recon-
struction and rehabilitation of these patients. New Mark L. Urken. MD. FACS
umerous pioneers in head and neck surgery are vital to providing a final product that we can all be very
N responsible for laying the foundations that have
led to the advances in reconstruction that are presented
proud of.
Four individuals played a very important role in
in this second edition of the adas. William Panje, Shan the painstaking dissections and photography that were
Baker, Hugh Biller, Sebastian Arena, and John Conley required to produce the countless changes in this edi-
are but a few of those individuals who had the vision tion. Dr. Arjun Joshi, Dr. Allan M. Goldstein, and
and the insight to make countless advances, without Dr. Robin W. Lindsay each contributed to the writing
their efforts, the field of head and neck reconstruction of multiple chapters in this edition. In addition, their
would have never reached the level that is reflected in efforts, along with Dr. Matthew Bak, contnbuted to
the pages of this book. M.u: Som was one of the great the efficiency and success of those long arduous days in
head and neck surgeons who had the foresight and the the laboratory that led to the tremendous quality of the
courage to perform the first free tissue transfer tech- images that provide clarity to the written word.
nique on a human in 1958. It was that groundbreaking Sharon Ellis is a medical illustrator who has an
procedure that led to the explosion in this field that we unparalleled understanding for the need for anatomic
currendy enjoy some six decades later. detail, portraying illustrations from a surgeons perspec-
There are numerous individuals that I would like tive, and providing an aesthetically pleasing product.
to thank for their help in making this second edition I have had the pleasure ofworking with her on three sep-
a reality. I would first like to express my gratitude to arate projects and my appreciation of her professional-
my coauthors on this endeavor. Mack L. Cheney was a ism, timeliness, and artistic accuracy continues to grow.
coauthor on the first edition and he continues to be one I would like to express my gratitude to Bob Hurley,
of the most creative surgeons that I have had the pleas- Dave Murphy, Eileen Wolfberg, and Franny Murphy at
ure of interacting with as a valued colleague through- Lippincott Willi.anul & Wilkins for understanding the
out my career. Mack and Tessa A. Hadlock have greatly need for a second edition of this book and their com-
advanced the management of facial reanimation sur- mitment to delivering the best possible product for our
gery and have provided a level of science and creativity readership. They shared our collective vision for the
to this field that is a remarkable achievement. Three type of resource that we wanted to provide and never
former fellows, Neal Futran, Keith Blackwell, and Jeff wavered in their support.
Harris have advanced what I have taught them and Finally, I and my coauthors would like to gM: a
moved the field of head and neck reconstructive sur- very special thanks to Synthes CMF Corporation for
gery to new heights. Each has made numerous con- the financial and material support that they provided
tributions and started their own fcllowships to ensure for this project. They understood the educational value
the quality of the next generation of head and neck of this book and its imponance for the next generation
surgeons. In addition to being a source of great pride of head and neck reconstructive surgeons and enthusi-
for me for their numerous individual accomplishments, astically commined critical resources that allowed this
their contributions to this edition as coauthors was project to be completed.


Contributors vi Chapter & Anterior and Posterior Scalp ........... 89

Foreword vii Mack L Cheney and Mark L Urkan
Preface ix Flap Harvest Techniques
Acknowledgements xiii Anterior Scalping Flap Dissection ................................. 94
Posterior Scalping Flap Dissection ................................ 98
PART 1 REGIONAL FLAPS 1 Chapter 7 The Submental Island ..................... 102
MarkL Ulten
Muscle and Musculocutaneous Flaps Flap Harvest Techniques
Chapter 1 Pectoralis Major .................................. 3 Submental Flap ............................................................ 111
Mark l. Ulten
Flap Harvest Techniques Chapter 8 Paramedian Forehead .................... 122
Tessa A. Hadlock. Robin W. undsay, and Mack L Cheney
Pectoralis Major Flap ..................................................... 20
Flap Harvest Techniques
Chapter 2 Trapezius System ............................... 27 Paramedian Forehead Flap ........................................... 124
Mark l. Ulten Calvarial Bane Graft ..................................................... 127
Flap Harvest Techniques
Superior Trapezius Flap .................................................. 37 Mucosal Flaps
Latera/Island Trapezius Flap ......................................... 39 Chapter! Palatal Island .................................... 130
Lower Trapezius Island Musculocutaneous Flap ........... 42 MarkL Ultan
Flap Harvest Techniques
Chapter 3 Temporalis ........................................... 47 Palata/Island Rap ........................................................ 133
Tessa A. Hadlock. Robin W. Lindsay, and Mack L. Cheney
Flap Inset Tee hniq ues
Muscular Anatomy of the Face 52
Palata/Island Flap ........................................................ 137
Flap Harvest Techniques
Temporalis Muscle ......................................................... 53
Temporalis Muscle Tendon ............................................ 56
Chapter 4 Sternocleidomastoid ......................... 59
Mark l. Ulten Muscle and Musculocutaneous Flaps
Flap Harvest Techniques Chapter 10 Rectus Abdominis ......................... 141
Sternocleidomastoid Flap .............................................. 72 Mark L Ulten and Keith E. Blackwell
Flap Harvest Techniques
Cutaneous and Fasciocutaneous Flaps Rectus Abdominis Flap (Extended Deep Inferior
Chapter 5 Deltopectoral ...................................... 76 Epigastric Flap) ........................................................ 152
Mark L. Ulten Rectus Abdominis Flap (Deep Inferior Epigastric
Flap Harvest Techniques Perforator Flap) ........................................................ 158
Deltopectoral Flap .......................................................... 86


Chapter 11 Gracilis ............................................ 162 Chapter 17 Ulnar Forearm Free Flap ............... 272
Tessa A. Hadlock, Robin W.lindsay. and Mack l. Cheney Jeffrey A. Harris and Arjun Joshi
Flap Harvest Techniques Flap Harvest Techniques
Gracilis Flap .................................................................. 168 Ulnar Forearm Free Flap ............................................... 282
Flap Inset Techniques
Gracilis Muscle for Facial Reanimation ....................... 171 Composite Free Flaps
Anastomosis of Cross Facial Nerve Graft to Chapter 18 Subscapular System ..................... 288
Obturator Nerve ................... ........... ........... .............. 172 Mark l. Urken
Isolation of Masseteric Motor Nerve .... .... .... ... .... ... .... 173
Reinnervation of the Masseteric Nerve and Chapter 19 Scapular and Parascapular
Bilateral Gracilis Muscle Transfer .......................... 174 Fasciocutaneous and Osteofasciocutaneous
and Subscapular Mega Flap ............................... 292
Fascial and Fasciocutaneous Flaps Mark l. Urken
Flap Harvest Techniques
Chapter 12 Radial Forearm ............................... 176
Mark l. Urken and Jeffrey R. Harris Scapular Osteocutaneous Flap .................................... 301
Flap Harvest Techniques Scapular-Latissimus Dorsi Mega Flap" .................... 309
Radial Forearm Fasciocutaneous Flap ......................... 187 The Scapular Tip Based on the Angular Branch
Beavertail Modification of the Radial and the Parascapular Flap ....................................... 313
Forearm Flap ............................................................ 192 Flap Inset Techniques
Flap Inset Techniques Inset of Scapular Osteocutaneous Flap-Latissimus
Insetting of the Radial Forearm Flap for Dorsi Flap for Mandibular Reconstruction .............. 320
Pharyngoesophageal Reconstruction ........ .............. 196 Reconstruction of the Hemipalatal Shelf
Inset of the Radial Forearm Cutaneous Flap with a Half of the Scapular Tip ............................... 322
for Reconstruction of the Circumferential Reconstruction of the Total Palatal Defect
Pharyngoesophageal Segment ................................ 198 with the Scapular Tip Osteocutaneous Flap ........... 323
Inset of the Radial Forearm Flap for Lengthening
Chapter 20 Latissimus Dorsi and Serratus
of the Mediastinal Trachea ..................................... 201
Anterior ................................................................... 326
Mark L. Urken and Keith E. Blackwell
Chapter 13 Lateral Arm ..................................... 206
Mark l. Urken Flap HarvestTechniques
Flap Harvest Techniques Latissimus Dorsi Myocutaneous Flap .......................... 343
Lateral Arm Flap ........................................................... 212 Flap Harvest and Inset Techniques
Latissimus Dorsi-Serratus Anterior-Rib
Chapter 14 Temporoparietal Fascia ................ 219 Osteomyocutaneous Flap for Oromandibular
Mack l. Cheney, Robin W.lindsay. and Tessa A. Hadlock Reconstruction ......................................................... 351
Flap Harvest Techniques
Tempoparietal Fascial Flap .......................................... 227 Chapter 21 Iliac Crest Osteocutaneous
Tempoparietal Fasciocutaneous Flap .......................... 231 and Osteomusculocutaneous ............................. 359
Mark L. Urken
Chapter 15 Anterolateral Thigh Free Flap ...... 234 Flap Harvest Techniques
Keith E. Blackwell Iliac Crest-Internal Oblique Flap .................................. 372
Flap Harvest Techniques Synthetic Mesh Closure of the Abdominal Wall ......... 385
Anterolateral Thigh Flap .............................................. 243 Closure of the Abdominal Wa/1 .................................... 389
Flap Inset Techniques Iliac Crest Osteocutaneous Flap .................................. 390
Inset of the Anterolateral Thigh Flap for Flap Inset Techniques
Circumferential Pharyngoesophageal Inset of Right Iliac Crest-Internal Oblique Composite
Reconstruction ......................................................... 249 Flap to Reconstruct a Right Oromandibular
Defect ...................................................................... 393
Chapter 16 Posterior Tibial Artery Inset of Left Iliac Crest-Internal Oblique
Free Flap ........................................................................ 257 Musculocutaneous Flap to Reconstruct an
Jeffrey R. Harris Anterolateral Mandibular Defect ............................ 395
Flap HarvestTechniques Reconstruction of a Right Total Maxillectomy Defect
Posterior Tibial Artery Flap .......................................... 266 with a Right Iliac Crest-Internal Oblique Flap ......... 398

Chapter 22 Fibular Osteocutaneous ............... 404 Chapter 25 Free Omentum and

Mark L. Urken and Neal Futran Gastro-Omentum ................................................... 475
Flap Harvest Techniques Mark L. Urken and Allan Mo Goldstein
Fibular Osteocutaneous Flap oooooooo ooooooooo ooooooooo oooooooo 413 Flap Harvest Techniques
Sensate Fibular Osteocutaneous Flap 414
Tubed Gastro-Omental Free Flap 481

Fibular Osteocutaneous Flap 415

Flap lnsetTechniques
Flap Inset Techniques Reconstruction of Circumferential
Orientation of the Fibular Osteocutaneous Flap Pharyngoesophageal Defect oooooooooo oooooooooooooooooooo oo 484
Relative to the Laterality of the Leg of Harvest
and the Position of the Cutaneous Paddle and the PART 3 NERVE GRAFT DONOR
Donor Vascular Pedicle 419
Contour and Rigid Fixation of the Fibular Free Flap to
Reconstruct a Right Hemimandibular Defect 421
Chapter 26 Medial Antebrachial Cutaneous
Management of the Resected Mandibular Nerve Graft ............................................................. 491
Condyle 428
Robin W. Lindsay, Tessa A. Hadlock, and Mack L. Cheney
Contouring and Inset of a Right Double Barreled Fibular Flap Harvest Techniques
Flap to Reconstruct a Right Hemimandibulectomy Medial Antebrachial Cutaneous Nerve 00000000000000000000000 494
Defect 434

Contouring and Fixation of a Fibular Osteocutaneous Chapter 27 Sural Nerve Graft .......................... 497
Flap for Reconstruction of a Right Infrastructure Robin W. Lindsay, Tessa A. Hadlock, and Mack L. Cheney
Maxillectomy Defect 436
Flap Harvest Techniques
Sural Nerve Graft 000000000000000000000000000000000000000000000000000000000 500

Chapter 23 Osteocutaneous Radial Forearm

Free Flap ................................................................. 445
Flap Harvest Techniques FREE TISSUE TRANSFERS 503
Radial Forearm Osteocutaneous Flap ooooo ooooooooo oooooooo 450
Chapter 28 Recipient Vessel Selection
in Free Tissue Transfer to the Head
Visceral Flaps
and Neck ................................................................ 505
Chapter 24 Free Jejunal Autograft .................. 455 Mark L. Urken
Mark L. Urken and Allan Mo Goldstein Recipient Vessel Harvest Techniques
Flap Harvest Tee hniq ues Harvest of the Lingual Artery in Lessers Triangle 510 0000000

Harvest of Free Jejunal Autograft 466


Harvest of the TACSystem of Recipient Vessels 512 00 0000 000

Flap Inset Techniques Harvest of the Internal Mammery Artery and Vein 000000516
Reconstruction of a Circumferential
Pharyngoesophageal Defect oooo ooooooooo ooooooooo oooooooo 468 Index 521
""rbe pectoralis major muscle has been applied to the as a carrier for the overlying skin in reconstruction of an
~ reconstruction of a variety of chest wall defects upper sternal defect. The authors designed this Bap with
since 1947 when Pickerel et al. (42) reported its use a broad base at the shoulder, which limited its arc of
as a turnover flap. Sisson et al. (52) used the pecto- rotation. In addition, they performed a delay procedure
ralis major as a medially based Bap to provide great to ensure the vascularity of the skin.
vessel protection and obliteration of dead space follow- It was not until the latter part of the 1970s that Ari-
ing mediastinal dissection for recurrent cancer of the yan and Cuono (2) and Ari~ (1) recognized the tre-
laryngostoma after total laryngectomy. In 1977, Brown mendous potential of the musculocutaneous unit based
et al. (13) descnoed the technique of bilateral island on the pectoralis major for the reconstruction of a large
pectoralis major Baps for the reconstruction of a mid- number of head and neck defects. nus discovery was of
line upper chest and lower neck defect. The muscle was paramount importance because it enabled the single-
completely isolated on its neurovascular pedicle follow- stage ttansfer of large amounts of wcll-vascularized skin
ing trans section of its origins and insertions. A skin graft formauy ofthe ablative and traumatic defects ofthe upper
was used for epithelial coverage after bilateral muscle aerod.igestive tract, face, and skull base, which heretofore
advancement. In 1968, Hueston and McConchie (26) could only be restored with s~d procedures, and inef-
reported a case in which the pectoralis major was used fectively at that. In addition, the hardiness of the vascular


supply permitted the creation of two skin paddles by de- The pectoralis major is a large fan-shaped muscle
epithelialization of an intermediate segment of akin so that that covers muc:h of the anterior thomcic wall. To a vari-
the inner and outer lining could be 1ran8ferred with a sin- able extent, it overlies the pectomlia minor, subclavius,
gle flap for re<:onstruction of compla, composite defe<:ts. serratus anterior, and intercostal muscles. The origins of
The impact of this new reconstructive technique on the pectoralis major are divided into two or, sometimes,
head and neck sw:gery was recognized almost immedi- three portions. The cephalad segment arises from the
ately. It rapidly replaced many ofthe existing reconstruc- medial third of the clavicle. The central, or sternocostal,
tive methods, and large series of cases from a variety of portion has a broad origin from the sternum and the
different medical centers were reported as testimony to cartilages of the first six nbs. The third origin of this
the reliability, versatility, and ease of harvesting this flap. muscle, from the aponeurosis of the external oblique
Although various modifications of the original descrip- muscle, is variable in size. The fibers of this broad mus-
tion of this fiap have been reported, along with a recog- cle cODVerge to form a tendon that passes deep to the
nition of its shortcomingB, it is still a mainstay of head deltoid and inserts into the crest of the greater tubercle
and neck reconstruction (11,48). One ofits major appli- of the humerus. As it narrows in its course toward the
cations is to provide coverage of the vital neurovascular humerus, it forms the anterior uillary fold (Fig. 1-1).
structures in the neck in patients who have undergone The medial aspect of the deltoid muscle is almost insep-
prior radiation with or without chemotherapy. arable from the muscle fibers of the pectomlis major.

RGURE 1-1. The pectoralis major is described as having three different heads of origin: clavicu-
lar, sternal-manubrial, and external oblique. The clavicular portion is distinct from the central and
inferior portions of the muscle, both in function and in its neurovascular supply. The central portion
of the muscle originates from the manubrium, the stemum, and the cartilages of the first six ribs.
The pectoralis major both adducts and medially rotates the arm. The relationship of the cephalad
portion of the rectus abdominis muscle to the caudal part of the pectoralis major should be noted.

The cleavage between these two muscles is referred to The total skin territory of the pectoralis major is often
as the deltopectoral groove, through which runs the greater than 400 cm2 However, it is rare for the entire
cephalic vein, which is a constant anatomic landmark. skin territory to be required to satisfy the demands of
The pectoralis major is surrounded by a layer of deep the ablative defect. As the cumulative experience in the
fascia. However, this is separate from the clavipectoral use of this flap has increased, its limitations have been
fascia that surrounds the pectoralis minor and extends identified, and modifications have been described to
cephalad from that muscle to the clavicle. Prior to help overcome them. The major modifications are dis-
attaching to the undersurface of the clavicle, this fas- cussed according to these problem categories.
cia splits to envelop the subclavius muscle. Both the
vascular and nerve supply to the pectoralis major pass
through the clavipectoral fascia en route to the deep
Methods to Improve the Arc of Rotation
surface of the muscle (see Fig. 1-12). Early in the history of this flap, it was recognized that a
The action of the pectoralis major is to adduct and distal skin paddle placed over the caudal extent of the
medially rotate the arm. It becomes active in internal muscle was not only well vascularized but it also per-
rotation of the arm only when working against resist- mitted a greater arc ofrotation (4). Ariyan's (1) original
ance. The upper muscle fibers help to flex the arm to the description of this flap incorporated a long segment of
horizontal level; the lower fibers assist in arm extension. skin that extended from the clavicle to the caudal extent
Contraction of the pectoralis major helps to extend of the muscle. The skin component was oriented over
the arm to the individual's side, but it plays no role in the course of the pectoral branch of the thoracoacromial
hyperextension beyond that point. artery. The excess skin resulting from this flap design
The loss of the dynamic activity of the pectoralis often required secondary trimming. An additional ben-
major appears to be well tolerated, although the true efit to placing the skin paddle over the lower portion of
impact on brachial function has not been studied exten- the muscle was that it permitted the deltopectoral flap to
sively in any of the large series of pectoralis major mus- be preserved for simultaneous or later use (55). Magee
culocutaneous flap transfers. The extent to which the et al. (32) described the placement of the skin paddle
humeral attachments are transsected undoubtedly leads over the lower portion of the pectoralis major, with an
to a variable impact on the functional loss resulting extension overlying the rectus abdominis muscle. Not
from harvest of this muscle. The additional morbidity only did this skin placement lead to less disfigurement
of combining the loss of pectoralis major function and of the breast in female patients, but, as noted earlier, it
a radical neck dissection has also not been investigated also provided a mechanism to achieve a greater arc of
in a systematic fashion. Much of the adductor activity is rotation of this flap to more cephalad defects. Magee
compensated for by the powerful latissimus dorsi mus- et al. described an array of vessels on the surface of the
cle, which makes up the posterior axillary fold. rectus sheath that he believed contributed to the vascu-
larity of a distally based skin paddle. Incorporation of
those vessels necessitated the harvest of this fascia to
FLAP DESIGN AND UTILIZATION ensure the blood supply to the overlying skin. Although
it is widely recognized that a portion of "random skin"
The major advantages of the pectoralis major muscu-
can be harvested, it is also recognized that it may be
locutaneous flap that distinguished it from the three
unreliable. The foundation for the claim of Magee et al.
major cutaneous flaps (deltopectoral, nape of neck, and
that a segment of skin could be harvested entirely distal
forehead) that were in use at the time that the pectoralis
to the pectoralis is tenuous. The general belief is that a
major flap was introduced are the following:
significant portion of the skin paddle must overlie the
1. Rich vascularity. pectoralis major to capture a sufficient number of mus-
2. Large skin territory. culocutaneous perforators (Fig. 1-2). The blood supply
to the skin is discussed later in detail.
3. Ability to transfer without prior delay.
Additional measures that have been used to enhance
4. Improved arc of rotation. the arc of rotation are related to the method of trans-
5. Increased bulk. fer of the muscular component of the flap. In the vast
6. Primary donor site closure. majority of cases, muscle is transposed over the clavicle
and tunneled deep to the cervical skin. This is helpful to
7. Well-vascularized tissue coverage of the carotid
provide coverage of the carotid artery and to augment
artery in the event of a salivary fistula or cervical
the soft tissue deficit following radical neck dissection.
skin necrosis.
When a radical neck dissection is not performed, the
8. Ease ofharvest in the supine position. bulk of the muscle may be problematic, requiring the
9. Ability to transfer two epithelial surfaces for inner use of a skin graft to achieve coverage. In Ariyan's (1)
and outer lining. early description, the muscle was completely exteriorized



Linea alba
abdominis m.

FIGURE 12. A skin paddle has been designed over the caudal aspect of the pectoralis major
and the cephalad portion of the rectus abdominis. A portion of the anterior rectus sheath that
is beneath the skin flap is incorporated to enhance the skin's vascularity. A sufficient por-
tion of the skin flap should overlie the pectoralis to ensure capture of the musculocutaneous

and later removed after neovascularization of the skin Methods to Deal with Excessive Bulk
had occurred. Fabian (21,22) and later Lee and Lore
(31) proposed the removal of a segment of the clavicle The body habitus of most patients with head and neck
to gain up to 3 em oflength..As a further modification of cancer rarely leads to concern about excessive bulk in a
this approach, Wilson et al. (62) reported tunneling the Bap. However, this may be a problem in certain patients,
muscle pedicle deep to the clavicle in a subperiosteal especially when tubing of the skin is required to recon-
plane. They warned of the potential risk related to vas- sttuct the pharyngoesophagus, or the inttoduction of
cular compression. De Azevedo (19) described a similar excess tissue in the oral cavity results in interference
modification by passing the flap through a subclavicu- with normal tongue movement (22). To reduce the bulk
lar tunnel. In addition, he reported the preservation of of the skin and subcutaneous tissue, Sharzer et al. (47)
the clavicular portion of the mwcle by harvesting only descnbed harvesting a vertically oriented "parasternal"
a distal island of muscle beneath the desired skin pad- skin paddle that extended across the sternum to the
dle. The neurovascular supply to the proximal muscle opposite internal mammary perforators. Although the
was preserved with this technique, which reportedly led skin paddle had a substantial portion overlying the mus-
to improved brachial function. In particular, he noted cle, the skin extension overlying the sternum achieved a
that patients were able to move their arms forward and considerable reduction in bulk (Fig. 1-3).
downward against resistance. However, this technique Alternative solutions to the problem of excessive
has not been evaluated in a systematic fashion. Bap bulk were achieved by eliminating the skin paddle
entirely. Murakami et al. (39) described a two-stage

FIGURE 1-3. A parasternal skin paddle may be designed that crosses over to the opposite side
of the sternum. The skin overlying the stemum markedly reduces the bulk of1his flap. There
must be a sufficient amount of the flap designed to capture perforators from the ipsilateral
pectoralis major muscle.

procedure in which a split-thickness skin graft was placed the muscle was found to be rapid and produced a satis-
over the muscle and then followed, 3 to 4 weeks later, factory long-term result. However, it is apparent to the
by the harvest of the muscle-skin graft unit (Fig. 1-4). experienced surgeon that this approach introduces some
They used this thinner Bap for the reconstruction of the degree of unpredictability due to soft tissue contracture
hypopharynx in four women in whom flap thiclaless was that occurs over the raw surface of the muscle.
particularly problematic. This concept was extended
by Robertson and Robinson (46) who reported the use Methods to Achieve Two Epithelial Surfaces
of a quilted skin graft over the pectoralis major in a
for Reconstruction of Compound Defects
one-stage reconstruction of the pharyngoesophagus.
Small mucosal defeas pose the additional problem of The reconstruction of compound defects involving the
requiring only small segments of skin for reconstruction. mucosa and overlying skin can be challenging. Early
By reducing the size of the skin paddle, there is a greater in the development of the pectoralis major Bap, it was
risk of missing a sufficient number of musculocutaneous recognized that the rich vascularity of the skin permitted
pe:rfw:ators to achieve adequate Sap vascularity.To prevent the design of two epithelial surfaces by removing the
the necessity ofincluding a larger skin paddle than needed, intervening bridge of skin (11). 'This design placed an
Johnson and Langdon (28) reported their experience added requirement that the Bap be of sufficient length
with seven patients whose oral defects were recOD.StrUcted to allow it to be folded upon itself. This also produced
with the pectoralis major alone. Re-epithelialization of additional bulk, which was either advantageous or

FIGURE 14. A two-stage procedure may be performed in which a skin graft is initially placed
over the muscle. This prefabricated composite flap is then transferred after a 2-week period.
allowing the skin graft to heal to the muscle.

disadvantageous, depending on the location ofthe defect. vascularity of the deltopectoral flap makes it necessary
Weaver et al. (60) described a bilobed "Gemini"' Bap to place a skin graft on the donor site overlying the del-
in which two separate skin paddles were harvested side toid muscle at the tip of the deltopectoral flap. Bunkis
by side to achieve opposing epithelial surfaces. These et al. (14) reported the combination of these two flaps to
authors split the intervening skin and underlying muscle reconstruct full-thickness defects of the cheek. In those
to achieve more complete separation between the two situations in which the deltopectoral Bap is preserved
skin paddles. Tobin et al. (58) atended this concept one but not primarily ttansferred, a delay procedure can be
step further by raising two separate musculocutaneous performed by making parallel incisions along the upper
units from the same pectoralis major: one based on the and lower limbs of the deltopectoralflap and raising the
lateral thoracic artery and the other based on the pecto- intervening skin to allow transfer of the pectoralis Bap
ral branch of the acromiothoracic artery (Fig. 1-5). (18). Either simultaneous ttansfer or delay of the del-
Preservation of the ipsilateral deltopectoral Bap topectoral Bap requires the preservation of the internal
allows the ttansfer of a musculocutaneous and a fascio- mammary perforators while harvesting the pectoralis
cutaneous flap from the same side of the chest to achieve major flap. Further details about the delay of a delto-
inner and outer lining (33). The benefit of the added pectoralflap are presented in Chapter 5.

RGURE 1-5. Two separate musculocutaneous units may be harvested with one based on the
pectoral branch of the thoracoacromialartery and the other supplied by the lateral thoracic

Dennis and Kashima (20) introduced the "Janus"' of composite defects of the head and neck. Experimen-
flap as a solution to the problem of reconstructing a tal work in the early 1970s demonstrated the advantage
defect that requires both inner and outer lining. These of using vascularized bone in a contaminated and irra-
authors reported a two-stage procedure in which a skin diated field (36,41). Cuono and Ariyan (17) were the
graft was placed on the deep surface of the pectora- first to report the use of the pectoralis osteomusculocu-
lis muscle and allowed to heal .After 1 to 2 weeks, the taneous flap for oromandibular reconstrUction. They
musculocutaneous Bap was harvested with the muscle demonstrated the viability of the transferred 5th rib
sandwiched between the skin graft and the skin paddle through Buorescence microscopy (Fig. 1-7). Pulse labe-
(Fig. 1-6). ling with different color markers showed the deposition
of new osteoid and, hence, indicated active metabolism.
However, the tenuous nature of the blood supply was
Methods to Include Vascularized Bone in the refiected by additional investigators who used this com-
Musculocutaneous Flap posite flap and reported bone failure rates of 21% (30),
The incorporation of vascularized bone with the pec- 28% (9), and 75% (ll).Additional complications asso-
toralis major musculocutaneous flap was intended to ciated with nb ha.rvt:st included pneumothorax and
expand the use of this technique for the reconstrUction pleural effusion.



FIGURE 1-6. The transfer of a Janus flap is achieved through a two-stage procedure in which
a skin graft is initially placed on the deep surface of the muscle. After a 2-week delay, the mus-
culocutaneous flap is harvested with a skin paddle on one side and a skin graft on the other side
of the muscle.

An alternative source of vascularized bone for tranafer muscular development of the individual patient, there
with the pectoralis major is the sternum. Green et al. (25) may be a significant bulge as the muscle passes over the
described the transfer of the outer cortex of the sternum clavicle. Tra1111ection of the medial and lateral pectoral
with a parasternal skin paddle. Although the harvest of nerves helps to promote muscle atrophy. In patients
this composite flap was associated with fewer pulmonary who have not undergone prior radical neck dissection
complications tlw:L with rib harvest, this teclmique has or in those patients with heavily irradiated cervical
not been embraced with much enthusiasm (Fig. 1-8). skin, it may be difficult to achieve primary closure of
With the emergence offree tissue transfer of osteocu- the skin of the neck over the muscle. In these cases,
taneous and osteomyocutaneous free flaps from a vari- the cervical skin may be split and a skin graft placed
ety of different donor sites, a technique that is highly over the exposed muscle. Alternatively, the muscle can
reliable and reproducble, the use of regional flaps to be completely exteriorized and then resected after a
transfer bone for mand:&bular and ma:zillary reconstruc- 2- to 3-week period to allow neovascularization of the
tion has all but disappeared. skin paddle. As noted previously, exteriorization of the
muscle can provide additional length to the vascular
Additional Flap Modifications to Manage the pedicle.
Wei et al. (61) described an alternative solution by
Muscular Pedicle in the Neck harvesting a skin paddle over the sternocostal pol'-
In most cases, the pectoralis major muscle provides tion of the muscle. The blood supply to that portion
coverage to the carotid artery and augments the radical of the muscle was distinct from the vascular supply
neck dissection contour deformity. Depending on the to the clavicular portion of the muscle. These authors

FIGURE 1-7. A segment of the 5th rib can be 1ransferred as a vascularized bone, composite
flap. The blood supply to the rib is derived from the periosteal feeders coming from the muscle.

noted that the blood supply to the clavicular portion flap through the harvest of the supraclavicular sensory
was derived &om the acromial, deltoid, and clavicular nerves.
branches of the acromiothoracic pedicle; the pectoral
branch supplies the sternocostal segment. Hence, the
sternocostal portion of the muscle could be isolated, FLAP DESIGN AND UTILIZATION
and either it could be tunneled under the clavicular por-
tion, or the latter could be divided. In so doing, the bulk The enthusiasm surrounding the inttoduction of the
of tissue crossing the clavicle is greatly diminished to pectoralis major musculocutaneous flap led to its appli-
only that tissue surrounding the vascular pedicle. cation to most of the major reconstructive challenges that
The ultimate solution to the problem of muscle bulk had not been adequately solved by the awilable tech-
and limited reach was proposed by Reid et al. (45) niques. The early ez.perience with this fl.ap included the
who used microvascular surgery to transfer a compos- reconstruction of mucosal defects of the oral cavity and
ite fiap based on the clavicular head of the pectoralis pharynx and cutaneous defects of the neck (4). Ariyan
major with a skin island and a segment of the medial and Cuono (2) and Ariyu~. (1) reported the successful
clavicle. They reported the successful use of this free application of this flap to the reconstruction of skull base
flap in four patients with oral cancer and one patient defects following temporal bone resection and orbito-
with a post-traumatic defect in the tibia. The thinness mazillary resection. Full-thickness defects of the pharym:
and mobility of the skin overlying the clavicle was par- and cheek were easily reconstructed by any of the tech-
ticularly advantageous for intraoral restoration. In addi- niques descn"bed previously that achieve two epithelial
tion, the authors discussed the potential for a sensate surfaces, including the use of the ipsilateral deltopectoral


FIGURE 18. The outer table of the sternum may be transferred as a vascularized bone com-
posite flap. The design of a parasternal skin paddle provides a thin soft tissue component.

flap (14). In 1970, Snyder et al. (54) described anum- noted that the bulk of the soft tissue component alone
ber of techniques to transfer vascularized hone to the provided an improved external profile ofthe mentum hut
head and ned: using regional cutmeous flaps. The use warned that, over time, gravity would lead to a distortion
of vascularized bone for primary reconstruction of the of the external contour when a flap of too great dimen-
mandible led to a flurry of activity, using the composite sions was used. This could be overcome through primary
osteomusculocutaneous pe<:toralis major flap. However, or secondary mand:&oular reconstruction. In 1981, Con-
advances in microvascular surgery that ocCUITed in the ley et al. (16) reported their experience in reconstruct-
latter part of the 1970s and early 1980s demonstrated ing total glossectomy defects with the reinnervated
that vascularized hone could be tl'&l:lSferred from anum- pectoralis major musculocutmeous flap. The pectoral
ber of distmt sites to achieve a more reliable and accu- nerves were anastomosed to the stump of the hypoglos-
rate restoration of mandibular continuity (59). sal nerve. Reinnervation of the muscle could he demon-
The pectoralis major fl.ap was used to restore form strated through ele<:tromyographic recordings. However,
and function to the crippled oral cavity. Conley and although atrophy of the muscle could be prevented,
Parke (15) reported its use to augment the chin follow- meaningful coordinated m<m:ment of the "new tongue"
ing glossectomy and anterior mand:&bulectomy. They could not he restored. This technique was invt:stigated in

the rat model in which a pectoralis muscle flap was rein- consecutive patients. The skin paddle was designed with
nervated through anastomosis to the hypoglossal nerve. a semilunar shape when resurfacing stomal recurrences
The restoration of contractile activity was confirmed by that involved the superior margin of the tracheostoma.
electromyographic recordings and the measurement of When circumferential skin defects were created, the new
isometric contractions. The use of horseradish peroxi- stoma was formed by placing the opening in the center
dase confirmed that the hypoglossal nerve was the source of the pectoralis skin paddle (Fig. 1-9). By suturing the
of the central motor neuron activity (29). distal trachea to the opening in the skin, a portion of the
Another use for the dynamic activity of the pectoralis depth of the new stoma was composed of the involuted
major is in facial reanimation. Milroy and Korula (37) pectoralis skin paddle. A redundant skin paddle was
transferred the clavicular head of the pectoralis major needed to accommodate the surface area required for
in a two-stage procedure, with the first stage being the the involuted portion. This technique not only solved
placement of a cross-facial nerve graft. The clavicular the problem of the "short trachea," but it also permit-
head was based on a separate neurovascular pedicle ted great vessel coverage and dead space obliteration.
rather than the one supplying the sternal head of the Sisson and Goldman (53) confirmed the value of this
muscle. They reported the restoration of dynamic facial reconstructive technique for stomal recurrence in their
reanimation by using this technique in one patient. report of seven cases in 1981.
The problem of pharyngoesophageal reconstruction As an extension of this technique, Fleischer and
continued to plague head and neck surgeons because Khafif (23) described a tubed pectoralis major muscu-
of the necessity for multistaged procedures when using locutaneous flap to reconstruct the trachea following
either the tubed deltopectoral flap or the Wookey tech- total laryngectomy and tracheal resection for a recur-
nique (7,64). In 1980, Theogaraj et al. (57) published rent thyroid carcinoma. The tracheal resection left only
their experience with the pectoralis major flap in seven one cartilaginous ring above the carina. One end of the
patients of whom six underwent secondary reconstruc- pectoralis skin tube was sutured to the trachea, and the
tions and one a primary reconstruction of the pharynx other end was sutured to the skin, creating a new stoma.
and esophagus. In five cases of pharyngoesophageal This technique is particularly useful when the depth of
stricture, the pectoralis major flap was used to aug- the cut end of the trachea relative to the level of the skin
ment the lumen after opening the stricture and preserv- and the remaining sternum makes placement of a fenes-
ing the posterior mucosal strip. Circumferential tubing of trated pectoralis major flap difficult. The depth of the
the pectoralis major musculocutaneous flap to recon- funnel that is created places additional tension on the
struct the total pharyngoesophageal segment was dif- tracheal suture line. We have used a trapezoid design of
ficult because of the bulk of the subcutaneous tissue. the tubed pectoralis major musculocutaneous flap for
As noted previously, Murakami et al. (39) overcame this this purpose. This technique creates a larger opening at
problem by placing a skin graft on the muscle and then, the skin level of the chest wall and, therefore, facilitates
at a second stage, creating a new pharyngoesophagus by visualization of the depth of the airway while helping to
tubing the skin-grafted muscle. Baek et al. (5) advised prevent stenosis. Alternatively, we have more recently
extending the skin paddle over the sternum to harvest approached this particular problem with a radial fore-
thinner skin to facilitate tubing of the flap. Fabian (21) arm flap that is more readily tubed in order to achieve
described a new technique for reconstructing the cir- the desired tension-free reconstruction of a short tra-
cumferential pharyngoesophageal segment by placing cheal stump (see Figs. 12-45-12-51).
a skin graft along the prevertebral fascia and using a
partially tubed pectoralis major flap to resurface the
anterior and lateral walls. In 1988, he updated his expe- NEUROVASCULAR ANATOMY
rience in 22 patients who underwent this form of recon-
struction and noted a success rate of 88%, with one flap According to the classification scheme of Mathes and
failure and one stenosis (22). Lee and Lore (31) modi- Nahai (35), the pectoralis major is a type V muscle with
fied this technique by placing a dermal graft along the one major vascular pedicle from the thoracoacromial
posterior wall of the reconstructed pharynx. artery and secondary segmental parasternal perforators
Reconstruction of the upper thoracic and lower cer- that arise medially from the internal mammary artery.
vical defects following ablative surgery for stomal recur- The thoracoacromial artery is a branch from the second
rence was considered a risky procedure and fraught part of the axillary artery (Fig. 1-10). It commonly
with complications as a result of the exposure of the divides into four major branches: deltoid, acromial, cla-
great vessels. In addition, the reconstructive techniques vicular, and pectoral (Fig. 1-11). It is the latter branch,
that were used for this defect, prior to the pectoralis which descends medial to the tendon of the pectoralis
flap, did not obliterate the dead space in the mediasti- minor, that supplies the pectoralis major.
num. In 1981, Biller et al. (10) reported the successful The lateral thoracic artery is not commonly believed
application of the pectoralis flap to this defect in seven to contribute significantly to the vascularity of the

FIGURE 1-9. The rich vascularity of the pectoralis major flap allows it to be modified for recon-
struction following ablative surgery for stomal recurrent cancer. The opening in the center of
the flap is sutured to the end of the trachea and, therefore, solves both the problems of the short
trachea as well as coverage of the great vessels in the mediastinum.

pectoralis major. However, Freeman et al. (24) reported In their investigation of 10 aortic arch arte-
information to the contrary. In a cadaveric study in riogram& and detailed dissections of 35 pectoralis
which they examined the vascular supply to the pecto- major muscles, Moloy and Gonzales (38) corrobo-
ralis major, they found that the lateral thoracic artery rated these findings. These authors reponed that,
was present in all 17 specimens that were eumined. It in all cases, the diameter of the lateral thoracic
arose from the axillary artery and pierced the clavipec- anery was equal to or greater than the diam-
toral fascia lateral to the tendon of the pectoralis minor. eter of the pectoral branch of the thoracoacro-
In its course within the muscular fascia, it provided a mial artery. Manktelow et al. (34) reported that a
significant vascular contribution to the pectoralis major branch of the lateral thoracic artery, approximately
and the major cutaneous supply to the female breast. 1 mm in diameter, entered the inferior one fifth of
Through the injection of contrast material, followed by the muscle in more than 70% of their dissections.
xeroradiography, the authors reported that the pectoral Although the lateral thoracic artery is sacrificed by
branch of the thoracoacromial artery supplied the clav- most surgeons to improve the arc of rotation of the
icular and upper sternal portion of the muscle, while the pectoralis major musculocutaneous flap, these ana-
lateral thoracic artery perfused the inferior and medial tomic studies suggest that it may provide an impor-
portions. tant contribution to the vascular supply of this flap.

Subclavian a. Lateral

Thoracoacromial a.

thoracic a.

thoracoacromial a. pectoral n.

FIGURE 110. The primary vascular supply to the pectoralis major muscle arises from the
thoracoacromial artery. which is a branch of the second part of the axillary artery. The lateral
thoracic artery also supplies some degree of vascularity to the pectoralis major muscle. the
extent of which is controversial. The lateral thoracic artery is variable in size and its contribu-
tion may be completely replaced by the lateral intercostal perforators. The medial and lateral
pectoral nerves supply motor innervation to different regions of the muscle. The clavicular head
is primarily supplied by the lateral nerve; the sternocostal head is supplied by the medial nerve.

Reid and 'Thylor (44) performed the most atensive revealed staining of the skin overlying the lateral and the
study of the vascular supply of the pectoralis major mus- sternocostal portion of the muscle. The clavicular head
cle that has been reported in the literature. Their study of the muscle was not stained until the deltoid branch of
included 50 dissections in fixed cadavers and 50 dissec- the acro.miothoracic uis was injected. The deltoid mus-
tions in fresh cadavers. In the latter group, injections of cle and its overlying skin were also stained by ink injection
the arterial tree included both ink and barium contrast of the deltoid branch. There were two other interesting
medium.Although their study focused on the acro.mio- obserwtions in this study. The first was that a significant
thomcic axis, they reported no significant contribution zone in the medial aspect of the pectoralis major was not
from the lateral thoracic artery. They found that the stained with injections of either the pectoml or deltoid
pectoralis major had a regional distribution of its blood branches. This zone was thought to be the primary ter-
supply, with the pectoral artery supplying the sterno- ritory of the internal mammary perforators. The second
costal portion and the deltoid artery supplying the cla- observation was that the major vessels supplying the
vicular head. They reported only one instance of a very skin in the territory of the pectoralis major were actu-
small pectoral branch and none of complete absence of ally fasciocutaneous perforators that ran a course around
this branch. Ink-injection studies of the pectoral artery the free lower and lateral border of the muscle. These

Thoracoacromial a.

Clavicular branch


Deltoid ~..,.---....;;_---,....--+--Pectoral
branch branch

Lateral thoracic a.

FIGURE 1-11. The thoracoacromial axis classically divides into four main branches: the clavic-
ular, deltoid, pectoral, and acromial arteries. The lateral thoracic artery may also arise from this
system but, more commonly, does so separately from the axillary artery. The thoracoacromial
artery commonly divides into two major branches: the pectoral and deltoid. The acromial and
clavicular arteries variably arise from either division. The deltoid artery runs in the deltopectoral
groove with the cephalic vein, supplying both the pectoralis major and deltoid muscles. It gives
off a cutaneous perforator in the mid portion of the deltopectoral groove. The acromial branch
contributes to a vascular plexus along with branches from the deltoid, suprascapular, and
posterior humeral circumflex vessels. The clavicular branch runs a cephalad and medial course
toward the sternoclavicular joint. The pectoral branch pierces the clavipectoral fascia and then
runs a cephalocaudal course on the deep surface of the pectoralis major, which it supplies.

fasciocutmeous vessels were considerably larger than the thoracoacromial artery accompanies the cephalic vein in
musculocutaneous perforators exiting from the muscle. the deltopectoral groove. Either the acromial or the del-
The superior thoracic artery provides a small vascu- toid branch gives off a direct cutaneous vessel at the most
lar supply to the pectoralis major. The parasternal inter- cephalad enent of the deltopectoral groove. In addition,
nal mammary perforators perfuse the medial aspect of the deltoid artery commonly gives rise to a cutaneous
the muscle, which allows it to be used as a turnover flap perforator in the midportion of the groove.
for reco1111truction of midline chest wall defects. The application of the angiosome concept to the
The pectoral branch of the thoracoacromial arterY blood supply of the anterior chest wall helps to explain
and the lateral thoracic artery penetrate the clavipectoral the observatio1111 related to the vascularity of the skin
fascia along with the medial and lateral pectoral nerves of the pectoralis major musculocutaneous flap. Taylor
(Fig. 1-12). The two arteries are both accompanied by and Palmer (56) defined an angiosome as a segment
their venae comitantes.After penetrating the clavipectoral of tissue supplied by a single-source artery and vein.
fascia, they run in a cephalocaudal direction before ente!'- A system of "choke" arteries was descn"bed that connect
ing the pectoralis major; either the pectoral branch of the adjacent angiosomes. Based on clinical observations and
thoracoacromial artery or the lateral thoracic artery sup- injection studies, it appears that an adjacent angiosome
plies branches to the pectoralis minor near the clavicle. can be reliably "captured" after intenupting its source
This explail18 the avascular plane of dissection between artery. However, when the area of tissue that is to be
the pectoralis major and minor. The deltoid branch ofthe harvested is enended to the subsequent angiosome, or

the "angiosome once removed,'" necrosis becomes more tenitory, leads to a tenuous blood supply in the skin oveJ:~
likely. Taylor and Palmer surmised that this phenomenon lying the upper abdomen. nus was evident by the poor
was caused by the pressure gradient across the choke ves- staining of skin in this region following ink injections of
sels that connect angiosomes. There is a greater reduc- the peaoral artery. Reid and 'Thylor (44) noted the stain-
tion in the pressure to the distal angiosomes when more iDa of a netWork of vessels on the surface of the rectus
skin territory is harvested based on a single-source vessel. sheath, which gives credence to the suggestion that this
The pectoralis major and itll overlying skin can be layer should be harvested along with skin e:xtensions dis-
divided into territories or &!l,giosomes. There tal to the territory of the pectoralis major. These authors
appears to be some controversy as to whether the lateral also advised great caution in the technique utilized when
portion of the muscle is supplied by the pectoral bnmclt or interrupting the internal mammary perforators on the
by the lateral thoracic artery. It seems clear, however, that undersurface of the muscle. They warned that the internal
the medial portion of the muscle is supplied by the inter- mammary branches should be either ligated or controlled
nal mammary perforators. The skin overlying the rectus with bipolar cautery. Excessive use of unipolar cautery
sheath is part of the &!l,giosome of the superior epigastric may lead to ascending trauma to the vessels in the internal
artery and vein. When based on the pectoral branch, it is mammary angiosome, which would further jeopardize the
no surprise, therefore, that capture of this skin in the upper flow across this &!l,giosome to the distal skin (56).
abdomen is tenuous because it is part of an &!l,giosome The nerve supply to the pectoralis major is from the
that is once removed from the primary &!l,giosome. This lateral (C5 to C7) and medial (C8 toTl) pectoral nerves.
hypothesis maintains that the reduction of the pressure Manktelow et al. (34) identified multiple nerves entering
gradient from the pectoral artery, as it traverses the sys- different parts of the pectoralis major, which numbered
tem of choke vessels that surround the internal mammary from 4 to 10 individual nerves entering the sternocostal

Subclavius m. Pectoralis major m.

Clavipectoral fascia

Subclavian a.

Pectoralis minor m.

FIGURE 112. The clavi pectoral fascia surrounds the pectoralis minor muscle. The fascial
layers from the posterior and anterior surfaces of this muscle converge to form a single fascial
sheath that runs cephalad toward the clavicle. Before reaching the clavicle, the clavipectoral
fascia again splits to surround the subclavius muscle. The thoracoacromial artery also traverses
this fascia before dividing into its terminal branches. The pectoral branch sends an artery to the
pectoralis minor before forming the primary pedicle of the pectoralis major.

portion of the muscle alone. This muscle has been trans- variety of systemic diseases were also associated with an
ferred as a dynamic free flap through anastomosis of increased risk of necrosis. Although many of the compli-
these motor nerves to recipient motor nerves (27,37). cations in this series did not require additional surgical
procedures, they did lead to prolonged hospitalization.
The potential pitfalls in harvesting the pectoralis
ANATOMIC VARIATIONS major musculocutaneous flap begin with flap selec-
tion. The use of this donor site to resurface defects that
Congenital absence of the pectoralis major is rare. In extend more cephalad on the face or scalp calls for skin
a clinic population, this anomaly was observed with a paddles designed over the more caudal aspects of the
frequency of approximately 1:11,000 (12). Congenital chest wall and upper abdomen. As noted previously, this
absence of the sternocostal head of the pectoralis major may result in high rates of partial flap failure. Excessive
was first reported by Alfred Poland (43) in 1841. This bulk may be problematic, not only from a functional
anomaly was described in conjunction with ipsilateral point of view, but also in terms of wound healing. In
syndactyly, and this combination bears the name Poland's wounds that are likely to pose problems with healing
syndrome or Poland's anomaly. It is reported to occur with as a result of prior radiation and/or poor nutrition, the
an incidence of I :25,000. The potential causes for this effect of gravity can be extremely detrimental and may
condition include abortion attempts and leukemia (8,63). require the selection of an alternative nondependent
The variability in the vascular supply to the pecto- donor site (3). Finally, the design of a small skin island
ralis major was studied by Moloy and Gonzales (38). may pose problems with incorporation of a musculocu-
They evaluated 10 aortic arch arteriograms and 35 fresh taneous perforator and may require the use of a Doppler
cadaver dissections. The study revealed that the lateral to identify the perforator upon which to center the flap.
thoracic artery was equal to or larger in diameter to the Pedicle compression may result from external causes,
pectoral branch of the thoracoacromial artery in 90% of such as tracheostomy tapes or circumferential dressings.
cases. They found extensive collateral flow between these The creation of an inadequate tunnel for the pedicle
two vessels in all cases. There was only one instance of a may also cause vascular compromise. Shearing of the
nonvisualized thoracoacromial system in a patient with skin paddle through excess tension of the skin relative to
extensive atherosclerosis in the subclavian artery. the muscle may disrupt the musculocutaneous perfora-
tors, leading to partial or complete necrosis.
Donor site problems are rare. Hematomas usually
POTENTIAL PITFALLS occur because of a failure to control bleeding adequately
following transsection of the humeral head of the mus-
The overall reliability of the pectoralis major musculocu- cle. The use of a large skin paddle may lead to excess
taneous flap is attested to by the low incidence of com- wound tension in donor site closure. Necrosis of the skin
plete flap failure. In several large series, the incidence of the chest wall may result. In theory, excess tension in
of total flap necrosis was reported to be 1.0% (40), closure may also lead to restrictive pulmonary disease,
1.5% (6), 3% (51), and 7% (62). This low incidence of although this is rare. The incidence of radiologically
total flap necrosis is a reflection of the constancy of the evident and clinically significant pulmonary atelectasis
anatomy and the ease of flap harvest. Partial flap necro- was investigated by Schuller et al. (49) who selected
sis, however, has been reported at a much greater rate. two groups of patients with head and neck cancer who
Schusterman et al. (50) noted a 14% incidence of flap underwent ablative surgery for their disease. One group
loss involving greater than 50% of the skin surface area. underwent reconstruction with a pectoralis major flap,
Other large series have reported partial necrosis rates in and the other did not. Both groups were subdivided into
the range of 4% (40) to 7% (6). Partial necrosis rates patients with and without preexisting pulmonary dis-
were probably a function of the caudal extent of the skin ease. In addition, the patients who underwent pectoralis
paddle design. Shah et al. (51) reviewed their compli- flap reconstruction were divided, based on whether the
cations in 211 pectoralis major flaps during a 10-year cutaneous paddle was greater than or less than 40 cm2
period. Although they reported a 29% incidence of Although there was a fairly high rate of radiographic
partial flap necrosis, they did not break down this fig- atelectasis in all patient groups, the incidence of clini-
ure according to the number of skin paddles that were cally significant pulmonary complications was low. The
"placed" at the risk of partial necrosis by virtue of their group of patients with preexisting pulmonary disease
caudal extension over the rectus sheath. In their series, and flaps greater than 40 cm2 had the highest incidence
the authors identified a number of patient-related, sta- of both major radiographic signs of atelectasis and clini-
tistically significant factors for the development of flap cal pulmonary symptoms. However, no statistical analy-
necrosis: age older than 70 years, female sex, overweight, sis was reported in this study. It should be noted that
albumin level less than 4 gldL, and oral cavity defects, in the development of postoperative pulmonary complica-
particular subtotal or total glossectomy. In addition, a tions is probably multifactorial, with the preoperative

nuuitional status being a potentially important factor pedicle. He also pointed out the significant morbidity to
not considered in this study. When bilateral pectoralis the shoulder when the pectoralis major is utilized on the
major flaps are harvested, it is not uncommon that clo- aide of a denervated trapezius. As noted previously, this
sure of the second side may require a skin graft. Expo- parameter has not been adequately studied.
sure of the costochondral cartilage may lead to serious
infections, including chondritis (60). We have experi-
enced one such case in a patient who developed necro- POSTOPERATIVE CARE
sis of the chest wall skin following closure with excess
tension. Debridement of the affected rib and coverage The use of a suction drainage system in the chest wall
with the ipsilateral latissimus dorsi muscle led to suc- donor site is imperative to help avoid the formation
cessful resolution of this problem. In women, distortion of a seroma. Passive and active range of motion and
of the breast following donor site closure may be mini- strengthening exercises for the shoulder are instituted
mized with an infmmammary skin paddle (Fig. 1-13). within a few days after surgery.
The use of this donor site in male patients may lead
to problems with excessive hair growth in the oral cavity
or pharym:. When radiation is given postoperatively, this
problem is usually remedied. Finally, Schuller (48) raised The authors would like to acknowledge the conuibu-
concern about the ability to detect recurrences in the tions of Dr. Hugh F. Biller to the writing of this chapter
neck in a timely fashion because of the bulk of the muscle in the first edition of this book.

FIGURE 113. The infra mammary skin paddle provides thinner skin and leads to less distortion
of the female breast by avoiding medial displacement following closure.

Pectoralis Major Flap

FIGURE 1-14. The clavicle and lateral borders

of the sternum are marked on the chest wall. The
approximate course of the dominant vascular
pedicle is marked along an axis drawn from the
acromion to the xiphoid process. The paraster-
nal perforators to the deltopectoral flap are also

FIGURE 1-15. Askin paddle has been marked

over the caudal, medial portion of the chest wall.
The upper limb of the pectoralis major skin paddle
corresponds to the lower border of the deltopec-
toral flap, which is preserved. Various skin paddle
shapes and sizes may be harvested, depending
on the requirements of the defect.

FIGURE 1-16. The lateral border of the

pectoralis major is identified through wide
undermining ofthe skin of the lateral chest wall.
Obtaining this exposure early in the dissec-
tion allows the surgeon to evaluate the caudal
extent of the muscle and, therefore, the extent
of the random component of the skin paddle.
It is evident that the skin flap that has been
designed completely overlies the pectoralis
major without any distal random component.

Pectoralis Major Flap

FIGURE 1-17. A circumferential incision around

the skin paddle has been completed, along with
exposure of the entire pectoralis major. The
deltopectoral flap is elevated to the level of the
clavicle without violating its parasternal blood
supply. Although tacking sutures were originally
placed between the skin and muscle to help
prevent shearing forces and injury to the muscu-
locutaneous perforators, this is no longer thought
to be necessary. However, care must be taken
in handling this flap to prevent devascularization
as a result of excess distortion of the skin paddle
relative to the muscle.

FIGURE 118. The pectoralis major is elevated

off the chest wall by blunt and sharp dissection.
Intercostal perforators entering the deep surface
of the muscle must be ligated or coagulated. The
deep plane of dissection along the intercostal
muscles must be respected to prevent entry into
the thoracic cavity.

FIGURE 119. The medial attachments to the

sternum are then transsected up to the level of the
clavicle. Careful attention must be paid to stay lat-
eral to the internal mammary perforators in the 2nd
and 3rd intercostal spaces in order to preserve
the blood supply to the deltopectoral flap. Internal
mammary perforators in the lower interspaces
must be identified and controlled.

Pectoralis Major Flap

FIGURE 1-20. The plane of dissection between

the pectoralis major and pectoralis minor is
avascular, and separation can be done largely
by blunt dissection. The cuff of muscle that is left
attached to the sternum in the region of the 2nd
and 3rd interspaces preserves the vascular sup-
ply to the deltopectora I flap.

FIGURE 1-21. The pectoral branch of the thora-

coacromial artery lsmsllsrraws) is easily visual-
ized on the undersurface of the pectoralis major.
The vascular pedicle is usually located along the
medial aspect of the pectoralis minor. In addition,
one of the pectoral nerves Iarrow) is seen exiting
the pectoralis minor and must be transsected to
achieve additional mobilization of the muscle.

FIGURE 1-22. The muscular attachments to the

humerus are transsected while keeping the vas-
cular pedicle in full view to prevent injury to the
nutrient supply. It is imperative to obtain good
hemostasis as the lateral portion of the muscle
is transsected. This is the most common location
for postoperative bleeding to occur.

Pectoralis Major Flap

FIGURE 1-23. A close-up view of the undersur-

face of the muscle reveals the vascular pedicle
and transsected muscle fibers coursing across
the axilla to insert on the humerus.

FIGURE 1-24. Atunnel is created for the pas-

sage of the pectoralis flap into the neck. Ade-
quate undermining must be achieved to prevent
compression of the vascular pedicle. The ability
to comfortably pass four fingers into this tunnel
is usually deemed adequate. A distal incision
has been made in the deltopectoral flap for the
purpose of delay to improve the vascular supply
in the event that it is needed. A delay procedure
may also be performed by elevating the delto-
pectoral flap without a distal incision to avoid
committing it to a predetermined length.

FIGURE 1-25. The pectoralis flap has been

transferred into the neck, superficial to the clav-
icle. It is important to avoid twisting or placing
excess tension on the pedicle in this maneuver.

Pectoralis Major Flap

FIGURE 1-26. Donor site closure has been

accomplished by wide undermining of the chest
wall skin. Suction drains are utilized to prevent
seromas and hematomas.

REFERENCES nec:k rrurgery. Analysis of complications in 42 cases .Arch

Or.olaf'Y"'''l Head Necle SJ1Tg 1981,;107:23.
11. Biller HF, K:rcspi Y. Lawson W. Back S: A one-6tage flap
1. Ariym S:The pectoralis major myocutaneous flap. Aver-
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12. Bing R: Ueber angeborene Muakekiefecte. Vm:horvs Arch
2. Ariym S, Cuono C: Use of the pectoralis major myocu-
taneow flap for rec:oostruction of large cervical facial or
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3. Aviv J, Urkcn ML, LawsonW. Biller HF:The superior tra-
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d~cts. Plan Recmutr SJ1Tg 1982;70:319.
4. Baek S, Biller HF, Krespi Y, Lawson W: The pectoralis
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1982;69:460. c:u~cow; flap. Plast lUetmstr Surg 1980;65:477.

7. BakamjianVA: A two-6tage method for pharyngoesopha- 18. Davis 1<, Price J: Bipedicled delay of the dcltopecton.l
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Plast Reumm S1WK 1965,;36:173. st.epe 1984;94:554.

8. Beals R, Crawford S: Congenital absence of the pecto- 19. De Azevedo JF: Modified pectoralis major myoc:utaneous
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1976;119:166. 55 cases. Hlad Nede SllTK 1986;8:327-331.
9. Bell M, Barron P: The rib-pectoralis major osteomusc:u- 20. Dennis J, Kaahima H: Introduction of the Janus flap.
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cal esophageal and pharyngeal reconstruction .Arch Oro-
10. Biller HF, Baek S, Lawson W, Krespi Y. Blaugrund S:
laryyil Head Nede Surg 1981;197:431.
Pectoralis major myocutaneous island flap in head and

21. Fabian R: Reconstruction of the laryngopharynx and grafted pectoralis major muscle flap. Arch Otolaryngol
cervical esophagus. Laryngoscope 1984;94: 1334. Head Neck Surg 1982;108:719.
22. Fabian R: Pectoralis major myocutaneous flap recon- 40. Ossoff R, Wurster C, Berktold R, Krespi Y, Sisson G:
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Laryngoscope 1988;98: 1227. reconstruction of head and neck defects. Arch Otolaryngol
23. Fleischer A. Khafif R: Reconstruction of the mediastinal Head Neck Surg 1983; 109:812.
trachea with a tubed pectoralis major myocutaneous flap. 41. Ostrup L, Fredrickson J: Reconstruction of mandibular
Plast Recomtr Surg 1989;84:342. defects after radiation using a free, living bone graft trans-
24. Freeman J, Walker E, Wilson J, Shaw H: The vascular ferred by microvascular anastomoses: an experimental
anatomy of the pectoralis major myocutaneous flap. Br J study. Plast &comr.r Surg 1975;55:563.
Plast Surg 1981;34:3. 42. Pickerel KL, Baker HM, Collins JP: Reconstructive sur-
25. Green M, Gibson J, Bryson J, Thomson E: A one-stage gery of the chest wall. Surg Gynecol Obstet 1947;84:465.
correction of mandibular defects using a split sternum 43. Poland A: Deficiency of the pectoral muscles. Guy's Hosp
pectoralis major osteomusculocutaneous transfer. Br J Rep 1841;6:191.
PlastSurg 1981;34:11. 44. Reid C, Taylor GI: The vascular territory of the acromio-
26. Hueston J, McConchie I: A compound pectoral flap. Ausx thoracic axis. Br J Plan Surg 1984;37: 194.
N ZJSurg 1968;38:61-63. 45. Reid C, Taylor GI, Waterhouse N: The clavicular head of
27. IkutaY, Kubo T, Tsuge K: Free muscle transplantation by pectoralis major musculocutaneous free flap. Br J Plan
microsurgical technique to treat severe Volkmann's con- Surg 1986;39:57.
tracture. Plan &comr.r Surg 1976;58:407. 46. Robertson M, Robinson J: Immediate pharyngoesopha-
28. Johnson M, Langdon J: Is skin necessary for intraoral geal reconstruction. Use of a quilted skin grafted pecto-
reconstruction with myocutaneous flaps? Br J Oral Max- ralis major muscle flap. Arch Otolaryngol Head Neck Surg
illofac Surg 1990;28:299-301. 1984;11 0:386.
29. Katsantonis G: Neurotization of pectoralis major myo- 4 7. Sharzer lA, Kalisma M, Silver CE, Strauch B: The para-
cutaneous flap by the hypoglossal nerve in tongue sternal paddle: a modification of the pectoralis major
reconstruction: clinical and experimental observations. myocutaneous flap.Plast&comr.rSurg 1981;67:753-762.
Laryngoscope 1988;98:1313. 48. Schuller D: Limitations of the pectoralis major myocuta-
30. Lam K, Wei W. Sui K: The pectoralis major costomyocu- neous flap in head and neck reconstruction. Arch Otolar-
taneous flap for mandibular reconstruction. Plast &comr.r yngol Head Neck Surg 1980;1 06:709.
Surg 1984;73:904. 49. Schuller D, Daniels R, King M: Analysis of frequency of
31. Lee K, Lore J: Two modifications of pectoralis major pulmonary atelectasis in patients undergoing pectoralis
myocutaneous flap (PMMF). Laryngoscope 1986;96:363. major musculocutaneous flap reconstruction. Head Neck
32. Magee W, McCraw J, Horton C, Mcinnis W: Pectoralis 1994;16:25.
"paddle" myocutaneous flaps. The workhorse of head 50. Schusterman M, Kroll S, Weber R, Byers R, Guillamon-
and neck reconstruction. Am J Surg 1980; 140:507. degui 0, Goepfert H: Intraoral soft tissue reconstruc-
33. Maisel RH, Liston SL: Combined pectoralis major myo- tion after cancer ablation: a comparison of the pectoralis
cutaneous flap with medially based deltopectoral flap for major flap and the free radial forearm flap. Am J Surg
closure of large pharyngocutaneous fistulas. Ann Otol 1991;162:397.
Rhinol Laryngo/1982;91:98-100. 51. Shah JP, Haribhakti V, Loree TR, Sutaria P: Complica-
34. Manktelow R, McKee N, Vettese T: An anatomical tions of the pectoralis major myocutaneous flap in head
study of the pectoralis major muscle as related to func- and neck reconstruction. Am J Surg 1990; 160:352-355.
tioning free muscle transplantation. Plast Recomr.r Surg 52. Sisson G, Bytell D, Becker S: Mediastinal dissec-
1980;65:610. tion-1976: indications and newer technique. Laryngo-
35. Mathes S, F: Clinical Applications for Musde and scope 1977;87:751.
Musculocutaneous Flaps. St. Louis: CV Mosby; 1991. 53. Sisson G, Goldman M: Pectoral myocutaneous island
36. McCullough D, Fredrickson J: Neovascularized rib grafts flap for reconstruction of stomal recurrence. Arch Otolar-
to reconstruct mandibular defects. Can J Otolaryngol yngolHead Neck Surg 1981;107:446.
1973;2:96. 54. Snyder C, Bateman J, Davis C, Warder G: Mandibulo-
37. Milroy BC, Korula P: Vascularized innervated transfer facial restoration with live osteocutaneous flaps. Plan
of the clavicular head of the pectoralis major muscle in RecomtrSurg 1970;45:14.
established facial paralysis. Ann Plast Surg 1988;20:75--81. 55. StrelzowV, Finseth F, FeeW: Reconstructive versatility of
38. Moloy P, Gonzales F: Vascular anatomy of the pectoralis the pectoralis major myocutaneous flap. Otolaryngol Head
major myocutaneous flap. Arch Otolaryngol Head Neck Neck Surg 1980;88:368.
Surg 1986;112:66. 56. Taylor G, Palmer J:The vascular territories (angiosomes)
39. Murakami Y, Saito S, lkari T, Haraguehi S, Okada K, of the body: experimental study and clinical applications.
Maruyama T: Esophageal reconstruction with a skin Br J Plast Surg 1987;40: 113.

57. Theogaraj S, Meritt W, Acharya G, Cohen I: The pecto- 61. Wei W, Lam K, Wong J: The true pectoralis major
ralis major musculocutaneous island flap in single-stage myocutaneous island flap: an anatomical study. Br J Plast
reconstruction of the pharyngoesophageal region. Plan: Surg 1984;37:568.
Recunst.r Surg 1980;65:267. 62. Wilson J, Yiacaimettis A, O'Neill T: Some observations
58. Tobin G, Spratt J, Bland K, Weiner L: One-stage pha- on 112 pectoralis major myocutaneous flaps. Am J Surg
ryngoesophageal and oral mucocutaneous reconstruction 1984;147:273.
with two segments of one musculocutaneous flap. Am J 63. Wolfson R: Syndactyly, a review of 122 cases. Proceed-
Surg 1982; 144:489-493. ings of the Western Orthopaedic Association. J Bune Joint
59. Urken ML: Composite free flaps in oromandibular SurgAm 1971;53A:395.
reconstruction: review of the literature. Arch Otolaryngol 64. Wookey H: Surgical treatment of carcinoma of the
Head Neck Surg 1991;117:724. pharynx and upper esophagus. Surg Gynecol Obstet
60. Weaver A, Vandenberg H, Atkinson D, Wallace J: Modi- 1942;75:499.
fied bilobular ("Gemini") pectoralis major myocutaneous
flap. Am J Surg 1982; 144:482.
""rbere are three distinct muaculocutaneous flaps that Conley (4) reported using the same skin design but
~ can be harvested from the ttapezius muscle, mak- incorporated the uapezius muscle in a nondelayed flap.
ing it unique among the regional muscle fiaps that are In addition, he reported that the uapezius muscle could
used in head and neck reconstruction. Conley (4), in be used as a vehicle to transfer a segment of vascularized
1972, is credited with being the first to report the use of clavicle to reconstruct the ma:xillofacial skeleton. Ariyan
the uapezius muscle as a carrier for skin.The skin design (1) and McCraw and D:ibbell (16) popularized the flap
of this flap was similar to the one that was reported by design that we now refer to as the superior ttapezius
Mutter (17) in 1842. Mutter used this cutaneous fiap, fiap, which is an extension of Conley's (4) original work.
which was based at the midline of the upper back and The superior ttapezius flap, based on the paraspinous
extended onto the shoulder, to release burn conttac- perforators, is a highly reliable flap, although limited in
tures of the neck. In 1957, Zovickian (26) reported its utility because of its short arc of rotation.
using a "mastoid-occiput-based shoulder flap" to close In 1978, Demergasso (6) reported a bipedicled tra-
pharyngeal fistulas. He staged these cutaneous fiaps by pezius fiap based on both the paraspinous perforators
putting a skin graft on the undersurface for lining, and a and the transverse cervical artery (TCA) and the trans-
skin graft on the recipient bed to close the donor defect. verse cervical vein (TCV). In the subsequent year, at
The fiap was staged one more time prior to transfer. the international meeting of the American Academy of


Facial Plastic and Reconstructive Surgery, both Demer- portion by its downward pull on the root of the scapular
gasso (6,7) and Panje (21) introduced the unipedicle spine, which helps in the rotation of the scapula.
lateral island trapezius flap, based solely on the TCA
and TCV. This musculocutaneous flap was useful but
limited because of its short arc of rotation and variable NEUROVASCULAR ANATOMY
vascular anatomy, which precludes the transfer of this
flap in a significant percentage of patients. The blood supply to the trapezius muscle is probably the
The third musculocutaneous flap, the lower trape- most confusing of any of the regional flaps. Mathes and
zius island musculocutaneous flap (LTIMF), was intro- Nahai (13) classified the vascular pattern to the trape-
duced by Baek et al. (3) in 1980. The transfer of a skin zius as a type IT muscle with a dominantTCA and TCV
island overlying the lower portion of the muscle pro- and with minor pedicles from the occipital artery and
vides an increased arc of rotation, which is independent vein and the perforating posterior intercostal vessels of
of the variable vascular anatomy of the TCA and TCV the cervical and thoracic regions. However, this classi-
in the posterior triangle of the neck. However, the need fication does not recognize the contributions to the dis-
to place the patient in the lateral decubitus position for tal muscle from the dorsal scapular artery (DSA). Even
harvest has limited the widespread use of the LTIMF. though the DSA and theTCA commonly arise from the
same parent vessel, they usually enter the trapezius mus-
cle at separate locations; their separate contributions
MUSCLE ANATOMY to different regions of the muscle have been described
(Fig. 2-1) (19). In reporting the "potential pitfalls" of
The trapezius muscle is a broad, thin, triangular mus- the trapezius musculocutaneous flap, Nichter et al. (20)
cle that covers much of the upper back and posterior described a case in which an "accessory vessel," arising
neck (Fig. 2-1). Its major action is to raise the lateral at the level of the scapular spine, was ligated to achieve
angle of the scapula, which is important for adduction greater mobilization of the muscle. However, the distal
of the arm. It is helpful to divide this muscle into three portion of the muscle and overlying skin showed signs
functional anatomic units. The cephalad unit arises of ischemia and became necrotic soon after interruption
from the superior nuchal line, external occipital pro- of this blood supply, despite the fact that the TCA and
tuberance, and ligamentum nuchae. The upper fibers TCV were intact. In an effort to clarify this situation, it
insert into the lateral third of the clavicle, defining the is easiest to begin by providing the classic description
lateral boundary of the posterior triangle of the neck. of the anatomy of these vessels before discussing the
The function of the upper trapezius fibers is to elevate numerous variations.
the tip of the shoulder. As classically described, theTCA arises from the thy-
The middle portion of the trapezius muscle takes rocervical trunk and courses along the posterior trian-
its origin from the seventh cervical and the upper six gle of the neck toward the trapezius muscle (Fig. 2-2).
thoracic vertebrae. These muscle fibers have a trans- The TCA divides into a superficial branch, which passes
verse orientation and insert into the acromion and the over the levator scapulae to run on the undersurface of
upper border of the scapular spine. The major activity the trapezius muscle, and a deep branch, which passes
of the midportion of the muscle is retraction of the under the levator scapulae, descending along the medial
shoulder. aspect of the scapula, deep to the rhomboid minor mus-
The caudal fibers of the trapezius muscle originate cle (Fig. 2-1). The superficial branch of the TCA divides
from the lower six thoracic vertebrae and course in an into descending and ascending branches. The former
oblique cephalad direction to insert into the medial runs a caudal course on the undersurface of the mus-
aspect of the scapular spine. This portion of the tra- cle, and the latter runs a more cephalad course, sup-
pezius muscle overlaps the upper medial border of plying the upper portions of the trapezius along with
the latissimus dorsi muscle. The caudal portion of the the occipital artery. The deep branch oftheTCA, which
trapezius assists in the functional activity of the upper we will refer to as the DSA, sends a significant branch

FIGURE 2-1. The trapezius is a broad thin muscle that arises from the superior nuchal line, the external occipital protuberance,
the ligamentum nuchae, and the spinous processes of the vertebrae of C7 through T12. The insertions of the trapezius muscle are
to the lateral third of the clavicle, the medial border of the acromion, and the entire length of the scapular spine. There is some
variability in the cephalad and caudal extent ofthe origin of the trapezius muscle, with the upper part failing to reach the skull
and the lower part arising from the vertebrae from T8 to Ll. The muscles lying deep to the trapezius include the levator scapulae,
rhomboid minor, and rhomboid major. In its lateral extent. the trapezius also overlaps the supraspinatus and infraspinatus. The
upper portion of the trapezius muscle is supplied by the TCA,. which exits the posterior triangle superficial to the levator scapulae.
The DSA supplies the caudal portion of the trapezius muscle. It emerges between the rhomboid major and minor muscles or less
commonly between the rhomboid minor and levator scapulae {dotted line*). Additional arterial supply to the trapezius muscle is
derived from the occipital artery and the intercostal perforating arteries, which emerge in the paraspinous region.

Levator scapulae m. Trapezius m.

Rhomboid minor m.

Rhomboid major m.

scapulae m.

Rhomboid --+.P.P
minor m.

major m.

Ascending - 4-........._...,.;-__, scalene m.

_ _ .__ Common
carotid a.

:---+-- Thyrocervical

-+---Subclavian a.


FIGURE Z-2. The anatomy of the TCA and the DSA in the posterior triangle is highly variable. A: The TCA is classically
described as arising from the thyrocervical trunk and running across the posterior triangle of the neck. It divides into a
superficial branch, which crosses over the levator scapulae, and a deep branch, which runs deep to the levator scapulae.
The superficial branch divides into an ascending branch and a descending branch, which supply the upper and lower por-
tions of the trapezius muscle, respectively. The deep branch of the TCA, the DSA. runs deep to levator scapulae and then
gives rise to a superficial branch that arises between either the levator scapulae and rhomboid minor or, more commonly,
between the rhomboid major and minor, supplying the distal portion of the trapezius muscle. B: A common anatomic variation
is shown in which the DSA arises separately from the second or third part of the subclavian artery. The TCA may also arise
directly from the subclavian artery. C: In some cases, the DSA and the TCA may run a course below or intertwined in the
brachial plexus. This variation is most important to identify when harvesting a lateral island trapezius flap in which mobiliza-
tion of the TCA is critical to achieving an adequate arc of rotation.

to the caudal aspect of the trapezius muscle, which vein. It can enter the lower portion of the external jugu-
emerges between the rhomboid major and minor and lar vein in one-third of cases.
less commonly between rhomboid minor and levator The accessory nerve, cranial nerve XI, provides motor
scapulae (Fig. 2-1). innervation to the trapezius muscle after supplying
Variations in the origin of the TCA and the DSA innervation to the sternocleidomastoid muscle. There
are the rule, rather than the exception (Fig. 2-2). Both are contributions to the nerve supply of the trapezius
branches may arise independently from the second or from C2 through C4, but the exact nature of this addi-
third part of the subclavian artery. The importance of tional innervation is uncertain. It is speculated that there
this variation is that the vessels may then run a circui- may be proprioceptive sensory fibers coursing through
tous course, intertwined in the brachial plexus, before the cervical contributions to the spinal accessory nerve.
passing out of the posterior triangle either over (TCA)
or under (DSA) the levator scapulae. This variation has
no bearing on the superior trapezius flap or the LTIMF. SUPERIOR TRAPEZIUS FLAP
However, the utility of the lateral island flap depends
greatly on the complete mobilization of the TCA and The superior trapezius flap is an extremely reliable
TCV, which is impossible when the artery courses source of coverage for defects of the posterolateral por-
through the brachial plexus. tion of the neck that extend no further medially than
Netterville and Wood (19) studied the relationship the midline. In our review of the literature on this flap,
between the TCA and DSA in supplying the trapezius we found no instances of total flap failure. In my expe-
muscle. They found that, in most cases, there was a rience, it has proven to be extremely reliable, with no
reciprocal relationship between these two vessels, with instances of either partial or total necrosis in more than
either one or the other being dominant. In 50% of 30 cases (2).
their dissections, the DSA was dominant, and theTCA This flap is usually transferred as a peninsula of skin
was a branch of the DSA. In 30% of the dissections, and muscle, which is based at the midline of the back.
the TCA was dominant, and the DSA was a branch However, an island of skin, overlying the lateral aspect
of the TCA. In the remaining 20% of cases, the DSA of the muscle, may also be transferred. The primary
and TCA appeared to be of equal dominance and size blood supply to this flap is derived from the paraspinous
and had a separate takeoff from the subclavian artery. perforators, with some contribution from the occipital
In addition, ink-injection studies of the TCA and the artery. This flap is unique among the trapezius flaps
DSA revealed that the former supplied the skin overly- in that its blood supply is unaffected by a prior radi-
ing the trapezius above the rhomboid minor and the cal neck dissection with transsection of the transverse
latter supplied the skin below the rhomboid minor. cervical vessels. In fact, the vascularity of the distal por-
These findings conflict with the results of selective tion of this flap may be enhanced through a delay phe-
intra-arterial injections of prostaglandin E 1 by Maruy- nomenon when the transverse cervical vessels have been
ama et al. (11). Following selective catheterization of previously interrupted.
the TCA, the authors reported that injection of pros- The rationale for this hypothesis is based on the
taglandin E1 led to flushing of the skin over the entire angiosome concept. Taylor et al. (24) proposed that the
territory of the trapezius muscle. These findings can be delay phenomenon is caused by the opening up of choke
explained by assuming that the DSA was a branch of vessels between angiosomes located in series as a result
the TCA, and therefore, both the proximal and distal of interrupting the source artery in an adjacent angio-
blood supplies were probably injected in Maruyama's some. Under normal circumstances, without a delay,
study. it was hypothesized that only one adjacent angiosome
The venous anatomy is equally variable. Goodwin could be captured, but not an angiosome once removed.
and Rosenberg (9) identified three major patterns of This hypothesis can be applied to the superior trapezius
TCV anatomy. In the majority of cases, the TCV is a flap by dividing it into its component angiosomes. The
single vessel, but it may be a dual system. TheTCV exits primary angiosome, which has its base at the midline
the trapezius muscle on its deep surface, close to the posteriorly, is supplied by the paraspinous perforators.
point of entry of the TCA, which is 2 to 5 em above The adjacent angiosome overlying the lateral aspect of
the clavicle. Although the TCA always runs deep to the the muscle is supplied by the transverse cervical vessels.
omohyoid muscle, theTCV may be superficial in 25% of Finally, the third angiosome in line, or the angiosome
cases. In 60% of cases, the authors found that theTCV once removed, which overlies the deltoid muscle, is sup-
traveled with the TCA; in 15%, it followed a course plied by a branch of the thoracoacromial artery (Fig.
under or through the brachial plexus. In the remain- 2-3). Following interruption of the transverse cervical
ing 25%, the TCV ran a more caudal course beneath vessels during a radical neck dissection, the choke sys-
the clavicle, terminating in the subclavian vein. In the tem of vessels between the three angiosomes becomes
majority of cases, the TCV enters the medial subclavian dilated. This allows a more favorable pressure gradient

FIGURE 2-3. Angiosomes of the superior trapezius flap. The superior trapezius flap is primarily supplied by the paraspinous
perforators that exit in the posterior cervical region. The primary angiosome Ill is shown in yellow; the adjacent angiosome (II),
supplied by the TCA. is shown in blue. Finally, the third angiosome (Ill) in the series, the angiosome once removed, is supplied by
a branch of the thoracoacromial system, which is the primary blood supply to the deltoid. Interruption of the TCA leads to a delay
phenomenon of the skin overlying the deltoid by opening up the choke vessels that separate these three angiosomes. The third
angiosome in the series can be more reliably captured by improving the hemodynamic pressure gradient across the middle zones.

by which the skin overlying the deltoid can be reliably Ryan et al. {23) described a novel use of the lateral
captured by the medial angiosome supplied by the par- island trapezius flap to achieve dynamic facial reani-
aspinous perforators (2_,24). mation in a variety of situations of facial paralysis. The
The major use for this flap is to resurface cutaneous surgical technique involved the transfer of an inner-
defects of the posterior and lateral aspects of the neck. vated and vascularized segment of the trapezius muscle
Following a radical neck dissection, the transfer of this to the paralyzed side of the face. The muscle was inset
flap is not only safe but also causes no further functional into the corner of the mouth and the temporalis fascia.
deficit because the muscle is already denervated. It is In some cases, the vascular pedicle was not long enough
especially advantageous for the coverage ofheavily irradi- to reach the defect, and the pedicled muscle flap was
ated wounds, including those in which the carotid artery converted to a free muscle flap. This technique was also
is exposed. It is unique among the regional musculocuta- used for composite cheek defects by transferring an
neous flaps in that it is superiorly based; therefore, gravity innervated musculocutaneous flap. By maintaining the
does not cause the flap to pull away from the recipient accessory nerve intact, there was no chance for den-
bed as readily as is the case with other regional flaps with ervation atrophy to occur. However, the disadvantage
a dependent muscle supply. The success of this flap in the of this technique is that facial movement requires a
"problem wound" is enhanced by inserting the flap along conscious effort by the patient to tense the ipsilateral
its entire path to the site of the defect, even if intervening shoulder.
skin must be excised to do so. The poorer aesthetic result
of wrapping the flap around the neck is counterbalanced
by the increased chances of successful wound healing. LOWER TRAPEZIUS ISLAND
More often than not, a skin graft is required for closure MUSCULOCUTANEOUS FLAP
of the donor site. Secondary correction of the "dog-ear"
deformity below the auricle is often necessary. The skin paddle of the LTIMF is designed over the infe-
rior aspect of the trapezius muscle between the midline
vertebrae and the medial border of the scapula. The
LATERAL ISLAND TRAPEZIUS FLAP harvest of this flap is facilitated by placing the patient
in the lateral decubitus position with adduction and
The lateral island trapezius flap is the least reliable of internal rotation of the ipsilateral arm to increase the
the three musculocutaneous flaps because its arc of space between the medial edge of the scapula and the
rotation is dependent on favorable anatomy and metic- midline of the back. The lower extent of the flap design
ulous mobilization of the TCA and TCV. Preliminary is somewhat controversial; some authors report reliable
exploration of the posterior triangle of the neck is essen- skin vascularity up to 15 em below the inferior border
tial to assess the suitability of these vessels. Because the of the scapula (22).
musculocutaneous island is completely isolated on the The angiosome concept provides some insight into
nutrient vascular pedicle, there are no alternative efilu- what the safe caudal extent of this skin flap should be.
ent routes through secondary venous channels, such The blood supply to the trapezius muscle allows it to be
as might occur in a musculocutaneous flap in which divided into three separate angiosomes. The TCA sup-
the muscle is not completely detached. It is therefore plies the angiosome of the lateral cephalad portion of
imperative that a patent TCV is present along with the the muscle; the cervical paraspinous perforators supply
artery. The likelihood of both vessels being present fol- the medial cephalad angiosome. The lower portion of
lowing radical neck dissection is small, and therefore, the trapezius is supplied by the DSA, which enters the
both the lateral island flap and the LTIMF should not deep surface of the muscle at the upper border of the
be selected in such patients. rhomboid major. The flaps that extend below the lower
The primary use of the lateral island flap is for exter- border of the trapezius muscle fall into the angiosome
nal defects of the lateral and anterior neck. It may also of the latissimus dorsi which, in this region, is supplied
be used for mucosal defects of the pharynx and oral by the intercostal arteries (Fig. 2-4) (24).
cavity. Panje (21) described an extension of the lateral By applying the principles of the angiosome concept
island flap, which he classified as the trapezius muscu- to the LTIMF, the safe lower border of this skin pad-
locutaneous island paddle flap. In this design, a small dle becomes readily apparent. When the skin paddle
island of muscle is used as a carrier for an extended extends beyond the lower border of the scapula, into
island of skin that is harvested well beyond the lower the medial angiosome of the latissimus dorsi, then this
lateral border of the muscle in the direction of the axilla. inferior portion of the skin is in the angiosome imme-
The proposed advantage of this flap is the large area of diately adjacent to the one supplied by the DSA. The
thin skin that can be harvested, which improves the arc skin overlying the latissimus dorsi angiosome should be
of rotation without completely interrupting shoulder readily captured if the dorsal scapular vessels are pre-
function (18). served. Attempts to capture the skin of an angiosome


FIGURE 24. The primary angiosomes of the trapezius muscle are divided between the paraspinous perforators, which
supply the medial aspect of zone I and the TCA which supplies the lateral aspect of zone I. The DSA supplies zone II. The
zone I angiosome also receives contributions from the occipital artery. The division between zones I and II is signified by the
underlying division between rhomboid minor and major, through which the contributions from the DSA enter the undersur-
face of the caudal aspect of the trapezius muscle. The division between the cephalad angiosomes I and II and the caudal
angiosome Ill is located at the transition point between the end of the trapezius muscle and the territory of the medial aspect
of the latissimus muscle, supplied by the paraspinous perforators. In harvesting the LTIMF. the position of the skin paddle
may extend caudal to the lower border of the trapezius muscle into the medialangiosome of the latissimus dorsi muscle.
This region can be reliably captured by the trapezius flap by incorporating the DSA. However if the DSA is interrupted and
the flap is based solely on the TCA. then the skin of the third angiosome in the series is less reliable. This explains some of

once removed, without a delay, are often met with com- patient in a lateral decubitus position. This flap is most
plications. However, we and others have transferred useful in patients who require reconstruction of lateral
distal skin paddles with success, despite the increased skull and cheek defects in which the ablative procedure
incidence of ischemia. Alternatively, a skin island that can also be performed in the lateral decubitus position.
does not extend beyond the confines of the trapezius
muscle can be reliably transferred on the TCA-TCV
pedicle alone, through capture of the adjacent angio- TRAPEZIUS OSTEOMUSCULOCUTANEOUS
some of the DSA and dorsal scapular vein (DSV) (24). FLAP
In routine cases in which the skin paddle is confined
to the territory of the TCA and DSA angiosomes, I do Although Conley (4) and Dufresne et al. (8) reported
not preserve the DSA pedicle. However, if a large DSA is the transfer of a portion of the clavicle with the trape-
encountered, then temporary occlusion of the DSA may zius flap, the most commonly transferred segment of
be accomplished with a microvascular clamp. Observa- bone is the spine of the scapula. Cadaveric injection
tion of the color and quality of the dermal bleeding in the studies indicated that the TCA provides a periosteal
distal skin allows the surgeon to decide whether the DSA circulation to the spine. Approximately 10 to 14 em of
pedicle needs to be preserved in order to prevent distal bone can be harvested while preserving the acromion
ischemia (25). Because preservation of the DSA severely to minimize shoulder and upper arm dysfunction (15).
limits the arc of rotation, this pedicle can be mobilized by The scapular spine is most effectively transferred with
cutting a cuff ofrhomboid minor on either side of the ves- the lateral island flap design. The transfer of bone with
sel to improve the arc of rotation. When this maneuver is the superior trapezius flap, although feasible, is limited
performed, the distal portion of the DSA that travels deep in its reach and the flexibility of positioning the skin
to the rhomboid major must be ligated (see Fig. 2-20). relative to the bone. The quality of the blood supply to
The tremendous arc of rotation of the LTIMF makes the scapular spine is probably comparable to the vas-
it the most versatile of the three trapezius musculocu- cularity of the rib transferred with the pectoralis major
taneous flaps. Mobilization of the entire muscle may be flap.
achieved by pedicling it solely on the TCA and TCV in Bone-containing composite free flaps offer several
the posterior triangle of the neck, similar to the lateral distinct advantages that favor their use for oromandibu-
island flap. I have not found such extensive dissection lar reconstruction as follows: (a) a rich vascular supply
to be necessary in the routine application of this flap to to the bone; (b) a flexible relationship of the soft tis-
defects of the lateral skull, the midface, the neck, and sue to the bone, allowing a more accurate restoration of
the oral cavity. The primary advantages of this flap, aside normal anatomy and function; and (c) a complete free-
from the arc of rotation, are the thinness and pliability of dom to position and contour the bone of defects involv-
the tissue compared with that of other regional muscu- ing the symphysis and contralateral body.
locutaneous flaps. The donor defect is also well camou-
flaged on the patient's back. Preservation of the function
of the upper trapezius muscle fibers can often be accom- POTENTIAL PITFALLS
plished by mobilizing only that portion of the muscle
needed to transfer the skin to the defect ( 12). The major Each of the three trapezius flaps has its own potential
disadvantage of the LTIMF is the necessity to place the problems, which may cause an unsuccessful outcome.

the variability that I have encountered in harvesting this flap and the questionable reliability of this skin paddle that has been
reported in the literature. On the left hand side of the figure, 2 different skin paddles are drawn. The solid line denotes a
skin paddle that would be theoretically readily captured by the TCA because of the fact that it lies almost entirely within the
territory of the adjacent angiosome (II). The datted line indicates a skin paddle that partially overlies the lower portion of the
trapezius and extends into the territory of the latissimus dorsi (Ill). The more caudal skin island has a greater arc of rotation.
However, the reliable transfer of this more caudal segment of skin would require preservation of the DSA. The disadvantage
of this approach is that it requires the harvest of a cuff of the rhomboid minor muscle to achieve an adequate arc of rotation.
The harvest of that muscle cuff allows the surgeon to incorporate the proximal portion of the DSA on the undersurface of this
musculocutaneous flap. The advantage of this approach is that it preserves the upper fibers of the trapezius muscle, which
helps to stabilize the shoulder and preserve its function. Our usual approach to harvesting skin paddles that extend more
than 5 em below the scapular border is to place a temporary microvascular clamp on the dorsal scapular vessels, occluding
the flow to the distal trapezius muscle, and to observe the blood supply to the skin paddle to determine whether interruption
of the DSA is safe.

The superior trapezius flap is probably the least scapula that results from total disruption of the medial
problematic if its limited arc of rotation is respected and muscle group outweighs the limited benefits of this
the extent of the defect for closure does not cross the flap design.
midline anteriorly. The LTIMF has been labeled an unreliable recon-
The lateral island flap is technically easy to harvest, structive technique, with complication rates caused by
but it is imperative that the posterior triangle be carefully partial or total flap necrosis ranging from 0% (14) to
explored to ensure that the anatomy of the TCA and 57% (5) among the larger series of cases in which this
TCV is favorable. Failure to identify and carefully iso- donor site was used (24). The interpretation of these
late both an artery and vein will lead to inevitable fail- complications must be placed in the context of the flap
ure. Particular attention must be taken in preserving the designs that were utilized in each series. Mathes and Ste-
TCV, which may be in jeopardy because of its course venson (14) reported a 0% rate of complications when
superficial to the posterior belly of the omohyoid and using the LTIMF for the repair of 13 posterior neck and
its entry into the external jugular vein. Both of these skull defects. Although these authors divided the dorsal
venous patterns must be sought when dissecting in this scapular pedicle, the arc of rotation to the defects of
region to avoid inadvertent injury (9). the posterior neck and skull allowed the skin paddle to
The most common error performed in harvesting be placed over the distal Trapezius muscle. Significant
the LTIMF is the failure to raise the trapezius mus- mobilization of the muscle was not required. Cummings
cle in the plane superficial to the rhomboid major and et al. (5) reported a 57% incidence of flap necrosis.
minor muscles. This is best accomplished by identi- Although these authors noted that they extended the
fying the lateral border of the caudal portion of the distal skin paddle beyond the lower border of the mus-
trapezius muscle. Meticulous dissection in the plane cle in some patients, they did not analyze their compli-
deep to the trapezius muscle allows the surgeon to cations with this variable in mind.
identify the fibers of the rhomboid major muscle that In the largest series of 45 LTIMFs reponed by Urken
run in a more transverse orientation and insert into et al. (25), there was a 6.5% incidence of major compli-
the medial border of the scapula. Krespi et al. (10) cations defined as a greater than 20% flap loss. There
described the combined rhombotrapezius flap, which was similarly a 6.5% incidence of minor (20%) flap loss.
reportedly enhanced vascularity to the overlying skin, In no case in this series was the dorsal scapular pedi-
provided added bulk, and allowed transfer of vascu- cle preserved. The lower border of the skin paddle was
larized bone from the medial border of the scapula. not extended beyond 5 em below the scapular border in
The additional vascularity is undoubtedly a result of most patients. Of note was the fact that all cases of flap
including the dorsal scapular system by dissecting in necrosis except one occurred in patients who underwent
the plane deep to the rhomboids. However, the harvest flap transfer on the side in which a prior neck dissection
of the rhomboid major is not critical to achieving this had been performed. It is evident from this finding that
end. The bulk that is obtained by incorporating the a prior radical neck dissection should be considered a
thin rhomboid muscles is minimal after denervation contraindication to harvesting an ipsilateral LTIMF.
atrophy occurs. Finally, the medial border of the scap- Donor site problems are rarely significant. However,
ula is a thin bone that is not suitable for functional seroma formation is common, and long-term suction
mandibular reconstruction. The morbidity of a winged drainage is recommended.

Superior Trapezius Flap

FIGURE 25. The superior trapezius flap is

based on the para spinous perforators of the
lower cervical region. The flap is outlined over
the upper portion of the trapezius muscle with
the anterior incision of the flap placed along
the anterior border of the trapezius muscle.
The posterior border of the flap is a transverse
incision parallel to the anterior incision. The
width of the flap is determined in part by the
width of the defect and by the necessity to
incorporate several perforators. The arc of
rotation of this flap is limited by the posterior
inferior attachment (arrow). This rotation may
be improved slightly by extending the incision
across the midline in a cephalad direction. This
modification was introduced by Panje (21) and
helps to add additional length to this flap. The
distal portion of the skin paddle may extend
several centimeters beyond the acromion pro-
cess. In my experience, this flap is extremely
reliable, and up to 8 to 10 em of random skin
beyond the distal lateral extent of the trapezius
muscle may be safely incorporated. The actual
dimensions of the flap have not been fully
defined through injection studies to determine
reliable parameters for flap design.

FIGURE 26. The posterior incision is made

through the skin and through the trapezius
muscle. The firm attachments of the trapezius
to the spine of the scapula must be incised
to maintain the proper depth of dissection.
The TCA and TCV are encountered in this
portion of the dissection and may or may not
be ligated and transsected. In theory, if the
anatomy of the TCAJTCV is favorable, and
these vessels can be mobilized and preserved
with the flap, then the distal end of the flap
should retain an enhanced vascularity. The
deep plane of dissection is between the trape-
zius and supraspinatus. In the medial aspect
of the dissection, the trapezius is elevated off
the levator scapulae and the rhomboid minor.

Superior Trapezius Flap

FIGURE 27. The incisions along the anterior

border of the flap is made to coincide with the
anterior border of the trapezius muscle. The
distal portion ofthe skin paddle is elevated
along the plane just superficial to the deltoid
fascia. On reaching the lateral aspect of the
trapezius muscle, the plane of dissection is
then deepened to incorporate that muscle.
The TCA and TCV are usually ligated and
transsected when encountered in the dissec-
tion along the anterior border. As noted above,
if the anatomy of these vessels is favorable
and they can be adequately isolated and
mobilized in the posterior triangle of the neck,
then this rich vascular supply to the trapezius
muscle should be preserved, thus preserving
the direct flow to the third angiosome. If the
clinical situation permits, and a longer supe
rior trapezius flap is desirable, then a delay
phenomenon can be performed whereby the
incisions around the flap are made and then
sutured into pia ce. In addition, the tip of the
flap may be raised and sutured. Two weeks
later, the entire flap can be elevated and

FIGURE 28. Demonstration of rotation of the

superior trapezius flap. This flap can be used
to close defects that do not extend beyond the
midline of the neck anteriorly. Closure of the
donor site is achieved by wide undermining.
In most cases, a skin graft is needed to cover
the wound. The area of skin grafting may be
reduced by using retention sutures to lessen
the area of the defect.

Lateral Island Trapezius Flap

FIGURE 29. Harvest of the Lateral Island Trapezius

Flap. The selection of this donor site is based on two
fundamental assessments. The first is the location
and size of the defect, which is usually limited in its
cephalad extent by the mastoid and lower border of the
mandible. The defect may extend either to or across
the midline anteriorly. The second is an anatomic
determination of the TCA/TCV to ensure that they are
favorable for flap rotation. The lateral island trape-
zius flap is designed as an island of skin overlying the
lateral aspect of the cephalad portion of the trape-
zius muscle where it inserts into the clavicle and the
acromion process of the scapula. The anterior border
of the trapezius muscle is marked at its insertion on
the distal one third of the clavicle. The skin island may
be designed over the approximate boundaries of the
trapezius muscle and with random portions extending
more distally. The dimensions of the flap are limited
by the redundancy of the tissue in this region, which
would permit primary closure of the defect.

FIGURE Z-10. The dissection begins by exposure of

the inferior aspect of the posterior triangle. The dis-
section begins by exposure of the inferior aspect of the
posterior triangle. This is best accomplished by making
the anterior incision of the flap. The supraclavicular
fossa is carefully dissected to identify the TCA and
vein. When a neck dissection is performed at the same
time as harvest of a lateral island flap, particular atten-
tion must be paid to preserving the TCV.

Lateral Island Trapezius Flap

FIGURE 211. The anterior border of the tra pe-

zius (large arrow} has been identified. The poste-
rior belly of the omohyoid has also been isolated
(small arrows}. The TCA runs along the floor of
the posterior triangle. The TCV may run a more
superficial course relative ta the omohyoid and
the artery. The incisions around the skin paddle
are made after the anatomy of the vessels has
been detennined and the surgeon has ensured
that the TCA and TCV are not intertwined with
the roots ofthe brachial plexus. Variations in
the entry site of the TCA and TCV along the
anterior border of the trapezius may cause the
skin paddle to be altered so that it is centered
on the vascular pedicle. After the skin paddle is
outlined, the incisions are made circumferentially
through the skin, subcutaneous tissue, and trape-
zius muscle.

FIGURE 212. Mobilization of the latera I island

flap has been completed. Ugation of the distal
TCA and TCV, as they descend along the more
caudal aspect of the trapezius muscle, must be
accomplished when the distal incision through
the flap is made. The DSA may arise as a branch
of the TCA. Beeause of its course deep to the
levator scapulae muscle, the DSA must be
ligated and transsected.

Lateral Island Trapezius Flap

FIGURE Z-13. Transposition of this flap into the

recipient site is now completed. Greater mobilization
of this flap can be achieved by dissection along the
vessels in the medial aspect of the posterior triangle
and extending into level IV of the neck toward the
origin of the thyrocervical trunk. Transection of
the posterior belly of the omohyoid muscle may be
required. Wide undermining, followed by layered
closure, is performed to manage the donor site

FIGURE 214. Harvest of the Lower Island Trape-

zius Flap. The patient is placed in a lateral decubitus
position with an axillary roll in the contralateral
axilla. The approximate position of the scapula is
outlined on the back along with that of the TCA,
which courses over the shoulder on the under-
surface of the trapezius muscle. The DSA enters
the deep surface of the trapezius along the medial
scapular border. Adduction and internal rotation of
the ipsilateral arm is helpful to lateralize the scapula
and open up the space between the scapula and the
midline of the back.

Lower Trapezius Island Musculocutaneous Flap

FIGURE Z-15. A skin paddle has been outlined

between the medial border of the scapula and the
midline of the back. The inferior extent of the skin
paddle may be reliably placed up to 5 em below the
inferior border of the sea pula. A Ia rger skin paddle
placed over the mare cephalad portion of the Tra-
pezius muscle helps to ensure capture of a greater
number of musculocutaneous perforators.

FIGURE Z-16. The dissection begins by incising

the skin paddle and a vertical line drawn from the
proximal tip of the skin paddle toward the posterior
triangle of the neck. This incision is carried down to
the level of the trapezius muscle, and then, skin flaps
are elevated both medially and laterally to expose the
full extent of the trapezius muscle.

FIGURE 2-17. The lateral border of the trapezius

(arrows) muscle has been identified and elevated,
with the overlying skin paddle, in the plane between
the trapezius and rhomboid muscles.

Lower Trapezius Island Musculocutaneous Flap

FIGURE Z-18. The muscle attachments to the midline

vertebrae are then transsected sharply to mobilize the
muscle from distal to proximal. Para spinous perfora-
tors Iarrow) must be ligated and transsected. A suture
has been placed around the dorsal scapular pedicle.

FIGURE 219. At the junction of the rhomboid major

and rhomboid minor. the DSA and DSV are identi-
fied as 1hey enter the undersurface of 1he trapezius

Lower Trapezius Island Musculocutaneous Flap

Rhomboid minor m. Trapezius m. Skin paddle


Rhomboid major m.

Descending branch of
dorsal scapular artery
and vein transsected

FIGURE Z-ZO. If the DSA and DSV are to be preserved, and further mobilization of the trapezius
muscle is required to reach the donor site, then dissection deep ta the rhambaid muscles must
be carried out in order to transsect the distal branches of the dorsal scapular pedicle. A cuff of
rhambaid miner must be harvested to allaw the DSA and DSV to be mobilized.

Lower Trapezius Island Musculocutaneous Flap

FIGURE 221. The DSA has been preserved

through harvest of the cuff of the rhomboid
minor muscle. With more proximal dissec-
tion, the TCA and TCV are identified on
the undersurface of the trapezius muscle.
Preservation of both of these pedicles to
ensure vascularity to the distal portion of the
muscle may be carried out, depending on the
location of the recipient defect If a tempo-
rary microvascular clamp applied to the DSA
reveals no disturbance in the circulation to
the distal skin paddle, then the DSA can be
ligated and transsected. The arc of rotation
is enhanced by transsecting the insertions of
the trapezius muscle along the scapular spine
and the medial attachments to the vertebrae.
The flap has been completely mobilized. The
cephalad extent to which the skin paddle can
be used is evident by its position relative to
the auricle. Wide undermining is critical for
closure of the donor defect. Adduction of the
arm helps to achieve a tension-free repair. A
suction drain must be placed with an exit site
along the midaxillary line.

FIGURE 222. Closure of the donor site has

been completed. The muscular pedicle may be
tunneled under the intervening skin to provide
access to the recipient defect In select situ-
ations, exteriorization of the trapezius muscle
may be preferable. The second-stage trans-
section of the muscle must then be carried out
in approximately 2 to 3 weeks.

REFERENCES 13. Mathes S, Nahai F: Clinical Applicatiom for Muscle and

Musculacutaneous Flaps. St. Louis: CV Mosby; 1982:50.
1. Ariyan S: One-stage repair of a cervical esophagostome 14. Mathes S, Stevenson T: Reconstruction of posterior neck
with two myocutaneous flaps from the neck and shoulder. and skull with vertical trapezius musculocutaneous flap.
Plast Recomtr Surg 1979;63:426. AmJ Surg 1988;156:248.
2. Aviv J, Urken ML, Lawson W. Biller HF:The superior tra- 15. Maves M, Phillippsen I.: Surgical anatomy of the scapu-
pezius myocutaneous flap in head and neck reconstruc- lar spine in the trapezius-osteomuscular flap. Arch Orolar-
tion. Arch Orolaryngol Head Neck Surg 1992;118:702. yngol Head Neck Surg 1986; 112:173.
3. Baek SM, Biller HF, Krespi YP, Lawson W: The lower 16. McCraw JB, Dibbell DG: Experimental definition of
trapezius island myocutaneous flap. Ann Plast Surg independent myocutaneous vascular territories. Plast
1980;5:108-114. &comtrSurg 1977;60:212.
4. Conley J: Use of composite flaps containing bone for 17. Mutter J: Cases of deformities of burns, relieved by oper-
major repairs in the head and neck. Plan: Reconnr Surg ation. Am J Med Sci 1842;4:66.
1972;49:522. 18. Netterville J, Panje W, Maves M: The trapezius myocuta-
5. Cummings C, Eisele D, Coltrera M: The lower trapezius neous flap: dependability and limitations. Arch Orolaryn-
myocutaneous island flap. Arch Orolaryngol Head Neck gol Head Neck Surg 1987;113:271.
Surg 1989;115:1181. 19. Netterville JL, Wood D: The lower trapezius flap: vascular
6. Demergasso F:The lateral trapezius flap. Presented at the anatomy and surgical technique. Arch Orolaryngol Head
Third International Symposium of Plastic and Recon- Neck Surg 1991;117:73.
structive Surgery, New Orleans, Louisiana, Apri129--May 20. Nichter L, Morgan R, Harman D, et al.: The trapezius
4, 1979. musculocutaneous flap in head and neck reconstruction:
7. Demergasso F, Piazza M: Colgajo cutaneo aislada a potential pitfalls. Head Neck 1984;7:129.
pediculo muscular en cirugia reconstruction por cancer 21. PanjeWR:The island (lateral) trapezius flap. Presented at
de cabeza y cuello: tecnica original. The 47th Congreso the Third International Symposium of Plastic and Recon-
Argentine de Cirugia Forum de Investigaciones. &fJ structive Surgery, New Orleans, Louisiana, April 29-May
Argent Chir 1977;32:27. 4, 1979.
8. Dufresne C, Cutting C, Valouri F, Klim M, Colen S: 22. Rosen H: The extended trapezius musculocutaneous flap
Reconstruction of mandibular and floor of mouth defects for cranio-orbital facial reconstruction. Plan: Recomtr
using the trapezius osteomyocutaneous flap. Plast Recon- Surg 1985;75:318.
str Surg 1987;79:687. 23. Ryan R, Waterhouse N, Davies D: The innervated trape-
9. Goodwin WJ, Rosenberg G: Venous drainage of the lat- zius flap in facial paralysis. Br J Plast Surg 1988;41 :344.
eral island trapezius musculocutaneous island flap. Arch 24. Taylor GI, Palmer JH, McManamny D: The vascular
Orolaryngol Head Neck Surg 1982; 108:411. territories of the body (angiosomes) and their clinical
10. KrespiY, Oppenheimer R, dud Flanyer J:The rhombotra- applications. In: McCarthy JG, ed. Plastic Surgery. Vol. 1.
pezius myocutaneous and osteomyocutaneous flaps. Arch Philadelphia:WB Saunders; 1990:329.
Orolaryngol Head Neck Surg 1988;114:734. 25. Urken ML, Naidu R, Lawson W, Biller HF: The lower
11. Maruyama Y, Nakajima H, Fujino T, Koda E: The defini- trapezius island musculocutaneous flap revisited.
tion of cutaneous vascular territories over the back using Report of 45 cases and a unifying concept of the vascu-
selective angiography and the intra-arterial injection of lar anatomy. Arch Otolaryngol Head Neck Surg 1991;
prostaglandin E 1: some observations on the use of the lower 117:502.
trapezius myocutaneous flap. Br J Plast Surg 1981;34:157. 26. Zovickian A: Pharyngeal fistulas: repair and prevention
12. Mathes S, Nahai F: Muscle flap transposition with using mastoid-occiput based shoulder flaps. Plast Recomtr
function preservation: technical and clinical consider- Surg 1957;19:355.
ations. Plast &comtr Surg 1980;66:242.
~e temporalis muscle, one of the muscles of with facial paralysis (32). In the 1970s and 1980s, numer-
~ mastication, has been used for a wriety of ous SUJ:geOD.S (12,2~26,32,33) expanded the use of the
reconstructive problems in the maxillofacial region temporalis muscle in the management of the paralyzed
(5,8,15,18,22,23,25,28,32). Described in 1898 by Golo- face. Rubin (30--32) and Rubin et al. (33) also clarified
vir&e (15), the temporalis is one of the earliest reported the application of this flap in oral commis!IUl'e reanima-
muscle flaps (19). It was initially described for use in oblit- tion, by carefully categOrizing human smile pane.rns, and
eratiD,g the dead space created by OJ.biw exenteration and detailing the anatomic relationship between the orbicula-
was felt to be an excellent choice based upon its bulk and ris oris and the facial muscles. These reports established
its prazimity to the OJ.bit (4,11, 15,27,28,35). In the 1930s, the temporalis as a logical option for reanimation of the
Gillies (14) introduced the teclmique oftemporalis lJ."aDS.- paralyzed face. Further refinements in the transfer of the
position as a method for rehabilitation of the paralyzed temporalis increased its clinical usefulness in managing
face. Sheehan (34) also conttibuted useful modifications contour defects follaw:ing maxillofacial resections (4,5,29)
of this technique, by describing the reduction or removal and in eyelid (17) and intraoral reconstruction (6).
of the zygomatic arch, increasing the arc of rotation of
the ttansposed muscle and minimizing the potential prob- FLAP DESIGN AND UTILIZATION
lem of excessive bulk in the midface. In 1961, Andersen
modified the Gillies technique by using temporalis fascia, The temporalis flap has gained acceptance for a variety
instead of fascia lata, to reconstruct the eyelids in patients of clinical pu:rposes, including the augmentation of


regional tissue deficiencies and the elimination of scar (TPFF) can be elevated as an independent flap, based
contractures. It may also serve as a vascular surface for upon the superficial temporal artery and vein, and used
skin grafting, to protect the carotid artery, as a myo- to reestablish the contour of this region (8).
osseous flap, and also to provide dynamic rehabilitation In the past decade, reports have emerged that describe
of the paralyzed face (8,12,23-26,31-33). an advancement technique of the muscle rather than a
The temporalis muscle may be transferred as a seg- transposition over the zygomatic arch (7, 10,20). In this
ment or in its entirety, depending on the specific recon- approach, the tendinous attachments of the muscle to
structive demand. The dimensions of the muscle vary, the coronoid process are released and advanced to the
with the thicker aspect of the muscle located in the ante- region of the modiolus and/or nasolabial fold. In some
rior third of the temporal fossa; the middle and posterior techniques, the belly of the muscle is elevated off of its
thirds of the muscle are consistently thinner and slightly bony deep surface attachment and then rotated and
longer. The muscle is longest in its middle third, ren- advanced anteriorly to produce the desired vector pull.
dering this portion ideal for use in rehabilitation of the While some descriptions involve removal and replace-
paralyzed face. Although some authors have relied upon ment of the zygomatic arch, others describe coronoid-
the muscle for ocular and midfacial rehabilitation, most ectomy without removal of the zygomatic arch.
surgeons favor independent reconstruction of these two The temporalis muscle has been used to reconstruct a
important functional zones of the face. variety of midfacial defects by designing it as a turnover
The temporalis is the only widely employed regional flap, with the point of rotation based at the zygomatic
muscle option for rehabilitation of the paralyzed face. arch. Because the flap has a rotational radius of8 em, it is
Although it does not produce spontaneous mimetic possible to cover defects of the mastoid, cheek, pharynx,
movement, the transferred temporalis permits immediate and palate. The muscle is longer and thinner than the
reanimation and repositioning of the paralyzed face, and masseter, and therefore can be placed throughout the
may be used when the potential for facial nerve recov- midface, providing bulk to anatomic locations that are
ery exists. The muscle has a contraction capability of 1 to not within the rotational range of other regional muscle
1.5 em, and the midportion of the muscle has sufficient flaps (9, 16). The arc of rotation can be improved by pass-
strength to adequately mobilize the face and resist the ing the temporalis deep to the zygomatic arch, a maneu-
forces of soft-tissue contracture (22,23). It is innervated ver that is often made simpler by osteotomies to remove
in a segmental pattern by the branches of the trigeminal and then replace the bone. The muscle readily accepts
nerve (branch V3), permitting independent segments of split-thickness skin grafts, a feature that makes it useful
the muscle to be designed for use in distinct regions of in the management of full-thickness defects of the middle
the face (i.e., one slip in the orbit and another in the mid- third of the face. It can provide adequate bulk to oblit-
face). The zygomatic arch can be used effectively as a ful- erate full-thickness defects of the orbit and the buccal sur-
crum, to provide the transferred muscle with a fixed point face of the oral cavity (18), and in the closure of oroantral
of origin following its transposition into the midface. fistulas, or defects of the lateral maxilla and skull base (6).
Although the temporalis is firmly attached to the Craniofacial surgical procedures often produce a
coronoid process and ramus, the point of attachment of communication between the anterior cranial fossa and
the distal transposed end of the muscle can be varied to the nasal or paranasal sinus cavities. Separation of these
individualize the procedure to the particular character- two regions is critical to minimize the incidence of cer-
istics of the patient's smile, as analyzed on the normal ebrospinal fluid leak, epidural abscess, and meningitis.
side (8,26,29,30). The temporalis muscle has been successfully used for
There are several limitations when using the tempo- this purpose (22,29), and does not interfere with the
ralis muscle for facial reanimation. Muscle contracture vascularity of the overlying scalp, as it is based upon
is initiated by the fifth cranial nerve and is therefore the deep temporal vascular system, and does not require
not mimetic with the contralateral face. This drawback transfer or disruption of the superficial temporal vessels.
can be minimized by early and regular physical therapy. The temporalis muscle has been described as a car-
The other significant concern with this technique has rier of vascularized outer calvarial bone for palatal (13),
been management of the donor site. When the muscle is orbital rim, and orbital floor reconstruction (3,13,22),
transferred over the zygomatic arch, the contour of the though more modem techniques usually involve either
temporoparietal scalp and the midface can become dis- free calvarial bone grafts or other composite myo-
torted. By limiting the amount of muscle that is trans- osseous free flaps. The temporalis muscle can also be
ferred to a 2-cm-wide strip of muscle from the middle transferred along with the coronoid process for recon-
third, the amount of bulk over the zygoma is minimized. struction of the orbital floor. Although described for
The secondary depression in the infratemporal fossa use in segmental defects of the lateral mandible, the
had historically been managed with synthetic implants, limited bone stock of this donor site is inferior to the
yielding an unnatural feel and a susceptibility to extru- bone stock of other donor sites currently in use for oro-
sion. As an alternative, the temporoparietal fascial flap mandibular reconstruction.

NEUROVASCULAR ANATOMY may occur following dissection of the scalp skin from the
superficial surface of the TPFF. This problem is more
The temporalis muscle is broadly based, arising from the common among patients who have undergone regional
superior temporal line. It fills the entire temporal fossa radiation therapy, and/or in whom a scalp incision has
and narrows as it inserts onto the coronoid process of been used to gain access to the skull base. Patients who
the mandible, via a thick tendinous sheath (Fig. 3-1). have undergone occipital approaches to the skull base,
It is covered superficially by the temporalis muscular involving temporal incisions around the auricle, are not
fascia. The temporalis functions in conjunction with the good candidates for the use of the TPFF because partial
masseter and pterygoid muscles, to elevate and retract devascularization of the auricle occurs in a significant
the mandible during mastication. The vascular supply to percentage of patients.
the temporalis muscle is provided by the deep temporal The frontal branch of the facial nerve is located in
artery and vein, which arise from the internal maxillary the temporoparietal fascia, superficial to the tempora-
system, deep to the zygomatic arch. The deep tempo- lis muscular fascia (Fig. 3-1, inset). It crosses the zygo-
ral vessels penetrate the undersurface of the temporalis, matic arch approximately 2.4 em from the tragus, along
providing a segmental vascular pattern (Fig. 3-2) (18). a line drawn from the tragus to the lateral canthus (2),
The muscle is classified as having a type m pattern of cir- and branches somewhat variably into anterior, middle,
culation (two dominant vascular pedicles), as described and posterior rami in the region from the zygomatic
by Mathes and Nahai (21).An additional arterial supply arch to the lateral border of the frontalis muscle. This
to the muscle arises from the middle temporal artery, nerve branch should be identified and avoided during
which sends minor branches through the superficial the anterior dissection and elevation of the muscle. The
aspect of the muscle. The middle temporal artery arises auriculotemporal nerve, a branch of the third division of
from the superficial temporal artery and crosses over the the trigeminal nerve, courses under the zygomatic arch
zygomatic arch to provide a separate vascular supply to and then runs in a cephalad direction posterior to the
the temporalis muscular fascia. superficial temporal artery and vein. It supplies sensa-
The temporalis muscular fascia inserts on the superior tion to the anterior auricle, the external auditory mea-
temporal line. Approximately 2 em above the zygomatic tus, and the scalp of the temporal region, and should be
arch it divides into two layers. The deep and superficial identified and preserved to maintain sensation to these
muscular fascial layers insert on the medial and lateral areas.
aspects of the arch, and are separated by a fat pad. The
muscular fascia fuses with the periosteum of the arch to
form a very dense fibrous layer. The temporal and zygo- PREOPERATIVE ASSESSMENT
matic branches of the facial nerve cross the zygomatic arch
in the temporoparietal fascia, superficial to the muscular The neurovascular integrity of the temporalis muscle is
fascia-periosteal layer. The fat pad that separates the two assessed by asking the patient to clench his or her teeth,
layers of the temporalis muscular fascia may be used to and palpating the area for the appropriate bulging,
protect the facial nerve branches. By starting at the root ensuring that the muscle exhibits normal strength and
of the zygomatic arch, and incising the superficial layer of tone. This is particularly important in patients who have
the temporalis muscular fascia, the fatty plane is entered. undergone skull base procedures where the viability of
H this incision is made at a 45-degree angle in the antero- the fifth cranial nerve is in question, and in edentulous
superior direction, and the zygomatic arch is uncovered patients who may suffer from disuse atrophy of the mus-
in a subperiosteal plane, the facial nerve branches can be cles of mastication. Asymmetric wasting of the temporal
protected by reflecting this fascial-periosteal layer in an fossa is a telltale sign of denervation atrophy of the tem-
anterior and inferior direction (1). poralis muscle. During the preoperative assessment, it is
also important to establish the patency of the superficial
temporal artery and vein via Doppler auscultation, to
POTENTIAL PITFALLS assess the utility of the temporoparietal fascia for donor
site obliteration (8).
Dynamic temporalis muscle transfer relies heavily on
capturing an adequate vascular supply, as well as an
intact neural supply, for use in facial reanimation. In POSTOPERATIVE WOUND CARE
patients who have undergone extensive skull base or
neck surgery, disruption of the neurovascular supply At the completion of the temporalis transfer procedure,
eliminates the temporalis as a viable regional option. a suction drain is placed in the temporoparietal scalp for
When transferring the temporalis muscle flap, a 24 to 36 hours. A bulky compressive dressing is used for
TPFF is raised independently to obliterate the donor the first 24 hours postoperatively to prevent hematoma
site defect. Secondary alopecia of the overlying scalp formation and reduce facial swelling.


musc:fe --+----,;..r+~

(wi1h superficial
temporal artery)
fat pad --+-+~
arch ---4-~ll


RGURE 3-1. The temporalis originates from the surface of the calvarium on the lateral aspect of
the skull. The superior attachment forms a gentle arc that is referred to as the superior temporal
line. The temporalis occupies the entire temporal fossa and inserts into the coronoid process and
the anterior aspect of the mandibular ramus. The temporalis is covered by athick fascial layer.
termed the temporalis muscular fascia. The temporalis fascia is adherent to the skull atthe supe
riortemporalline where it is continuous with the pericranium that covers the remainder of the skull.
Inferiorly, the temporalis muscular fascia splits into a deep and superficial layer approximately2 em
cephalad to the arch {see inset), with a fat pad between these layers. These two layers merge with
the periosteum of the medial and lateral surfaces of the zygomatic arch, respectively. The superfi-
ciallayer of the temporalis muscular fascia is continuous with the masseteric muscular fascia.

Deep temporal
arteries and veins

Superficial temporal
artery and vein

Internal maxillary a.- - -

FIGURE 3-Z. The temporalis muscle is supplied by the anterior and posterior deep tempo-
ral arteries, which arise from the internal maxillary artery and enter the muscle anterior and
posterior to the coronoid process, respectively. These two vessels enter the muscle on its deep
aspect. The anterior artery tends to enter the muscle at a more caudal point than the posterior
artery does, but both vessels usually enter the substance of the muscle by the upper edge of the
zygomatic arch. The nerves to the temp ora lis also enter on its deep surface and are typically
three but, sometimes, four in number. The temporal nerves run between the superior and infe-
rior heads of the lateral pterygoid muscle, crossing over the superior head along with the deep
temporal arteries, to enter the temporal is.

FIGURE 3-3. A lateral view of the face

demonstrates the relationship between the
mimetic muscles and the temporalis and mas-
seter muscle bodies. Note the key character-
istics of the facia I muscles; they have a bony
origin, with a soft tissue or muscular insertion,
allowing them to move the overlying integu-
ment of the face and, therefore, produce
changes in facial expression.

FIGURE 3-4. A close-up frontal view of a facial

dissection demonstrates the position of the
midfacial mimetic musculature. The importance
ofthe orbicularis oris to facial expression is
evident; the mimetic muscles insert into or
adjacent to this circular sphincteric muscle.
The small and delicate nature of the mimetic
muscles can be appreciated.

Temporalis Muscle

FIGURE 3-5. The approach to the temporalis

muscle is made through a scalp incision, with a
vertical component extending from the midpor-
tion of the superior auricular helix to approxi-
mately 2 em above the superior temporal line.
This incision allows full exposure of the muscle
and its overlying fascia. The incision can be
extended into the preauricular crease to gain
exposure of the superficial temporal artery and
vein. Preservation of the vascular pedicle to the
temporoparietal fascia permits its use for donor
site obliteration.

FIGURE 3-6. The deep muscularfascia is

exposed by elevating scalp flaps approximately
6 em anteriorly and posteriorly. The width and
orientation of the portion of the temporalis
transfer is determined. A 2- to 3-cm strip har-
vested from the mid portion of the muscle region
is most commonly used. This segment provides
adequate length and exhibits active contractile
properties that are ideal for facial reanimation.
If a larger portion of the muscle is required for
reconstruction of a midfacial or an oral cavity
defect the incisions can be modified to elevate
as much of the muscle as is needed.

Temporalis Muscle

FIGURE 3-7. The temporalis and its averlying

fascia are raised down to the zygomatic arch.
In the caudal aspect of this dissection, the
neurovascular supply is at risk. so both blunt
dissection and avoidance of electrocautery are
necessary, to prevent injury to the neurovascu-
lar pedicle as it enters the undersurface of the

Temporalis Muscle

FIGURE 38. There are three accepted approaches to medial inset of the temporalis muscle
for facial reanimation, as shown. In the vermilion border incision, a 1.5-cm incision is made
along both the upper and lower vermilion borders, meeting at the commissure. In patients with
extensive facial rhytids, a nasolabial fold incision yields an acceptable cosmetic result. Another
option is to extend the tern poral and preauricular incision inferiorly below the angIe of the man-
dible. This latter option is the most lengthy, but avoids any direct facial incision. It is favored in
young patients and those opposed to direct facial incisions.

Temporalis Muscle Tendon

FIGURE 3-9. Mattress sutures are used to

secure the temporalis muscle and fascia to
the lateral border of the orbicularis oris. Direct
contact between the two muscles is thought ta
be important to maximize postoperative facial
mavement. To achieve aral cammissure and
nasalabial fald symmetry at rest, the pull of the
temporalis must be exaggerated at the time of
surgery. This overcorrection will account for the
known stretching and relaxation of the trans-
ferred muscle over time.

RGURE 310. An alternate approach totem-

poralis transfer can be accomplished with use
of the temporalis tendon. The insertion of the
temporalis tendon onto the caronoid process
of the mandible is shown (zygomatic arch and
masseter muscle removed). The line deman-
strates the osteotomy site for coronoidectomy.

Temporalis Muscle Tendon

FIGURE 3-11. The tendon has been dissected

from the coronoid process, and secured to
the modiolus. The oral commissure should be
modestly overcorrected, with exposure of the
first molar.

FIGURE 3-12. The muscle is rotated anteriorly, and secured to a remnant of temporalis fascia at
the anterior aspect of the temporal line. The solid line represents the true origin of the temporalis
muscle along the superior temporal line. The dashed line indicates the neo-origin after transfer,
encompassing only the anterior 40% of the fascial remnant at the superior temporal line.

REFERENCES 17. Hallock GG: Reconstruction of a lower eyelid dc:fect

using the temporalis muscle. A7171 Plast Surg 1984; 13: 157.
1. Al-Kayat A. Bramley P: A modified preauricular approach 18. Hollinshead WH: Textbook of Anaw1ey. 3rd ed. Hager-
to the temporomandlbular joint and malar arch. Br J Oral stown: Harper and Row; 1974.
Surg 1978;17:91-103. 19. Holmes AD, Marshall KA: Uses of the temporalis
2. Ammirati M, Spallone A, Ma J, Cheatham M, Becker muscle flap in blanking out orbits. Plast Reconstr Surg
0 : An anatomicosurgical study of the temporal 1979;63:336.
branch of the facial nerve. Neurosurgery 1993;33(6): 20. Labbe D, Huault M: Lengthening temporalis myoplasty
1038-1043. and lip reanimation. Plast Reconstr Surg 2000;105:1289-
3 . Antonyshyn 0, Colcleugh RG, Hurst l.N, Anderson C: 1297; discussion 1298.
The temporalis myo-osseous flap: an experimental study. 21. Mathes S, Nahai F: Clinical Applications for Muscle and
Plast Reconstr Surg 1986;77 :406. Musculocutaneous Flaps. St. Louis: CV MosbyYearbook;
4 . Antonyshyn 0, Gruss JS, Birt BD: Versatility of temporal 1982:40.
muscle and fascial flaps. Br J Oral Surg 1988;41: 118. 22. Matsuba HM, Hakki AR, Little )W, Spear SL: The tem-
5. Bakamjian V, Souther S: Use of the temporal muscle flap poral fossa in head and neck reconstruction: twenty-
for reconstruction after orbito-maxillary resections for two flaps of scalp, fascia and full thickness cranial bone.
cancer. Plasc Reconm Surg 1975;56:171. Laryngoswpe 1988;98:444.

6. Bradley P, Brockbank J: The temporalis muscle flap in 23. May M: Muscle transposition for facial reanimation. Arch
oral reconstruction. A cadaveric, animal and clinical Owlaryngol1985;110:184.
study.J Maxillofac Surg 1981;9: 139. 24. May M: Facial reanimation after skull base trauma. Am J
7. Byrne PJ, Kim M, Boahene K, Millar J, Moe K: Tempo- Owl (Nov. Suppl.):62~7 .
ralis tendon transfer as part of a comprehensive approach 25. May M: The Facial Nerve. New York: Thieme; 1986.
to facial reanimation. Arch Facial Plast Surg 2007;9: 26. McKenna MJ, Cheney ML, Borodic G, Ojemann RG:
234-241. Management of facial paralysis after intracranial surgery.
8. Cheney ML, McKenna MJ, Ojemann RG, Nadol JB: Contemp Neura/1991;13:519.
Early temporalis muscle transposition for the manage- 27. Naquin HA: Orbital reconstruction utilizing temporalis
ment of facial paralysis. LaryngosaJpe 1995;105(9 Pt 1): muscle. Am J Ophchalmol 1956;41 :519.
28. Reese AB, Jones IS: Exenteration of the orbit and repair
9. Conley J, Patow C: Flaps in Head and Neck Surgery. New by transplantation of the temporalis muscle. Am J Oph-
York: Thieme; 1989. chalmol1961;51:217.
10. Contreras-Gareis R, Martins PO, Braga-Silva J: Endo- 29. Renner G, Davis WE, Templer J: Temporalis pericranial
scopic approach for lengthening the temporalis muscle. muscle flap for reconstruction of the lateral face and
Plast Reconstr Surg 2003; 112: 192-198. head. Laryngoswpe 1984;94:1418.
11. Deitch RD, Callahan A: Temporalis muscle transplant 30. Rubin LR: Reanimation of the Paralyzed Face: New
for tissue defects about the orbit. Am J Ophthalmol Approaches. St. Louis: Mosby Yearbook; 1977.
31. Rubin LR: The anatomy of a smile: its importance in
12. Edgerton MT, Tuerk DB, Fisher JC: Surgical treatment the treatment of facial paralysis. Plast R econstr Surg
of Moebius syndrome by platysma and temporalis muscle 1974;53:384.
transfers. Plast Reccmstr Surg 1975;55:305.
32. Andersen JG: Surgical treatment of lagophthalmos in
13. Ewers R: Reconstruction of the maxilla with a double leprosy by the Gillies temporalis transfer. Br J Plast Surg
musculoperiosteal flap in connection with a composite 1961;14:339-345.
calvarial bone graft. Plast Reccmstr Surg 1988;3:431.
33. Rubin LR, Mishiki Y, Lee G: Anatomy of the nasolabial
14. Gillies HD: Experience with fascia lata grafts in the fold: the keystone of the smiling mechanism. Plast ReaJn-
operative treatment of facial paralysis. Proc R Soc Med szr Surg 1989;83: 1.
34. Sheehan )E: The muscle nerve graft. Surg Clin North Am
15. Golovine SS: Procede de cloture plastique de l'orbitc: 1935;15:471.
apres l'e:xenteration.J Fr Ophtalmol1898;18:679.
35. Tessier P, Krastinova 0 : La transposition du muscle
16. Habel G, Henscher R: The versatility of the temporalis temporal dans l'orbite anophtalme. Ann ChiT Plast Esthet
muscle flap in reconstructive surgery. BrJ Oral MaxilltJfac 1982;27:212.
Surg 1986;24:96.
""rbe first reported we of the sternocleidomastoid (Fig. 4-1). Owens incorporated the platysma and the
~ (SCM) muscle in head and neck reconstruction SCM to enhance the blood supply to the skin. Bakam-
was by Jiano (20) in 1908 in which it was transposed to a jian (4) modified Owens flap by extending the skin ter-
paralyzed face to restore dynamic reanimation. Schotts- ritory below the level of the clavicle. Littlewood (24)
taedt et al. (33) used the SCM to replace the masseter reported additional experience in wing the extended
muscle in a child who had developed paralysis in the SCM flap and identified the conttibutions of the occipi-
disttibution of the ttigeminal nerve, which resulted &om tal and posterior auricular arteries to the vascular supply
poliomyelitis. Additional cases were reported by Ding- of the muscle. O'Brien (28) is credited with being the
man et al. (10) and Hamacher (15) who ttansferred first to transfer an island of skin overlying the caudal
a segment of the SCM muscle with its intact motor aspect of the neck with the SCM pedicled superiorly
nerve and vascular supplies for replacement of the con- (Fig. 4-2). Finally, Ariyan (2,3) identified the inferior
genitally absent or paralyzed masseter. Owens (29), in vascular supply from the thyrocervical trunk and suc-
1955, is credited with being the first to report a mus- cessfully transferred an inferiorly based flap (Fig. 4-3).
culocutaneous flap based on the SCM. He ttansferred The SCM flap has been extensively studied but not
a superiorly based flap but maintained a broad cutane- widely wed. It has been criticized on oncologic grounds,
ous attachment of the skin in the region of the mastoid which are related to the safety of preserving this muscle


Internal jugular v.

Common carotid a.

Omohyoid m. Sternocleidomastoid m.

FIGURE 4-1. The original SCM musculocutaneous flap described by Owens (29) had a broad
attachment superiorly at the level of the mastoid and included the SCM and the platysma
muscles. Bakamjian (4) modified this design by extending the skin paddle below the clavicle.

when there are regional lymphatic metastases. The FLAP DESIGN AND UTILIZATION
limited aize of the musculocutaneous flap restricts its
use to amall defecta. Finally, thia flap has been criticized The evolution in flap design since the inttoduction of
for the unreliability of the skin paddle and for the con- the broad superiorly baaed musculocutaneous flap of
tour deformity in the neck following flap transfer. These Owens (29) was outlined in the introduction to this
iaauea are addreaaed in this chapter. chapter. The superiorly based and inferiorly based
The SCM ia a round muscle that originates from the island musculocutaneous flaps, as weD as the SCM used
manubrium and the medial aspect ofthe clavicle. It nms aa a muscle flap only, are presently the moat commonly
an oblique course in the neck to insert on the mastoid used SCM flaps. Although Bakamjian (4) and Little-
process and the superior nuchal line (Fig. 4-4). Con- wood (24) extended the stin territory below the clavi-
traction of the SCM leads to tilting ofthe head, bringing cle with the superiorly based "peninsular'' flap, there
the ipsilateral ear closer to the shoulder. The superficial has been little reported that substantiates the maximum
layer of the deep cervical fascia splits to aWTOUild the dimensions when the flap is harvested as an island of
SCM on both its deep and superficial surfaces (17). stin. In addition to transfer of the musculocutaneous

SCM branch

FIGURE 4-Z. The superiorly based SCM island musculocutaneous flap transfers skin from the
caudal aspect of the neck that overlaps the distal third of the muscle and the medial portion of
the clavicle. The primary blood supply to this flap arises from the posterior auricular, the occipi-
tal, and the superior thyroid arteries.

Branch of
thyrocervical a.

FIGURE 4-1. The inferiorly based SCM island musculocutaneous flap transfers a segment
of skin overlying the upper third of the SCM muscle. The primary blood supply to this flap arises
from the thyrocervical trunk and the superior thyroid artery.


FIGURE 4-4. The SCM muscle originates from the manubrium and the medial aspect of the
clavicle. It inserts into the mastoid process and the superior nuchal line. The spinal accessory
nerve supplies the motor innervation to the SCM and the trapezius muscles.

unit, there have been numerous reports of using the The ability to transfer the SCM with the preserva-
SCM to transfer clavicular periosteum (12,37,38) and tion of its vascular and neural supply led to the appli-
segments of the clavicular bone for reconstruction of cation of this fl.ap to reconstructive problems requiring
the mandible (5,36). dynamic activity. The early report by Jiano (20) in
The problem of the donor site contour deformity was restoring mimetic activity to the paralyzed face was one
addressed by Alvarez et al. (1) who reported the use of such ez.ample. O,Brien (28) used the SCM to recon-
the split SCM musculocutaneous flap in 1983. Trans- struct a total lower lip defect, with the skin island pro-
position of the entire belly of the SCM produced an viding the inner lining. The dynamic activity of the
obje<:tionable bulge in the midne<:k and a concavity in SCM was preserved and believed to have functional
the lower ned::. Alvarez et al. (1) described a series of value in restoring oral competence. In the introduc-
cases in which either the sternal head or the clavicular tion to this chapter, it was noted that this flap was also
head of the muscle was transferred to the recipient site. applied to the problem of dynamic restoration of the
They cautioned that this longitudinal split could only masticator muscle sling (10,14,32). Finally, Matulic et
be carried through appro.Umately two thirds of the mus- al. (27) reported the combination of the SCM muscle
cle's belly in its longitudinal direction. flap with a forehead cutaneous flap to reconstruct the

oral cavity following performance of a glossectomy. The biopsies from the healed reconstructed site demonstrated
forehead flap provided the inner lining, and the SCM preservation of the dermal layer. In this report, Ariyan
was transposed to provide dynamic tongue movement. also described primary closure of the donor site defect
As in many reconstructive techniques that purport to through cutaneous advancement flaps rather than by
restore motion, the documentation by electromyogra- application of a skin graft. Additional reports on the
phy of electrical or contractile activity does not nec- SCM musculocutaneous flap cited varying degrees of
essarily translate into coordinated functional activity. skin viability. Sasaki (32) used four inferiorly based and
An exception to this statement is in facial reanimation one superiorly based flap to reconstruct the floor of the
in which muscle transposition has been shown to be an mouth and tonsillar regions. The skin of one of the supe-
effective means of restoring mimetic activity. The SCM riorly based flaps underwent total necrosis; partial skin
has been supplanted by the temporalis muscle because necrosis was reported in two of the remaining inferiorly
of the improved axis of pull of this muscle in producing based flaps. Despite these complications, there were
a symmetric smile. More recently, there are numerous no cases of salivary fistulas, which Sasaki attributed
reported strategies for transfer offree innervated muscle to the viability of the underlying SCM muscle. Marx
flaps that produce a more natural reanimation triggered and McDonald (25) reported a more favorable expe-
by the facial nerve rather than by the act of biting. rience with the superiorly based flap in eight patients
The SCM muscle flap has also been used to restore in whom they noted distal skin necrosis 2 em from the
a normal lateral facial contour following parotidectomy tip of the flap. These 8 cases of oral cavity reconstruc-
and mandibular reconstruction. Hill and Brown ( 16) tion represented a subset of the 16 reported cases of
transposed a superiorly based muscle flap over a free SCM flaps also used for a variety of other indications.
iliac bone graft to achieve a more satisfactory lower These authors emphasized the necessity of maintain-
facial contour in secondary mandibular reconstruction. ing the vascular contributions from the superior thyroid
Bugis et al. (7) reported their experience with the use artery and vein. The importance of this contribution
of the SCM muscle flap to restore the facial contour in from the superior thyroid pedicle is discussed later in
31 patients following parotidectomy. In addition, they detail. Finally, Ariyan (2) reported closure of a cervical
reported the successful application of this flap in two esophagostoma by using a superiorly based SCM flap
patients who had postoperative salivary fistulas. Despite for inner lining followed by a superior trapezius flap for
these findings, the SCM muscle flap was not an effective outer cutaneous coverage.
method to prevent Frey syndrome in an extensive series The use of vascularized segments of the clavicle sup-
of patients reported by Kornblut et al. (21,22). A group plied by adjacent soft tissue was introduced in the early
of 35 patients who underwent parotidectomy and SCM 1970s as a solution to the frustrating problem of restor-
muscle transposition into the parotid bed were com- ing bone continuity following segmental mandibulec-
pared with a control group of 35 patients who under- tomy. Siemssen et al. (36) referred to two of the earliest
went comparable ablative procedures but no muscle reports that used portions of the clavicle to reconstruct
transposition. The rationale for transposing the muscle the mandible, which dated back to the beginning of the
was to interfere with the presumed mechanism of Frey 20th century. They credited Rydygier (31) with being
syndrome, which is the misdirection of auriculotempo- the first to transfer an osteocutaneous flap containing
ral secretomotor fibers from their normal end organ, a portion of the clavicle. This was followed by Blair's
which is the salivary tissue. It is thought that the trans- (6) description of composite flaps containing clavicle
sected nerves are rerouted to the sweat glands of the and rib. Snyder et al. (37) are credited with reviving this
overlying skin, thereby producing "gustatory sweating." concept with a report issued in the current era in which
Komblut et al. reported no difference in the incidence vascularized bone was used to restore bony defects of
of Frey syndrome in the two study groups. the maxillofacial skeleton. They reported several cases of
The SCM musculocutaneous flap has been used for vascularized bone transfer based on regional cutaneous
oral and pharyngeal mucosal defects since Bakamjian's flaps. They transferred either full- or split-thickness seg-
(4) initial report of the use of this flap to reconstruct ments of clavicle with the overlying skin in a two-stage
the palate following radical maxillectomy. As noted pre- procedure. This publication was followed by Conley's
viously, Bakamjian used an extended peninsular skin (9) report in 1972 of a series of 50 regional bone-con-
muscle flap that was transferred through the posterior taining flaps for mandibulofacial reconstruction. This
oral cavity. At a second stage, the flap's pedicle was series was composed of a variety of different composite
transsected, with closure of the orostoma. Ariyan (3) flaps, including the deltopectoral acromion flap, the tra-
reported 14 cases of either superior or inferior muscu- pezius-scapular flap, the temporalis--calvarial flap, and
locutaneous flaps used in the oral cavity or pharynx. He the SCM-clavicular flap. Although Conley reported
noted "partial epithelial loss" in seven cases, but only three complete flap failures in this series, there were few
one developed a salivary fistula. Reepithelialization of details regarding the actual techniques used for each
the denuded areas of the oral cavity was reported, and of these donor sites. He warned about the potential

shoulder morbidity resulting from segmental defects under the sternal head to avoid a contour deformity in
of the clavicle and advised that a sagittal split be per- the neck. Finally, they speculated about the possibil-
formed to transfer only the outer cortex. ity of reconstructing a near-total mandibular defect by
Siemssen et al. (36) reported on a series of 18 patients transferring the anterior portions of both clavicles with
who underwent mandibular reconstruction with either an intervening segment of the manubrium pedicled on
split or segmental segments of the clavicle pedicled on both SCM muscles.There was only one total Bap necro-
the clavicular head of the SCM. Although seven bone sis in this series.
flaps were transferred in the primary setting, internal Barnes et al. (5) reported a similar favorable experi-
lining was achieved with either a forehead or a deltopec- ence with the use of this musculoclavicular flap in four
toral flap. There were significant complications in the primary and one delayed mandibular reconstruction.
group of five patients in this series who underwent split The viability of the neomandible was confirmed with
clavicle transfers, with fractures occurring at both the postoperative technetium scans.
donor and recipient sites. In the remaining patients in The SCM musculoclavicular Bap has also been used
this series, a full segment of the clavicle was harvested for rigid support in laryngotracheal reconstruction for
anterior to the attachment of the trapezius muscle the correction of stenotic segments. Schuller and Par-
(Fig. 4-5). The authors reported little to no shoulder rish (34) reported the successful use of vascularized split
morbidity in these patients. In addition, the clavicle was clavicle grafts to provide rigid support of the cervical
pedicled on the clavicular head of the SCM and passed airway. Approximately one half the circumference of the

FIGURE 4-5. A segment of 1he clavicle, pedicled on the clavicular head of the SCM, may be
transferred as a vascularized bone graft.

clavicle was harvested and "hollowed out,. with a bone Following research on the SCM Bap performed in
curette to create a rigid lumen. The bony shell waa then dogs, Friedman later reported his series ofusing the SCM
lined with a free mucosal graft. Alternatively, Tovi and periosteal Bap to reconsttuct defects of the trachea and
Gittot (38) described a myoperiosteal flap to achieve subglottic region in humans, resulting from resection of
a similar result (Fig. 4-6). The clavicular periosteum, inwsive thyroid cancer.nus one-stage technique involved
pedicled on the SCM, waa used to repair noncirCUIIlieJ:.. the transfer of periosteum from the clavicle or the manu-
ential defecta of the larynx and trachea in three patients. brium, based on the SCM as a carrier. A stent was left
A stent was placed in one patient. All three patients were in place for several weeks to facilitate restoration of an
successfully decannulated, and at the time of follow-up adequate lumen. Ten of eleven patients were successfully
endoscopy, the reconsttucted portion of the airway was decannulated using this tec:hnique (12,13). It was unclear
relined with normal-appearing respiratory epithelium. from this report as to how large a segment of the trachea
Friedman et al. (12) examined the SCM myoperiosteal can be restored with this technique. The SCM muscle
Bap in dogs that underwent tracheal reconattuction. The or musculoperiosteal Bap can be used to close a window
growth of new bone from the transplanted periosteum defect in the trachea and larym, while the same muscle
was documented at the 6- and 9-month follow-ups. Bap can be used to bolster a primary tracheal repair by
In addition, the patency of the lumen waa preserved. suturing the muscle over the suture line (Fig. 4-7A,B).

RGURE 4-6. The SCM myoperiosteal flap transfers vascularized periosteum for use in airway

FIGURE 4-7. A:. The inferiorly based SCM can be utilized in tracheal repair following resection
for an invasive thyroid cancer. In limited defects of the trachea, up to one third of the circumfer-
ence, the window can be repaired with an SCM muscle flap, used as a patch. {continued)

FIGURE ~7. (continued) B: Fcllcwing primary repair cf segmental tracheal defects with
end-toend anastomosis, the closure can be augmented with an SCM muscle flap placed over
the suture line. This technique helps to prevent and limit the extent of a leak.

An alternative teclmique for the repair of laryngotta- of Mathes and Nahai (26). There is one dominant
cheal stenoses was described by Eliachar and Moscona pedicle arising superiorly from the occipital artery and
(11) who used a SCM island musculocutaneous flap. vein and three minor pedicles: a branch of the poste-
This flap augmented the lumen after resection of the rior auricular artery and vein, a branch of the superior
stenotic framework. A T.-tube, with a laryngeal stent, thyroid artery and vein, and a branch of the thyrocervi-
was kept in place for 4 to 6 weeks after surgery. cal trunk (Fig. 4-8). As noted previously, the segmental
nature of the vascular supply allows this muscle to be
pedicled either superiorly or inferiorly. The motor sup-
NEUROVASCULAR ANATOMY ply to the SCM is from a branch of the accessory nerve,
which continues across the posterior ttiangle of the neck
The vascular supply to the SCM muscle and its overly- to innervate the trapezius muscle as well. There remains
ing skin is arguably the most confusing of any flap used some conttoversy as to whether the contribution to the
in head and neck reconstruction. This is one explana- SCM's innervation from C2 and C3 is motor or sensory.
tion why this flap has not been embraced with a sig- The successful ttansfer of skin as a musculocutane-
nificant amount of enthusiasm. The SCM has a type II ous flap requires preservation of the vascular supply
vascular supply, according to the classification scheme to the muscle and capture of the musculocutaneous


Occipital a.
(SCM branch)

External carotid a.

Internal jugular v.

Branch of
thyrocervical a.

Branches of
superior thyroid a.

FIGURE 4-8. The dominant arterial supply to the SCM muscle is from the occipital artery. Minor
vascular contributions arise from branches of the posterior auricular artery, the superior
thyroid artery, and the thyrocervical trunk.

perforators that exit the superficial surface of the mus- layer. This difference can readily be felt by assessing the
cle. The relationabip of the SCM to the overlying cervi- relative mobility of the lower neck skin compared with
cal skin variea, depending on whether one is looking at the tightly adherent skin of the upper neck.
the caudal aspect of the neck or the region below the The platySma muscle is a vestige of the panniculus
mastoid tip. The reason for this difference is the pres- carnosus in lower animals. The skin is tightly adherent
ence of the platysma muscle, which is a sheetlike muscle to this muscle, and it has long been recognized that cer-
of varying thickness that runs in the superficial fascia vical skin flaps are more viable when the platysma is
of the neck (Fig. 4-9). It arises below the clavicle from included. The platySma has been successfully used as
the muscular fascia overlying the pectoralis major and a carrier of cervical skin, as introduced by Futrell et
the deltoid. It courses obliquely across the neck at right al. (14) in 1978. The platysma is primarily supplied by
angles to the SCM to blend with the muscles inserting the submental branch of the facial artery. The platysma
on the lower lip. The paired platysma muscles are defi- musculocutaneous unit has been shown to be reliable in
cient in the midline of the neck; laterally, they overlap subsequent reports (8).
the lower portion of the SCM only to approximately What is unique about the superiorly based SCM
the midlevel of the neck. Therefore, the caudal half of island flap is that a successful outcome requires capture
the SCM is separated from the overlying skin by a layer by a deeper muscle (SCM) of a more superficial muscu-
of platysma; the cephalad half has no such intervening locutaneous unit (platysma). There is no other flap used

Sternocleidomastoid m.

FIGURE 4-9. The platysma muscle originates from the muscular fascia overlying the pectoralis
major and runs an oblique course across the neck. It completely overlaps the caudal aspect of
the SCM muscle.

in the head and neck or perhaps elsewhere in the body overlying the cephalad portion of the SCM appears
in which the blood supply to the skin must traverse two to be more favorably related to the muscle because of
distinct muscle layers. The cephalad portion of the mus- the absence of the platysma. The peninsular skin flap,
cle appears to be a more favorable donor site to harvest as described by Owens (29), should have an excel-
skin because of the lack of the intervening muscle layer. lent chance of viability because of the preservation of
However, the inferiorly based flap is at a disadvantage the dominant blood supply to the muscle and direct
as a result of the smaller vascular pedicle entering the cutaneous feeders to the skin entering from the occipi-
caudal aspect of the muscle. tal and posterior auricular branches. Muscle only or
Studies that have investigated the vascular supply to muscle plus periosteum, with or without clavicle, also
the cervical skin are helpful in shedding light on this appear to be reliable flaps.
problem. One of the earliest reports that looked at the
vascular contributions from the SCM to the cervical
skin was by Jabaley et al. (19). In a series of cadaver POTENTIAL PITFALLS
dissections, these investigators reported an extreme
paucity of musculocutaneous perforators arising from Many of the potential complications of this donor site
the lower two thirds of the SCM. They did, however, have been discussed in this chapter. The viability of the
identify a direct cutaneous branch from the transverse skin of either a superiorly or an inferiorly based flap
cervical artery that penetrates the platysma to supply is questionable. However, the experience of Marx and
the supraclavicular skin. McDonald (25) suggests that preservation of the supe-
Two publications from the University of Pittsburgh rior thyroid artery may be extremely important for the
reported on a series of fresh cadaveric studies that also reasons mentioned. It may be possible to mobilize the
examined the blood supply to the cervical skin. A sum- superior thyroid pedicle to enhance the arc of rotation.
mary of the findings in these two studies is enlightening One of the other major criticisms of this donor site
(18,30). These investigators corroborated the observa- is its intimate relationship to the region of most com-
tions ofJabaley et al. (19) that there are few musculocu- mon nodal metastases from the head and neck pri-
taneous perforators from the SCM and those that were mary malignancies. The necessity for a formal radical
present are extremely small. Direct cutaneous perfora- neck dissection eliminates this flap as a surgical option.
tors were identified from a number of sources, includ- Modified neck dissections may allow preservation of
ing the occipital, posterior auricular, and superior the SCM, but its vascular supply is placed in jeopardy.
thyroid arteries, which were the most consistent. These Transfer of a SCM flap from the contralateral neck may
three branches of the external carotid artery, therefore, be feasible. Arguments against violating a potential site
supply feeders to the SCM muscle and direct perfora- of regional metastases have been raised (23). However,
tors to the skin. In 80% of the cadaver dissections, a the opposing point of view in this controversy is that,
large cutaneous vessel from the superior thyroid artery in raising the SCM, the posterior fascial layer does not
was identified coursing around the anterior border of need to be violated and, therefore, the envelope of deep
the SCM, which supplied the platysma and skin ofthe cervical fascia that encloses the lymph node-bearing tis-
midneck. It is likely that the success reported by Marx sue can be preserved.
and McDonald (25) in their series of superiorly based The largest published series of SCM flaps was
SCM flaps was directly related to the preservation of reported by Sebastian et al. (35) in 1994. A total of 121
the superior thyroid branches. Ink-injection studies of superiorly based SCM flaps were utilized in 120 patients
the cutaneous branch of the superior thyroid artery with clinically NO necks. The branches to the SCM
caused staining of the skin of the middle and lower muscle arising from the occipital artery were preserved.
cervical regions. In one dissection, the direct cutane- Total flap loss occurred in 7.3% of patients while super-
ous branch from the superior thyroid system traveled ficial skin loss was reported in 22.7%. Orocutaneous
on the undersurface of the SCM and then entered the fistulas were noted in 11.8% of patients. The authors
platysma and the overlying skin between the sternal noted a significantly higher incidence of flap complica-
and clavicular heads of the SCM (30). tions in patients who were previously irradiated. Finally,
This review of the vascular anatomy points out nodal recurrence occurred in 5.7% of ipsilateral necks
potential pitfalls in regard to both the superiorly and that were pathologically NO and in 17.4% of ipsilateral
the inferiorly based island flaps. The superiorly based necks that demonstrated pathologically positive nodes.
flap preserves the dominant blood supply to the mus-
cle but is problematic because of the intervening layer
of platysma. The inferiorly based flap relies on the
nondominant contributions to the muscle from the The author would like to acknowledge the contribu-
caudal aspect of the neck after transsecting the domi- tions of Dr. Hugh F. Biller to the writing of this chapter
nant cephalad muscular branches. However, the skin in the first edition of this book.

Sternocleidomastoid Flap

FIGURE 4-10. The left SCM muscle is outlined

over the left neck with the approximate posi-
tions of the superior, middle, and inferior blood

FIGURE 4-11. The skin paddle of a superiorly

based island flap is outlined over the caudal
aspect of the muscle.

FIGURE 4-12. An incision is made around the

perimeter of the skin flap. The caudal aspect
of the flap overlies the clavicle. The incision is
carried through the skin, subcutaneous tissue,
and platysma muscle to expose the superfi-
cial layer of the deep cervical fascia, which
encompasses the SCM.

Sternocleidomastoid Flap

FIGURE 4-13. The random caudal extension

of the skin is elevated off the clavicular perios-
teum. The inferior attachments of the SCM to the
clavicle are transsected. Care must be taken to
avoid causing any shearing forces between the
SCM and the overlying skin. If a segment of the
clavicle is to be harvested, osteotomies would
be made at this time.

FIGURE 4-14. A vertical incision has been

made to expose the cephalad portion of the
SCM. The inferior blood supply from the thyro-
cervical trunk has been transsected. The middle
blood supply from the superior thyroid artery and
vein is shown entering the deep surface of the
SCM just above the omohyoid muscle.

FIGURE 4-15. Preservation of the superior

thyroid pedicle limits the arc of rotation but
improves the vascular supply to the superiorly
based SCM flap.

Sternocleidomastoid Flap

FIGURE 4-16. The dominant superior blood

supply arising from either the occipital artery
or directly from the external carotid artery
has been isolated. This branch usually runs a
course cephalad to the hypoglossal nerve.

FIGURE 4-11. By transsecting the caudal

and middle blood supply, the arc of rotation
is greatly improved. This flap can be used for
intraoral, facial, and pharyngeal defects.

REFERENCES 5. Barnes D, Ossoff R, Pecaro B, Sission G: Immediate

reconstruction of mandibular defects with a composite
sternocleidomastoid musculoclavicular graft. Arch Our
1. Alvarez G, Escamilla J, Carranza A: The split ster- laryngol Head Neck S1ng 1981;107:711-714.
nocleidomastoid myocutaneous ftap. BT J Plasr Surg
1983;36: 183--186. 6. Blair VP: S1ngery and Diseases of the Mouth and Jaws.
St. Louis: CV Mosby; 1918.
2. Ariyan S: One-stage repair of a cervical esophagostoma
with two myocutaneous flaps from the neck and shoul- 7. Bugis S, Young J, Archibald S: Sternocleidomastoid flap
der. Plast Reconm Surg 1979;63:426--429. following parotidectomy. Head Neck 1990;12:430--435.

3. Ariyan S: One stage reconstruction for defects of the 8. Coleman J, Jurkiewicz M, Nahai F, Matthes S: The pla-
mouth using a sternomastoid myocutaneous flap. PltJn tysma musculocutaneous flap: experience with 24 cases.
Reamstr SUTg 1979;63:618-625. Plast RecMUtr Surg 1983;72:315--321.

4. Bakamjian V: A technique for primary reconstruction 9. Conley J: Use of composite flaps containing bone for
of the palate after radical maxillecoomy for cancer. Plast major repairs in the head and neck. Plast Reconsrr Surg
Reamstr S1ng 1963;31: 103--117. 1972;49:522-526.

10. Dingman RO, Grabb WC, O'Neal RM, Ponitz RJ: 24. Littlewood M: Compound skin and sternomastoid flaps
Sternocleidomastoid muscle transplant to masseter area: for repair in extensive carcinoma of the head and neck.
case of congenital absence of muscles of mastication. PlastReconstrSuTg 1967;20:403--419.
Plast Reconstr Surg 1969;43:5-12. 25. Marx RE, McDonald DK: The sternocleidomastoid
11. Eliachar I, Moscona AR: Reconstruction of the laryngo- muscle as a muscular or myocutaneous flap for oral and
tracheal complex in children using the sternocleidomas- facial reconstruction. J OTal Maxillofac Surg 1985;213:
toid myocutaneous flap. Head Neck 1981;4:16-21. 155-162.
12. Friedman M, Grybaieskas V, Skolnick E, Toriumi D, 26. Mathes S, Nahai F: Clinical Applications joT Muscle and
Chills T: Sternomastoid myoperiosteal flap for recon- Musculocutaneous Flaps. St. Louis: CV Mosby; 1982:38-
struction of the subglottic larynx. Ann Otol Rkinol 39.
Laryngo/1987;96:163-169. 27. Matulic Z, Bartovic M, Mikolji V, Viras M: Tongue recon-
13. Friedman M, Toriumi D, Owens R. Grybauskas VT. struction by means of the sternocleidomastoid muscle
Experience with the sternocleidomastoid myoperiosteal and a forehead flap. BT J Plast SuTg 1978;31:147-151.
flap for reconstruction of subglottic and tracheal defects: 28. O'Brien B: A muscle-skin pedicle for total reconstruc-
modification of technique and report oflong-term results. tion of the lower lip: case report. Plast Reconstr SuTg
Laryngoscope 1988;98: 1003-101 1. 1970;45:395-399.
14. FutrellJ,Johns M, Edgerton M, Cantrell R. Fitz-Hugh GS: 29. Owens N: A compound neck pedicle designed for the
Platysma myocutaneous flap for intraoral reconstruction. repair of massive facial defects: formation, development,
AmJ Surg 1978;136:504--507. and application. Plast Reconstr Surg 1955; 15:369-389.
15. Hamacher E: Sternocleidomastoid muscle transplants. 30. Rabson J, Hurwitz D, Futrell J:The cutaneous blood sup-
Plast Reconstr Surg 1969;1: 1--4. ply of the neck: relevance to incision planning and surgi-
16. Hill H, Brown R: The sternocleidomastoid flap to restore cal reconstruction. BT J Plast Surg 1985;38:208-219.
facial contour in mandibular reconstruction. BT J Plast 31. Rydygier LR: Zum Osteoplastischen ersatz nach
Surg 1978;31:143-146. Unterkieferresektion. Zentralbl ChiT 1908;36: 1321.
17. Hollinshead WH: AnatomY joT Surgeons: The Head and 32. Sasaki C: The sternocleidomastoid myocutaneous flap.
Neck. New York: Harper and Row; 1982:446. ATck OtolaTyngol Head Neck Surg 1980;106:74--76.
18. Hurwitz D, Rabson J, Futrell ]W: The anatomic basis 33. Schottstaedt E, Larsen I.., Bost F: Complete muscle
for the platysma skin flap. Plast &constr Surg 1983;72: transposition. J Bone Joint Surg Am 1955;37:897-919.
34. Schuller D, Parrish RT: Reconstruction of the larynx
19. Jabaley M, Heckler F, Wallace W, Knott L: Sternocleido- and trachea. ATck OtolaTyngol Head Neck Surg 1988;114:
mastoid regional flaps: a new look at an old concept. BT J 278-286.
Plast SuTg 1979;32:106-113.
35. Sebastian P, Cherian T, Ahamed I, Jayakumar K, Sivara-
20. Jiano J: Para.lizie faciale dupa extriparea unei tumori a makrishnan P: The sternomastoid island myocutaneous
parotidee trata prin operatia dlui gomoue. Bull Mem Soc flap for oral cancer reconstruction. ATck OtolaTyngol Head
Clin BuckaTest 1908:22. Neck SuTg 1994;120:629.
21. Kornblut A, Westphal P, Michlke A: The effective- 36. Siemssen S, Kirkby B, O'Connor T: Immediate recon-
ness of a sternomastoid muscle flap in preventing post- struction of a resected segment of the lower jaw using
parotidectomy occurrence of the Frey syndrome. Acta a compound flap of clavicle and sternomastoid muscle.
OtolaTyngol1974;77:368-373. Plast Reconstr SuTg 1978;61 :724--735.
22. Kornblut A. Westphal P, Michlke A: A re-evaluation 37. Snyder C, Bateman J, Davis C, Warden G: Mandibu-
of the Frey syndrome following parotid surgery. ATck lofacial restoration with live osteocutaneous flaps. Plast
OtolaTyngol Head Neck SuTg 1977;103:258-261. Reconstr Surg 1970;45:14--19.
23. Larson DI..., Goepfert H: Limitations of the 38. Tovi F, Gittot A: Sternocleidomastoid myoperiosteal flap
sternocleidomastoid musculocutaneous flap in head and for the repair of laryngeal and tracheal wall defects. Head
neck cancer reconstruction. Plast&constr SuTg 1982;3:328- Neck 1983;5:447--451.
"T""'be medially based deltopectoral Bap, also refened dormant in the medical literature until Bakamjian
~ to as the Bakamjian flap, was a major adwnce in (2,3) described its versatility and wide application in
head and neck surgery when it was popularized in the head and neck reconstruction. Along with the forehead
early 1960s by V. Y. Bakamjian (2) as a solution to the Bap introduced by McGregor (18), it was the primary
problem of pharyngoesophageal reconstruction. The method for resurfacing cutaneous and mucosal defects
design of this flap, with its pedicle based at the ster- until the late 1970s when musculocutaneous flaps were
num, represented a divergence from the commonly held introduced. It remains a useful tool in the reconstruc-
belief that the midline of the body was a relatively avas- tive surgeon's armamentarium, although it has primar-
cular territory (19). There remains some controversy as ily been relegated for use in reconstructing external
to whether the Bap reported in 1917 by Aymard (1) for cutaneous defects of the neck. The major disadvantages
nasal reconstruction was the first description of the del- of this flap include the requirement, in most cases, for
topectoral flap. This flap was again described by Joseph a skin graft to close the donor site, and the unreliability
(14) in the 1930s in his book on plastic surgery. Joseph of the distal portions of this flap when extended over
referred to Manc:hot's description of the vascular ter- the deltoid region. I have found the design and harvest
ritories of the body and clearly understood the nature of an island deltopectoral flap to be a useful method to
of the blood supply to this flap (10). For apprazimately overcome the need to transfer the medial portion of the
40 years, the deltopectoral Bap remained essentially Bap as a peninsula. The color match of the skin paddle

provides an excellent method to resurface the anterior

neck to achieve an aesthetically pleaaing result.
The deltopectoral flap is a faaciocutaneoua Bap baaed
on the perforating branches of the internal mammary
artery. Although originally described as having a pedi-
cle baaed on the first three perforators, it is now most
commonly baaed on the second and third. When a clearly
dominant perforator is present, the entire flap could
probably be based on that single vascular pedicle. Pri-
mary tmnafer of the deltopectoral flap may be performed
with a high degree of reliability provided that it does not
extend into the territory overlyiD,g the deltoid muscle.
Distal Bap necrosis occurs with significant frequency
when a Bap extending onto the shoulder is raised without
prior delay. Flap vascularity and the reliability of different
Bap designs are discussed in detail later in this chapter.


A variety of different flap designs have been described to
reconstruct many different defects in the head and neck.
Greater length and greater diversity can be achieved
when a delay procedure is instituted. The body habitus
of the patient greatly influences the arc of rotation of the
medially based Bap. The optimal situation is a patient
with broad shoulders and a short neck.
There are several d.Uferent ways to ttansfer this flap to
the recipient site. The bridgiD,g portion of the flap can be
tubed over the clavicle and neck skin. A staged secondary
procedure is required to either return or excise the tubed
component. Alternatively, the intervening skin between
the defect and the clavicle may be excised to allow a one-
stage insertion of the entire length of the Bap. Finally, an
island flap can be created by de-epithelializing the proxi- FIGURE 5-1. A modified design of the deltopectoral flap
mal portion of the flap, which is then buried beneath the with the proximal portion de-epithelialized and buried
cervical skin betWeen the defe<:t and the clavicle. When beneath the intervening bridge of skin (see Fig.5-2). The fas-
buried in this fashion, a secondary procedure is not ciocutaneous nature of this flap ensures that this maneuver
required (Fig. 5-1) (13). An alternative approach to cre- will not impede vascularity to the distal portion. The skin
ating an island Bap is to raise the skin over the prozima1 island for this flap is more reliably placed more medially
portion of the island flap in a subdermal plane, which than shown, unless a delay procedure is performed.
facilitates the closure of the donor defect (Fig. 5-2).
Krizek and Robson (17) described the longitudinally
split Bap in which an incision is made through the distal In the initial delay procedure, the upper arm extension
end of the skin paddle creating two separate segments for was folded under the deltoid component to produce a
restoration of the inner and outer lining (Fig. 5-3). This buried skin Bap. The two epithelial surfaces were then
design places less stress on the vascularity to the tip than transferred at the time of the second procedure. An alter-
de-epithelializing a segment and folding the Bap on itself. native solution to the requirement for a double epithelial
A transverse fold in the tip of the flap allows the distal surface is the use ofa skin graft on the undersurface of the
portion to be used for the internal lining of composite flap. The graft may be buried at the time ofan initial delay
defects. However, this technique requires that a loDger procedure (22).
Bap be harvested, and the distal fold occurs in the por- East et al. (8) described the placement of a fenestra-
tion that is the least well vascularized. Bakamjian et al. tion in the distal portion of the deltopectoral ftap for
(5) described the !..-shaped design of the deltopectoral reconstruction of a ttacheostoma. Although I would
Bap, with the short limb of the L extending downward be wary of causing tip necrosis with this technique, the
along the upper arm. This Bap design was used to obtain authors advised that the short arc of rotation required to
an inner lining by using a two-stage procedure (Fig. 5-4). reach the ttacheostoma allows the design of a short flap,

FIGURE 5-2. The island deltopectoral flap can be harvested by elevating skin flaps over the
proximal portion of the fascial subcutaneous pedicle in a subcutaneous plane in order to allow
transfer of the island of skin. After incising the distal skin island. the proximal flap is elevated in
the plane deep to the fascia. The flap can be tunneled into the neck in a plane over the clavicle.

and, therefore, the fenestra can be placed in a relatively Bap is more limited by the upper limb of the Bap than
well-vascularized portion of the flap. by the inferior limb, as is most commonly believed. The
The length of the deltopectoral flap that can be safely rationale for this statement is based on the contention
transferred without a delay is somewhat controversial. that the skin of the anterior a:Dllary fold is intrinsically
Kirkby et al. (15) reported that the end of the Bap could the most redundant portion of the skin of the distal end
be safely extended to the tip of the shoulder.When addi- of the flap. The inferior limb of the Bap captures that
tional length was required, these authors re<:ommended anterior uillary fold skin, while the superior limb of
the creation of a back cut from the inferior limb of the this Bap, which is located parallel and just inferior to the
medial portion of the Bap across the sternum. They clavicle, captures the less redundant upper skin. It is easy
descnoed the cephalad extension of the cut lateral to the to demonstrate the relative redundancy of the skin in the
contralateral internal mammary perforators (Fig. 5-5). anterior axillary fold by raising an arm abovt: the head
However, the efficacy of this maneuver is somewhat con- and realizing the amount of skin laxity in that location.
troversial in light of the contention of McGregor and Bilateral deltopectoral Bap transfers havt: been reported
Jackson (19) that the arc of rotation of a deltopectoral for complex reconstrUctions or recurrent cancers (15).

FIGURE 5-3. The longitudinally split deltopectoral flap

provides two epithelial surfaces. This design is safer than
de-epithelializing a horizontal strip and folding the tip to
achieve an inner lining.

The deltopectoral fiap was t:r&l:ISferred as a microvas-

cular free flap, as first reported by Harii et al. (12) in
1974 and then by Fujino et al. (9) in the following year.
The publication ofFujino et al. described the tranafer of FIGURE 5-4. A delay procedure is required to improve the
a de-epithelialized dermis-fat fiap for augmentation of chances of successfully transferring distal portions of the
contour deformities of the head and neck. Percutaneous deltopectoral flap, which extend down the arm and around
Doppler sonography was used to localize the dominant the shoulder.
perforator on whic:b. to base the flap. The free fiap is usu-
ally harvested on the second internal mammary perfora-
tor, which is most commonly the la:rgest. The vascular were mobilized and not transsected, he did not report
pedicle for this fiap is quite short, and it is rarely used sensory recovery when the nerves were transsected and
for free tissue transfer due to the abundance of other then reanastomosed to recipient sensory nerves in the
donor sites that are available. neck. The potential for tranafer of a sensate deltopeo-
David (7) introduced the concept of an inner- toral free flap is readily apparent. The concept of tran5-
vated deltopectoral flap for intraoral reconstruction ferring sensate skin to the oral cavity and pharynx to
with sensory restoration reestablished through the assist in postoperative rehabilitation was not pursued
supraclavicular nerves of the cervical plexus (Fig. 5-6). until Urken et al. (26) reported the first sensate radial
Although he noted excellent sensation when the nerves forearm fiap in pharyngeal reconstruction.

Deltoid m.

Pectoralis major m.

FIGURE 5-5. The desire to improve the arc of rotation of the deltopectoral flap has led to a num-
ber of modifications, including the use of a back cut on the contralateral side of the sternum.

The deltopectoral flap has been applied to a wide secondary reconstruction of the pharyngoesophagus by
variety of re<:onstructive problems in the head and neck. tubing the deltopec:toral flap on the chest wall prior to
As noted previously, Bakamji&n (2) first descnoed this transfer.
flap as a solution to the problem of restoring continu- Additional experience with the deltopectoral flap led
ity to the gullet following laryngopharynge<:tomy. In to its application to intraoral reconsttuction of the tODgUe,
a landmark publication in 1965, he reported a two- floor of the mouth, tonsil, and pharynx. It has also been
stage technique that involved the transfer of a tubed widely used for external defects of the neck, cheek, ear,
deltopectoral flap (Fig. 5-7). Following the initial pro- and mentum (19). Ingenious teclmiques, albeit through
cedure, a conttol salivary fistula was created at the lower staged procedures, of reconsttucting extensive mid and
end of the tube that was positioned lateral and inferior upper facial defects have been reported by "waltzing"
to the tracheostoma, permitting a safer and more man- the pedicle to more cephalad regions. Resw:facing hemi-
ageable salivary egress (Fig. 5-8). The stump of the facial and OlbitomaziDary defects have been descnoed.
esophagus was sutured in end-to-side fashion to the skin (6,23). A favorable body habitus and, more often, the
tube. After a 3- to 5-week interval, the base of the delta- institution of a prior delay are critical to the use of this
pectoral flap was transsected and closed to complete the flap for more cephalad defects of the face. McGregor and
pharyngoesophageal reconstruction (Fig. 5-9). Bakam- Reid (21) descn"hed the combined use of the forehead
jian and Holbrook (4) later described the use of a staged flap to achieve internal lining and the deltopeaoral

FIGURE 5-i. The supraclavicular sensory nerves arise from C3 and C4 and can easily be traced
through the posterior triangle fat pad to be mobilized or transsected and then anastomosed to
an appropriate recipient nerve in order to transfer sensate skin.

Proximal portion
of esophagus -------1;...._.,~

FIGURE 5-7. The use of1he deltopectoral peninsular flap

for reconstruction of the pharyngoesophageal segment
requires a two-stage procedure. A peninsula of skin is
harvested as a routine deltopectoral flap and passed under
the lower cervical skin into the neck.

flap for external lining when reconstructing through-

and-through defeas of the cheek. Babmjian and Poole (6)
descnoed the use of the deltopeaoral flap for reconstruct-
ing the palate following ablative surgery. In most cases, FIGURE 5-8. In the first stage, the flap is tubed upon itself.
e:xcept where an island Bap is created, the use of the delto- At the distal end, it is sutured to the pharyngeal opening at
pectoral flap for relining any part of the gullet required the the base of tongue. The flap is partially sutured to the proxi-
creation of a control salivary fistula that was subsequently mal esophagus with creation of a controlled fistula.
closed at the time ofreturning the pedicle to the dlestwaD.
harvested with this fascial layer to protect the circula-
tion, it is not an absolute requirement to do so (16).
NEUROVASCULAR ANATOMY A number of articles have been wrinen on the nature
of the vascular supply to the deltopectoral flap and the
The blood supply to the deltopectoral flap is derived implications for safely harvesting skin overlying the
from parasternal perforators of the internal mammary deltoid muscle. A review of the vascular territories of
anery and vein, which traverse the intercostal inter- the upper chest provides a bener understanding of the
spaces. The 2-cm. zone lateral to the border of the potential problems that may arise when using skin from
sternum should not be violated when raising this Bap distal portions of this Bap. The angiosome concept may
to avoid injury to these vessels. The second and third be applied to this discussion by defining the source ves-
perforators are usually the largest in size with external sels that supply the anterior thoracic skin. The primary
diameters in the range of 1.2 mm. The venae comitantes region of the internal mammary perforators extends
are usually equal or greater in diameter (Fig. 5-10). from the lateral border of the sternum to the delta-
The vessels of the deltopectoral Bap run in a plane pectoral groove. This territory is also supplied by mus-
superlicial to the fascia overlying the pectoralis major and culocutaneous perforators arising from the pectoralis
deltoid muscles. Although this flap is most commoDly major. In the region of the deltopectoral groove, there is

RGURE 5-9. In the final stage, the fistula located at the flap to esophageal anastomosis is closed
in order to complete the repair of the pharyngoesophagus (blue srrovi}.

a direct cutaneous artery arising from the thoracoacro- removed from the internal mammary angiosome, and,
mial system, which supplies a small area of skin below therefore, that skin is at risk for partial or total necrosis.
the clavicle. The skin of the deltoid territory, lying lat- It is possible that the variable pattern of reliability of
eral to the deltopectoral groove, is supplied by muscu- the tip of the deltopectoral fl.ap is a function of the size
locutaneous branches arising from the deltoid branch of the thoracoacromial angiosome that is the middle
of the thoracoacromial system and the anterior circum- territory in this series.With a larger and more dominant
fl.ex humeral artery. It is therefore evident that, in rais- cutaneous branch from the thoracoacromial axis, the
ing a deltopectoral Bap, the skin overlying the deltoid deltoid skin may be rendered less reliable (Fig. 5-11).
muscle and the deltopectoral groove, which were previ- The aDgiosome concept provides a &amework for
ously supplied by musculocutaneous vessels and direct describillg delay procedures that are used to increase the
cutaneous vessels, respectively, must now be captured reliability ofthe deltoid skin (Fig. 5-4).To capture the blood
and made exclusively dependent on the internal mam- supply ofthat tenitory, it is e98elltial to reverse the direction
mary perforators. In the angiosome model descnoed by offl.ow in the adjacent thoracoacromial angiosome and the
Taylor et al. (25), the blood supply to skin in imme- third aDgiosome in line overlying the deltoid region. It is
diately adjacent angiosomes is usually quite reliable. critical that the direction of fl.ow aao98 the choke arteries
However, the pressure gradient of the nutrient fl.ow that connect adjacent aDgiosomes be uniformly oriented
diminishes as one moves to the angiosome next in line, from the sternum to the tip ofthe shoulder.The most prom-
or "once removed," from the primary source vessel. The ising delay procedures an: those that interrupt the source
skin overlying the deltoid muscle is an angiosome once arteries and veins in the :intermediate and distal angiosomes

Internal mammary
perforators to skin
Subclavian a.

Oeltopectoral g

Internal mammary a.


FIGURE ~10. The dettopectoral flap is supplied by internal mammary perforators, which emerge
from the 2nd and 3rd intercostal space in the parasternal region.

to allow revasa1 of flow and more favorable p.resslm: gra- POTENTIAL PITFALLS
dients. 'This was demonstrated by the :fluorescein injec-
tion studies of McGregor and Mozgm (20). A successful The technique of deltopectoral flap harvest is so
delay procedlm: for the deltopectoral flap muat interrupt straightforward that it is rare to encounter problems
the direct cutmeoua branch of the thOiacoacr:oJ:n syati:Dl leading to total flap necrosis. The incidence of partial
and the distal musculocutaneous branches of the deltoid tip necrosis has varied in different series, depending on
adliewd by raising the tip ofthe flap lateral to the deltopeo- the lecgth of the ftap and the use of a delay procedure.
toml gi'O(M! and underminillg in the infraclavicular foaaa. Park et al. (24) warned that factors contnbuting to flap
The sensory nerve supply to the deltopecto.ral skin is loss included diabetes, wound infection, and a radiated
derived from the supraclavicular nerves of C3 and C4 recipient bed. In a series of51 deltopectoral flaps placed
and the anterolateral intercoatlll nerves ofT2, T3, and T4. in irradiated beds, Krizek and Robson (16) reported
The ability to maintain the sensory supply intact lqely only fi'VI! major complications. Kirkby et al. (15) noted
depends on whether a radical neck dissection is pe:rformed. an overall totalfl.ap failure rate of 26%, which required
As noted previously, the report by David (7) of a sensate secondary reconstructive procedures. Higher rates of
deltopectoml flap was the first succeaaful n::sto:ration of flap failure were noted in flaps placed for intemallining
sensation to the reconstructed oral lining (Fig. 5-6). and for flaps used in an irradiated field. The total flap

FIGURE 5-11. The three major angiosomes of the upper chest and shoulder, moving from
medial to lateral, are the internal mammary, the acromiothoracic, and the deltoid angiosomes.
The regions that are marked represent the approximate territories of these source vessels.
To capture the skin in the deltoid angiosome, or the angiosome once removed, flow from the
internal mammary perforators must traverse the acromiothoracic angiosome, which causes a
pressure gradient prior to reaching the deltoid region.

failure rate of 26% was considerably greater than that through which to pass the deltopectoral flap for mucosal
reported in other large series, e.g., 9% (5), 12% (17), replacement (11). The wide array of flaps available for
16% (24), and 14% (22) . .Minor complications that did oral and pharyngeal defects have limited the current role
not require additional surgery ranged from 14% (5) to of the deltopectoral flap to reconstruction of cervical
26% (17). cutaneous defects. For this purpose, the deltopectoral
.Although extension of the flap over the deltoid leading flap should be considered a highly reliable teclmique.
to disw ischemia is the most common cause of partial
necrosis, there are a variety of other etiologic factors that
have been implicated, e.g., placement of the flap over a
mandibular K wire, folding of the flap for inner and outer The author acknowledges the conttibutions of Dr.
lining, head movement causing flap tension or kink- Hugh F. Biller to the writing of this chapter in the first
ing, and inadequate oro- or pharyngostomal aper1.'Un: edition of this book.

Deltopectoral Flap

FIGURE 5-12. A deltopectoral flap is shown

outlined over the right upper chest. The upper
incision runs just inferior to the clavicle; the
inferior incision extends from the 4th or 5th
interspace, parallel to the upper incision. The
distal extent of the flap is determined by the
defect. The dominant pedicle to this flap arises
in the 2nd or 3rd interspace, and therefore to
ensure viability, the base should overlie these
two interspaces.

FIGURE 5-13. Incisions are made alang the

upper, lower, and distal margins. The incision
is made through the skin, subcutaneous tissue,
and deltopectoral fascia.

FIGURE 5-14. As the flap is elevated laterally

to medially in a subfascial plane, the deltopec-
toral groove {large arrows) is encountered. The
direct cutaneous branch arising from either
the deltoid or acromial branches (small arrow)
has been isolated in the cephalad aspect of the

Deltopectoral Flap

FIGURE 5-15. The medial extent of the dis-

section is usually to a point approximately
2 em lateral to the sternal border. Although an
internal mammary perforator (srrowt has been
isolated to demonstrate its position, these ves-
sels are not identified in the dissection for fear
of injuring the blood supply to the flap.

FIGURE 5-16. The deltopectoral flap has

been completely isolated and transposed over
the clavicle onto the anterior neck. Closure
of the donor site is accomplished by wide
undermining and the use of retention sutures.
Although primary closure may be achieved,
the use of a skin graft is the norm.

REFERENCES 6. BakamjianVY, Poole M: Muillofacial and palatal recon-

structions with 1he deltopeaoral flap. Br J Platt Swg
1. Aymard JL: Nasal re(;onsttuction with a note on nature's
plastic surgery. l..a'IIUf 1917;2:888. 7. David JD: Use of an innervated deltopectoral flap for
intraoral reconstruction. Pfast Ruomtr SUYg 1977;60:377.
2. BakamjianVY: A two-stage method for phar}lngoesopha-
geal re(;onsttuction wilh a primary peaoral skin flap. 8. East C, A, Brough M: Tracheostomal r:on-
Pfast Recorutr Surg 1965;36: 173. struction using a fenestrated deltopectoral skin flap.
J lAryngol Otcl1988;102:282.
3. Bakamjian VY: Total re<X~nstruction of pharynx with
medially based deltopectoral skin flap. NY St4U J Med 9. Fujino T, Tanino R, Sugimoto C: Microvascular transfer
of free deltopectoral dermal-fat flap. Pkm ReCO'/UtT Swg
4. BakamjianVY, Holbrook I..: Prefabrication techniques in
cervical phar}lngoesophageal reconstruction. Br J Plast 10. Gibson T, Robinson D: The mammary artery pectoral
Swg 1973;26:214. flaps of Jacques Joseph. Br J Platt Sfi.Tg 1976;29:370.
5. Bakamjian VY, Long M, Rigg B: Ezperience with me 11. Gingrass R., Culf N, Garrett W, Mladick R: Complica-
medially based deltopectoral flap in reconstructive tions with lhe deltopectoral flap. Pkm &ccnm Surg
surgery ofthe head and neck. BrJPfast SUYg 1971;24:174. 1972;49:501.

12. Harii K, Ohmori K, Ohmori S: Free deltopectoral skin 20. McGregor I, Morgan G: Axial and random pattern flaps.
flaps. Br J Plast Surg 1974;27:231. Br J Plast Surg 1973;26:202.
13. Jackson I, LangW: Secondary esophagoplasty after pha- 21. McGregor I, Reid W: The use of the temporal flap in the
ryngolaryngectomy using a modified deltopectoral flap. primary repair of full-thickness defects of the cheek. Plast
PlastReconszrSurg 1971;48:155. Reconstr Surg 1966;38: 1.
14. Joseph J: Nasenplastik und sonstige Gesicktsplastik nebs 22. Mendelson B, Woods J, Masson J: Experience with the
reinem Anhang uber Mammaplastik und einige weitere Oper- deltopectoral flap. Plast Reconstr Surg 1977;59:360.
ationen aus dem gebiek der ausseren Korperplastik. Leipzig: 23. Nickell W, Salyer K, Vargas M: Practical variations in the
Verlag von Curt Kabitzchl; 1931:673--677,811-819. use of the deltopectoral flap. South MedJ 1974;67:697.
15. Kirkby B, Krag C, Siemssen 0: Experience with the dd- 24. Park J, Sako K, Marchette F: Reconstructive experience
topectoral flap. Scand J Plast Reconstr Surg 1980; 14:151. with the medially based deltopectoral flap. Am J Surg
16. Krizek T, Robson M: The deltopectoral flap for recon- 1974;128:548.
struction of irradiated cancer of the head and neck. Surg 25. Taylor GI, Palmer J: The vascular territories (angiosomes)
Gynecol Obstet 1972; 135:787. of the body: experimental study and clinical applications.
17. Krizek T, Robson M: Split flap in head and neck recon- Br J Plast Surg 1987;40: 113.
struction. Am J Surg 1973; 126:488. 26. Urken ML, Vickery C, Weinberg H, Biller HF: The neu-
18. McGregor I: The temporal flap in intraoral cancer: its use rofasciocutaneous radial forearm flap in head and neck
in repairing the post-ex:cisional defects. Br J Plast Surg reconstruction-a preliminary report. Laryngoscope
1963;16:318. 1990;100:161.
19. McGregor I, Jackson I: The extended role of the
ddtopectoral flap. Br J Plast Surg 1970;23:173-185.
~e myriad of regional and free flaps that are pres- primary source of tissue for bead and neck reconstruc-
~ ently available has made it possible to transfer skin tion until the development of the extensive range of
of virtually any size and shape to the facial region. How- regional musculocutaneous and free flaps that began
ever, the requirement of using skin of similar color and in the 1970s and continued to the present. Although
texture to that of the native facial skin greatly limits the MacGregor's (21) transverse forehead flap is rarely
available donor sites (2,5,6,12,13,14,18,20). In survey- used today because of the morbidity of the skin-grafted
ing the available donor sites to accomplish that goal, the donor site, the forehead continues to be widely utilized
skin of the forehead and the posterior neck perhaps come for resurfacing cutaneous and soft tissue defects of the
closest to mimicking the facial skin. Tissue from both of nose and cheek (3). A variety of forehead flap designs
these regions can be transferred to the midface for cheek have been reported during the last six decades, includ-
and nasal reconstruction by using the scalp as a carrier. ing the median, the paramedian, the sickle, and the
In the 1930s, Gillies (14,15) developed the principles of oblique patterns of forehead skin transfers.
transferring forehead skin for nasal reconstruction. DuringWorldWarn, Converse (7,8,9,10) introduced
.MacGregor (21) is credited with introducing the the anterior scalping flap, which transferred the skin of
forehead flap for intraoral reconstruction in 1963 (17). one half of the forehead. The flap is based on the con-
Along with the deltopec:toral flap, this flap was the tralateral vascular supply of the scalp. It was originally


developed as a variation of Gillies "up-and-down flap" Alternatively, laser depilation can be performed either
and includes the forehead skin, the scalp, and galea before or after transfer to eliminate hair growth on the
with its vascular supply derived from the vessels of the reconstructed portion of the nose. One of the unique
forehead and anterior portion of the scalp. Despite features of the anterior scalp flap is that there is suf-
the necessity of a two-stage procedure, this technique ficient length to fold the flap on itself to create an inner
continues to have specific applications for the recon- lining for both the ala and the columella.
struction oflarge nasal, upper lip, and cheek cutaneous It is often helpful to fashion a template of the nasa-
defects for which color match and tissue pliability are facial defect that can be used to design the area of skin
priorities. Its role in partial and total nasal reconstruc- to be transferred from the forehead. The pattern that is
tion has been replaced by the paramedian forehead flap. created should be as accurate as possible to minimize
Arena (1) recognized that the posterior neck skin has the amount of skin transferred and the necessity for sec-
similar qualities to that of the facial skin and reported ondary flap debulking (2,3,16).
a two-stage technique for transferring skin from this Secondary flap division is customarily performed at
region to the face. Using surgical principles similar to 21 days unless the recipient bed has been compromised
those developed by Gillies (14) and Converse (7) for by prior radiation or scar. At the time of the initial flap
transferring forehead skin to the nose, he took advan- transfer, the donor site is covered with a full-thickness
tage of the rich vascularity of the scalp to use it as a vehi- skin graft harvested from the postauricular or supracla-
cle for transporting favorable skin from the nape of the vicular areas (24).
neck to the midface. This technique may be considered The anterior scalping flap's biggest drawback is the
an extension of the flap developed byWashio (29,30) in donor-site defect. The aesthetic deformity can be mini-
which postauricular skin is transferred for reconstruct- mized by preserving innervated frontalis muscle. Place-
ing limited facial and nasal defects (22). Closure of this ment of the skin graft over this muscle improves the
donor site was most often accomplished with a skin contour of the forehead and preserves expressive move-
graft or a scalp advancement flap. As a result of its pos- ment in this region (24). As a secondary procedure, the
terior location, the donor-site defect is more easily cam- donor site can be reduced by serial excisions or resur-
ouflaged than the deformity caused by an anterior scalp faced with a temporofasciocervical flap (19,26). This
flap. In addition, the pre-expansion of this flap with a technique may be particularly necessary in male patients
tissue expander not only enhances the vascularity of this and in cases in which hyperpigmentation of the graft
flap but also allows the surgeon to achieve primary clo- develops. Additional options for donor-site camouflage
sure while transferring a sufficient amount of tissue to include changes in the patient's hairstyle and the use of a
resurface virtually the entire cheek (23). tissue expander to allow advancement of the contralateral
forehead for full-thickness skin coverage of the defect.
When contemplating the use of a posterior scalp flap, it
FLAP DESIGN AND UTILIZATION is important to examine the texture and color of the pos-
terior neck skin to determine its suitability for replacing
The anterior scalp flap is most useful in the reconstruc- skin in the midface region. In women who have longer
tion of large nasal and cheek defects. The pliability of hairstyles, the skin of this region tends to be well protected
the distal aspect of the flap allows it to be contoured from the effects of the sun. In addition, longer hair makes
to recreate the anatomic details that are required to the camouflage of this defect much easier. The posterior
satisfactorily reconstruct the nose ( 4,25). The anterior neck skin in patients who have spent considerable time
scalping flap offers some distinct advantages compared in the sun may be unsuitable for resurfacing cutaneous
with other forehead flaps. The design of the flap pro- defects of the face. In most individuals, however, the pro-
vides an adequate pedicle length due to the extensive cess of photoaging tends to affect the skin in the posterior
undermining that can be safely performed. Because of neck in a manner similar to that of the skin of the face (28).
the limited tension in the forehead skin that is trans- The scalp is the thickest skin in the human body. The
ferred, lower nasal and columellar reconstruction can dermis and epidermis of the scalp region vary in thick-
be safely performed when required. When columellar ness from 3 to 8 mm. However, the skin in the postau-
reconstruction is needed, an adequate vertical length ricular area and the posterior neck is much thinner and
is essential to allow the tip of the reconstructed nose more pliable. It is therefore suitable for the reconstruc-
to be sufficiently projected (Fig. 6-1) (11). The area tion of large defects of the nose, cheek, and orbital cav-
of flap harvest is limited to one half of the forehead, ity. Its use in the reconstruction of the upper and lower
which facilitates concealment of the donor site. This lips has also been described (29,30). In addition to its
flap should be considered in patients whose foreheads use in oncologic surgery, the posterior scalp flap may be
are narrow or who have a low hairline. In such patients, extended onto the posterior shoulder to provide a large
a median or paramedian forehead flap would transfer area of skin that may be utilized to replace areas of scar
hair-bearing skin when resurfacing caudal nasal defects. contracture caused by trauma, irradiation, or burns.

FIGURE 6-1. The anterior scalp flap transfers up to one half of the forehead skin, using the
scalp as a carrier. Its primary advantages are that it provides skin of the closest color and tex-
ture to the skin of the cheek and nose. In addition, it has the viability and the length to achieve
a detailed reconstruction of the caudal portion of the nose. Inner lining of the caudal portion
of the nose may be achieved by folding this flap on itself. When significant defects of the nose
require reconstruction, then local or distant flaps may be required to achieve an adequate
lining. This factor is of paramount importance when replacing the architectural support of the
nose by the use of free bone grafts. A reliable inner lining, under these circumstances, is critical
for the protection and revascularization of these nonvascularized structural grafts.

NEUROVASCULAR ANATOMY artery should be identified prior to surgery by palpation

or Doppler sonography. This branch should be incol.'-
The scalp is supplied by a rich array of arteries, includ- porated by designing the fl.ap so that the transverse and
ing the superficial temporal, supraorbital, supratroch- vertical supraauricular limbs of the incision that crosses
lear, occipital, and postauricular (Fig. 6-2). There are over the scalp are placed behind this vessel.
significant anastomotic channels between the different The venous drainage to this area is reliable. The
primary scalp vessels that make it possible to transfer supraolbiW veins run superficial to the fronWis muscle
large areas of the scalp on a single arterial pedicle. and communicate with the frontal branch of the superli-
The anterior scalp Bap is supplied by the supratroch- cial temporal vein and the supraorbital vein. AD these veins
lear, supraorbital, and superficial temporal vessels of the contribute to the venous egress in the anterior scalping flap.
side opposite to that in which the forehead skin is har- The vascular supply of the posterior scalping Bap is
vested. The frontal branch of the superficial temporal similar to that of the anterior fl.ap. The contnbutions

Superficial temporal a. Superficial temporal a.

(parietal branch) (frontal branch)

aurtcular a.

Splenius capitis m.

Galea aponeuro11ce.


from the occipital artery are transsected in the process lematic in causing flap separation from a poor recipient
of raising this flap, and, therefore, it is entirely depend- bed. The latter problem is often encountered in heavily
ent on the blood flow from the anterior system. The irradiated wounds when the flap pedicle is located in a
parietal branch of the superficial temporal artery is dependent position.
preserved when harvesting the posterior scalp flap, and It is virtually impossible to push the limits of the vas-
this branch plays a significant role in ensuring an ade- cularity of the anterior scalping flap due to the fact that
quate circulation to the posterior neck skin. The venous the lower limit of that flap is the eyebrow, which can-
supply to the posterior scalp flap parallels that of the not be violated. Alternatively, the limits of the posterior
arteries. The full extent of the skin territory that can scalping flap are not as clearly defined. Extension of the
be harvested with this flap is unknown. We have safely skin paddle laterally and inferiorly can push the limits
harvested skin to the level of the scapular spine, which of the vascularity. Problems with tip ischemia, primarily
increases both the surface area and the arc of rotation. venous in nature have been encountered (23). Ifthe clin-
The sensory supply to the anterior scalp is primarily ical situation permits, a delay procedure, with or without
derived from the supraorbital nerve, which is a branch tissue expansion has proven to be extremely helpful in
of the ophthalmic branch of the trigeminal nerve. avoiding tissue loss when a larger flap is required (27).
The auriculotemporal branch of the trigeminal nerve
supplies sensation to the temporoparietal scalp. Con-
tributions from the cervical plexus supply sensation to POSTOPERATIVE WOUND CARE
the posterior scalp through the greater auricular and the
greater and lesser occipital nerves. Both the anterior and posterior scalp flaps have the
disadvantage of requiring a two-stage procedure.
The nutrient vascular flow through the scalp must be
POTENTIAL PITFALLS maintained for 2 to 3 weeks until neovascularization at
the recipient site has occurred. The interval between the
The rich vascularity of the scalp makes it uncommon first and second procedures is uncomfortable for the
for ischemic complications to occur in either the pos- patient because of the cosmetic deformity of the dis-
terior or anterior flaps. These two flaps are unique in placed scalp and the necessity for biologic dressings
the head and neck because of the fact that the pedicle over the denuded portion of the skull. The patient must
is located either cephalad or on an even plane to the be advised preoperatively of these factors in order to be
defect, and, therefore, the effects of gravity are not prob- psychologically prepared.

FIGURE 6-2. The scalp has a rich vascular supply that arises from the supratrochlear, the supraorbital, the two major
branches of the superficial temporal, the occipital, and the posterior auricular arteries. There are significant anastomoses
between all of these systems that allow long narrow flaps to be transferred if at least one of these major arteries is incorpo-
rated in the base of the flap. The posterior scalp flap involves the transfer of skin from the nape of the neck region overlying
the splenius capitis and trapezius. The major layers of the scalp are shown. The vascular channels are located in the galea
and subcutaneous tissue layers. The loose areolar layer that separates the galea from the periosteum is a relatively avascu-
lar plane that is responsible for the mobility of the scalp over the bone.

Anterior Scalping Flap Dissection

FIGURE 6-3. The primary vascular supply to

the anterior scalp flap is from the supratroch-
lear and supraorbital vessels in conjunction
with the frontal branch of the superficial tempo-
ral artery and vein.

FIGURE 6-4. The anterior scalping flap has

been outlined to transfer skin from the right side
of the forehead. It is often fabricated from a tem-
plate of the defect to transfer only that portion of
the forehead that is needed. However, the aes-
thetic result is improved by skin grafting a defect
that extends from the eyebrow to the hairline, as
well as by using a full-thickness graft. The exten-
sion of the incision across the vertexcfthe scalp
to the contralateral ear ensures vascularity
through the three dominant pedicles of this flap.

Anterior Scalping Flap Dissection

FIGURE 6-5. The skin of the forehead is

elevated over the frontalis on which a split- or
full-thickness skin graft is
subsequently applied.

FIGURE 6-6. It is important when making the

lateral incision to preserve the innervation to
the frontalis. After the upper limit of the frontalis
has been reached, the level of dissection is
changed to the supra periosteal plane, which is
carried over the remainder of the skull.

Anterior Scalping Flap Dissection

FIGURE 6-7. The anterior scalp flap has been

elevated. The large area of denuded skull is
noted. The transitional zone can be easily seen
on the undersurface of the flap. In addition the
vascular supply to this flap from both the super-
ficial temporal and the supraorbital system of
vessels is readily seen on the undersurface of
the flap. Undermining over the contralateral
forehead is performed to provide adequate
mobility to achieve caudal transposition of the
forehead skin.

FIGURE 6-8. A Ia rge quantity of thin pliable

skin can be transferred to reconstruct total or
near-total nasal defects. Further undermining
of the contralateral scalp allows the forehead
skin to be placed onto the upper lip or cheek as
needed. Following this stage of the procedure,
the denuded skull must be carefully covered
with a biologic dressing for the 2- to 3-week
period prior to the second stage.

Anterior Scalping Flap Dissection

FIGURE 6-9. The scalp is transferred back

to the donor site, leaving the forehead defect,
which was previously covered at the time of
the first procedure with a split- or full-thickness
graft. Smaller defects may be covered with
a skin graft harvested from the postauricular
region. Advancement of the contralateral fore-
head may be achieved by either serial excision
or use of a tissue expander.

RGURE 6-10. Harvest of the Posterior Scalp-

ing Flap. The dominant blood supply to the pos-
terior scalping flap is derived from the anterior
blood supply to the scalp through the supraor-
bital, the supratrochlear, and both branches of
the superficial temporal artery and vein. The
occipital and posterior auricular branches that
supply the posterior scalp are transsected in
the process of elevating this flap.

Posterior Scalping Flap Dissection

FIGURE 6-11. The incisions for raising the

posterior scalp flap are shown. The extension in
the postauricular sulcus is required to achieve
adequate mabilization of this flap. It is impera-
tive that the postauricular incision stop at the
superior attachment of the helix to avaid violat-
ing the vascular supply from the superficial tem-
poral vessels. The dotted line in the midline af
the scalp demonstrates a possible extension af
the incision, depending on the degree to which
the flap must be mobilized to achieve tension-
free closure of the defect. Anterior extension of
the midline incision can be performed without
concern about compromise of the flap vascular-
ity. However, the fulcrum point at the top of the
ear, is usually the limiting factor in rotation of
the flap over the cheek. The caudal and lateral
extension of the skin flap provides a greater arc
of rctation and a greater amount of non-hair-
bearing skin. The occipital hairline is a distinct
landmark for the upper limits of usable skin.

RGURE 6-12. The skin of the posterior neck is

elevated superficial to the trapezius, splenius
capitis, and levator scapulae. At the superior
nuchal line, the plane of dissection changes to
a supraperiasteallevel, which is continued over
the remainder of the skull.

Posterior Scalping Flap Dissection

FIGURE 6-13. Elevation of the scalp is contin-

ued until the posterior neck skin can be placed
in the desired recipient defect. The midface can
be easily reached and a tension-free closure
performed without doing extensive undermining.

FIGURE 6-14. The arc of rotation can be

increased to reconstruct the nose or upper lip
by extending the incision in the midline of the
scalp. Extensive undermining does not in any
way compromise the blood supply to the pos-
terior neck skin, which runs through the galea
and subcutaneous tissue layers.

Posterior Scalping Flap Dissection

FIGURE 6-15. The skin of the posterior neck

has been detached from the scalp pedicle. Dur-
ing the time interval prior to the second surgical
procedure, the denuded posterior skull must be
covered with a biologic dressing. A skin graft
is placed over the donor defect in the neck that
overlies the posterior neck muscles.

FIGURE 6-16. The posterior neck defect can

often be well camouflaged in individuals with
longer hairstyles and by the use of high-col
Ia red shirts. Over time, the aesthetic appear-
anee of this defect improves. The size of the
defect may be diminished by serial excision or
the use of a tissue expander.

REFERENCES 17. Hamaker RC, Singer MI: Regional flaps in head and neck
reconstruction. Otolaryngol Clin North Am 1982; 15:99.
1. Arena S: The posterior scalping flap. L aryngoscope 18. Joseph}: Nasenplastik und sonstige GeisidJ.toplastik nebst
1977;137:98-104. einem Anhang uber Mammaplastik und einige weitere
Operationen aus dem Gebiete der a.ussereu Korperplas-
2. BlairVP: Reconstructive surgery of the face. Surg Gynecol tik. In: BinAtlas und Lehrbuch. Leipzig: Kabitzsh; 1931.
Obstet 1922;34:70 1.
19. Juri J, Juri C, Cerisola J: Contribution to Converse's flap
3 . Burget GC, Menick FJ: Aesthetic Reconnrucrion of the for nasal reconstruction. Plast Reconstr Surg 1982;69:697.
Nose. St. Louis: CV Mosby; 1994:57-91.
20. Kazanjian VH: The repair of nasal defects with the
4. Coiffman F: Total reconstruction of the nose. In: Stark
median forehead flap: primary closure of the forehead
RB, ed. Plastic Surgery of the Head and Neck. Vol. 1. wound. Surg Gynecol Obstet 1946;83:37.
NewYork: Churchill; 1986:704-705.
21. MacGregor lA: The temporal flap in the intraoral defects:
5. Coleman CC: Scalp flap reconstruction in head and neck its use in repairing postexcisional defects. Br J Plant Surg
cancer patients. Plmt Reconnr Surg 1959;24:45. 1965;16:318-335.
6. Conley J: Regicnal Flaps of the Head and Neck. Stuttgart: 22. Maillard GF, Montandon D : The Washio tempororetro-
Georg Thieme Verlag; 1976. auricular flap: its use in 20 patients. Plast Reconstr Surg
7. Converse JM: A new forehead flap for nasal reconstruc- 1982;70:550.
tion. Proc R Soc Med 1942;35:811. 23. Mandell DL, Genden EM, Biller HF, Urken MI... Pos-
8. Converse JM: Reconstruction of the nose by scalping flap terior scalping flap revisited. Arch Otolaryngol Head Neck
technique. Surg Clin NorthAm 1959;39:335. Surg 2000; 126(3):303-307.
9. Converse JM: Clinical application of the scalping flap in the 24. McCarthy JG, Converse JM: Nasal reconstruction with
reconstruction of the nose.PlastReconnrSurg 1969;43:247. scalping flap. In: Brent B, ed. TheArristry of Reconstructiw
10. Converse JM: Full-thickness loss of nasal tissue. In: Surgery. St. Louis: CV Mosby; 1987.
Converse JM, ed. Reconsr:rucu"ve Plastic Surgery. Vol. 2. 25. Millard DR: Total reconstructive rhinoplasty and a miss-
Philadelphia: WB Saunders; 1977:1236. ing link. Plast Reconstr Surg 1966;37:167.
11. Converse JM, McCarthy JG: The scalping forehead flap 26. Schimmelbusch C: Bin neues Verfahren der Rhinoplas-
revisited. Clin Plast Surg 1981;8:413. tik und Operation der Sattelnase. Verh Duch Ges Chir
12. Denneny EC, Denneny J III: Forehead and scalp recon- 1895;24:342.
struction. In: Papel ID, Nachlias NE, eds. Facial Plastic 27. Smet HT: Tissue Transfers in Reconstructifle Surgery.
and Reconstructiw Surgery. St. Louis: Mosby-Year Book; NewYork: Raven Press; 1980:6-7.
1992:392-398. 28. Stark RB, Khoury F: Anatomy of the skull, scalp, and
13. Friedman M : Parietal occipital nape of neck flap. Arch brow. In: Stark RB, ed. Plastic Surgery of the Head and
Otolaryngol Head Neck Surg 1986;112:309. Neck. Vol. 1. NewYork: Churchill Livingstone; 1987:3-6.
14. Gillies liD: Plastic Surgery of the Face. London: Oxford 29. Washio H: Retroauricular-temporal flap. Plast R.eccnstr
University Press; 1920. Surg 1969;43: 162- 166.
15. Gillies liD: The development and scope of plastic sur- 30. Washio H: Further experiences with the retroauricular
gery. Northwest Unif.J BuU 1935;35:1. temporal flap. Plast Reconstr Surg 1972;50:160.
16. Gonzalez-Ulloa M: Restoration of the facial covering by
means of selected skin in regional aesthetic units. Br J
Plast Surg 1956;46:265.
~e desire to ttansfer tissue of similar color and te:z:ture defects of the oral cavity and larynx being described
~ to the facial skin for aesthetic restoration ofcutmeous (5,20). When utilized in the reconstruction of intraoral
de:feas of the lower and middle thirds of the face led to the mucosal defects, the surgeon must be mindful of the
development of the submental island ftap by Mar1in et al. fact that the first echelon lymph nodes in the subman-
in 1993 (12). They described this flap as either a regional dibular and submental basins are likely to be subop-
or a free flap and noted that it had the added benefit of a timally dissected and removed when harvesting this
well-camouflaged donor site scar.Aside from its advantage flap for cases involving malignancies that metastasize
of transferring skin of favm:able quality for facial recon- to this region (20).
struction, it has the versatility of t:rallSfe.rring haiJ:I..beariD,g The submental fl.ap has also been utilized to repair
skin in males for beard and mustache restoration, as well as mucosal defects of the pharyngoesophagus for cases of
the capacity to transfer vascularized bone from the lower stenoses as well as the closure of pharyngocutaneous
border of the mandlble (3,22). It has also been utili7.ed as a fistulae (2,20).
vascul&rized subcutaneous tissue Bap for facial augmenta- The reverse fl.ow modification of this fl.ap has pur-
tion in cases of hemifacial microsomia (17). ponedly increased its cephalad reach in order to expand
This donor site has been utilized for reconstruc- its use for reconstruction of the upper third of the face,
tion of the upper aerodigestive tract with mucosal including the periorbital region (4).


FLAP DESIGN AND UTILIZATION the hair-bearing quality of the skin in this region may be
problematic when placing the skin in the midface region
Age plays a critical role in determining the vertical or when using it to reconstruct mucosal defects of the
dimension of skin that can be harvested from this donor upper aerodigestive tract, unless the skin has already
site and still achieve primary closure. The "pinch test" been irradiated or the recipient site will be irradiated in
is utilized to determine the amount of skin laxity that the postoperative setting.
exists in a vertical direction, in the anterior neck, that Martin et al. (12) described the potential to harvest
permits upward to 6 to 8 em of skin to be harvested in vascularized bone from the inner table of the mandi-
patients with significant skin redundancy. However the ble at the level of the mentum. Use of a split mandible
vertical dimension for safe flap harvest is significantly harvest with preservation of the outer table maintains
greater, as indicated by injection studies by Faltaous the contour of the lower border of the jaw in this criti-
and Yetman (4), which documented that a skin territory cal location. Yilmaz et al. (22) reported the successful
of 10 em by 16 em can be safely based on a single sub- transfer of bone to the upper maxilla for restoration of
mental artery. In a horizontal direction, the flap can be contour. Although they reported a successful transfer of
designed from one mandibular angle to the contralat- this composite flap, there was no long-term follow-up to
eral angle, and, therefore, a skin paddle with as much gage the viability of the bone. The shape of the anterior
as 16 em of length can be safely transferred based on a mandible at the level of the symphysis is ideally suited
unilateral blood supply ( 4). Transfer of a skin flap based for reconstruction of the premaxilla. We have utilized
on a bilateral blood supply has been reported in order this composite flap for that purpose but have little long-
to bring hair-bearing skin to the upper lip (9). How- term follow-up, and the patient was not rehabilitated
ever, the rich vascular supply from a unilateral arte- with either a tissue-hom or an implant-born prosthesis.
rial supply is usually sufficient to perform a safe and Prefabrication and multiple flap combination strate-
efficient transfer with a wider arc of rotation than can gies have been employed in order to expand the ver-
be achieved with a bilateral blood supply. The smallest satility of this donor site. Tan et al. (18) described a
flap dimension that can be harvested is the skin terri- two-stage procedure involving the initial placement of
tory surrounding the dominant perforator located in a 3-em strip of costal cartilage between the skin and
the region overlying the ipsilateral anterior belly of the the platysma muscle in order to reconstruct an exten-
digastric muscle. Doppler localization of that perforator sive defect in the columella. One month after the initial
can be performed in a manner similar to perforator flaps stage, the composite flap was transferred. Subsequent
harvested elsewhere in the body. stages were required to thin the soft tissue in order to
As noted above, the dimensions of the flap that can achieve the final result (18).
be harvested are limited in the vertical direction by the Barthelemy et al. (1) reported the combination of
laxity of the anterior cervical skin that can be recruited the submental flap with the temporoparietal fascial flap
for tension-free primary closure. In the horizontal direc- for cheek reconstruction in patients suffering from oro-
tion, the limits of safe harvest are usually determined by facial noma. In the first stage of this reconstruction, a
the angles of the mandible, beyond which the vascularity split-thickness skin graft was placed over the temporo-
to the skin becomes compromised on both the ipsilat- parietal fascia and left in place for 5 days in order to pre-
eral and the contralateral sides. Preharvest tissue expan- pare the flap for use as the inner lining of the cheek. At
sion of the anterior cervical skin in order to facilitate the the second stage of this procedure, the scarred tissue of
donor-site closure was alluded to by Martinet al. (12) the cheek was excised and the prefabricated temporo-
in their initial description of this donor site. However, to parietal fascial skin graft composite flap was transferred
date, there have been no reported cases of utilizing this along with a submental flap for resurfacing the exterior
strategy. In order to preserve the blood supply to the of the cheek. This technique was successfully employed
flap, it would be prudent to place the expander below in five patients with extensive deformity of the cheek
the hyoid bone in order to avoid compromise of the caused by noma.
perforators to the skin. A novel approach for reconstruction of the oral com-
When harvesting a subcutaneous flap with the platy- missure was devised and reported by Koshima et al.
sma muscle, the dimensions of the flap can be broadened, (10). The submental flap was combined with the dor-
so long as the skin is elevated off of the subcutaneous tis- salis pedis flap from the first toe web space, in order to
sue and utilized in the anterior cervical closure. Smaller provide both inner lining and cheek skin repair in two
skin islands can be harvested with subcutaneous exten- cases of full-thickness loss. The thin pliable skin from
sions, depending on the needs ofthe reconstruction (17). the dorsum of the foot was used to restore the mucosal
Hair-bearing skin for use in upper lip and chin loss from the upper and lower lip, while the submental
reconstruction has been reported in males in order to flap was used to restore the cheek skin with color- and
restore the mustache and beard (9,22). Alternatively, texture-matched skin (10).

Several strategies have been reported to lengthen the middle third of the face and lower periorbital regioos
reach of the submental flap in order to expand its appli- (Fig. 7-1). Extension of the venous pedicle can be
cation. The caliber of the facial artery and vein makes achieved by taking advantage of reverse flow in the
them very cooducive to transfer this flap as a microvas- cQD.D.ecting venous branch between the retromandibu-
cular free flap in order to reach the upper third of the lar vein and the facial vein (Fig. 7 -2). While the venous
face and scalp. Martin et al. (12) reported one case of a anatomy of the neck is susceptible to variations, the
free submental flap in a patient who sustained a gunshot classic descriptioo of the venous anatomy includes an
wound that destroyed the ipsilateral submental vessels. anastomosing branch betWeen the facial vein and the
I have utilized this technique in patients in whom the retromand:&bular vein that combine to create the com-
submental flap was the ideal dooor site for recoostruc- mon facial vein. If the common facial vein is ligated and
tioo, but the ipsilateral level 1 lymph nodes required divided, then reverse flow in the communicating branch
complete dissectioo to satisfy the oocologic needs of the permits venous drainage to be established into the
patient. Harvest of the flap on the contralateral facial external jugular system, thereby lengthening the venous
vessels permits both the oncologic and reconstructive pedicle by several centimeters (Fig. 7-3).
goals to be met. The third optioo for lengthening the vascular pedi-
The complete mobilization of the submental and cle is to employ the reverse flow strategy by ligating
facial artery and vein is usually sufficient to reach the the antegrade blood supply and basing the flap on the

RGURE 71. Harvest of the submental flap is demonstrated. The facial artery and vein are
ligated at the level of the lower border of the mandible. The facial artery and vein are mobilized
to achieve a greater arc of rotation for antegrade flow into the flap.


"'HM.,.,,_- - + - - - Retromandlbular

'-----+--- Posterior branch of

vein retromandlbular vein

------ vein

FIGURE 1-Z. The venous anatomy of the neck is quite variable. A common description of the
superficia l veins includes the retromandibular vein which divides into anterior and posterior
brsnche~. The anterior branch joins with the facial vein to become the common facial vein that
drains into the interns/ jugular vein. The posterior brsnch joins with the retraauricular vein to
form the external jugular vein.

FIGURE 7-3. Greater length of the venous pedicle can be obtained by ligating the common facial
vein in order to establish reverse flow through the anterior branch of the retromandibular vein.

retrograde arterial and venous blood supply through the upper third of the face by ligating the proximal facial
distal facial artery and vein (Fig. 7-4). The arterial pres- artery and vein and rotating the flap under the marginal
sure head through the distal facial artery is more than mandibular branch of the facial nerve. Without this
adequate to supply the submental flap. This was rec- mobilization under the branch of the facial nerve, the
ognized by Martinet al. (12) in their original descrip- fulcrum point for rotation of the flap would be the'-
tion of this donor site and referred to it as a "distally ginal branch and thereby limit the arc of rotation.
based flap" rather thm the nomenclature that has been Karac:al et al. (7) reported the successful use of
adopted as the "reverse flow flap."The potential to base the reverse flow strategy for periorbital defects in six
this flap on reverse flow in the facial artery was dem- patients. These authors reported one case of temporary
onstrated by Neligan et al. (13) in their description of paralysis of the facial nerve and one case of venous con-
the use of the distal facial artery as a source of recipi- gestion. The latter resolved spontaneously over the first
ent vessels for free tissue transfer to the head and neck. postoperative day. Kim et al. (8) used the reversed flow
These authors measured the arterial pressure in the submental flap in three cases of nasal reconstruction
distal stump of the facial artery and found it to he on and descnoed the superficial win as the basis for venous
average 55 6.3 mm Hg. They alluded to the example outflow in the flap. That superficial vein is the facial vein
of the distally based radial forearm flap used in hand that drains into the common facial vein, in contradis-
reconstruction in which blood flow through the palmar tinction to the venae comitants that run parallel to the
arch is sufficient to produce retrograde flow through the submental artery. Sterne et al. (16) reported a case of
radial artery (13). The reverse flow submental artery total flap loss in a patient who underwent transfer of a
flap represents a strategy for transfer of this flap to the submental flap using the reverse flow orientation. They

FIGURE 7-4. Retrograde flow has been reported to enhance the arc of rotation of the flap for
use in defects on the upper third of the face. ligation of the proximal facial artery and common
facial vein establishes retrograde flow though the facial artery and vein. The skin paddle must
be swept under the marginal mandibular nerve in order to maximize the arc of rotation.

attributed this loss to progressive venous congestion regarding the necessity to include that muscle in the
and speculated that it was due to a valve in the facial harvest of the submental fl.ap. The submental artery not
vein located at the lower border of the mandible. On only supplies the overlying skin in the submental and
the basis of this one adverse event, they advised that a submandibular regions but also gives off branches to
separate venous anastomosis should be performed (16). the lower lip, the periosteum, as well as the mylohyoid
The number of cases of reverse fl.ow submental fl.aps and digastric muscles (Fig. 7-5).
reported in the literature is limited and therefore it is Whetzel and Mathes (21) identified 14 arteries that
difficult to make a definitive statement regarding the provide the major blood supply to each side of the face,
safety of this approach with respe<:t to the risk ofvenous neck, and scalp.They described 11 anatomically distinct
congestion. It appears from the review of the experience cutaneous territories that are akin to the angiosomes
of the authors noted above, that this approach has been described by Houseman et al. (6). In a detailed ana-
used successfully with only one adverse event. tomic study, Houseman et al. described 13 angiosomes
One further option that can be entertained for use in of the head and neck; however, they did not divide the
expanding the cephalad reach of this fl.ap is to interpose territory supplied by the submental branch specifically
vein grafta on either the arterial, venous, or both limbs from the remainder of the territory supplied by the
of the vascular pedicle. In this approach, antegrade 1iow facial artery.
is preserved, but there is an additional amount of work, Through latex injections of the dominant nutrient
and potential risk, involved in performing the requisite arteries, Whetz:el and Mathes (21) were able to iden-
microvascular anastomoses, albeit to very large cabber tify and characterize the dominant perforating vessels to
vessels in the facial artery and the common facial vein. the overlying skin in the 11 territories that they identi-
fied in the head and neck region. While the perforating
branches from the ttansverse facial, zygomatico-orbital,
NEUROVASCULAR ANATOMY suprattochlear, supraorbital, and superficial temporal
vessels could be predicted to within a 2-cm region with
There are several important anatomic points to be con- 95% confidence limits, the perforators from the sub-
sidered in discussing the neurovascular anatomy of the mental and descending branch of the posterior auricu-
submental fl.ap. One of the most important is related lar arteries were found to be less consistent. Through
to the location of the cutaneous perforators and their selective ink injections, they defined the cutaneous tel.'-
relationship to the anterior belly of the digastric mus- ritory supplied by the submental artery as being an area
cle. There is a conttoversy that exists in the literature 5 em x 5 em extending superiorly over the mandible to


FIGURE 7-5. The submental artery arises as a branch of the facial artery, which courses over
the superior surface of the submandibular gland. The facial artery continues over the mandible.
The submental artery runs anteriorly along the surface of the mylohyoid muscle and gives off
cutaneous perforators in direct proximity to the anterior belly of the digastric muscle. The nerve
to the mylohyoid muscle travels in close proximity to the submental artery.

about the level of the oral commissure, anteriorly to a the second is given off medial to that muscle. They also
point 1.5 em lateral to the oral commissure, posteriorly descn'bed several smaller perforators arising directly
to a point 2 em anterior to the anterior border of the from the anterior belly of the digastric muscle. In the
sternocleidomastoid muscle, and inferiorly to a point detailed cadaveric dissections performed by Kim et al.
3 em below the mandibular border. This territory is (8), only one reliable perforator was found to be perfus-
obviously smaller than the one reported by both Martin ing the unilateral submental territory in 87.5% of cases.
et al. (12) and Faltaous andYetman (4). The same authors reported that there was a single arte-
Perforating vessels connect the deep fascial plane to rial perforator supplying the overlying skin in 56.3% of
the subdermal arterial plexus. These vessels represent their clinical dissections. The location of that perforator
fasciocutaneous perforators as opposed to the muscu- was quite variable in that series. The authors noted that
locutaneous perforators seen in other parts of the body the perforator was located at the medial border of the
and more commonly in the anterior portion of the face. anterior belly of the digastric muscle in 29% of cases,
The submental perforator was reported by Whetzel at the lateral border in 37.5%, and on either side of the
and Mathes (21) as the only vessel that emerged from anterior belly in the remaining 33%. There was little
the swface of the platysma to traverse the subcutane- correlation in the location of the perforator on the two
ous tissue to the dermal layer in this region. Faltaous sides of the anterior neck (8).
and Yetman (4) described two major cutaneous perfo- The submental artery arises from the facial artery
rators, with one arising proximal to the digastric and and travels over the upper portion of the submandibular

gland in an anterior direction. The point of its branching and Yetman (4). Demonstrable vascular connections
from the facial artery is usually after that vessel emerges between the submental vascular systems on opposing
from its intraglandular course on the superior surface sides were reportedly seen in 92% of the cadaveric dis-
of the submandibular gland (Fig. 7-5). After running sections performed by Magden et al. (11).
anteriorly in a groove on the upper surface of the gland, There are numerous nerves in the submandibular
the submental artery continues forward on the surface triangle, of which the marginal mandibular branch of
of the mylohyoid muscle. Magden et al. (11) reported the facial nerve has already been mentioned. Its vari-
that the submental artery was superficial to the sub- able course places its caudalmost dissent either below
mandibular gland in 69% of their dissections, while it or above the lower border of the mandible and therefore
ran between the superior border of the gland and the the only safe way to preserve this structure is to iden-
mandible in the majority of the remainder. In one case, tify it in order to avoid deformity of the lips. The motor
the submental artery was found to pass through the sub- nerve to the mylohyoid muscle also passes through the
mandibular gland. It gives rise to numerous branches submandibular triangle and consistently lies deep to the
that supply the submandibular salivary gland and the submental artery (Fig. 7-5). That nerve can, therefore,
platysma muscle (11). In the dissections performed by be preserved in all cases provided that a meticulous dis-
Faltaous and Yetman (4), the submental artery was section of this region is performed. Magden et al. (11)
found to run deep to the anterior belly of the digastric reported that the submental artery crosses the nerve to
in 70% of cases and superficial to that muscle in the the mylohyoid muscle, on average, 16.8 mm from the
remainder. Very similar results were noted by Magden point of origin of the submental artery.
et al. (11) who noted that 81% ofthe submental vessels
ran deep to the anterior belly of the digastric muscle.
The diameter of the submental artery ranges from ANATOMIC VARIATIONS
1.0 to 1.5 mm, while the diameter of the facial artery
is 2.0 to 2.8 mm. Alternatively, the facial vein diameter In their original anatomic and clinical description of
is 2.2 to 3.2 mm and the common facial vein is slightly the submental flap, Martinet al. (12) reponed one case
larger at 2.4 to 3.5 mm (4). in which the submental artery arose as an independent
Due to the variable point of origin of the perforators branch from the external carotid artery in close proxim-
and the variable relationship of the submental artery to ity to the takeoff of the facial artery. In this particular
the anterior belly of the digastric muscle, it would seem case, they described the cutaneous perforating branch
prudent to harvest the anterior belly of the digastric as arising 8 em anterior to the mandibular angle, very
muscle with this flap in order to ensure the capture ofthe distal in the course of this unusual submental artery.
dominant blood supply to the overlying skin. However, In three other cases, these authors noted a more proxi-
in their original description of this donor site, Martin mal takeoff of the submental artery between 2 and
et al. (12) did not include this muscle and reported no 3 em from the origin of the facial artery from the exter-
flap failures. The functional impact of the loss of the nal carotid artery. Martin et al. (12) identified no sig-
anterior belly of the digastric is relatively small and nificant variations in the submental vein and noted a
therefore the risk to benefit ratio would favor the sacri- consistent communicating branch between the facial
fice of that muscle. To take this one step further, Patel vein and the external jugular vein, allowing an alternate
et al. (14) described a modification of the harvest of this basis for venous egress in all cases.
flap by incorporating the mylohyoid muscle, which these In one cadaveric dissection, Magden et al. (11)
authors feel helps to avoid any potential injury to the described the lingual artery arising from the submental
submental vessels or its perforating branches to the skin. artery. This was the only such anatomic variation of its
In my experience, the submental flap can be reliably kind reported.
harvested without incorporating the mylohyoid muscle
in the flap, as long as the surgeon adheres to the strategy
of including the anterior belly of the digastric muscle. POTENTIAL PITFALLS
In the anatomic study by Magden et al. (11), detailed
vascular information was reported. On average the Perhaps the most likely risk associated with the harvest
length of the facial artery from its origin to the takeoff of of a submental island flap is injury to the marginal man-
the submental branch is 27.5 mm while that of the facial dibular branch of the facial nerve. In most cases, the
vein is 19.3 mm. These distances represent the potential nerves on both sides are at risk in the dissection. This
gain in the arc of rotation by harvesting a flap on the complication is best avoided by early identification of
facial vessels rather than the submental artery and vein. those nerves soon after completing the upper incision
Magden et al. (11) reported that the vessel diameter of and beginning the cephalad portion of the dissection.
the submental artery and vein were 1.7 and 2.2 mm, The incidence of marginal mandibular nerve injury in
which are very similar to the ones reponed by Faltaous reported series is very low. Pistre et al. (15) identified

one case of a temporary weakness in 31 patients who donor site in that patient population and have chosen
underwent this procedure. They reported that identifi- alternative donor sites or elected to harvest the submen-
cation of the nerve early in the procedure was not criti- tal flap as a free flap based on the contralateral facial
cal when the upper dissection is performed by staying vessels when the tissue from this donor site was clearly
close to the undersurface of the platysma layer in the superior to any other reconstructive option. In the lat-
region between the angle and the anterior body of the ter strategy, the ipsilateral nodes can be safely removed
mandible. Alternatively, Sterne et al. (16) reported 2 of without placing the flap vascular supply at risk.
12 patients suffered marginal mandibular nerve palsy The placement of the upper skin incision approxi-
for an incidence of 16%. mately 1 em behind the lower border of the mandible
Partial flap loss has been reported in most larger helps to avoid a conspicuous scar. In addition, it is
series, with 2 cases out of 31 described by Pistre et al. imperative for the surgeon to avoid undermining the
(15) and 1 case of 12 patients reported by Sterne et al. skin over the mandible in order to prevent postoperative
(16). The reverse flow orientation of flap transfer eversion of the lower lip. Restoration of the cervicomen-
appeared to be more hazardous with Sterne et al. (16) tal angle is accomplished by suturing the anterior cer-
reporting one complete failure, which they attributed to vical skin to the perihyoid soft tissue in order to avoid
a venous problem secondary to a valve in the facial vein blunting of that angle and altering the normal contour
that led to intractable congestion. of the neck.
The transfer of hair-bearing skin into the oral cav-
ity and other portions of the upper aerodigestive tract
can also be problematic as reported by Vural and Suen PREOPERATIVE MANAGEMENT
(20) in a case of reconstruction of a hemilaryngectomy
defect. This problem is restricted to males and, in par- There are very few preoperative measures that need
ticular, to those who have not been irradiated. to be taken prior to flap harvest. The most important
The ease of closure of the donor site is a function is related to patient selection and the dimensions of
of the size of the flap and the laxity of the skin of the the flap required and the risk of metastases to level
anterior neck. Radiation to this region will place added 1 lymph nodes. A careful determination of the amount
stress on the closure and mandates a flap design with of skin that can be safely harvested is best made with the
more conservative vertical dimensions. Wound break- patient in the neutral position, prior to extension of the
down and the need for a skin graft have been reported neck. The pinch test can be performed with the patient
in this population of patients who underwent transfer of in this position in order to determine a safe amount of
this flap following radiation (20). skin that can be harvested and still achieve a primary
The issue of safety of transfer of this flap in patients closure.
who are at risk for lymph node metastases requires
that the surgeon be very careful in patient selection for
use of this donor site. Preoperative imaging will pro- POSTOPERATIVE CARE
vide information regarding the presence of suspicious
macroscopic adenopathy, but microscopic disease in Maintaining the head in a neutral or partially flexed
submental and submandibular lymph nodes can be position during the postoperative period will help to
problematic in patients with primary malignancies that keep tension off the suture line, especially following
put them at risk. Although technically feasible, it is very harvest of flaps with a larger dimension or in patients
challenging to skeletonize the submental vessels to the who have been previously irradiated. A suction drain
extent that a thorough level 1 lymph node dissection is placed in order to avoid hematoma formation in the
can be performed without compromising the circula- widely undermined anterior neck. This complication
tion to the flap. I have been very reluctant to utilize this has been reported in most series (12,15,19).

Submental Flap

FIGURE 7-6. Harvest of a submental flap

begins with identification of the approximate
position of the facial artery and vein as well as
the marginal mandibular branch of the facial
nerve (yellow line).

FIGURE 7-7. The lower border of the mandible

(dotted line) is an important landmark to ensure
that the outline of the flap does not extend
superior to that line. The position of the hyoid
bone is also marked.

FIGURE 7-8. The approximate position of the

anterior and posterior bellies ofthe digastric
muscle is marked. The ipsilateral anterior belly
will be harvested to ensure capture of the cuta-
neous perforator.

Submental Flap

FIGURE 19. A large submental flap has been

marked for harvest. The maximum horizontal
dimensions extend from the angle of the man-
dible on one side to the angle on the other.
The vertical dimension is limited by the pinch
test to determine the vertical height of the
flap that can be harvested and still achieve
primary closure. The smallest flap that can be
harvested requires more precise identification
of the cutaneous perforator in order to reduce
the vertical dimension of the flap.

FIGURE 7-10. The surgical procedure is initi-

ated by making the inferior incision.

Submental Flap

FIGURE 711. The subplatysmal dissection is

elevated only to the point of identification of the
intermediate tendon of the digastric muscle.

FIGURE 712. The superior incision has been

made along the lower border of the mandible.
The attachment of the anterior belly of the
digastric muscle (blue srrowt has been identi-
fied, as well as 1he intermediate tendon (yellow

Submental Flap

FIGURE 713. The facial vein has been dis-

sected and isolated in its path over the sub
mandibular gland (blue srrowt. The submental
vein is identified as a branch coursing over the
top ofthe gland in an anterior direction (yellow
arrow). The marginal mandibular branch of the
facial nerve must be identified to avoid injury to
it and resultant deformity of the lower lip.

FIGURE 7-14. The facial artery (red arrow)

and facial vein (blue srrow) have been isolated
both proximally and distally as they continue
over the mandible {red snd blue arrows Mth
white outline). The submental artery and vein
have been isolated coursing in an anteromedial
direction under the flap (green arrow).

FIGURE 7-15. The submental artery and vein

(blue arrow) are shown following removal of the
submandibular gland. The nerve to the mylohy-
oid muscle runs deep to the vascular pedicle
and can be preserved (yellow arrow).

Submental Flap

FIGURE 7-16. The anterior belly of the digas-

tric muscle insertion into the lower border of
the mandible has been severed.

FIGURE 7-11. The intermediate tendon of the

ipsilateral digastric muscle has been transected
to allow harvest of the anterior belly so as to
protect the cutaneous perforator supplying the

FIGURE 7-18. The flap is elevated from distal

to proximal or from the contralateral side
toward the side of the vascular pedicle. The
plane of dissection on the contralateral side is
over the submandibular gland fascia (yellow
srrow) and over the ipsilateral anterior belly of
the digastric muscle (blue arrow).

Submental Flap

FIGURE 7-19. Flap elevation viewed from the

contralateral side with the submandibular gland
preserved. The marginal mandibular branch of
the facial nerve should be identified on both
sides to avoid injury.

FIGURE 7-20. As the dissection proceeds

medial to the contralateral anterior belly of
the digastric muscle, the plane deepens to the
fascia overlying the mylohyoid muscle (yellow
arrow). As the ipsilateral anterior belly of the
digastric muscle is approached, the cutaneous
perforator is identified on the undersurface of
the flap Iblue arrow).

FIGURE 721. Harvest of the ipsilateral

anterior belly ofthe digastric muscle is shown
to protect the perforator that may arise either
medial or lateral to that muscle.

Submental Flap

FIGURE 7-22. The vascular pedicle to the flap

is identified from the contralateral orientation
as the dissection proceeds deep to the ipsilat-
eral anterior belly of 1he digastric muscle . The
perforator to the skin has been demonstrated
(blue arrow). The submental artery and vein
have been isolated (green arrow). A branch of
the pedicle to 1he mylohyoid muscle {MM) must
be ligated (red arrowt.

FIGURE 7-23. A close-up view of the vascular

pedicle {red arrowt to the flap is shown with the
nerve to the mylohyoid muscle demonstrated
deep to the submental vessels (yellow srrowt.
A superior branch of the submental vessels
courses toward the lower border of the man-
dible and supplies the periosteum (blue srrow).

FIGURE 72.4.. The flap {yellow srrowt has

been isolated on the ipsilateral facial artery and
vein. The mylohyoid muscle is shown following
removal of the anterior belly of the digastric
muscle (blue arrow).

Submental Flap

FIGURE 7-25. Extensive mobilization of the

facial artery and vein has been performed to
optimize the arc of rotation of the flap that has
been transposed to the midface regioll.

FIGURE 7-26. Harvest of the submental flap as

a free flap has been performed with isolation of
the facial artery and vein.

FIGURE 1-11. The undersurface of the

submental flap shows the anterior belly of the
digastric muscle (blue arrow).

Submental Flap

FIGURE 728. Closure of the defect is per-

formed with wide undermining of the lower
anterior cervical skin in order to advance it
superiorly. The surgeon should avoid under-
mining the superior skin over the mentum in
order to avoid eversion of the lower lip.

FIGURE 729. Closure of the neck is per-

formed with a deep suture to the undersurface
of the flap that is suspended to the periosteum
ofthe hyoid bone. This maneuver is required
to restore the normal cervicomental angle.

Submental Flap

FIGURE 1-30. Multiple subJres should be

placed to the hyoid bone in order to ensure
creation of that angle.

FIGURE 1-31. Final skin closure has been

aceom plished with flexion of the neck to rei ieve
tension on the repair.

REFERENCES 12. Martin D, Pascal JF, Baudet J, et al: The submental island
flap: a new donor site: Anatomy and clinical applications
as a free or pedicle flap. Plast Reronm Surg 1993;92:867-
1. Barthelemy I, Martin D, Sannajust J, et al: Prefabri- 873.
cated superficial temporal fascia flap combined with
a submental flap in noma surgery. Plast Recomtr Surg 13. Neligan P, She-)Ue H, Gullane P: Reverse flow as an
2002; 109:936-940. option in microvascular recipient anastomoses. Plast
Reconstr Surg 1997;100:1780--1785.
2. Demir Z, Him V, Celebioglu S: Repair of pharyngocuta-
neous fistulas with the submental artery island flap. Plast 14. Patel U, Bayles S, Hayden R: The submental flap: a
Reconm Surg 2005;115:38--44. modified technique for resident training. Laryngoscope
3. Demir Z, Kurtay A, Sabin U, et al.: Hair-bearing sub-
mental artery island flap for reconstruction of mustache 15. Pistre V, Pelissier P, Martin D, et al: Ten years of expe-
and beard. Plast Reromtr Surg 2003;112:423-429. rience with the submental flap. Plast Reconstr Surg
4. Faltaous A,Yetman R:The submental artery flap: an ana-
tomic study. Plast Reconstr Surg 1996;97:56--60. 16. Sterne G, Januskiewicz P, Hall P, Bardsley A: The sub-
mental island flap. Br J Plast Surg 1996;49:85--89.
5. Genden EM, Buchbinder D, Urken ML: The submental
island flap for palatal reconstruction: a novel technique. 17. Tan 0, Bekir A, Parmaksizoglu D: Soft tissue aug-
J OralMaxillajac Surg 2004;62(3):387-390. mentation of the middle and lower face using the
deepithelialized submental flap. Plast Reconstr Surg
6. Houseman N, Taylor I, Pan W: The angiosomes of the 2007;119:873-879.
head and neck: anatomic study and clinical applications.
Plast Recomtr Surg 2000;1 05:2287-2313. 18. Tan 0, Kiroglu Q, Atik B,Yuca K: Reconstruction of the
columella using the prefabricated reverse flow submental
7. Karacal N, Ambarcioglu 0, Topal U, et al: Reverse-flow flap: a case report. Head Neck 2006;28:653--657.
submental artery flap for periorbital soft tissue and socket
reconstruction. Head Neck 2006;28:40-45. 19. Uppin S, Ahmad Q, Yadav P, Shetty K: Use of the sub-
mental island flap is orofacial reconstruction-a review
8. Kim JT, Kim SK, Koshima I: An anatomic study and of 20 cases. J Plast Reconm Aesrlzet Surg 2009;62(4) :514-
clinical applications of the reversed submental artery 519.
island flap. Plast Reconstr Surg 2002;109:2204-2210.
20. Vural E, Suen J: The submental island flap in head and
9. Kitazawa I<, Harashina T, Thira H, Thkamatsu A: Biped- neck reconstruction. Head Neck 2000;22:572-578.
icled submental island flap for upper lip reconstruction.
Ann Plast Surg 1999;42:83. 21. Whetzel T. Mathes S: Arterial anatomy of the face: an
analysis of vascular territories and perforating cutaneous
10. Koshima I, Inagawa I<, Urushibara I<, Moriguchi T: vessels. Plast Reconstr Surg 1992;89:591-603.
Combined submental flap with toe web for reconstruc-
tion of the lip with oral commissure. Br J Plast Surg 22. Yilmaz M, Menderes A, Barutcu Q: Submental artery
island flap for reconstruction of the lower and mid face.
Ann Plast Surg 1997;39:30--35.
11. Magden 0, Edizer M, Tayfur V, Atabey A: Anatomic
study of the vasculature of the submental artery flap. Plast
Reconstr Surg 2004; 114: 1719-1 723.
""rrte pedicled transfer of a segment of forehead tis- FLAP DESIGN AND UTILIZATION
~ sue has its roots in ancient history; descriptions
of rudimentary forms of the technique are found as The paramedian forehead flap is most often designed
early as 700 BC (1). It appeared in the Indian litera- with the base centered over one of the supratrochlear
ture, where punishment for certain crimes was nasal arteries (3,5,9,10). By capturing the dominant arterial
tip amputation, and forehead flaps were used as a pedicle, it is possible to raise and transfer a large amount
means for restoring the nasal tip. European descrip- of skin and subcutaneous tissue, on a pedicle as narrow
tions of forehead flaps appeared starting in the 15th as 1.2 em (Fig. 8-1). Burget and Menick descnoed an
century, and the operation achieved popularity by the extension of the incisions for the pedicle down below the
mid-1800s. In the 1930s, Kazanjian and Roopenian bony orbital rim, to provide additional flap length, and
(6) identified that the supratrochlear and supraorbital this method is in common use today (2,7,8). A signifi-
arteries were in fact the primary blood supply of the cant benefit of extending the incisions below the bony
fl.ap, and this led to the flap becoming a mainstream orbital rim is the avoidance of transferring haiJ:I.bearing
tool in the armamentarium of the facial reconstructive scalp into the nose or midface, where hair growth is

undesirable. The narrow pedicle also provides increased NEUROVASCULAR ANATOMY

freedom of transposition around the pivot point and
more effective arcs of rotation. In addition, the narrow The anatomy of the paramedian forehead flap was best
pedicle permits primary closure of at least the inferior described by Mangold, McCarthy, and Shumrick in the
portion of the donor site. 1980s (3,5,9,10). They demonstrated that the forehead
Paramedian forehead flaps are designed from skin is supplied by a terminal branch of the angular
templates of the nasal, orbital, or midfacial defect that artery, as well as the supratrochlear, supraorbital, and
requires coverage. For any of these areas, a template superficial temporal arteries. While each of these vessels
of the defect is created and then drawn onto the fore- provides a primary blood supply to a single region of the
head just underneath the hair-bearing skin. Planned forehead, all demonstrate significant interconnecting
incisions are extended inferiorly to the orbital rim in anastomoses. Based upon this rich overlap of arterial
order to capture the supratrochlear artery, which is eas- input, the surrounding skin is not at risk for necrosis
ily identified with the assistance of a Doppler probe. following the removal of the supratrochlear supply to
Dissection proceeds in a cephalocaudal direction. While the region. Some experimental evidence suggests that
the supraperiosteal plane is appropriate for the superior the vascular supply to the forehead is so rich that even
50% of the flap, below the midforehead, the plane of in the absence of the supratrochlear artery within the
dissection deepens to the subperiosteal layer in order pedicle, the forehead flap may still receive ample arte-
to safely capture the pedicle (Fig. 8-2). Because this rial input from small tributaries in the pedicle to survive
area is nearly always able to be closed primarily, there elevation and transfer into a recipient bed (3).
is no portion of the cranium that is exposed without The supratrochlear artery exits the superomedial
periosteal coverage. When the superior aspect of the orbit approximately 2 em lateral to the midline, trav-
incision cannot be closed primarily, maintenance of els for approximately 2 em vertically, and then begins
the periostium provides a bed for either skin grafting or significant branching. The branching pattern includes
healing by secondary intention. Aggressive thinning of multiple branches across the midline, to anastomose
the flap is possible during the inset step, based upon the with the contralateral supratrochlear artery. As the
superficial location of the artery in the distal portion of artery travels superiorly, it traverses planes and becomes
the flap (9).This operation is performed as a two-staged increasingly superficial until reaching the subdermal
procedure in nasal reconstruction, where the pedicle plane at the hairline. This important fact permits the
is divided in the second stage, usually after a matura- extensive thinning of the flap at the inset stage, without
tion period of 3 weeks (Fig. 8-3). However, single-stage compromising distal flap vascularity (9).
paramedian forehead flap reconstruction is possible for
isolated midfacial defects as well as for orbital socket
Over the past decade, Burget and Walton (4) have
popularized the paramedian forehead flap in conjunc- While the supratrochlear artery has been shown to
tion with a free radial forearm free flap and free struc- provide the dominant axial blood supply to the median
tural grafts (cartilage and calvarial bone) for total and paramedian forehead tissues, the rich anastomotic
nasal reconstruction (Figs. 8-4-8-6). Their results, network in the medial canthal region may permit sur-
combining pedicled and free tissue in carefully exe- vival of this flap even in the absence of the dominant
cuted, staged reconstructive efforts, have revolution- artery (3). Thus, even in situations where the arterial
ized the way reconstructive surgeons think about the anatomy differs from the normally expected location,
total rhinectomy defect and about the functional and this flap remains a reliable reconstructive option. In such
esthetic results that are achievable. They describe circumstances, a delay procedure may be prudent to
harvesting a radial forearm free flap containing multi- enhance the vascular supply to the distal tip of the flap.
ple skin islands, each for a separate component of the
internal reconstruction (Fig. 8-4). The skin islands
can then be rotated independently from one another POTENTIAL PITFALLS
for reconstruction of the columella, nasal lining, nasal
floor and the lip. Free cartilage or bone grafts are then Several drawbacks to the paramedian forehead flap
fashioned to provide the necessary structural elements must be recognized before it is selected as the recon-
of the nasal skeleton, and a paramedian forehead structive modality in nasal, midfacial, and orbital socket
flap is raised to cover the structural elements, sand- reconstruction. The first drawback is the requirement
wiching them between two well-vascularized tissue for a second-stage surgical procedure for pedicle divi-
layers. They emphasize the need for secondary pro- sion. It has been well established that the pedicle can
cedures to achieve the desired functional and esthetic be divided as soon as 10 days following tissue trans-
results. fer, though most surgeons prefer to wait a full 3 weeks
(JUt conr.inwd on pa.g~ 129)

Paramedian Forehead Flap

FIGURE 8-1. A. B: The traditional paramedian

forehead flap is based upon the supratrochlear
vessels. There are adjacent supraorbital and
infratrochlear vessels. Capture of the vascular
pedicle requires a 1.2 em cutaneous base at
the orbital rim, centered on the supratrochlear
vessels. The distal cutaneous paddle can be
designed to repair a wide range of defects,
including the external lining for a total nasal
defect. The final flap design is based upon a
template reflecting the cutaneous nasal defect,
after the subunit principle has been applied. B

FIGURE 8-2. An appropriate pattern is

designed, followed by paramedian forehead
flap elevation, proceeding superiorly to
inferiorly. The superior aspect of the flap can
be elevated in either a supraperiosteal plane
or a subperiosteal plane and then debulked.
However, the inferior flap must be elevated in
a subperiosteal plane to protect the vascular
pedicle. The elevated flap is then rotated medi-
ally and inset.

Paramedian Forehead Flap

FIGURE 8-3. Final repair of 1he nasal defect

requires tension-free inset of the distal portion
of the flap.



FIGURE 8-4. In total nasal reconstruction,

radial forearm tissue is used for internal lining
and can be customized depending upon the
defect. Multiple semi-independent skin paddles
may be transferred based upon the radial

Paramedian Forehead Flap

FIGURE 8-5. Various structural elements for

nasal reconstruction. Top: Rib (or conchal)
cartilage fashioned into relevant nasal skeletal
elements: nasal tip graft upper lateral cartilage
graft, paired lower lateral cartilages. Calvarial
bone graft fashioned into nasal dorsal shape.
Bonom: Harvested synchondrosis of the 7th
and 8th ribs, demonstrating ideal location for
cartilage harvest from chest wall.

Rib cartilage

u~ / -:.

FIGURE 8-6. Completed total nasal recon-

struction, employing free tissue for the inner
lining and columella, structural elements (not
shown), and paramedian forehead flap external
coverage. This trilayered approach optimizes
functional and esthetic outcome.

Calvarial Bone Graft

FIGURE 8-1. An outer calvarial bone graft is harvested and cantilevered over the dorsum to
provide structural support. Calvarial bone grafts are used when structural support is required
for nasal dorsal reconstruction.

Calvarial Bone Graft

FIGURE 8-8. A: The ideal donor site lies 1 em

medial to the superiortemporalline, as shown.
This site avoids the temporalis muscle, ensures B
adequate graft thickness, and possesses the
proper natural curvature to yield a natural
appearance to the reconstructed nasal dorsum.
B: Harvest ofthe outer calvarium is initiated by
drilling a circumferential trough that penetrates
the diploic layer of the calvarium without
violating the inner calvarium, using an otologic
cutting burr. Copious irrigation is required to
prevent thermal injury to the bone graft. The
outer edges of the drilled trough must be bev-
eled to permit introduction of the osteotome
parallel to the inner calvarium. C: An osteotome
is used to elevate the graft from the inner
calvarium. Meticulous elevation prevents graft
fracture. The donor site is managed by simple
contouring to prevent obvious step-offs. c

before pedicle division. In the intervening time between a daily basis for the intervening 3 weeks, and pedicle divi-
flap inset and pedicle division, the wound is unsightly sion may be accomplished in the office setting. Once the
and requires extensive patient counseling. A second pit- paramedian forehead flap has completely healed, there
fall, occurring when a large amount of cutaneous cover may be requirements for flap debulking and additional
is necessary, is failure of the wound donor site to close contouring, which the transferred tissue tolerates easily.
with simple undermining and advancement techniques.
Options when this occurs include skin grafting or leav-
ing the wound to granulate on the bed of exposed peri- REFERENCES
osteum. While this method of handling the donor site
can yield a reasonable aesthetic result, it occasionally 1. Baker SR: Interpolated paramedian forehead flaps. In:
results in a stellate scar, requiring revision via forehead Baker SR, ed. Local Flaps in Head and Neck Reconstruc-
expansion. However, the inferior 50% of the incision tion. Philadelphia: Mosby; 2007:265-312.
can almost always be closed primarily, so with appropri- 2. Burget GC: Aesthetic restoration of the nose. Clin Plan:
ate hairstyling techniques when possible, the superior Surg 1985;12:463-480.
aspect may present less of an esthetic issue. 3. Burget GC, Menick FJ: The subunit principle in nasal
A third pitfall involves undesirable hair-bearing reconstruction. Plan: Reromtr Surg 1985;76:239-247.
skin on the forehead flap. If flap design requires the 4. Burget GC, Walton RL: Optimal use of microvascular
incorporation of some hair-bearing skin, the hair will free flaps, cartilage grafts, and a paramedian forehead
continue to grow on the transferred cutaneous seg- flap for aesthetic reconstruction of the nose and adjacent
ment over the long term. This growth may be treated facial units. Plast Reromtr Surg 2007;120:1171-1207;
with depilatory creams or electrolysis or with laser discussion 1208-1116.
hair removal. Hair removal requires multiple treat- 5. Kazanjian VH: The use of skin flaps in the repair of facial
ments and is not effective for the villous hair that can deformities. Plast Reromtr Surg (1946) 1950;5:337-352.
be found lower on the forehead. Villous hair is not 6. Kazanjian VH, Roopenian A: Median forehead flaps in
responsive to laser hair removal and must be consid- the repair of defects of the nose and surrounding areas.
ered in flap design. Tram Am Acad Opkthalmol Otolaryngo/1956;60:557-566.
7. Mangold U, Lierse W. pfeifer G: The arteries of the fore-
head as the basis of nasal reconstruction with forehead
POSTOPERATIVE CARE flaps.ActaAnat (Basel) 1980;107:18-25.
8. McCarthy JG, Lorenc ZP, Cutting C, Rachesky M: The
The paramedian forehead flap is straightforward to har- median forehead flap revisited: the blood supply. Plan:
vest and can be performed under local anesthesia, intra- Reconm Surg 1985;76:866-869.
venous sedation, or general anesthesia. Postoperative 9. Menick FJ: Aesthetic refinements in use of forehead for
care involves retaining moisture around the pedicle, so nasal reconstruction: the paramedian forehead flap. Clin
that desiccation does not create thrombosis of the arterial Plast Surg 1990; 17:607-622.
and venous structures. This is accomplished with the top- 10. Shumrick KA, Smith TL: The anatomic basis for the
ical use of bacitracin or loose wrapping of the pedicle in design of forehead flaps in nasal reconstruction. Arch
petrolatum-impregnated gauze. The gauze is changed on Otolaryngol Head Neck Surg 1992;118:373-379.
The reconstruction of mucosal defects of the oral cavity resurface the oral cavity or pharynx. The tongue is the
following ttauma or ablative surgery can be a cllalleng- most critical structure in the oral cavity for postopera-
ing problem. Primary closure, healing by secondary tive oral function. To interfere with its activity, in any
intention, or the application of skin grafts are effective way, should be condemned.
techniques in most situations. It is tempting to borrow However, this philosophy does not take away from
mucosa from adjacent areas of the oral cavity, and a wide the desirability of using "like tissue,. to accomplish the
variety of oral fiaps" have been described (3). In par- reconstruction. The transfer of well-vascularized, sen-
ticular, the tongue has been subjected to assault as the sate mucosa is particularly appealing. The palatal island
source of well-vascularized mucosa to resurface defects mucoperiosteal flap is an atttactive reconstructive option
&om the palate to the hypopharynx. However, when the for those reasons. Originally introduced by Millard (5)
surgeon borrows tissue from the region that is being in 1962, it was populari2:ed for use in ablative defects of
reconstructed, it is imperative that a critical appraisal the posterior oral cavity by Gullane and Arena (1). The
be made of the potential deficits associated with bor- laner authors expanded the utility of this flap by repon-
rowing that tissue. The availability of a wide range of ing the safe transfer of vinuaUy the entire hard palate
alternative flaps from regional or distant sites makes it mucoperiosteum on a single neurovascular pedicle (2).
generally unnecessary to use tissue from the tongue to Although the loss of mucosa from the palate creates a

donor-site defect of exposed bone, the healing of that obturator. Tilis flap is also useful in cleft palate repair
defect by secondary intention causes no functional mor- and for closure of oroanttal fistulas (2).
bidity. The fact that the secondary defect overlies bone
ensures that it will heal without contraction.
The vascular pedicle of the palatal island mucoperi- NEUROVASCULAR ANATOMY
osteal flap is unique becauae it traverses a bony canal
and also because of ifll nondependent position in the A thorough understanding of the osteology of the palate is
oral cavity, which eliminates the deuimental effects of crucial to raising the mucoperiosteal flap. The hard palate
gravitational pull. is formed by the palatine processes of the maxillae and the
horizontal laminas of the palatine bones. There is a lon-
gitudinal suture that separates the palate in the midline
FLAP DESIGN AND UTILIZATION and a t:ransVerse suture that separates the maxillary shelf
from the palatine shelf posteriorly. The greater palatine
Because of the small area of mucosa of the palate, there foramen is located in the lateral aspect of the t:ransverse
is a limited range of flap designs. The island flap that was suture just opposite the second molar (Fig. 9-1). Postero-
reported by Millard (5) was harvested from one side of lateral to the greater palatine foramen are the lesser pala-
the palate. Gullane and Arena (2) expanded the area of tine foramina, of which there are UBUally two. The latter
transfer to include virtually the entire palatal mucoperi- foramina are located in the palatine bone and transmit
osteum, providing approximately 8 to 10 cm2 of tissue. the lesser palatine artery and nerves. The hard palate is
The flap island is created by incising the palate 1 em covered by a mucosal layer, which is firmly adherent to
medial to the teeth and 1.5 em anterior to the junction the periosteum. The periosteum is firmly attached to the
of the hard and soft palate. The flap can be rotated 180 palatal bone through the fibrous pegs of Sharpey.
degrees for inserting it into defects of the retromolar The blood supply to the palate is derived from the
trigone and tonsillar fossa. To improve the arc of rota- descending palatine artery, which is a branch of the inter-
tion, the hook of the hamulus can be removed, thereby nal ma:xillary artery (Fig. 9-2). The descending palatine
providing an additional! em oflength. artery gives offthe greater palatine branch, which emerges
The island palatal flap is ideal for resurfacing defects through the greater palatine foramen with the greater pala-
of the hard and soft palate. Perhaps one of its great- tine nerve. The greater palatine artery runs forward on the
est applications in contemporary reconstructive algo- lateral aspect of the palate to supply the mucoperiosteum.
rithms is the restoration of posterior palatal resections,
most commonly for minor salivary gland malignancies.
As long as the remaining palatal mucosa is larger than
the defect, this technique can be successfully applied
(see Figs. 9-12 and 9-13). While we uaually prefer to Greater
have a two-layer closure with both an inner and outer palatine a.
lining, the combination of the mucosal, submucosal,
and periosteal layers makes for a finn composite of tis-
sue that lends itself to a single-layer repair. Greater
Previoualy used to restore defects of the retromo- palatine
lar trigone, tonsil, and lateral pharyngeal wall, tumors
in these locations are now more often operated in the
salvage setting following radiation, which is a contrain-
dication to the use of the palatal flap for fear of osteo-
radionecrosis. When the situation arises that a defect in
these regions is created, then the palatal island flap is a
reasonable reconstructive choice. It is imperative that
early and frequent physical therapy be implemented to
avoid fibrosis and the development of trismus. The pala-
tal island flap is not as pliable as a cutaneous flap, and as
a result, it may form a firm band betWeen the mandible
and Jll.Uilla that restricts oral opening.
This donor site has been used to restore velopharyn- FIGURE 9-1. The greater palatine artery and nerve emerge
geal competence in combination with a mucosal flap from the greater palatine canal through the greater palatine
from the posterior pharyngeal wall (6). I have used this foramen. The neurovascular pedicle runs forward on the
combination on several occasions for early-stage soft palate, and the artery then ascends through the incisive
palate cancers in an effort to avoid the need for a palatal canal to supply the nasal mucosa.

palatine a.
palatine a.

FIGURE 92. The greater palatine artery is a branch of the descending palatine artery, which in
turn, arises from the internal maxillary artery.

The descending palatine artery traverses the greater pala- this technique when any of the following three condi-
tine canal, which connects the pterygoma.illary fossa tions were present: (a) ligation of the external carotid or
with the hard palate. The lesser palatine artery, a branch internal ma:r.illary artery, (b) prior palatal surgery with
of the descending palatine artery, emerges through the possible disruption of the greater palatine vessels, or (c)
lesser palatine foramina to supply the soft palate. Addi- prior radiation to the palate. The surgeon should also
tional blood supply to the palate comes through branches be cautious about placing excess tension on the pala-
of the ascending pharyngea, facial, and lingual arteries. tal blood supply, which may be less forgiving than most
This collateral supply is primarily to the soft palate. island flaps because of the course of the vessels through
The vascular supply to the palatal island mucoperi- a bony canal.
osteal flap is the greater palatine artery and vein. Mter
rwming their posteroanterior course on the hard pal-
ate, these vessels ascend in the incisive canals to sup- POSTOPERATIVE CARE
ply the nasal mucosa. The greater palatine vein drains
into the pterygoid plexus of veins. Despite the presence The exposed palatal bone is cleansed on a regular basis
of a midline longitudinal raphe that divides the palatal with frequent oral irrigations. The ingrowth of mucosa
mucosa in half, Gullane and Arena (1,2) demonstrated from the edges of the defect occurs fairly rapidly. It
that the entire palate could be supplied by one greater has been our experience that the mucosal ingrowth
palatine pedicle. They referred to the work reported by brings sensory nerve fibers, which reduces the donor-
Maher (4) in 1977, which showed an extensive arbori- site morbidity. The fact that the defect overlies bone
zation of the greater palatine vessels, which was termed ensures that there is no scar contracture, which would
the "macronet." By arteriographic studies, Maher found otherwise occur. Fabrication of a prosthesis to cover
evidence of three vascular layers: mucosal, submucosal, the denuded palate may provide valuable pain relief
and periosteal. The arterial netWork crossed the mid- during the early postoperative period until mucosaliza-
line raphe to provide nutrient fl.ow through one pedicle tion has occurred.
when the contralateral one was sacrificed.


The author acknowledges the contnbutions of
Gullane and Arena (2) reported a 5% failure rate in a Dr. Hugh F. Biller to the writing of this chapter in the
series of 53 palatal flaps. They warned against the use of first edition of this book.

Palatal Island Flap

FIGURE 9-3. The palatal island mucoperiosteal

flap is outlined with the approximate position of
the greater palatine neurovascular pedicles on
either side.

FIGURE 9-4. The mucoperiosteal flap is

elevated by sharp and blunt dissection, moving
in an anterior to posterior direction. The
mucosal layer is intimately associated with the
palatal periosteum.

Palatal Island Flap

FIGURE 9-5. The neurovascular arcade

(arrows) is visualized on the undersurface of
the periosteum. It is best to begin the dissectian
on the side opposite the pedicle that is to be

FIGURE 9-6. The contralateral neurovascular

pedicle has been isolated and is now readyta
be transsected.

Palatal Island Flap

FIGURE 9-7. The mucoperiosteal flap is care-

fully elevated toward the nutrient neurovas-
cular pedicle. The fixed position of the vessels
exiting through the greater palatine foramen
provides little leeway in mobilizing the flap.
The contralateral pedicle has been ligated and

FIGURE 9-8. The palatal flap is completely

isolated on its pedicle and can now be rotated
to resurface the mucosal defect.

Palatal Island Flap

FIGURE 9-9. A common use of the palatal flap

is to close defects of the tonsillar fossa and the
retromolar trigone. Early mobilization of the jaw
to prevent scar formation and resultant trismus
is very important.

FIGURE 9-10. The palatal island flap has been

rotated 180 degrees. Further mobilization can
be achieved by cutting the hook of the hamulus
and decompressing the posterior wall of the
greater palatine foramen.

Palatal Island Flap


FIGURE 9-11. The palatal flap is sutured into

the defect. It is important that undue tension
is not placed on the flap because the pedicle's
course through the greater palatine canal is

Defect in

FIGURE 9-12. Use of the palatal island flap for

reconstruction of through-and-through oroan-
tral and oronasal defects created by resection
of palatal carcinomas is an ideal reconstruc-
tive technique. The surgeon must size up the
defect and the remaining palatal mucosa that is
available for reconstruction to ensure that there
is an adequate surface area of mucosa for the
size of the defect such that the flap can be
sutured to the palatal bone with some degree of

Palatal Island Flap

FIGURE 9-13. Rotation of the flap is readily

accomplished to provide a complete repair of
the posterior defect. The leading anterior edge
of the flap is tacked to the palate at a distance
from the bony defect with the use of com-
mercially available implants that are placed
into holes that are drilled into the bone. These
implants have 8 suture with 8 needle attached
to it and provide an excellent method for secur-
ing the leading edge of the flap.

REFERENCES 4. Maher W: Distribution of palatal and other arteries in

cleft and non-deft human palates. Cleft Palau Cnmiojac
J 1977;14:1.
1. Gullane P, Arena S: Palatal island flap for reconstruc-
tion of oral defects. Arch Otolaryngol Head Neck SUTg 5. Millard DR: Wide: and/or short cleft palate:. Plast Reronm-
1977;103:598. SU1't 1962;29:40.

2. Gullane P, ArenaS: Extended palatal island mucoperios- 6. Millard DR. Seider H: The versatile palatal island flap: its
teal flap. Arch Orolaryngol Head Neck SUTg 1985;111:330. use in soft palate reconstruction and nasopharyngeal and
choanal atresia. BT J Plan SUTg 1977;30:300.
3. Komisar A. Lawson W: A compendium of intraoral flaps.
Head Neck 1985;8:91.
rown et al. (3) are credited with being the first to The rectus abdominis musculocutaneous flap has
B use abdominal cutmeous flaps based on the perfo-
rators of the rectus abdominis muscle. However, Drev-
assumed an important role in. head and neck reconstruc-
tion because of its ease of harvest, long vascular pedicle,
er's (7) report of the "epigastric island flap" was the first and tremendous reliability. Pedicle flaps, based on the
to recognize the potential of transferring an island of deep superior epigastric vascular supply to the rectus
skin supplied by a segment of the underlying muscle. abdominis, have been used extensively in. reconstruction
He described a vertically oriented musculocutaneous of the breast. Pedicled transposition flaps can also be
flap that was transferred to a defect of the chest wall based on the deep inferior epigastric system for use in
based on the deep superior epigastric vascular supply. reconstructing defects in. the groin. and upper thigh (20).
Pennington and Pelly (27) are credited with the first The DIEA and DIEV are much more useful for free
report of transferring a free rectus abdominis muscu- tissue transfers because of their greater diameter and
locutaneous flap based on the deep inferior epigastric length and the larger skin territory that can be captured.
artery (DIBA) and the deep inferior epigastric vein The rectus abdominis muscles occupy the paramed-
(DmV). These authors described the results of ink- ian position of the anterior abdominal wall. Eac:b. mus-
injection studies that demonstrated the rich vascularity cle spans the entire length of the abdomen, arising from
of the abdominal skin through the DIBA. the pubis and inserting into the anteroinferior part of

142 CHAPTER 10

Linea alba

Tendinous e::;.-1-- - - --r::-r-.


~~i~~lJ_ abdominis m.

FIGURE 10..1. The rectus abdominis arises from 1he pubis and runs the entire length of the
abdomen to insert on the 5th, 6th, and 7th costal cartilages and the xiphoid process. The
muscle is wider in its cephalad portion. Two to five tendinous inscriptions divide the muscle
transversely. These inscriptions are firmly adherent to the anterior, but not 1he posterior. rectus

the thorax (Fig. 10-1). The primary action of the rec- subcutaneous tissue. Dye-injection studies by Boyd et
tus abdominis is to flex the trunk. The rectus abdominis al. (2) showed vascularity to the 6th rib and, therefore,
donor site is a useful source of vascularized muscle and introduced the possibility of incorporating bone in this
skin for a variety of ablative defects of the head and neck flap. The 6th through the 1Oth costal cartilages can be
(23). It offers several unique features compared with the harvested with the flap to provide bone-cartilage with a
regional musculocutaneous flaps based on the pectoralis length of up to 10 em and a width of 2 em. The segmen-
major, trapezius, and latissimus dorsi. The area of skin tal nerve supply to the muscle provides the potential for
that can be reliably harvested with a single rectus muscle a dynamic reconstruction, and we have successfully used
encompasses a substantial portion of the abdomen and this flap for facial reanimation (36). Although there are
lower chest. The size of the muscle component ranges no reported cases of sensate rectus abdominis flaps, this
from the entire muscle to only a small portion in the potential exists through the mixed motor-sensory nerves.
paraumbilical region where the dominant perforators There are a multitude of flap designs that havt! been
are located. The caudal portion of the muscle may be reported that permit the contouring of this flap to vir-
trimmed to add length to the vascular pedicle. "Muscle tually any defect in the head and neck. The patient,s
sparing" transverse rectus abdominus musculocutane- body habitus may be a limiting factor with regard to
ous (TRAM) flaps havt! been described that preservt! excess thickness of the subcutaneous tissue component.
the medial and lateral portions of the rectus muscle However, the muscle alone may be transferred and then
in situ and harvest only the central portion of the muscle resurfaced with a split-thickness skin graft. The skin of
with the cutaneous perforators. It is imperativt! that the a significant portion of the abdomen may be reliably
remaining segments of muscle maintain their vascular transferred because of the network of subcutaneous
and nerve supply in order to provide a meaningful advan- vessels emanating from the musculocutaneous perfo-
tage for the function and integrity of the abdominal wall. rators in the paraumbilical region. These perforators
This "alternate" neurovascular supply arises laterally, are located in a zone that extends from 2 em above to
where the intercostal nerves and vessels course through 3 em below the umbilicus. Boyd et al. (2) speculated
the layer between the internal oblique and the transversus that the deep inferior epigastric flap may provide the
abdominis muscles. In addition to harvest of the central largest potential territory of vascularized skin of any
muscle, perforawr flaps based on paraumbilical perfora- donor site in the body (Fig. 10-2).
tors have been described for use in breast reconstruction There are many factors that enter into the decision
{18). However, one of the great advantages of the rectus with regard to flap design. The defect's size and volume
abdominis muscle in head and neck reconstruction is the play a significant role, along with its proximity to the
ability to transfer large amounts ofwell-vascularized mus- recipient vessels. Lengthening of the donor vascular
cle in addition to the large surface area of skin to solvt! pedicle may be achieved by placing the skin paddle in
challenging reconstructive problems. Vascularized mus- a more cephalad position on the abdominal wall. The
cle is invaluable for managing problem wounds that are entire rectus abdominis may be transferred if needed.
radiated and/or where separation of ccwities is required. As noted above, preservation of a portion of that muscle
The thickness of the subcutaneous tissue varies from at the donor site adds little to maintain the integrity of
being very thick in the lower abdomen to rather thin in the abdominal wall to prevent ventral herniation, unless
the region above the costal margin. Thinning of this flap it has a good blood and nerve supply. As with any mus-
by excision of subcutaneous tissue can provide a thinner culocutaneous flap, the muscle component provides lit-
flap, but it must be performed with caution to preserve tle long-term bulk as a result of denervation atrophy.
the blood supply to the skin. It is imperativt! to avoid The degree of atrophy may be diminished by reestab-
injury to the very small vessels ttavt!rsing the subcuta- lishing a motor input through repair of the flap motor
neous tissue, which may compromise the vascularity to nerves to suitable recipient motor nerves in the neck.
larger flaps, more so than smaller flaps. The rich vascu- A more accurate method to provide bulk for contour is
larity of the skin territory permits a greater flexibility in to transfer vascularized subcutaneous tissue.
the flap design, leading to more accurate contouring to The most commonly used design for this donor site
the surgical defects. Finally, the ability to harvt!st this is the TRAM flap (29). Popularized for use in breast
flap with the patient in the supine position greatly facili- reconstruction, this design incorporates skin from the
tates the use of a two-team approach. entire lower abdomen. Four different skin zones have
been identified. Zone 1 refers to the skin overlying the
ipsilateral rectus muscle. Zone 2 denotes the skin of
FLAP DESIGN AND UTILIZATION the contralateral lower abdomen overlying the oppo-
site rectus muscle. The skin territory on the ipsilateral
The rectus abdominis muscle may be transferred alone, side of the abdomen lateral to the linea semilunaris is
with overlying fascia and subcutaneous tissue, or as a referred to as zone 3, and the skin lateral to the opposite
composite flap consisting of muscle, fascia, skin, and linea semilunaris is zone 4. The blood supply to zone
144 CHAPTER 10

Deep superior

epigastric artery

(perforators) ' ~I ..)

Deep inferior
epigastric artery

~~ ~

FIGURE 10-2. The versatility of the deep inferior epigastric system of flaps is largely the result of the periumbilical perfora-
tors, which send branches in all directions on the anterior abdominal wall like the spokes on a wheel. The DSEA and the
DIEA communicate through a system of choke vessels. Other vascular systems that contribute to the blood supply of the
abdominal wall are the DCIA and SCIA. Not shown in this illustration are the superficial inferior epigastric pedicle and the
superficial epigastric artery. An array of different flap designs are shown that may be combined to meet the needs of the
particular defect. A:. Transverse skin paddle placed below or above the umbilicus. It is imperative to capture the dominant
periumbilical perforators. B: The extended OlEA flap may be transferred with the entire rectus muscle. C: The extended DIEA
flap may be 1ransferred with only a small cuff of muscle in the region of the umbilicus. D: A longitudinal skin paddle oriented
over the entire length of the muscle provides a rich vascularity to the skin but a thicker flap due to the large muscle compo-
nent. E: Athinner flap can be achieved by harvesting the rectus abdominis with the anterior rectus sheath above the arcuate
line. F: A deep inferior epigastric perforator (DIEP) flap that contains skin and subcutaneous fat is harvested based upon
musculocutaneous perforators while preserving in situ the anterior rectus sheath and rectus abdominis muscle.

4 is the most tenuous. Investigations of the vascular sup- perforators. The dominant perforators were dissected
ply to the TRAM flap reveal vessels that arise from one through the muscle to the DIEA and DIEV. Branches to
rectus abdominis and cross the midline to supply the the muscle were ligated, and no muscle was transferred
skin of zone 3. The examination of these crossing ves- with the skin. The advantages of this flap included not
sels and contrast-injection studies have confirmed the only its thinness but also the fact that the integrity of
poor blood supply to zone 4 (17). However, Takayanagi the abdominal wall musculature was not disturbed.
and Ohtsuka {30) reported a technique that augmented The authors warned, however, that the dissection
the vascular supply in the zone 4 skin when its viability through the muscle may be technically difficult. Along
was deemed critical to the success of the reconstruc- similar lines, Akizuki et al. {1) described harvesting the
tion. They anastomosed the superficial epigastric or "extremely thinned" rectus abdominis free flaps. The
the superficial circumflex iliac pedicle to enhance the basic design was an extended deep inferior epigastric
vascular supply to that region. flap based on a small segment of muscle in the peri-
A vertically oriented skin paddle that overlies the umbilical region. The portion of the flap that extended
entire length of the rectus muscle may be harvested lateral to the muscle was thinned by removing all fatty
from the pubis to the xiphoid. This design is reliable tissue deep to Scarpa's fascia, thereby preserving the
but has the disadvantage of the additional buJk of the vascularity through the subdermal plexus. This tech-
muscle. An alternative flap design {referred to as the nique is an important contribution because it provides
thoracoumbilical flap or the extended deep inferior epi- a method to utilize the rectus abdominis donor site in
gastric flap) crosses the abdomen in an oblique fashion, individuals who might otherwise not be considered can-
extending from the infraumbilical region to above the didates because of an unfavorable body habitus.
ipsilateral costal margin (Fig. 10-2). The advantage of Virtually, any combination of these flap designs may
this skin design is that it introduces a range of tissue be used. Two separate skin paddles may be oriented
thickness that is at its greatest in the portion overlying over the longitudinal axis of the muscle to reconstruct
the muscle and least in the region that extends above composite defects requiring inner and outer lining.
the costal margin. More accurate flap contouring may Although primary closure of the abdominal wall skin
be achieved by trimming the muscle component to is highly desirable, the application of a skin graft may
only that portion in the periumbilical region with the be performed and, certainly, represents a better option
greatest concentration of dominant musculocutaneous when wound tension and respiratory compromise
perforators {32). become an issue.
In patients with excessive amounts of subcutaneous We have used this donor site for a variety of head and
tissue in the anterior abdominal wall, a thinner flap may neck defects. It serves as an alternative source of skin for
be harvested by skin grafting the muscle or just using the external coverage when regional flaps are not available
anterior rectus sheath above the arcuate line. We have or are unsuitable because of the defect's size or distance
used the latter technique in reconstructing through- from the donor site. Although the radial forearm and
and-through defects of the cheek. In such cases, the anterolateral thigh flaps remain the workhorse flaps for
external skin is restored with a skin paddle from the oral cavity reconstruction, the rectus abdominis is use-
periumbilical region, and the inner lining is resurfaced ful to supply buJk following total glossectomy. The goal
with the anterior sheath overlying the cephalad por- in total tongue reconstruction is to supply sufficient soft
tion of the muscle. The muscle is folded upon itself to tissue height for an approximation of the neotongue
achieve inner and outer epithelial surfaces. As noted to the palate without the use of a palatal augmenta-
previously, the anterior sheath from the region above tion prosthesis. The rectus abdominis flap is an excel-
the arcuate line can be harvested without fear of ventral lent choice as a result of the tendinous inscriptions of
herniation. The anterior sheath provides a thin, tough the anterior rectus sheath, which can be sutured to the
layer to achieve a watertight seal. We have also used this mandible to form a platform for the overlying skin pad-
technique in palatal reconstruction in which the rectus dle. The tissue above this platform does not atrophy,
sheath provides a suitable lining for the oral cavity fol- and, therefore, the shape and volume of the neotongue
lowing ablative procedures of the sinuses, nasopharynx, can be precisely contoured (36).
or skull base. Chicarilli and Davey (6) used the rectus Perhaps the greatest use of this flap has been in skull
abdominis flap to reconstruct a cranio-orbitomaxillary base reconstruction; it has become the flap of choice
defect. The anterior rectus sheath was sutured to the for many skull base defects requiring free tissue transfer
bony margins of the cranial defect above the orbit to (35). Jones et al. {16) reported the use of this flap for
serve as a hammock to support the intracranial contents. defects involving the middle and posterior cranial fossa;
An alternative technique to harvest a thinner flap Yamada et al. (37) described its application to defects
from this donor site was described by Koshima et al. of the anterior cranial fossa. In the latter report, the free
(18). They reported the transfer of "thinned, paraum- rectus abdominis flap was used in patients who had
bilical" flaps based solely on the musculocutaneous undergone prior surgery or radiation to help prevent a
146 CHAPTER 10

cerebrospinal fluid leak, to prevent ascending infection, umbilicus through a system of small-caliber vessels that
and to provide vascularity to free bone grafts used in Taylor and Palmer (34) referred to as "choke" vessels.
the periorbital region. I have used the rectus abdominis Through cadaveric studies, the degree of arboriza-
free flap in the anterior cranial fossa in a patient who tion of the DIEA and the DSEA has been classified into
had a postoperative collection of pus following resec- three different types. In the type 1 pattern, the DIEA
tion of a recurrent frontal meningioma. The free rectus does not divide, remaining a single vessel as it runs its
muscle successfully achieved a functional separation of course on the undersurface of the muscle (29%). The
the nasal and anterior cranial cavities, with complete type 2 pattern refers to a DIEA that divides into two
resolution of the infectious process (35). I normally do dominant branches (57%). The type 3 pattern is a tri-
not like to place a microvascular free flap in a grossly furcation of the DIEA (14%). The extent of branching
infected field because of the extremely detrimental of the inferior system is mirrored by the DSEA (25).
effect that infection has on the microvascular pedicle. The division of the vascular pedicle into two or three
However, this was a unique circumstance, and the abil- branches is the basis for the "split muscle" transfer that
ity of the rectus flap to survive in this environment is a was reported by Sadove and Merrell (28).
testimony to its hardiness. It also highlights the impor- The DIEA, measuring an average of 3 to 4 mm, is
tance of vascularized muscle in the management of roughly twice the diameter of the DSEA. The venous
"problem wounds," which are common occurrences in supply of the inferior muscle is composed of paired
the head and neck. venae comitantes, which usually join to form a single
The versatility of flap design of the rectus abdominis venous pedicle prior to their junction with the exter-
flap is extremely useful when trying to achieve a water- nal iliac vein. The DIEV is approximately 3.5 mm in
tight seal of the various cavities that are opened follow- diameter. Extensive studies of the venous circulation
ing many skull base procedures (10). This is particularly of the TRAM flap revealed a superficial and deep sys-
challenging in the "three-cavity defect," which involves tem. The veins of the superficial system were above
the nasal, oral, and intracranial cavities in which multi- Scarpa's fascia and communicated extensively across
ple epithelial surfaces are required for a successful out- the midline. The superficial veins drained into the deep
come. De-epithelialized portions of the flap can be used inferior epigastric system by way of the veins accompa-
to enhance the contour of regions such as the infratem- nying the musculocutaneous arterial perforators. Valves
poral fossa or the orbit following exenteration. Finally, located in the connecting veins regulated the direction
the extremely reliable nature of this flap is a critical fac- of flow from the superficial toward the deep system. The
tor in ensuring protective coverage to exposed portions findings from this study confirmed the safety of thin-
of the brain (35). ning the rectus abdominis musculocutaneous flaps by
Many different free flaps have been used to recon- removing fat from below Scarpa's fascia, as long as the
struct defects of the scalp. Miyamoto et al. (25) reported musculocutaneous perforators were preserved (5).
four cases of extensive scalp reconstructions using the In addition to the size of the vascular pedicle, there
rectus abdominis free flap. Aside from the large surface are a variety of compelling reasons why the inferior
area, the length of the vascular pedicle was noted to be pedicle is a better supply for free tissue transfer than
a particular advantage for this donor site. The vascu- is the superior pedicle. The musculocutaneous perfora-
lar pedicle can be lengthened by judicious skin paddle tors are direct branches of the DIEA and DIEV and
placement and careful removal of the caudal portion of are therefore capable of supplying a much larger ter-
the rectus muscle. These techniques help to avoid the ritory of skin. Although the deep superior epigastric
use of vein grafts. system is capable of capturing these perforators, it does
so through a reversal of flow in the DIEA and DIEV,
across the choke system of vessels that connect the two
NEUROVASCULAR ANATOMY systems. Boyd et al. (2) studied the distribution of mus-
culocutaneous perforators exiting through the anterior
According to the classification system of Mathes and rectus sheath. By dividing the length of the muscle into
Nahai (22), the rectus abdominis is a type III muscle horizontal segments, they found that the dominant per-
with two dominant vascular pedicles: the deep superior forators were located in a zone close to the umbilicus,
epigastric artery (DSEA) and deep superior epigastric with very few perforators arising in the most caudal or
vein (DSEV) and the DIEA and DIEV. The DSEA is a cephalad portions of the muscle. These perforators were
continuation of the internal mammary artery; the DIEA also mapped according to a longitudinal division of the
is a branch of the external iliac artery arising directly muscle into thirds. The greatest concentration of large
opposite the deep circumflex iliac artery (Fig. 10-3). The perforators traversing the anterior sheath was located in
DSEA and DIEA pedicles arborize as they approach the middle and medial zones, with few exiting laterally.
each other in a longitudinal direction on the undersur- The inferior pedicle runs an extraperitoneal course
face of the muscle. The two systems connect above the in close proximity to the deep inguinal ring. It crosses

mammary a.--:-----__,~~-:-~--11

.- + - - - Rectus
abdominis m.

----"l!~+f-"""+~;.._--- Posterior
Musculocutaneous -----~
rectus sheath

~~t-~----- Segmental
nerve supply

Arcuate line

nerve supply


FIGURE 10-3. The rectus abdominis has a type Ill vascular supply with two dominant pedicles, the DSEA and DSEV and
the OlEA and DIEV. These two systems communicate through a rich system of anastomoses located approximately halfway
between the xiphoid and 1he umbilicus. Musculocutaneous perforators arise in the paraumbilical region and send an array
of dominant branches that are oriented toward the inferior border of the scapula. The segmental nerve supply to 1he rectus
abdominis arises from the terminal branches of the lower six intercostal nerves, which run across the abdominal wall from
lateral to medial in the layer between the transversus abdominis and the internal oblique muscles. These nerves penetrate
the posterior rectus shea1h approximately 3 em medial to the linea semilunaris.
148 CHAPTER 10

the lateral border of the rectus muscle and pierces the be reliably harvested on a single DIEA is so great that
transversalis fascia approximately 3 to 4 em caudal to a delay phenomenon is rarely needed in head and neck
the arcuate line. The DIEA gives off a number of smaller reconstruction, there are certain complex defects in
branches to the pubis and the caudal aspect of the rec- which this technique may be helpful.
tus muscle prior to entering the rectus sheath. The system of branches of the periumbilical perfo-
Additional cadaveric studies by Taylor et al. (31) rators has the appearance of the radiating spokes of a
demonstrated the rich connections between different wheel with the hub located at the umbilicus, thus giv-
arterial supplies to the anterior abdominal wall skin. ing credence to the clinical observation that incorpora-
The periumbilical musculocutaneous perforators of tion of the periumbilical perforators permits a skin flap
the DIEA give off a series of radiating branches that to be harvested with virtually any orientation from the
anastomose with the cutaneous branches of the fol- midline. However, the dominant orientation of these
lowing arteries: the superficial superior epigastric, the branches is 45 degrees from the horizontal toward the
intercostal, the deep and superficial circumflex iliac, the inferior scapular border (32). This explains the extreme
superficial inferior epigastric (SIEA), and the puden- reliability of the oblique flap design that was previously
dal. The dominant connections between these sys- referred to as the extended deep inferior epigastric or
tems were found to occur within the subdermal plexus the thoracoumbilical flap. Taylor et al. {32) reported
(Fig. 10-2). As previously noted, there are also anasto- that this design may safely incorporate skin above the
motic connections in the intermuscular layer running costal margin as far lateral as the midaxillary line.
between the transversus abdominis and internal oblique The nerve supply to the rectus abdominis is derived
muscles. The primary connections occurring in this from the lower six intercostal nerves, which traverse the
layer are between the branches of the epigastric system plane between the transversus abdominis and the inter-
and the lower six intercostal vessels. nal oblique muscles. These nerves are mixed motor and
Taylor et al. {33) used the angiosome concept of sensory nerves, providing a segmental innervation to
defining the vascular territories of the abdominal wall the rectus muscle and sensory supply to the overlying
to describe a technique of surgical delay to enlarge the skin. The intercostal nerves enter the midportion of the
territory of skin that can be safely transferred on the muscle on its posterior surface (9). By stimulating one
DIEA and DIEV. The angiosome theory proposes that of the segmental nerves, it is possible to select a portion
the region of skin that is most reliably harvested on the of the rectus muscle for use in facial reanimation. We
deep inferior epigastric vascular system is defined by a have done this successfully in one patient who under-
line that marks the interface between the DIEA and the went a composite reconstruction of the cheek follow-
other source arteries of the abdominal wall. This line of ing radical parotidectomy. Good dynamic activity was
demarcation denotes the system of choke vessels that obtained by anastomosing two segmental nerves to the
connect two adjacent angiosomes. Thus, the system of upper and lower divisions of the ipsilateral facial nerve
choke vessels between the DIEA and the DSEA is con- (36). Hata et al. (15) reported successful facial reani-
sistently located above the umbilicus. The interface zone mation in two patients with chronic facial paralysis.
with the contralateral DIEA is along the linea alba. In a A cross-facial nerve graft was initially placed and then
two-stage procedure, surgical delay can be achieved by followed at 1 year with a free rectus abdominis transfer
ligating the source artery in the adjacent territory, which in which several of the segmental nerves were anasto-
varies depending on the orientation of the desired skin mosed to the cross-facial graft. The rectus abdominis
flap. This delay procedure causes a dilation of the choke was considered a good muscle for facial reanimation
vessels connecting the two adjacent territories leading to because of the ease of harvest and the length of the neu-
a more favorable hemodynamic gradient across the two rovascular pedicle. A particular advantage that is unique
systems. Although the surgeon can usually capture the to the rectus abdominis is the tendinous inscriptions,
skin in an adjacent angiosome without surgical delay, which allow placement of anchoring sutures.
it becomes progressively more difficult when more
than one system of choke vessels is traversed in series.
If a longer, vertically oriented flap is desired, then the ANATOMY OF THE RECTUS SHEATH
appropriate delay procedure would involve interruption
of the deep superior epigastric pedicle. Enhancement An understanding of the anatomy of the fascial enve-
of the vascularity to the skin of the TRAM flap can be lope of the rectus abdominis is perhaps more critical
achieved by interruption ofthe other vascular supply to than with any other flap. The prevention of herniation
the skin of the lower abdomen. On the ipsilateral side, depends on restoring the integrity of the abdominal wall
the delay procedure would involve ligation of the SIEA. by effectively closing the fascial layers.
Improving the vascular supply to the skin of zones The aponeurotic extensions of the three muscles of
2 and 4 can be achieved by interrupting the contralat- the anterior abdominal wall merge to form the anterior
eral DIEA and SIEA. Although the area of skin that can and posterior sheaths of the rectus fascia (Fig. 10-4).

Rectus abdominis m. Linea alba Anterior rectus sheath

oblique m.

oblique m.
Posterior Transversalis
~~~--- Transversus
rectus sheath fascia
abdominis m.


8 Transversalis fascia

FIGURE 11).4. Transverse sections through the anterior abdominal wall reveal the fascial
anatomy of the anterior and posterior rectus sheaths at two different levels in the abdomen.
A:. Above the arcuate line, the posterior sheath is composed of contributions from the aponeu-
roses of the transversus abdominis and the internal oblique muscles. The aponeurosis of the
internal oblique muscle splits to form part of the anterior rectus sheath with the external oblique
aponeurosis. B: Below the arcuate line, at about the level of the anterior superior iliac spine, the
aponeurotic extensions of all three muscle layers contribute to the anterior rectus sheath. The
posterior sheath is composed only of the transversalis fascia.

The compositions of these sheaths vary in different loca- below the arcuate line. Maintaining the integrity of the
tions between the pubis and the :xiphoid. Above the cos- blood supply to the skin requires only that the anterior
tal margin, there is no posterior sheath, and the anterior rectus sheath is harvested in the paraumbilical region
sheath is formed by an extension of the external oblique where the dominant perforators are located. Although
aponeurosis. In the upper two thirds of the muscle, the it is probably not essential to do so above the arcuate
anterior sheath is formed by the external oblique plus a line, we routinely augment the posterior sheath by clos-
contribution from the internal oblique aponeurosis. The ing cuB's of the anterior sheath that are preserved both
internal oblique aponeurosis also contributes to the pos- medially and laterally. Taylor et al. (31) described a fa5-
terior sheath where it joins with the aponeurosis of the cial sparing technique whereby cuts in the anterior reo-
transversus abdominis. An important transition occurs tus sheath are made based on direct visualization of the
in the posterior sheath at the arcuate line (semicircular dominant perforators. The amount of anterior sheath
line or arch qj Douglas), which is approximately at the that is harvested may be minimized by this teclmique.
level of the anterosuperior iliac spine. From this point to Augmentation of the anterior rectus sheath may also be
the pubis, the posterior sheath is composed only of the achieved with a synthetic mesh that adds greatly to the
transversalis fascia. The strength of the posterior rectus strength of the repair.
sheath above the arcuate line is sufficient to prevent an Three other terms related to the fascia must be
abdominal bulge or herniation. Below the arcuate line, defined (Fig. 10-1). The linea alba is the midline fas-
these sequelae undoubtedly occur if the transversalis cial condensation that divides the two rectus muscles.
fascia is not augmented. It is rarely necessary to design The linea semilunaris refers to the fascial condensation
a flap that requires harvest of the anterior rectus sheath that marks the lateral extent of each rectus muscle.
150 CHAPTER 10

The rectus abdominis is subdivided by two to five tendi- As noted above, we have found that the DIEA and
nous inscriptions. The anterior sheath but not the poste- omv run a longitudinal course along the lateral aspect
rior sheath is firmly adherent to each inscription. These of the muscle prior to arborizing on the undersurface of
fascial condensations do not extend to the posterior the muscle. Extreme care must be taken when making
sheath. Moon and Taylor (26) reported that 93.5% of a the cuts in the anterior rectus sheath medial to the linea
series of 108 muscles had three tendinous inscriptions semilunaris.
with the most caudal one at the level of the umbilicus. Although the requirements of the recipient defect
usually dictate the size and design of the abdominal skin
paddle, there are situations in which the surgeon has
ANATOMIC VARIATIONS options for planning the incisions and the approach to
the rectus muscle. Taylor et al. (31) and Hallock (12)
In a series of 25 cadaver dissections reported by Boyd advocated a transverse suprapubic incision for the expo-
et al. (2), the average diameter of the DIEA was 3.4 nun. sure of the vascular pedicle. The resulting scar is well
The vessel was slightly larger in instances in which the camouflaged. Alternatively, Hallock (12) described the
DIEA was the source of an abnormal obturator artery. use of an abdominoplasty approach but warned that
The authors reported that the omv entered the exter- proper case selection was imperative.
nal iliac vein as a single trunk in 68% of cases and as a Removal of one rectus abdominis muscle along with
double trunk in 32%. In a series of 115 cadaver dissec- a portion of the overlying fascia creates a potential
tions, Milloy et al. (24) reported no cases ofabsent DIEA weakness in the anterior abdominal wall that may pre-
and DffiV and only three cases in which the DSEA and dispose the patient to ventral herniation or a midline
DSEV could not be identified. In the vast majority of bulge. A preexisting hernia or diastasis recti may com-
cases, the DIEA-DffiV pedicle runs its usual course plicate donor-site closure and mitigate against the use
along the deep surface of the rectus abdominis. We have of this flap. Taylor et al. (31) warned that divarication of
encountered two cases in which the pedicle tracked for the recti must be recognized preoperatively to account
an unusual distance along the lateral aspect of the mus- for the more lateralized position of the rectus muscles in
cle before taking a medial intramuscular route. Another designing the flap.
anomalous course of the deep inferior epigastric pedicle The rectus abdominis muscles assist in flexion of
has been described in which it winds around the medial the torso and also provide static support to the anterior
aspect of the muscle and does not give feeders to the abdominal wall. There is a tremendous amount of con-
muscle until assuming a position along its superficial troversy regarding the optimum method for closure of
surface. In this particular instance, the perforators to the abdominal wall defect following rectus abdominis
the skin run directly through the anterior rectus sheath flap harvest. Much of the data on donor-site complica-
without traversing the muscle (11). tions are derived from large series of pedicled flaps that
were used for breast reconstruction. For the purposes of
this discussion, we will not cover all of the issues regard-
POTENTIAL PITFALLS ing closure of the abdominal wall following harvest of rec-
tus abdominis muscles. There are two major camps that
The reliability of the rectus abdominis free flap is are divided over the necessity of introducing a synthetic
reflected by the success rate of 93% in a large series of mesh for closure of the anterior rectus sheath. Drever
cases in which this flap was used throughout the body and Hodson-Walker (8) described the technique of
(23). In a review of all reported cases used for head placing a mesh of the exact dimensions to the area of
and neck reconstruction, we found only one failure in the anterior rectus sheath that was removed with the
73 free flaps transferred to the head and neck (36). flap. Using this method in 87 cases, they reported no
The preoperative assessment must include a careful cases of ventral hernias and only 2 cases of abdominal
history and examination of the abdomen to be certain wall bulging. In a comparable group of 31 patients who
that prior surgery will not interfere with flap harvest. were closed primarily without a mesh, there was a 43%
Most intraperitoneal procedures involve a longitudinal incidence of bulging or hernias. These authors argued
incision through the linea alba, even though the skin that the mesh maintained the position of the remain-
incision is transverse. A right subcostal incision for an ing abdominal wall musculature and did not cause an
open cholecystectomy does not preclude the use of the increased resting tone resulting from direct approxima-
rectus muscle. This procedure almost invariably inter- tion of the linea alba to the linea semilunaris. Lejour and
rupts the nerve supply to the cephalad portion of the Dome (19) reported using a 4-cm wide double-layered
muscle. The surgeon should be aware of the potential synthetic mesh between the posterior sheath and the
for denervation atrophy in the postcholecystectomy direct closure of the anterior sheath. They reported no
patient. However, this does not interfere with the vascu- hernias or bulging in their series of unilateral flaps. Har-
larity of the atrophic muscle or its suitability for transfer. trampf ( 13) espoused a different view of this controversy.

He argued for direct approximation of the residual ante- most extensive study of abdominal wall function in 300
rior fascial margins to achieve a centralization of the patients, of whom the majority returned to their preop-
remaining muscles. By so doing, he believes that the erative level of function, based on the parameters used
mechanical advantage of the residual abdominal mus- in their investigation. Lejour and Dome (19) reported
cles is restored. In 300 patients who underwent either that follow-up studies in 57 patients revealed a signifi-
unilateral or bilateral rectus muscle transfers, there cant discrepancy between a patient's responses to a
was a 0.3% incidence of abdominal hernia and a 0.8% questionnaire and objective findings that were recorded
incidence of abdominal wall laxity (14). In my experi- by a physiotherapist. Although the majority of patients
ence of more than 300 unilateral rectus abdominis free reported either no disturbance or improvem.ents in
flap transfers in which the abdominal wall was closed abdominal strength and sports activities following sur-
in this manner, there has been one patient who has gery, the physiotherapist reported a marked decrem.ent
had an abdominal wall hernia that required repair. An in the functions of the recti and the external oblique
additional technique of anterior sheath closure using muscles.
autologous tissue should be mentioned. A "turnover,"
contralateral, anterior rectus sheath flap based at the
midline has been reported for donor-site closure (23). POSTOPERATIVE CARE
The postoperative function of the abdominal wall is
generally believed to be unaffected by transfer of a single Because of retraction of the peritoneal cavity for dis-
rectus abdominis muscle. Bunkis et al. ( 4) warned that section of the vascular pedicle, it is not uncommon for
in patients who are active in sports or who engage in patients to develop an ileus in the early postoperative
other physical activities, there may be an impact on their period. Interim feedings must be delayed for a short
lifestyle. However, there are few reports that quantify period until this resolves. Early postoperative ambulation
the actual effects of removing a single rectus abdominis is encouraged. Exercises that involve the abdomen may
muscle. Hartrampf and Bennett (14) conducted the be resumed in approximately 6 weeks following surgery.
152 CHAPTER 10

FIGURE 10-5. The tapographical anatomy of

the rectus abdominis flap is autlined an the
abdomen. The position of the palpable pulse
of the femoral vessel is shown. In addition, the
iliac crest and costal margins are outlined.
In the midline, the linea alba has been drawn
from the pubis to the xiphoid. The approximate
position of the linea semilunaris is outlined
by a dashed line at the mid paint between the
pubis and the anterior superior iliac spine.
The OlEA and DIEV and the DSEA and DSEV
are shown in their approximate course on the
undersurface of the rectus abdom inis.

FIGURE 10-6. An extended deep inferior epi-

gastric flap has been outlined on the left side of
the abdamen. This flap extends over the costal
margin and provides an abundance of thin
well-vascularized pliable skin. The vascularity
to this flap depends an capture of the dominant
periumbilical perforators. This flap may extend
across the midline, capturing well-vascularized
tissue to approximately the level of the con-
tralateral linea semilunaris. The arcuate line is
located at the approximate longitudinal level
on the abdominal wall of the anterior superior
iliac spine. The anterior rectus sheath should
not be harvested below this level.

FIGURE 10-7. The dissection begins in the

cephalad portion of the flap by incising the
skin and subcutaneous tissue to the level
of the fascia. The full breadth of the rectus
abdominis is identified by incising the anterior
rectus sheath to expose the rectus abdominis
from the linea alba to the linea semilunaris.

Rectus Abdominis Flap (Extended

Inferior t:P1aa1r11

FIGURE 10-8. The dissection is continued infe-

riorly in a similar plane through the skin and sub-
cutaneous tissue to expose the full width of 1he
caudal portion of the rectus abdominis. This is
achieved by incising the anterior rectus sheath
and exposing the rectus abdominis muscle from
the linea alba to the linea semilunaris.

FIGURE 10-9. Having identified the linea semi-

lunaris in its cephalad portion and in its caudal
portion, the skin paddle can now be elevated off
the external oblique muscle and aponeurosis
to the linea semilunaris, which is identified by
the dashed line. Identification of the dominant
perforators to the skin may allow1he surgeon
to further limit the dimensions of the anterior
sheath harvest. Defatting of the portion of this
flap, which has been elevated, may be safely
performed deep to Scarpa's fascia.

FIGURE 1010. Meticulous dissection in 1his

plane superficial to the external oblique fascia
is performed to identify the first set of muscu-
locutaneous perforators (srrow). The anterior
sheath is then incised laterally, preserving these
dominant perforators.
154 CHAPTER 10

FIGURE 10-11. The medial dissection is performed

by elevating the skin and subcutaneous tissue in a
prefascial plane above the contralateral anterior
rectus sheath. The exact position of the linea alba
is marked by a dotted line, having been identified
in both the cephalad and caudad exposure. A cuff
of anterior rectus sheath is preserved by making a
longitudinal incision lateral to the linea alba, as indi-
cated by the dashed line.

FIGURE 10-12. The lateral aspect of the dissection

is completed by incising the anterior rectus sheath
medial to the linea semilunaris, preserving a small
cuff of fascia to facilitate closure of the anterior
sheath. Exposure of the caudal aspect of the rectus
fascia has been obtained through a vertical skin inci-
sion. However, the exposure may be achieved with-
out this incision and simply by retracting on the lower
abdominal flap. A corresponding vertical incision in
the anterior rectus sheath is then made (dashed line)
in order to expose the caudal portion of the museIe
for harvest
FIGURE 10-13. Full exposure of the rectus abdominis
has been achieved by longib.ldinally incising the ante-
rior rectus sheath interiorly in the midportion between
the linea alba and the linea semilunaris. The anterior
rectus fascia is elevated both medially and laterally to
obtain full exposure ofthe muscle. The skin paddle is
completely isolated, except for its attachments to the
anterior rectus sheath in the midportion of the muscle.
Only that portion of the anterior rectus sheath that is
immediately subjacent to the skin paddle needs to be
harvested. The cephalad portion of the rectus abdomi-
nis may be incorporated in this flap by gaining expo-
sure through elevation of the anterior rectus sheath
to the costal margin. The attachments of the anterior
sheath to the muscle at the level of the tendinous
inscriptions require sllarp dissection.

Rectus Abdominis Flap (Extended

Inferior t:P1aa1r11

FIGURE 10-14. The dissection progresses from

cephalad to caudad by elevating the rectus abdomi-
nis off the posterior rectus sheath. This is achieved
by transecting the rectus abdominis above and
bluntly dissecting between the muscle and the
posterior sheath. Blunt dissection along the linea
semilunaris reveals the segmental nerve supply
(small arrows). In the caudal aspect of this exposure,
the deep inferior epigastric pedicle (lsrge srrowt is

FIGURE 10-15. A closer view of the undersurface

of the rectus abdominis reveals the segmental nerve
supply and the deep inferior epigastric pedicle.

FIGURE 10-16. The extended deep inferior epigas-

tric flap has been completely isolated on its vascular
supply, and the segmental nerves are shown against
the blue backgrounds. Proximal dissection of the
vascular pedicle is achieved by the use of deep
abdominal retractors. Despite the large caliber and
length of the DIEA. it is helpful to extend the dis-
section to the takeoff from the external iliac artery
and vein because the venae comitantes join in most
cases to create a single DIEV at a variable distance
from the external iliac vein.
15& CHAPTER 10

FIGURE 1D-17. Meticulous closure of the donor

defect is required to prevent weakening or hernia-
tion of the anterior abdominal is impera-
tive to close the anterior rectus sheath below
the arcuate line. This can be readily achieved by
designing the skin paddle so that only that portion
of the anterior rectus sheath above the arcuate
line is harvested.

FIGURE 1D-11. Closure of the anterior rectus

sheath below the arcuate line has been accom-
plished. The integrity of the anterior abdominal
wall is fortified by suturing the anterior rectus
sheath to the posterior rectus sheath at the level
of the arcuate line (arrowheads). Although the
posterior rectus sheath cephalad to the arcuate
line is probably of sufficient strength, it can be
augmented by closing the preserved cuffs of ante-
rior fascia attached to the linea semilunaris and
the linea alba. A ribbon retractor is usually placed
along the posterior rectus sheath to prevent the
errant placement of a suture into the peritoneal

RGURE 1019. The anterior rectus sheath has

bee11 closed. An alternative approach to fortifying
the anterior abdominal wall is to suture a mesh to
the linea alba and the linea semilunaris, above the
arcuate line.

Rectus Abdominis Flap (Extended

Inferior t:P1aa1r11

FIGURE 10-20. Closure of the skin is accom-

plished by wide undermining.

FIGURE 10-21. The rectus abdominis muscu-

locutaneous flap provides a large area of skin,
a long vascular pedicle, and a segmental nerve

FIGURE 10-22. If desirable, because of excess

bulk or the necessity for a longer vascular
pedicle, the amount of muscle that is incorpo-
rated in this flap may be significantly reduced
by separating the loose attachments of the
DIEA and DIEV on the undersurface of the
muscle in its proximal portion. In so doing, the
caudal aspect of the rectus abdominis may be
removed. This provides further length to the
vascular pedicle and reduces the amount of
muscle to only that portion in the paraumbilical
region that harbors the dominant musculocuta-
neous perforators.
158 CHAPTER 10

Rectus Abdominis Flap (Deep

Inferior igastric Perforator

FIGURE 1D-Zl. Harvest of a deep inferior

epigastric perforator flap is initially outlined as
a vertical skin paddle on the anterior abdomi-
nal wall.

FIGURE 1D-24. Three dominant cutaneous

perforators are identified exiting through the
anterior rectus sheath to supply the overlying
skin (marked A B. and CJ.

Rectus Abdominis Flap (Deep

Inferior igastric Perforator Fla

FIGURE 10-25. Dissection through the mus-

cle has been performed to harvest a perfora-
tor flap based on the DIEA/DIEV with minimal
to no muscle surrounding 1he pedicle.

FIGURE 10-2&. The perforatorflap is shown

based on a single dominant musculocutane-
ous perforator.
160 CHAPTER 10

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16. Jones N, Sekhar L, Schramm V: Free rectus abdominis 33. Taylor I, Corlett R, Caddy C, Zeit Z: An anatomic review
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cranial fossa. Plast Reconstr Surg 1986;78:471--473. Reconszr Surg 1992;89:408.

34. Taylor G, Palmer }:The vascular territories (angiosomes) 36. Urken MI.., Turk J, Weinberg H, Vickery C, Biller HF:The
of the body: experimental and clinical applications. Br J rectus abdominis free flap in head and neck reconstruc-
Plan Surg 1987;40:113-131. tion. Arch OUJlaryngolHeadNeikSurg 1991;117:857-866.
35. Urken MI.., Catalano PJ, Sen C, Post K, Futran N, Biller 37. Yamada A, Harii I{, U eda K,Asato H: Free rectus abdom-
HF: Free tissue transfer for skull base reconstruction: inis muscle reconstruction of the anterior skull base. Br J
analysis of complications and a classification scheme for Plast Surg 1992;45:302-306.
defining skull base defects. Arch Owlaryngol Head Neck
Surg 1993;119:1318.
'"'J""he gracilis muscle was one of the first musculocu- and adductor magnua muscles compensate for the func-
~ taneous flaps to be transferred by microvascular tional loss of the gracilis muscle (Figs. 11-1 and 11-2).
teclm.iques. Harii et al. (4) introduced this free flap in
1976 and subsequently popularized ita use for dynamic
facial reanimation. The gracilis flap has also been used FLAP DESIGN AND UTILIZATION
extensively as a pedicled flap for defects of the peri-
neum, including the vagina, rectum, and even pres- The gracilis muscle is a long thin muscle, measuring
sure ulcers overlying the ischium (11-13). The gracilis 4 to 6 em in width. The neurovascular pedicle enters
muscle has an easily identifiable vascular pedicle with a the proximal portion of the muscle 8 to 10 em cau-
large motor nerve that makes it suitable for transfer and dal to the pubic tubercle (Fig. 11-3). The dominant
reinnervation. musculocutaneous perforator is located in the same
The gracilis muscle is an adductor and a medial rota- vicinity.
tor of the thigh. It is a long strap-like muscle that arises The primary use of the gracilis muscle in the head
from the pubic symphysis and ramus and inserts below and neck has been for facial reanimation; the mus-
the knee onto the tibia. The powerful adductor longus cle is both revascularized and reinnervated to restore


:..;..;..iOF.-fW-1- Adductor
magnus m.


-+--- Sartorius m.

-+--- Rectus femoris m.

FIGURE 112. The surgical approach to 1he gracilis is

performed from the medial aspect of the thigh. The muscle
tendons that converge to make up the pes anserinus are the
sartorius, gracilis, semimembranosus, and semitendinosus.
The powerful adductor longus and mag nus compensate for
the loss of the gracilis muscle.

FIGURE 11-1. The muscular anatomy of the medial1high is other end was sutured under tension to the temporal
shown from the anterior view. The gracilis arises from the fascia.
body and inferior pubic ramus. It crosses 1he knee to insert Over time, there have been several refinements
into the medial aspect of1he upper end of the tibia. As it to Harii's original technique. To achieve synchro-
runs its cephalocaudal course, it narrows significantly until nous mimetic movement in the absence of the ipsi-
terminating at its tendinous insertion. lateral facial nerve stump, a two-stage procedure was
described employing a cross-face sural nerve graft in
its contractile activity. In Harii et al.'s (5) original the first stage, followed by second-stage muscle ttans-
description of this technique, a segment of the gra- fer once axons populate the tip of the cross-face nerve
cilis muscle was transferred to the paralyzed side of graft (3). The arrival of axons at the tip of the graft
the face, and its motor nerve was coapted to the deep is determined by the presence of Tinel sign, a tin-
temporal nerve. One end of the muscle was sutured to gling in the donor muscle when tapping over the tip
the orbicularis oris at the lateral commissure, and the of the nerve graft. The utilization of branches of the
164 CHAPTER 11

healthy conttalateral facial nerve is feasible based upon

the known. robust arborization of the facial nerve in
the midface. Selective neurectomy of donor branches
does not result in loss of smile function on the donor
' -- -- An tenor branch side. Kumar and Hassan (6) describe favorable results
obturator n.
combining the two stages into one in a small series
rw~~l-- Profunda femoris
artery and vein
of patients. After placing the obturator nerve across
the face, it was coapted directly to the contralateral
l.:r ..,.....,+-- Branch of
adductor a. facial nerve at the time of muscle inset. This technique
resulted in the recovery of more rapid muscly activity,
compared with a 2-stage transfer. However, most facial
reanimation surgeons agree that the critical element
to successful cross-face nerve grafting is to harvest the
...;.~H-- Adductor donor branches much more proximally than the obtu-
longus m. rator nerve is able to reach, and so the one-stage tech-
nique has not been widely adopted.
In addition to introducing cross-face nerve grafts to
achieve mimetic activity, an effort was made to reduce
the bulk of the muscle in the face. Harii (3) described
transfer of a gracilis muscle segment 10 em in length
and 3 em in width, approximately one-half the breadth
of the muscle belly. M&nktelow (8) investigated the fas-
cicular pattern of the motor branch of the obturator
nerve, which supplies the gracilis. Of the three fascicles
usually present in that nerve, one was usually responsi-
ble for the innervation of the anterior 25% to 50% of
the muscle. Interfascicular dissection and intraoperative
stimulation allow selective harvest of only a small por-
tion of the muscle innervated by a single or a pair of
fascicles. Through this technique, .Manktelow has trans-
ferred a smaller portion of the muscle while maintain-
ing a neurovascular pedicle suitable for microvascular
anastomosis (Fig. 11-4).
Profunda femoris
Harii et al. (5) reported a wide range of results in the
artery and vein quality of facial reanimation using the free gracilis mus-
cle transfer in 122 patients. The selection of the donor
Branch of adductor ~-:.-+.....,.
artery and vein nerve used to drive the transplanted muscle appeared to
have the greatest impact on the results of reanimation.
The most consistent results were achieved with coap-
tation of the motor nerve of the gracilis to the stump
Adductor ~- of the ipsilateral facial nerve. However, good to satis-
-'*"-~-+- Adductor
longus m. factory results were also achieved with the two-stage
magnus m.
cross-face nerve grafting method (see Fig. 11-14). Frey
FIGURE 11-3. The vascular supply to the gracilis muscle et al. discovered that results were relatively independent
is from a terminal branch of the adductor artery and vein, of the total number of neurons traversing the graft (2).
which arise from the profunda femoris artery and vein. The .Manktelow and Zuker and others have written
adductor artery usually arises from the profunda femoris extensively on the utility of the motor branch to the
artery, but it may also arise from the medial circumflex masseter muscle to supply neural input to the graci-
femoral artery. The gracilis branch of the adductor artery, lis muscle in one-stage facial reanimation procedures
accompanied by paired venae comitantes, passes between (1,6,7,9) and popularized the technique for the treat-
adductor longus and adductor magnus. The anterior divi- mentofMobiussyndrome (Figs.ll-17 and 11-18)(15).
sion of the obturator nerve supplies the motor innervation to They have found that using the masseteric nerve leads
the gracilis muscle. It enters the muscle in a more cephalad to increased average excursion compared with cross-
location and runs a more oblique course than the main face nerve grafting, and numerous groups describe
vascular pedicle. that cortical adaptation occurs, permitting voluntary

Gracilis harvested

FIGURE 11-4. The branching pattern of the anterior division of the obturator nerve allows the
gracilis muscle to be separated into at least two functional muscular units. A single fascicle
usually supplies the anterior 25% of the muscle; the remaining nerve fascicles supply the rest of
the muscle. A small portion of the muscle can be harvested with the main vascular pedicle and
the fascicle from the anterior branch of the obturator nerve.

amiling in the absence of teeth clenching. The current branch of the adductor artery, which arises from the
hypothesis for this phenomenon involves neural plas- profunda femoris. It runs a circuitous course between
ticity at the level of the motor cortex, whereby path- the adductor longus anteriorly and the adductor brevis
ways connecting the "command" to initiate a voluntary and magnus posteriorly before entering the gracilis at
smile with the cortical zone responsible for mastication the junction of the upper third and lower two-thirds
become established, through repetition and visual and/ (Fig. 11-3). This point of entry is consistently located
or EM.G biofeedback. between 8 and 10 em inferior to the pubic tubercle.
The gracilis musculocutaneous flap was originally The adductor artery arises from the profunda femo-
descn"bed by Harii et al. (5) with a skin island designed ris in the vicinity of the first perforator or from the
over the prcmmal muscle. A longitudinally oriented skin medial femoral circum1lex artery. It gives off branches
paddle overlying the proximal muscle was transferred to adductor longus and brevis, which must be ligated
for a variety of defects (Fig. 11-S).An alternative trans- to obtain adeq_uate pedicle length, which is usually 6
verse skin paddle design was descn"bed by Yousif et al. em. The average arterial diameter is 2 mm. Although
(14) and is believed to increase the reliability of the skin the adductor artery may take its origin from the medial
paddle. However, given the superior reliability of other circumflex femoral artery, the main vascular supply to
musculocutaneous free fiaps, the gracilis musculocuta- the gracilis muscle is not the medial circumflex femoral
neous fiap is no longer a first-line choice in head and artery itself.
neck reconstruction when skin is req_uired. The minor vascular pedicle arises from the supel.'-
ficial femoral artery and enters the lower third of the
muscle. An additional minor vascular supply arises from
NEUROVASCULAR ANATOMY the medial circumfiex femoral artery.
The major artery to the gracilis is accompanied by
The gracilis muscle has a type II vascular pattern, two venae comitantes. These veins may either join or
according to the classification system of Mathes and drain separately into the profunda femoris vein. The
Nahai (10). The dominant pedicle is the terminal average diameter of the veins is 1.5 to 2.5 mm.
16& CHAPTER 11

Profunda femoris a.

Adductor brevis m.
FIGURE 11-5. The cross-sectional anatomy of the medial thigh shows the course of the
adductor artery arising from the profunda femoris artery and running between the adductor
muscles with the brevis and mag nus located posteriorly and the longus located anteriorly. The
musculocutaneous perforator enters the skin opposite the point where the main pedicle enters
the muscle.

The blood supply to the skin is derived through the no published reports of sensory reinnervation with the
system of musculocutaneous perforators. The domi- gracilis musculocutaneous fiap.
nant perforators exit the muscle in the upper third,
with few noted in the middle and lower portions. Yousif
et al. (14) described an additional skin supply through ANATOMIC VARIATIONS
septocutaneous vessels that ezited through the intermu5-
cularseptumbetween the gracilis and the adductor longus. The vascular and nerve supply to the gracilis mus-
The orientation of the terminal bnmches of the septocu- cle is consistent. The major variability is noted in
taneous vessels was also transVerse. The septocutaneous the blood supply to the overlying skin, both in the
vessels in the distal thigh are bnmches of the superficial number and the size of musculocutaneous perfora-
femoral artery, rather than the profunda system. tors. Yousif et al. (14) described several dissections
Motor input to the gracilis muscle is provided by in which there were no musculocutaneous perfora-
the anterior branch of the obturator nerve, which tors exiting the gracilis, and the major skin supply
enters the muscle obliquely, 2 to 3 em cephalad to the was derived from septocutaneous vessels or from the
entry point of the vascular pedicle. The nerve may be inferior branch of the superior external pudendal
traced proximally betWeen adductor longus and bre- artery, which extended into the territory of the gra-
vis to gain additional length. The sensory supply to cilis. Because the skin paddle vascularity is less pre-
the medial thigh skin is from branches of the obtura- dictable than other musculocutaneous free flaps, it is
tor nerve, which may be dissected in the subcutaneous employed much more often as a muscle on{y flap for
tissues cephalad to the skin paddle, though there are dynamic facial reconstruction.

POTENTIAL PITFALLS adductor longus muscle, which, when unrecognized, can

compromise pedicle length and necessitate vein grafting
The morbidity of removing the gracilis muscle is limited during inset. It is critical to recognize when the domi-
because of the strength of the remaining adductor mus- nant pedicle enters the adductor longus, because simple
cles. Due to the small average artery and vein diameter dissection of the artery and venae comitantes through
compared with other free flaps, they are more techni- a small segment of muscle will then permit continued
cally demanding for the novice microvascular surgeon. pedicle dissection toward the profunda femoris system,
Occasionally, the vascular pedicle can enter the overlying with resultant harvest of appropriate length vessels.
168 CHAPTER 11

Gracilis Flap

FIGURE 116. This dissection demonstrates

the harvest of the left gracilis muscle flap.
With the leg flexed and abducted, a dotted line
is drawn between the pubic tubercle and the
medial condyle ofthe tibia. The superior edge
of the gracilis muscle lies approximately 1to
1.5 em posterior to this line. The neurovascular
pedicle enters the muscle on its undersurface
approximately 8 to HI em below the pubic
tubercle. If a musculocutaneous flap was
harvested, the skin paddle would be centered
over this point, oriented either in a transverse
or in a longitudinal direction.

FIGURE 117. The initial incision is carried

through the skin and subcutaneous tissue to
identify the midbelly of the gracilis muscle. The
sartorius is a good landmark to help identify
the gracilis in the midthigh. From the surgical
position, the sartorius is located immediately
above the gracilis. In the proximal thigh, the
adductor longus is immediately above the
gracilis, which is shewn at this point in this

FIGURE 11-8. With the anterior edge of the

gracilis muscle reflected pasteriorly, the neura-
vascular pedicle is easily identified as it enters
the muscle on its deep surface. The neurovas-
cular pedicle exits between the adductar longus
above and adductor magnus below before
entering the gracilis.

Gracilis Flap

FIGURE 11-9. After the artery and vein are

identified, the anterior obturator nerve (arrow)
is found entering the muscle in a mare ablique
course and 2 to 3 em proximal to the vascular

FIGURE 11-10. Branches (arrows) from the

vascular pedicle to the adductor longus muscle
must be ligated ta maximize the length of the

FIGURE 11-11. The vascular pedicle can be

dissected medially to obtain an average of6 em
of length. The maximum diameter af the artery
is approximately 2 mm, and the vein may reach
a diameter of3 mm.
110 CHAPTER 11

Gracilis Flap

FIGURE 1112. The wound is closed by

reapproximating the fascia of adductor longus
and mag nus and then closing the skin in layers.

FIGURE 11-13. A segment of the gracilis

muscle has been harvested with the nutrient
artery and its paired venae comitantes. The
anterior obturator nerve is shown entering the
muscle in a more proximal location. The muscle
may be divided longitudinally to reduce the bulk
while preserving the neurovascular pedicle to
the anterior segment.

Gracilis Muscle for Facial Reanimation

Fac:llll artery and velA

FIGURE 11-14. The harvested gracilis is inset systematically. A pseudotendon is created on

both ends of the harvested muscle using a 3-0 vicryl running locking suture. The proximal inset
is performed using 0-vicryl at five carefully determined locations that duplicate the normal smile
pattern. Two sutures are placed in the upper lip, one at the modiolus and two in the lower lip,
utilizing a mattress suture technique. The distal inset is performed using 0-vicryl, securing the
muscle to the true temporalis fascia.
112 CHAPTER 11

Anastomosis of Cross Facial Nerve

Graft to Obturator Nerve

FIGURE 11-15. The distal end of the previously

placed cross-facial sural nerve graft is located
through a mucosal incision in the upper lip.
The obturator nerve is passed medially through
the intraoral incision prior to muscle inset, and
the neurorrhaphy is performed via an intraoral

Isolation of Masseteric Motor Nerve





FIGURE 1116. The masseteric branch of the trigeminal nerve (V3) can be used as the donor
nerve when patients desire a one-stage procedure or the contralateral facial nerve is not an
appropriate donor nerve {i.e., NF-2 or bilateral facial paralysis). It is located by first reflecting
the masseter muscle inferiorly through division of its fascial attachments to the zygomatic arch.
The masseter nerve is typically located 1 to 11 mm anterior to the articular tubercle and within
the body of the masseter muscle. The use of a lighted retractor and a nerve stimulator facilitates
this dissection.
114 CHAPTER 11

Reinnervation of the Masseteric Nerve and Bilateral Gracilis Muscle Transfer




FIGURE 11-17. When using the masseteric

branch of V3, the vascular anastomoses are
performed, and the neurorrhaphy is executed
under the zygomatic arch prior to lateral muscle Facial artery and vein

RGURE 11-11. In bilateral facial paralysis,

simultaneous bilateral free gracilis muscle
transfer with oral sphincter reconstruction
can be performed for one-stage bilateral facial
reanimation. Two extended gracilis muscles
are harvested (14-16 em) and bivalved at one
end. Coaptation of the left and right gracili is
performed through vertical incisions made in
the midline of the upper and lower lip vermilion,
creating a complete oral sphincter.

REFERENCES 8. Manktelow R: Mic!ooarcular RecomtTUCrion: Anatong~,

Applications and Surgical Technique. New York: Springer-
Verlag; 1986.
1. BaeYC, Zuker RM, Manktelow RT, Wade S: A comparison
of commissure excursion following gracilis muscle trans- 9. Manktelow Kr, Tomat LR, Zuker RM, Chang M: Smile
plantation for facial paralysis using a cross-face nerve graft reconstruction in adults with free muscle transfer inner-
versus the motor nerve to the masseter nerve. Plart Reconm vated by the masseter motor nerve: effectiveness and cere-
Surg 2006;117:2407-2413. bral adaptation. Plast Reconm Surg 2006;118:885-899.
2. Frey M, Happak W, Girsch W, Bittner RE, Gruber H: His- 10. Mathes S, Nahai F: Clinical Application for Muscle and
tomorphometric studies in patients with facial palsy treated Musculocutaneous Flaps. London: CV Mosby; 1982.
by functional muscle transplantation: new aspects for the 11. McGraw J, Massey F, Shanklin K, Horton C: Vaginal
surgical concept. Ann Plast Surg 1991;26:370-379. reconstruction with gracilis myocutaneous flaps. Plast
3. Harii K: Microneurovascular free muscle transplantation. ReconstT Surg 1976;58:176.
In: Rubin 1.., ed. The Paralyzed Face. Philadelphia: Mosby 12. Pickrill K, Georgiade N, Maquire C, Crawford H: Graci-
Yearbook; 1991:178-200. lis muscle transplants for rectal incontinence. Surgery
4. Harii K, Olunori K, Sekiguchi J:The free musculocutane- 1956;40:349.
ous flap. Plast ReconstT Surg 1976;57:294-303. 13. Wingate G: Report of treatment of ischial pressure ulcers
5. Harii K, Ohmori K, Torii S: Free gracilis muscle transplan-
with gracilis myocutaneous island flaps. Plast ReconstT
tation with microvascular anastomosis for the treatment of Surg 1978;62:245.
facial paralysis. PlastReccnstrSurg 1976;57:133-135. 14. Yousif N, Matloub H, Kabachalam R, Grunert B,
6. Kumar PA, Hassan KM: Cross-face nerve graft with free- Sanger J: The transverse gracilis musculocutaneous flap.
muscle transfer for reanimation of the paralyzed face: a com- Ann Plasz Surg 1992;29:482-490.
parative study of the single-stage and two-stage procedures. 15. Zuker RM, Goldberg CS, Manktelow RT. Facial ani-
Plast ReccnstT Surg 2002;109:451-462; discussion 463-454. mation in children with Mobius syndrome after seg-
7. l..ifchez SD, Matloub HS, Gosain AI<: Cortical adaptation mental gracilis muscle transplant. Plast RecomtT Surg
to restoration of smiling after free muscle transfer inner- 2000;106:1- 8; discussion 9.
vated by the nerve to the masseter. Plast ReconstT Surg
2005;115:1472- 1479.
~e first free fiap to be transferred that was based reliability, is the key reason why the radial forearm flap
~ on the radial artery was a segment of the superfi- has assumed such an important place in head and neck
cial branch of the radial nerve and was performed by reconstruction.
'Iltylor in 1976 (48). However, the radial forearm fiap,
as a fasciocutaneous flap, was first introduced by Yang
et al. (57) in the Chinese litezature in 1981. This ini- FLAP DESIGN AND UTILIZATION
tial report of 60 radial forearm fiaps with only one fail-
ure was soon followed by additional publications from The skin of virtually the entire forearm, extending from
China (40), and, hence, this flap became known as the the antecubital fossa to the fiexor crease of the wrist,
"Chinese fiap." Soutar's group ( 42-44) popularized the may be harvested (Fig. 12-1). The thickness of this
radial forearm fiap for intraoral reconstruction through fiap varies among individuals but tends to be thinner
a number of publications, the first of which appeared in its distal portion. The fiap is also usually thinner in
in 1983. male than in female patients. The degree and pattern of
Baaed on the radial artery and either the cephalic hair-bearing skin also varies between individuals.
vein or the venae comitantes, this fiap may be trans- The radial forearm fasciocutaneous flap bas
ferred as a composite fiap containing vascularized bone been used more extensively and for more diverse
( 43), vascularized tendon (34), the brachioradialis mus- reconstructive problems than any other free flap.
cle (36), vascularized nerve (19), or sensory nerves (20). Unquestionably, its greatest application is in the res-
However, its thin pliable skin with its rich vascularity, toration of oral mucosal defects following ablative sur-
permitting a flexibility in design and a high degree of gery. It has been used in virtually every portion of the



FIGURE 121. The size and shape of the radial forearm flap vary with the defect. The axis of the flap
should be centered over the course of the radial artery and the cephalic vein. The flap may extend
from the flexor crease of the wrist to above the antecubital fossa. There are regional differences in
the thickness of the subcutaneous tissue with the thinnest flaps harvested from the distal forearm.
The donor site is more easily camouflaged when the majority of it is located on the volar surface.

oral cavity (23,27,28,29,42,43,55).In 1994, Urken and to achieve a mucosal surface. In addition, this teclm.ique
Biller (52) deacribed a bilobed design for the radial produced a thinner and less mobile layer over the man-
forearm flap to help preserve the mobility of the residual dible that was more conducive to the placement of a
tongue following significant glossectomy. Toward that dental prosthesis.The avoidance ofa skin graft produced
end, this fl.ap provides thin and redundant tissue. The a more favorable donor-site appearance. Although this
bilobed design allows one lobe to be used to resurface technique has merit in resurfacing the alveolus, it may
the tongue defect; the second lobe is placed in the Boor lead to tethering in the Boor of the mouth as a result of
of mouth. In so doing, the rest of the tongue remains scar formation.
separate from the inner table of the mand:&ble. The deep Another disadvantage of using a fascial free flap is
fascia and subcutaneous tissue can be harvested with- that it removes the sensory receptors preaent in the skin
out the overlying skin. Ismail (20) desenbed this fasci and therefore leads to less predictable sensory restora-
subcutaneous fl.ap for extremity reconstruction and also tion following anastomosis of the antebrachial cutane-
reported the improved aesthetic result of a straight-line ous nerves to recipient nerves in the head and neck. We
closure of the preserved forearm skin. This fascial flap reported the first successful sensate radial forearm flap
may be covered with a skin graft to resurface epithelial in head and neck reconstruction (56). A young woman
defects. It is also highly effective in skull base surgery to with a pharyngeal defect underwent reconstruction
assist in dural repair; this thin well-vascularized tissue is with a forearm Bap, and the sensory nerve was anasto-
more easily inset in locations adjacent to the brain that mosed to the greater auricular nerve. The patient expe-
will not accommodate thicker flaps. Martin and Brown rienced sensation when driD.king hot and cold liquids
(27) introduced the free radial forearm fascial Bap for that was referred to her ear. Arguably, the greater auric-
intraoral reconstruction. They described a rapid re- ular nerve was not the best recipient nerve for a pharyn-
epithelialization of the fascial-subcutaneous tissue layer geal defect, but it provided a valuable result. It showed
178 CHAPTER 12

that sensate flaps could be successfully used in the head (36). The palmaris longus tendon was transferred with
and neck and that the mechanism for sensory recov- the forearm skin to provide support to the lower lip
ery was through the nerve anastomosis. Our experience and to maintain the height of the lower lip. The com-
with sensate flaps has grown to include more than 60 bination of the palmaris longus tendon with the sen-
cases, and our enthusiasm for this technique remains sory nerve supply provides an elegant total lower lip
high, based on the predictable level of sensory recov- reconstruction.
ery and the functional impact on patient rehabilitation There are occasions in head and neck reconstruction
(52). The upper aerodigestive tract defects in which we in which multiple skin paddles are required. The radial
believe sensate flaps have their greatest applications are forearm flap has been divided into two epithelial sur-
mobile tongue and tongue base reconstructions, phar- faces separated by a de-epithelialized zone for providing
yngeal wall reconstruction, laryngeal reconstruction inner and outer linings (5). The intervening zone has
following partial laryngectomy, and restoration of the been divided down to the level of the fascia while still
upper and lower lips. providing adequate vascularity to the distal skin pad-
In addition to defects of the lower half of the oral dle (3).YousifandYe (58) divided the perforators to the
cavity, the radial forearm flap has been used for palatal forearm skin into three clusters of vessels along the lat-
reconstruction. Hatoko et al. (18) reported their favora- eral intermuscular septum, each capable of supporting
ble experience with reconstructing the hard palate with a segment of skin.
a folded double-layer forearm flap following maxil- A segment of radius, limited proximally by the inser-
lectomy. One layer was used for the oral side and the tion of the pronator teres and distally by the insertion of
other layer for the nasal and sinus floors. These patients the brachioradialis, may also be harvested (Fig. 12-2).
were reportedly able to wear a maxillary denture. We The length of bone is no greater than 10 to 12 em, and
have had considerable success in reconstructing partial the bone stock is restricted to 40% of the circumference
and total soft palate defects with a folded radial fore- of the radius. Soutar and Widdowson (44) reponed the
arm flap. The two layers of the flap are used for the oro- successful use of the osteocutaneous radial forearm
pharyngeal and nasopharyngeal sides of the defect. To flap in 12 of 14 patients who undeiWent oromandibu-
achieve velopharyngeal competence, the folded edge of lar reconstruction. Osteotomies were created in nine
the flap is sutured to the posterior pharyngeal wall by patients to achieve a more favorable contour of the
de-epithelializing opposing surfaces. Bilateral mucosa- neomandible. Although the composite osteocutaneous
lined pons provide communication on either side of the flap is conceptually attractive for the reconstruction of
midline attachment. oromandibular defects, there are two major factors that
The desire to add to the versatility of the forearm restrict its use. The dimensions of the bone that can be
donor site has led investigators to include additional safely harvested are limited by the necessity to maintain
components to this flap. The use of the brachioradialis is the structural integrity of the remaining radius. Other
a product of that desire. It has been shown that although donor sites for vascularized bone provide much better
the dominant muscular perforator to the brachioradialis bone stock for functional mandibular reconstruction
may arise from the radial artery (40%), the radial recur- (31,51). The second major factor mitigating against the
rent artery (33%), or the brachial artery (37%), it can use of the radius is the potential morbidity resulting from
be reliably transferred with the radial artery because of pathologic fractures that have occurred in up to 23%
a series of secondary perforators (37). There are a large of reported cases (51). Although specific techniques in
number of musculocutaneous perforators that exit the creating the osteotomies and prolonged postoperative
surface of the brachioradialis that allow a separate skin immobilization help to limit the incidence of fractures,
paddle to be harvested with the muscle as a carrier. Not the potential morbidity and the poor bone stock make
only does this add bulk to the flap but it also permits this a less favored site for harvesting vascularized bone.
separate epithelial surfaces to be harvested for complex A more detailed discussion of the osteocutaneous radial
defects. The brachioradialis may also be transferred as a forearm flap is provided in Chapter 23.
functional muscle unit if desired (36). As noted above, the superficial branches of the radial
The brachioradialis has been used for total upper lip nerve may be transferred as vascularized nerve grafts.
reconstruction by suturing the two ends of the mus- An isolated case report using this technique for the
cle to the inferior mbicularis oris. Reinnervation of the repair of the facial nerve revealed excellent results (20).
muscle was accomplished by suturing the motor nerve However, the true value of vascularized nerve grafts
of the brachioradialis to a buccal branch of the facial over nonvascularized grafts remains controversial.
nerve. Swanson et al. (45) reponed excellent functional The radial forearm flap has been used successfully to
results and electromyographic evidence of electrical cover large cutaneous defects of the head and neck, in
activity in the muscle. Total lower lip reconstruction particular, those involving the scalp where thin coverage
with a radial forearm flap was reported by Sadove et al. is desirable (8). The radial forearm flap has also been

Cephalic v

Segment of radius

FIGURE 12-Z. The cross-sectional anatomy of the forearm reveals the radial artery with its
venae comitantes in the lateral intermuscular septum. The connection of the septum to the
radius provides vascularity through perforators that supply the periosteum. The amount of
radius that may be safely harvested is limited to 40% of the circumference.
180 CHAPTER 12

applied to the restoration of complex defects of the nose the flap was folded to line the hemilarynx and the medial
and forehead (1,7). wall of the pyriform sinus. All four patients were able to eat
Regional differences in the thickness of the skin of the orally, and three of the patients were decannulated. The
forearm can be used to achieve a more aesthetic result, full extent to which this technique can be applied in partial
as dictated by the particular defect. More proximal skin laryngeal surgery has not y.:t been realized.
paddles offer thicker tissue and the potential for wider Hagen (14) presented a modified design of the radial
flaps. Skin grafts placed over the proximal muscle bed forearm flap for postlaryngectomy voice rehabilitation.
are more reliable than those that are placed over the The forearm flap was tubed to create a skin-lined tube
distal tendons. The disadvantage of a skin flap harvested that was sutured to the cephalad end of the trachea. An
from a proximal location is that it significantly shortens epiglottis-like structure that was reinforced with autol-
the arterial pedicle. Baird et al. (1) described a proximal ogous cartilage was sutured over the open end of the
forearm flap for forehead reconstruction in which per- tube positioned at the base of tongue. The advantage
fusion was maintained by retrograde flow through the of this form of alaryngeal speech was that there was no
distal radial artery, which was attached to the superficial prosthesis required, and the phonation pressure was
temporal artery on one side of the head. The cephalic less than that with a tracheoesophageal prosthesis. Most
vein was dissected proximally in the arm for additional importantly, the seven patients in the series were able to
length and was anastomosed to the external jugular vein swallow without aspiration.
in the contralateral neck. The use of the radial forearm flap in the oro- or
The radial forearm flap has also been applied to hypopharynx creates a problem for postoperative moni-
smaller defects in the head and neck. Tahara and Susuki toring because of the limited access to these regions.
(46) reported favorable results when introducing a I introduced a new design for the buried radial forearm
radial forearm flap into the orbit to correct malignant flap in which there are two skin paddles: a distal one for
contracture of an irradiated enophthalmic eye socket. resurfacing the mucosal defect and a smaller proximal
The creation of an epithelium-lined socket permitted one that is exteriorized in the neck (Fig. 12-3) (53). The
the patient to wear an orbital prosthesis. intervening fascial subcutaneous tissue is used to cover
Another application for the radial forearm flap is in the carotid artery and provide augmentation to the radi-
circumferential pharyngoesophageal reconstruction. cal neck dissection defect. Because the superficial veins
Harii et al. (17) introduced the concept of a tubed and the radial artery are completely encompassed by
radial forearm flap to reconstruct a laryngopharyngec- this vascularized subcutaneous tissue, it provides an
tomy defect. The thin pliable tissue from this donor site effective barrier for the pedicle in the event of a salivary
is more readily tubed than is a thicker musculocuta- fistula.
neous flap. In addition, this method of reconstruction A design of the radial forearm flap, described as the
offers distinct advantages over free jejunal autografts beavertail modification, has been published by Seikaly
because of the avoidance of a laparotomy. Two differ- et al. (38). In their modification, the fat and fascia of the
ent designs for a tubed radial forearm flap reconstruc- upper part of the forearm are separated from the vas-
tion of the pharyngoesophagus are demonstrated in this cular pedicle and left attached to the proximal portion
chapter: one is a more longitudinal orientation of the of the skin paddle to function as a random adipofas-
flap (Figs. 12-32 to 12-36) and the second a horizontal cial extension of the radial forearm flap (Fig. 12-21 to
design (Figs. 12-37 to 12-44). In addition, the tubed 12-31). The fat is then rolled and precisely placed into
radial forearm flap can be used to lengthen the short the defect to provide bulk in the area required. Excellent
tracheal stump following resection of stomal recur- functional outcomes have been documented using this
rences. The design of a trapezoid-shaped flap produces technique for base of tongue reconstructions (35), and
a funnel-shaped tube that can bridge the gap between this modification can be used in many situations where
the tracheal stump and the cervical skin (Figs. 12-45 to strategically placed bulk is required in conjunction with
12-51). a radial forearm flap.
The versatility of the forearm donor site is further
reflected by its use in reconstructing defects of the larynx
and pharynx. Chantrain et al. ( 6) described the application NEUROVASCULAR ANATOMY
of the radial forearm flap to the reconstruction of a vt:rtical
hemipharyngolaryngectomy defect in three patients with a The blood supply to the lower arm and the hand is
pyriform sinus cancer and one patient with a transglottic derived from the brachial artery, which divides into the
carcinoma.The tendon of the palmaris longus was included radial and ulnar arteries at the level of the antecubital
with the flap and fixed anteriorly to the thyroid cartilage fossa. The radial artery gives rise to the deep palmar
and posteriorly to a hole drilled in the midline of the ros- arch; the ulnar artery terminates in the superficial pal-
trum of the cricoid cartilage. This maneuver provided a mar arch. Harvest of the radial forearm flap requires
fixed position for the neocord. The cutaneous portion of complete interruption of the radial artery and therefore

Lateral antebrachial cutaneous n.

FIGURE 12-3. A modified design of the radial forearm flap has a distal skin paddle for resurfac-
ing a mucosal defect and a proximal skin paddle 1hat is exteriorized in the neck to serve as a
monitor. The intervening subcutaneous tissue provides coverage of 1he great vessels and the
microvascular pedicle and also leads to augmentation of the radical neck dissection deformity.

total reliance on the ulnar system to maintain the be based on the radial artery are undetermined. Yang
vascular supply to the hand (Fig. 12-4). et al. (57) reported a radial forearm fl.ap that measured
There are four arterial systeDUI that supply the 35 x 15 em. There is at least one case in the literature
forearm skin through an array of septocutaneous and in which the entire skin of an amputated forearm was
musculocutaneous perforators. These four vessels are ttansferred as a free flap based on the radial artery (56).
the radial, ulnar, anterior, and posterior interosseous In addition to supplying the forearm skin through
arteries (24). the fascial plexus, the radial artery sends branches to
The fl.exor and extensor muscles of the forearm are the muscles of the flexor compartment, the palmaris
enclosed by a common fascial sheath. A condensation longus tendon, and the radial nerve. The lateral intel'-
of this fascia, referred to as the lateral intermuscular muscular septum is attached to the distal radius, and it
septum, separates the brachioradialis and the flexor is through this connection that it supplies branches to
carpi radialis in the forearm (Fig. 12-2). The radial the periosteum, allowing harvest of a segment of vas-
artery, with its two venae comitantes, runs in the lat- cularized bone (10). A longitudinal vascular arcade has
eral intermuscular septum and gives off 9 to 17 fascial been described on the surface of the periosteum that
branches in the forearm. 'Ihis fascial plexus supplies the originates in close proximity to the insertions of fl.exor
skin of virtually the entire forearm. There are few fas- pollicis longus and pronator quadratus (42).
cial branches in the middle third of the forearm, and The radial forearm flap has a deep venous supply
in fact, the connections between the radial artery and through the two paired venae comitantes, which run in
the deep fascia are attenuated because of the overlap the intermuscular septUm as well as the larger superficial
between the flexor carpi radialis and the brachioradialis. veins, such as the cephalic vein. Both venous systems
The radial artery gives off a few fascial branches in the have valves that permit unidirectional fl.ow. The veins
prcmmal third of the forearm. There is one dominant that supply the fascial plexus run with the branches of
faaciocutaneous branch in the proximal forearm, the the radial artery and drain into the venae comitantes.
inferior cubital artery, which has been used to supply a The multiple connections between the venae comitantes
prcmmally based fasciocutaneous fl.ap. This vessel may and the superficial veins form the basis for using either
arise from either the radial or the radial recurrent arter- of these two systems to drain the flap. The branching
ies (24). Ink-injection studies revealed that the vessels patterns of the deep and superficial venous systems
in the distal zone are capable of supplying a fasciocu- have been classified into five different types (49). In the
taneous fl.ap that atends proximally to the elbow (48). type 1 pattern (20%), there is a wide communication
The maximum dimensions of the skin territory that can through an anastomotic vein between the superficial
182 CHAPTER 12

~lnara. Deep palmar arch Superficial palmar arch

FIGURE 12-4. The radial artery runs a course between the flexor carpi radialis and the bra-
chioradialis muscles before terminating in the deep palmar arch. The deep palmar arch sup-
plies the principal circulation to the thumb and index finger. The ulnar artery terminates in the
superficial palmar arch, which primarily supplies the third, fourth, and fifth digits and often also
the index finger.

and deep systems. In addition, the median cubital vein ciency when using either the superficial or deep systems
splits into two large branches: the cephalic median vein independently.
and the baailic median vein. The type 2 pattern (43%) In addition, it has been my experience that in
is the most common and is identical to type 1 except patients who have been hospitalized for prolonged peri-
that the median cubital vein does not bifurcate. The ods of time, the antecubital veins are often thrombosed.
type 3 pattern (18%) includes a conBuence of the two In these patients the deep venous system is usually
venae comitantes to a sizable common trunk, but there enlarged and suitable for microvascular anastomosis.
is no significant communication of this common trw::Lk The length of the arterial pedicle to this fiap is lim-
with the cephalic vein to form a median cubital vein. ited by the radial recurrent artery, which is the first
In the type 4 pattern (5%), the venae comitantes do major branch of the radial artery following ita takeoff
not converge or join with the cephalic vein, but each is from the brachial artery. The radial recurrent artery is
of suitable caliber for microvascular anastomosis. The primarily a muscular branch. Alternatively, the cephalic
type 5 pattern (15%) is similar to type 4 except that vein may be traced throughout its entire course in the
one of the venae comitantea is dominant relative to the upper arm to ita junction with the subclavian vein in the
other. I prefer to use the subcutaneous venous system infraclavicular region. The additional length of vein that
because of the larger caliber vessels and the thicker wall, can be harvested by extending the dissection above the
which permits an easier anastomosis. Often, there are antecubital fossa may be helpful in skull base reconatruo-
multiple subcutaneous veins suitable for anastomosis, tions in which vein grafts are frequently needed. This
depending on the design of the radial forearm flap. flap has been used in the head and neck in a manner in
When the types 1 and 2 patterns are identified, I prefer which the venous outfiow is maintained without intel'-
to use the median cubital vein for anastomosis based ruption of the cephalic vein while performing only an
on the theoretical advantage that both the deep and anerial anastomosis (32). Using this technique of an
superficial systems are being directly drained. However, extensively mobilized but uninterrupted cephalic vein,
I have never encountered a problem of venous :insuffi.- Bhathena and Kavarana (3) described using a proximal

forearm fiap that was revascularized through retrograde then divides into the dorsal digital nerves supplying sen-
arterial flow through the distal radial artery. The reli- sation to the dorsum of the hand, thumb, and index and
ance on retrograde flow through the radial artery is rou- middle fingers. Although the distal branching pattern is
tinely used when the "reversed radial forearm flap" is highly variable, the major branches are always encoun-
transferred as a pedicled fiap to the hand (21). tered in the wrist while elevating the radial forearm
The cutaneous innervation of the forearm is derived flap. This nerve and all ita branches can be routinely
&om the medial, lateral, and posterior antebrachial preserved to maintain sensation to the hand.
cutaneous nerves (Fig. 12-5). The lateral antebrachial
cutaneous nerve, the continuation of the musculocuta-
neous nerve, is the primary sensory nerve to the ter- ANATOMIC VARIATIONS
ritory of forearm skin most commonly harvested. nus
nerve usually runs in close proximity to the cephalic The anatomy of the superficial venous system in the
vein in the upper forearm before ramifying in the distal forearm is highly variable. However, the pattern of veins
forearm and continuing onto the hand in the region of can be easily mapped prior to surgery by placing a tour-
the thenar eminence. The medial antebrachial cutane- niquet on the upper arm and tracing the course of the
ous nerve arises &om the medial cord of the brachial engorged veins.
plexus, runs with the basilic vein, and supplies the skin The greatest concern in harvesting the radial fore-
of the medial aspect of the forearm. The skin of the dor- arm flap is the integrity of the ulnar arterial supply
sum of the forearm is supplied by posterior branches to the hand through the superficial palmar arch. It is
of the medial and lateral antebrachial cutaneous nerves therefore the anomalies of the arterial blood supply to
and by the posterior antebrachial cutaneous nerve, a the hand that must be addressed. On the moat basic
branch of the radial nerve. The medial and posterior level, the blood supply to the hand following radial
antebrachial cutaneous nerves are rarely encountered in artery transsection relies on the presence of an ulnar
the dissection of a forearm flap, except when very large artery. In a cadaveric study of 750 upper extremities,
fiaps are harvested. McCormack et al. (30) found the ulnar and radial arter-
The radial nerve is a mixed motor and sensory nerve. ies to be present in all cases. The ulnar artery supplies
It supplies most of the muscles of the extensor compart- the hand through the superficial palmar arch, which is
ment and the abductor pollicis longus and brevis. The either "complete,"' in the sense that it provides branches
sensory distribution of this nerve includes portions of to four fingers and the thumb, or "completed"' through
the upper arm and the dorsum of the forearm through communications with the deep palmar arch. Cadaveric
the posterior antebrachial cutaneous nerve. The super- studies by Coleman and Anson (9) revealed that the
ficial branch of the radial nerve courses in the forearm, ulnar artery supply to the third, fourth, and fifth digits
deep to the brac:hioradialis, and passes laterally to the is rarely, if ever, compromised by anomalous patterns.
brachioradialis tendon where it becomes superficial and When harvesting a radial forearm flap, it is the vascular

Basilic v. Medial antebrachial cutaneous n.

FIGURE 12-5. The sensory nerve supply to the forearm skin consistently follows a course that
parallels the major subcutaneous veins. Depending on the size and orientation of the flap, either
the medial, the lateral, or both antebrachial cutaneous nerves would be incorporated.
184 CHAPTER 12

supply to the thumb and the index finger that is most POTENTIAL PITFALLS
at risk by the combination of two concurrent arterial
variations. The first is an incomplete superficial arch Although the radial forearm flap is a highly reliable
that does not send branches to the thumb and index method of reconstruction, there are a number of donor-
finger. The second anomaly, which must also be pre- site problems that may be encountered. The perfor-
sent for there to be a problem of digital ischemia, is a mance of an accurate Allen test is the most important
complete lack of communication between the superfi- consideration in avoiding the catastrophic complication
cial and deep arches. In 265 cadaveric specimens, Cole- of an ischemic hand. There is one report in the literature
man and Anson found a complete superficial arch in by Jones and O'Brien (22) in which insufficient flow to
77.3% of cases. The coexistence of the two anomalies, the hand resulted from flap harvest despite a normal
which would put the thumb at least at risk of ischemia Allen test result. The hand was salvaged by intraopera-
in the event of radial artery occlusion, occurred in 12% tive recognition of the problem and reconstruction of
of specimens. The problem of anomalous circulation to the radial artery by an interposition vein graft. Bardsley
the hand is reviewed in Chapter 17 and highlighted in et al. (2) reported on a subset of 12 patients in their
Figure 17-6. total series of 100 patients who underwent radial fore-
A third source of blood supply to the hand may arm flaps in whom reconstitution of the radial artery
arise from a persistent median artery, which has been was performed. This group constituted the earliest
noted in up to 16% of cases (9). This vessel usually patients in their series. Despite reestablishing flow in
joins the superficial palmar arch. It is therefore possi- the operating room, only six vein grafts remained pat-
ble that this vessel may supply protective circulation to ent over time. None of the patients with occluded grafts
the hand in those cases in which the thumb and index suffered any complications. Vascular insufficiency may
finger are otherwise at risk following sacrifice of the also result from too tight a closure of the forearm skin or
radial artery. compression from the forearm dressing. Careful obser-
He den and Gylbert (19) reported an aberrant radial vation of the hand both during and after surgery will
artery that was encountered while raising a radial help to avoid such problems.
forearm flap. A small branch of the radial artery was Poor take of the skin graft may result from shearing
found in the normal anatomic position, but the main forces of the underlying muscles as a result ofinadequate
vessel ran a divergent course in the distal forearm immobilization of the hand. Failure to preserve the par-
that was superficial to the extensor pollicis tendons atenon over the flexor tendons may also contribute to
and entered the hand several centimeters radial to its problems with the skin graft.
normal location. This anomaly has been reported to Infection of the forearm donor site is uncommon.
occur in 1% of the population, and its importance is However, the devastating effects of this complication
evident when considering the implications for per- were reported by Hallock (16) who described a patient
forming an accurate Allen test as well as an effective with a frozen hand resulting from a descending sup-
harvest of a radial forearm flap (19,26). Compression purative tenosynovitis. Meticulous sterile technique
of the rudimentary branch may not demonstrate an and avoidance of cross-contamination from the head
abnormality in the palmar arch, putting the thumb at and neck by using a separate set of instruments are
risk for ischemia. If encountered during a dissection absolutely imperative.
of a forearm flap, it is imperative that the true aberrant The aesthetic deformity of the skin-grafted donor site
radial artery is temporarily occluded and the tourni- is recognized as one of the major disadvantages of the
quet released to assess the impact on the vascularity radial forearm free flap. A variety of different techniques
of the hand. have been reported to modify the appearance of the
Additional, although rare, anomalies of the radial skin-grafted forearm defect. Direct closure of the flap
artery have been reported. Otsuka and Terauchi (33) defect has been reported by the use of an ulnar transpo-
reported an aberrant dorsal course of the radial artery sition flap. Long fascial attachments provide a reliable
that passed around Lister tubercle of the radius to enter blood supply to these flaps, which can be used to close
the hand above the extensor tendons. Small and Miller small to medium-sized defects. In muscular individuals,
(39) reported a radial artery that passed deep to the there is often a problem of closing the secondary defect
pronator teres. in the proximal forearm that results from using an ulnar
Anomalies of the ulnar artery are equally rare. How- transposition flap. The usual technique of a V-to-Y
ever, Fatah et al. (12) described an ulnar artery that ran closure will not work, and in such cases, a skin graft can
a course superficial to the flexor muscles in the fore- be placed proximally while achieving full-thickness skin
arm. The importance of recognizing such an anomaly coverage of the flexor tendons distally (2, 11). Poor take
is essential to avoid catastrophic injury to the remaining of the skin graft over the distal flexor tendons can be
blood supply to the hand following harvest of the radial problematic, despite care in preserving the paratenon.
forearm flap.

Coverage of the flexor carpi radialis tendon with tum- is created may be important in avoiding a significant
over muscle flaps of the flexor pollicis longus and the donor-site problem. Bardsley et al. (2) recommended
flexor digitorum superficialis was described to improve removal of as small a segment of bone as possible, and
the donor-site bed to accept a skin graft (13). in the process, they advised creating smooth ''boat-
The use of tissue expanders has been reported to shaped" bone cuts rather than right-angled ones, which
achieve full-thickness coverage of the donor defect. were prone to fracture. Prolonged immobilization and
Masser (28) placed a tissue expander several weeks serial radiographs of the healing donor site were also
prior to flap harvest to facilitate forearm coverage. advised to ensure adequate bone remodeling prior to
The expanders were placed deep to the forearm fas- stressing the forearm.
cia and deep to the radial artery. Careful monitoring Swanson et al. ( 45) tested the hypothesis that the
of the Doppler signal during the expansion phase was type of osteotomy influenced the mechanical strength
critical to prevent occlusion of the radial artery. The of the residual radius. They did not find a statistically
pre-expansion was believed to achieve a greater flap significant difference in the breaking force between a
surface area and to delay marginal areas that may have right-angled bone cut and a beveled bone cut. There
been ischemic following transfer. In addition, Masser was a significant difference in breaking strength (24%)
reported reduced thickness of the forearm flaps. in the group of osteotomized radii compared with that
As an alternative to this approach, Hallock (15) in intact controls. However, the authors did advise the
placed tissue expanders under the residual forearm skin use of a beveled bone cut to reduce the concentration
at the time of harvesting a radial forearm flap. He waited of stress at the corners of right-angled cuts and to mini-
a minimum of 2 weeks to begin serial expansion. In mize the amount of bone removed, which they believe
10 patients so treated, 5 had linear scars; the remaining should not exceed one-third of the radial diameter. In
patients had a significant reduction in the size of the addition, they advised an above-elbow splint for 8 weeks
skin-grafted area. after surgery.
The transfer of a fascial flap alone avoids the problem The institution of postharvest protective measures
of a cutaneous donor-site defect. Fascial flaps can be with rigid fixation will be presented in Chapter 23
transferred and covered with a split-thickness skin graft. and has greatly reduced the incidence of donor-site
To eliminate the necessity of using a separate donor complications.
site for harvesting a skin graft, Kawashina et al. (23)
described the de-epithelialized forearm flap for resur-
facing the lining of the upper aerodigestive tract. The PREOPERATIVE MANAGEMENT
forearm flap was harvested and then de-epithelialized
on a drum dermatone. The resulting split-thickness graft Factors, such as tissue thickness, hair-bearing skin,
was returned to the forearm, avoiding the deformity of a and the distribution of superficial veins, can be
second donor site for a skin graft. The de-epithelialized assessed preoperatively to plan the design of the fore-
flaps healed uneventfully and were rapidly covered by arm flap. The flap,s dimensions and shape can usually
an epithelial layer. be accurately determined by direct laryngoscopy and
The most common neurologic problems in the fore- manual palpation. However, we usually wait to harvest
arm are related to sensory loss following injury to the this flap until frozen sections on tumor margins have
superficial branches of the radial nerve and transsection been determined. The Allen test is the most important
of the antebrachial cutaneous nerves. Anesthesia over preoperative evaluation to assess the adequacy of the
the region of the anatomic snuffbox and the thumb and circulation to the hand through the ulnar artery. The
first finger can be troublesome for patients and every Allen test must be performed properly. Simultaneous
effort should be taken to avoid this complication. Pain- compression of the ulnar and radial arteries is applied
ful neuromas have not been a problem in my experience, by the examiner while the hand is alternately opened
but the potential certainly exists. and closed. This pumping action causes the hand to
The function of the hand following routine harvest of become pale as a result of mechanical exsanguina-
a radial forearm flap is usually normal. The potential for tion. The hand is then opened to a relaxed position
morbidity in the hand mounts when an osteocutaneous prior to the release of the ulnar artery. It is impor-
flap is harvested. Fracture of the radius can have a sig- tant that the fingers are not held in a hyperextended
nificant detrimental effect on supination, wrist flexion, position, which can cause them to remain pale and
grip strength, and pinch strength ( 4). As noted previ- therefore lead to a false-positive result. Release of the
ously, this potential morbidity and the poor bone stock ulnar artery should cause reperfusion through a blush
greatly limit the advisability of routinely using the oste- of the hand within 15 to 20 seconds. Hthere is a delay
ocutaneous flap. However, there are situations in which beyond this time, then this raises concern about the
a very small composite flap may be needed. Under these ulnar circulation, and a radial forearm flap should not
circumstances, the method by which the osteotomy be performed. In dark-skinned individuals in whom
186 CHAPTER 12

capillary blush is not easily assessed, the perfusion of were employed. Failure to detect a palpable pulse in the
the hand can be confirmed by checking the capillary radial artery should trigger concern or selection of an
refill of the nail bed on compression and release of the alternative donor site. Doppler assessment will confirm
fingernail. It is imperative that the examiner observe the integrity of flow through that vessel.
the vascularity to the thumb for the reasons outlined
earlier. It is our preference to select the nondominant
arm for flap harvest. The Allen test should be repeated POSTOPERATIVE CARE
to confirm the initial findings. A final check may be
performed in the operating room where a pulse oxime- After applying a split-thickness skin graft, a volar plas-
ter can be attached to the thumb to assess the wave- ter splint is formed that extends from the fingers to the
form changes when the Allen test is repeated. Little et antecubital fossa. A compressive wrap is then placed
al. (25) reported a 3% incidence of positive Allen test over the splint, and the forearm is elevated. Immobili-
findings in the general population. The reliability of zation of the forearm is important to prevent shearing
this test for screening individuals with poor ulnar cir- of the muscles underneath the skin graft. It is impera-
culation is attested to by my experience with over 500 tive that the vascularity of the hand be confirmed after
patients and Soutar's (41) experience with 200 radial releasing the tourniquet. The circulation to the thumb
forearm flaps in which no cases of hand ischemia have must be assessed to ensure once again that the collat-
occurred. eral circulation through the ulnar artery provides suf-
On admission to the hospital for a radial forearm ficient vascularity. The dressing and the volar splint are
flap, a bandage is placed over the donor forearm to pre- left in place for approximately 7 days following surgery.
vent anyone from using that arm for arterial or veni- During this time, the forearm is elevated, and monitor-
punctures. The patient must also be instructed to warn ing of the vascularity to the hand is continued to be
all hospital personnel against violation of the forearm. certain that the bandage does not cause compression of
Patients who have been hospitalized for prolonged peri- the circulation as a result of the postoperative edema.
ods may have few patent superficial veins in their arms. On the seventh day following surgery, the dressing is
A forearm flap may be harvested in these patients based removed, and the skin graft is observed. A conforming
on the venae comitantes, or perhaps more prudently, an elastic stocking is then used to assist in wound healing
alternative donor site should be selected. and reduce edema in the hand resulting from the inter-
The patency of the radial artery is rarely an issue ruption of the venous and lymphatic supplies. Copious
except in those patients who have had a previous padding must be placed in the operating room prior
indwelling radial artery catheter. Although flow in these to the compressive dressing in order to avoid pressure
vessels is usually restored over time, I have encountered ulceration over prominent points. The development of
a small number of cases in which this has not occurred. pain in the wrist or hand under the volar splint should
The Allen test will obviously not detect an occluded trigger an urgent examination to ensure that pressure
radial artery unless a reverse occlusion of the ulnar ulceration has not occurred.

Radial Foreann Fasciocutaneous Flap

FIGURE 12-6. The design of the radial fore-

arm flap begins by outlining the path of the
dominant subcutaneous veins and the palpable
pulse of the radial artery. The paths of the
cephalic vein and the radial artery have been
drawn on the left forearm. In this dissection,
the approximate topographical anatomy of the
sensory nerves is outlined in orange. The lateral
antebrachial cutaneous nerve runs adjacentto
the cephalic vein, and the approximate course
of the superficial branches of the radial nerve
is shown as the branches terminate on the
dorsum of the hand.
FIGURE 127. A rectangular radial forearm
flap has been outlined on the distal forearm.
The axis of this flap is centered on the radial
artery and the cephalic vein. A curvilinear
dotted line indicates the incision in the proximal
forearm where skin flaps will be elevated to
provide access to the proximal portion of the
neurovascular pedicle. A larger skin paddle
can be harvested that extends proximally to the
antecubital fossa and virtually encompasses
the entire circumference of the forearm, except
for a bridge of skin along the ulnar aspect.

FIGURE 12-8. The dissection begins distally

after exsanguination of the forearm through the
use of an elastic bandage and raising the tour-
niquet to approximately 250 mm Hg. The distal
skin incision is made to gain exposure of the
radial artery and its adjacent venae comitantes.

Radial Foreann Fasciocutaneous Flap

FIGURE 129. The radial artery is then ligated

and divided.

FIGURE 12-10. Dissection may begin either

from the ulnar or from the radial direction. In
this particular dissection, the skin flap has
been elevated, starting from the radial aspect.
The distal portion ofthe cephalic vein must be
ligated and transsected.

FIGURE 1211. The skin flap has been elevated

with the deep fascia to the level of the lateral
intermuscular septum marked by the border of
the brachioradialis. The superficial branches of
the radial nerve are isolated and preserved to
maintain sensation to the dorsum of the hand.
The dissection of the ra dia I nerve requires that
the subfascial plane of dissection be broken.

Radial Foreann Fasciocutaneous Flap

FIGURE 12-12. The ulnar dissection of the flap

is carried out in a subfascial plane, elevating
the flap off the tendons of the muscles in the
flexor compartment. It is imperative to maintain
the integrity of the paratenon when perform-
ing this dissection. The forearm flap has been
elevated in an ulnar direction to the border of
the flexor carpi radialis, which marks the posi-
tion of the intermuscular septum.

FIGURE 12-13. Skin flaps are elevated in

the dissection proximal to the skin paddle by
making an incision along the dotted line. The
skin flaps are elevated in a subcutaneous plane
to preserve the integrity of the subcutaneous
veins and the adjacent sensory nerves. In this
dissection, there are two subcutaneous veins,
and the lateral antebrachial cutaneous nerve
(arrowhead) is demonstrated lying adjacent to
the cephalic vein.

FIGURE 1214. Atthis point in the procedure,

the radial artery (arrowhead) is dissected
distally to proximally by transsecting and
cauterizing the deeper branches that supply the
muscles of the forearm and the radius.

Radial Foreann Fasciocutaneous Flap

FIGURE 12-15. Dissection along the intermus-

cular septum is continued proximally until the
point of overlap (arrowhead) of the brachiora-
dialis and the flexor carpi radialis.

FIGURE 12-16. In the proximal forearm,

the radial artery courses deep to the
brachioradialis. Therefore, it is apparent that
the primary arterial inflow to the skin com-
ponent of the forearm flap arises through its
fasciocutaneous perforators, which are given
off in the distal third of the forearm.
FIGURE 12-11. Exposure of the proximal radial
artery and the venae comitantes is achieved by
separating the brachioradialis from the flexor
carpi radialis. The radial artery may be traced all
the way to the brachial artery. The forearm flap
is then reperfused by releasing the tourniquet
The vascularity is ensured through observation
of the color and dennal bleeding. In addition,
it is prudent to assess the vascularity of the
hand and in particular the thumb. At this point,
hemostasis is obtained, and the flap is prepared
for harvest when the recipient site is ready. If
a proximal monitor paddle has been designed
for monitoring of a buried flap, it is important to
assess the vascularity ofthe monitor paddle to
ensure that it will be reliable.

Radial Foreann Fasciocutaneous Flap

FIGURE 1218. The donor site is closed by

reapproximating 1he proximal skin flaps as
shown. The remainder of the defect is closed
wi1h a split-thickness skin graft.

FIGURE 12-19. As noted previously, it is imper-

ative to maintain the thin paratenon layer over
the tendons in the distal forearm to facilitate
skin grafting of this donor site.

FIGURE 12-20. The radial forearm flap is

shown wi1h 1he radial artery, the cephalic vein,
and the lateral antebrachial cutaneous nerve.

Beavertail Modification of the Radial Foreann Flap

FIGURE 1221. The beavertail modification is

shown with the beavertail adipofascial paddle
indicated in green {yellow arrowj.

FIGURE 1222. The ulnar (upper) skin flap

is elevated in a subdermal plane to maintain
the maxi mum amount of fat and fascia in the
beavertail portion of the flap.

FIGURE 1223. The ulnar and radial skin flaps

have been elevated. Dissection ofthe radial
forearm flap proceeds, as shown in the prior
description with the inclusion of the large
beavertail portion of fat and fascia.

Beavertail Modification of the Radial Forearm Flap

FIGURE 12-24. The proximal portion of the flap

is shown with the beavertail component high-
lighted with a dashed yellow line. The antecubi-
tal vein is marked with a blue pin.

FIGURE 12-25. The proximal neurovascular

pedicle has been dissected and is shown with
a red pin to demonstrate the radial artery, the
blue pin indicates the antecubital vein, and the
yellow pin highlights the position of the ante-
brachial cutaneous nerve.

FIGURE 12-2&. The flap has been harvested

with a large beavertail paddle. The radial artery
is indicated by the red pin. The cephalic vein
and antebrachial cutaneous nerve are seen
lying in close proximity as indicated by the
blue and yellow pins. The communicating vein
between the deep and superficial systems is
indicated by the middle blue pin (green arrow).

Beavertail Modification of the Radial Foreann Flap

FIGURE 1Z-Z7. In order to mobilize the beaver-

tail, the radial artery pedicle is dissected free of
the surrounding tissue, taking care not to divide
the perforatars to the skin paddle partion of the

FIGURE 1Z-Z8. With the radial artery and

venae comitantes having been separated from
the flap, the attention is turned to performing
the same maneuver for the venous supply to the

FIGURE 1Z-Z9. The cephalic vein is released

fram the beavertail to the level of the skin

Beavertail Modification of the Radial Forearm Flap

FIGURE 12-30. The flap is shown with the bea-

vertail portion dissected free of the pedicle. The
lateral antebrachial cutaneous nerve (yellow
pin), cephalic vein (blue pin), communicating
vein (green arrow), and radial artery (red pin)
are shown.

FIGURE 12-31. The beavertail portion has

been rolled to provide bulk to the distal portion
of the flap. This orientation would commonly
be used for base of tongue reconstruction or
other reconstructions where carefully placed
bulk is required to enhance the functional and
aesthetic result.

Insetting of the Radial Forearm Flap for Pharyngoesophageal Reconstruction

Longitudinal fla orientation

FIGURE 12-32. Harvest of a longitudinally

oriented radial forearm flap for circumferen-
tial pharyngoesophageal reconstruction is
performed with a design as sllown in (A) and
(B), where the length of the defect from the
esophagus to the base of tongue is shown by
the yellow arrow. The width of1he proximal por-
tion of the flap is wider than tile distal flap due
to the larger caliber of the pharyngeal lumen
compared to the esophagus. A B

FIGURE 12-33. The radial forearm flap

has been harvested with a distal extension
(blue arrow) to be incorporated in the dis-
tal anastomosis in a tongue and groove..

FIGURE 12-34. Following a total laryngophar-

yngectomy, the tracheostome (blue arrow) is
formalized and the esophageal stump is pre-
pared for anastomosis (yellowsrrow).

Insetting of the Radial Forearm Flap for Pharyngoesophageal Reconstruction

Longitudinal fla orientation

FIGURE 12-35. A cut is made in the esopha-

geal stump (blue srrow) in order to allow
insertion of the V-shaped extension of the flap,
designed to interrupt the distal anastomosis.

FIGURE 12-36. Insetting of the flap is per-

formed with the distal anastomosis performed
first followed by the proximal repair, and then,
tubing of the flap with a longitudinal suture line.
The monitor paddle is exteriorized in a suture
line in the neck.

Inset of the Radial Forearm Cutaneous Flap for Reconstruction of the

Circumferential Pharyngoesophageal Segment
Horizontal flap orientation
FIGURE 12-37. Harvest of the radial forearm
flap for circumferential pharyngoesophageal
reconstructian is perfarmed with a flap that
is designed with the width detennined by the
distance between the esophagus and the base
of tongue (yellow arrow). This design usually
requires that the flap extends beyond the
volar surface of the forearm. A monitor flap is
designed in the proximal portion of the forearm
(green arrow).

FIGURE 12-38. The flap has been harvested

with the portion of the flap slated for the proxi-
mal anastomosis indicated by line A-B. The
esophageal portion is shorter and indicated by
line C-O. Extensions ofthe radial forearm flap
to be inset into both the esophageal and the
pharyngeal repairs are demanstrated by the
green and blue arrows, respectively.

FIGURE 12-39. Similar to the cut in the proxi-

mal esophagus, an apening is created in the
pasterior wall of the pharynx for inset of the
V-sha ped partion of the radial fares rm flap.

Inset of the Radial Forearm Cutaneous Flap for Reconstruction of the

Circumferential Pharyngoesophageal Segment
Hotizontsl tis otientstion

FIGURE 12-40. The flap is inset into the

pharynx as well as the esophagus.

FIGURE 12-41. Once the posterior walls of the

proximal and distal repairs are completed, the
flap is tubed upon itself.

FIGURE 12-42. The completion of the skin-

lined tube is carried out over a salivary bypass
tube. Meticulous suturing is required to avoid a
sa Iiva ry fistula.

Inset of the Radial Forearm Cutaneous Flap for Reconstruction of the

Circumferential Pharyngoesophageal Segment
Hotizontal flap otientation

FIGURE 12-43. The repair has been completed

and the flap revascularization is now set to be

FIGURE 12-44. With this flap design the vas-

cular anastomoses are usually performed to the
transverse cervical artery and the transverse
cervical or external jugular veins. The monitor
flap is readily placed in the apron incision for
easy access.

Inset of the Radial Forearm Flap for Lengthening of the Mediastinal Trachea

FIGURE 12-45. A radial forearm flap with

similar shape to that of the horizontal orienta-
tion noted above is designed. A monitor is not
required since the flap will be visible in the

FIGURE 12-46. A radial forearm flap is

designed in a fashion so as to create a 'b.Jbed
funnel-shaped structure that bridges the gap
between the cut end of the mediastinal tra-
chea and the cervical skin. This 'b.Jbed flap is
designed with the tracheal end matching up
with the desired circumference of the cut end
of the trachea and the opposite end is Ion ger
so as to create a funnel, with the opening in the
neck considerably larger. The length of the flap
reflects the distance that the flap will have to
traverse in order to comfortably form a conduit
(yellow arrawj. A subcutaneous extension has
been harvested to allow a double-layer closure
of the tracheal anastomosis (blue arrow).

FIGURE 12-47. As is often the case with

stomal recurrences, the pharyngoesophageal
repair has been accomplished with a separate
flap. In this case, a free jejunum was utilized.
The manubrium and the clavicular heads have
been resected with exposure of the great ves-
sels in the mediastinum. The posterior wall af
the tracheal repair has been completed.

Inset of the Radial Flap for Lengthening of the Mediastinal Trachea

FIGURE 12-41. The proximity of the innominate

artery and vein provides impetus for a secure
anastomosis of the skin flap to the tracheal
stump. The development of a leak in this loca
tion will result in seeding of the mediastinum
and a resultant mediastinitis. A double-layer
repair is performed with the skin to mucosal
anastomosis (blue arrow) and then the fascial
subcutaneous extension is sutured to the outer
wall of the trachea (green arrow).

FIGURE 1249. The skin to mucosal anastomo-

sis has been completed and the vertical limb
remains for closure. A circumferential two-layer
anastomosis has been performed.

Inset of the Radial Forearm Flap for Lengthening of the Mediastinal Trachea

FIGURE 12-50. The vertical skin to skin closure

has been completed with everting sutures. The
pedicle exits to the right side.

FIGURE 12-51. The position of the upper

opening to the neotrachea can be altered to
fit the contour of the cervical skin and the
remaining bony architecture of the upper
sternum and clavicles.
204 CHAPTER 12

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Plan Surg 1986;39: 173. 31. Moscoso J, Keller J, Genden E, et al.: Vascularized bone
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1988;41 :358. suitability for enosseous dental implants.Arch Otolaryngol
12. Fatah M, Nancarrow J, Murray D: Raising the radial Head Neck Surg 1994;120:36.
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J Pfast Surg 1985;38:394. based on an extended dissection of the cephalic vein.
13. Fenton 0, Roberts J: Improving the donor site of the The longest venous pedicle? Case report. Br J Pfast Surg
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14. Hagen R: Laryngoplasty with a radialis pedicle flap from 33. Otsuka T, Terauchi M: An anomaly of the radial
the forearm: a surgical procedure for voice rehabilitation artery-relevance for the forearm flap. Br J Plast Surg
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15. Hallock G: Refinement of the radial forearm flap donor 34. Reid CD, Moss AIR: One stage repair with vascularized
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forearm flap. Br J Pfast Surg 1983;36:473.
16. Hallock G: Complication of the free flap donor site from
a community hospital perspective. J Reconstr Microsurg 35. Rieger JM, Zalmanowitz JG, Li SY, et al.: Functional out-
1991;7:331. comes after surgical reconstruction of the base of tongue
using the radial forearm free flap in patients with oropha-
17. Harii K, Ebihara S, Ono I, Saito H, Terui S, Thkato T: ryngeal carcinoma. Head Neck 2007;29(11):1024-1032.
Pharyngoesophageal reconstruction using a fabricated
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the lower lip and chin with the composite radial
18. Hatoko M, Harashina T, Inoue T, Thnaka I, Imai K: forearm-palmaris longus free flap. Plast Reconstr Surg
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of 3 cases. Br J Plan Surg 1990;43:350.

37. Sanger J, Ye Z, Yousif N, Matloub H: The brachioradialis 48. Taylor GI, Ham FJ: The free vascularized nerve
forearm flap: anatomy and clinical application. Presented graft. A further experimental and clinical applica-
at the 8th Annual Meeting of the American Society tion of microvascular techniques. Plast Reconstr Surg
for Reconstructive Microsurgery, Scottsdale, Arizona, 1976;57:413.
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38. Seikaly H, Rieger J, O'Connell D,Ansari K, Alqahtani K, patterns of venous drainage of the free forearm flap
Harris JR: Beavertail modification of the radial forearm in head and neck reconstruction. Plast Reconstr Surg
free flap in base of tongue reconstruction: technique 1994;93:54.
and functional outcomes. Head Neck 2009;31(2):213- 50. Timmons M: The vascular basis of the radial forearm
219. flap. Plast Recomtr Surg 1986;77:80.
39. Small J, Miller R: The radial artery forearm flap: an 51. Urken ML: Composite free flaps in oromandibular
anomaly of the radial artery. Br J Plast Surg 1985;38:50 1. reconstruction: review of the literature. Arch Otolaryngol
40. Song R, Gao Y, SongY, Yu Y, SongY: The forearm flap. Head Neck Surg 1991;117:724.
Clin Plast Surg 1982;9:21-26. 52. Urken MI.., Biller HF: A ne'W' bilobed design for the sen-
41. Soutar D: Radial forearm flaps. In: Baker S, ed. Micro- sate radial forearm flap to preserve tongue mobility fol-
surgical Reconstruction of the Head and Neck. Ne'W' York: lowing significant g]ossectomy. Arch Otolaryngol Head
Churchill Livingstone; 1989. Neck Surg 1994;120:26-31.
42. Soutar DS, McGregor IA: The radial forearm flap in 53. Urken MI.., Futran N, Moscoso J, Biller HF: A modified
intraoral reconstruction: the experience of 60 consecu- design of the buried radial forearm free flap to exteriorize
tive cases. Plast Recomtr Surg 1986;78: 1. a monitoring segment. Arch Otolaryngol Head Neck Surg
43. Soutar DS, Scheker LR, Tanner NSB, McGregor IA: The 1994;120(11):1233-1239.
radial forearm flap: a versatile method for intraoral recon- 54. Urken MI.., Weinberg H, Vickery C, Biller HF: The
struction. Br J Plast Surg 1983;36: 1. neurofasciocutaneous radial forearm flap in head and
44. Soutar DS, Widdowson WP: Immediate reconstruction neck reconstruction: a preliminary report. Laryngoscope
of the mandible using a vascularized segment of radius. 1990; 100:161.
Head Neck 1986;8:232. 55. Vaughan ED: The radial forearm free flap in orofacial
45. Swanson E, Boyd J, Mulholland R: The radial forearm reconstruction. J Craniomaxillojac Surg 1990; 18:2.
flap: a biomechanical study of the osteotomized ramus. 56. Wakrhouse N, Moss A, Townsend Pl.: Lower limb sal-
Plast Reconstr Surg 1990;85:267. vage using an extended free radial forearm flap. Br J Plast
46. Tahara S, Susuki T: Eye socket reconstruction with free Surg 1984;37:394.
radial forearm flap. Ann Plast Surg 1989;23: 112. 57. Yang G, Chen B, Gao Y, et al.: Forearm free skin flap
4 7. Takada K, Sugata T, Yoshiga K, Miyamoto Y: Total upper transplantation. NatlMedJ China 1981;61:139.
lip reconstruction using a free radial forearm flap incor- 58. Yousif NJ, Ye Z: Analysis of cutaneous perfusion: an
porating the brachioradialis muscle: report of a case. aid to lower extremity reconstruction. Clin Plast Surg
J Oral MaxU/tJjac Surg 1987;45:959. 1991;18:559.
With the expansion of new donor sites for cutaneous and is based on the arteria deltoidea subcutanea, a con-
and fasciocutaneous free flaps that has occurred during stant branch of the posterior circum1la: humeral artery.
the past three decades of free tissue transfer, the upper However, a deep dissection with limited exposure is neo-
arm was a logical choice for harvest of well-vascularized, essary to obtain an adequate pedicle length.The vascular
apendable, intermediate thickness skin. The upper arm pedicle also rests dangerously close to the u.illary nerve.
has numeroua advantages to harvest of skin relative to In 1982, Song et al. (17) introduced the lateral arm
the forearm, not the least of which is the ability to place fasciocutaneous flap, which has become a uaeful free
the scar in a location that can be camouflaged with even flap in head and neck and extremity reconstruction.
a short sleeve shirt. A variety of different flaps have been Prior to the introduction of the anterolateral thigh flap,
described from this location. The medial arm flap, how- this donor site was often considered the second line flap
ever, was found to have an unreliable vascularity. The for harvest of a fasciocutaneous flap. The lateral ann
variability in the size of the nutrient septocutaneous per- flap may be transferred with a segment of the humerus,
forators arising from the superior ulnar collateral artery triceps tendon, and two nerves, one of which can serve
along the medial intermuscular (IM) septum (3) led to as a sensory supply and the other as a vasculari2:ed nerve
an unpredictable vascular system upon which to base a graft. It has similarities to the radial forearm flap but
free flap. The deltoid flap was introduced by Franklin (4) offers the distinct advantages that its nutrient artery,

the profunda braclili, is not essential to the vascularity Alternatively, donor site closure following harvest of
of the distal upper extremity, and the donor defect can larger flaps can be accomplished by making a longitu-
most often be closed with a linear scar. dinal counterincision along the medial surface of the
upper arm where placement of a skin graft is less notice-
able than along the lateral surface of the upper arm.
FLAP DESIGN AND UTILIZATION The axis on which the flap is usually designed is a
line drawn from the insertion of the deltoid to the lateral
The territory of the lateral ann flap has been investi- epicondyle. Alternatively, a line connecting the tip of the
gated through dye-injection studies. The maximum acromion and the lateral epicondyle has been advocated
dimensions of the cutaneous paddle have not been (Fig. 13-1) (20).
determined; however, flaps as large as 18 x 11 em have The blood supply to the skin of the lateral ann flap
been reported (14). Rivet et al. (14) descnoed a "zone is derived from a series of four to five septocutaneous
of security" that extended 12 em proximal to the lateral perforators that arise from the posterior branch of the
epicondyle and included one-third of the circumference radial collateral artery in the lateral 1M septum. Katsa-
of the arm. They advised that flaps should incorporate ros et al. (7) described a technique to achieve a wider
this zone to ensure vascularity and a successful recon- segment of skin, by harvesting a long flap and dividing it
struction. Katsaros et al. (7) reported that dye-injection transversely, as long as adequate perforators are present
studies yielded areas of staining that ranged from 8 x to perfuse both the proximal and distal portions. The
10 em to 15 x 14 em. In a review of 150 lateral ann flaps, additional width was achieved by folding the distal seg-
Katsaros et al. (8) reported the successful transfer ofskin ment so that it lay adjacent to the proximal one, thereby
flaps that extended over a longitudinal direction both doubling the width while still achieving primary closure.
10 em proximal to the deltoid insertion and 10 em distal Kuek and Chuan (9) investigated the distal limits of
to the lateral epicondyle. These authors also speculated the skin paddle through eosin injections and found that
that the profunda bracbii pedicle could support a com- the area of staining extended an average of7 .9 em (range
plete tube of skin from the shoulder to the midforearm. of 4.5 to 10.0 em) distal to the lateral epicondyle. The
In most cases, the width of the harvested skin is limited additional length of the flap not only allows the flap to be
to 6 to 8 em, or one-third of the arm's circumference, to used for wider defects by folding it on itself but also pel'-
allow primary closure. However, larger flaps have been mits a distal skin paddle to be harvested that effectively
harvested, with a skin graft placed over the donor site. lengthens the vascular pedicle. In addition, the skin of

FIGURE 13-1. The topographical anatomy of the lateral arm flap is illustrated. Although a line
drawn between the deltoid insertion and the lateral epicondyle is classically used as the axis of
the flap, the lateral 1M septum is actually located 1 to 2 em posteriorly to that line. The central
axis of the flap should be adjusted for this as shown.
208 CHAPTER 13

the distal portion of the upper arm tends to be thinner nerve in the head and neck (19). Matloub et al. (11)
than the skin in the more proximal portion of this region. reported on six patients who underwent sensate lat-
The lateral arm flap may be harvested as a fascial eral arm flap restoration of the oral cavity. Two patients
flap or as a fasciocutaneous flap. The use of a vascu- who underwent reconstruction of partial glossectomy
larized fascial flap allows a much larger surface area of defects were reportedly able to differentiate light and
tissue to be harvested without having an impact on the deep touch and hot and cold stimuli. The PCNF has
primary closure of the donor site. A split-thickness skin been described by Rivet et al. (14) as a "nerve in tran-
graft may be applied to the fascial flap to achieve epithe- sit." This nerve travels in the 1M septum to supply sen-
lial coverage. This is also an effective means to harvest sation to the skin of the lateral forearm. It receives its
thin tissue from this donor site in patients who have a blood supply from the branches of the posterior radial
thicker adipose layer in this region. Large segments of collateral artery (PRCA) and, therefore, may be used as
well-vascularized fascia measuring 12 x 9 em have been a vascularized nerve graft. Katsaros et al. (8) reported
harvested while still achieving primary donor site do- using this nerve to bridge facial nerve gaps in four cases.
sure. Small islands of skin may be included to facilitate Katsaros et al. (7) reported harvesting a segment
postoperative monitoring (21). The fascial subcutane- of vascularized triceps tendon for use in extremity
ous free flap has been used to augment contour defects reconstruction. The use of this tissue in head and neck
of the maxillofacial region (18). reconstruction is limited.
This donor site usually provides a layer of adipose tis-
sue that is intermediate in thickness between that of the
radial forearm flap and the scapular flap. The body habi- NEUROVASCULAR ANATOMY
tus of the patient will influence the relative thickness of a
flap from this donor site compared to that of the antero- The profunda brachii artery is the largest branch of the
lateral thigh. Yousif et al. (21) reported detailed descrip- brachial artery in the arm. It runs a course on the pos-
tions of the fascial envelope that surrounds the triceps, terior aspect of the arm that parallels the radial nerve
brachialis, and brachioradialis. Portions of this layer fuse as it spimls around the humerus in a medial to lateml
to form the IM septum. The superficial layer of this enve- direction. The profunda brachii divides into two termi-
lope is continuous with the fascial sheath that covers the nal branches (Fig. 13-2). The nomenclature of these
entire arm. The two layers are separated by adipose tis- branches is somewhat confusing. The PRCA, which
sue. The fascia anterior to the IM septum averages 0.41 is the main nutrient artery of the lateral arm flap, has
mm in thickness compared with the 0.21 mm average also been referred to as the middle collateral artery. This
thickness of fascia posterior to the septum. vessel passes through the lateral 1M septum and anas-
Shenaq (16) reported an alternative solution to the lim- tomoses with the interosseous recurrent artery. This
ited dimensions of the lateral free flap by using pretrans- "flow-through" system of the PRCA to the interosseous
fer tissue expansion. He was able to harvest an 11 x 18 em recurrent artery is the anatomic basis for the reverse-flow
flap from a child's arm and still achieve primary closure. lateml upper arm flap that has been used for coverage
The ability to tailor donor site properties through staged, of the elbow region. In this flap, the PRCA is ligated
pretransfer expansion is a technique with significant proximally, and flow to the lateral arm flap is achieved
potential that has not been extensively explored. through the anastomotic channels of the interosseous
An osteocutaneous flap may be harvested by includ- recurrent artery (2). The anterior radial collateml artery,
ing a segment of humerus measuring 1 x 10 em. Septal which has also been referred to as the radial collateml
perforators extend to the periosteum in a manner similar artery, runs a divergent and more anterior course along
to the blood supply to the radius in an osteocutaneous with the radial nerve between the origins of the brachialis
radial forearm flap. A muscular cuff of triceps and bra- and brachioradialis muscles. The anterior radial collat-
chioradialis is left attached to the lateral 1M septum to eral artery anastomoses with the radial recurrent artery.
protect the blood supply (8, 10).This segment ofbone has In the classic description, the profunda brachii also sup-
been used in mandibular reconstruction, but its limited plies the main nutrient artery ofthe humerus, the deltoid,
bone stock imposes restrictions on the capacity to insert and the three heads of the triceps muscles (Fig. 13-3).
endosteal implants for dental rehabilitation. Although The average diameter of the profunda brachii was
limited in dimensions because of concern about patho- found to be 2.45 mm (range, l.7 5 to 2. 7 mm) at a dis-
logic fracture of the residual humerus, this segment of tance of 1 em below its origin from the brachial artery
bone may be useful in midface reconstruction. (14). In the region of the deltoid insertion, where it
The posterior cutaneous nerve of the arm (PCNA) enters the lateral IM septum, the artery has an average
and the posterior cutaneous nerve of the forearm diameter of 1.55 mm (range, 1.25 to 1.75 mm) (14).
(PCNF) provide the potential for reneurotized lateral Moffett et al. (12) described a technique to lengthen
arm flaps. Sensation can be restored to the transferred the vascular pedicle by 6 to 8 em by extending the dis-
skin by anastomosing the PCNA to a suitable recipient section proximally between the lateral and long heads

Biceps brachii m.

Anterior radial collateral a.

Profunda brachii a .
Posterior radial collateral a.
Brachialis m.

Profunda brachii a .

Radial n.

Anterior radial collateral a.

Posterior radial collateral a.

Triceps brachii m.
lateral head
Brachioradialis m. Lateral 1M septum

FIGURE 13-2. A:. Anatomy of lateral arm musculature. The lateral 1M septum is located between
the triceps posteriorly and the brachia lis and the brachioradialis anteriorly. The actual position
of the lateral 1M septum can be seen to lie 1to 2 em behind the deltoid insertion. B: The profunda
brachii artery arises from the brachial artery and winds its way in the spinal groove along with
the radial nerve. Splitting of the long and the lateral heads of the triceps provides extended
exposure of the neurovascular pedicle. As the arterial pedicle descends in the upper arm, the
profunda brachii divides into the anterior and posterior radial collateral arteries. The anterior
radial collateral artery runs an anterior course with the radial nerve between the insertions of
the brachioradialis and the brachialis. C: Aclose-up view of the neurovascular anatomy of the
lateral 1M septum. The radial nerve and the anterior branch of the radial collateral artery are
seen diverging anteriorly between the brachial is and brachioradialis. The posterior branch of the
radial collateral artery supplies the lateral arm flap; the PCNA provides sensation to the flap.

Posterior cutaneous n.
of arm Triceps brachii
medial head

Posterior cutaneous n.
Triceps brachii
of the forearm
long head

Triceps brachii
lateral head

FIGURE 13-3. Cross-sectional anatomy of the upper arm reveals the lateral 1M septum with
the neurovascular pedicle running in close proximity to the humerus. PRCA, posterior radial col-
lateral artery; PRCV: posterior radial collateral vein.

of the triceps muscle. In this technique, the standard (8). Inoue and Fujino (6) reportedly transferred a lateral
dissection is performed until the fibers of the lateral arm flap based on an extended dissection of the cephalic
head of the triceps limit further dissection along the vein, without its interruption, while performing a conven-
spiral groove. A tunnel is created underneath the tri- tional microarterial anastomosis to a recipient artery in
ceps insertion by working both from below and above the neck. This flap was used to resw:face a defect in the
through the exposure gained by splitting the lateral temporal region. Nakayama et al. (13) described a similar
and long heads of the triceps. The takeoff of the pro- technique for a radial forearm flap in which the cephalic
funda brachii from the brachial artery can usually be vein was dissected to the level of the clavicle, with a sepa-
exposed by this approach. The authors caution that rate arterial anastomosis performed for the radial artery.
the muscular branches from the radial nerve to the There are two sensory nerves that course through the
triceps muscle must be identified and preserved. lateral IM septum. The nomenclature of these sensory
They tested triceps strength following the extended nerves in the literature is also confusing. The nerve that
approach in four patients at 3- and 6-month intervals supplies sensation to the skin of the lateral arm flap is the
(12). There was a slight deficit in both extension and PCNA, a branch of the radial nerve. The PCNA ramifies
flexion relative to the contralateral, nonoperated arm. into four to five fascicles within the subcutaneous tissue
This slight discrepancy could be attributed to postop- (7).1llis nerve has also been referred to as the inferior
erative disuse of the operated arm and to the fact that lateral brac::hial cutaneous nerve, the upper branch of the
the flaps were harvested from the nondominant arm. posterior antebrachial cutaneous nerve (5), or the lower
The lateral arm flap has both a superficial and deep lateral cutaneous nerve of the arm (15). The PCNF,
venous system. The superficial system drains through the which runs through the septum en route to the forearm,
cephalic vein; the deep system drains through the paired does not supply sensation to the lateral arm fiap.As noted
venae comitantes, which are about 2.5 mm in diameter previously, this nerve can be used as a vascularized nerve

Brachioradialis m .


Posterior cutaneous n. of the forearm


FIGURE 13-4. The lateral arm flap has been elevated from an anterior approach to show the
PCNA ramifying in the subcutaneous tissue of the flap. This nerve can be traced proximally to
provide additional length for anastomosis to a suitable recipient nerve in the head and neck.
The PCNF. also a branch of the radial nerve, provides no sensation to the lateral arm flap but
may be used as a vascularized nerve graft However, if the lateral arm flap is designed to extend
distal to the elbow, then the PCNF may be considered for use to reinnervate the distal portion
of the flap. It is imperative to differentiate these two nerves to reinnervate the lateral arm flap
successfully. Interruption of the PCNF leads to an area of anesthesia in the lateral portion of the
proximal forearm distal to the lateral epicondyle.

graft. It too has been referred to by a variety of names, profunda brac:hii may be interrupted without ischemic
including the posterior antebrachial cutaneous nerve (5). sequelae. Most of the anatomic variations that have
Reportedly, the PCNF can be preserved to avoid the been reported are related to duplication of the vascu-
sensory loss in the forearm, but it requires meticulous lar pedicle within the septum. The incidence of double
dissection in the septUm to do so and may compromise profunda brachii arteries has been reported to be 4%
the vascular supply to the flap (Fig. 13-4). The associated (7), 8% (12), and 12% (14) in di1Jerent studies. Moffett
functional deficit over the lateral aspect of the forearm is et al. (12) recommended temporary occlusion of eac:h of
rarely an issue for the patient in the postoperative period. the arteries to determine whether one or both should be
Brandt and Khouri (1) descnbed a lateral arm- revascularized. Sc:heker et al. (15) reported a single case
proximal forearm flap that extended up to 12 em distal of duplication of the PRCA, which required two anerial
to the lateral condyle. The vascular supply to the fore- anastomoses to achieve total revascula:rization of the flap.
arm component was based on the rich vascular plexus
that was located over the posterior elbow and that was
fed by the PRCA. The primary sensory nerve supply POTENTIAL PITFALLS
in this extended flap was the PCNF. In addition to an
alternative sensory nerve supply, the skin over the lateral Postoperative radial nerve palsies have been reported and
arm, distal to the lateral condyle, is usually thinner than were attributed to compressive dressings or tight wound
the skin in the lateral aspect of the upper arm. closure (8). Split-thickness skin grafts can be applied
when wound closure is difficult. A light compressive
dressing should be applied to avoid iatrogenic injuries.
Unlike the radial forearm flap, there is no concern in
harvesting the lateral arm flap for the integrity of the col- The author thanks Dr. Michael Sullivan who contrib-
lateral circulation to the distal portion of the limb. The uted to this chapter in the first edition of this book.
212 CHAPTER 13

Lateral Arm Flap

FIGURE 13-5. The topographical anatomy of

the lateral arm flap is outlined. The key land-
marks are the V-sh aped point of insertion of the
deltoid into the humerus and the lateral epicon-
dyle. The dashed line represents the intersec-
tion of these two points. The point of insertion
of the deltoid may be best determined when the
patient is awake. The patient is placed in the
sitting position and asked to press their hand
against the hip.

FIGURE 13-&. The lateral 1M septum is located

approximately 1 em posterior to the line drawn
from the insertion of the deltoid and the lateral
epicondyle. The central axis of the flap design
is based on the IM septum. The territory of skin
may extend distal to the epicondyle and proxi-
mal to the deltoid.

FIGURE 13-7. Harvest of the lateral arm

flap may be performed either with or without
tourniquet control, but more commonly without.
The dissection begins with an anterior incision
through the skin and subcutaneous tissue down
to the brachioradialis and brachialis.

Lateral Arm Flap

FIGURE 138. The PCNF is identified in the soft

tissue of the flap as it courses distally to supply
sensation in the forearm. This nerve may be pre-
served by meticulous dissection but usually is
cut leaving an area of anesthesia in the forearm.

FIGURE 13-9. Dissection proceeds in a

subfascial plane toward the IM septum; at this
point, a number of septocutaneous perforators
(arrowheads) are identified coursing up into the
subcutaneous tissue.

FIGURE 13-10. Attention is then turned to the

posterior incision, which is carried through the
skin and subcutaneous tissue and the deep
fascia overlying the triceps muscle.
214 CHAPTER 13

Lateral Arm Flap

FIGURE 13-11. The posterior approach to

the IM septum is easier because, unlike the
brachioradialis, the triceps muscle does not
originate from the septum itself.

FIGURE 13-12. As the septum is approached,

the septocutaneous perforators are easily iden-
tified. These perforators lead to the PRCA.

FIGURE 13-11 Having identified the main vascu-

lar pedicle from the posterior approach, attention
is then tumed to finding the PRCA and PRCV
from the anterior approach. This is done by blunt
dissection along the fibers of the brachiorad ialis,
which must be separated from the septum.

Lateral Arm Flap

FIGURE 13-14. Continued dissection along

the anterior aspect of the IM septum leads to
the radial nerve (arrowhead). which is easily
identified because of its large caliber and its
course between the origins of the brachialis and
brachioradialis. The anterior branch of the radial
collateral artery travels with the radial nerve.

FIGURE 1315. Flap elevation proceeds distally

to proximally by sharplytranssecting the fascial
and vascular connections to the humerus.

FIGURE 1316. The continuation of the PRCA,

which anastomoses with the interosseous
recurrent artery. must be identified in the soft
tissue and ligated.
216 CHAPTER 13

Lateral Arm Flap

FIGURE 1317. After ligation ofthe distal por-

tion of PRCA, the dissection proceeds along the
depth of the IM septum. The PCNA and PCNF
are closely associated with the PRC vascular

FIGURE 1318. The neurovascular pedicle is

followed with the radial nerve toward the spiral
groove. Extreme care is taken not to injure the
radial nerve or its branches to the surrounding
musculature in the posterolateral arm.

FIGURE 13-19. Posterior dissection of the flap

reveals the PCNA !arrowhead), which can be
seen to ramify in the subcutaneous tissue of the

Lateral Arm Flap

FIGURE 1320. The neurovascular pedicle is

skeletonized as it passes in the spiral groove.
Blunt dissection and retraction may improve
visualization of its course.

FIGURE 13-21. Afew centimeters of attach-

ment of the deltoid to the humerus may also
be divided to improve visualization in the spiral
groove. The vascular pedicle is ligated at a
comfortable point in the spiral groove. Ideally,
the ligation of the pedicle is performed proximal
to the point where the venae comitantes merge
into a single vein. More proximal dissection of
the pedicle may be achieved by creating a tunnel
deep to the lateral head of the triceps and then
separating the long head from the lateral head.

FIGURE 1322. Closure is accomplished by

suturing the fascia of the brachia lis to the triceps.
A layered soft tissue closure is accomplished
routinely. A light pressure dressing is applied for
severs I days following the procedure.
218 CHAPTER 13

Lateral Arm Flap

FIGURE 13-23. The lateral arm flap has been

harvested. The neurovascular pedicle can be
lengthened by more proximal dissection and by
designing the flap more distally in the arm and
proximal forearm.

REFERENCES 11. Matloub H, Larson D, Kuhn J, Yousif J, Sanger J: lAteral

arm free ftap in oral cavity reconstruction: a functional
evaluation. Head Neck 1989;11:205-211.
1. Brandt K. Khouri R: The lateral arm/proximal forearm
flap. Ffast &consrr Surg 1993;92: 1137. 12. Moffett T, Madison S, Derr J, Aclan.d R: An extended
approach for the vascular pedicle of the lateral arm free
2. Culbertson J, Mutumer K.: The reverse lateral upper arm flap. Plmt Recomt1' Surg 1992;89:259-267.
flap for elbow coverage. Ann Plast Surg 1987; 18:62--68.
13. NakayamaY, Soeda S, Iino T: A radial forearm flap based
3. Daniel R, Terzis J, Schwarz G: Neurovascular free flaps: a on an extended dissection of the cephalic vein. The lon-
preliminary repon. Plmt Reconst1' Surz 1975;56:13-20. gest venous pedicle? Br J Pfast Surg 1986;39:454-457.
4. Franklin J: The deltoid flap: anatomy and clinical appli- 14. Rivtt D, Buffet M, Martin D, et al.:The lateral arm flap:
cations. In: Buncke HJ, Furnas H, eds. Symposium on an anatomic study. J &consrr Mit:To.surg 1987;3:121-132.
Fmnrier.r in &comt.nlr:liw Mirmst.rrzery. Vol. 24. St. Louis:
MosbyYear Book; 1984. 15. Scheker L, Kleinert H, Hanel D: Lateral arm compos-
ite tissue transfer to ipsilateral hand defects. J Hand Surz
5. Hollinshead WH: A~ for Surgeons. 3rd ed. Vol. 3. [Am] 1987;12A:665--672.
Philadelphia: JB Lippincott; 1982.
16. Shenaq S: Pretmnsfer expansion of a sensate lateral arm
6. Inoue T, Fujino T: An upper arm flap, pedicled on the free flap. Ann Ffast Surg 1987;19:558--562.
cephalic vein with arterial anastomosis for head and neck
reconstruction. Br J Plast Surg 1986;39:451-453. 17. Song R. SongY. Yu Y. SongY: The upper arm free flap.
Clin Plast Surg 1982;9:27-35.
7. Katsaros J, Schusterman M. Beppu M, Banis J, Acland R:
The lateral upper ann flap: anatomy and clinical applica- 18. Sullivan M, Carron W. Kuriloff D: Lateral arm free flap
tions. Ann Plast Surg 1984;12:489-:500. in head and neclr: reconstruction. Atrlt Ot.Dlmyngol Head
Neck Surg 1992;118:1095-1101.
8. Katsaros J, Tan E, Zoltie N, Barton M, Venugopalsrini-
vasan, Venkataram.akrisbnan: Further experience with 19. Urken MI.., Vickery C, Weinberg H, Biller HF: The neu-
the lateral arm free flap. Pltur Recomt1' Surg 1991;87: rofasciocutaneous radial forearm flap in head and neck
902-910. reconstruction----a preliminary report. l...arynzoscope
9. Kuek L, Chuan T: The c:xte:nded lateral arm flap: a new
modification. J Reconm Mit:Tosurz 1991;7:167-173. 20. Waterhouse N, Healy C: The versatility of the lateral arm
flap. Br J PlmtSurg 1990;43:398.
10. Martin D, Mondie JM, DeBiscop J, Schon H, Peri ~:
The osteocutaneous outer arm flap: a new concept m 21. Yousif NJ, Warrm. R. Matloub H, Sanger J: The lateral
microsurgical mandibular reconstructions. Rev SUmtatol arm fascial free flap: its anatomy and use in reconstruc-
tion. Pitm Recomtf' Surg 1990;86:1138--1145.
Chir Maxillofoe 1988;89:281-287.
early one century ago, Monks (44) and Brown durability. It is particularly resistant to infection when
N (11) separately reported cases in which the tem-
poroparietal fascia, based on the superficial temporal
transferred into infected or irradiated tissue beds. In
head and neck reconstruction, the fascia is most com-
vessels, was used for eyelid and auricular reconstruc- monly transferred as a pedicled flap, but it may also be
tion. More recently, the temporoparietal fascial ftap used as a free ftap when the arc of rotation is not ade-
(TPFF) has become popular as a pedicled fl.ap for use quate or for defects located at a distance from the donor
in periorbital (20,27,43) and auricular reconstruction site. This Bap offers the advantage of a well-concealed
and as a free ftap for the management of a variety of donor site in the haiJ:I..bearing scalp (20,48).
defects (5,22,30,55,58). During the last three decades,
the Bap has become a wluable tool in the reconstruc-
tion of a variety of extremity defects (32,35,62). As FLAP DESIGN AND UTILIZATION
experience with this ftap has increased, surgeons have
come to appreciate several features that make it particu- The TPFF is based upon the superficial temporal artery
larly useful in head and neck reconstruction (20,53). It and vein. It may be transferred independently or in
is ultrathin, highly vascular, and exhibits a significant combination with skin (9,10,16,20,21,26,33,48,49,
degree of fiexibility, allowing it to drape around grafts 52,54) and calvarial bone (Fig. 14.-1) (18,24,41,42).
and into cavities while, at the same time, maintaining its The key feature of the TPFF is its rich vascularity and

pliability, making it especially useful in managing prob- When necessary, a split-thickness skin graft is easily
lem cavities (19,39) and for coverage of cartilage grafts applied to the fascia after its transfer. However, in the
uaed in such challenging areas of head and neck recon- oral cavity, even without a skin graft, it may provide a
struction as the auricle and the larynx (8-1 0,20,39).'Ibis watertight seal and a surface for remucosalization.
tissue may be used in the face, hand, Ql' lower extremity Brent and others (8-1 O) outlined in detail the use
when a skin graft is preferable to a bulky flap, but where of this Bap for auricular reconstruction, in conjunc-
a suitable recipient bed is lacking (10,20,48,54). tion with autogenous costal cartilage (7) and silastic
The TPFF may be harvested with dimensions in the (47) framewQI'ks. The pliability of this flap makes it
range <>f 14 x 17 em without extensive scalp undermin- ideally suited to cover a convoluted auricular frame-
ing. The thickness <>f the flap ranges &om 2 to 4 mm. WQI'k. In auricular reconstruction, the success of the

Frontal branch Galea aponeurotica

Temporal branch
of facial n.

Auriculotemporal n.

FIGURE 14-1. The TPFF is supplied by the superficial temporal artery and vein. The superficial
temporal vessels divide into the parietal and frontal branches at approximately the superior
limit of the helix. Prior to crossing the arch, the superficial temporal vessels usually give rise to
the middle temporal artery and vein, which supply the temporalis muscular fascia. There are
cutaneous branches that are given off to the root of the helix that allow transfer of a composite
graft from this region. The temporal branch of the facial nerve crosses the zygoma and is at risk
of injury during anterior dissection of the flap.

surgery depends largely on robust but ultrathin soft temporalis muscular fascia (Fig. 14-2). This vascular
tissue coverage, which permits appreciation of the pattern. permits simultaneous tranafer of two separate
three-dimensional details of the ear. It may also be leaves of vascularized fascia. East et al. (27) used this
used in the acutely traumatized auricle as a method composite flap in a case of posttraumatic tracheoma-
of providing immediate auricular cartilage coverage lacia, in which a nasal septal cartilage graft was sand-
(23,37,61). wiched between the two leaves of fascia and then inset
Acland et al. (2) identified the middle temporal into the anterior tracheal wall.
artery, which is a branch of the superficial temporal The TPFF may also be used in the management of
artery and vein, as the primary vascular supply to the radiated temporal bone and o:drital cavities (19,28,40,59).

Frontal and
parietal branches

Deep temporal arteries

Maxillary a.

Middle temporal a.
FIGURE 14-2. The muscular and fascial layers of the temporal fossa are shown. The
deepest plane is the temporalis muscle, supplied by the anterior and posterior deep temporal
arteries, arising from the internal maxillary artery. The temporal is muscular fascia is supplied
by the middle temporal artery, which arises from the superficial temporal artery below the
zygomatic arch. The terminal branches of the superficial temporal artery and vein supply the
temporoparietal fascia.

The fiap has also been described in co:rre<:ting c<mtour than aiiY other tissue in the body and is well suited to
defects of the midface and orbital regi<m (42). this particular defect.
In addition to its traditional application as a fascial McCarthy and Zido (42) descnbed the elevation of
Bap, the tissue may also he used to ttansfer overlying temporoparietal fascia in c<mjunction with outer calvaJ.'I-
scalp skin and hair during scalp and lip reconstruction ial bone and documented the contnbution of the supet'l-
(34,38,39,45,46) (see Pip. 14-15 to 14-18). By extend- ficial temporal artery to the vascularity of this bone
ing the vascular pedicle with an interposed vein graft, (17,25,51). Experimental work by Antonyshyn et al. (3)
the fiap can be mobilized by using a V-Y technique to suggested that the vascularized calvarial bone transfers
close full-thickness defects of the scalp (32). are superior to standard calvarial bone grafts in terms
A series of reports descnbe reconstructions in which of early viability and new osteoid formation. The reli-
the superficial temporal artery and vein were used to ability and l<mg-term results of vascularized calvarial
transfer skin and cartilage from the root of the auricular bone grafts placed into craniofacial defects have been
helix. This composite graft may he used to reconstruct demonstrated in large clinical series (6,50). If bone is
sizable defects of the nasal ala (49,50,57). Duplication to be transferred with the flap, a generous cutf of fascia
of the thin natural contour of the nasal ala with its car- and pericranium must he preserved at the periphery of
tilage covered by skin, both on the inside and outside, is the graft. The outer table of the skull is harvested as
one of the most challenging aspects of nasal reconstruc- a split cranial graft (20). The temporoparietal fascia is
tion. The root of the helix matches the ala perhaps better fixed to the h<me with a suture to prevent shearing of the

Deep temporal a.

Middle temporal a.

Temporalis muscle fascia

Temporoparietal fascia

FIGURE 14-3. The layers of the scalp in the temporal fossa are shown, extending from the
calvaria I bone to the skin. The temporalis muscular fascia splits into two layers approximately
2 em above the zygomatic arch. These two fascial leaves are separated by fat, which provides
a natural plane of dissection. The temporalis muscular fascia is continuous with the masseter
muscular fascia below the arch; the temporoparietal fascia is continuous with the superficial
muscular aponeurotic system below the arch. The temporalis muscular fascia and the TPFF are
separated by a loose areolar plane, which also separates the pericranium from the galea in the
region cephalad to the superior temporal line. TPFF, temporoparietal fascial flap.

delicate vessels that perforate the pericranium (53). By The superficial temporal artery and vein are moderate-
combining the bone graft with the temporoparietal fas- sized vessels that are most easily isolated approximately
cia, studies have documented that the surviving osseous 3 em superior to the root of the helix where they branch
mass is increased compared with that of cODVentional into frontal and parietal divisions (Fig. 14-1). These
nODVa.scularized calvarial grafts (14,15,25). However, branches anastomose freely with the supraorbital and
the clinical relevance of this higher surv.iving mass may supratrochlear vessels over the forehead (4). The flap is
not be clinically significant, as most surgeons do not most commonly based upon the parietal branch, with
have difficulty with volume loss following free calvarial its base centered over the middle third of the superior
bone grafting.
The vascularity of the TPFF extends to the midline
of the skull, and may be extended to this point if the flap
is to be used for intraoral reconstruction (31). Transfer
of the pedicled TPFF, with or without attached calva-
rial bone, will reach the malar, olbital, and mandibular
regions in most patients. Pedicle length is often inade-
quate when transposing the TPFF into the oral cavity.
Several maneuvers increase the arc of rotation, including
the temporary removal of the zygomatic arch or the prox- ~H'""''r-+--Temporalis
imal dissection of the pedicle below the tragus. Mobiliza- mullde fascia
tion of the vascular pedicle below the tragus places the
facial nerve at risk and requires identification of the nerve
in the parotid gland. An incision can be made through mullde------+~~ ltTir--+T- Subcutaneous
the buccal sulcus to permit intraoral transfer of the flap. 1!S&~e

Inconsistent nomenclature plagues the description
of the anatomic layers of the temporoparietal region 1/IJH~r---Temporoparietal
(Fig. 14-3) (1,36,60). The temporoparietal scalp con- fascia
sists offive distinct layers. The temporoparietal fascia lies (with superficial
temporal artery)
in the central position between two tis9Ue planes in the
area below the superior temporal line. It lies deep to the
skin and subcutaneous tissue to which it is firmly bound.
The temporoparietal fascia must not be confused with temporal
the temporalis muscular fascia, which envelops the tem- fat pad ---r~rt:~
poralis muscle. The temporoparietal fascia is a superior
extension of the superficial musculoaponeurotic system,
both of which attach to the zygomatic arch. The tempo-
ralls muscular fascia splits, and one lamella passes deep aroh--------~~~
to the arch to insert on the coronoid process of the man-
dible (43), while the other inserts on the lateral surface temporal
of the zygomatic arch, contiguous with the masseteric fat pad - - - -+T-T
fascia. Above the superior temporal line, the temporo-
parietal fascia becomes the galea aponeurotica. Below
the superior temporal line, the tissue planes deep to the +;++++---+-Masseter
temporoparietal fascia consist ofloose areolar tissue and
temporalis muscular fascia. Loose areolar tissue sepa-
11-l--++++------4--- Masseteric
rates the temporoparietal fascia from the muscular fascia fascia
of the temporalis, giving the scalp its natural mobility. Coronoid
When the scalp is moved, the temporoparietal fascia process
moves with it, but the muscular fascia and periosteum Parotid gland
remain stable. In the area above the temporal line, the FIGURE 14-4. A coronal section through the left temporal
temporalis muscular fascia and the periosteum converge region demonstrates the fascial and muscular anatomy. In
and continue cephalad as the pericranium overlying the addition, the relationship of the fat pads located above and
superior aspect of the cranium. (Fig. 14-4). below the zygomatic arch is demonstrated.

auricular helix. The frontal branch is routinely ligated nerve and the superficial temporal vein where it can be
approximately 3 to 4 em distal to its separation. from easily palpated. It may lie beneath the anterior auricular
the parietal branch. Dissection beyond this point risks muscle and may often have a tortuous course. The sig-
injury to the frontal branch of the facial nerve. nificance of that tortuosity is that if this is "released," it
At its origin, the superficial temporal artery has may increase the length of the pedicle of an island flap
an average diameter of 1.89 mm and lies deep to, or by up to 1.5 em. The middle temporal branch of the
within, the parotid gland (55). In the first part of its artery, which supplies the temporalis muscular fascia, is
course, appr<Wmately 15 mm, it ascends behind the given off in this region.. Because of this branching va5-
ramus of the mand:&ble and then pierces the super- cular pattern, a two-layered fascial ftap can be raised on
ficial fascia 4 to 5 mm in front of the tragus (29). In a single vascular pedicle (Fig. 14-5) (23).
the second, or superficial, part of its course, it crosses At a point 2 to 4 em above the zygomatic arch (range,
the posterior portion of the zygomatic process of the 0 to 5 em), the superficial temporal artery divides into
temporal bone, lying anterior to the auriculotemporal two terminal branches: the frontal and the parietal.

Tempo<al;s muscle lascia~

Middle temporal
artery and vein

Temporoparietal fascia

Superficial temporal
artery and vein

FIGURE 14-5. If two layers of vascularized fascia are required for reconstruction, the TPFF may
be harvested along with the temporal is muscular fascia. The two separate nutrient vascular
systems allow two independent thin layers of tissue to be harvested, which makes this donor
site unique. Careful dissection of the middle temporal artery in the region of the zygomatic
arch is required to harvest these two fascial leaves as a single microvascular free flap. TPFF,
temporoparietal fascial flap.

A delayed division is commonly associated with a well- the ear for a short distance, supplying the uppermost
developed zygomatico-orbital branch from the main part of the cranial surface of the ear, and anastomosing
stem of the superficial temporal artery and occurs with the posterior auricular artery (22).
in 80% of cases (51). The frontal branch is generally The zygomatico-orbital artery may arise from the
slightly larger (1.2 mm in diameter) than the parietal superficial temporal artery, the middle temporal branch,
branch (1.1 mm in diameter) (22). The frontal branch or the frontal branch. It runs along the upper border
runs in a tortuous fashion, anterior and medial, supply- of the zygomatic arch, in the fat pad between the deep
ing all layers of the scalp, and it anastomoses with the and superficial layers of the temporalis muscular fascia,
corresponding vessel of the opposite side and also with to the lateral aspect of the orbit (Fig. 14-4). It supplies
the ipsilateral supraorbital and supratrochlear arteries. branches to the orbicularis oculi, anastomoses with
The parietal branch passes superiorly toward the the lacrimal and palpebral branches of the ophthalmic
vertex. In approximately 7.5% of patients, that branch artery, and completes the perimbital ring with the infra-
may divide into two branches, which travel roughly and supraorbital vessels (22). Inadvertent entry into the
parallel to each other. Its course lies within a 2-cm fat pad encased by the deep and superficial layers of
strip centered on the auditory meatus and passing the temporalis muscular fascia places the zygomatico-
upward to the vertex. Within this band, the artery usu- orbital artery at risk. Cautery to control bleeding in this
ally traverses from the anterior to the posterior mar- location can inadvertently damage the frontal branch of
gins. The superficial temporal vein may be single or the facial nerve.
duplicate. In most cases, the vein runs with the artery, There are various motor and sensory nerves that trav-
but slightly superficial to it. In 20% to 30% of cases, erse the temporoparietal donor site. The auriculotem-
however, the vein takes a divergent course above the poral nerve, a sensory branch of the trigeminal nerve,
level of the root of the helix and may travel up to 3 em lies posterior to the superficial temporal artery, within
posterior to the arterial pedicle (53,58). There are a the temporoparietal fascia, and supplies the regional
rich set of anastomoses of the terminal portions of the scalp skin. The frontal branch of the facial nerve courses
parietal branch both with its opposite member, which obliquely across the zygomatic arch and lies approxi-
arises from the contralateral superficial temporal sys- mately 1.5 em lateral to the orbital rim. This nerve runs
tem, and with the ipsilateral posterior auricular and within the temporoparietal fascia and represents the
occipital arteries (22). anterior limit of flap elevation (see Figs. 14-6 to 14-14).
The superficial temporal system gives off several
branches to the skin of the face. The transverse facial
artery arises deep to the parotid gland and runs for- ANATOMIC VARIATIONS
ward over the masseter. In 35% of cases, the trans-
verse facial artery arises from the external carotid Five distinct branching patterns of the superficial tem-
artery directly. It runs forward and is accompanied by poral artery have been described (13,56), though in
branches of the facial nerve in the region between the general there is such high vascularity that these vari-
zygomatic arch and the parotid duct, often crossing the ations do not hold clinical significance. Variability
duct. It supplies the parotid gland and duct, the mas- involves anastomotic connections with tributaries of the
seter muscle, and the skin. A large cutaneous branch is occipital artery, and in cases where a large, posterior
consistently found at the point of intersection of a verti- segment of fascia is required, the course of the posterior
cal line drawn 2 em laterally to the lateral canthus with parietal branch can be traced with Doppler sonography
a horizontal line through the alar base. The transverse to ensure that the planned territory of the TPFF is well
facial artery anastomoses superiorly with the lacrimal vascularized.
and infraorbital arteries, anteriorly with the premas-
seteric and facial arteries, and deeply with the buccal
artery. This artery primarily supplies muscle, but it may POTENTIAL PITFALLS
also make a significant contribution to the blood sup-
ply of the skin over the masseter and the parotid and, The most common complication after the elevation of
to a lesser extent, to the skin of the inferior orbital and the TPFF is secondary alopecia. This has been noted
nasolabial regions (22). around the incision site for up to 2 em and can be
The superficial temporal artery gives rise to three avoided by meticulous preservation of hair follicles
groups of auricular branches: (a) an inferior group sup- on the undersurface of the scalp flap. Prior radiation
plies the lobule and tragus; (b) two or three branches in therapy or surgery in this area predisposes the overlying
a superior group often form a common trunk and run scalp to ischemic injury after raising the flap, and care-
onto the upper part of the helix, its crura, and triangular less surgical dissection can result in direct injury to the
fossa (48); and (c) the superficial temporal or its parietal hair follicles. Avoidance of cautery on the undersurface
branch gives off a small branch that runs down behind of the skin flap greatly reduces the risk of alopecia.
226 CHAPTER 14

Anterior dissection of the TPFF is limited by the the TPFF is utilized as a regional flap. This is because
frontal branch of the facial nerve, and failure to identify venous egress from the TPFF occurs both through the
this branch during the dissection of the flap will risk superficial temporal vein and the myriad of intercon-
its inadvertent injury. This may lead to brow paralysis. nected venous tributaries; even in the absence of a
When the injury is simple praxia, full recovery can be detectable vein, outflow through venules in the pedicle
expected, but transection injuries require microsurgical is nearly always adequate. However, when free TPFF
repair. transfer is contemplated, more formal venous assess-
ment is desirable through Doppler auscultation and/or
ultrasonographic color flow Doppler assessment.
Many factors influence the viability of the TPFF and POSTOPERATIVE WOUND CARE
limit its use in the reconstruction of selected head and
neck defects. Preoperative radiation, neck surgery, or After transfer of the TPFF, careful hemostasis is per-
external carotid embolization may affect the vascular formed with bipolar cautery. Special effort is made to
pedicle and are considered relative contraindications avoid thermal injury to the hair folJicles. A suction drain
to the elevation of this tissue. The most important pre- is routinely used and should be placed in a superior
operative test to determine the reliability of this flap position to avoid inadvertent contact with the vascular
is Doppler auscultation, which should be performed pedicle when a transposition flap has been performed.
in the office before finalizing the surgical plan. This The wound is closed in layers, and a bulky compressive
ensures the presence of a viable arterial input. Preopera- dressing is applied for 24 hours. The suction drain is
tive assessments of venous outflow are not critical when kept in place for 24 to 48 hours.

Tempoparietal Fascial Flap

FIGURE 14-6. The topographical anatomy of the

TPFF is outlined. The approximate course of the
superficial temporal artery and vein has been
drawn, with division of the pedicle into anterior
and posterior branches at a point approximately
3 em above the tragus. The vein may run concur-
rentlywith the artery or may separate from the
artery and run 2 to 3 em posteriorly. The superior
temporal line is shown. This bony ridge begins
at the zygomatic process of the frontal bone and
curves upward and backward across the frontal
bone along the lateral margin of the forehead. It
passes over the parietal bone and ends by joining
the supramastoid crest The most cephalic origin
of the temporalis muscle is at the superior tem-
poral line. This is an important landmark,. where
the temporoparietal fascia becomes confluent
with the galea aponeurotica. At the superior tem-
poral line, the temporalis muscular fascia merges
with the periosteum that covers the calvarium.

FIGURE 147. A vertical incision extend-

ing from the root of the helix to the superior
temporal line is used in harvesting the tempo-
roparietal fascia. A V-extension atthe superior
aspect ofthe incision is used to gain full access
to the fascial layers in this region. Inferiorly, the
incision is placed in the preauricular crease
adjacent to the root of the helix. In most cases,
both the arterial and venous components of
the vascular pedicle are located anterior to the
initial incision; however, the dominant venous
system may travel a more posterior course, just
underneath the skin incision. Therefore, dissec-
tion must proceed cautiously until the vein is
identified. If the vein is found in an unconven-
tional location, flap harvest must be tailored to
capture its more posterior course.

Tempoparietal Fascial Flap

FIGURE 14-8. The approximate course of the

frontal branch of the facial nerve has been
drawn as it courses from the main trunk, over
the zygoma, and toward the lateral aspect of the
forehead. The dissection must remain posterior
to this region to avoid injury to this nerve.

FIGURE 14--9. The dissectian begins by elevat-

ing anterior and posterior scalp flaps. Particular
attention is given to avoiding injury ta the hair
follicles as these flaps are elevated. The frontal
branch afthe superficial temporal artery is
Iig ated at the anteriar limit of the flap.

Tempoparietal Fascial Flap

FIGURE 14-10. With the posterior, superior,

and anterior scalp flaps elevated in the plane
superficial to the temporoparietal fascia, the
deep dissection and elevation of the flap are
performed. This elevation is best initiated at
the superiortemporalline.ldentification of the
temporalis muscular fascia assures elevation
in the proper plane. The layer of loose areolar
tissue that separates the temporoparietal fascia
from the muscular fascia at this level permits a
straightforward dissection in a nonvascular plane.

FIGURE 14-11. The TPFF has been elevated to

the root of the helix. Meticulous dissection must
be performed in this region to avoid injury to the
vascular pedicle. If the temporalis muscular fas-
cia (arrowheads) is to be harvested, the plane
of dissection is developed along the surface of
the temporalis muscle. In addition, more caudal
dissection ofthe pedicle is required in order to
capture the middle temporal artery.

FIGURE 1412. The temporoparietal fascia is

elevated, and the superficial temporal artery
and vein (arrowheads) are isolated. The width
of the flap base is normally 2.0 to 2.5 em. As
demonstrated, the flap is flexible, thin, and
highly vascular. It exhibits exceptional drap-
ing characteristics.

Tempoparietal Fascial Flap

FIGURE 14-13. When the temporoparietal

fascia is elevated and the superficial temporal
artery and vein are identified linked), the base
of the flap can be left extremely wide, even
capturing the occipital contributions (inked).
As demonstrated, the flap is flexible, thin, and
highly vascular, and it exhibits exceptional
draping characteristics. The elevation shown
would be useful for total auricular reconstruc-
tion to drape over a cartilage framework.

FIGURE 14-14. The superficial temporal artery

(diameter, 1.8 to 2.2 mm) and vein (diameter, 2.0
to 3.0 mm) are limited in length by the dangers
of extending the caudal dissection in the vicinity
of the main trunk of the fa ciaI nerve. Also shown
is the occipital pedicle Iarrow}, variably present
but critical to identify and preserve in the har-
vest of a large surface area pedicled TPFF.

FIGURE 14-15. In male patients with complex

upper lip defects, the hair-bearing TPFF can be
utilized to restore hair-bearing skin to the upper
lip. A template is made of the lip defect to assist
in flap design, as shown.

Tempoparietal Fasciocutaneous

FIGURE 14-16. A 1.5-cm cutaneous pedicle is

centered over the superficial temporal vessels,
using Doppler auscultation.

FIGURE 14-17. The flap is elevated from the

true temporalis fascia in a superior to inferior
direction, working toward 1he zygomatic arch,
to maximize pedicle length. Care is taken to
capture 1he vascular pedicle, leaving a 1.5-cm
cutaneous base.

FIGURE 14-18. The hair-bearing TPFF is trans-

posed into the defect. This is followed, approxi-
mately 3 weeks, later, by division of the vascular
pedicle and inset of the lateral border of the
flap. During this stage, the pedicle is transected
and 1he proximal portion is either returned to its
original bed in the temporal scalp or discarded,
depending upon the healing of the donor site.
232 CHAPTER 14

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1983;72:141. 29. Esser JFS: Uber eine gestielte Ueberpflanzung eine sen-
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1985;76:177- 188. Augen}teilkd 1919;63:379.

11. Brown WJ: Extraordinary case of horse bite: the exter- 30. Fox JW, Edgerton MT: The fan flap: an adjunct to ear
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13. Busthianos NA: Etude anatomique sur les arteres tempo- free" flap. Ann Plast Surg 1988;21 :65.
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14. Canalis RF: Further observation of the fate of pedi- Orthop 1990;21 :542.
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16. Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE: Clini-
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1991;87:615. erton MT: Galeal-pericranial flaps in head and neck
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Psillakis JM: Anatomic basis for vascularized outer-table
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18. Cheney ML, Gliklich RE: The use of calavarial bone in cal reconstruction following ear avulsion using the
nasal reconstruction. Arch Otolaryngol Head Neck Surg temporoparietal fascial island. Plast Reconstr Surg
1995; 121 (6) :643-648. 1989;83: 148.

38. Kim JC, Hadlock T, Varwres MA, Cheney ML: Hair- 50. Pribaz )J, Falco N: Nasal reconstruction with auricular
bearing temporoparietal fascial flap reconstruction microvascular transplant. Ann Plast Surg 1993;31:289.
of upper lip and scalp defects. Arch Facial Plast Smg 51. Psillakis JM, Grotting JC, Casanow R, Cavalcante D,
2001;3:170-177. Vasconez LO: Vascularized outer-table calwrial bone
39. Lyons GB, Milroy BC, Lendwy PG, Teston LM: Upper flaps. Plart Recomtr Surg 1986;78:309.
lip reconstruction: use of the free superficial temporal 52. Rieboung B. Mitz., Lass au JP: Artere temporale superfici-
artery hair-bearing flap. BT J Plan Smg 1989;42:333. elle. Ann Chir Plan Esthet 1975;20: 197.
40. Maillard FG, Gumener R. Montandon D: Correction of 53. Rose EH, Norris MS: The versatile temporoparietal fas-
depressed supratarsal sulcus by an arterial subcutaneous cial flap: adaptability to a wriety of composite defects.
composite flap. Plast Recomtr Surg 1984;74:362. Plast Reconstr Surg 1990;85:224.
41. McCarthy JG, Cutting CB, ShawWW:Vascularized cal- 54. Smet HT: Fascial flaps. In: Tissue Tramfers in Recomtruc-
wrial flap. Clin Plast Smg 1987;14:37. tifJe Smgery. Part 2. New York: Raven Press; 1989:51.
42. McCarthy JG, Zido BM: The spectrum of calvarial bone 55. Smith RA: The free fascial scalp flap. Plast Reconstr Surg
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56. Stock AI., Collins HP, Davidson TM: Anatomy of the
43. Mitz V, Peyronie M: The superficial musculoaponeu- superficial temporal artery. Head Neck 1980;2:466.
rotic system (SMAS) in the parotid and cheek area. Plast
57. Tanaka Y, Tojima S, Tsuijiguchi K, Fukea E, Ohmiya Y:
Recomtr Surg 1976;58:80.
Microwscular reconstruction of the nose and ear defects
44. Monks GH: The restoration of a lower lid by a new using composite auricular free flaps. Ann Plast Surg
method. N Engl J Med 1898; 139:385. 1993;31:298.
45. Ohmori K: Free scalp flap. Plast Recomtr Surg 1980;65:42. 58. Tegtmeier RE, Gooding RA: The use of a fascial flap in
46. Ohmori K: Free scalp flap surgery. Ann Plast Smg ear reconstruction. Plan Recomtr Smg 1977;60:406.
1980;5:17. 59. Teichgraeber JF: Temporoparietal fascial flap in orbital
47. Ohmori S: Reconstruction of microtia using the Silastic reconstruction. Laryngoscope 1993; 103:931.
frame. Clin Plast Surg 1978;5:379. 60. Tolhurst DE, Carstins MH, Graco RJ, Hurwitz DJ:The sur-
48. Panje R. Morris MR: The temporoparietal fascial gical anatomy of the scalp. Plast Reconstr Surg 1991;87:603.
flap in head and neck reconstruction. Ear Nose Throat 61. Tmpin JM, Altman 01, Cruz G, Acjaver BM: Salwge of
J 1991;70:311. the severely injured ear. Ann Plast Smg 1988;21:170.
49. Parkhouse N, Evans D: Reconstruction of the ala of the 62. UptonJ, Rogers C, Durham-Smith G, SwartzW: Clinical
nose using a composite free flap from the pinna. Br J Plast applications of free temporoparietal fascial flaps in hand
Surg 1985;38:306. reconstruction.J Hand Surg [Am] 1986;lla:475.
The anterolateral thigh (ALT) free flap was first clinical series published to date included 1,284 cases,
described by Song et al. in 1984 as a soft tissue flap that including 911 cases of head and neck reconstruction,
is perfused by septocutmeous branches of the lateral performed betWeen 1991 and 2001 at the Chang Gung
circumflex femoral artery (LCFA) (38). Subseq_uent Memorial Hospital inTaiwan (12). During the first deo-
cadaver dissections (8,27,37,42,44) and an early clinical ade of the 2 bt century, ALT flaps became increasingly
case series (19) clarified that the majority of ALT flaps popular for head and neck reconstruction in North
are supplied by musculocutaneous perforators of the America and Europe (23,26,43,46).
LCFA that pierce the medial edge of the vastuslateralis
muscle (Fig. 15-1). It also became evident that while
most cutaneous perforators to the ALT Bap arise from FLAP DESIGN AND UTILIZATION
the descending branch of the LCFA, skin perforators
also arise from the transverse branch of the LCFA in A large amount of skin from the thigh is available for
about 10% of cases. The ALT flap was popularized for transfer with the ALT flap. In a longitudinal direction,
head and neck reconstruction in the 1990s by Koshima the vascular territory extends from the level ofthe greater
et al. (20) and Kimata et al. (17). Thereafter, the ALT trochanter of the femur superiorly to just above the level
Bap became a commonly used method for soft tissue of the patella inferiorly. The donor thigh is placed into
reconstruction of the head and neck in Asia. The largest a neutral position without internal or extemal rotation,


perforator ---~;w.~

lateralis nus11:1e -t:;wt~

FIGURE 15-1. Cross-sectional anatomy of the thigh demonstrates the vascular blood supply to
the ALT flap. The LCFA arises from the proximal portion of the profunda femoris artery and gives
off cutaneous perforators to the skin paddle of the ALT flap in the mid-thigh region. About 10%
of perforators to the skin paddle of the flap are septocutaneous blood vessels that travel though
the intermuscular septum that separates the rectus femoris muscle from the vastus latera lis
muscle. About 90% of perforators to the skin paddle of the flap are musculocutaneous blood
vessels that travel through the medial edge of the vastus lateral is muscle.

and an elliptical skin paddle with a width that permits cutaneous perforators from the LCFA. LCFA cutane-
primary closure of the donor site wound is designed. ous perforators are usually located within a 3 to 5 em
The Bap is centered around the long axis of the flap radius from the midpoint of the axis that is drawn from
parallel to and a few centimeters lateral to a line that is the ASIS to the lateral border of the patella, which
drawn from the anterior superior iliac spine (ASIS) to denotes the position of the intermuscular septum that
the lateral border of the patella (Fig. 15-2). A territory separates the rectus femoris and vastus lateralis mus-
of up to 20 em in width and 30 em in length is avail- cles. Doppler-detected pulses, denoting the position of
able for transfer based upon cutaneous branches of the peiforators, are most frequently identified 1 to 2 em
LCFA. The width of the skin paddle that can be har- lateral to the intermuscular septum. Most authors
vested while allowing for primary closure of the thigh of clinical series on ALT flaps report that they use a
donor site defect varies according to patient stature, Doppler stethoscope to estimate the location of cutane-
body habitus, and skin laxity. The upper thigh usually ous perforators and to help position and design the flap
has more skin laxity than the distal thigh, which permits skin paddle. Lueg is a strong advocate of the Doppler
the harvest of a wider Bap in the proximal thigh while stethoscope technique, reporting that he centered ALT
still achieving primary wound closure. The mu.imum flap skin paddles on DoppleJ.'I-dete<:ted pulses and made
Bap width that allows for primary wound closure can be no attempt to identify or dissect the cutaneous perfo-
estimated by pinching the skin of the thigh flap donor rators during Bap harvest (23). However, there is con-
site between the thumb and fingers. This width varies siderable evidence to doubt the accuracy and precision
from 8 to 10 em in most patients, although primary clo- of Doppler stethoscopes for localization of cutaneous
sure of defects as wide as 12 em has been reported (23). perforators from the LCFA. Yu and Adel examined the
'When wider skin paddles are needed, the donor site efficacy of handheld Doppler stethoscopes for identifi-
defect can be repaired using a split-thickness skin graft cation of cutaneous peiforators in 100 patients under-
harvested from the anteromedial aspect of the ipsilateral going harvest of ALT Baps (48). They noted that while
thigh or from the contralateral thigh. Repair of the thigh the sensitivity of two commercially available Doppler
wound using V-to-Y advancement flaps has also been stethoscopes was 91% to 100%, the specificity was only
descnoed (15). 0% to 55%. Cutaneous peiforators that were confirmed
The role of the Doppler stethoscope in determin- by surgical exploration were present within 1 em of the
ing the location of cutaneous peiforators and, in turn, Doppler-detected pulse in 70% to 74% of cases. Based
using that information to design the ALT Bap skin pad- on this experience, the authors abandoned use of a
dle position remains controversial. In this application, a Doppler stethoscope in planning the skin paddle design
Doppler stethoscope is used to identify the location of in their next 20 cases and alternatively positioned the

Anterior superior --~-

iliac spine

Perforator from
transverse branch

Vastus lateralis
muscle -------4r-t

~-~r-+--+-+-- Rectus remoris


Perforator from
descending branch

Lateral border of ----+-


FIGURE 15-2. The skin paddle is centered on a line that is drawn from the AS IS to the lateral
border of the patella (green line). This line denotes the position of the intermuscular septum
that separates the rectus femoris muscle from the vastus latera lis muscle. Other muscles of the
anterior thigh include the sartorius and vastus medialis muscles. Cutaneous perforators of the
descending branch as well as the transverse branch of the lateral femoral circumflex artery are

fiap relative to the location of the bo:ay landmarb of the when compared to other donor sites such as the radial
ASIS and patella. All flap transfers were successful with- forearm and rectus abdominis flaps. Nakayama et al.
out attempting to localize the perforators by Doppler used ultrasonography to measure skin and subcutane-
stethoscope. ous thickness in 31 Asian patients undergoing evalua-
A variable amount of subcutaneous tissue is available tion for head and neck reconstruction (30). The average
for transfer with the ALT free flap, depending upon thickness of the flaps was 2.1 mm for radial forearm
multiple variables that include body habitus, gender, flaps, 7.1 mm for ALT flaps, and 13.7 mm for rectus
ethnicity, flap design and harvest technique. ALT flaps abdominis flaps. ALT flap thickness correlated well to
offer an intermediate thickness of subcutaneous fat body mass index (BMI) for males but not for females,

although their analysis of female patients suffered from subcutaneous fat to protect the subdermal vascular
a small sample size. ALT flaps have a thicker subcutane- plexus and preserving a 1 to 2 em wide cuff of subcuta-
ous layer in Western patients when compared to Asians, neous tissues around the skin perforators. It is recom-
and this observation is independent of BMI. Yu exam- mended that flap thinning be done while the flap is still
ined the characteristics of ALT flaps in 72 patients of attached to its vascular blood supply in the thigh, rather
Western ethnicity (46). He found that ALT flaps were than performing flap thinning during flap insetting in
consistently thicker in the proximal thigh and became the head and neck. This allows for improved visualiza-
progressively thinner in the distal thigh. In that series tion of the cutaneous blood supply to the flap and for
the mean proximal, mid, and distal ALT flap thickness clinical assessment of the flap skin vascularity after thin-
was 18.3, 15, and 12.5 mm, respectively. Mean flap ning is completed. Kimura et al. reported outcomes in
thickness in women (19. 9 mm in the midthigh) was sig- 31 patients who underwent primary thinning of ALT
nificantly thicker than mean flap thickness (12.9 mm) free flaps (18). They concluded that cutaneous circula-
in men. Yu found that flap thickness did indeed corre- tion was reliable within a radius of 9 em of cutaneous
late well to BMI, with the correlation being stronger in perforators after primary ALT flap thinning. However,
men than in women. cautionary reports regarding primary ALT flap thin-
Variations in ALT flap harvest technique can also ning by Ross et al. should be noted (34). In their initial
greatly influence the volume of subcutaneous tissues report of four ALT flaps that were thinned primarily,
that are transferred. Suprafascial versus subfascial flap one flap failed completely and two flaps experienced
dissection affects flap thickness. The suprafascial tech- partial necrosis. In a follow-up cadaver dissection study,
nique produces a thinner cutaneous ALT flap, while the the anatomy of cutaneous perforators from the LCFA
subfascial flap dissection produces a thicker fasciocu- was examined by performing Indian ink and latex rub-
taneous ALT flap. With both flap harvest techniques, ber injections (3). These dissections demonstrated an
the initial flap incision is made along the medial flap arterial plexus at the level of the deep fascia, with fur-
skin paddle margin. With suprafascial flap dissection, ther branches that traveled obliquely through the fat to
the subcutaneous tissues are elevated laterally in a plane reach the subdermal plexus. The authors surmised that
superficial to the investing fascia of the rectus femoris primary flap thinning might disrupt the vascular supply
muscle to the medial edge of the fascia lata, where cuta- to the skin and lead to skin necrosis.
neous perforators from the LCFA are identified. The ALT flaps have been applied for reconstruction of a
cutaneous flap is then elevated while removing only a wide variety of soft tissue defects in the head and neck.
small cuff of the deep fascia that is located immediately The most common indication for ALT flap reconstruc-
adjacent to the perforators. With the subfascial flap dis- tion of the head and neck is after resection of tumors
section technique, the initial skin incision is carried that arise in the oral cavity, with defects of the tongue,
more deeply through the investing fascia of the rectus buccal mucosa, palate, and lips accounting for more
femoris muscle. The rectus femoris muscle is retracted than half of all cases described in a selection of case
medially, while the fasciocutaneous component of the series (23,26,36,43). Other common indications for
flap that includes the rectus femoris muscular fascia and ALT flap transfer include reconstruction of the pharyn-
fascia lata is retracted laterally. Cutaneous perforators goesophageal segment and reconstruction of soft tissue
to the skin component of the flap are then identified at defects of the skull base, midface, and scalp.
the point where they pierce the deep surface of the deep A wide variety of defects of the tongue are amena-
fascia. Using this approach, a moderate or large amount ble to reconstruction using ALT free flaps. Thick, bulky
of deep fascia can be harvested with the flap. Since the ALT flaps are useful for tongue reconstruction after total
LFCA also provides the dominant blood supply to the or near-total glossectomy, while thin ALT free flaps are
vastus lateralis muscle, a variable amount of vastus lat- useful for tongue reconstruction after hemiglossectomy.
eralis muscle can be harvested with the flap to further Yu reported outcomes in 13 patients who underwent
increase flap bulk. When designing a musculocutane- ALT free flap tongue reconstruction after total or near-
ous flap that includes a vastus lateralis component to total glossectomy (4 7). Among 11 patients with retained
increase flap bulk, it is important to anticipate that most larynges and adequate follow-up, all patients regained
of the volume of the vastus lateralis muscle will be lost intelligible speech, and 6 patients were able to main-
secondary to denervation atrophy. When augmentation tain all of their nutrition solely through oral nutrition.
is provided by the vastus lateralis muscle, overcorrection Sensory recovery and swallowing outcomes were signifi-
of contour is recommended. cantly improved among patients who underwent ALT
Primary ALT flap thinning has been reported as flap sensory reinnervation by anastomosis of the lateral
a method to reduce the volume of subcutaneous fat femoral cutaneous nerve to the lingual nerve. Farace
when the defect characteristics favor use of a thin et al. examined functional outcomes in 20 patients
flap. With this technique, the subcutaneous fat of the who underwent tongue reconstruction after hemiglos-
flap is excised, preserving a 3 to 4 mm thick layer of sectomy using either ALT free flaps or radial forearm
238 CHAPTER 15

free flaps (11). Speech and swallowing outcomes were outcome of ALT flap pharyngoesophageal reconstruc-
not significantly different between the two groups of tion in 41 patients (49). A linear tubed flap insetting
patients, indicating that the increased thickness of ALT was used in all patients. In his initial nine patients, a
flaps compared to radial forearm flaps was of no func- small segment of flap skin was separated by de-epithe-
tional consequence in hemiglossectomy reconstruc- lialization and used for postoperative flap monitoring.
tion. Agostini and Agostini described a method for oral However, use of the flap monitoring skin paddle was
reconstruction using an adipofascial ALT flap (1). With abandoned after this technique resulted in a high inci-
this technique, a standard fasciocutaneous ALT flap was dence of fistulas (33%) and strictures (22%). In the fol-
harvested, and then the skin and superficial subcutane- lowing 32 cases without a flap monitoring skin paddle,
ous tissues were excised, leaving a flap that consisted fistulas developed in 13% cases, while strictures devel-
of vascularized fascia lata covered by a variable amount oped in 9% cases, with all strictures occurring in patients
of subcutaneous fat that was used to reconstruct oral with circumferential defects. Successful tracheoesopha-
cavity mucosal defects. Advantages of this technique geal speech was achieved in three of three patients with
include the ability to precisely match the ALT flap's a preexisting tracheoesophageal puncture, four of four
volume to that of the defect while avoiding the risk of patients with a secondary tracheoesophageal puncture,
skin paddle devascularization that is seen with primary and six of nine patients with a primary tracheoesopha-
ALT flap subcutaneous thinning. The authors reported geal puncture. Ultimately, 88% of patients were able
that the vascularized fascia lata graft prevented scar to consume a regular diet. Murray et al. reported the
contraction of the reconstruction, and the remucosal- outcome of ALT flap pharyngoesophageal reconstruc-
ized adipofascial flap provided a hairless reconstruction tion in 14 patients (29). Reconstructions were done
that mimicked the physical appearance and function of using flaps that were stented during the postoperative
native oral mucosa. period using salivary bypass tubes. There were no post-
ALT flaps are also useful in the oral cavity for recon- operative salivary fistulas, and 14% of patients devel-
struction of the buccal mucosa and lips. Satisfactory oped neopharyngeal stenosis. Seventy-nine percent of
restoration of oral competence is achieved in patients patients ultimately achieved an oral diet, and all eight
who undergo reconstruction of extensive lip defects patients who underwent tracheoesophageal punctures
using ALT free flaps that contain vascularized fascia lata achieved functional speech.
that is used for static suspension of the reconstructed ALT flaps are becoming increasingly popular for
lip position (21,45). Defects of the buccal mucosa reconstruction of defects involving the skull base, scalp,
are effectively reconstructed using ALT flaps (7,31). and midface (33). They offer many characteristics that
Through-and-though defects of the buccal mucosa can are well suited for reconstruction of defects in this region.
be reconstructed using independent skin paddles for The long vascular pedicle allows for flap revasculariza-
replacement of buccal mucosa and cheek skin, either by tion using recipient blood vessels in the neck without
centering each skin paddle on independent cutaneous the need to use vein grafts (4,24), In addition, fascia lata
perforators or by de-epithelializing the portion of the grafts are available for harvest to repair resected dura and
flap that is located between the internal and external for creation of static slings when necessary. The subcuta-
skin paddles. Flap volume can be adjusted as needed, neous bulk provided by ALT flaps allows for obliteration
with thin flaps used for isolated defects of the buccal of dead space and restoration offacial contour. Multiple
mucosa and thick flaps used for reconstruction of high skin paddles can be designed based upon independent
volume, through-and-through defects of buccal mucosa cutaneous perforators or skin paddle de-epithelialization
and cheek skin. to reconstruct the complex three-dimensional anatomy
ALT flaps provide an ample source of skin for of the midface and skull base (32,39).
pharyngoesophageal reconstruction in patients who
undergo laryngopharyngectomy. Two methods of ALT
flap insetting are possible to achieve reconstruction of NEUROVASCULAR ANATOMY
the pharyngoesophageal segment, which involved use of
either a linear tubed flap or a spiral tubed flap (Figs. The blood supply to ALT flaps is derived from cutaneous
15-17 to 15-29). Genden reported the results of ALT branches of the LCFA. The LCFA most often arises as a
flap pharyngoesophageal reconstruction in 12 patients proximal branch of the profunda femoris artery. Shortly
(13). A spiral tubed flap insetting was used in 11 of 12 after its takeoff from the profunda femoris artery, the
patients. While one patient experienced perioperative LCFA divides into ascending, transverse, and descend-
free flap failure and another patient developed stenosis ing branches (Fig. 15-3). There are from one to three
of the neopharyngeal segment, all long-term survivors cutaneous perforators (average two perforators per flap)
tolerated an unrestricted oral diet. Tracheoesophageal having diameters of 0.5 to 1.5 mm that arise from the
speech was achieved in 10 of 11 patients who underwent descending branch of the LCFA and/or the transverse
tracheoesophageal puncture. Yu and Robb reported the branch of the LCFA. The length of the vascular pedicle

can vary from 8 to 16 em, depending upon patient stat- Mter identifying the lateral femoral cutaneous nerve at
ure, the extent of proximal dissection of the LCFA that the proximal margin of the Bap skin paddle, it can be
is performed, and the location of the cutaneous perfo- dissected proximally through the subcutaneous tissues
rators relative to their origin from the LCFA. Perfora- of the thigh toward the ASIS to provide a sensory nerve
tors located in the disw thigh provide a longer vascular graft that is about 5 em in length (47).
pedicle than those that arise in the proximal thigh. The The motor branch of the femoral nerve that innel'-
diameter ofthe proximal LCFA at the site used for micro- vates the vastus lateralis muscle runs in close proxim-
vascular anastomosis is usually about 2.5 mm, while the ity to the descending branch of the LCFA. This nerve
diameter of the proximal lateral circumBe:x femoral venae should be preserved if possible. Distal branches of this
comitantes is usually about 3.5 mm. nerve are commonly sacrificed when a musculocutane-
Sensory reinnervation of the skin paddle of the ALT ous ALT flap that includes a significant portion of the
Bap can be performed using the lateral femoral cutane- vastus lateralis muscle is harvested. When there is more
ous nerve. The lateral femoral cutaneous nerve enters than one cutaneous perforator of the LCFA supply-
the proximal aspect of the ALT flap in a deep subcuta- ing the skin paddle of an ALT Bap, some of the motor
neous plane, immediately above the investing fascia of branches to the vastus lateralis muscle may be intel.'l-
the quadriceps muscles. It can be located along a line twined with the cutaneous perforators. The motor nerve
that connects the ASIS and the superolateral patella. to the vastus lateralis muscle often runs medial to the

LCFA branch of LCFA
Transverse Transverse
branch of LCFA branch of LCFA
femoris a
branch of LCFA femoris Descending
branch of LCFA

Rectus femoris
Rectus femoris
cutaneous muscle
perforators Musculo-
Vastus lateralis
muscle Vastus lateralis

FIGURE 15-3. A:. Type I cutaneous perforators arise from the descending branch of1he LCFA and
occur in about 90% of patients. Approximately 90% of type I cutaneous perforators are musculocu-
taneous perforators that take a short intramuscular course through the medial aspect of the vas-
tus latera lis muscle. About 10% of type I cutaneous perforators are septocutaneous perforators
and travel through the intermuscular septum that separates the vastus lateralis and rectus femoris
(RF) muscles. B: Type II cutaneous perforators arise from the transverse branch of1he LCFA. Type
II perforators occur in about 5% to 10% of patients. Most type II perforators are musculocutaneous
perforators thattake a long intramuscular course 1hrough the vastus lateralis muscle. (Continued}
240 CHAPTER 15

branch of the LCFA and accounted for 4% of cutaneous

//~\ perforators. 'J:Ype m perforators originated directly
from the profunda femoris artery and accounted for 4%
of cutaneous perforators. Type m perforators were very
small in size (<1 mm in diameter) and were unsuitable
Ascending for microvascular anastomosis.
~..+--branch of LCFA Numerous cadaver dissections and clinical case
series have documented that the cutaneous perforators
from the LCFA more frequently take a musculocuta-
neous course through the vastus lateralis muscle rather
than a septocutaneous course through the intermus-
femoris artery +--11"~~ cular septum that separates the vastus lateralis muscle
from the rectus femoris muscle (36). In the largest case
series to date that reported this data, Wei et al. reported
that 87.1% of 504 fasciocutaneous or cutaneous ALT
flaps were perfused by musculocutaneous perforators,
Rectus femoris while 12.9% were pezfused by septocutaneous perfora-
muscle ---+-~;
tors (40). Dissection of type I and type n septocutane-
cutaneous ous perforators is usually straightforward, as the entire
perforator course of the perforators lie within the intermuscular
septum. Type I musculocutaneous perforators take a
relatively short (usually 2 to 3 em) medial-to-lateral
oriented intramuscular course from the descend-
ing branch of the LCFA through the medial edge of
the vastus lateralis muscle before they reach the thigh
skin. Because of their relatively short intramuscular
course, type I musculocutaneous perforators are usually
unroofed and dissected with relative ease. Type n mus-
c culocutaneous perforators from the transverse branch
FIGURE 15-3. (Continued} C: Type Ill cutaneous perfora- of the LCFA take a relatively long (up to 10 em) supe-
tors arise directly from 1he profunda femoris artery. Type Ill rior-to-inferior oriented intramuscular course through
perforators occur in about 1% to 5% of patients. Most type the medial aspect of the vastus lateralis muscle before
Ill perforators are musculocutaneous perforators thattake they reach the thigh skin. Because of their long intra-
an intramuscular course through the rectus femoris (Rf) muscular course, type n musculocutaneous perforators
muscle. Most type Ill perforators are of very small caliber are the most difficult to dissect.
and are unsuitable for microvascular anastomosis.

most proximal perforators and lateral to the most distal
perforators (5). In this instance, it is not possible to pre- The rectus femoris muscle receives its blood supply
serve all of the perforators as well as the intertwined from branches of the LCFA. There are usually one to
motor nerves. It is the author's practice to divide the three branches that emerge from the proximal portion
intertwined motor nerve during flap elevation and then of the LCFA and have a shon anteromedial course
perform a neurorrbaphy of the divided motor nerve before entering into the rectus femoris muscle. Com-
after flap harvest bas been completed. plete elimination of the LCFA blood supply to the rec-
tus femoris muscle places the rectus femoris muscle at
risk to suffer ischemic necrosis. When dissecting the
ANATOMIC VARIATIONS proximal segment of the LCFA, branches to the rectus
femoris muscle should ideally be preserved intact if
'Yu described a useful method for classification of the the LCFA vascular pedicle located distal to the rectus
common variants of the vascular anatomy of ALT flaps femoris branches is of sufficient length and adequate
(46) (Fig. 15-3). He noted that cutaneous perforators to caliber for microvascular anastomosis to the recipient
the ALT skin derive from three possible sites of origin. vessels in the bead and neck. If multiple rectus femo-
'J:Ype I perforators accounted for 90% of perforators in ris branches are present, only the most proximal rec-
his series and originated from the descending branch of tus femoris branch needs to be preserved during ALT
the LCFA. Type n perforators arose from the transverse flap harvest.

It is well established that the majority of cutaneous course; this manoeuver avoids inadvertent injury to
perforators from the LCFA take a musculocutaneous the perforator during incision of the muscle, and also
course through the medial edge of the vastus lateralis establishes that the perforator supplies the skin paddle
muscle. When harvesting a cutaneous or fasciocutane- of the musculocutaneous flap. Determining the course
ous perjoraror ALT flap that is perfused by musculocuta- of the perforator to the source vessel is important since
neous perforators, it is mandatory to identify and dissect in 10% of cases the perforator may arise from the trans-
the musculocutaneous perforators. Controversy exists verse branch of the lateral circumflex artery, and enters
regarding the need to dissect the intramuscular course the muscle superiorly with a vertical course and is sus-
of these musculocutaneous perforators when harvesting ceptible to damage during muscle incision at the upper
musculocutaneous ALT flaps that include the medial border of the flap" (6).
aspect of the vastus lateralis muscle. In reporting a With increased clinical experience using both the
series of 672 ALT flaps, Wei et al. transferred 95 mus- muscle cuff technique and the perforator unroofing
culocutaneous ALT flaps that included a portion of the technique, the latter technique is now the author's pre-
vastus lateralis muscle (40). In these cases, Wei et al. ferred approach to harvest of musculocutaneous ALT
stated that no dissection of the cutaneous perforators flaps. Unroofing of musculocutaneous perforators by
was required to harvest musculocutaneous ALT flaps. dividing the overlying vastus lateralis muscle is not usu-
The vastus lateralis muscle cuff technique for muscu- ally difficult, since most of the muscular side branches
locutaneous flap harvest was embraced by Lueg, who of the perforators arise from the lateral aspect of the
reported 34 consecutive cases of ALT flap reconstruc- perforators, so that they are less prone to injury while
tion of the head and neck. In his series, Lueg included dividing the muscle that covers medial aspect of the per-
a cuff of the medial edge of the vastus lateralis mus- forators. We examined the efficacy of ultrasonic shears to
cle in all cases, and no effort was made to identify or unroof and dissect musculocutaneous perforators from
dissect the cutaneous perforators (23). There were no the LCFA during harvest of ALT perforator flaps (2).
cases of complete flap necrosis and two cases of partial Successful dissection of intact perforators was achieved
flap necrosis, which the author attributed to excessive in 27 out of 28 perforators arising from the descending
flap de-epithelialization that disrupted the subdermal branch of the LCFA and 9 out of 9 perforators arising
vascular plexus while creating double skin paddled from the transverse branch of the LCFA, for an overall
flaps for through-and-through reconstructions. Mal- success rate of 97% for dissection of these musculocu-
hotra et al. performed cadaver dissections to determine taneous perforators. ALT flap viability was 100% with
if the vastus lateralis muscle cuff technique was a safe this technique, with no instances of partial or complete
approach to harvesting musculocutaneous ALT flaps flap necrosis.
(27). They determined that at least one cutaneous per- Anatomic variations in the blood supply to the skin
forator was preserved intact in all of their 27 dissections make ALT flap harvest, based upon the LCFA, not
by harvesting a 2 em wide cuff of the medial edge of the possible in less than 5% of dissections (e.g., cases that
vastus lateralis muscle. are found to have only type III perforators on explo-
The risk of not performing an intramuscular dissec- ration). For this reason, it is the author's practice to
tion of the musculocutaneous perforators while har- inform, consent, and prep and drape all patients to
vesting musculocutaneous ALT flaps is evident when undergo a bilateral thigh exploration, in case the ini-
faced with the situation in which type IT musculocuta- tial dissection on one side reveals unfavorable anat-
neous perforators arise from the transverse branch of omy. Another option in this situation is to harvest a
the LCFA. The intramuscular course of musculocuta- myofascial vastus lateralis flap based upon the LCFA
neous perforators through the vastus lateralis muscle is vascular pedicle. The vastus lateralis muscle can be
not clear by observing their location or appearance as covered with a skin graft to achieve a very satisfactory
they enter the skin paddle of the flap during the early aesthetic outcome for external skin reconstruction
stages of flap harvest, and it cannot reliably be deter- (25). Alternatively, vascularized vastus lateralis mus-
mined whether musculocutaneous perforators are type cle can be used for intraoral mucosal reconstruction,
I perforators or type II perforators unless their course with flap remucosalization occurring during the post-
through the vastus lateralis muscle is defined by divid- operative period (41). When a skin paddle is needed
ing the overlying vastus lateralis muscle and following but the vascular anatomy of the LCFA proves to be
the course of the perforators to their vessel of origin. In unfavorable for harvest of a skin paddle, then the dis-
a subsequent publication that described their preferred section can be converted to harvest of an anterome-
technique for harvest of musculocutaneous flaps, Chana dial thigh flap (35) or tensor fascia lata flap (9). Either
and Wei stated: "it is prudent to determine the course the anteromedial thigh flap or the tensor fascia lata
of the perforator to the source vessel by deroofing the flap can be harvested while using the same initial skin
muscle fibres over the chosen perforator. The perfo- incision that is used to expose the LCFA during ALT
rator may have a variable and tortuous intramuscular flap harvest.
242 CHAPTER 15

Long-term flap donor site and recipient site com- disease remains controversial. As a branch of the pro-
plications appear to be rare after ALT flap reconstruc- funda femoris system, the LCFA is relatively spared by
tion of the head and neck. Most case series describe peripheral vascular disease in patients who have devel-
a very acceptable degree of donor site morbidity after oped vasoocclusive disease affecting the superficial
harvest of ALT free flaps, with the flap donor site femoral system. Indeed, this recognition has led to the
rarely resulting in problems that affect daily activities use of the LCFA as an arterial graft source in patients
(1,3,7,13,23,26,34). Kimata et al. noted increased who require coronary artery bypass grafting (10). How-
donor site morbidity in cases where wide flaps required ever, Hage and Woerdeman reported a case of a patient
skin graft reconstruction of the donor site defect and with a history of intermittent claudication and no pal-
in cases where there was damage to the vastus lateralis pable popliteal pulse who developed distal leg ischemia
muscle (16). To the contrary, Lipa et al. found no cor- that resulted in soft tissue necrosis of the toes and calf
relation between the occurrence of donor site morbidity after harvest of an ALT free flap (14). In this patient,
and the need to perform skin grafts or an intramuscular the descending branch of the LCFA likely provided a
dissection of the perforators through the vastus lateralis major source of collateral blood flow to the distal lower
muscle (22). However, persistent leg weakness was sig- extremity in the face of severe peripheral vascular dis-
nificantly associated with extensive elevation and har- ease that resulted in occlusion of the superficial femoral
vest of the leg fascia with the flap, as opposed to only a artery. The authors recommended preoperative angiog-
very limited fascial sacrifice near the pedicle. raphy before harvesting ALT flaps in patients who have
With regards to long-term recipient site wound com- no palpable popliteal pulse.
plications, thigh skin is a poor match of facial skin with
regard to skin color, thickness, texture, and hair growth
patterns (28). This problem is more pronounced in POSTOPERATIVE CARE
patients who receive radiation therapy and in patients
of Western ethnicity as opposed to patients of Asian When primary wound closure is achieved at the thigh
ethnicity. wound donor site, a subcutaneous closed suction drain
is placed and removed when the output is less than 30 cc
over a 24-hourperiod.Wounds that are closed by skin graft
PREOPERATIVE ASSESSMENT are bolstered using a cotton and bismuth-petrolatum
gauze dressing for 5 to 7 days after surgery. Thereafter,
ALT flaps are contraindicated in patients with past thigh the skin graft recipient site wound is dressed daily with
surgery in whom cutaneous branches of the LFCA a bismuth-petrolatum gauze dressing until the skin graft
may have been divided during elevation of the thigh site is matured and fully epithelialized. The patients are
skin from the underlying quadriceps muscles. The util- allowed to weight bear on the leg of harvest as tolerated
ity of the ALT flap in patients with peripheral vascular by discomfort during the postoperative period.

Anterolateral Thigh Flap

FIGURE 15-4. The donor thigh is positioned

in a neutral position without internal or exter-
nal rotation. The skin paddle of the ALTflap is
roughly centered on a line that is drawn from
the AS IS to the lateral border of the patella.
This line marks the position of the intermuscu-
lar septum that separates the vastus lateralis
muscle from the rectus femoris muscle. In this
illustration, cutaneous perforators of the LCFA
are shown to be arising from the descending
branch of the LCFA (type I perforators). This
is the most common anatomic variant and is
encountered in about 90% of dissections. The
most common perforators arise near the mid
point of the line that is drawn from the AS IS to
the patella and is denoted by the letter B in this
illustration. Most flaps will be supplied by one to
three perforators from the LCFA that are usually
found within a 5-cm radius of the point marked
by point B. In this illustration, the letters A and C
denote the upper and lower limits of that 5-cm
range of perforator location.

FIGURE 15-5. The initial skin incision is made

along the medial aspect of the flap skin paddle.
In this case, the incision is carried through the
subcutaneous fat and through the investing
fascia ofthe rectus femoris muscle to harvest
a fasciocutaneous flap. The deep fascia and
skin paddle are reflected laterally off the rectus
femoris muscle until the intermuscular septum
between the rectus femoris and vastus lateralis
muscle, denoted by a yellow line of fat (arrow)
along the lateral aspect of the rectus femoris
muscle, is identified.
244 CHAPTER 15

Anterolateral Thigh Flap

FIGURE 15-6. A: At this point in the harvest,

the cutaneous perforators to the skin paddle of
the flap are identified immediately deep to the
fascia of the flap skin paddle. In this case, two
perforators are marked by red markers. B: Both
perforators are musculocutaneous perforators
that are traveling through the vastus latera lis
muscle, which is the muscle seen immediately
lateral to the intermuscular septum (arrowl. B

Anterolateral Thigh Flap

FIGURE 15-7. A: The rectus femoris muscle is

retracted medially to expose the descending
branch of the LCFA (srrow), which runs in the
intermuscular septum and along the superficial
aspect of the vastus intermedius muscle. B: A
close up view of the LCFA is demonstrated. The
pedicle is traced proximally in the septum to
achieve greater length and diameter. B

FIGURE 15-8. At. this point, the course of

the musculocutaneous perforators is 1raced
by performing a distal to proximal perforator
dissection. The courses of the perforators are
unroofed by lifting the vastus lateral is muscle
that lies medial to the perforators.
246 CHAPTER 15

Anterolateral Thigh Flap

FIGURE 15-9. After lifting the vastus latera lis

muscle off the perforators, the vastus lateral is
muscle is divided and any small blood vessels
contained within the vastus lateralis muscle are
simultaneously sealed using ultrasonic shears.
Alternatively, hemostasis can be achieved
using bipolar electrocautery or hemaclips.

FIGURE 15-10. A: The portion of the vastus

lateralis muscle overlying bath musculocuta
neous perforators has been divided. B: This
has led to exposure of the full course of bath
perforators (black arrows), which are arising
from the descending branch of the LCFA (whfte
arrow). These are type /musculocutaneous
perforators, which is the most common ana-
tomic variant that is encountered during flap
harvest B

Anterolateral Thigh Flap

FIGURE 15-11. ALT flap dissection (right leg)

in a different cadaver after unroofing of two
musculocutaneous perforators by division of
the overlying vastus lateralis muscle reveals
that the distal perforator is a type I perfora-
tor (black arrow) arising from the descending
branch LCFA. while the proximal perforator is a
type II perforator (white Bffowt arising from the
transverse branch of the LCFA. type II perfora-
tors account for 5% to 10% of the perforators
encountered during ALT flap harvest.
FIGURE 15-12. The lateral dissection is per-
formed after the medial dissection is completed
with successful dissection of the vascular
pedicle. In the instance where ALT flap elevation
is unsuccessful secondary to a lack of suit-
able cutaneous perforators from the LCFA, the
dissection can be converted to harvest of an
anteromedial thigh flap, a tensor fascia lata flap,
or the anterior thigh skin incision can be closed
in favor of performing a contralateral thigh ALT
flap harvest. After a favorable vascular pedicle
has been confirmed by the medial dissection, the
lateral skin incision is made to the fascia lata. A
variable amount of fascia lata can be harvested.
In this instance, a medial subcutaneous dissec-
tion is performed until the perforators are visual-
ized, and a small cuff offascialata is harvested
immediately adjacent to the perforators.

FIGURE 1513. The perforators are dis-

sected free from the vastus lateralis muscle.
A 5 to 10-mm cuff of vastus latera lis muscle
is harvested adjacent to the perforators to
harvest a perforatorfasciocutaneous flap. A
larger amount of vastus latera lis muscle can be
harvested in order to create a bulkier, muscu-
locutaneous flap. The vastus latera lis muscle
is divided and small muscular side branches of
the perforators are simultaneously sealed using
ultrasonic shears. Alternatively, bipolar electro-
cautery and hemoclips can be used to maintain
hemostasis during this dissection.
248 CHAPTER 15

Anterolateral Thigh Flap

FIGURE 1514. The motor nerve branches of

the femoral nerve (arrow) to the vastus lateralis
muscle is dissected and separated from the
vascular pedicle.

FIGURE 1515. Flap harvest of a fasciocutane-

ous perforator ALT flap that is perfused by two
type I musculocutaneous perforators has been
completed. The length of the vascular pedicle
usually varies from 8 to 16 em.

FIGURE 1516. View of the deep surface of

the harvested flap reveals a small cuff of deep
fascia that is preserved immediately adjacent to
the two cutaneous perforators.

Inset of the Anterolateral Thigh Rap for Circumferential

----LDngitudinal orientation

FIGURE 1~11. A circumferential defect of the

pharyngoesophageal segment is shown after
tota IIaryngopha ryng ectomy with preservation
of the cervical esophagus. The black arrow
indicates the lumen of the oropharynx. The
blue arrow indicates the lumen of the cervical

FIGURE 15-18. The cervical esophagus is

spatulated by making a longitudinal linear inci-
sion for a length of about 2 em. This enlarges
the circumference and breaks up the linear
nature of the distal enteric anastomosis,
thereby reducing the risk of stricture forma-
tion at the anastomosis of the ALT flap to the
cervical esophagus.
250 CHAPTER 15

Inset of 1he Anterolateral Thigh Flap for Circumferential

Longitudinal orientation

FIGURE 1519. Flap design is demonstrated in red ink for linear ALT flap tubing for pharyngoesophageal reconstruction. The
precise position of the flap along the axis (drawn from the AS IS to the lateral patella) is adjusted after flap harvest, based
upon 1he location of cutaneous perforators. The flap dimensions are adjusted according to the size of the pharyngoesopha
geal defect. With this design, the proximal flap wid1h equals 1he circumference of the proximal enteric anastomosis. Since
the circumference of the oropharynx is larger superiorly than it is inferiorly, 1his width can commonly vary from 8 to 14 em.
The distal flap width equals the circumference of the cervical esophagus before it is spatulated. This width is commonly
6 to 7 em. The leng1h of the flap is equal to the length of the pharyngoesophageal defect. The length of the triangular exten-
sion at1he distal end of the flap is equal to the length of the longitudinal incision that was made to spatulate the cervical
esophagus. An elliptical flap is harvested that encompasses the flap that will be used for pharyngoesophageal reconstruc-
tion. This design facilitate thigh wound closure and provides extra flap skin that can be used as an external skin paddle to
monitor postoperative flap perfusion. A disadvantage of this flap design arises when the width of the required flap exceeds
Sto 10 em. In this instance, primary closure of the thigh wound defect may not be possible, and skin graft reconstruction of
the thigh donor site may be necessary.

FIGURE 15-20. The flap is shown after de

epithelialization according to the dimension
described in Figure 15-19. The skin paddle is
centered on two skin perforators from the LCFA.
A small distal skin paddle (arrow) is included to
serve as an external flap monitor paddle.

Inset of the Anterolateral Thigh Rap for Circumferential

----LDngitudinal orientation
FIGURE 1~21. The flap is tubed longitudinally
ever a salivary bypass tube. In the author's
experience, stenting the reconstruction with a
size 10- or 12-mm salivary bypass tube reduces
the incidence of pestoperative salivary pha-
ryngocutaneous fistulas. One end of the red
rubber catheter is sutured te the praximal end
of the salivary bypass tube, while the ether
end is sutured to the caudal nasal septum. This
technique is applied to help prevent migration
of the salivary bypass tube and to facilitate its
removal at the bedside. The salivary bypass
tube is removed about 2 weeks after surgery
by cutting the nasal septum suture, grasping
the red rubber catheter in the oropharynx using
a tonsil clamp, and withdrawing the salivary
bypass tube through the mouth.

FIGURE 1~22. Longitudinal flap tubing is


FIGURE 1~23. The tubed flap is inset into the

pharyngoesophageal defect. The flap vascular
pedicle {blue arrow) is braught into the right
neck for anastomosis to cervical recipient blood
vessels. The flap monitoring skin paddle is inset
into the right neck suture line.
252 CHAPTER 15

Inset of 1he Anterolateral Thigh Flap for Circumferential

~Djri'IJI orientation

FIGURE 15-24. Skin paddle design for a spiral

ALT flap tubing demonstrates a long, narrow
flap. The flap width is determined by thigh skin
laxity that allows for primary closure of the
thigh donor site wound and is frequently in
the range of 8 to 10 em. The length of the flap
should exceed the sum of the circumference
of the proximal and distal enteric anastomoses
and the linear length of the pharyngoesopha-
geal reconstruction. This is frequently in the
range of about 30 em.

FIGURE 15-25. The ALT flap is tubed using a

spiraling configuration. In this example, the skin
of the distal tip of the flap is sutured to the distal
lateral edge of the flap to create a distal flap
lumen circumference that matches the circum-
ference of the spatulated cervical esophagus.

Inset of the Anterolateral Thigh Flap for Circumferential

Pharyngoesophageal Reconstruction
Spkmorie~6on ____________

FIGURE 15-2&. The skin of the proximal tip

of the flap is sutured to the proximal medial
edge of the flap to create a proximal flap lumen
circumference that matches the circumference
of the oropharyngeal lumen.

FIGURE 15-27. Spiral flap tubing continues by

suturing the medial flap skin edge to the lateral
flap skin edge. This view shows that the tubing
of the flap has almost been completed.
254 CHAPTER 15

Inset of 1he Anterolateral Thigh Flap for Circumferential

~Djri'IJI orientation

FIGURE 15-28. Flap tubing has been

completed over a salivary bypass tube.

FIGURE 15-29. The spiral-tubed flap has been

inset into the pharyngoesophageal defect.
The vascular pedicle {arrow) is brought into
the right neck for anastomosis to right-sided
cervical recipient blood vessels.

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the free anterolateral thigh flap for reconstruction of
head and neck defects. Arch Otolaryngol Head Neck Surg
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19. Koshima I, Fukuda H, Utunomiya R, Soeda S: The
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20. Koshima I, Fukada H, Yamamoto H, Morigushi T,
4. Amin A, Rifaat M, Civaatos F, Weed D, Abu-sedira M, Soeda S, Ohta S: Free anterolateral thigh flaps for recon-
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21. Kuo YR, Jeng SF, Wei FC, Su CY, Chien CY: Functional
5. CaseyWJ, Rebecca AM, SmithAA, Craft RO, Hayden RE, reconstruction of complex lip and cheek defects with free
Buche! EW: Vastus lateralis motor nerve can adversely composite anterolateral high flap and vascularized fascia.
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22. Lipa JE, Novak CB, Binhammer PA: Patient-reported
6. Chana JS, Wei FC: A review of the advantages of the donor-site morbidity following anterolateral thigh free
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Br J Plast Surg 2004;57:603--609.
23. Lueg EA: The anterolateral thigh flap: radial forearm's "big
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TY: Anterolateral thigh flaps for reconstruction of head Arch Otolaryngol Head Neck Surg 2004;130;813-818.
and neck defects. J Oral MaxiJJojac Surg 2005;63:948-952.
24. Lutz BS: Aesthetic and functional advantages of the
8. Choi SW, Park JY, Hur MS, Park HD, Hu KS, Kim HJ: anterolateral thigh flap in reconstruction of tumor-related
An anatomic assessment on perforators of the lateral scalp defects. Microsurgery 2002;22:258-264.
circumflex femoral artery for anterolateral thigh flap.
J Crani<Jjac Surg 2007;18:866-871. 25. Lutz BS: Beauty of skin-grafted muscle flaps in head and
neck reconstruction. Microsurgery 2006;26:177-181.
9. Coskunfirat OK, Ozkan 0: Free tensor fascia lata perfO-
rator flap as a backup procedure for head and neck recon- 26. Makitie AA, Beasley NJ, Neligan PC, Lipa J, Gullane
struction. Ann Plast Surg 2006;57: 159-163. PJ, Gilbert RWL: Head and neck reconstruction with
anterolateral thigh flap. Otolaryngol Head Neck Surg
10. Fabbrocini M, Fattouch K, Carnporini G, et al.: The 2003; 129:547-555.
descending branch of lateral femoral circumflex artery
in arterial CABG: early and midterm results. Ann Thorac 27. Malhotra K, Lian T, Chakradeo V: Vascular anatomy
Surg 2003; 75: 1836-1841. of the anterolateral thigh flap. Laryngoscope 2008;118:
11. Farace F, Fois VE, Manconi A, et al.: Free anterolateral
thigh flap versus free forearm flap: functional results 28. Mureau MA, Posch NA, Meswis CA, Hofer SO: Antero-
in oral reconstruction. J Plan Reconstr Aesrlzet Surg lateral thigh flap reconstruction of large c:xternal facial
2007 ;60:583-587. skin defects: a follow-up study on functional and aes-
thetic recipient- and donor-site outcome. Plast Recomtr
12. Gebebou TM, Wei FC, LinCH: Clinical experience of Surg 2005;115:1077-1086.
1284 free anterolateral thigh flaps. Handckir Mikrockir
Plast Chir 2002;34:239-244. 29. Murray DJ, Gilbert RW, Versely MJ, et al.: Functional
outcomes and donor site morbidity following circum-
13. Genden EM, Jacobson AS: The role of the anterolateral ferential pharyngoesophageal reconstruction using an
thigh flap for pharyngoesophageal reconstruction. Arch anterolateral thigh flap and salivary bypass tube. Head
Otolaryngol Head Neck Surg 2005;131:796-799. Neck 2007;29:147-154.
14. Hage D, Woerdeman IA: Lower limb necrosis after use of 30. Nakayama B, Hyodo I, Hasegawa Y, et al.: Role of the
the anterolateral thigh free flap: is preoperative angiogra- anterolateral thigh flap in head and neck reconstruction:
phy indicated? Ann Plast Surg 2004;52:315-318. advantages of moderate skin and subcutaneous thickness.
15. Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii J Recomtr Microsurg 2002;18:141-145.
K: Anatomic variations and technical problems of the 31. Ozkan 0, Mardini S, Chen HC, Cigna E, Tang WR, Liu
anterolateral thigh flap. A report of74 cases. Plast Recon- YT: Repair of buccal defects with anterolateral thigh
str Surg 1998;1 02:1517-1523. flaps. Microsurgery 2006;26: 182-189.
16. Kimata Y, Uchiyama K, Ebihara S, et al.: Anterolateral 32. Rodriguez-Vegas J, Angel PA, Manuela PR: Refining the
thigh flap donor-site complications and morbidity. Plast anterolateral thigh free flap in complex orbitomaxillary
Recomtr Surg 2000;106:584-589. reconstruction. Plast Reconstr Surg 2008; 121 :481-486.
256 CHAPTER 15

33. Rosenthal EL, King T, McGrew BM, Carrol W, 42. Wolff KD, Grundmann A: The free vastus lateralis flap:
Magnuson JS, Wax MK: Evolution of a paradigm for free an anatomic study with case reports. Plast Reconstr Surg
tissue reconstruction of the lateral temporal bone. Head 1992;89:469--47 5-
Neck 2008;30:589-594. 43. Wolff KD, Kesting M, Thurmuller P, Bockmann R.
34. Ross GL., Dunn R. Kirkpatrick J, et a.L: To thin or not to Holzle F. The anterolateral thigh as a universal donor
thin: the use of the anterolateral thigh flap in the reconstruc- site for soft tissue reconstruction in maxillofacial surgery.
tion of intraoral defects. BrJ Plast Surg 2003;56:409-413. J Craniomaxillojac Surg 2006;34:323--331.
35. Schoeller T, Huemer GM, Shafighi M, Gurunluoglu R. 44. Xu DC, Zhong SZ, Kong JM, et al.: Applied anat-
Wechselberger G, Piza-Katzer H: Free anteromedial omy of the anterolateral thigh flap. Plast Recomrr Surg
thigh flap: clinical application and review of the literature. 1988;82:305-310.
Microsurgery 2004;24:43--48. 45. Yildirim S, Gideroglu K, Aydogdu E, Avci G, Akan M,
36. Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL: Akkoz T: Composite anterolateral thigh-fascia lata flap:
Free anterolateral thigh flap for reconstruction of head a good alternative to radial forearm-palmaris longus
and neck defects following cancer ablation. Plast Recomtr flap for total lower lip reconstruction. Plast Recomtr Surg
Surg 2000; 105:2349-2357 _ 2006;117 :2033--2041.
37. Shimizu T, Fisher DR. Carmichael SW, Bite U: An ana- 46. Yu P: Characteristics of the anterolateral thigh flap in a
tomic comparison of septocutaneous free flaps from the western population and its application in head and neck
thigh region. Ann Plast Surg 1997;38:604-610. reconstruction. Head Neck 2004;26:759-769.
38. SongYG, Chen GZ, SongYL:The free thigh flap: a new 47. Yu P: Reinnervated anterolateral thigh flap for tongue
free flap concept based on the septocutaneous artery. reconstruction. Head Neck 2004;26: 1038-1044.
Br J Plast Surg 1984;37:149-159. 48. Yu P, Adel Y: Efficacy of the handheld Doppler in
39. Wang X, Qiao Q, Liu Z, et al.: Free anterolateral thigh preoperative identification of the cutaneous perfora-
adipofascial flap for hemifacial atrophy. Ann Plast Surg tors in the anterolateral thigh flap. Plast Reconstr Surg
2005;55:617-622. 2006;118:928-933.
40. Wei FC, Vivek Jain MC, Celik N, Chen HC, Chuang 49. Yu P, Robb GL: Pharyngoesophageal reconstruction with
DC, Un CH: Have we found an ideal soft-tissue flap? An the anterolateral thigh flap: a clinical and functional out-
experience with 672 anterolateral thigh flaps. Plast Recon- comes study. Plast Recomtr Surg 2005;116:1845-1855.P
str Surg 2002; 109:2219-2226.
41. Wolff KD: Indications for the vastus lateralis flap in
oral and maxillofacial surgery. Br J Oral Maxi/lajac Surg
INTRODUCTION used in all cases to cover post-traumatic tissue defects
of the extremities. Although Hwang et ai.a description
With the rise in popularity of the fibular osteocuta- in 1985 was reported as a new medial leg skin fiap,
neous free flap, the lower leg has become one of the Zhang also described a similar flap in the OUnese lit-
most common donor sites for head and neck recon- erature in 1983 (19).
struction. A number of other lower leg donor sites have Based on the PTA, with the venous supply arising
been described, including the peroneal fiap, gastrocne- from the paired <venae comitantes, this fiap is predomi-
mius flap, saphenous Bap, and posterior leg flap (17). nandy used as a fascial or fasciocutaneous flap. It can
Although the other lower leg flaps have not gained also be elevated as a sensate flap with incoxporation of
popularity in head and neck reconstruction, there has the sensory nerve supply through the saphenous nerve.
been increasing interest in the use of the posterior tibial Although there has been limited experience with this
artery (PTA) flap. flap in head and neck reconstruction, a number of
The PTA flap was initially descnoed by Hwang advantages have been proposed. These include large
et al. in 1985 who referred to it as the medial leg skin flap dimension, relatively thin and Bez.ible tissue, and
Bap (5). This group reported on 17 cases with 100% long pedicle length with large-cahoer vessels. As it is a
Bap survival rate. In this initial description, the flap was lower leg donor site, the akin graft is less conspicuous

258 CHAPTER 1&

than that on the volar aspect of the upper extremity fol- as for recontouring procedures. The predictable vascu-
lowing harvest of a radial forearm flap. Also, there is lit- lar anatomy and the presence of multiple subcutane-
tle anatomic variation in the vascular anatomy of this ous perforators allow significant freedom with regard
area. Potential disadvantages include the placement of a to manipulation and contouring of the flap, as well as
skin graft over the tibia in a vulnerable location that may the potential harvest of independent skin paddles. The
be at risk of noDhealing following trauma. In addition, lower leg donor site facilitates elevation by a separate
the sacrifice of one of the dominant blood supplies to team of surgeons.
the foot may not be advisable in the event oflater devel- Despite these advantages, there have been limited
opment of atherosclerosis that places the foot at risk of descriptions of using this flap in head and neck recon-
ischemia. To date, these complications are theoretical struction. As stated above, one of the earliest descrip-
and have not been reported in the literature. tions was its use for esophageal reconstruction as a large
tubed free flap (1). A recent report looking at the PTA
flap specifically for head and neck reconstruction was
FLAP DESIGN AND UTILIZATION published by Ng et al. (13). This paper reported on
11 patients having PTA free flap reconstruction with
The territory of the PTA free flap (Fig. 16-1) has been 100% flap survival. Nine of these flaps were used for
investigated through a number of anatomic studies intraoral mucosal lining reconstructions. The remaining
(4,8,15,18). Although the maximum possible dimen- two were used for external skin coverage. Flap dimen-
sions of the skin paddle have not been specifically iden- sions ranged from 6 x 8 em to 8 x 12 em. The authors felt
tified, it is felt that skin paddles of up to 19 X 13 em that the advantages of this flap were significant and that
may be safely raised on a single perforator (6). Chen it may, in many circumstances, replace the radial fore-
et al. reported the use of a 30 x 10 em PTA flap for arm free flap for head and neck reconstruction. Another
esophageal reconstruction (1). Venous insufficiency has recent report in the Chinese literature described the
been described as a possible complication in the case of "medial leg fascial cutaneous flap" for reconstruction
large pedicled flaps based on the distal perforators of of base-of-tongue defects in four patients. They also
the PTA. Ozdemir et al. described that three of eight reported a 100% free flap survival rate and an accept-
patients developed venous congestion postoperatively, able donor site morbidity.
with one patient having partial flap loss (15). The flaps Although proposed as an advantage of the PTA
with venous congestion ranged from 18 to 24 em in free flap, the incorporation of the saphenous nerve
maximum length. The authors felt that increased flap for sensation has not been specifically reported on in
size may have contributed to the venous congestion. head and neck reconstruction. We have successfully
However, in this report, flaps were designed as distally incorporated the saphenous nerve with the PTA free
based, pedicled flaps, not free tissue transfers, and likely flap for sensate reconstruction of a hemiglossectomy
do not reflect the vascular physiology when this flap is defect with good functional outcomes, and we have
used as a free tissue transfer. Venous insufficiency has previously shown the importance of reinnervation in
not been reported as a complication following transfer tongue reconstruction (14). Interestingly, in the initial
of the PTA free flap. description of this flap by Hwang et al., the sural nerve
Preoperative evaluation of the donor site is impor- was incorrectly identified as the sensory nerve running
tant. The skin and subcutaneous tissue characteristics with the saphenous vein to supply this free flap. In fact,
are important to identify prior to utilizing this free flap the saphenous nerve is identified running with the long
for complex head and neck reconstructions. Although saphenous vein. This nerve can be easily incorporated
the area usually provides thin and pliable tissue, in into the flap design. Zhang et al. indicated that they
patients with a large body habitus, there may be signifi- used this nerve for sensate reconstruction of hand and
cant amounts of subcutaneous fat. This can make deli- foot defects (20).
cate head and neck reconstructions challenging and
direct the reconstructive surgeon away from the tissue
of this region. When designing the flap, our experience NEUROVASCULAR ANATOMY
has been that the tissue from the anterior portion of
the flap over the tibia tends to be thinner and more pli- The lower leg is supplied primarily by the posterior tibial,
able (Fig. 16-2). This tissue can be used preferentially anterior tibial, peroneal, and sural arteries. The popliteal
where thin pliable tissue is advantageous. Similarly, artery, originating in the thigh, provides several branches
the portion of the flap that extends posteriorly tends including the anterior and posterior tibial arteries.
to have more abundant subcutaneous tissue. This The PTA arises at the distal border of the popliteus
area can be preferentially harvested in circumstances muscle, between the tibia and the fibula, and descends
where an increased volume of tissue is required, such medially in the flexor compartment of the lower leg

RGURE 16-1. The size and shape of1he posterior tibial artery flap vary with the defect. The axis of
the flap should be centered over1he course of the transverse intennuscular septum around zone
II of the lower leg as described by Wu et al. and described above. The flap may include most of1he
medial aspect of1he lower leg. There are regional differences in the 1hickness of1he subcutaneous
tissue. with the 1hinnestflaps harvested over the tibia and thicker flaps designed more posteriorly.
2&0 CHAPTER 16


\T'-'t - - t - + - - - Soleus

+ - l - H t - - - - Flexor

RGURE 1&-2. Medial view of lower leg, demonstrating the tibia, flexor digitorum longus muscle,
and soleus. The transverse intermuscular septum. through which the perforators pass, lies
between the soleus and the flexor digitorum longus muscle, as demonstrated in Figure 16-4A.
Palpating the posterior medial aspect of the tibia can identify the position of this septum.

(Fig. 16-3). The PTA passes under the fibrous arch of

the soleus muscle and I'Uil8 distally between the soleus
and the flexor digitorum longus muscles. Along its
course, the artery provides direct cutaneous branches
(Fig. 16-4B) that supply the posterior uoial free flap, as
well as muscular branches to supply adjacent muscles.
It is commonly accompanied by two venae comitantes,
referred to as the posterior tibial veins. It bifurcates
midway between the medial malleolus and the medial
tubercle of the calcaneus into the medial and lateral
plantar arteries, which supply the foot (3).
The PTA lies posterior to the tibialis posterior and
flexor digitorum longus muscles and behind the tibia and
the ankle joint. In the praximal por1ion ofthe lower leg, the
gastrocnemius, soleus, and deep t:nu:lSVei'Se fascia of the
leg are superficial to the PTA, whereas distally the vessel
becomes much more superficial and is covered only by the
skin and fascia.'IWo wnae comittmtes and the uDial nerve
accompany the PTA. The tibial nerve originates medially
Posterior but later crosses posterior and remains largely posterolat-
tibial artery - - - +-Ht-1!+-a eral to the artery in the foot. Terminally, the artery is deep
to the flaor retinaculum and abductor hallucis.
The branches of the PTA include the peroneal and
circumflex fibular arteries as well as the nutrient artery
of the tibia, and the medial and lateral plantar arter-
nerve-----+-++V ies. In addition, the PTA gives rise to the perforating
branches to the skin and periosteum and muscular
branches mentioned above. Both the circumflex fibular
artery and the nutrient artery of the tibia arise near the
Long takeoff of the peroneal artery from the PTA and as such
saphenous may be preserved during flap dissection. The circum-
vein-----411-++H flex fibular artery anastomoses with the lateral inferior
genicular artery, the medial genicular artery, and the
anterior tibial recurrent arteries. It supplies bone and
articular structures around the knee. The nutrient artery
of the tibia arises from the PI'A near its origin. It sup-
plies muscular branches to the soleus and deep flexors
of the lower leg. The communicating branch of the PTA
runs posterior and deep to the flez.or hallucis longus,
across the uoia, approximately 5 em above its distal end
to join a branch of the peroneal artery. The calcaneal
branches of the nutrient artery arise just proximal to the
FIGURE 16-3. The neurovascular supply of the medial terminal division of the PI'A and penetrate the flexor
aspect of the lower leg is shown. The posterior tibial retinaculum posterior to the tendocalcaneus muscle.
artery (PTA) arises at the distal border of the popliteus, These branches anastomose with the medial malleolar
between the tibia and the fibula, and descends medially in arteries and calcaneal branches of the peroneal artery.
the flexor compartment. The PTA passes under the fibrous The peroneal artery arises approximately 2.5 em
arch of the soleus muscle and runs distally between the distal to the popliteus, high in the posterior compart-
soleus and the flexor digitorum longus. Along its course, ment. It descends between the tibialis posterior mus-
the artery provides direct cutaneous branches that supply cle and the flexor hallucis longus to the tibiofibular
the posterior tibial free flap. The saphenous nerve gener- syndesmosis, where it subsequently divides into calca-
ally lies anterior to the long saphenous vein. Both of these neal branches. This artery supplies a nutrient branch
structures can be preserved or harvested with the flap, as to the fibula and a perforating branch that pierces the
required. interosseous membrane about 5 em proximal to the
262 CHAPTER 16

anterior muscle

posterior musde
longus mus.---+fl~

tibial artery,
vein and nerve

anterior muscle

posterior musde


RGURE 16-4. A:. The cross sectional anatomy of the lower leg demonstrates the transverse
intennuscular septum lying between the flexor digitorum longus and soleus muscles. Unlike in many
cases of harvest of a fibular free flap, the perforators are true septocutaneous perforators and it
is not necessary to include a cuff of muscle to protect musculocutaneous perforators. B: In cross
sectional view. the flap has been elevated. The septum containing the perforating branches of the
PTA is identified, and the posterior tibial nerve has been left in the deep portion of the dissection.

lateral malleolus to enter the extensor compartment, on the posterior tibial perforator branches in 12 patients.
where it anastomoses with the anterior lateral malleo- They achieved a 100% flap survival rate with no major
lar artery. It also supplies muscular branches to the complications.
soleus, tibialis posterior, flexor hallucis longus, and An investigation by Schaverien and Saint-Cyr further
peronei muscles. The peroneal artery is a highly uti- illustrated the predictable presence of perforators from
lized donor artery in the transfer of fibular free flaps in the PTA, anterior tibial, and peroneal arteries when
head and neck reconstruction and is discussed in more they found that these vessels could be located in distinct
detail in Chapter 22. 5-cm intervals within the intermuscular septum. The
The medial plantar artery and the much smaller authors mentioned that of the distribution of perfora-
lateral plantar artery are the terminal branches of the tors of these three systems, the most clinically useful
PTA. The medial plantar artery progresses forward were that of the PTA, stating that the distal perforators
along the medial side of the foot, accompanied by the could be used to cover defects of the heel, medial malle-
medial plantar nerve. It branches from the PTA deep olus, Achilles tendon, and distal two-thirds of the tibia.
to the abductor hallucis, running distally between this They suggested that this consistency in the distribution
muscle and the flexor digitorum brevis, supplying feed- of these nutrient vessels would allow for better design
ing vessels to both. The artery terminates by joining the and manipulation of pedicled perforator flaps for lower
digital branch of the deep plantar arch, which supplies leg reconstruction ( 16).
the medial border of the great toe. The lateral plantar Hung et al. conducted an investigation of the anat-
artery passes anterolaterally into the sole of the foot, omy of cutaneous perforators of the PTA in 20 limbs
deep to the proximal end of the abductor hallucis mus- of 10 cadavers and after localizing the majority of
cle. It then traverses obliquely across the sole between the perforators to the middle two-quarters of the leg
the quadratus plantae and the flexor hallucis brevis and (zones II and III) designed a free fasciocutaneous flap
curves medially to form the deep plantar arch, which based on one of these vessels. They named the flap
supplies the toes. the posterior tibial perforator flap and transferred it in
Venous drainage of the PTA flap is through its accom- six cases of hand and wrist defects (4). They reported
panying venae comitantes, the posterior tibial veins. a 100% flap survival rate and very minor donor site
These veins receive branches from the gastrocnemius morbidity.
and soleus muscles, including the venous plexus in the The saphenous nerve, arising from L2 to IA, is
soleus muscle, and contributions from the superficial the terminal sensory branch of the femoral nerve.
veins and the peroneal veins. The deep plantar venous The saphenous nerve travels with the femoral artery
arch in the foot accompanies the arterial arch, giving and vein through the adductor hiatus. After passing
rise to the medial and lateral plantar veins. From the through the hiatus, the saphenous nerve separates
deep plantar venous arch, the medial and lateral plantar from the vessels and travels through the fat between
veins run backward close to the corresponding arter- the sartorius and vastus medialis. The saphenous nerve
ies and, after communicating with the great and small provides sensation to the medial aspect of the lower
saphenous veins, unite behind the medial malleolus to leg from the knee to the medial malleolus, and this ter-
form the posterior tibial veins (3). ritory may extend as distal as the great toe in 20% of
The PTA provides a robust supply of perforators in the population (11). In the lower leg, it travels in close
the lower leg. Many perforator-based flaps have been proximity to the long saphenous vein. Saphenous neu-
designed to avoid sacrifice of the PTA and its supply ralgia describes the symptom complex of anesthesia,
to the muscles, nerves, and bones of the lower leg. The hyperaesthesia, and pain in the area innervated by the
reliability of the location of perforators has been a con- saphenous nerve and has been described after saphen-
cern in designing this type of flap. A study by Wu et al. ous vein harvesting for cardiac surgery procedures, but
extensively examined the perforators of the PTA and its the incidence following posterior tibial flap elevation is
clinical applications for pedicled flaps (18). They studied unknown (12).
the vascular anatomy of the posterior tibial vessels in 20
cadaveric legs and noted the number, size, and distribu-
tion of the direct cutaneous and direct muscle branches. ANATOMIC VARIATION
The lower leg was divided into four equal segments from
proximal to distal, with zone I being the most distal and Major variations in the popliteal artery branching pat-
zone IV being the most proximal. The direct cutane- terns are observed in up to 12% of individuals (6).
ous branches were found to cluster primarily in zone II, As the development of the arteries of the lower limb
whereas the direct muscle branches to the soleus and results from the union of dorsal and ventral systems,
flexor digitorum longus muscles originate chiefly in variations at many levels can be expected. Lippert
zones II and ill. As a result, the authors performed fas- originally classified these variations into three types:
ciocutaneous and musculofasciocutaneous flaps based normal level of popliteal branching, high division of
264 CHAPTER 1&

the popliteal artery, and hypoplastic or aplastic artery is hypoplastic, often either the peroneal artery or the
with altered distal supply (10). As stated earlier, nor- PTA provides the main blood supply to the anterior
mally the popliteal artery divides at the lower margin compartment of the lower leg. In the presence of such
of the popliteus muscle. This occurs in approximately an abnormality, the harvest of either of these arter-
95% of individuals. In the remainder, the popliteal ies could cause subsequent ischemic necrosis of their
artery often divides at or above the level of the knee supplied tissues, depending on the organization of the
joint and in very rare cases, the artery branches at anomalous vessels.
a more inferior location in the lower leg. H the low
branching pattern is not identified prior to microvas-
cular flap harvesting, this variation can lead to the loss POTENTIAL PITFALLS
of vascular supply to the foot.
One obvious peril of harvesting the PTA for recon- The greatest concern regarding the use of the PTA
struction of head and neck defects is the rare chance flap is the requirement for sacrifice of one of the major
that the artery will be absent. Lippert classified this arterial supplies to the lower leg. Avoidance of lower
abnormality as a hypoplastic or aplastic PTA. This vari- leg ischemic problems is fundamental to a successful
ation has been reported to occur in 3.8% to 5% of indi- reconstruction. The approach to this potential problem
viduals and can result in altered vascular supply to the varies. In the initial description by Hwang et al., the
lower leg in several forms (7). In cases where the PTA saphenous vein was used to restore the continuity of
is aplastic or hypoplastic, often the peroneal artery is the PTA (5). More recently, Ng et al. have suggested
enlarged. It has many communicating branches and that all patients have preoperative assessment of lower
gives rise to a distally based PTA and the plantar arter- leg vascularity by clinical and radiologic means (13).
ies. One particular case study noted the absence of a They further suggested that all patients younger than
PTA, presence of a hypoplastic anterior tibial artery, 50 years of age undergo saphenous vein reconstruction
and compensatory marked hypertrophy of the peroneal of the PTA to avoid future vascular insufficiency (13).
artery and supply of the dorsalis pedis, medial plantar, Li et al. reconstructed the PTA in half of their cases
and lateral plantar arteries (21). As such, in these situa- with synthetic grafts but made no recommendations on
tions, harvest of the peroneal artery for a microvascular routine reconstruction of the vessels (9). A perforator-
fibular flap would also compromise the vascularity of based flap has been described to allow preservation of
the foot. the PTA (4). We evaluate all patients preoperatively
In a study of 1,000 femoral arteriograms by Kim with computed tomography angiography and do not
et al., it was found that in 0.8% of cases, the PTA routinely reconstruct the PTA. To date we have not had
branches at or above the knee joint, also producing any significant issues with lower leg ischemia. Further
a common trunk for the peroneal and anterior tibial study in this area is required prior to making defini-
arteries (7). The incidence of other variations noted tive recommendations. Long-term follow-up is criti-
by the authors was that of a hypoplastic-aplastic pos- cal in order to assess the impact of loss of one of the
terior and anterior tibial artery, wherein (a) the dorsa- major arterial supplies to the foot as the patient ages
lis pedis is a branch of the peroneal artery (1.6%) or and lower extremity atherosclerosis in the remaining
(b) both the posterior tibial and dorsalis pedis arter- arteries worsens.
ies are branches of the peroneal artery (0.2%). Day Donor site complications have not been well
and Orme reported the incidence of this abnormality described, but complications similar to other donor
to be in only I of 662 specimens examined (2). These sites may be predicted. Skin grafting directly over the
findings advocate for the use of preoperative vascular tibia may be of some concern; however, we have found
imaging of the lower extremity to assess the vascularity it possible to rotate the flexor digitorum longus over the
in the lower leg when considering a peroneal or pos- tibia to allow skin grafting to a muscular bed rather than
terior tibial artery flap to avoid the catastrophic com- periosteum.
plication of compromising the vascular supply to the
lower leg and foot.
Alternatively, vascular anomalies involving the PREOPERATIVE MANAGEMENT
peroneal artery can compromise the blood supply
to the leg if the PTA is harvested without an aware- Careful clinical assessment of the leg should be per-
ness of the abnormality. Abnormalities of the pero- formed prior to selecting this donor site. Signs of
neal artery have been documented in the literature in arterial or venous insufficiency should be carefully
conjunction with anatomical variants of the popliteal noted and may require selection of another donor site.
artery (7). In cases where the anterior tibial artery Ng et al. advised that this flap is contraindicated in

patients with ischemic ulcers of the foot, claudication, POSTOPERATIVE CARE

or foot or lower leg cold intolerance. Reports vary as
to the appropriate preoperative evaluation of lower A drain is placed in the deep compartment of the wound
leg vasculature. Angiography and Doppler exam are underneath the muscle closure, and a skin graft is placed
the two most common recommendations (8, 13). As over the defect (see "Flap Harvest Techniques" section).
stated above, we routinely perform computed tomog- A splint is applied postoperatively and left intact for 7
raphy angiography to evaluate the vascular anatomy days to allow adherence of the skin graft. Mter 7 days
of the legs. After tourniquet release, the foot should of no weight bearing, the patient is started on range-
be carefully assessed for vascular compromise and, if of-motion exercises and weight bearing is increased to
necessary, revascularization can be performed. With full weight bearing by day 10. The patient is discharged
appropriate preoperative assessment, revascularization home with written instructions for an appropriate home
should be rarely required. exercise program.
266 CHAPTER 1&

Posterior Tibial Artery Flap

FIGURE 16-5. The tnpographical anatomy is

outlined on the medial aspect of the leg. The
medial aspect of the tibia is marked in brown
between the posterior border of the medial
malleolus and the condyle of the tibia. This line
identifies the transverse intermuscular sep-
tum through which the perforators pass. The
approximate courses of the long saphenous
vein and saphennus nerve are shown as blue
and yellow lines, respectively.

FIGURE 16-6. The safid green line indicates

the anterior incision. The posterior aspect of
the incision is not performed until perforators
are identified following anterior dissection.

RGURE 16-7. The anterior incision is extended

to the level of the tibia. Periosteum is left on the
tibia. The flap is reflected posteriorly, taking
care to not extend the dissection beyond the
posterior border of the tibia.

Posterior Tibial Artery Flap

FIGURE 16-8. A:. The long saphenous vein {blue

srrowt and saphenous nerve (yellows"ow) are
identified at the inferior portion of the dissection.
The long saphenous vein can be dissected free
of the flap and preserved intact or incorporated
with the flap. Alternatively, it can be preserved
and harvested later for posterior tibial artery
reconstruction. B: The saphenous nerve is found
in close proximity to the saphenous vein. This can
be left intact or incorporated with the flap to pro-
vide sensation. If the nerve is sacrificed, numb-
ness will occur in the distribution of the nerve in
the lower leg. This includes the medial aspect of
the lower leg and may extend to the great toe in
20% of patients undergoing flap transfer. B

FIGURE 16-9. Having elevated the flap to the

posterior border of the tibia, the flexor digitorum
longus muscle is identified. The fascia over this
muscle is divided at the posterior border of the
268 CHAPTER 1&

Posterior Tibial Artery Flap

FIGURE 16-10. The fascia is reflected posteri-

orly off the flexor digitorum longus muscle, and
the septocutaneous perforators and the poste-
rior tibial artery pedicle are easily identified in
the septum between the flexor digitorum longus
and soleus muscles.

FIGURE 16-11. The anatomy ofthe posterior

tibial artery relations is shown. The red pin
identifies the posterior tibial artery pedicle. The
blue pin indicates the long saphenous vein.
The posterior tibial nerve lays posterior to the
pedicle and is indicated by the yellow pin. A
large septocutaneous perforator is indicated by
the blue arrow.

FIGURE 16-12. Having identified the location

of the perforators, a posterior incision may be
planned (green fine) depending on the size of
flap required. The posterior incision is extended
through the fa sci a of the soleus muscle, which
is reflected anteriorly, leading to the intermus-
cular septum and vascular pedicle.

Posterior Tibial Artery Flap

FIGURE 1&-13. A:. The posterior tibial artery

is divided distal to the level of the cutaneous
perforators which are incorporated with the
flap. B: The pedicle is dissected from distal to
proximal with division of the muscular perfora-
tors (as shown). Care must be taken to protect
the posterior tibial nerve. B

FIGURE 16-14. If the long saphenous vein

(blue pin) and the saphenous nerve (yellow
pin) have been incorporated in the flap, they
must be identified and dissected atthe proxi-
mal aspect of the flap.
270 CHAPTER 1&

Posterior Tibial Artery Flap

FIGURE 16-15. The flap is dissected until

appropriate pedicle length has been attained.
If necessary, it can be dissected to the level of
the peroneal artery. The tourniquet if used, is
released. When ready for inset. the pedicle is

FIGURE 16-16. A-C: The incision is closed

primarily using deep and superficial sutures
at the superior aspect A drain is placed in the
deep compartment The flexor digitorum longus
(white srrawt, in many cases, can be rotated
over the tibia and closed to skin. The soleus
(yellow srrawt can be adva need to suture to the
posterior aspect of the flexor digitorum longus,
which provides a flat vascularized surface for
skin graft application. C

Posterior Tibial Artery Flap

FIGURE 1&-11. The posterior tibial artery free

flap is shown with the posterior tibial artery
pedicle (red pin), long saphenous vein (blue
pin), and saphenous nerve (yellow pin).

REFERENCES 13. Ng RW, et al.: Free posterior tibial flap for head and
neck reconstruction after tumor expiration. lAryngoscope
1. Olen HC, TangYB, Noordhoff' MS: Posterior tibial artery
14. O'Connell D, Reiger J, Dziegielewski PT, Tang JL,
flap for reconstruction of the esophagus. Plast 1W:tm.m
Wolfaardt J, Harris ]R, Mlynarek A, Se:ikley H: Effect of
Surg 1991;88(6):980-986.
lingual and hypoglossal nerve reconstruction on swal-
2. Day CP, Orme R: Popliteal artery branching patterns-an lowing function on head and neck surgery: prospective
angiographic study. Clin Radicl2006;61 (8):696--699. functional outcomes study. J Otolaryn.j:ol Head Heck Surg
3. Gray H, et al.: Gray's A~: The Anatomical Bam of 2009;38(2):246--254.
Clinical Practice. 39th ed. Vol. 20. Edinburgh: Elsevier 15. Ozdemir R, et al.: Examination of the skin perfora-
O&urcl:lilll.ivingstone; 2005:1627. tors of the posterior tibial artery on the leg and the
4. Hung LK, Lao J, Ho PC: Free posterior tibial perfora- ankle region and their clinical use. Plan RJu:tmm Surg
tor flap: anatomy and a report of 6 cases. Microsurgery 2006;117(5):1619-1630.
1996;17{9):503-511. 16. Scllsverien M, Saint-Cyr M: Perforators of the lower
5. Hwang WY, et al.: Medial leg skin flap: vascular anatomy leg: analysis of perforator locations and clinical appli-
and clinical applications. Ann Pfasr Surg 1985;15(6): cation for pedicled perforator flaps. Plan Reoonstr Surg
489-491. 2008;122(1):161-170.
6. Kadir S: Atlas of Normal and Winant Angiographic Anat- 17. Strauch B, Yu H-L: Atlas of Microoascular Surgery: Anat-
~.Vol. 11. Philadelphia: Saunder; 1991:529. ono' and Operarive Techniques. 2nd ed. Vol. 8. New York:
7. Kim D, Orron DE, Skillman U: Surgical significance of Thieme; 2006:686.
popliteal arterial variants. A unified angiographic classifi- 18. Wu WC, et al.: The anatomic basis and clinical appli-
cation. Ann Surg 1989;210{6):776--781. cations of flaps based on the posterior tibial vessels.
8. Koshima I, et al.:The vasculature and clinical application Br J Plast Surg 1993;46(6):470-479.
of the posterior tibial perforator-based flap. Pfasr 1W:tm.m 19. Zhang SC: Clinical application of medial skin flap
Surg 1992;90{4):643-649. of leg-analysis of 9 cases. Zlwnghua Wai ~ Za Zhi
9. liYY, et al.: ~onstruction of limb defects with the free 1983;21{12):743-745.
posterior tibial artery wciocutaneous flap. Br J Plan Surg 20. Zhang X, et al.: Posterior tibial artery-based multilobar
1994;47{7):502-504. combined flap free transfer for repair of complex. soft tis-
10. lippert KM:Treatment of wounds of the popliteal artery. sue defects. MicroSUYgery 2008;28{8):643-649.
AmJSurg 1949;77(1):114-116. 21. Zwus A, Abdelwahab IF: A case report of anoma-
11. Meier G, Buttner J: Peripheral Regional Anesthesia: An lous branching of the popliteal artery. Angiology 1986;
Atlas ofAnato'lt'ly and Techniques. NewYork: l'hieme; 2005. 37(2):132-135.
12. Mountney J, Wllkinson GA: Saphenous neuralgia after
coronary artery bypass graf\iJJg. Eur J CardiotJufrtu: Surg
INTRODUCTION A commonly cited disadvantage to the UFFF is the
length of the pedicle. The ulnar pedicle is taken distal
Fasciocutaneous flaps from the forearm are ideally to the takeoff of the common interosseous artery, and
suited for reconstruction of head and neck defects. Ease thus the maximal length of the ulnar pedicle (1 0 em) is
of harvest, remote location from the head and neck, pli- shorter than that of the radial pedicle by 4 to 5 em. This
ability of skin, minimal donor site morbidity, and abil- may be of concern in reconstructing defects that require
ity to incorporate bone, muacle, tendon, and nerve for a longer pedicle length.
composite resections are all advantages of the forearm
donor site. The ulnar forearm free flap (UFFF), as orig-
inally descnbed by Lovie et al. in 1984, is one of the NEUROVASCULAR ANATOMY
two forearm flaps commonly in use today (15). The first
transfer of this flap took place in New Zealand in 1982 The blood supply to the lower arm and hand is supplied
shortly after the popularization of the radial forearm by the brachial artery, which divides into the ulnar artery
free flap (RFFF) by the Chinese in 1981 (27). and the radial artery (Fig. 17-lA,B) at the level of the
The ulnar forearm flap has wide potential application antecubital fossa. After its takeofffrom the brachial artery,
for reconstruction of head and neck defects, namely, the ulnar artery descends approximately 1 em distal to the
for cutaneous and soft-tissue defects, intraoral mucosal flexor crease of the elbow and passes medially to the ulnar
defects, and glossal, pharyngeal, tracheal, and esophageal border of the forearm, midway between the elbow and
defects. It has also been used for a variety of other recon- wrist. The artery then crosses the transverse carpal liga-
structions including upper extremity, hand, and urologic ment on the radial side of the pisiform bone, terminating
defects, which are outside the focus of this chapter. in the superficial palmar arch in the hand.11lroughout its
Its advantages as compared to the RFFF include (a) course, the ulnar artery is situated deeply in the forearm,
less donor site morbidity from flexor tendon exposure, covered in the proximal half of the forearm by the prona-
(b) better cosmesis (the wound is less conspicuous on tor teres, fl.ez.or carpi radialis, palmaris longus, and flexor
the ulnar/volar aspect of the forearm), and (c) rela- digitorum superficialis. Distally, the artery is bordered
tive hairlessness of the flap. It is easily harvested using medially by the flexor carpi ulnaris (FCU) and laterally
a two-team approach. The surgical time, reliability of by the flexor digitorum superficialis and lies superficial
the vascular pedicle, and size of skin paddle do not dif- to the flexor digitorum profundus (Fig. 17-2A,B). The
fer significantly when compared to the RFFF (15,25). ulnar artery is accompanied throughout its course in the
Additionally, in a comparative study, the ulnar pad- forearm by one or two 'Ve'IU1e comitantes (9). The ulnar
dle was found to be thinner than the skin of the radial bone is supplied through multiple metaphyseal nutti-
forearm (25). Although not studied through detailed ent foramina that transmit branches of the radial, ulnar,
functional outcomes studies, this may confer additional anterior, and posterior interosseous arteries. Usually one,
advantage in the reconstruction of some defects. but occasionally two, major nuttient diaphyseal foramina


Palmartslongus Flexor carpi

A ulnarls

B Ulnar artery
FIGURE 17-1. A:. The superficial muscles of 1he forearm are illustrated. The septocutaneous
perforators for the ulnar forearm free flap pass through the intermuscular septum between 1he
flexor carpi ulnaris and flexor digitorum superficialis muscles. B: The radial and ulnar arteries are
shown after their branching from the brachial artery. The ulnar artery descends approximately
1 em distal to the flexor crease of the elbow, passes medially to 1he ulnar border of the forearm,
midway between the elbow and wrist, and terminates in 1he superficial palmar arch in the hand.

are located on the anterior surface of the bone, directed proz.imally in the arm, betWeen the brachialis and pro-
proximally toward the elbow. A network of small fascia- nator teres. The posterior ulnar recurrent artery arises
periosteal and mWiculoperiosteal branches given offfrom distal to the anterior ulnar recurrent artery and runs
the compartmental vessels reaches the bone via septal superior and posterior to the medial epicondyle, where
and muscular attachments (9). it lies deep to the tendon of the FCU. The dorsal ulnar
}Wit distal to the radial tuberosity, the ulnar artery artery (also known as the dorsal carpal branch of the
gives off the common interosseous artery laterally, ulnar artery) arises 2 to 5 em before the pisiform bone
which subsequently separates into anterior and pos- and runs dorsally and distally under the FCU muscle,
terior branches (Fig. 17-3). The anterior interosseous to which it provides both proximal and distal branches.
artery descends on the anterior aspect of the interos- The proximal branch extends as far as the medial epi-
seous membrane with the anterior interosseous branch condyle of the humerus. It forms the pedicle on which
of the median nerve. The posterior interosseous artery the dorsal ulnar artery flap is based (2). The distal
passes dorsally between the extensor carpi ulnaris and branch supplies the pisiform bone. The middle branch
the extensor digitorum and accompanies a deep branch of the dorsal ulnar artery supplies the skin and divides
of the radial nerve before distally anastomosing with the into two smaller arterial branches that pierce the fascia.
terminal component of the anterior interosseous artery The ascending branch of the artery runs between the
in the hand. The posterior interosseous artery has been ulna and FCU, supplying the skin of the medial border
used to supply a fasciocutaneous flap for the recon- of the distal forearm. The descending branch accompa-
struction of hand defects (5,20). nies the dorsal sensory branch of the ulnar nerve that
Distal to the elbow joint, the ulnar artery gives supplies the skin over the ulnar metacarpals and the
rise to the anterior ulnar recurrent artery, which runs ulnar hypothenar region (11).
274 CHAPTER 17


A Flexor digitorum

Flexor dlgltorum
S(.lperflclalls muscle



FIGURE 112. A: The cross-sectional anatomy of the ulnar forearm flap identifies the location
of the ulnar pedicle. The pedicle is bounded by the flexor carpi ulnaris medially, the flexor digito-
rum superficial is laterally, and the flexor digitorum profundus on the deep surface. B: Across-
sectional view demonstrates the surrounding anatomic structures of the distal forearm after
elevation of the ulnar flap. The ulnar nerve is left intact in the forearm. The median antebrachial
cutaneous nerve has been incorporated and may be used to perform a sensate reconstruction.

,~--+/ Anterior ulnar

recurAlnt artery

Posterior ~~+--+-Common Inter-

Interosseous osseous artery
branch - - - + - --lli'""""''HI
Deep radial

/J-1--_.,.-+1-l...._ Posterior
branch -----+-~t+--H Extensor
clgitorum - - - + - HI'Ii-
oM-~-- Extensor
Interosseous radialis
~mb~----~1---r w

FIGURE 11-3. The proximal branches of the ulnar artery are shown. Just distal to the radial
tuberosity, the ulnar artery gives off the common interosseous artery laterally, which subse-
quently separates into anterior and posterior branches. A:. The anterior interosseous artery
descends on the anterior aspect of the interosseous membrane with the anterior interosseous
branch of the median nerve. B: The posterior interosseous artery passes dorsally between the
extensor carpi ulnaris and the extensor digitorum and accompanies a deep branch of the radial
nerve before distally anastomosing with the terminal component of anterior interosseous artery
in the hand. The posterior interosseous artery has been used to supply a distally based fascio-
cutaneous flap for the reconstruction of hand defects.
276 CHAPTER 17

Perforators to the skin arise &om both the ulnar and septocutaneous perforators and three distal fasciocuta-
posterior ulnar recUITent arteriea (26). The skin ovet'- neous perforators that were captured when harvesting
lying the FCU is supplied by both musculocutaneous a standard ulnar artery fasciocutaneous flap. Notably,
and septocutaneous perforators &om the ulnar artery. septocutaneous perforators in a UFFF were found to be
Septocutaneous perforators &om the ulnar artery sup- evenly spaced from the wrist to the medial epicondyle,
ply the skin extending from the cubital fossa to the wrist whereas perforators associated with the RFFF are typi-
and from the medial third of the anterior aspect of the cally concentrated in the distal third of the forearm (26).
forearm to the medial quarter of the posterior sutface Additionally, there are two pro.ximal and distal muscu-
of the forearm (9) (Fig. 17-4A,B). Lovie et al. descnbed locutaneous perforators arising from the FCU muscle,
the position of the perforators as being 3 to 4 em from along with a dominant musculocutaneous perforator
the takeoff of the common interosseous branch, the that is found midway betWeen the medial epicondyle
most dominant of which was constant in location (15). and the wrist. If the FCU is required for reconstruction,
Yii and Niranjan described the perforator anatomy of attention should be paid to preserving these perforators.
the ulnar forearm pedicle based on their experience A cadaveric study and subsequent dynamic studies
with the reconstruction of 13 donor defects resulting including Doppler sonography in 22 individuals eluci-
from radial forearm flap harvesting. They reported the dated the issue of vascular dominance in the forearm
consistent presence of one or two perforators located 8 (10). Theae studies demonstrated that the ulnar artery
to 10 em proximal to the pisiform bone (31). is dominant at the elbow, but after giving off collat-
A 2008 study by Shen confirmed these findings and eral branches, the radial artery becomes the dominant
added that there are 6 to 7 septocutaneous perforators artery in the distal forearm. They concluded that the
that arise from the radial border of the FCU (26). In radial artery is the major blood supply to the hand and
their anatomic description, there were two proximal stated that there is no anatomic basis for selecting the

RGURE 174. A. B: The size and shape of the ulnar flap is designed to suit the defect. Flap
dimensions of 10 x 22 em can be safely harvested. The flap should be centered over the ulnar
artery and basi lie vein. Septocutaneous perforators from the ulnar artery supply the skin
extending from the cubital fossa to the wrist and from the medial third of the anterior aspect of
the forearm to the medial quarter of the posterior surface of the forearm.

radial artery to the ulnar artery in invasive maneuvers venous system, which forms multiple anastomoses along
(i.e., catheterization). the forearm (Fig. 17-5). Hence, the basilic vein as well as
Vascularity of the hand relies on the deep palmar the t.1e11ae comitantes drain the ulnar forearm Bap. Con-
arch, which is the distal extension of the radial artery, sideration of the different branching patterns of the deep
and the superficial palmar arch, which is derived from and superficial venous systems as well as the variability
the ulnar artery. Sacrifice of either artery for use in a of the size of the vessels and the identified course of the
fa.sciocutaneow flap requires that there be a communi- subcutaneous veins, all play a role in the decision to anas-
cation between the deep and superficial palmar arches tomose to either a superficial vein or the venae comitantes.
to maintain an adequate circulation to all portions of The ulnar nerve enters the forearm after passing
the hand (30). posterior to the medial epicondyle of the humerus and
From the hand, venous arches accompany the super- gives offmotor branches to the head of the FCU. It then
ficial and deep arterial palmar arches. Common pal- descends inferiorly between the FCU and the fiexor
mar digital veins drain into the superficial arch; palmar digitorum profundus, providing branches to the ulnar
metacarpal veins join the deep arch. The deep veins of (medial) part of the muscle that sends tendons to the
the forearm are responsible for draining the deep and third and fourth digits (17). The ulnar nerve runs on
superficial palmar venous arches. Most of the blood the medial aspect of the ulnar artery and lateral to the
from the upper limb is returned by the superficial FCU tendon. The nerve descends medially on the fiexor
venous system, and thus, the deep veins or venae comi- digitorum profundus, covered proximally by the FCU,
tantes are relatively small (Fig. 17-5). The radial wnae while the distal half, covered by skin and fascia, is lat-
comitantes receive blood from the deep dorsal veins of eral to this muscle. The proximity of the ulnar nerve to
the hand. The ulnar venae comitantes drain the deep pal- the ulnar pedicle can make dissection of this Bap more
mar venous arch and connect with superficial veins near complicated and precariow.
the wrist. AB both the radial and ulnar venae comitantes Approximately 5 em proximal to the wrist, the ulnar
ascend in the forearm, they receive the anterior and pos- nerve provides a dorsal branch, which passes distally
terior interosseous wnae comitantes, after which a large into the hand on the lateral side of the pisiform bone,
branch connects the deep system to the medial cubital anterior to the Bexar retinaculum and posteromedial to
vein (1). the ulnar artery. The nerve passes behind the superficial
The reestablishment of venous drainage of forearm portion of the Bexar retinaculum with the ulnar artery
fasciocutaneous flaps is usually performed by the deep and divides into superficial and deep terminal branches
radial or ulnar venae comitantes and/or by the superficial in the hand.


FIGURE 115. The venous and sensory supply to the forearm is shown. The reestablishment of
venous drainage of the ulnar flap can be safely performed by anastomosis of 1he ulnar venae
comitantes and/or by the superficial venous system, which forms multiple anastomoses along
the forearm. Hence, the basilic vein as well as the venae comitsntes drain the ulnar forearm
flap. Consideration of the different branching patterns of the deep and superficial venous
systems, 1he variability of the size of the vessels, and the identified course of the subcutane-
ous veins all play a role in the decision to anastomose to either a superficial vein or1he venae
278 CHAPTER 17

ANATOMIC VARIATIONS or index finger and a lack of communication between

the deep and superficial palmar arches. Coleman and
Several vaacular anomalies must be considered before Anson found that in 265 cadaveric specimens, a com-
harvest:il:lg any forearm 1lap, as the potential hazard plete superficial arch was present in only 77.3% of
aists for compromised blood supply to the forearm and cases; the coexistence of an incomplete superficial arch
hand. Theae anomalies include the hypoplastic or aplas- and a lack of communication between deep and supel'-
tic radial artery, the incomplete superficial palmar arch ficial palmar arches was found in 12% of anatomic di.-
with no communication to the deep palmar arch, and sections (4). Thus, one can conclude that 12% of the
the superficial ulnar artery. When harvesting a UFFF population who have these coexisting arterial anomalies
in patients with such vascular anomalies, it is the sur- would n ot be candidates for harvest of a fasciocutaneoua
geon's responsibility to identify and avoid potentially flap from the forearm. After reviewing 92 angiographic
catastrophic ischemia of the soft tissues of the hand. studies of the hand, Varro et al. found that the superficial
The hypoplastic or aplastic radial artery is found in palmar arch was incomplete in 66.3% and the deep arch
approximately 0.1% of the population and can be asso- was incomplete in 9 .8% of banda (29). In a study by
ciated with Down's syndrome (12,19). In patients with Ozkus et al., the superficial palmar arterial systems of 80
this anomaly, the radial artery is markedly reduced in cadaver hands were dissected. Although 78 of the speci-
caliber and usually terminates proximal to the wrist. mens (97 .5%) were shown to possess a superficial arch,
The ulnar artery is often enlarged as a result and sup- 17.5% of the specimens revealed a superficial arch that
plies both the deep and superficial palmar arches. Alter- was formed by the ulnar artery alone without commu-
natively, the m edian artery may be enlarged and persist nication to the deep arch (18) . These studies underscore
with a codominant ulnar artery. Obviously, an ulnar the importance of adequate preoperative evaluation, in
microvascular 1lap is not feasible in the absence of a the form of careful palpation of the forearm, Allen's test,
normal radial arte.r y. and/or ultrasound Doppler evaluation, as 10% to 20%
The blood supply to the hand can also be compro- of forearms may have a vascular anomaly that could
mised by the combination of an incomplete super1icia1 compromise blood supply to the hand after harvest of
palmar arch that does not send branches to the thumb the radial or ulnar artery (Fig. 17-6).

Normal Hypoplastic radial artery Incomplete superficial ard'land

no connection
FIGURE 11-6.. Anatomic variations of the ulnar and radial systems are demonstrated. The
hypoplastic or aplastic radial artery is found in approximately 0.1% of the population and can
be associated with Dawn's synd ram e (15, 16). In patients with this anomaly, the radial artery is
marked ly reduced in ca liber and usually terminates proximal to the wrist. The ulnar artery is
aften enlarged as a result and supplies both the deep and superficial palmar arches. Alterna-
tively, the med ian artery may be enlarged and persist with a codominant ulnar artery. Obviously,
an ulnar microvascular flap is not feasible in the absence of a normal radial artery. The blood
supply to the hand can also be compromised by the combination of an incomplete superficial
palmar arch that does nat send branches ta the thumb or index finger and a lack af communica-
tion between the deep and superficial palmar arches.

Another anatomic variant, the superficial ulnar component on the dorsal ulnar aspect of the forearm
artery, was first documented by McCormack et al. ( 16). when compared to the RFFF. Similar to the RFFF, the
This anomaly occurs in 0.7% to 9.38% of cases (32). UFFF can be utilized for the reconstruction of a myriad
The superficial ulnar artery can originate from the bra- of defects in the head and neck, which include oral cav-
chial or, less commonly, the axillary artery (6). It passes ity (tongue, floor of mouth), oropharyngeal (base of
medial to the biceps and superficial to the pronator tongue, soft palate, lateraVposterior pharyngeal wall),
teres and flexor muscles, lying deep or superficial to the pharyngoesophageal defects, and neck skin or other
fascia, finally establishing a normal superficial palmar soft-tissue defects. Additionally, the UFFF can be used
arch in the hand with adjunct supply from the super- reliably with an osseous fibula or iliac crest flap in cases
ficial branch of the radial artery. The palmaris longus that require double flaps (8).
muscle is often described as being absent in cases where The first large series involving the ulnar forearm free
a superficial ulnar artery is found (32). flap was published in 1995 by Salibian et al. who reported
During dissection of fasciocutaneous forearm flaps on oropharyngeal reconstruction involving the base of
based on the ulnar artery, Sieg et al. revealed a super- tongue in patients after primary extirpation or after
ficial ulnar artery (SUA) in 4 of 107 forearms: 3.3% in neoadjuvant radiotherapy and/or chemotherapy failure
women and 3. 9% in men. All four of the flaps harvested (22). Ten patients underwent reconstruction with an
based on the SUA survived. Postopemtive angiography ulnar flap after having 30% to 100% of the tongue base
allowed for the detection of a bilateral vascular anomaly resected. The base of tongue was resected to the level of
in one of the four cases, noting additionally that the the hyoid, sacrificing the hypoglossal nerve and the lin-
SUA divided about 10 em proximal to the elbow joint gual artery, as well as various other nearby oropharyn-
and failed to terminate in a superficial palmar arch. The geal subsites. In all the patients, both superior laryngeal
authors concluded from their study that (a) the SUA nerves and one hypoglossal nerve were left intact. The
is typically not identified preoperatively; (b) in radial authors used a large flap measuring 8 x 20 em, three
forearm flaps, sacrifice of arteries that cross the fore- of which were neurotized using the medial antebrachial
arm superficially should be avoided; and (c) the SUA cutaneous nerve of the forearm. The proximal portion
is found to be an easy and safe alternative to the radial of the flap was used to reconstruct the soft palate and
forearm flap (24). Other authors suggest that the SUA pharynx, while the remaining distal portion was used in
can be identified preoperatively with careful palpation a "jellyroll" fashion to reconstruct the tongue base. The
of the forearm as well as a directed Allen's test but agree authors advocated suturing the rolled portion of the flap
that the finding of an SUA should not preclude the per- in layers to the cut edge of the tongue to minimize con-
formance of a fasciocutaneous flap harvest (32). tractures and grooving along the flap-tongue interface.
Other rare anomalies of the ulnar artery have also Additionally, the authors suggested doubling the rolled
been described. Tcacencu discovered a large branch of flap volume compared to the tongue base defect to allow
the ulnar artery in the carpal tunnel, which crossed the for flap shrinkage during healing (22). The authors con-
median nerve anteriorly and terminated without pro- cluded that the UFFF has several properties that make
ducing a superficial palmar arch (28). Another study by it well suited for oropharyngeal reconstruction involving
LeGeyt and Ghobadi noted the position of the ulnar the base of tongue. First, the proximal portion of the
nerve and artery overlying the carpal canal, leaving flap confers more soft-tissue bulk as compared to the
Guyon's canal empty and posing risk of damage to the RFFF, which allows one to overcorrect the volume of
artery and paralysis to the nerve (13). Durgun et al. the resected tongue base and helps to approximate the
reported on a case of multiple and bilateral arterial vari- palate and pharyngeal wall during swallowing. Second,
ations of the radial and ulnar arteries and with associ- the distal skin paddle is thin and pliable, which makes it
ated abnormal metacarpal vascularity (7). The authors optimal for resurfacing the tonsillar fossa and postero-
suggest that a documented abnormality in one area of lateral pharyngeal wall, as well as for reconstructing the
the upper limb should prompt investigation for other soft palate (22).
vascular anomalies. The ulnar forearm flap has also been demonstrated
to be effective for reconstruction of the pharyngoesoph-
agus after total laryngopharyngectomy. In a 1998 study,
FLAP DESIGN AND UTILIZATION Li et al. performed 20 ulnar forearm flaps for partial
to near total circumferential pharyngoesophagectomy
Design of a UFFF is similar to the design of an RFFF. defects. The flaps avemged 9 x 22 em and were designed
The flap is usually harvested with the skin paddle cen- in a trapezoidal fashion, 7 em wide distally and 10 em
tered over the axis of the ulnar artery. The skin pad- wide proximally, centered on the ulnar pedicle. The
dle can measure as much as 10 x 22 em according to authors included the basilic vein as their venous pedi-
some series (22,23). One of the distinct advantages of cle and followed it proximal to the antecubital fossa to
the UFFF is the relatively thin nature of the adipofascial obtain another 10 to 15 em of length. The region of the
280 CHAPTER 17

flap along the suture line was de-epithelialized, and the view for the osteotomy. Up to 16 em of the ulna can be
adjacent vascularized fascia was used to provide a sec- harvested, noting that the bone is especially thin in the
ond layer of closure. After reconstruction of the pharyn- middle and distal portions.
goesophageal segment, the remaining distal portion of Wax et al. reported on the use of the ulnar flap for
the flap was de-epithelialized and was used to obliterate oral cavity and oropharyngeal defects as well as for neck
dead space and/or to provide coverage for the cervical skin and soft tissue for the lateral skull. Their indica-
vessels. A small cutaneous paddle was exteriorized as a tions for the use of the ulnar forearm flap included a
skin monitor in all cases. Out of 20 flaps, 19 were suc- failed Allen's test, need for a less hairy part of the fore-
cessful. The one failure was early in the authors' expe- arm, and surgical preference. The authors stressed the
rience and involved a flap that could not be salvaged decreased donor site morbidity and improved cosme-
due to venous thrombosis, despite a successful primary sis of the ulnar flap as compared to the RFFF (30).
transfer. Fistulae occurred in three cases (15%), includ- Rodriguez et al. have also used the UFFF for closure of
ing the one failure. Stricture occurred in one patient. cutaneous defects involving the cheek, nasal ala, fore-
Swallowing function was restored in all but one patient head, lips, and most notably, eyelid (21). The superficial
who had undergone a previous mandibulectomy and temporal artery and vein were the recipient vessels in
tongue base resection. However, speech was restored the majority of cases. The authors commented on the
with tracheoesophageal prostheses in only two patients, reliability of the UFFF and stated that its use does not
with the rest communicating with the aid of an elec- result in functional, motor, sensory, or vascular compli-
trolarycx. The authors concluded that the ulnar fore- cations, as once thought.
arm flap offered the benefits of abundant vascularized
fascia with a reliable pedicle and minimal donor site
morbidity, making it well suited for pharyngoesopha- POTENTIAL PITFALLS
geal reconstruction {14).
The UFFF has been described for use in oral cav- Without a doubt, the most devastating complication
ity reconstruction as well. In a series of 13 patients, a of UFFF harvest is hand ischemia. In all reports of
large 10 x 20 em ulnar forearm flap was transferred for UFFF, none of the authors described the development
reconstructing a hemiglossectomy defect. The authors of hand ischemia postoperatively. However, flap har-
chose to inset the flap in a spiral fashion, using the dis- vest had to be abandoned twice in one series secondary
tal two-thirds of the flap for reconstruction of the oral to vascular variations that were recognized intraopera-
tongue and the proximal one-thirds to recreate the floor tively. In the first case, there was no identifiable sep-
of mouth along a separate suture line. The rationale tocutaneous perforator, and in the second case, 50% of
was to design the ulnar forearm flap in such a way as to the flap showed signs of ischemia (3). Other series have
maximize bulk at the root of the tongue, with a gradual demonstrated that a finding of SUA is not a contrain-
reduction in volume toward the front. Replacing the dication to the UFFF harvest, although its presence
resected mylohyoid muscle with a deepithelialized por- along with other vascular aberrations should be identi-
tion of the proximal flap and suturing this to the ante- fied preoperatively (24,32). Indeed, prior to dividing
rior mandible also addressed the potential for caudal the UFFF pedicle, the blood supply to the hand should
flap displacement. be tested while clamped, ensuring that the hand has
Christie reported on the use of ulnar flaps over a adequate blood flow.
7-year period. Of 56 ulnar flaps, 38 were used for recon- Donor site complications include hematoma, minor
struction of head and neck cancer defects. Of these, skin graft losses, and pathologic ulnar fracture. The inci-
31 were used to reconstruct intraoral defects.The major- dence of hematoma is roughly 3% to 5% after evaluat-
ity of these flaps {32) included a segment of the ulna, ing all series (30). The reported rate of flexor tendon
along with a fasciocutaneous component. Six fractures exposure after UFFF varies from 0% to 14% across all
occurred in total. One fracture was managed intraop- studies (30). Rodriguez et al. underscored the impor-
eratively. The remainder were managed with immobi- tance of suprafascial dissection in order to reduce ten-
lization in the postoperative period. The authors added don exposure and subsequent donor site complications
that in addition to bone, the palmaris longus tendon (21). The only series to report on the incidence of path-
and/or the FCU may also be harvested depending on ologic fracture in the remaining length of the hemiulna
the reconstructive requirements. The authors suggested stated a 29% rate. To minimize this risk, it is suggested
that in order to include a length of hemiulna, either the that in patients in whom a portion of the hemiulna is
FCU should be included or a cuff of FCU should be also harvested, the arm should be immobilized for at
dissected in order to preserve the periosteal perforators least 6 weeks with an above-the-elbow cast (3). Experi-
to the bone. Additionally, it is suggested that limited ence with the ulnar osteocutaneous flap is not nearly as
subperiosteal stripping of extensor compartment mus- robust as the experience with the radial osteocutaneous,
cles may help to provide an unobstructed longitudinal which is described in detail in Chapter 23.

One of the criticisms of the UFFF is the proximity of performed, looking for scars or vascular anomalies that
the ulnar nerve to the vascular pedicle and the potential may preclude the use of the UFFF. Some authors have
for injury to the ulnar nerve and resulting paresthesia. advocated the use of Doppler flow imaging for preop-
In one of the first series on the UFFF, the incidence erative arterial evaluation, especially in the case of upper
of transient ulnar nerve paresthesia was 32% (3). It is limb vascular abnormalities (30). We do not study the
notable, however, that all cases of paresthesia were mild vasculature of the arm for routine preoperative evalua-
and resolved within 2 weeks. In two series of UFFF tion, unless preopemtive clinical exam indicates a pos-
transfers, there were no ulnar nerve injuries or pares- sible vascular abnormality.
thesias noted (21,30). H the ulnar nerve is exposed, as
a result ofFCU harvest, some authors suggest that the
nerve should be buried by suturing the flexor digitorum POSTOPERATIVE CARE
superficialis over the nerve to cover it in order to prevent
direct apposition of the skin gmft to the ulnar nerve (3). Postoperative care involves placement of a skin gmft in
cases where defects cannot be closed primarily. Wax et
al. advocate the use of a circumferential "purse string"
PREOPERATIVE MANAGEMENT stitch to reduce the size of the defect prior to skin gmft-
ing (30). Volar splints are typically placed after skin
Harvest of the UFFF is usually performed on the grafting and removed on postopemtive day 10. H an
nondominant forearm. Preopemtive management osteocutaneous UFFF has been harvested and internal
includes careful assessment with Allen's test to assess fixation is not applied, it is advised that an above- the-
the adequacy of flow to the hand through the mdial elbow cast be placed for 6 weeks to reduce the risk of
artery. Additionally, a careful clinical exam should be pathologic fracture following a UFFF (3).

Ulnar Forearm Free Flap

FIGURE 11-7. The design of the ulnarfore-

arm flap begins by identifying the path of the
subcutaneous veins, including 1he basilic vein
and the ulnar artery. The course of the basili c
vein and the ulnar artery have been drawn on
the forearm in blue and red, respectively. The
approximate course of the medial antebrachial
cutaneous nerve of the forearm has been
outlined in yellow. Tendons of the PT, FDS, and
FCU are shown in brown. PT, palmaris longus;
FDS, flexor digitorum superficialis; FCU, flexor
carpi ulnaris.

FIGURE 17-8. A: A rectangular ulnar forearm

flap has been outlined in green on the distal
forearm including the superior aspect of the
incision that provides access to the proximal
course of the ulnar artery and basilic vein. The
flap is centered over the course of the ulnar
artery. B: Flap design may include the basilic
vein. However, small ulnar flaps may be based
only on the ulnar artery and paired venae
comitantes. The dissection begins after exsan-
guination of the forearm and application of the
tourniquet to 250 mm Hg. B

Ulnar Forearm Free Flap

FIGURE 17-9. Circumferential incisions to the

level of the dermis are then made around the
skin paddle, including the proximal extension
to the antecubital fossa.

FIGURE 1710. Medial and lateral skin flaps

are elevated along the proximal incision line.
These flaps may be elevated along the supra-
fascial muscular plane, preserving the basilic
vein (blue pin) and median antebrachial cuta-
neous nerve (yellow pin), if a neurotized thin
skin flap is desired. Alternatively, subdermal
flaps may be elevated in order to incorporate
proximal fat and fascia from the upper forearm,
if proximal fat around the pedicle is desired for
reconstructive purposes.

FIGURE 1111. Dissection is initially performed

from the radial aspect of the flap. The flap is
elevated off the flexor muscles. The flap eleva-
tion may be either subfascial or suprafascial.
As the dissection is carried from radial to ulnar,
the flexor carpi radialis, palmaris and flexor
digitorum superficialis muscles will be encoun-
tered. Careful dissection on the medial aspect
of the flexor digitorum superficialis allows
retraction of this muscle and identification of
the full course of the ulnar artery and ulnar
nerve (red pin).

Ulnar Forearm Free Flap

FIGURE 11-12. Dissection can now be per-

formed along the ulnar aspect of the flap. The
flap is elevated to the level of the flexor carpi
ulnaris. Careful dissection is performed on this
muscle, allowing itto be retracted medially
to identify the ulnar artery and intermuscular
septum. The flexor carpi ulnaris is freed along
its entire length to provide exposure to the
proximal portion of the ulnar artery.

FIGURE 11-13. If the basilic vein has been

incorporated into the free flap, it is ligated at
its distal portion on the ulnar side of the flap.

FIGURE 11-14. The ulnar artery is now ligated

under direct visualization at its distal aspect.
Care is taken to preserve the ulnar nerve.

Ulnar Forearm Free Flap

FIGURE 17-15. The free flap is then elevated

from distal to proximal, with careful dissection
and ligation of the muscular perforators and
preservation of the septocutaneous perfora-
tors and ulnar nerve.

FIGURE 17-16. A large muscular perforator

(yellow arrow) and smaller septocutaneous
perforator are shown from the radial side of
the dissection.

FIGURE 17-17. The flap is elevated proximally

to the level of the interosseous artery. (arrow)
near to where the ulnar artery passes deep to
the median nerve (upper yellow pin). At this
level. the artery is carefully separated from the
paired vense comitsntes. Often, the two vense
comitsntes will connect to form a single larger
vena comitantes. The tourniquet is released.
and a check is made for adequate vascular
supply to the free flap through dermal bleed-
ing. Hemostasis in the flap in situ in the arm is

Ulnar Forearm Free Flap

FIGURE 1118. The flap is harvested by divid-

ing the ulnar pedicle, basilic vein, and median
antebrachial nerve. The median nerve (upper
yellow pin) and ulnar nerve (lower yellow pin)
are carefully preserved.

FIGURE 1119. The ulnar forearm flap is

shown with the ulnar artery Ired pin) and basilic
vein (blue pin), and median antebrachial cuta-
neous nerve identified (yellow pin).

REFERENCES The experience of 100 anatomical dissections and 102

clinical cases. J Plast Rec<mstr Aesthet Surg 2007;60(7):
1. Arnstein, PM, Lewis JS: Free ulnar artery forearm flap: a
modification. Br J Plan Surg 2002;55(4):356--357. 6. Dcvansh MS: Superficial ulnar artery flap. Piau Rectmm
Surg 1996;97(2):420-426.
2. Becker C, Gilbert A; The ulnar flap. Ht:mdchit Mikrothtr
Plast Chir 1988;20(4):180-183. 7. Durgun B, Yiiccl AH, Kizilkanat ED, Dere F: Multiple
arterial variation of the human upper limb. Surg RJldiol
3. Christie DR, Duncan GM, Glasson DW: The ulnar Anat 2002;24(2):125-128.
artery free flap: the first 7 years. Plast Recomtr Surg
1994;93(3) :547-551. 8. Gabr EM. Kobayashi MR. Salibian AH, Armstrong WE,
Sun.dine ~ Calvert Jw. Evans GR: Role of ulnar forearm
4. Coleman SS, Anson BJ: Arterial patterns in the hand
free flap in oroman.dlbular reconstruction. ~
based upon a study of 650 specimens. Surg Gynecol Obsrer 2004;24(4):285-288.
9. Standring S: Gray'r Anatm!U': The Anaromical Bam of
5. Costa H, Pinto A. Zenha H: Th.e posterior interosse- Clinical Praaice. 39th ed. London, UK: Churchill Living-
ous flap-a prime technique in hand reconstruction. stone; 2004.

10. Haerle M, Hiifner HM, Dietz K, Schaller HE, Brunelli F: Reconstruction of the base of the tongue with the micro-
Vascular dominance in the forearm. Plast Reconstr Surg vascular ulnar forearm flap: a functional assessment. Plast
2003;111(6):1891-1898. Reconszr Surg 1995;96(5):1081-1089; discussion 1090-
11. lgnatiadis lA, Mavrogenis AF, Avram AM, Georgescu AV, 1091.
Perez ML, Gerostathopoulos NE, Soucacos PN: Treat- 23. Salibian AH, Allison GR, Armstrong WB, Krugman ME,
ment of complex hand trawna using the distal ulnar Strelzow VV, KellyT, Brugman JJ, Hoerauf P, McMicken
and radial artery perforator-based flaps. Injury 2008;39 BL: Functional hemitongue reconstruction with the
(suppl3):S116--S124. microvascular ulnar forearm flap. Plast Reconstr Surg
12. Kadir S: Atlas of Normal and Mlriant Angiographic Anat- 1999; 104 (3) :654-660.
omy. Philadelphia: WE Saunders Company; 1991. 24. Sieg P, Jacobsen HC, Hakim SG, Hennes D: Superficial
13. LeGeyt MT, Ghobadi F: Aberrant position of the ulnar ulnar artery: curse or blessing in harvesting fasciocutane-
nerve and artery overlying the carpal canal. Am J OrdJop ous forearm flaps. Head Neck 2006;28(5):447-452.
1998;27(6) :449-450. 25. Sieg P, Bie:rwolf S: Ulnar versus radial forearm flap in
14. U KK. Salibian AH, Allison GR, Krugman ME, Arm- head and neck reconstruction: an experimental and clini-
strong W, Wong B, Kelly T: Pharyngoesophageal recon- cal study. Head Neck 2001;23(11):967-971.
struction with the ulnar forearm flap. Arch Orolaryngol 26. Shen S, Pang J, Seneviratne S, Ashton MW, Corlett
Head Neck Surg 1998;124(10):1146-1151. RJ, Taylor GI: A comparative anatomical study of bra-
15. Lovie MJ, Duncan GM, Glasson DW: The ulnar artery chioradialis and flexor carpi ulnaris muscles: implica-
forearm free flap. Br J Plast Surg 1984;37(4):486-492. tions for total tongue reconstruction. Plast &conszr Surg
2008;121 (3):816-829.
16. McCormack lJ, Cauldwell Ew, Anson BJ: Brachial and
antebrachial arterial patterns: a study of 750 extremities. 27. Song R, Gao Y, SongY, YU Y, SongY: The forearm flap.
Surg Gynecol Obstet1953;96(1):43-54. Clin Plast Surg 1982;9(1):21-26.
17. Moore KL, Dalley AF: Clinically Oriented Anatono~. 4th 28. Tcacencu 1: A rare hwnan variation: a major branch of
ed. Baltimore, MD: UppincottWilliams &Wilkins; 1999. the ulnar artery found in the carpal tunnel. Surg Radiol
Anat 2001;23(5):359-360.
18. Ozkus K, Pe~telmaci T, Soyluoglu AI, Akkin SM, Ozkus
HI: Variations of the superficial palmar arch. Folia Mor- 29. Varro J, Horvath L, Varga G: Anatomy of the hand arter-
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19. Porter CJ, Mellow CG: Anatomically aberrant forearm
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and ulnar arteries. Br J Plast Surg 2001;54(8):727-728. Andersen PE: The ulnar fasciocutaneous free flap in head
and neck reconstruction. Laryngoscope 2002;112(12):
20. Purl V, Mahe:ndru S, Rana R: Posterior interosseous artery
flap, fasciosubcutaneous pedicle technique: a study of 25
cases.JPlasz&comzrAesthetSurg2007;60(12):1331-1337. 31. Yii Nw. Niranjan NS: Fascial flaps based on perforators
for reconstruction of defects in the distal forearm. Br J
21. Rodriguez ED, Mithani SK, Bluebond-Langner R,
Plast Surg 1999;52(7):534-540.
Manson PN: Hand evaluation following ulnar forearm
perforator flap harvest: a prospective study. Plast Reconstr 32. Yildirim M, Kopuz C, Yildiz Z: Report of a rare human
Surg 2007;120(6):1598-1601. variation: the superficial ulnar artery arising from the
axillary artery. Okajimas Folia Anaz Jpn 1999;76(4):
22. Salibian AH, Allison GR, Krugman ME, Strelzow VV,
Brugman JJ, Rappaport I, McMicken BL, Etchepare TL:
"T""'he subscapular system of flaps is unique among The branching pattern of the subscapular artery and
~ all awilable donor sites for free tissue transfer vein permits the transfer of the following flaps on a sin-
because of the diversity of tissue types, the potential gle pedicle (Fig. 18-1):
surface area of tissue that can be transfe!Ted, and the
1. Scapular fasciocutaneous flap.
mobility of the various flaps relative to each other, and
in particular, to the bone. In addition, this donor site is 2. Parascapular fasciocutaneous flap.
more easily camouflaged than most other sites due to 3. Scapular-parascapular osteofasciocutaneous flap (e.g.,
its location. One of the earliest free flaps that was har- angular branch osteowtaneous flap with two pedicles).
vested from the axillary region was the lateral thoracic 4. Latissimus dorsi muscle flap.
flap, which is based on the lateral thoracic artery or the
S. Latissimus dorsi musculocutaneous flap.
accessory lateral thoracic artery (2,4,7). The variabil-
ity in the vascular anatomy to this flap, in addition to 6. Latissimus dorsi rib osteomusculocutaneous flap.
the emergence of the subscapular system of flaps, soon 7. Serratus anterior muscle flap.
relegated the lateral thoracic flap to one of historical 8. Serratus anterior musculocutaneous flap.
interest only.
9. Serratus anterior musculocutaneous-no flap.


Axillary a.

Subscapular a.

Circumflex scapular

cutaneous Thoracodorsal a.

Angular branch


Branch to serratus anterior m.

Vertical branch to
Transverse branch tn ----7~ latissimus dorsi m.
latissimus dorsi m.

FIGURE 18-1. The multiple branches of the subscapular artery are the key to understand-
ing the range of flaps with independent pedicles that can be harvested with this system. The
subscapular artery divides into the circumflex scapular and the thoracodorsal arteries. The
former supplies the periosteum of the lateral scapular border and the scapular and parascapu-
lar fasciocutaneous flaps. The thoracodorsal artery gives off the angular branch to the tip of the
scapular bone and the muscular branch to the serratus anterior. It terminates in the transverse
and vertical branches that supply the latissimus dorsi muscle.
290 CHAPTER 18

Although the necessity to transfer more than one flap dorsi muscle to be particularly beneficial in patients
to the head and neck is rare, there are occasions when who undergo salvage surgery after radiation therapy. In
this can be very advantageous and help to overcome this population of patients, the placement of a sheet of
some of the most challenging reconstructive situations. healthy, well-vascularized muscle in the neck over the
Harii et al. (6,8) reported the combination of a latissi- carotid artery and jugular vein provides a valuable layer
mus dorsi musculocutaneous flap with a serratus ante- of protection in the event of either cervical skin break-
rior musculocutaneous flap to provide inner and outer down or intraluminal breakdown with the development
linings for through-and-through defects of the cheek. of a salivary fistula.
In 1984, Batchelor and Tully {3) reported on the resur- Composite defects of the midface often cause very
facing of a total scalp defect with a single cutaneous flap complex problems because of the three-dimensional
that included the territories of the scapular, parascapu- nature of the reconstruction. Replacement of the palate
lar, latissimus dorsi, and lateral thoracic flaps. In their with vascularized bone must often be accompanied by
patient, the thoracodorsal and subscapular arteries had restoring oral lining, nasal lining, and cutaneous defects
a separate origin and required two arterial anastomoses. of the cheek. The freedom to move the multiple soft tis-
Richards (1 0) used the combination of the latissimus sue flaps of the subscapular system relative to the bone
dorsi and the serratus anterior muscles to resurface a has been extremely beneficial (1,9).
scalp and calvarial defect. A vascularized segment of the The latissimus dorsi, its musculocutaneous flap, the
6th rib was included with the serratus muscle to recon- scapular-parascapular fasciocutaneous and osteofascio-
struct the superior and lateral orbital rims. cutaneous flaps, as well as the serratus anterior flap with
In a large series using the scapular osteocutaneous the subjacent rib, are some of the more commonly used
flap for head and neck reconstruction, Swartz et al. {11) components of the subscapular system of flaps.
included the latissimus dorsi musculocutaneous flap for
reconstruction of a composite defect of the oral cavity.
The symphysis was restored with the lateral scapular bor- Acknowledgments
der, and the floor of mouth was closed with the scapular
skin paddle. The latissimus dorsi flap provided coverage The author acknowledges Michael J. Sullivan, MD, for
his contributions to this chapter in the first edition of
of the external cutaneous defect. Similarly, Granick et al.
this atlas.
(5) transferred the latissimus dorsi-scapular osteocutane-
ous flap to close a composite defect, but skin grafted the
latissimus dorsi muscle because of the bulk of its cutane-
ous island. These authors also reported that the use of this
composite flap with an innervated latissimus dorsi mus-
cle improves lower lip competence. The muscle was sus- 1. Aviv JE, Urken ML, Vickery C, Weinberg H,
pended from the 01bicularis oris on both sides, and the Buchbinder D, Biller HF: The combined latissimus dorsi-
scapular free flap in head and neck reconstruction. Arch
thoracodorsal nerve was anastomosed to the lower divi-
Otolaryngol Head Neck Surg 1991;117:1242.
sion of the facial nerve. The overlying skin of the latissi-
mus dorsi was used to reconstruct the cutaneous defect of 2. BakerS: Free lateral thoracic flap in head and neck recon-
struction.Arch Otolaryngol Head Neck Surg 1981; 107:409.
the mentum. The restoration of dynamic activity and the
degree of oral competence could not be assessed, because 3. Batchelor A, Tully 1..: A multiple territory free tissue
the patient had an anoxic cerebral injury followiDg surgery. transfer for reconstruction of a large scalp defect. Br J
Plast Surg 1984;37:76.
However, the concept of using the dynamic potential
of the latissimus dorsi muscle remains an intriguing one. 4. Baudet J, Guimberteau JC, Nascimento E: Successful
This is particularly true when reconstructing composite clinical transfer of two free thoracodorsal axillary flaps.
Plast Reconstr Surg 1976;58:680.
defects of the cheek in which the mimetic muscles are
removed but the proximal portion of the facial nerve 5. Granick MS, Newton ED, Hanna DC: Scapular free flap
remains intact. In this situation, a portion of the latis- for repair of massive lower facial composite defects. Head
Neck Surg 1986;8:436-441.
simus dorsi muscle can be inset to restore upward and
lateral movement to the corner of the mouth by anas- 6. Harii K. Ono I, Ebihara S: Closure of total cheek defects
tomosing the thoracodorsal nerve to the facial nerve. with two combined myocutaneous free flaps. Arch
Otolaryngol Head Neck Surg 1982; 108:303.
Complex reconstructions that include the mandible,
inner and outer linings, and facial reanimation can be 7. Harii K, Torii S, Sekiguchi J:The free lateral thoracic flap.
achieved by the transfer of a variety of flaps based on the Plast Reconsr.r Surg 1978;62:212.
subscapular pedicle (1). I have found the combination 8. Harii K, Yamada A, Ishihara K. Miki Y, Itoh M: A free
of the scapular osteocutaneous flap with the latissimus transfer of both latissimus dorsi and serratus anterior

flaps with thoracodorsal vessel anastomosis. Plart Reconm 10. Richards M: Free composite reconstruction of a complex
Surg 1982;70:720. craniofacial defect. Aust N Z J Surg 1987;57:129.
9. Jones N, Hardesty R, SwartzW, Ramasastry S, Heckler F, 1 1. Swartz W, Banis J, Newton D, Ramasastry S, Jones N,
Newton E: Extensive and complex defects of the scalp, Acland R: The osteocutaneous scapular flap for
middle third of the face, and palate: the role of microsur- mandibular and maxillary reconstruction. Plart Reconstr
gical reconstruction. Plarl Reconstr Surg 1988;82:937. Surg 1986;77:530.
aijo (20) should be credited with being the first to along with Gilbert and Teot (13). The next major mile-
S recognize the potential for transfer of a vascular-
ized cutaneous free fiap based on the circumfiex scapu-
stone in the evolution of this donor site was reported by
Teot et al. (25) in1981 when a series of cadaver dis-
lar artery (CSA) and circumBex scapular vein (CSV). sections demonstrated the area of vascularized bone
Dye-injection studies of the CSA led to staining of that could be harvested from the lateral scapular border
the skin overlying the scapula. Saijo hypothesized that based on the circumfiex scapular pedicle. In addition,
separate uial pattern flaps based on the CSA and the they described the various cross-sectional shapes and
thoracodorsal artery and vein could be successfully har- dimensions ofbones that were present at diffen:nt points
vested as free fiaps. dos Santos (10,11) made significant along the lateral border from the glenohumeral joint to
contributions to our understanding of this donor site the tip. The technical aspects of harvesting a composite
through a large series of cadaver dissections and per- flap from this region were described along with three
formed the first clinical ttansfer of a free scapular flap successful clinical cases of free scapular osteocutaneous


flap transfers that included one case of orbital floor and parascapular flaps have been reported with lengths up
one case of mandibular reconstruction. The use of this to 25 em (5). An anatomic study of the dorsal thoracic
composite flap for head and neck reconstruction was fascia by Kim et al. (16) provided justification for refer-
popularized by the work of Swartz et al. (23) in the lat- ring to the scapular and parascapular flaps as fasciocuta-
ter part of the 1980s. neous flaps. Their study also demonstrated rich vascular
In 1982, Nassif et al. (18) reported a longitudinally communications between branches of the CSA and the
oriented skin paddle referred to as the parascapular flap. musculocutaneous perforators of the trapezius and latis-
This fasciocutaneous flap was based on the descend- simus dorsi, suggesting that much of the skin overlying
ing branches of the CSA and CSV. An additional major the latissimus dorsi muscle could be transferred based
contribution to the clinical usefulness of this donor site on the CSA by including the dorsal thoracic fascia. Kim
was made by Coleman and Sultan (6) in 1991 who et al. also showed that the CSA runs within the layers
described an alternative vascular supply to the tip of the of the posterior thoracic fascia, which could therefore be
lateral scapular border through the angular branch of transferred by itself as a thin vascularized tissue layer. De-
the thoracodorsal artery and vein. epithelialized scapular and parascapular flaps have been
used extensively for soft tissue augmentation to restore
the facial contour in a wide range of disorders, including
FLAP DESIGN AND UTILIZATION hemifacial microsomia; atrophy; and deformities caused
by radiation, trauma, and ablative cancer surgery (28).
The unique features that make the scapular system of The anatomic features of the dorsal thoracic fascia and
flaps so useful for head and neck reconstruction are as the transverse and descending branches of the CSA pro-
follows: vide the basis for designing multiple skin paddles when
needed. Scapular and parascapular skin flaps may be
1. The long length and large caliber of the vascular simultaneously transferred based on a single CSA. Alter-
pedicle. natively, the dorsal thoracic fascia allows the transfer of
2. The abundant surface area of relatively thin skin multiple skin paddles that are separated by a considera-
that can be transferred. ble distance and connected only by this fascial layer (26).
3. The separation of the soft tissue and bone flaps, The medial extent of the scapular skin flap has been
which provides the most freedom for three-dimen- traditionally limited by the midline of the back. This
sional insetting compared to any of the available concept was challenged byThoma and Hiddle (27) who
composite free flaps. reported their experience in five patients who required
"extended free scapular flaps;' which crossed the mid-
4. The ability to combine the latissimus dorsi and the
line and measured up to 39 em in length. The basis for
serratus anterior muscles, along with overlying skin,
their work was a report by Batchelor and Bardsley (3)
and adjacent segments of rib.
of a scapula flap with two pedicles that spanned the
The dimensions of the territory supplied by the cir- entire width of the back and was based on the anas-
cumflex scapular pedicle have grown since the earliest tomosis of both CSAs. However, after the release of
description. Based on the results of the dye-injection the clamps on the anastomosis of the first CSA and
studies, dos Santos (10,11) placed the following limita- CSV and prior to performing the second set of anas-
tions on the skin flap supplied by the CSA: 10 em in the tomoses, the entire skin paddle was noted to be well
vertical dimension, 13 em in the horizontal dimension, vascularized. The reliability of the extended scapular
no further cephalad than the scapular spine, no further flap can be examined by invoking the angiosome con-
caudal than 3 em above the inferior scapular tip, no fur- cept ofTaylor and Palmer (24). The vascular anatomy
ther medial than 2 em from the vertebral column, and of the back can be separated into longitudinally divided
no further lateral than the posterior axillary line. Other zones based on different source arteries. The regions
authors placed similar or even more stringent restric- over each scapula represent the primary angiosomes
tions (2,14,29). Urbaniak et al. (29) proposed the "rule of the CSA. On either side of the midline, there are
of twos" to define the skin territory. They advised that two trapezius angiosomes, each supplied by the trans-
the upper limit should be 2 em inferior to the scapu- verse cervical artery and vein. Hence, as the transverse
lar spine and the inferior limit should be 2 em superior dimensions of a scapular flap are extended, it is neces-
to the tip of the scapula. They also limited the medial sary to cross three successive angiosomes (Fig. 19-1).
extent to a point 2 em lateral to the vertebral processes. Taylor and Palmer suggested that the source artery of
In 1982, Nassif et al. (18) introduced the parascapu- a single angiosome can reliably capture the territory of
lar flap, which is based on the descending branch of the an adjacent angiosome, but that the angiosome once
CSA. This vertical skin paddle, oriented over the lateral removed (i.e., zone III) is less predictable. The dynam-
scapular border, markedly expanded the dimensions ics of the flow across angiosomes through the connect-
of the cutaneous territory of the CSA (4). Successful ing choke vessels can be altered by prior ligation of the
294 CHAPTER 19

RGURE 19-1. The vascular zones of the scapular system have been labeled I through IV. When
harvesting a transverse scapular flap based on the left CSA, the skin paddle extends from the pri-
mary angiosome (I) into the angiosome of the transverse cervical artery and vein (II). As this trans-
verse flap crosses the midline, the third angiosome in the series, that of the contralateral trapezius
flap, is entered (Ill). Finally, the fourth angiosome in the series is the one primarily supplied by the
contralateral CSA (IV). By performing a radical neck dissection on the left side and interrupting
the transverse cervical artery, the skin overlying zone II may be partially or totally delayed so as to
make it, and the skin of zone Ill, more reliably captured in the transfer of the left scapular flap.

source artery that supplies the adjacent territory. This Regardless of the design or dimensions of the distal
maneuver essentially produces a delay phenomenon portions of the scapular-parascapular flaps, it is critical
by opening up the choke vessels and achieving a more that the base of the flap is centered over the infraspinatus
favorable hemodynamic situation by which to capture fossa, which is the dorsal enent of the triangular space.
more distant angiosomes. It is tempting to speculate That space may be found by palpation of the muscular
that such a delay phenomenon may be achieved when hiatus along the lateral scapular border or by Doppler
harvesting an extended scapular flap on the side of the sonographic localization of the CSA as it emerges from
back on which a radical neck dissection was previously its origin in the uilla. The infraspinatus fossa has been
performed. Prior interruption of the transverse cervical roughly localized to a point either halfway (14) or two
vessels should allow the scapular flap to be more reli- fifths of the way (18) along the lateral scapular border
ably extended across the midline. when measuring from the spine to the tip (Fig. 19-2).

Circumflex scapular a.

Infraspinatus m.


Thoracodorsal a.

Triceps brachii m.
long head

- - - - - - - Serratus anterior m.

Latissimus dorsi m.

FIGURE 19-Z. The muscles that make up the posterior axillary and scapular region are critical to
the understanding of the subscapular system of flaps. The CSA and CSV traverse the triangular
space before reaching the infraspinatus fossa. The triangular space is bounded by the teres major,
teres minor, and the long head of the triceps muscles. The teres minor originates from the upper
two thirds of the lateral scapular border and inserts into the greater tuberosity of the humerus.
Its action is opposite to that of the teres major, which arises from the inferior aspect of the lateral
scapular border and inserts into the bicipital groove of the humerus. The terminal branches of the
CSA anastomose with the suprascapular and transverse cervical vessels.
29& CHAPTER 19

The successful transfer of vascularized hone from the

lateral scapular border dramatically expanded the versa-
tility ofthe subscapular donor site and the range of appli-
cations to the head and neck. The length of bone that
can be harvested ranges from 10 to 14 em, depending on
the sex and size of the patient (Figs. 19-3 and 19-4). It is
limited in its cephalad extent by the glenohumeral joint,
which must be protected. The variations in thickness of
the bone allow it to be used for different purposes in the
head and neck. The thin blade of the midportion of the
scapula is useful for reconstructing the orbital floor and
the palate. The greatest application of this composite
flap is in restoring the bone and soft tissue components
of oromand:ibular defects. The periosteal blood supply
derived from the CSA permits osteotomies to be made
to contour the bone to the shape of the mandible. The
vascularity to distal segments is maintained as long as
the periosteum and a cuff of muscle are preserved when
providing exposure to perform the osteotomy (23).
The separation of the scapular and parascapular skin
flaps from the bone provides a unique capacity to
restore the complex three-dimensional defects of the
FIGURE 19-4. A lateral view of the scapular border reveals
head and neck. Extensive experience with the compos-
that the bone is fairly straight Contouring of this bone to fit
ite scapular flap has demonstrated ita utility in recon-
the shape of bone defects in the maxillomandibular skeleton
structing the oral cavity following trauma and ablative
requires ostectomies to be performed while preserving the
surgery (21,22).
nutrient periosteal layer.

Swartz et al. (23) descnoed an extension of the bone

harvest along the medial aspect of the scapular tip to
provide an additional 3 to 4 em of bone. However, the
blood supply to distal portions of the scapular bone was
somewhat suspect, especially after the creation of an
osteotomy. This was evident by the findings on postop-
erative hone scans, the occurrence of nonunions, and the
necessity to perform sequestrectomies. In 1991, Cole-
man and Sultan (6) reported their experimental and
clinical findings using a separate vascular supply to the
caudal portion of the lateral scapular border based on
the angular branch of the thoracodorsal artery and vein
(Fig. 19-5). They credited Deraemaecher et al. (9) for
the initial discovery and report of this branch in 1988.
The identification of a separate blood supply to the tip
of the scapula is important for a number of reasons.
1. Osteotomies can be made in the lateral scapula with-
out concern about devascularization ofthe distal bone
because of the preservation of the angular branch.
RGURE 19-3. The lateral scapular border. extending 2. Two separate segments of bone with their own
from the glenohumeral joint to the scapular tip, may be vascular supply can he used to re<:onstruct bone
transferred as a vascularized bone flap based on the CSA defects that are separated in space.
and the CSV. The thick bicortical bone of the lateral border 3. The tip of the scapula can be ttansferred alone
becomes markedly thinner in the midsection of the blade without requiring the intervening bone of the lateral
of the scapula. Approximately 10 to 14 em in length can be scapula.The tip provides a reasonable replication of
harvested from the lateral border. The bone cuts may be the shape of the hard palate for restoring bone to
extended to include the inferomedial border. that region of the oral cavity.

4. Maximum separation betWeen the soft and hard two pedicles to advance the symphysis in a patient with
tissues can be achieved by tran.sfenin.g a scapular a hypoplastic mandible by performi:ng bilateral mandib-
or paraacapular Bap based on the CSA and a seg-- ular osteotomies and inserting two vascularized bone
ment of bone supplied by the angular branch. These segments to maintain the advanced symphysis. They
two components may be separated by as much as also reported using the scapular tip to reconstruct the
15 em. This contrasts with the 2.5 em that separates orbital floor. We have had experience in using the scapu-
the skin and bone segments when transfe:r:ri:ng both lar tip supplied by the angular branch to reconstruct
on the CSA (Fig. 19-6). partial and total hard palate defects.
Coleman and Sultan (6) reported the successful trans- Thoma et al. (26) transferred the medial scapular
fer of segments of the scapula measuring up to 8 em border, based on the CSA's supply of the dorsal thomcic
in length. They used the osteocutaneous fiap with fascia. The vascularity of this segment ofbone is entirely

Axillary a. Circumflex
scapular a.
Subscapular a.

Thoracodorsal a.

~-~~T-~~~-!.-- Periosteal
blood supply

Angular branch
Branch to
latissimus dorsi m.

serratus anterior
Latissimus dorsi m. ~----

FIGURE 19-5. With the overlying muscles removed, the blood supply to the scapular bone is
shown arising from periosteal feeders of the CSA that supplies the upper portions ofthe lateral
scapula and the angular branch that supplies the periosteum of the caudal scapular border.
298 CHAPTER 19

A. B.

Parascapular flap

Latissimus dorsi
musculocutaneous flap

scapular a.

dorsi m.

RGURE 19-6. A variety of different flaps can be simultaneously harvested on 1he subscapular
artery and vein. A: The bone ofthe lateral scapular border can be transferred with a small cuff
of muscle for pure bony reconstructions. The caudal tip can be used to reconstruct the angle of
the mandible. Alternatively, the thin central portion of the bone can be used as a shelf to replace
the hard palate. B: The most common varieties of subscapular soft tissue flaps are shown. These
flaps can be harvested separately or in concert In addition, the serratus anterior muscle and
musculocutaneous flaps can be included with 1his vascular axis. C: The bone of the lateral scapu-
lar border can be divided on two separate vascular pedicles: the circumflex scapular and the
angular. A scapular-parascapular cutaneous flap has been reflected to show the periosteal vas-
cular supply. D: The multiple different soft tissue and osseous components 1hat can be harvested
on 1he subscapular system are shown. Intramuscular bifurcation of1he thoracodorsal artery
allows splitting of the latissimus dorsi muscle. Both 1he latissimus dorsi and the serratus anterior
muscles can be transferred with 1heir nerve supply for restoration of dynamic motor activity.

dependent on preserving the fascial attachments to it. thoracodorsal artery provides antegrade flow in the
The rationale for designing this composite flap is that CSA. Due to the presence of the valves in the thora-
it lengthens the vascular pedicle to the bone and avoids codorsal vein, the opportunity to lengthen the venous
disruption of the muscular attachments to the lateral pedicle cannot be safely accomplished through a similar
scapula. The disadvantages of this flap are that the bone strategy of reverse flow.
of the medial scapular border is thinner than that of the The CSA and CSV run in the fascial septum between
lateral border, the relationship of the bone to the under- the teres major and minor, and then they divide into the
surface of the skin must be maintained to preserve the transverse and descending branches, which run in the
fascial blood supply, and the tolera