PART 1 — PRINCIPLES
3 Considerations in
Flap Selection
Geoffrey G. Hallock
INTRODUCTION
A meticulous preoperative problem analysis leading to the
selection of the proper strategy for solving the given wound,
defect, or deformity1 can be a difficult task, yet certainly as
critical as the actual surgical procedure that may be required.
If a vascularized tissue transfer is indicated, there can then
be little question that the selection of the correct flap is
imperative as, if chosen improperly, the entire reconstruc-
tive endeavor may be doomed to failure – no matter how
careful the subsequent surgical execution. This initial phase
of planning should be appreciated as the most intellectually
stimulating and challenging stage, as sometimes the hours
spent in the operating room afterwards may seem actually
too much like “work.” Unfortunately, if simplicity were the
only goal, unlike the early days of plastic surgery, when the
only option was to use some variation of the random flap,
now an almost overwhelming cornucopia of flap alternatives
is available. A “laundry list” of all the available flaps and
their indications would be an impossible job, even if limited
to the “workhorse” flaps outlined in the other chapters in
this book (Fig. 3.1); but a brief dissertation on basic prin-
ciples to follow in completing this selection process may
prove invaluable. An appreciation of the attributes and limi-
tations of the many available flaps (Tables 3.1–3.6) and their
specific indications for use (Tables 3.7–3.9) is critical before
a decision can be made as to which is most appropriate for
the task at hand.
THE RECIPIENT SITE
The primary objective in the reconstruction of any wound,
defect, or deformity, is to restore as closely as possible the
“normal”2 appearance and function; but in that process also
to minimize any residual abnormality or accrue any addi-
tional disability, including that at the donor site. Many
concerns must thus be addressed in an orderly fashion,
beginning with an assessment as to whether a vascularized
flap is even needed in the first place. Yet if not, would a
flap nevertheless still be the preferable solution to provide
the most optimal outcome not just for today, but also in the
long term?
Specific requirements at the recipient site must be met as
closely as possible, beginning with the use of flaps with
similar tissue characteristics (Tables 3.1–3.6). In addition,
will the structural integrity within the region or function
6
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need to be re-established? Can this be accomplished with a
single flap, or are multiple flaps each with different compo-
nents required? The answers to these basic questions will
immediately narrow the search for the proper flap donor
site. This is most obvious if specialized tissues such as joints,
cartilage, nail, nerve, tendon, bone, or viscera are needed,
as the available resources are extremely limited (Table 3.6).
On the contrary, soft tissue coverage problems, which are
more commonplace, have a plethora of potential options.
Herein lies the major dilemma where proper flap selection
deserves the most emphasis.
If a local or so-called “pedicled flap” is available,3–6 and
best satisfies all the criteria to provide what is needed, that
will always be preferable to the vagaries and inherent risks
of a microsurgical tissue transfer. Indeed, the hierarchy for
flap selection in the upper7 and lower extremities8 has tra-
ditionally emphasized the value of local flaps. Although
these schema typically have also suggested the use of free
flaps for more acral defects,9 a revolution has recently
emerged in the consideration of distal-based regional
flaps10–12 or perforator propeller flaps13–16 that can capture
more proximal extremity skin territories for distal transfer
as an acceptable alternative. These newer possibilities can
be especially valuable if the patient has multiple comorbidi-
ties that would preclude any lengthy surgical procedure, if
the allocation of resources including time is limited, or if
the requisite technical expertise is absent.
Soft tissue coverage can basically always be achieved using
either a cutaneous or muscle flap. Each has distinct attri-
butes that must be considered (Tables 3.1–3.5), and the
preference for either will differ from patient to patient. One
must remember that the use of any muscle as a flap, even if
function preservation techniques were observed,17 will
always result in some loss of function. This risk is minimized
if a cutaneous flap or especially if a perforator flap is used.
The availability and quality of the recipient site vascula-
ture if a free flap is indicated for either type of flap, will
further limit the alternatives. The length of the potential flap
pedicle must be long enough to reach them, and preferably
do so without the need for vein grafts. The caliber of the free
flap vessels should be similar to and definitely not exceed a
3 : 1 ratio to those at the recipient site. This will simplify any
microanastomosis, increase the patency rate and reliability,
and thereby minimize the risk of complications.
Not only must the initial coverage result be satisfactory,
but long-term durability and stability,18 coupled with a rea-
sonable cosmetic appearance must always be a concern
Text continued on p. 11
 CHAPTER 3 — Considerations in Flap Selection 6.e1

Table 3.1 Comparison of attributes of the basic flap subtypes

Cutaneous
non-perforator Cutaneous
Bone based perforator Intestine Muscle Toe
Ease of dissection Somewhat Easy Difficult Requires Easy Moderately
difficult laparotomy difficult
Anatomic anomalies Occasional Rarely important Expected Rare Rare Common
Availability Always Always Usually Always Always Possible
Potential for harvest as Sometimes Sometimes Always Never Usually Sometimes
compound flap
Contour (thin → bulky) N/A Variable Variable Moderate Relatively N/A
thickness thin
Potential for thinning No Secondarily Immediate No Yes No
Donor site morbidity Potential If skin graft If skin graft Requires Loss of Potential,
necessary necessary laparotomy function especially
great toe
Dynamic transfer No No No No Yes No
Expendability Maybe Yes Yes Yes Maybe Maybe
Reliability (blood supply) Usually Can be Usually good Always Best Sometimes
good precarious
Sensibility No Yes Yes No No Yes
Surface area N/A Small Very large Moderate Large N/A
Vascular pedicle caliber Large Variable Can be large Very large Large Large
Vascular pedicle length Short Variable Exceedingly long Very long Medium Medium
When used as pedicled flap
Arc of rotation Short Limited Wide N/A Wide N/A
Reliability Usually Can be Usually good N/A Best N/A
good precarious
Need for supercharge Sometimes Usually not Sometimes N/A Not N/A
possible possible

N/A, not applicable.

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 6.e2

Table 3.2 Comparison of attributes of “workhorse” muscle-free and pedicled flaps

Latissimus Pectoralis Rectus

Gracilis Gastrocnemius Gluteus dorsi major abdominis Soleus Trapezius
Ease of dissection Easy Minimal difficulty Moderate Easy Easy Easy Minimal Moderate
difficulty difficulty difficulty
PART 1 — PRINCIPLES

Anatomic anomalies Not Not important No No Not important No Not Sometimes

important important
Potential for harvest as Yes/skin Yes/skin, tendon Yes/skin, Most versatile/ Yes/skin, rib Yes/skin Not usually Yes/skin,
compound flap/component bone unusual skin, rib, scapula bone
tissues that can be included scapula bone
Contour (thin → bulky) Moderately Moderately thick Thick Moderately Moderately Thin Moderately Thin
thin thick thick thick
Potential for thinning Yes Yes Yes No No Difficult due to Yes No
inscriptions
Dynamic transfer Best Pedicle transfer No Minimal value Minimal value Segmental Pedicle Yes, for
innervation transfer shoulder
Donor site morbidity None Some, if athletic Significant, if Minimal Limited Can be Some, if Possible,
ambulatory significant athletic shoulder drop
Surface area Narrow Moderate Small Largest Moderate Small Moderate Moderate
Vascular pedicle caliber Moderate Moderate Large Large Moderate Large Small Moderate
Vascular pedicle length Medium Medium Short Long Short Long Variable Medium
When used as pedicled flap
Arc of rotation Moderate Limited Limited Great Great Wide Limited Great
Reliability Very good Always Usually Always Very Usually Usually Usually
adequate
Need for supercharge No No No No No Possible No Possible
Potential for harvest as No Unusual No Yes, on Yes, on Yes, has two Only if distal No
distally based secondary secondary dominant perforator
pedicles pedicles pedicles present
Need for delay procedure No No No No Sometimes, if Sometimes, if No No
composite flap composite flap

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Splitting into subportions Maybe No Yes Yes Yes No Yes Maybe

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 Table 3.3 Comparison of attributes of “workhorse” fasciocutaneous pedicled and free flaps

Deltopectoral Groin Lateral arm Parascapular Radial forearm Scapular Temporoparietal

Ease of dissection Unusual Difficult Moderately Easy Easy Easy Moderately
difficult difficult
Anatomic anomalies Sometimes Major concern Minimal No No No Rarely
Potential for harvest as Usually not Usually not Minimal/bone, Excellent/ Minimal/bone, tendon Excellent/ Yes/bone, hair
compound flap/component tendon bone, muscle bone, muscle
tissues that can be included
Contour (thin → bulky) Medium Usually bulky Medium Usually thick Moderately thin Usually thick Very thin
thickness thickness
Potential for thinning Not immediate Not immediate Not immediate Not immediate No Not immediate No
Donor site morbidity Disfiguring Most easily hidden Minimal Minimal Maximal Minimal Little
Surface area Medium Maximum Small Long Medium Medium Small
Vascular pedicle caliber Large Variable Medium Large Large Large Small
Vascular pedicle length Variable Variable Medium Long Long Long Short
When used as pedicled flap
Arc of rotation Medium Long Marginal Medium Moderate Medium Limited
Reliability Moderate Unpredictable Good Good Good Good Moderate
Need for supercharge No No No No Sometimes, especially No No
if distally based
Potential for harvest as No Not usually Yes No Yes No Unusual
distally based
Need for delay procedure Sometimes to No No No No No No
extend length

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CHAPTER 3 — Considerations in Flap Selection
6.e3
 6.e4

Table 3.4 Comparison of attributes of “workhorse” perforator flaps

ALT AMT DIEAP Freestyle IGAP PTAP SIEA SGAP TFL TDAP
Ease of dissection Moderate Depends Easy Depends Difficult Easy Depends Moderate Difficult Easy
on anatomy on anatomy on anatomy
Anatomic anomalies Can be Major Sometimes Depends Variable Minimal Major Not a Not Can be
PART 1 — PRINCIPLES

compensated concern on location concern problem usually compensated

for for
Potential for harvest Yes/muscle, Yes/muscle Yes/ Depends Yes/ No No Yes/ Yes/ Yes/muscle,
as compound flap/ fascia muscle on chosen muscle muscle muscle, bone
component tissues perforator fascia
that can be
included
Contour (thin → Moderate Moderate Very bulky Variable Extremely Thin Very bulky Extremely Moderate Moderate
bulky) bulky bulky
Potential for Yes Yes Yes Variable Difficult No Possible Difficult Yes Possible
thinning
Donor site Moderate Moderate Least Variable Limited Minor Least Somewhat Moderate Limited
morbidity
Surface area Large Moderate Huge Variable Limited Small Large Limited Moderate Large
Vascular pedicle Large Small Large Variable Moderate Small Variable Large Moderate Large
caliber
Vascular pedicle Long Short Long Short Short Short Variable Short Moderate Long
length
When used as
pedicled flap
Arc of rotation Wide Limited Large Limited Limited Limited Limited Limited Wide Wide
Reliability Good Variable Great Good Moderate Good Unreliable Good Moderate Good
Need for Sometimes, if No Possible No No No No No No No
supercharge distal-based
Need for delay No No No No No No No No No No
procedure

DIEAP, deep inferior epigastric artery perforator; SIEA, superficial inferior epigastric artery; SGAP, superior gluteal artery perforator; IGAP, inferior gluteal artery perforator; ALT, anterolateral

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thigh; AMT, anteromedial thigh; TFL, tensor fascia lata; TDAP, thoracodorsal artery perforator; PTAP, posterior tibial artery perforator.
 Table 3.5 Comparison of attributes of “workhorse” bone pedicled and free flaps

Fibula bone Humerus bone Iliac bone Rib bone with Radius bone Scapula bone Scapula bone
with peroneal with lateral arm with iliac pectoralis major with radial with scapular/ with trapezius
perforator flap flap flap flap forearm flap parascapular flap flap
Ease of dissection Easy Moderate Difficult Easy Moderate Moderate Moderate
Anatomic anomalies No No Minimal No No Sometimes Sometimes
Potential for harvest as Yes/muscle, skin Yes/fascia, tendon Yes/muscle Yes/skin Yes/fascia, Yes/muscle Yes/skin
compound flap/component tendon
tissues that can be included
Contour (thin → bulky) Thin Moderate thickness Bulky Moderate thinness Thin Moderate thickness Thin
Implant osseointegration Yes No Yes No Unlikely Maybe Maybe
Donor site morbidity Limited Minor Sometimes Minimal Major Minimal Minimal
significant
Bone length Long Very short Moderate Minimal Short Short Short
Vascular pedicle caliber Large Moderate Moderate Moderate Large Large Moderate
Vascular pedicle length Moderate Moderate Moderate Minimal Long Long Minimal
When used as pedicled flap
Arc of rotation Moderate Limited Very limited Large Moderate Large Moderate
Reliability Best Somewhat Good Somewhat Moderate Very Somewhat
Need for supercharge No No No No Possible, if No No
distally based
Potential for harvest as Possible Possible No No Yes No No
distally based
Need for delay procedure No No No No No No No

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CHAPTER 3 — Considerations in Flap Selection
6.e5
 CHAPTER 3 — Considerations in Flap Selection 7

Median forehead (S) TPF (F, FS)

Cervicofacial (S) FAMM (Mu)

Submental (S)
Trapezius (M, MS, BMS, BM)
Supraclavicular (S)
Deltopectoral (FS, S) Pectoralis major
(M, MFS, BMFS, BM)
Lateral arm (FS, MFS, BMFS)
Rectus abdominis (M, MFS)
DIEAP (FS, S)
SIEA (FS, S)
Jejunum (M, Mu)
Groin (FS, S, BFS)
Iliac (B, BFS)
Radial forearm (FS, S, B, BFS)
Gracilis (M, MFS)
ADM (M, SM)

TFL (MF, MFS)

ALT (M, MF, MFS, FS, S)
AMT (M, MF, MFS, FS, S) MFC (B)

Descending genicular (S, SB) Gastrocnemius (M, MS)

PTAP (FS, S) Soleus (M, MS)
Fibula (B, BS, BMS)
FDB (S)
(medial plantar, Supramalleolar (S)
medialis pedis)
Toe (B, BS) EDB (S)
Pulp (S)
Abductor hallucis (M)
A

TPF (F, FS)

Trapezius (M, MS, BMS, BM)

Scapular/parascapular (FS, S, BFS)

Lateral arm (FS, MFS, BMFS)
Latissimus (M, MS, BM, BMS)
Serratus (M, BM)
TDAP (FS, S)
Posterior interosseous (S)
Radial forearm (FS, S, B, BFS)
Ulnar artery perforator (S) SGAP and IGAP (FS, S)
Dorsal metacarpal (S)
TFL (M, MF, MFS)
Gracilis (M, MFS)
ALT (M, MF, MFS, FS, S)
AMT (M, MFS, FS, S)

Sural (F, FS, FSM, S)

Gastrocnemius (M, MS)
PTAP (S) Soleus (M, MS)
Fibula (B, BS, BMS)

Toe (B, BS)

B
Figure 3.1 (A,B) Conventional and perforator-based workhorse flaps available in several regions of the body. Tissue types and some potential
combinations that can be carried with the flaps are mentioned: B, bone; M, muscle; S, skin; F, fascia; Mu, mucosa.

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8 PART 1 — PRINCIPLES

Scalp Temporoparietal, Latissimus, ALT, Trapezius Forehead Temporoparietal, Radial forearm, median forehead
Midface/nose Median forehead, Nasolabial, Radial forearm, Fibula, Iliac,
Orbit Temporoparietal, Radial forearm, ALT Rectus abdominis, submental, cervicofacial
Ear Temporoparietal, ALT fascia flap, Lateral arm fascia flap Tongue/floor of mouth Radial forearm, ALT, AMT, DP, PM, FAMM
Neck Deltopectoral, Pectoralis major, ALT, Parascapular, supraclavicular
Buccal FAMM Radial forearm, ALT, DP, PM
Shoulder Latissimus dorsi, Esophagus Jejunum, ALT, Radial forearm, Colon
supraclavicular, Scapular, Trapezius, Pectoralis major Empyema/bronchopleural fistula Latissimus dorsi,
Adynamic shoulder Trapezius, Gracilis Serratus anterior, Pectoralis major
Chest wall Pectoralis major, Rectus abdominis,
Arm Scapular, Latissimus dorsi,
Omentum, External oblique, ALT, TFL
Radial forearm, ALT, Lateral arm
Sternum/mediastinum Pectoralis major, Rectus abdominis,
Breast Latissimus dorsi, DIEP, TRAM, Omentum, ALT, TFL
Transverse gracilis myocutaneous flap, SGAP, IGAP Abdominal wall Rectus abdominis, ALT, TFL, DIEAP, SEAP
Elbow flexion Latissimus dorsi, Gracilis Groin DIEP, TRAM, Gracilis, ALT, TFL, SCIA
Palm Glabrous skin flaps, Homodigital, ADM Wrist flexion/extension Gracilis
(Medial plantar, Medialis pedis), Penis ALT, Fibula, Rectus abdominis, Groin
Radial forearm, Posterior interosseous
Finger amputation
Replantation of amputee, Vagina (in female) Jejunum, Colon, Gracilis, VRAM, DIEP
Toe, Glabrous skin Thigh TFL, ALT, Gracilis, SCIA
Finger pulp Glabrous skin flaps Knee Latissimus dorsi, Reverse ALT,
(Medialis pedis, Toe pulp flap, Medial plantar) Reverse vastus lateralis, Gastrocnemius, Sural
Cross-finger, Moberg, homodigital
Upper Gastrocnemius, ALT, Sural
Tibia Middle Soleus, ALT
Lower Soleus, Reverse sural, ALT
supramalleolar

Foot Glabrous skin flaps (FDB, medialis pedis, medial plantar),

Radial forearm, Temporoparietal, Rectus abdominis, EDB,
C abductor hallucis

Skull base Scalp Temporoparietal, Latissimus dorsi, ALT

Rectus abdominis, ALT, Vastus lateralis
Mandible
Fibula, Iliac, Metatarsal, Radial forearm Neck Trapezius, Latissimus dorsi, ALT

Midline back Latissimus dorsi, Trapezius, Parascapular

Arm Latissimus dorsi, Radial forearm,
ALT, Lateral arm, Scapular
Elbow Radial forearm, Lateral forearm, Latissimus dorsi
Lower back SGAP, Lumbar perforator, Latissimus dorsi
Sacrum SGAP, IGAP, Gluteus Dorsal forearm Radial forearm, Lateral arm, Latissimus dorsi

Ischium
IGAP, Gracilis, Posterior thigh, Inferior gluteal, TFL Dorsal hand
Posterior interosseous, Radial forearm, Temporoparietal, ALT
Finger Dorsal metacarpal, Ulnar artery perforator
Posterior interosseous, Toe, Dorsal metacarpal,
Cross finger, Homodigital Greater trochanter TFL, ALT, Vastus lateralis

Posterior thigh Gracilis, ALT, IGAP

Popliteal Gastrocnemius, ALT, Latissimus dorsi, Sural

Achilles Distal sural, Radial forearm,

ALT, TFL, Lateral arm, Distal soleus, EDB

D
Figure 3.1, cont’d (C,D) Workhorse flaps commonly used for reconstruction of specific body regions. These are flaps customarily used for
each body part, and include both free flap and pedicled flap alternatives. Although it may not be specifically listed, many workhorse flaps often
have additional potential roles as a choice for other body regions. ADM, abductor digiti minimi; ALT, anterolateral thigh; AMT, anteromedial
thigh; DIE(A)P, deep inferior epigastric (artery) perforator; DP, deltopectoral; EDB, extensor digiti brevis; FAMM, facial artery musculomucosal;
FDB, flexor digitorum brevis; IGAP, inferior gluteal artery perforator; MFC, medial femoral condyle; PM, pectoralis major; PTAP, posterior tibial
artery perforator; SEAP, superior epigastric artery perforator; SGAP, superior gluteal artery perforator; SIEA, superficial inferior epigastric artery;
TDAP, thoracodorsal artery perforator; TPF, temporoparietal fascia; TFL, tensor fascia lata; TRAM, transverse rectus abdominis myocutaneous;
VRAM, vertical rectus abdominis myocutaneous.

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 CHAPTER 3 — Considerations in Flap Selection 9

Table 3.6 Comparison of attributes for “workhorse specialized” tissue flaps

Glabrous
Colon skin Jejunum Joints Nail beds Toe

Ease of dissection Simple Not easy Easy Moderate Difficult Moderate

Anatomic anomalies No Usually No Common No Common
Potential for harvest as No No No Yes/bone, Yes/any Yes/any part of foot
compound flap/component skin part of toe
tissues that can be included
Contour (thin → bulky) Bulky Thin Moderate N/A N/A N/A
thickness
Implant osseointegration N/A N/A N/A No N/A Yes
Donor site morbidity Laparotomy Minimal Laparotomy Can be Loss of First toe, yes;
needed needed minimal nail Second toe, minimal
Bone length N/A N/A N/A Shorter Variable Short
Vascular pedicle caliber Large Small Very large Large Small Large
Vascular pedicle length Long Short Very long Medium Short Medium
When used as pedicled flap
Arc of rotation Wide Limited Moderate N/A N/A N/A
Reliability Good Moderate Good N/A N/A N/A
Potential for harvest as N/A Yes N/A N/A N/A N/A
distally based

N/A, not applicable.

Table 3.7 Typical and atypical indications for the free and pedicled version of “workhorse” flaps harvested
from the head and neck, chest, abdomen, and back regions

Free microvascular transfer Pedicled

Flap Typical indication Atypical indications Typical indication Atypical indications
Temporoparietal Thin, gliding surface Hair transplant Ear salvage Beard or eyebrow
fascia to cover tendons, reconstruction
especially hand
Pectoralis major None None Closure of chest or Repair of esophagus or
facial wounds trachea
Deltopectoral None None Oropharynx Chest wounds
Rectus abdominis Breast reconstruction Lower extremity Breast reconstruction Groin
Jejunum Cervical esophagus Oropharynx lining N/A N/A
Trapezius None None Midline posterior neck Lateral face
coverage
Scapular and Large defects Bone flap Axillary contractures Head and neck coverage
parascapular
Latissimus flap Large defects Quadriceps function Breast, chest wounds, Axillary contractures, head and
restoration thoracic spine neck, dynamic upper extremity

N/A, not applicable.

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10 PART 1 — PRINCIPLES

Table 3.8 Typical and atypical indications for the free and pedicled version of “workhorse” flaps harvested
from the upper extremities, pelvis, groin, buttock, and lower extremities

Free microvascular transfer Pedicled

Flap Typical indication Atypical indications Typical indication Atypical indications
Lateral arm Small defect of arm or leg Short segment bone or Elbow coverage Axilla
tendon defect
Radial forearm Oral lining Foot or distal third leg Hand coverage Elbow coverage
Iliac Mandible Long bone segmental defects Pubis Sacrum
Groin Large defect if cosmetic Extremities Thigh or abdomen Staged upper extremity
donor site imperative pedicle flaps
Gluteus Breast reconstruction None Sacral or ischial Lumbar pressure sores
pressure sores
Tensor fascia Vascularized fascia, Abdominal wall Abdominal wall Groin
lata Achilles repair
Gracilis Small extremity wound, Breast reconstruction Groin, perineum Scrotum, penis
facial reanimation or vagina
Gastrocnemius None Pressure sore Knee wound Cross-leg flap
Soleus None None Proximal leg Distal leg
Fibula Mandible or large bone Pelvis Knee arthrodesis Ipsilateral tibia
segmental gap segmental gap
Glabrous skin Hand Foot Foot None
Toe Hand Nail transfer N/A N/A

N/A, not applicable.

Table 3.9 Typical and atypical indications for the free and pedicled version of “workhorse” perforator flaps

Free microvascular transfer Pedicled

Flap Typical indication Atypical indications Typical indication Atypical indications
Deep inferior epigastric Breast reconstruction Large soft tissue Groin coverage Abdomen
artery perforator flap defect
Superficial inferior epigastric Breast reconstruction Extremity defect Groin Staged upper
artery perforator flap extremity coverage
Superior gluteal artery Breast reconstruction None Sacral pressure Lumbar pressure
perforator flap sores sores
Inferior gluteal artery Breast reconstruction None Ischial pressure Perineum
perforator flap sores
Anterolateral thigh (ALT) flap Large soft tissue defect Achilles tendon Thigh wounds Abdomen
Anteromedial thigh flap Large soft tissue defect None Thigh wounds Groin
if ALT flap unavailable
Thoracodorsal artery Large soft tissue Breast Breast Axilla
perforator flap defects reconstruction reconstruction
Posterior tibial artery Thin contour required None Distal lower None
perforator flap extremity

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 CHAPTER 3 — Considerations in Flap Selection 11

A B
Figure 3.2 (A) Although the bulk and contour of this latissimus dorsi muscle free flap used to cover the degloved plantar and posterior hindfoot
was acceptable, the final appearance after the necessary skin graft was not ideal. (B) This can be compared with metachronous bilateral
anterolateral thigh free flaps used to cover complications of an open distal tibial fracture, where both blend almost imperceptibly into each
other and the surrounding lower limb to give a superior appearance.

Wei and colleagues20 in their voluminous experience with

the anterolateral thigh flap, consider it to be the “ideal”
soft tissue flap for “all seasons” (Table 3.4 and Chapter 59),
since it can be prefabricated,21 thinned to the desired
contour,22 used as a megaflap or split into multiple flaps,23
has a long and reliable vascular pedicle, and can be used in
combination with multiple other tissue components such as
fascia lata or muscle if desired.24
Few would disagree that muscle perforator flaps, at least
in the Western Hemisphere, where obesity is more preva-
lent, require a more difficult dissection that potentially
makes them less reliable.25–27 Logically then, the muscle flap
will still have a role particularly in obese patients; and, of
course, if a dynamic muscle transfer is required.28 If used
for coverage only, a skin graft will be needed on the muscle,
so that the cosmetic result will virtually always be inferior to
that possible with any cutaneous flap (Fig. 3.2).

THE DONOR SITE

Solving the given problem element that the reconstructive

Figure 3.3 This scapular free flap was obviously too bulky for cover-
age of the dorsal foot subunit. A thin flap would have been a prefer-
able choice to allow more immediate use of shoewear.
(Fig. 3.2). Secondary touch-ups may be inevitable, but
should be avoided whenever possible by the proper flap
selection to begin with (Fig. 3.3). Whether or not muscle
flaps atrophy with time is a controversial point,19 but cutane-
ous flaps after resolution of edema will maintain the char-
acteristics of the initial donor site, even over time as regards
their size and contour.
surgeon is confronted with by incorporating the proper
restorative surgical strategy,1 is of paramount importance.
Yet an equally important objective must be to minimize any
iatrogenic morbidity, especially when inflicted at the donor
site of the selected flap. Currently, the total absence of
donor site morbidity is possible only if the patient with the
defect to be reconstructed has an identical twin willing to
donate the missing part.29,30 As previously mentioned, and
again here reiterated for emphasis, all muscles used as a flap
will result in some function loss even with function preserva-
tion techniques.17 The reality is that the same is true with
muscle perforator flaps, even though all muscle is totally
excluded from these cutaneous flaps. The unavoidable

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12 PART 1 — PRINCIPLES
intramuscular dissection of the requisite musculocutaneous
perforator will cause some minor injury,31 albeit usually
undetectable.
Mathes and Nahai32 clearly showed that the extent of
viability of muscle flaps depends on the pattern of the intrin-
sic circulation to that muscle. Since this anatomy is fairly
constant, the surgical approach to harvest a given muscle or
portion thereof can be predictably reliable. The same has
not been the case for cutaneous flaps, so most donor sites
have been restricted to specific angiosomes fed by relatively
large and relatively consistent source vessels. This opinion
has changed dramatically with our realization that now any
part of the body can be used as a “free-style” local33,34 or
“free-style” free flap35,36 chosen on the basis of its special
characteristics, as long as an identifiable and adequate cuta-
neous perforator exists. Even this has become a less haphaz-
ard experience and perhaps no longer even “free-style”, as
preoperative imaging studies such as computed tomography
(CT)37 or magnetic resonance angiography (MRA)38 can
pinpoint not only the location and size of the requisite
perforator, but its course as it spreads out into the periphery
on its way to the subdermal plexus.
Of course, the preferred perforator flap donor site can
now also be selected on the basis of the potential donor site
deformity. This must be comparable with that possible with
muscle flaps, where direct closure leaving a linear scar is the
routine that will always be preferable from an aesthetic
standpoint. Endoscopic techniques for the harvest of muscle
flaps have minimized even the extent of this residual scar-
ring to little more than that required for access ports,
although this does increase the complexity of flap harvest.39
Yet this preceding goal will never be obtainable for all
perforator flaps. For example, a large cutaneous flap usually
will need a donor site skin graft to avoid the risk of a com-
partment syndrome;40 and the result may be unacceptable
A B
Figure 3.4 (A) A linear scar typical when primary closure of the anterolateral thigh free flap donor site is possible; (B) and the poor aesthetic
result if a skin graft were necessary.
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even if the skin graft could be readily hidden by clothing
(Fig. 3.4). Preoperative tissue expansion techniques can
ultimately eliminate the need for a skin graft,21 but often as
in traumatic wounds this may not be an option. Similarly,
postoperative tissue expansion can reduce the non-cosmetic
appearance of the skin grafted donor site, but either way
this is a lengthy process requiring great patience.41 Some-
times a second local flap can instead be used to avoid a skin
graft at the donor site, but that may require comparatively
more complex surgery while still causing additional local
scarring at the least.42
ROLE OF COMBINED FLAPS
Compound flaps can be composite flaps such as any muscu-
locutaneous flap, or a combination of flaps, e.g., the con-
joined or chimeric flap.43,44 The latter flap combinations
can provide multiple tissue components in a single yet com-
prehensive unit of virtually unlimited size to simultaneously
fill any volume deficit, re-establish any underlying frame-
work, and provide immediate coverage.43 The final shape
and contour of this unit can be independently customized
ex vivo and then inset with impunity, as is particularly true
of the chimeric type of combined flap (Fig. 3.5).45 The ideal
scenario would allow all the necessary components of a flap
to be obtained from a single donor site that can be closed
primarily so as to minimize both the recipient site and
donor site morbidity. Wei and colleagues24 have shown this
to be another “ideal” attribute of the anterolateral (medial)
thigh region, which is also true of the subscapular axis,
where the latissimus dorsi and serratus anterior muscles,
parascapular or scapular fasciocutaneous flaps, and even
scapular bone or rib can be assorted together into numer-
ous combinations and permutations.46
 CHAPTER 3 — Considerations in Flap Selection 13

C D
Figure 3.5 (A) Open left mid-tibia fracture with a large cavity surrounding the exposed bone (arrow); (B) undersurface of chimeric anterolateral
(ALT) thigh free flap with two perforators (p), and a portion of vastus lateralis (VL) muscle that is separately supplied by the distal continuation
(arrow) of the lateral circumflex femoral descending branch source vessel (proximal pedicle in microclamps). (C) The ALT flap was used to
cover the bone and medial leg open wound, whereas the VL muscle (arrow) was independently inset into the cavity between the exposed ends
of the tibia to eliminate all dead space. (D) Once coverage had healed satisfactorily, conversion to internal fixation of the tibia was possible
with minimal risks of infection.

If a combined flap has a single source vessel that supplies
all its independent portions, then only a single recipient site
may be required for revascularization if used as a free flap.
This is most advantageous if there is a paucity of recipient
vessels, such as after bilateral radical neck dissections or in
a single-vessel lower extremity. Other advantages include
the capability of retaining a small independent cutaneous
flap as part of a chimeric free flap that could relieve tension
on insetting or provide coverage at a tenuous recipient
site,46 or perhaps serve as a monitoring flap for a muscle or
buried free flap.47
FUTURE CONSIDERATIONS
Fear of iatrogenic morbidity at the donor site if a vascular-
ized flap is the selected surgical strategy, must always be
tempered by ensuring that the needs of the recipient site
will be solved. Compromise usually is inevitable, even if an
identical twin exists.29,30 Until the day arrives when bioengi-
neering technology can be used for the fabrication in the
laboratory or via autogenous regeneration of parts, the
only presently foreseeable recourse to avoid any donor site
morbidity altogether, while still maximizing the desired
outcome at the recipient site, may be via vascularized com-
posite allotransplantation (VCA). Long-term successful VCA
has already included the hand,48 abdominal wall,49 and skel-
etal muscle.50 VCA of the face and its parts is in its infancy,51
but the results so far have been spectacular, especially con-
sidering the relatively mediocre outcomes achieved using
our currently limited flap capabilities. Of course, lifelong
immunosuppression currently remains the obstacle for uni-
versal acceptance of this concept. Someday soon, however,
it is conceivable that the flap of choice that has just the right
size, color, vascular pedicle length and caliber, and exact
secondary characteristics to perfectly restore a missing part
such as an ear, nose, or eyebrow, could be taken “off the
shelf” from where it is stockpiled in the storeroom of every
hospital! Then, there would be absolutely no donor site
morbidity, and the appearance of the final result truly pre-
dictable. We must remember that these will still be “free
flaps” awaiting their replantation, and that the services of a
skilled, dedicated, and interested microsurgeon will con-
tinue to be in demand.

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14 PART 1 — PRINCIPLES
Expert Commentary
Milomir Ninković, MD, PHD
Reconstructive microsurgery has progressed from its initial
ability to achieve a wound coverage using free tissue transfer
to new levels of sophistication in regard to restoration of func-
tion and aesthetics when dealing with acquired or congenital
problems in all body regions. The ability to select optimal
reconstructive procedure, concerning suitable donor tissue and
to transfer them directly to the sites of the tissue or/and func-
tional defects has permanently altered many reconstructive
methods and has expanded the indications for microsurgery.
Advances in anatomy, concerning vascular and nerve supply,
established the unique role of free tissue transfer in reconstruc-
tive surgery. However, in my experience in order to select the
optimal reconstructive procedure, the following guidelines have
to be taken into consideration:
1. Definition of reconstructive requirements according to
assessment of damaged or missing structures based on:
a. Anatomical requirements (localization, extent of soft/bone
loss-size and depth, extent of nerve injury, quality of
vascular supply, presenting infection …)
b. Functional requirements (restoration of sensibility, mobil-
ity …)
c. Aesthetic requirements (skin color/texture, volume …)
2. Etiology of the defect
a. Trauma (complexity, full spectrum of severity …)
b. Tumour resection/radiation
c. Infection
d. Congenital anomalies
e. Vascular disease
Access Tables 3.1 to 3.5 online at
http://expertconsult.inkling.com
REFERENCES
1. Lineweaver WC. Problem analysis in reconstructive surgery: up and
beyond the reconstructive ladders. In: Wei FC, Mardini S, editors.
Flaps and reconstructive surgery. Philadelphia, PA: Elsevier; 2009.
p. 3–6.
2. Millard DR Jr. Tissue losses should be replaced in kind. Principaliza-
tion of Plastic Surgery. Boston, MA: Little, Brown; 1986. p. 191–228.
3. Hallock GG. Evidence-based medicine: lower extremity acute
trauma. Plast Reconstr Surg 2013;132:1733–41.
4. Lu TC, Lin CH, Lin CH, et al. Versatility of the pedicled peroneal
artery perforator flaps for soft-tissue coverage of the lower leg and
foot defects. J Plast Reconstr Aesthet Surg 2011;64:386–93.
5. Lee BT, Lin SJ, Bar-Meir ED, et al. Pedicled perforator flaps: a new
principle in reconstructive surgery. Plast Reconstr Surg 2010;125:
201–8.
6. Maciel-Miranda A, Morris SF, Hallock GG. Local flaps, including
pedicled perforator flaps: anatomy, technique, and applications.
Plast Reconstr Surg 2013;131:896e–911e.
7. Hallock GG. The utility of both muscle and fascia flaps in severe
upper extremity trauma. J Trauma 2002;53:61–5.
8. Hallock GG. Utility of both muscle and fascia flaps in severe lower
extremity trauma. J Trauma 2000;48:913–17.
9. Hollenbeck ST, Woo S, Komatsu I, et al. Longitudinal outcomes
and application of the subunit principle to 165 foot and ankle free
tissue transfers. Plast Reconstr Surg 2010;125:924–34.
10. Hallock GG. A paradigm shift in flap selection protocols for zones
of the lower extremity using perforator flaps. J Reconstr Microsurg
2013;29:233–40.
11. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries
of the cutaneous veins and cutaneous nerves in the extremities:
anatomical study and a concept of the venoadipofascial and/or
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Elsevier on November 29, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
3. Flap features (characteristics)
a. Size, color, bulk, pliability, durability
b. Composite flap possibilities (tendon, nerve, bone …)
c. Sensibility
d. Functional motor units
4. Donor site morbidity
5. Time of reconstruction
a. Primary/immediate
b. Primary delayed
c. Secondary
6. Needs for secondary procedure
a. Tendon, nerve, bone repair
b. Implant use …
7. Age and general condition of the patient
8. Capability of the surgical team
9. Equipment available in the hospital.
The goal in reconstructive microsurgery today is to obtain the
best possible result regarding function and aesthetics, with
minimal donor site morbidity. It is known that the major role of
free flaps remains the coverage of difficult wounds. However,
after the first successful functioning neurovascular muscle, the
work in this area has led to exciting concepts on the capability
of functioning muscle to restore facial expression, to improve
extremity flexion or extension, or to replace paralyzed urinary
bladder detrusor. Functional reconstruction is a most fascinat-
ing challenge.
neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr
Surg 1998;102:779–91.
12. Baumeister SP, Spierer R, Erdmann D, et al. A realistic complica-
tion analysis of 70 sural artery flaps in a multimorbid patient group.
Plast Reconstr Surg 2003;112:129–40.
13. Jiga LP, Barac S, Taranu G, et al. The versatility of propeller flaps
for lower limb reconstruction in patients with peripheral arterial
obstructive disease: initial experience. Ann Plast Surg 2010;64:
193–7.
14. Teo TC. The propeller flap concept. Clin Plast Surg 2010;37:
615–26.
15. Oh TS, Hallock GG, Hong JP. Freestyle propeller flaps to recon-
struct defects of the posterior trunk: a simple approach to a diffi-
cult problem. Ann Plast Surg 2012;68:79–82.
16. Pignatti M, Ogawa R, Hallock GG, et al. The “Tokyo” consensus on
propeller flaps. Plast Reconstr Surg 2011;127:716–22.
17. Mathes SJ, Nahai F. Muscle flap transposition with function preser-
vation: technical and clinical considerations. Plast Reconstr Surg
1980;68:242–9.
18. Hallock GG. Long-term superiority of composite versus muscle-
only free flaps for skull coverage. Ann Plast Surg 2004;52:507–11.
19. Salmi A, Tukiainen E, Härmä M, et al. Prospective study of changes
in muscle dimensions following free-muscle transfer measured by
ultrasound and CT scanning. Plast Reconstr Surg 1996;97:1443–50.
20. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue
flap? An experience with 672 anterolateral thigh flaps. Plast Recon-
str Surg 2002;109:2219–26.
21. Hallock GG. The pre-expanded anterolateral thigh free flap. Ann
Plast Surg 2004;53:170–3.
22. Kimura N, Satoh K, Hasumi T, et al. Clinical application of the free
thin anterolateral thigh flap in 31 consecutive patients. Plast
Reconstr Surg 2001;108:1197–208.
23. Tsai FC, Yang JY, Mardini S, et al. Free split-cutaneous perforator
flaps procured using a three-dimensional harvest technique for the
reconstruction of postburn contracture defects. Plast Reconstr
Surg 2004;113:185–93.

24. Wei FC, Celik N, Jeng SF. Application of “simplified nomenclature
for compound flaps” to the anterolateral thigh flap. Plast Reconstr
Surg 2005;115:1051–5.
25. Hallock GG. Have we found an ideal soft-tissue flap? An experience
with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:
2227–30.
26. Alkureishi LWT, Shaw-Dunn J, Ross GH. Effects of thinning the
anterolateral thigh flap on the blood supply to the skin. Br J Plast
Surg 2003;56:401–8.
27. Hallock GG. Is there a “learning curve” for muscle perforator flaps?
Ann Plast Surg 2008;60:146–9.
28. Hallock GG. In an era of perforator flaps, are muscle flaps passé?
Plast Reconstr Surg 2009;123:1357–63.
29. Kaplan JI, Allen RJ. Transplantation in breast reconstruction.
Semin Plast Surg 2002;16:101–7.
30. Valauri FA, Buncke HJ, Alpert BS, et al. Microvascular transplanta-
tion of expanded free scalp flaps between identical twins. Plast
Reconstr Surg 1990;85:432–6.
31. Kimata Y, Uchiyama K, Ebiharra S, et al. Anterolateral thigh flap
donor-site complications and morbidity. Plast Reconstr Surg 2000;
106:584–9.
32. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg
1981;67:177–87.
33. Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforator-
based v-y advancement flaps in the reconstruction of lower limb
defects. Br J Plast Surg 2000;53:679–89.
34. D’Arpa S, Cordova A, Pignatti M, et al. Freestyle pedicled perfora-
tor flaps: safety, prevention of complications, and management
based on 85 consecutive cases. Plast Reconstr Surg 2011;128:
892–906.
35. Mardini S, Tsai FC, Wei FC. The thigh as a model for free style free
flaps. Clin Plast Surg 2003;30:473–80.
36. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg
2004;114:910–16.
37. Rozen WM, Ribuffo D, Atzeni M, et al. Current state of the art in
perforator flap imaging with computed tomographic angiography.
Surg Radiol Anat 2009;31:631–9.
Downloaded for David Sidhom (david.sidhom@health.qld.gov.au) at Queensland Health Clinical Knowledge Network from ClinicalKey.com.au by
Elsevier on November 29, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
CHAPTER 3 — Considerations in Flap Selection 15
38. Masia J, Kosutic D, Cervelli D, et al. In search of the ideal method
in perforator mapping: noncontrast magnetic resonance imaging.
J Reconstr Microsurg 2010;26:29–35.
39. Miller MJ, Robb GL. Endoscopic technique for free flap harvesting.
Clin Plast Surg 1995;22:755–73.
40. Addison PD, Lannon D, Neligan PC. Compartment syndrome after
closure of the anterolateral thigh flap donor site: a report of two
cases. Ann Plast Surg 2008;60:635–8.
41. Hallock GG. Tissue expansion techniques to minimize morbidity
of the anterolateral thigh perforator flap donor site. J Reconstr
Microsurg 2013;29:565–70.
42. Marsh DJ, Chana JS. Reconstruction of very large defects: a novel
application of the double skin paddle anterolateral thigh flap
design provides for primary donor-site closure. J Plast Reconstr
Aesthet Surg 2010;63:120–5.
43. Hallock GG. Simplified nomenclature for compound flaps. Plast
Reconstr Surg 2000;105:1465–70.
44. Hallock GG. The complete nomenclature for combined perforator
flaps. Plast Reconstr Surg 2011;127:1720–9.
45. Kohsima I, Yamamoto H, Hosoda M, et al. Free combined com­
posite flaps using the lateral circumflex femoral system for repair
of massive defects of head and neck regions: an introduction
to the “chimeric” flap principle. Plast Reconstr Surg 1993;92:
411–27.
46. Hallock GG. Permutations of combined free flaps using the sub-
scapular system. J Reconstr Microsurg 1997;13:47–54.
47. Hallock GG. Free-flap monitoring using a chimeric sentinel muscle
perforator flap. J Reconstr Microsurg 2005;21:351–4.
48. Francois CG, Breidenbach WC, Maldonado C, et al. Hand trans-
plantation: comparisons and observations of the first four clinical
cases. Microsurgery 2000;20:360–71.
49. Levi DM, Tzakis AG, Kato T, et al. Transplantation of the abdomi-
nal wall. Lancet 2003;361:2173–6.
50. Piza-Katzer H. Free allogeneic muscle transfer for cranial recon-
struction. Br J Plast Surg 2002;55:436–8.
51. Pomahac B, Bueno EM, Sisk GC, et al. Current principles of facial
allotransplantation: the Brigham and Women’s Hospital Experi-
ence. Plast Reconstr Surg 2013;131:1069–76.