4 Part 1 Flaps of the Upper Extremity

Chapter 1 dyle are palpated and marked. A straight line is The Deltoid Fasciocutaneous Flap marked to connect these two landmarks. The groove between the posterior border of the del- toid muscle and the long head of triceps is pal- pated and marked. The intersection of these two lines denotes approximately the location of the vascular pedicle, as it emerges from under- The deltoid free flap is a neurovascular fascio- neath the deltoid muscle. This point may be cutaneous tissue, providing relatively thin sen- studied with a hand-held Doppler and marked sate tissue for use in soft-tissue reconstruction. if required. The deltoid fasciocutaneous flap was first de- Depending on the recipient area, the patient scribed anatomically and applied clinically by is positioned either supine, with the donor Franklin.1 Since then, the deltoid flap has been shoulder sufficiently padded with a stack of widely studied and applied.2–5 This flap is sup- towels, or in the lateral decubitus position. Myo- plied by a perforating branch of the posterior relaxants are required in muscular individuals, circumflex humeral artery and receives sensa- so as to ease retraction of the posterior border tion by means of the lateral brachial cutaneous of the deltoid muscle, especially if a long vascu- nerve and an inferior branch of the axillary lar pedicle is required for reconstruction. nerve. This anatomy is a constant feature, thus making the flap reliable. The ideal free deltoid Neurovascular Anatomy flap will be thin, hairless, of an adequate size, and capable of sensory reinnervation. These A large portion of the fasciocutaneous territory characteristics of the flap make it an attractive overlying the deltoid muscle is nourished by option for reconstructing defects of the orofa- the posterior circumflex humeral artery with its cial region. However, in adipose individuals, the paired venae comitantes (Fig. 1.1). The sensory fat tissue might add to the bulk of the flap. innervation of this skin area is through the lat- eral brachial cutaneous nerve, which is the ter- minal sensory branch of the axillary nerve, a Preparation musculocutaneous nerve arising from the pos- The course of the neurovascular pedicle is de- terior cord. This nerve accompanies the vascu- terminedandmarkedbeforesurgeryasfollows. lar pedicle, passing behind the humerus and With the patient in sitting or standing position, emerging from the quadrangular space, which the acromion and the lateral humeral epicon- is bordered by the teres major muscle below,

Fig. 1.1 Anatomical basis of the deltoid Cutaneous branch Vascular pedicle of flap of (beneath the deep ) flap. axillary nerve

Posterior circumflex humeral artery

Long head of triceps Quadrangular space

Teres minor Teres major

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG The Deltoid Fasciocutaneous Flap 5

Fig. 1.2 Planning markings of Acromioclavicular Anterior margin of flap the deltoid flap. joint

Lateral epicondyle

Posterior border of deltoid Vascular pedicle

teres minor muscle above, long head of triceps lavicular junction with lateral epicondyle.3 The medially, and the lateral head of triceps later- intersection of the first two lines denotes the ally. The vascular pedicle gives off branches to point where the vascular pedicle emerges to the deltoid muscles before its emergence. The the surface behind the deltoid muscle; whereas nerve, as already mentioned, is a musculocu- the third line should ideally be the anterior bor- taneous nerve and provides motor innervation der of the planned skin flap. Any variation in to the deltoid muscle. The neurovascular pedi- the point of emergence of the vascular pedicle cle emerges at the posteroinferior border of the canbemarkedbeforesurgeryusingahand- deltoid muscle, turns cranially after its emer- held Doppler. gence, and supplies the skin overlying the pos- The anterior border of the marked skin flap terolateral aspect of the deltoid muscle. Thus a is incised first, extending it along the inferior safe flap will be carved behind the line connect- border as required. The overlying ing the acromioclavicular joint and the lateral the deltoid muscle is sharply cut and the flap is epicondyle, with an adducted and internally elevated in a plane underneath the fascia. Dis- rotated arm (Fig. 1.2). section proceeds toward the vascular pedicle, which is visualized in the under surface of the flap, after partially raising it (Fig. 1.3). An occa- Incisions and Dissection sional perforator from the deltoid muscle With the patient’s arm adducted and internally should be coagulated and divided. The neuro- rotated, three lines are drawn1: a line connect- vascular pedicle is traced to the delto-tricipital ing the acromion and the lateral epicondyle,2 a groove and carefully isolated. Now the rest line along the groove between the posterior of the skin incision can be completed border of the deltoid muscle and the long head (Fig. 1.4). The posterior border of the deltoid of triceps, and a line connecting the acromioc- muscle is retracted to gain length of the vascu-

Fig. 1.3 Dissection of the deltoid flap.

Direction of dissection (in the subfascial plane)

Neurovascular pedicle

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG 28 Part 2 Flaps of the Lower Extremity

Chapter 7 TheTensorFasciaeLataeMuscleFlap

The tensor fasciae latae muscle arises from the anterior part of the outer lip of the and is invested in a double fascial layer. These fascial Fig. 7.1 Patient positioning for the harvest of the layers blend at the junction between the upper tensor fasciae latae flap. and the middle thirds of the lateral aspect of the and course down as the ilio-tibial tract to Preparation insert into the lateral femoral . The mus- cle flexes and rotates the femur internally. Ifnototherwisedictatedbythesitetoberecon- Themuscleisprovidedwithaconstant structed, the patient is positioned supine with blood supply through one reliable vascular ped- the and joints gently flexed. The thigh icle arising from the lateral circumflex femoral is rotated internally, so that its lateral aspect artery and its accompanying vein. The motor faces the surgeon (Fig. 7.1). The anterior supe- innervation is through the descending branch rior iliac spine and the iliac crest are palpated of the superior gluteal nerve. The overlying skin and marked. The line joining the lateral most has two sources of sensory innervation: (1) the aspect of the iliac crest and the lateral femoral cutaneous branch of the T12 segment (upper condylemarksthecourseoftheiliotibialtract. part), and (2) the lateral femoral cutaneous The position of the patient is determined by nerve (lower part). the area to be reconstructed. For instance, in us- Thetensorfasciaelataewasfirstdescribed ing the tensor fasciae latae muscle as a pedicled as a free musculocutaneous flap by Hill, Nahai, rotation flap for the reconstruction of decubitus and Vasconez in 1978.1,2 This musculocutaneous wounds, the patient may be positioned either unit can be transferred with motor as well as onthesideorinaproneposture. sensory innervation; there are ample and dif- ferent types of tissue that may be transferred Neurovascular Anatomy (Fig. 7.2) based on the vascular pedicle of this muscle.3–6 These properties make the tensor fasciae latae The vascular pedicle that nourishes the tensor muscle a very reliable workhorse for dealing fasciae latae muscle arises either from the lat- with various reconstructive challenges.4,6 eral circumflex femoral artery or, in some cases,

Profunda femoris artery Fig. 7.2 Anatomical basis of the Lateral circumflex tensor faciae latae (TFL) flap. femoral artery Femoral artery

Transverse and descending branches

Ascending branch (vascular pedicle of TFL) Superior gluteal nerve (inferior branch)

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG The Tensor Fasciae Latae Muscle Flap 29

Fig. 7.3 Planning markings of Point of entry of vascular pedicle Lateral femoral condyle thetensorfaciaelataeflap. Lateral cutaneous nerve of thigh Iliac crest ca. 4 cm 8 cm

Lazy-S incision

Skin flap Sensory branch of T12 directly from the profunda femoris artery as an points, 8 and 10 cm distal to the iliac crest and ascending branch. The pedicle enters the muscle along the anterior muscle border, are marked. belly ˚ 6–8 cm distal to the muscle’s origin from These represent the entry points of the vascular theiliaccrest.Theskinoverlyingthemuscleis pedicleandthelateralfemoralcutaneous richlyvascularizedbyaboutfourorfiveperfora- nerve, respectively. tor vessels arising from this vascular pedicle. The anterior border of the skin flap is incised The motor innervation is executed from the first, extending the incision in a lazy-S pattern dorsal aspect through the descending branch of proximally and distally as found necessary. Care the superior gluteal nerve. The sensory innerva- is taken to preserve the lateral femoral cutane- tion of the overlying skin is accomplished by ous nerve that appears along the incision. the cutaneous branch of T12 that enters the lat- After the anterior border of the tensor fas- eral thigh region after crossing the iliac crest, ciae latae muscle has been identified and dis- and by the lateral femoral cutaneous nerve that sected free, the muscle belly is retracted later- enters the anterior border of the lateral thigh ally and dorsally to reveal the entry point of the skin ˚ 10–12 cm distal to the origin of the ten- vascular pedicle ( ˚ 6–8 cm distal to the muscle sor fasciae latae muscle. origin). These vessels travel in the septal space The vascular pedicle as well as the motor between the rectus femoris (anteriorly) and and sensory nerves can be reliably dissected by (posteriorly). Thus the orienting oneself on the landmarks as de- rectus femoris is separated bluntly from the scribed later. septal space and retracted anteromedially to vi- sualize the course of the vascular pedicle (Fig. 7.4). Incisions and Dissection Now the posterior incisions of the skin island The iliac crest, the anterior iliac superior spine, arecompleted,takingcaretopreservethecuta- as well as the lateral femoral condyle are pal- neous nerve entering the skin island laterally pated and marked. A straight line joining the along the iliac crest. The is dis- lateral-most aspect of the iliac crest and the lat- sectedandtransectedasdistallyasneeded. eral femoral condyle mark the approximate If the recipient site demands the transfer of a course of the musculofascial tract (Fig. 7.3). functional muscle, the dissection of the motor Moreover, the muscle belly is palpated and nerve is performed as follows: the posterior marked. If needs be, practically the whole of the border of the muscle is freed sharply cut from skin of the lateral thigh may be raised along the fascial attachments and the muscle is re- with the underlying muscle and fascia based on tracted anteromedially (Fig. 7.5). The gluteus thesinglevascularpedicle. medius muscle that inserts into the greater A skin island centered along the tensor fas- femoral trochanter is retracted posteriorly to ciae latae muscle belly is described here. Two reveal the motor nerve innervating the tensor

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG 30 Part 2 Flaps of the Lower Extremity

Sartorius and rectus femoris (retracted) Fig. 7.4 Dissection of thetensorfaciaelatae (TFL) flap. Vastus lateralis (wound floor)

TFL (retracted postero-laterally) Vascular pedicle

TFL flap (retracted antero-medially) Fig. 7.5 Harvesting the tensor faciae latae (TFL) Superior gluteal nerve (inferior branch) flap.

Motor nerve

Lateral cutaneous nerve of thigh

Gluteus medius Greater trochanter (retracted) Piriformis (floor)

Sensory branch of T12 TFL musculocutaneous flap

fasciae latae muscle. This nerve courses be- this single vascular pedicle it is possible and re- tween the piriformis (anteriorly) and the glu- liable to raise the whole of the iliotibial tract teus medius muscle (posteriorly). The nerve is along with the overlying skin ( ˚ 40 × 20 cm). now stimulated and transected after confirm- Themotornerveis1–1.5mmindiameterandis ing the motor response from the muscle flap. relatively short in length (approx. 5 cm). After the muscle or musculocutaneous flap Disadvantages associated with raising a large has been cut, the vascular pedicle is followed to tensor fasciae latae musculocutaneous flap in- its origin, retracting the clude muscle herniation and a long scar. Skin anteromedially. The artery and veins are tran- grafting may be necessary, where a broad skin sected separately between ligating clips. flap has been cut. The vascular pedicle is ˚ 6–8 cm in length; the vessel diameters are in the order of 2–2.5 mm (artery) and 3 mm (vein). Based on

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG The Tensor Fasciae Latae Muscle Flap 31

Pitfalls 2 Nahai F, Silverton JS, Hill HL, Vasconez LO.The Dissection of this usually reliable flap may be de- tensor fascia lata musculocutaneous flap. mandingwhenaninnervatedflaphasbeen Ann Plast Surg 1978;1:372–379 planned. Particular care is necessary during the 3 Brenner P, Krebs C. Brachial plexus inner- posterior dissection, where the motor nerve runs. vated, functional tensor fasciae latae muscle It is surprisingly easy to transect the innervating transfer for controlling a Utah Arm after dis- nerves, since these are relatively small in caliber location of the shoulder caused by an electri- and short in length. Some situations may demand cal burn. J Trauma 2001;50:562–567 anervegraftbetweenthedonornerveatthere- 4 Deiler S, Pfadenhauer A, Widmann J, Stutzle H, cipientsiteandthemotornerveoftheflap,owing Kanz KG, Stock W. Tensor fasciae latae perfo- to the limited length of the motor nerve. In our rator flap for reconstruction of composite experience results after transferring functional defects with skin and vascu- muscle flaps were better when no nerve grafts larized fascia. Plast Reconstr Surg 2000; were used. 106:342–349 It is safe to transfer this flap without motor inner- vation. Recipient sites that definitively demand a 5 Ihara K, Doi K, Shigetomi M, Kawai S.Tensor motor innervated muscle may be better treated fasciae latae flap: alternative donor as a func- with the gracilis or latissimus dorsi muscle flaps tioning muscle transplantation. Plast Re- instead of the tensor fasciae latae muscle. constr Surg 1997;100:1812–1816 6 Krishnan KG, Winkler PA, Müller A, Grevers G, Steiger HJ. Closure of recurrent frontal skull References base defects with vascularized flaps – a tech- 1 Hill HL, Nahai F, Vasconez LO. The tensor fas- nical case report. Acta Neurochir (Wien) cialatamyocutaneousfreeflap.PlastRe- 2000;142:1353–1358 constr Surg 1978;61:517–522

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG 44 Part 2 Flaps of the Lower Extremity

Chapter 11 and the pulled to a more favorable plantar The Dorsalis Pedis Flaps flexion. It is a good idea to apply a tourniquet to the thigh in a non-exsanguinating manner, so as to ease dissection of the subcutaneous veins.

Neurovascular Anatomy (Fig. 11.2) The medial three toes, their metatarsals as well The dorsalis pedis artery, the continuation of as the dorsal skin of the foot, are nourished by the anterior tibial artery, passes forward from the dorsalis pedis artery. Thus any of these the ankle-joint, lying beneath the retinaculum, structures, separately or combined,1 may be along the tibial side of the dorsum of the foot to raised on the basis of the dorsalis pedis artery theproximalpartofthefirstintermetatarsal and the saphenous veins. Furthermore, it is space. Here it bifurcates into the first dorsal possible to raise a skin flap based on the distal metatarsal and the deep plantar arteries, estab- communications of the dorsalis pedis artery lishing communication with the deep plantar with the deep plantar arch.2–4 arch. At the level of the ankle this artery bor- As early as 1967, Young5 described reliable derswiththeextensorhallucislongusfromthe transfer of the second toe for thumb recon- tibial side, and with the first tendon of the ex- struction in the Chinese language. However, it tensor digitorum longus and the deep peroneal was not until two years later that the free toe nerve from the fibular side. In a small minority transfer was reported in English.6 of patients the dorsalis pedis artery may arise The dorsum of the foot offers thin, pliable, from the perforating branch of the deep pero- and reliably vascularized skin that also provides neal artery. In these cases the flap pedicle re- the option of using it as a neurosensate flap. mains short. The artery is accompanied by two Starting from narrow strips (for finger recon- comitant veins. struction) ending with almost the whole dor- Infrequently the dorsal artery of the foot sumofthefootmaybefavorablytransferred, may be larger than usual, mostly to compensate based on the dorsalis pedis vessels, to meet dif- for a deficient plantar artery; or its terminal ferent reconstructive challenges, especially of branches to the toes may be absent, the toes the hand. However, this flap has gained notori- then being supplied by the medial plantar. ety owing to the healing problems it leaves be- These anatomical variations are broadly classi- hind at its donor site. fied under three types as shown in Figure 11.2. These variations do not play a role in raising the flap alone from the foot dorsum for free trans- Preparation fer. However, they have to be considered while The positioning of the patient may be varied ac- planning a free toe transfer, or raising a distally cording to the approach to the recipient area, based skin flap. from supine to lateral decubitus. A strip of The greater and the lesser saphenous veins rolled soft gauze-cloth is used to grasp the first course along the tibial and the fibular aspects of two toes in the manner shown in Figure 11.1 the dorsal foot, respectively, receiving tributar-

Extensor hallucis Artery palpated here Fig. 11.1 Positioning and plan- longus ning markings for the harvest of Lazy-S the dorsalis pedis flap. incision Long axis of flap

Extensor digitorum communis First metatarsal space

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG The Dorsalis Pedis Flaps 45

Fig. 11.2 Neurovascular ana- Communicating tomical basis of the dorsalis pe- Dorsalis pedis artery artery dis flap. Deep peroneal Deep peroneal nerve nerve

Anterior tibial artery

Superficial peroneal nerve

Communicating artery First dorsal Dorsalis pedis artery metatarsal artery Tiny superficial Type A (49%) artery

First plantar Type C (11%) digital artery

Type B (40%)

Dorsalis pedis artery (with comitant veins)

Transverse crural ligament (split) Extensor digitorum communis (retracted)

Cruciate crural ligament Extensor hallucis longus and brevis

First dorsal metatarsal Vascular pedicle artery

Communicating artery Deep fascia Superficial peroneal nerve raised with flap

Great saphenous vein

Fig. 11.3 Dissection of the dorsalis pedis flap.

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG 80 Part 3 Flaps of the Torso

Chapter 18 ing anteriorly located recipient sites, where pa- The Scapular Skin Flap tient repositioning will be necessary for scapu- lar flap harvest. Thus in such situations, it ap- pears logical, if possible, to choose other cuta- neous flaps from the anterior body surface or the extremities. The vertically oriented scapular flapcanalsoberaisedwiththepatientinalat- The scapular cutaneous flap was one of the ear- eral decubitus position. Preoperative Doppler liest free flaps to be clinically applied. The sub- examination of the triangular space will prove scapular artery branches off the third part of useful in locating the branches of the circum- the axillary artery, as we have already seen in flex scapular vessels. the description of the latissimus dorsi and ser- ratusanteriormuscleflaps.Itisoneoftheves- Neurovascular Anatomy sels with minimal, or practically no, variability of its consistent thoracodorsal and other arte- The harvestable cutaneous territory of the rial branches. Gilbert performed early cadaver transverse scapular flap ( ˚ 20 cm × 10 cm) is lo- dissections, isolating oblique skin territories cated between the angle and spine of the scap- based on the circumflex scapular arterial ula, whereas the obliquely oriented parascapu- system, and later applied the knowledge clini- lar flap (25 cm × 10 cm) is outlined, centered cally.1 Others followed suit and delineated the over the lateral border of the scapula. Both characteristics of the cutaneous branches of these territories are nourished by the two re- the circumflex scapular artery more clearly, so spective branches of the circumflex scapular ar- that the territories of its two largest terminal tery that emerges to the suprafascial surface branches were described.2 This led to the for- from the triangular space, bordered laterally by mation of the transverse and oblique scapular the long head of triceps and inferiorly by the te- cutaneous flaps, the latter also being called res major muscle belly and superiorly by the te- the “parascapular” flap. Further, other com- res minor muscle (Fig. 18.1). ponents, such as bone from the lateral border The triangular space should be included in of the scapula3 and deep fascia overlying the the either of the above-mentioned flap geome- back muscles,4 were added to the original cuta- tries. The circumflex scapular artery may be neous flap, making the scapular and parascap- traced to the subscapular artery, which in its ular flaps a more versatile option. Additionally, turn arises from the third part of the axillary ar- the scapular flaps offer the possibility of com- tery, lateral to the border of the subscapularis bining them with other muscular and bone muscle. As the circumflex scapular artery flaps, all based on the subscapular vascular curves around the lateral border of the scapula pool. to “surface” through the triangular space, it The scapular flap is a popular option among gives off tiny branches to the teres major, teres reconstructive surgeons, owing to its easy har- minor, and infraspinatus muscles, as well as to vest, reliable and large caliber microvascular the periosteal vessels of the scapular border, pedicle, as well as the availability of compound based on which a strip of bone may be raised neighboring tissue blocks that may be raised with the flap. After emerging from the triangu- with it. lar space, the circumflex scapular artery takes a short caudal course (ca. 2–3 cm), after which it bifurcatesintothetransverseandvertical Preparation branches. Venous drainage of the flaps is The scapular flap is advantageous for recipient through venae comitantes that accompany the defects located in the posterior parts of the arterial branches. Cutaneous nerves do not ac- body, since the patient is ideally placed in the company the vessels. Sensory innervation of prone position for the harvest of the scapular the flaps is achieved by segmental branches flap. This is also a disadvantage in reconstruct- that run from medial to lateral and is usually

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG The Scapular Skin Flap 81

Fig. 18.1 The vascular anatomi- cal basis of the scapular and parascapular flaps.

Circumflex scapular artery

Teres minor Triangular space Long head of triceps

Teres major

Fig. 18.2 Planning markings of Medial border of scapula the scapular and parascapular flaps.

Medial third of spine of scapula

Spine of scapula Triangular space Transverse branch and descending branch Scapular flap of curcumflex scapular artery

Scapular angle

Parascapular flap

Lateral border of scapular

aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG