These authors contributed equally.

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[51] Yang J, Finke JC, Yang J, Percy AJ, von Fritschen U, Borchers CH, Glocker MO. Early risk prognosis of free-flap transplant failure by quantitation of the macrophage colonystimulating factor in patient plasma using 2-dimensional liquid-chromatography multiple reaction monitoring-mass spectrometry. Medicine. 2016;**95**(39):e4808. DOI: 10.1097/ MD.0000000000004808

**Chapter 2**

**Provisional chapter**

**Experimental Rat Flap Models**

**Experimental Rat Flap Models**

DOI: 10.5772/intechopen.69923

Experimental flap surgery aims to increase our understanding of flap physiology and to test new surgical techniques to increase flap viability. Many experimental flap models have been described with the advancement of flap surgery and research. Most commonly used experimental flaps used in rats, including dorsal skin, flank, epigastric, oblique groin, pectoral, latissimus dorsi, rectus abdominis and fibula flaps, will be described.

Animal experiments performed on rats have played a crucial role in the development of flap surgery over the past years. There are many experimental rat flap surgery models. Main purposes of these models include understanding flap physiology, as a training tool for residents and to test new surgical techniques. The effect of pharmacological agents, delay procedures and different anastomosis techniques on flap survival can be studied on these models. The evaluation of the results of these experiments usually involves flap necrosis area calculation

based on calibrated photographs, histological evaluation and angiographic imaging.

Merdan Serin and Mehmet Bayramicli

Merdan Serin and Mehmet Bayramicli

http://dx.doi.org/10.5772/intechopen.69923

**Abstract**

**1. Introduction**

**2. Skin flaps**

**2.1. Dorsal skin flap**

Additional information is available at the end of the chapter

**Keywords:** experimental flaps, rat, flap physiology

Additional information is available at the end of the chapter

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

This flap was described by McFarlane et al. [1] in 1965. This is one of the most commonly used flaps for random flap studies. This flap is raised based on a caudal pedicle from the


## **Chapter 2**

**Provisional chapter**

## **Experimental Rat Flap Models**

**Experimental Rat Flap Models**

#### Merdan Serin and Mehmet Bayramicli Merdan Serin and Mehmet Bayramicli Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69923

#### **Abstract**

[51] Yang J, Finke JC, Yang J, Percy AJ, von Fritschen U, Borchers CH, Glocker MO. Early risk prognosis of free-flap transplant failure by quantitation of the macrophage colonystimulating factor in patient plasma using 2-dimensional liquid-chromatography multiple reaction monitoring-mass spectrometry. Medicine. 2016;**95**(39):e4808. DOI: 10.1097/

[52] Koy C, Heitner JC, Woisch R, Kreutzer M, Serrano-Fernandez P, Gohlke R, Reimer T, Glocker MO. Cryodetector mass spectrometry profiling of plasma samples for HELLP diagnosis: An exploratory study. Proteomics. 2005;**5**(12):3079-3087. DOI: 10.1002/pmic.

[53] Montgomery DC. In: Anderson W, editor. Design and Analysis of Experiments. United

States of America: John Wiley & Sons; 2001. pp. 65-75

MD.0000000000004808

200402098

24 Issues in Flap Surgery

Experimental flap surgery aims to increase our understanding of flap physiology and to test new surgical techniques to increase flap viability. Many experimental flap models have been described with the advancement of flap surgery and research. Most commonly used experimental flaps used in rats, including dorsal skin, flank, epigastric, oblique groin, pectoral, latissimus dorsi, rectus abdominis and fibula flaps, will be described.

DOI: 10.5772/intechopen.69923

**Keywords:** experimental flaps, rat, flap physiology

## **1. Introduction**

Animal experiments performed on rats have played a crucial role in the development of flap surgery over the past years. There are many experimental rat flap surgery models. Main purposes of these models include understanding flap physiology, as a training tool for residents and to test new surgical techniques. The effect of pharmacological agents, delay procedures and different anastomosis techniques on flap survival can be studied on these models. The evaluation of the results of these experiments usually involves flap necrosis area calculation based on calibrated photographs, histological evaluation and angiographic imaging.

#### **2. Skin flaps**

#### **2.1. Dorsal skin flap**

This flap was described by McFarlane et al. [1] in 1965. This is one of the most commonly used flaps for random flap studies. This flap is raised based on a caudal pedicle from the

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

dorsal rat skin. This flap was originally described as being 10×4 cm in dimension or as having a length‐to‐width ratio of 2,5/1. Later, this original description was modified to 9×3 and 10×3 dimensions, a modification that proved to demonstrate more consistent results [2]. Various flap viability ratios have been reported depending on dimension. The author believes that 9×3 cm flap provides the most consistent flap viability ratio (**Figure 1**).

Templates are commonly used to mark flap dimension on the skin before the flap elevation. It is important to note that these templates might result in inaccuracies due to the curvature of animal's body.

#### **2.2. Flank flap**

Syed et al. [3] described this flap as the skin area supplied by the iliac branch of iliolumbar artery. Its borders were from the back of 12th rib to the proximal part of the tail medially and the axillary line laterally. It was suggested as a consistent model for experimental flap research (**Figure 2**).

**Figure 2.** Flank flap. (a) Flank flap and its cranial extension; (b) skin marking and (c) flap elevation.

Experimental Rat Flap Models

27

http://dx.doi.org/10.5772/intechopen.69923

**Figure 3.** Oblique rat groin flap.

**Figure 1.** Dorsal skin flap. (A) Flap elevation and (B) angiographic image.

**Figure 2.** Flank flap. (a) Flank flap and its cranial extension; (b) skin marking and (c) flap elevation.

**Figure 3.** Oblique rat groin flap.

dorsal rat skin. This flap was originally described as being 10×4 cm in dimension or as having a length‐to‐width ratio of 2,5/1. Later, this original description was modified to 9×3 and 10×3 dimensions, a modification that proved to demonstrate more consistent results [2]. Various flap viability ratios have been reported depending on dimension. The author believes that 9×3

Templates are commonly used to mark flap dimension on the skin before the flap elevation. It is important to note that these templates might result in inaccuracies due to the curvature

Syed et al. [3] described this flap as the skin area supplied by the iliac branch of iliolumbar artery. Its borders were from the back of 12th rib to the proximal part of the tail medially and the axillary line laterally. It was suggested as a consistent model for experimental flap

cm flap provides the most consistent flap viability ratio (**Figure 1**).

**Figure 1.** Dorsal skin flap. (A) Flap elevation and (B) angiographic image.

of animal's body.

research (**Figure 2**).

**2.2. Flank flap**

26 Issues in Flap Surgery

be variable by some studies [5]. The median vessels collateralize with the branches of internal mammary vessels. The lateral branches collateralize with lateral thoracic artery (**Figure 3**).

Experimental Rat Flap Models

29

http://dx.doi.org/10.5772/intechopen.69923

Nishikawa et al. [6] described this flap in 1991. The purpose of this flap is to prevent flap neovascularization from its underlying bed, which could interfere with the results in certain type of studies. This flap is designed over adipose fat pads which act as a barrier for new vessel

Various muscle flaps have been identified for research in rats. Other than those included in this section, adductor muscle flap [7], gracilis flap [8], gluteus maximus [9], gastrocnemius

This flap was first defined by Zhang et al. [14]. It consists of two parts, superficial and profundus. These parts are supplied by separate neural and vascular systems. The profundus

[10, 11], quadriceps femoris flap [12] and cremaster flaps have been described [13].

**2.4. Oblique rat groin flap**

formation (**Figure 4**).

**3. Muscle flaps**

**3.1. Pectoral flap**

**Figure 5.** Pectoral flap.

**Figure 4.** Epigastric flap. (A) Flap elevation and (B) angiographic image.

#### **2.3. Epigastric flap**

Finseth and Cutting [4] first described this flap back in 1978 as a neurovascular island flap. This flap is commonly used for axial flap studies and microvascular anastomosis studies. This flap is also commonly used in conjunction with angiographic studies. The flap is designed on superficial epigastric vessels which originate from the femoral artery. The superficial epigastric trunk divides into lateral and medial branches. The lateral branches have been reported to be variable by some studies [5]. The median vessels collateralize with the branches of internal mammary vessels. The lateral branches collateralize with lateral thoracic artery (**Figure 3**).

#### **2.4. Oblique rat groin flap**

Nishikawa et al. [6] described this flap in 1991. The purpose of this flap is to prevent flap neovascularization from its underlying bed, which could interfere with the results in certain type of studies. This flap is designed over adipose fat pads which act as a barrier for new vessel formation (**Figure 4**).

## **3. Muscle flaps**

Various muscle flaps have been identified for research in rats. Other than those included in this section, adductor muscle flap [7], gracilis flap [8], gluteus maximus [9], gastrocnemius [10, 11], quadriceps femoris flap [12] and cremaster flaps have been described [13].

#### **3.1. Pectoral flap**

This flap was first defined by Zhang et al. [14]. It consists of two parts, superficial and profundus. These parts are supplied by separate neural and vascular systems. The profundus

**Figure 5.** Pectoral flap.

**2.3. Epigastric flap**

28 Issues in Flap Surgery

**Figure 4.** Epigastric flap. (A) Flap elevation and (B) angiographic image.

Finseth and Cutting [4] first described this flap back in 1978 as a neurovascular island flap. This flap is commonly used for axial flap studies and microvascular anastomosis studies. This flap is also commonly used in conjunction with angiographic studies. The flap is designed on superficial epigastric vessels which originate from the femoral artery. The superficial epigastric trunk divides into lateral and medial branches. The lateral branches have been reported to part is in association with axillary vessels and is more commonly used for experimental studies (**Figure 5**).

#### **3.2. Latissimus dorsi flap**

Tilgner et al. [15] described the latissimus dorsi flap in rats. Rat latissimus dorsi muscle has a similar vascular anatomy when compared to humans. It is supplied by the thoracodorsal pedicle and five to six intercostal perforators. It is a suitable model for vascular delay studies and has been reported to have a consistent necrosis pattern [16] (**Figure 6**).

#### **3.3. Rectus abdominis flap**

This flap was described by Zhang et al. [17]. Myocutaneous flaps can be raised with this model. The skin island is designed over the anterior sheath of the rectus muscle. Inferior edge of the flap is planned 2.5 cm above the symphysis. The muscle is supplied by superior and inferior epigastric arteries and veins. Microvascular flap transplantation is possible with this model with average vessel diameter of 0.5 mm (**Figure 7**).

**4. Fibula flap**

**Figure 7.** Rectus abdominis flap. (a) Flap design and (b) flap elevation.

Fibula flap is one of the most common flaps used in mandibular reconstruction in clinical practice. Chen et al. [18] described the rat fibula bone flap as a free vascularized bone flap model. The flap is usually raised with a medial incision as opposed to humans in which a lateral approach is used. Flexor halluces muscle is usually included in the flap. Peroneal vessels that supply the flap originate from the popliteal and anterior tibial artery vessels (**Figure 8**).

Experimental Rat Flap Models

31

http://dx.doi.org/10.5772/intechopen.69923

**Figure 6.** Latissimus dorsi muscle flap.

**Figure 7.** Rectus abdominis flap. (a) Flap design and (b) flap elevation.

### **4. Fibula flap**

**Figure 6.** Latissimus dorsi muscle flap.

studies (**Figure 5**).

30 Issues in Flap Surgery

**3.2. Latissimus dorsi flap**

**3.3. Rectus abdominis flap**

part is in association with axillary vessels and is more commonly used for experimental

Tilgner et al. [15] described the latissimus dorsi flap in rats. Rat latissimus dorsi muscle has a similar vascular anatomy when compared to humans. It is supplied by the thoracodorsal pedicle and five to six intercostal perforators. It is a suitable model for vascular delay studies

This flap was described by Zhang et al. [17]. Myocutaneous flaps can be raised with this model. The skin island is designed over the anterior sheath of the rectus muscle. Inferior edge of the flap is planned 2.5 cm above the symphysis. The muscle is supplied by superior and inferior epigastric arteries and veins. Microvascular flap transplantation is possible with this

and has been reported to have a consistent necrosis pattern [16] (**Figure 6**).

model with average vessel diameter of 0.5 mm (**Figure 7**).

Fibula flap is one of the most common flaps used in mandibular reconstruction in clinical practice. Chen et al. [18] described the rat fibula bone flap as a free vascularized bone flap model. The flap is usually raised with a medial incision as opposed to humans in which a lateral approach is used. Flexor halluces muscle is usually included in the flap. Peroneal vessels that supply the flap originate from the popliteal and anterior tibial artery vessels (**Figure 8**).

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1553‐1556

1992;**45**(1):23‐25

Surgery. 1991;**44**(4):295‐298

Microsurgery. 1991;**12**(4):262‐267

Microsurgery. 1993;**14**(2):120‐124

fur Versuchstierkunde. 1988;**31**(5):225‐232

1997;**13**(4):251‐255

**15**(12):853‐856

[1] McFarlane RM, Deyoung G, Henry RA. The design of a pedicle flap in the rat to study necrosis and its prevention. Plastic and Reconstructive Surgery. 1965;**35**:177‐182

Experimental Rat Flap Models

33

http://dx.doi.org/10.5772/intechopen.69923

[2] Kelly CP, et al. *A* new design of a dorsal flap in the rat to study skin necrosis and its prevention. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2010;**63**(9):

[3] Syed SA, et al. A new experimental model: The vascular pedicle cutaneous flap over the dorsal aspect (flank and hip) of the rat. British Journal of Plastic Surgery.

[4] Finseth F, Cutting C. An experimental neurovascular island skin flap for the study of the

[5] Petry JJ, Wortham KA. The anatomy of the epigastric flap in the experimental rat. Plastic

[6] Nishikawa H, Manek S, Green CJ. The oblique rat groin flap. British Journal of Plastic

[7] Koudsi B, Khouri RK. Thigh adductor flap: An experimental model for free flap transfer

[8] Yim KK, et al. Microvascular transfer of anterior and posterior gracilis muscles in rats.

[9] Battal MN, et al. A new experimental model of a true myocutaneous flap in the rat: The gluteus maximus myocutaneous flap. The Journal of Reconstructive Microsurgery.

[10] Black KS, et al. Two new composite tissue allograft models in rats to study neuromuscular functional return. Transplantation Proceedings. 1987;**19**(1 Pt 2):1118‐1119

[11] Tonken HP, et al. Microvascular transplant of the gastrocnemius muscle in rats.

[12] Dogan T, et al. Quadriceps femoris muscle flap: Largest muscle flap model in the rat. The

[13] Bayramicli M. Experimental microsurgery (in Turkish). Istanbul, Argos iletisim; 2005

[14] Zhang F, et al. Pectoralis major muscle free flap in rat model. Microsurgery. 1994;

[15] Tilgner A, Herrberger U, Oswald P. Myocutaneous flap models in the rat. Anatomy, histology and operative technique of the latissimus dorsi myocutaneous flap. Zeitschrift

Journal of Reconstructive Microsurgery. 1999;**15**(6):433‐437

delay phenomenon. Plastic and Reconstructive Surgery. 1978;**61**(3):412‐420

and Reconstructive Surgery. 1984;**74**(3):410‐413

in the rat. Microsurgery. 1992;**13**(6):338‐339

**Figure 8.** Fibula flap.

### **5. Conclusion**

Rat models have been proven to be a very valuable tool for flap research. In spite of the developments in the field of cell cultures, in vitro studies are usually not as valuable as animal studies in this field. Although other animal models have been proposed, rats are by far the most commonly used species for these purposes. They are easier to maintain and more readily available. Although much more valuable than in vitro studies, rat experiments do also have their limitations. The application of the results of rat model experiments on human subjects may not always be possible. Differences in the life span and the wound healing processes between humans and rats should be considered.

## **Author details**


## **References**

**Figure 8.** Fibula flap.

32 Issues in Flap Surgery

**5. Conclusion**

**Author details**

Merdan Serin<sup>1</sup>

between humans and rats should be considered.

\* and Mehmet Bayramicli2

\*Address all correspondence to: merdanserin@gmail.com

1 Plastic Surgery Clinic, Istanbul Training and Research Hospital, Turkey 2 Plastic Surgery Department, Marmara University Medical School, Turkey

Rat models have been proven to be a very valuable tool for flap research. In spite of the developments in the field of cell cultures, in vitro studies are usually not as valuable as animal studies in this field. Although other animal models have been proposed, rats are by far the most commonly used species for these purposes. They are easier to maintain and more readily available. Although much more valuable than in vitro studies, rat experiments do also have their limitations. The application of the results of rat model experiments on human subjects may not always be possible. Differences in the life span and the wound healing processes


[16] Wan C, et al. Reducing the vascular delay period in latissimus dorsi muscle flaps for use in cardiomyoplasty. Plastic and Reconstructive Surgery. 2002;**109**(5):1630‐1637

**Section 2**

**Perforator Flaps**


**Section 2**

## **Perforator Flaps**

[16] Wan C, et al. Reducing the vascular delay period in latissimus dorsi muscle flaps for use in cardiomyoplasty. Plastic and Reconstructive Surgery. 2002;**109**(5):1630‐1637

[17] Zhang F, et al. Microvascular transfer of the rectus abdominis muscle and myocutane-

[18] Chen SG, et al. Free vascularized fibular bone flap in the rat. Microsurgery. 2000;**20**(1):1‐5

ous flap in rats. Microsurgery. 1993;**14**(6):420‐423

34 Issues in Flap Surgery

**Chapter 3**

Provisional chapter

**Perforator Flaps: Principles and Techniques**

Evolution of flaps has continued after the introduction of fasciocutaneous and musculocutaneous flaps. Perforator flaps have evolved, and they have provided many new flaps with new pedicles all over the body presenting important advantages. Better understanding of vascular anatomy and pattern of skin circulation has become possible by numerous cadaveric studies. As a result, widespread use of perforator flaps, either pedicled or free, has become possible. Perforator flaps have provided freedom of flap design with over 350 perforators all over the body, reliability, and reduced donor site morbidity. However, success begins with planning and continues with operative procedure. Here, in this relatively new field of reconstructive surgery, the following are discussed: the correct planning of perforator flaps, microanatomy of perforators, and what to do during the operation based on previous reports. Lastly, some brief informa-

DOI: 10.5772/intechopen.71270

Two main algorithms are applied for reconstruction of tissue defects: the reconstructive ladder and the reconstructive elevator systems. The philosophy of the reconstructive ladder system is to use the simplest possible reconstructive option to reconstruct the defect. According to the "reconstructive ladder" concept primary closure, skin graft, local flap, and lastly distant flap options are evaluated and used for reconstructing a defect. The simplest option to reconstruct a defect in this order is used. However, according to the reconstructive elevator system, patients' needs determine the reconstructive option to be used. In order to achieve a better functional and esthetic outcome, to improve donor site appearance, and to reduce its morbidity, many surgeons have used free flap transfer as the first choice over the past two decades [1]. Therefore, the reconstructive elevator system is favored since it is more functional and reduces

> © The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

Perforator Flaps: Principles and Techniques

tion and examples of perforator-based workhorse flaps are given.

donor site morbidity especially after the introduction of perforator-free flaps.

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.71270

Keywords: perforator, flap

Goktekin Tenekeci

Goktekin Tenekeci

Abstract

1. Introduction

#### **Perforator Flaps: Principles and Techniques** Perforator Flaps: Principles and Techniques

DOI: 10.5772/intechopen.71270

#### Goktekin Tenekeci Goktekin Tenekeci

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.71270

#### Abstract

Evolution of flaps has continued after the introduction of fasciocutaneous and musculocutaneous flaps. Perforator flaps have evolved, and they have provided many new flaps with new pedicles all over the body presenting important advantages. Better understanding of vascular anatomy and pattern of skin circulation has become possible by numerous cadaveric studies. As a result, widespread use of perforator flaps, either pedicled or free, has become possible. Perforator flaps have provided freedom of flap design with over 350 perforators all over the body, reliability, and reduced donor site morbidity. However, success begins with planning and continues with operative procedure. Here, in this relatively new field of reconstructive surgery, the following are discussed: the correct planning of perforator flaps, microanatomy of perforators, and what to do during the operation based on previous reports. Lastly, some brief information and examples of perforator-based workhorse flaps are given.

Keywords: perforator, flap

#### 1. Introduction

Two main algorithms are applied for reconstruction of tissue defects: the reconstructive ladder and the reconstructive elevator systems. The philosophy of the reconstructive ladder system is to use the simplest possible reconstructive option to reconstruct the defect. According to the "reconstructive ladder" concept primary closure, skin graft, local flap, and lastly distant flap options are evaluated and used for reconstructing a defect. The simplest option to reconstruct a defect in this order is used. However, according to the reconstructive elevator system, patients' needs determine the reconstructive option to be used. In order to achieve a better functional and esthetic outcome, to improve donor site appearance, and to reduce its morbidity, many surgeons have used free flap transfer as the first choice over the past two decades [1]. Therefore, the reconstructive elevator system is favored since it is more functional and reduces donor site morbidity especially after the introduction of perforator-free flaps.

© The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

Modern technology has enabled us to produce finer microsurgical and surgical instruments; improvement in optics has produced improved operative microscopes [2]. Along with this, an increasing number of centers all over the world give microsurgical training opportunities, enabling more and more reconstructive surgeons to perform reconstructive microsurgical operations [2]. As a result of this, there is a general shift in favor of the reconstructive elevator versus the reconstructive ladder system all over the world. This means, more complicated operations that consider patients' future functionality and donor site morbidity are performed. Donor site morbidity does not always refer to donor site appearance but, more importantly, it refers to sacrification of important vessels, underlying muscle, etc. After the introduction of perforator flaps to the field of reconstructive surgery, harvest and use of perforator flaps as a new option has become popular because of its numerous advantages compared to more traditional flaps. These advantages include the reliability of perforator flaps, decrease in donor site morbidity when compared to nonperforator options, and the possibility to use each perforator flap as a local pedicled flap or as a free flap. As a result of this, perforator flaps have gained legitimate popularity all over the world. Radial forearm free flaps or latissimus dorsi free flaps can be given as examples for less frequently used reconstructive options after popularization of perforator based free flaps.

subcutaneous tissue, (4) indirect perimysial perforators that traveled within the perimysium between the muscle fibers before piercing the deep fascia, (5) indirect septal perforators that traveled between the intermuscular septum, and pierced the deep fascia and supplied the subcutaneous tissue and skin" [4]. After the "2001 consensus" in classification of perforators, Blondeel et al. reported on roundtable talks on flap terminology at the "Sixth International Course on Perforator Flaps" that was held in Taipei from October 23 until October 26, 2002. During this meeting, they tried to simplify perforator classification and reported this simplified consensus in 2003 [5]. According to this, flaps are classified under three types: "(1) indirect muscle perforators or myocutaneous perforators that traverse through muscle and perforate the outer layer of deep fascia to supply overlying skin, (2) indirect septal perforators or septocutaneous perforators that traverse septum and supply overlying skin after perforating the outer layer of deep fascia, and (3) direct perforators that perforate deep fascia only" [5]. If we look from a practical point of view, it is important to know what kind of dissection is to be made: an intramuscular dissection or a dissection for a septocutaneous perforator. Dissection of a septocutaneous perforator requires a tedious dissection but is easier when compared with the dissection of a musculocutaneous perforator. However, dissection of a musculocutaneous perforator requires experience and much care. From this point, it is important to distinguish between two. On the other hand, we believe it is also very important to know the subtypes of

Perforator Flaps: Principles and Techniques http://dx.doi.org/10.5772/intechopen.71270 39

Another issue concerns the nomenclature of perforator flaps. In Gent, they tried to reach a consensus on the nomenclature of new perforator flaps. Until this time, same perforator flaps are being reported in articles or in scientific meetings under different names, and this causes confusion among readers or audients. For this reason, the following statement is accepted:

"A perforator flap should be named after the nutrient artery or vessels and not after the underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel,

Perforasome theory has been raised by Saint-Cyr et al. as a result of a cadaveric study [6]. This theory defines the perforators supplying skin, the microanatomy of perforating vessels, perfusion characteristics, and the relationship among neighboring perforators all around the body. This theory also gives us clues in correct designing of perforator flaps. The importance of direct and indirect linking vessels has also been shown in this study. Similarly, Taylor and Palmer have defined the angiosome concept; they have demonstrated that the whole body is divided into composite blocks of tissue supplied by source vessels and each neighboring tissue block and source vessels communicate with each other by means of anastomotic vessels [7, 8]. Both are quite important studies that try to find answers to similar questions and are milestones in

The term "perforasome" has been used by Saint-Cyr et al. to describe the vascular arterial territory supplied by an individual perforator [6]. Over 350 perforators exist throughout the

the name of each flap should be based on its anatomical region or muscle" [4].

musculocutaneous perforators for academic purposes.

3. Perforasome theory and perforator anatomy

understanding the vascularization of skin.

In the past, before perforator flaps gained popularity, random pattern flaps with no described or known vascular supply had been frequently used to reconstruct defects. Ponten has described various lengths to width ratios for random pattern flaps in different locations of the body. However, as a result of a better understanding of blood supply to skin, a new era has begun in the field of reconstructive surgery. This has led to the development and use of fasciocutaneous and musculocutaneous flaps supported by the "angiosome theory."

Evolution of flaps has continued contrary to the belief that there is very little left to discover about flap design [2]. In 1989, Koshima and Soeda reported on a skin flap supplied by a perforating vessel originating from the deep inferior epigastric artery and perforating the deep fascia [3]. This was the first perforator flap reported and was the beginning of another era in the field of reconstructive microsurgery. Following this report, an increasing number of papers have been reported sharing experience in reconstructing defects all over the body either by using local perforator flaps or by using perforator-free flaps.

#### 2. Description, classification, and nomenclature of perforator flaps

In 2003, Blondeel et al. reported a paper representing the consensus of opinions of a group of pioneers in the field of perforator flap surgery that were reached during the Fifth International Course on Perforator Flaps in Gent in September 2001 [4]. They tried to classify perforators according to perforators' anatomy, the route they passed through until they reached the subcutaneous tissue by piercing the deep fascia. According to this paper, five types of perforators were defined: "(1) direct perforators: these perforated the deep fascia and supplied the subcutaneous tissue and skin, (2) indirect muscle perforators that gave muscular branches but predominantly supplied skin and subcutaneous tissue, (3) indirect muscle perforators that gave branches to muscle, predominantly supplied muscle but gave secondary branches to subcutaneous tissue, (4) indirect perimysial perforators that traveled within the perimysium between the muscle fibers before piercing the deep fascia, (5) indirect septal perforators that traveled between the intermuscular septum, and pierced the deep fascia and supplied the subcutaneous tissue and skin" [4]. After the "2001 consensus" in classification of perforators, Blondeel et al. reported on roundtable talks on flap terminology at the "Sixth International Course on Perforator Flaps" that was held in Taipei from October 23 until October 26, 2002. During this meeting, they tried to simplify perforator classification and reported this simplified consensus in 2003 [5]. According to this, flaps are classified under three types: "(1) indirect muscle perforators or myocutaneous perforators that traverse through muscle and perforate the outer layer of deep fascia to supply overlying skin, (2) indirect septal perforators or septocutaneous perforators that traverse septum and supply overlying skin after perforating the outer layer of deep fascia, and (3) direct perforators that perforate deep fascia only" [5]. If we look from a practical point of view, it is important to know what kind of dissection is to be made: an intramuscular dissection or a dissection for a septocutaneous perforator. Dissection of a septocutaneous perforator requires a tedious dissection but is easier when compared with the dissection of a musculocutaneous perforator. However, dissection of a musculocutaneous perforator requires experience and much care. From this point, it is important to distinguish between two. On the other hand, we believe it is also very important to know the subtypes of musculocutaneous perforators for academic purposes.

Another issue concerns the nomenclature of perforator flaps. In Gent, they tried to reach a consensus on the nomenclature of new perforator flaps. Until this time, same perforator flaps are being reported in articles or in scientific meetings under different names, and this causes confusion among readers or audients. For this reason, the following statement is accepted:

"A perforator flap should be named after the nutrient artery or vessels and not after the underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap should be based on its anatomical region or muscle" [4].

## 3. Perforasome theory and perforator anatomy

Modern technology has enabled us to produce finer microsurgical and surgical instruments; improvement in optics has produced improved operative microscopes [2]. Along with this, an increasing number of centers all over the world give microsurgical training opportunities, enabling more and more reconstructive surgeons to perform reconstructive microsurgical operations [2]. As a result of this, there is a general shift in favor of the reconstructive elevator versus the reconstructive ladder system all over the world. This means, more complicated operations that consider patients' future functionality and donor site morbidity are performed. Donor site morbidity does not always refer to donor site appearance but, more importantly, it refers to sacrification of important vessels, underlying muscle, etc. After the introduction of perforator flaps to the field of reconstructive surgery, harvest and use of perforator flaps as a new option has become popular because of its numerous advantages compared to more traditional flaps. These advantages include the reliability of perforator flaps, decrease in donor site morbidity when compared to nonperforator options, and the possibility to use each perforator flap as a local pedicled flap or as a free flap. As a result of this, perforator flaps have gained legitimate popularity all over the world. Radial forearm free flaps or latissimus dorsi free flaps can be given as examples for less frequently used reconstructive options after

In the past, before perforator flaps gained popularity, random pattern flaps with no described or known vascular supply had been frequently used to reconstruct defects. Ponten has described various lengths to width ratios for random pattern flaps in different locations of the body. However, as a result of a better understanding of blood supply to skin, a new era has begun in the field of reconstructive surgery. This has led to the development and use of

Evolution of flaps has continued contrary to the belief that there is very little left to discover about flap design [2]. In 1989, Koshima and Soeda reported on a skin flap supplied by a perforating vessel originating from the deep inferior epigastric artery and perforating the deep fascia [3]. This was the first perforator flap reported and was the beginning of another era in the field of reconstructive microsurgery. Following this report, an increasing number of papers have been reported sharing experience in reconstructing defects all over the body either by

fasciocutaneous and musculocutaneous flaps supported by the "angiosome theory."

2. Description, classification, and nomenclature of perforator flaps

In 2003, Blondeel et al. reported a paper representing the consensus of opinions of a group of pioneers in the field of perforator flap surgery that were reached during the Fifth International Course on Perforator Flaps in Gent in September 2001 [4]. They tried to classify perforators according to perforators' anatomy, the route they passed through until they reached the subcutaneous tissue by piercing the deep fascia. According to this paper, five types of perforators were defined: "(1) direct perforators: these perforated the deep fascia and supplied the subcutaneous tissue and skin, (2) indirect muscle perforators that gave muscular branches but predominantly supplied skin and subcutaneous tissue, (3) indirect muscle perforators that gave branches to muscle, predominantly supplied muscle but gave secondary branches to

popularization of perforator based free flaps.

38 Issues in Flap Surgery

using local perforator flaps or by using perforator-free flaps.

Perforasome theory has been raised by Saint-Cyr et al. as a result of a cadaveric study [6]. This theory defines the perforators supplying skin, the microanatomy of perforating vessels, perfusion characteristics, and the relationship among neighboring perforators all around the body. This theory also gives us clues in correct designing of perforator flaps. The importance of direct and indirect linking vessels has also been shown in this study. Similarly, Taylor and Palmer have defined the angiosome concept; they have demonstrated that the whole body is divided into composite blocks of tissue supplied by source vessels and each neighboring tissue block and source vessels communicate with each other by means of anastomotic vessels [7, 8]. Both are quite important studies that try to find answers to similar questions and are milestones in understanding the vascularization of skin.

The term "perforasome" has been used by Saint-Cyr et al. to describe the vascular arterial territory supplied by an individual perforator [6]. Over 350 perforators exist throughout the body [6]. In order to correctly plan perforator flaps, we have to know the territory of each perforator, the direction along which the perforator branches travel, and the anastomoses of each perforator with its neighboring perforators. For this purpose, Saint-Cyr et al. have published a study performed on fresh human cadavers; this study is a milestone in understanding the microanatomy of perforators and provides valuable information on how to plan a perforator flap [6]. "It has been reported that each perforasome is linked to the adjacent perforasomes by "direct and indirect linking vessels" [6]. "Indirect linking vessels are effective in capturing adjacent perforasome by means of recurrent blood flow through subdermal plexus" [6]". Indirect linking vessels and the choke vessels of "angiosome theory" reported by Taylor et al. are the same [9]. According to Taylor et al., every angiosome is usually connected to other angiosomes by reduced caliber vessels named "choke vessels." "Direct linking vessels are larger vessels that link adjacent perforators resulting in capturing of neighboring perforasomes based on single perforator [6]." The synonym of direct linking vessels in perforasome theory is "true anastomosis." The vessel calibers of true anastomosis do not change and are especially found in places where vessels are accompanied by cutaneous nerves, in muscles, nerve trunks, or after flaps that have been delayed [10–15]. Therefore, knowledge about the direction along which direct and indirect linking vessels lie is very important to correctly plan perforator flaps because inclusion of direct and indirect perforators secures perforator flaps. Making sure to include direct and indirect linking vessels into the flap enables reconstructive microsurgeons to harvest a larger flap by incorporating neighboring perforasomes into the flap. "Flaps raised from the extremities should be designed parallel to the extremities since the direction of the linking vessels follow the axiality of the involved limb [6]." "However, flap design should be made perpendicular to the midline for flaps that will be harvested from the trunk since the axiality of the trunk follows the axiality of the muscle fibers of posterior trunk and chest, and this is perpendicular to the midline [6]." That is why long axis of anterolateral thigh flaps, posterior tibial artery perforator flaps, medial sural artery perforator flaps, and many other flaps raised on the extremities are planned parallel to the long axis of the extremity, whereas long axis of dorsal intercostal artery perforator flaps, lateral intercostal artery perforator flaps, thoracodorsal artery perforator flaps, and other perforator flaps harvested from trunk and chest wall are planned perpendicular to the midline and have a horizontal oblique direction.

are to be incorporated instead of perforasomes of thoracodorsal artery perforators, the vascular filling pressure of that flap may be less in the perforasomes of other source arteries. This is

Perforator Flaps: Principles and Techniques http://dx.doi.org/10.5772/intechopen.71270 41

"Perforators found close to an articulation have a flow distribution away from this articulation [6]." "However, perforators found at a midpoint between two articulations or found at the midpoint of trunk have multidirectional flow distribution [6]." Planning of posterior tibial artery perforator flaps are good examples of perforators found close to articulations. Distal perforators of posterior tibial artery arise 9–12 cm proximal to the medial malleolus of tibia at the ankle joint [16]. Skin island of posterior tibial artery perforator flaps supplied by distal perforators of posterior tibial artery must be planned toward the proximal part of cruris (away from the articulation). On the other hand, perforators of anterolateral thigh flaps arise around the midpoint of the line drawn between anterior superior iliac spine and the superolateral part of patella. That is why, anterolateral thigh flaps may be planned proximal to and distal to the

Advantages of perforator flaps include the potential to harvest flaps based on any reliable perforator throughout the body that they do not sacrifice major vessels since they are supplied by the branches of these vessels and that they do not necessarily sacrifice muscle if muscle is not needed for reconstruction. In radial forearm flaps, the radial artery is incorporated. Therefore, after the radial forearm flap has been harvested, the whole hand is supplied by ulnar artery only. Sacrification of an artery such as the radial artery is believed to produce considerable morbidity. On the other hand, when perforator flaps are used, the source artery can be preserved. In case of a musculocutaneous perforator, intramuscular dissection may become challenging. However, if intramuscular pedicle dissection is performed, sacrification of muscle can be avoided. For instance, when a thoracodorsal artery perforator flap is being harvested based on a musculocutaneous perforator, intramuscular dissection must be performed in order to preserve underlying muscle namely latissimus dorsi muscle in this example. The same is true for anterolateral thigh flaps whenever the flap is supplied by a musculocutaneous perforator. However, if needed, such as in the obliteration of a dead space, a muscle cuff can be

Tedious dissection is very important in perforator flap harvest. It must be performed under loupe magnification and requires special expertise and experience. Especially, intramuscular perforator dissection can be challenging. That is why, perforator flap harvesting requires a learning curve. For beginners of perforator flap dissection, a detailed anatomy of the perforator flap being harvested must be known and training in one of the experienced centers on perfo-

There is a conflict about the skeletonization of the perforators supplying perforator flaps. Some groups claim that skeletonization of perforators supplying local perforator flaps is not needed, whereas some others, including us, believe that without skeletonization of perforators, flap

incorporated into the harvested flap based on a separate perforator.

rator flap dissection is strongly recommended.

very important in flap planning.

perforator due to the multidirectional flow.

4. Harvesting a perforator flap

"Vascular filling and density is highest in the perforasomes of perforators from the same source artery, but lower in the neighboring perforasomes of other perforators branching from different source arteries [6]." This is known as the "preferential filling" of perforasomes; preferential filling occurs in the perforators branching from the same source artery initially, but later occurs in the perforators branching from neighboring source arteries. Therefore, it may be concluded that a perforator flap carrying neighboring perforasomes arising from different source arteries harvested on a single perforator will have less perfusion than a flap harvested on single perforator carrying two adjacent perforasomes arising from the same source artery. For example, when a large thoracodorsal artery perforator flap is planned, it must be planned over the latissimus dorsi muscle to incorporate neighboring perforasomes of other perforators arising from the thoracodorsal artery. It must be remembered that if perforasomes of dorsal intercostal artery perforators or circumflex scapular artery perforators are to be incorporated instead of perforasomes of thoracodorsal artery perforators, the vascular filling pressure of that flap may be less in the perforasomes of other source arteries. This is very important in flap planning.

"Perforators found close to an articulation have a flow distribution away from this articulation [6]." "However, perforators found at a midpoint between two articulations or found at the midpoint of trunk have multidirectional flow distribution [6]." Planning of posterior tibial artery perforator flaps are good examples of perforators found close to articulations. Distal perforators of posterior tibial artery arise 9–12 cm proximal to the medial malleolus of tibia at the ankle joint [16]. Skin island of posterior tibial artery perforator flaps supplied by distal perforators of posterior tibial artery must be planned toward the proximal part of cruris (away from the articulation). On the other hand, perforators of anterolateral thigh flaps arise around the midpoint of the line drawn between anterior superior iliac spine and the superolateral part of patella. That is why, anterolateral thigh flaps may be planned proximal to and distal to the perforator due to the multidirectional flow.

## 4. Harvesting a perforator flap

body [6]. In order to correctly plan perforator flaps, we have to know the territory of each perforator, the direction along which the perforator branches travel, and the anastomoses of each perforator with its neighboring perforators. For this purpose, Saint-Cyr et al. have published a study performed on fresh human cadavers; this study is a milestone in understanding the microanatomy of perforators and provides valuable information on how to plan a perforator flap [6]. "It has been reported that each perforasome is linked to the adjacent perforasomes by "direct and indirect linking vessels" [6]. "Indirect linking vessels are effective in capturing adjacent perforasome by means of recurrent blood flow through subdermal plexus" [6]". Indirect linking vessels and the choke vessels of "angiosome theory" reported by Taylor et al. are the same [9]. According to Taylor et al., every angiosome is usually connected to other angiosomes by reduced caliber vessels named "choke vessels." "Direct linking vessels are larger vessels that link adjacent perforators resulting in capturing of neighboring perforasomes based on single perforator [6]." The synonym of direct linking vessels in perforasome theory is "true anastomosis." The vessel calibers of true anastomosis do not change and are especially found in places where vessels are accompanied by cutaneous nerves, in muscles, nerve trunks, or after flaps that have been delayed [10–15]. Therefore, knowledge about the direction along which direct and indirect linking vessels lie is very important to correctly plan perforator flaps because inclusion of direct and indirect perforators secures perforator flaps. Making sure to include direct and indirect linking vessels into the flap enables reconstructive microsurgeons to harvest a larger flap by incorporating neighboring perforasomes into the flap. "Flaps raised from the extremities should be designed parallel to the extremities since the direction of the linking vessels follow the axiality of the involved limb [6]." "However, flap design should be made perpendicular to the midline for flaps that will be harvested from the trunk since the axiality of the trunk follows the axiality of the muscle fibers of posterior trunk and chest, and this is perpendicular to the midline [6]." That is why long axis of anterolateral thigh flaps, posterior tibial artery perforator flaps, medial sural artery perforator flaps, and many other flaps raised on the extremities are planned parallel to the long axis of the extremity, whereas long axis of dorsal intercostal artery perforator flaps, lateral intercostal artery perforator flaps, thoracodorsal artery perforator flaps, and other perforator flaps harvested from trunk and chest wall are planned perpendicular to the midline and have a

"Vascular filling and density is highest in the perforasomes of perforators from the same source artery, but lower in the neighboring perforasomes of other perforators branching from different source arteries [6]." This is known as the "preferential filling" of perforasomes; preferential filling occurs in the perforators branching from the same source artery initially, but later occurs in the perforators branching from neighboring source arteries. Therefore, it may be concluded that a perforator flap carrying neighboring perforasomes arising from different source arteries harvested on a single perforator will have less perfusion than a flap harvested on single perforator carrying two adjacent perforasomes arising from the same source artery. For example, when a large thoracodorsal artery perforator flap is planned, it must be planned over the latissimus dorsi muscle to incorporate neighboring perforasomes of other perforators arising from the thoracodorsal artery. It must be remembered that if perforasomes of dorsal intercostal artery perforators or circumflex scapular artery perforators

horizontal oblique direction.

40 Issues in Flap Surgery

Advantages of perforator flaps include the potential to harvest flaps based on any reliable perforator throughout the body that they do not sacrifice major vessels since they are supplied by the branches of these vessels and that they do not necessarily sacrifice muscle if muscle is not needed for reconstruction. In radial forearm flaps, the radial artery is incorporated. Therefore, after the radial forearm flap has been harvested, the whole hand is supplied by ulnar artery only. Sacrification of an artery such as the radial artery is believed to produce considerable morbidity. On the other hand, when perforator flaps are used, the source artery can be preserved. In case of a musculocutaneous perforator, intramuscular dissection may become challenging. However, if intramuscular pedicle dissection is performed, sacrification of muscle can be avoided. For instance, when a thoracodorsal artery perforator flap is being harvested based on a musculocutaneous perforator, intramuscular dissection must be performed in order to preserve underlying muscle namely latissimus dorsi muscle in this example. The same is true for anterolateral thigh flaps whenever the flap is supplied by a musculocutaneous perforator. However, if needed, such as in the obliteration of a dead space, a muscle cuff can be incorporated into the harvested flap based on a separate perforator.

Tedious dissection is very important in perforator flap harvest. It must be performed under loupe magnification and requires special expertise and experience. Especially, intramuscular perforator dissection can be challenging. That is why, perforator flap harvesting requires a learning curve. For beginners of perforator flap dissection, a detailed anatomy of the perforator flap being harvested must be known and training in one of the experienced centers on perforator flap dissection is strongly recommended.

There is a conflict about the skeletonization of the perforators supplying perforator flaps. Some groups claim that skeletonization of perforators supplying local perforator flaps is not needed, whereas some others, including us, believe that without skeletonization of perforators, flap harvest is not completed. Groups who do not skeletonize perforating vessels claim that skeletonization of perforators is not performed in order to reduce the risk of damage to the perforating artery and its venae commitantes [17]. We believe that complete skeletonization of perforator is required, since soft tissue and fibrous bands around perforators may cause compression of perforating artery and venae commitantes, thus causing venous insufficiency and/or arterial compromise of perforator flaps. Therefore, we believe that it is a "must" in perforator dissection. We know that skin is supplied by rich vascular plexuses including subepidermal plexus, dermal plexus, subdermal plexus, subcutaneous plexus, prefascial plexus, and subfascial plexus. All these plexuses contribute to the vascularization of skin. Our opinion is to harvest the flap with the fascia overlying the muscle because it is important in vascularization of the harvested flap. This is especially so, when a large flap is being harvested since prefascial and subfascial plexuses will be left intact on the harvested flap.

in local perforator flaps and perforator-free flaps. However, in order to cover the defect, local perforator flaps are mobilized in a propeller, rotational, advancement, or transpositional movement fashion. Perforator free flaps require vascular anastomosis; therefore, a longer operation is performed. Correct planning of perforator flaps is of primary importance for the success of flaps. Perforators supplying perforator flaps have a static zone and a dynamic zone. The static zone is the zone supplied by the perforator itself, whereas the dynamic zone is the zone a perforator can supply beyond its own perforasome. This means that the dynamic zone is the potential zone of a perforator to supply the perforasomes of neighboring perforators. Saint-Cyr et al. reported that vascular filling of perforators from the same source artery is more, when compared to vascular filling of neighboring perforators from different source arteries, and this is explained by "preferential filling" [6]. Therefore, a perforator flap planned incorporating perforasomes of perforators arising from the same source artery may be safer than that combining perforasomes of perforators from different source arteries. For the same reason, after identifying a large perforator at the desired flap base, Taylor et al. [21] look for another perforator close to the first perforator in all radial directions and combine both perforators on a line drawn in between; this line is going to be the flap axis. They believe that this kind of flap planning is safe [21]. The anatomical territory of a cutaneous perforator is defined as the zone that connects the perforator with adjacent perforators in all directions and is separated from the anatomical zones of other perforators by the anastomotic zone between each anatomical territory. On the other hand, the clinical territory of each perforator is wider than its particular anatomical territory as it usually captures the neighboring anatomical territory of the neighboring perforator. It may even capture the anatomical territory of the one beyond, especially when

Perforator Flaps: Principles and Techniques http://dx.doi.org/10.5772/intechopen.71270 43

perforators are linked together by true anastomosis or direct linking vessels [7].

Taylor et al. have reported that locating perforators correctly in well-muscled volunteers using a handheld Doppler is comparable with the location of corresponding perforators found in fresh cadavers after dissection and concluded that there was a close correlation [22]. However, investigation in this issue continued. Color Doppler ultrasound and computed tomography angiography (CT angiography) is frequently performed for this purpose. Feng et al. have compared color Doppler ultrasound and CT angiography for their reliability and sensitivity in detecting the location of perforators accurately [23]. They have reported that, preoperative color Doppler ultrasound (95%) is more accurate with respect to CT angiography (82.5%) in detecting the localization of dominant perforators. However, this difference has not been statistically significant. The results obtained with Color Doppler Ultrasound has a mean error of 1.11 1.29 mm, whereas CT angiography has a mean error of 2.55 2.63 mm, a statistically significant difference. On the other hand, the time needed to evaluate the images using CT angiography (27.2 1.77 minutes) has been less than those used for color Doppler ultrasound (34.83 3.55 minutes). The success of color Doppler ultrasound has been directly related to the experience of radiologist; however, the same has not been true for CT angiography [23]. Metal implants are known to cause artifact formation in CT angiography images; however, this does

6. Assessment of perforator location

## 5. Flap circulation

Flap circulation is a dynamic process. Therefore, cadaveric studies are not sufficient to help us understand the exact margins a perforator can supply. It must be remembered that when all the side branches (muscle and cutaneous branches) of a perforator emanating from the source artery are ligated, hyperperfusion of the flap pedicle will occur [6]. Hyperperfusion of the perforator artery and its increased vascular filling cause its dilatation [6]. This, in turn, will open up the anastomotic vessels, namely direct and indirect linking vessels, and result in perfusion of adjacent perforasomes belonging to neighboring perforators [6]. Choke vessels (synonymous with indirect linking vessels) dilate as much as true anastomosis size; however, this takes 2–3 days [12, 13]. During this time, hyperplasia, elongation, and hypertrophy of cells in the tunica intima, media, and adventitia occur. This leads to the thinning of vessel walls, followed by thickening by the seventh day [13]. However, if necrosis occurs, it usually takes place in this anastomotic zone. Perfusion pressure decreases, arteriovenous shunting occurs, and oxygen tension is subsequently lowered during the first 3–4 days, a process that leads to necrosis [18, 19].

There are over 350 perforators throughout the body [6]. Perforator flaps can be potentially harvested from anywhere, where there is a reliable perforator. Perforator flaps can be used as local perforator flaps or as perforator-free flaps. With the report of freestyle free flaps by Wei and Mardini [20], a new gate has been opened for reconstruction of defects using tissues harvested from anywhere of the body provided that tissue encountered is "the most suitable and similar" and is supplied by a reliable perforator. However, freestyle perforator flaps can also be used as local options for soft tissue reconstruction. For local perforator flaps, defectperforator distance, reliability of perforator, scar tissue around the perforator, and over the planned flap (if there is) must all be considered. As mentioned before, perforator flaps can be used as local perforator flaps or as perforator-free flaps. Perforator-free flaps require vascular anastomosis onto the source vessels or onto other perforating vessels in the recipient site, whereas local perforator flaps do not. Therefore, the dissection part of the operation is similar in local perforator flaps and perforator-free flaps. However, in order to cover the defect, local perforator flaps are mobilized in a propeller, rotational, advancement, or transpositional movement fashion. Perforator free flaps require vascular anastomosis; therefore, a longer operation is performed. Correct planning of perforator flaps is of primary importance for the success of flaps. Perforators supplying perforator flaps have a static zone and a dynamic zone. The static zone is the zone supplied by the perforator itself, whereas the dynamic zone is the zone a perforator can supply beyond its own perforasome. This means that the dynamic zone is the potential zone of a perforator to supply the perforasomes of neighboring perforators. Saint-Cyr et al. reported that vascular filling of perforators from the same source artery is more, when compared to vascular filling of neighboring perforators from different source arteries, and this is explained by "preferential filling" [6]. Therefore, a perforator flap planned incorporating perforasomes of perforators arising from the same source artery may be safer than that combining perforasomes of perforators from different source arteries. For the same reason, after identifying a large perforator at the desired flap base, Taylor et al. [21] look for another perforator close to the first perforator in all radial directions and combine both perforators on a line drawn in between; this line is going to be the flap axis. They believe that this kind of flap planning is safe [21]. The anatomical territory of a cutaneous perforator is defined as the zone that connects the perforator with adjacent perforators in all directions and is separated from the anatomical zones of other perforators by the anastomotic zone between each anatomical territory. On the other hand, the clinical territory of each perforator is wider than its particular anatomical territory as it usually captures the neighboring anatomical territory of the neighboring perforator. It may even capture the anatomical territory of the one beyond, especially when perforators are linked together by true anastomosis or direct linking vessels [7].

### 6. Assessment of perforator location

harvest is not completed. Groups who do not skeletonize perforating vessels claim that skeletonization of perforators is not performed in order to reduce the risk of damage to the perforating artery and its venae commitantes [17]. We believe that complete skeletonization of perforator is required, since soft tissue and fibrous bands around perforators may cause compression of perforating artery and venae commitantes, thus causing venous insufficiency and/or arterial compromise of perforator flaps. Therefore, we believe that it is a "must" in perforator dissection. We know that skin is supplied by rich vascular plexuses including subepidermal plexus, dermal plexus, subdermal plexus, subcutaneous plexus, prefascial plexus, and subfascial plexus. All these plexuses contribute to the vascularization of skin. Our opinion is to harvest the flap with the fascia overlying the muscle because it is important in vascularization of the harvested flap. This is especially so, when a large flap is being harvested

Flap circulation is a dynamic process. Therefore, cadaveric studies are not sufficient to help us understand the exact margins a perforator can supply. It must be remembered that when all the side branches (muscle and cutaneous branches) of a perforator emanating from the source artery are ligated, hyperperfusion of the flap pedicle will occur [6]. Hyperperfusion of the perforator artery and its increased vascular filling cause its dilatation [6]. This, in turn, will open up the anastomotic vessels, namely direct and indirect linking vessels, and result in perfusion of adjacent perforasomes belonging to neighboring perforators [6]. Choke vessels (synonymous with indirect linking vessels) dilate as much as true anastomosis size; however, this takes 2–3 days [12, 13]. During this time, hyperplasia, elongation, and hypertrophy of cells in the tunica intima, media, and adventitia occur. This leads to the thinning of vessel walls, followed by thickening by the seventh day [13]. However, if necrosis occurs, it usually takes place in this anastomotic zone. Perfusion pressure decreases, arteriovenous shunting occurs, and oxygen tension is subsequently lowered during the first 3–4 days, a process that leads to

There are over 350 perforators throughout the body [6]. Perforator flaps can be potentially harvested from anywhere, where there is a reliable perforator. Perforator flaps can be used as local perforator flaps or as perforator-free flaps. With the report of freestyle free flaps by Wei and Mardini [20], a new gate has been opened for reconstruction of defects using tissues harvested from anywhere of the body provided that tissue encountered is "the most suitable and similar" and is supplied by a reliable perforator. However, freestyle perforator flaps can also be used as local options for soft tissue reconstruction. For local perforator flaps, defectperforator distance, reliability of perforator, scar tissue around the perforator, and over the planned flap (if there is) must all be considered. As mentioned before, perforator flaps can be used as local perforator flaps or as perforator-free flaps. Perforator-free flaps require vascular anastomosis onto the source vessels or onto other perforating vessels in the recipient site, whereas local perforator flaps do not. Therefore, the dissection part of the operation is similar

since prefascial and subfascial plexuses will be left intact on the harvested flap.

5. Flap circulation

42 Issues in Flap Surgery

necrosis [18, 19].

Taylor et al. have reported that locating perforators correctly in well-muscled volunteers using a handheld Doppler is comparable with the location of corresponding perforators found in fresh cadavers after dissection and concluded that there was a close correlation [22]. However, investigation in this issue continued. Color Doppler ultrasound and computed tomography angiography (CT angiography) is frequently performed for this purpose. Feng et al. have compared color Doppler ultrasound and CT angiography for their reliability and sensitivity in detecting the location of perforators accurately [23]. They have reported that, preoperative color Doppler ultrasound (95%) is more accurate with respect to CT angiography (82.5%) in detecting the localization of dominant perforators. However, this difference has not been statistically significant. The results obtained with Color Doppler Ultrasound has a mean error of 1.11 1.29 mm, whereas CT angiography has a mean error of 2.55 2.63 mm, a statistically significant difference. On the other hand, the time needed to evaluate the images using CT angiography (27.2 1.77 minutes) has been less than those used for color Doppler ultrasound (34.83 3.55 minutes). The success of color Doppler ultrasound has been directly related to the experience of radiologist; however, the same has not been true for CT angiography [23]. Metal implants are known to cause artifact formation in CT angiography images; however, this does not apply to color Doppler ultrasound. On the other hand, compared to CT angiography, Doppler ultrasound is a cheaper modality [23]. As a result, Feng et al. have advocated the use of color Doppler ultrasound in experienced hands instead of CT angiography for more correctly locating perforators, and also, it is less expensive [23].

#### 7. Risk factors of perforator flaps

In order to identify risk factors of perforator propeller flaps in lower extremity defects, Bekara et al. searched MEDLINE, PubMedCentral, Embase, and Cochrane databases for reported series of lower extremity reconstruction using pedicled perforator propeller flaps between 1991 and 2004 [24]. In total, 428 perforator propeller flaps from 40 articles which performed for lower extremity reconstruction were included in the study [24]. Partial necrosis was found in 10.2%, whereas total flap necrosis was found in 3.5% of cases [24]. Patients older than 60, or patients who had diabetes or arteriopathy, were determined as significant risk factors for flap failure [24]. However, smoking, acute injury, post-traumatic injury, location of defect over the distal third of lower leg, inclusion of fascia, pedicle rotation greater than 120, accompanying bone fracture, and surface area greater than 100 cm<sup>2</sup> were found to have no significant effect on flap success [24]. Hypertension could not be evaluated due to lack of data [24]. Since this study was a meta-analysis, it had some limitations, however: lack of standardization (different surgical techniques and different approaches by different surgeons, and flaps used for reconstruction), missing data (comorbidity, localization, size of flap, cause, pedicle rotation), and including nonhomogenous patient groups [24]. Nevertheless, it is important to identify risk factors threatening perforator flap viability since patients are to be selected considering those risk factors along with many other factors. Another important issue that must be considered in reconstructive planning is defect etiology. In traumatic defects, post-traumatic vessel disease may have developed [25]. "Post-traumatic vessel disease is defined as progressive changes in vessel and perivascular tissues following trauma" [24] and "loss of normal easy dissection planes, around the vessels, loss of vasa vasorum, increased tendency of vessels to vasospasm or easily damaging vessels during dissection along with lack of thromboresistant properties of healthy vessels" [24]. Therefore, post-traumatic vessel disease is considered as a risk factor in reconstructive surgery, and the reconstructive surgeon must be aware of this. Because of this, the reconstructive surgeon must be familiar with problem solving and must have a special strategy for each case, individualizing each patient during reconstructive planning.

flap is supplied by the descending branch of lateral circumflex femoral artery, which is the branch of deep femoral artery [26]. A straight line is drawn from the anterior superior iliac spine to the superolateral edge point of patella [26]. The flap pedicle lies between rectus femoris and vastus lateralis [26]. The perforator supplying this flap can be septocutaneous or musculocutaneous. The anterolateral thigh flap has a long pedicle that is a great advantage for use as a free flap or for use in reconstruction of locoregional defects (Figure 1). It can be harvested with a muscle cuff or with fascia according to patients' needs [27]. This flap can be raised with a muscle cuff from vastus lateralis muscle as a chimeric flap [28] or with fascia lata

Figure 1. (a) The patient is feeling discomfort standing upright because of unstable scarring and a slight contracture over the right inguinal region. The operative plan is to excise the contracture band and reconstruct the defect using a pedicled anterolateral thigh flap. (b) The anterolateral thigh flap has been elevated. Note that two pedicles supplying the flap have been dissected off. (c) Patient as seen 18 months postoperatively. Note that patient can easily abduct and extend her

Perforator Flaps: Principles and Techniques http://dx.doi.org/10.5772/intechopen.71270 45

The source vessel for the thoracodorsal artery perforator flap is the thoracodorsal artery. This artery is a branch of the subscapular system and divides into transverse and descending branches after entering to the latissimus dorsi muscle. According to the cadaveric dissections of Heitmann et al. investigating the anatomical basis of thoracodorsal artery perforator flaps, out of 20 specimens, a total of 64 musculocutaneous perforators larger than 0.5 mm were found [30]. In total, 36 of these perforators were arising from the descending branch whereas 28 were arising from the transverse branch [30]. However, in 11 dissections, there was also a direct cutaneous branch with an extravascular course [30]. The flap is raised in the lateral decubitus position, and an incision lateral to the lateral border of latissimus dorsi muscle is made [31] (Figure 2). After the perforator is found, dissection of the perforator is continued until adequate length is reached. However, during dissection of the flap, attention must be paid for preservation of the thoracodorsal nerve [31]. In addition to their local use, thoracodorsal artery perforator flaps are also favorable flaps for transfer as free flaps taking advan-

for different reconstructive purposes [29].

thighs.

tage of their long pedicle.

9. The thoracodorsal artery perforator flap

Brief information about some of the workhorse flaps and some case examples will be given in the following section.

#### 8. The anterolateral thigh flap

The anterolateral thigh flap is probably the most commonly used perforator flap for reconstruction of soft tissue defects especially when transferred as a free flap. The anterolateral thigh

Figure 1. (a) The patient is feeling discomfort standing upright because of unstable scarring and a slight contracture over the right inguinal region. The operative plan is to excise the contracture band and reconstruct the defect using a pedicled anterolateral thigh flap. (b) The anterolateral thigh flap has been elevated. Note that two pedicles supplying the flap have been dissected off. (c) Patient as seen 18 months postoperatively. Note that patient can easily abduct and extend her thighs.

flap is supplied by the descending branch of lateral circumflex femoral artery, which is the branch of deep femoral artery [26]. A straight line is drawn from the anterior superior iliac spine to the superolateral edge point of patella [26]. The flap pedicle lies between rectus femoris and vastus lateralis [26]. The perforator supplying this flap can be septocutaneous or musculocutaneous. The anterolateral thigh flap has a long pedicle that is a great advantage for use as a free flap or for use in reconstruction of locoregional defects (Figure 1). It can be harvested with a muscle cuff or with fascia according to patients' needs [27]. This flap can be raised with a muscle cuff from vastus lateralis muscle as a chimeric flap [28] or with fascia lata for different reconstructive purposes [29].

#### 9. The thoracodorsal artery perforator flap

not apply to color Doppler ultrasound. On the other hand, compared to CT angiography, Doppler ultrasound is a cheaper modality [23]. As a result, Feng et al. have advocated the use of color Doppler ultrasound in experienced hands instead of CT angiography for more

In order to identify risk factors of perforator propeller flaps in lower extremity defects, Bekara et al. searched MEDLINE, PubMedCentral, Embase, and Cochrane databases for reported series of lower extremity reconstruction using pedicled perforator propeller flaps between 1991 and 2004 [24]. In total, 428 perforator propeller flaps from 40 articles which performed for lower extremity reconstruction were included in the study [24]. Partial necrosis was found in 10.2%, whereas total flap necrosis was found in 3.5% of cases [24]. Patients older than 60, or patients who had diabetes or arteriopathy, were determined as significant risk factors for flap failure [24]. However, smoking, acute injury, post-traumatic injury, location of defect over the distal third of lower leg, inclusion of fascia, pedicle rotation greater than 120, accompanying bone fracture, and surface area greater than 100 cm<sup>2</sup> were found to have no significant effect on flap success [24]. Hypertension could not be evaluated due to lack of data [24]. Since this study was a meta-analysis, it had some limitations, however: lack of standardization (different surgical techniques and different approaches by different surgeons, and flaps used for reconstruction), missing data (comorbidity, localization, size of flap, cause, pedicle rotation), and including nonhomogenous patient groups [24]. Nevertheless, it is important to identify risk factors threatening perforator flap viability since patients are to be selected considering those risk factors along with many other factors. Another important issue that must be considered in reconstructive planning is defect etiology. In traumatic defects, post-traumatic vessel disease may have developed [25]. "Post-traumatic vessel disease is defined as progressive changes in vessel and perivascular tissues following trauma" [24] and "loss of normal easy dissection planes, around the vessels, loss of vasa vasorum, increased tendency of vessels to vasospasm or easily damaging vessels during dissection along with lack of thromboresistant properties of healthy vessels" [24]. Therefore, post-traumatic vessel disease is considered as a risk factor in reconstructive surgery, and the reconstructive surgeon must be aware of this. Because of this, the reconstructive surgeon must be familiar with problem solving and must have a special

strategy for each case, individualizing each patient during reconstructive planning.

Brief information about some of the workhorse flaps and some case examples will be given in

The anterolateral thigh flap is probably the most commonly used perforator flap for reconstruction of soft tissue defects especially when transferred as a free flap. The anterolateral thigh

correctly locating perforators, and also, it is less expensive [23].

7. Risk factors of perforator flaps

44 Issues in Flap Surgery

the following section.

8. The anterolateral thigh flap

The source vessel for the thoracodorsal artery perforator flap is the thoracodorsal artery. This artery is a branch of the subscapular system and divides into transverse and descending branches after entering to the latissimus dorsi muscle. According to the cadaveric dissections of Heitmann et al. investigating the anatomical basis of thoracodorsal artery perforator flaps, out of 20 specimens, a total of 64 musculocutaneous perforators larger than 0.5 mm were found [30]. In total, 36 of these perforators were arising from the descending branch whereas 28 were arising from the transverse branch [30]. However, in 11 dissections, there was also a direct cutaneous branch with an extravascular course [30]. The flap is raised in the lateral decubitus position, and an incision lateral to the lateral border of latissimus dorsi muscle is made [31] (Figure 2). After the perforator is found, dissection of the perforator is continued until adequate length is reached. However, during dissection of the flap, attention must be paid for preservation of the thoracodorsal nerve [31]. In addition to their local use, thoracodorsal artery perforator flaps are also favorable flaps for transfer as free flaps taking advantage of their long pedicle.


Figure 2. (a) An exposed pacemaker is seen over the left pectoral region. The operative plan is to excise the infected skin and reconstruct the defect using a thoracodorsal artery perforator flap. Flap planning is seen. A 9 9 cm defect is formed after excision and flap dimensions are 20 9 cm. (b) The thoracodorsal artery perforator flap has been elevated. (c) Patient as seen 3 months postoperatively.

#### 10. Superior gluteal artery perforator flap

Koshima et al. were probably the first to report on the use of gluteal artery perforator flaps for reconstruction of sacral pressure sores [32]. Superior gluteal artery perforator flaps can be used in soft tissue reconstruction of locoregional defects as well as in breast reconstruction when used as free flaps [33]. However, for use in breast reconstruction, they are usually indicated in those whom abdominal flaps are risky or cannot be used [31]. Usually, three perforators supply superior gluteal artery perforator flaps [31]. Superior gluteal artery perforators are found one-third of the distance along the line drawn from the posterior superior iliac spine to the greater trochanter [31]. After the localization of the pedicle using a handheld Doppler, the flap may be centered on that pedicle or may be designed eccentrically. After the incisions have been made and the perforator supplying the flap has been found, intramuscular dissection toward the sacrum is performed in order to elongate the flap pedicle (Figure 3). Dissection of a single perforator is adequate to supply the flap. However, one can dissect more than one perforator to supply the flap. The donor area can be closed primarily.

reconstructive surgery. Perforator flaps provide very important advantages in reconstructive surgery. Nevertheless, they are not without hazards. For this reason, risk factors in perforator flap surgery and clues to successful planning must be kept in mind while planning reconstruc-

Figure 3. (a) A presacral pressure sore is seen in a previously operated meningomyelocele patient. The operative plan is to reconstruct the defect using a superior gluteal artery perforator flap. The defect size is 4.5 5.5 cm and the planned flap is 16 8.5 cm. (b) The superior gluteal artery perforator flap has been elevated based on a single perforator. (c) The patient following reconstruction as seen 1 year postoperatively. Note that a small area of recurrence is seen at the superior border

Perforator Flaps: Principles and Techniques http://dx.doi.org/10.5772/intechopen.71270 47

Department of Plastic, Reconstructive and Aesthetic Surgery, Mersin University Hospital,

tion using perforator flaps.

Address all correspondence to: dr\_tenekecig@hotmail.com

Author details

of the flap after 1 year.

Goktekin Tenekeci

Mersin, Turkey

#### 11. Conclusion

Perforator flaps have evolved as a result of better understanding of the dynamics of the vascular supply and drainage as well as the vascular microanatomy of flaps. Perforator flaps are a step forward in reconstruction of soft tissue defects; they have opened a new era in

Figure 3. (a) A presacral pressure sore is seen in a previously operated meningomyelocele patient. The operative plan is to reconstruct the defect using a superior gluteal artery perforator flap. The defect size is 4.5 5.5 cm and the planned flap is 16 8.5 cm. (b) The superior gluteal artery perforator flap has been elevated based on a single perforator. (c) The patient following reconstruction as seen 1 year postoperatively. Note that a small area of recurrence is seen at the superior border of the flap after 1 year.

reconstructive surgery. Perforator flaps provide very important advantages in reconstructive surgery. Nevertheless, they are not without hazards. For this reason, risk factors in perforator flap surgery and clues to successful planning must be kept in mind while planning reconstruction using perforator flaps.

## Author details

10. Superior gluteal artery perforator flap

as seen 3 months postoperatively.

46 Issues in Flap Surgery

perforator to supply the flap. The donor area can be closed primarily.

11. Conclusion

Koshima et al. were probably the first to report on the use of gluteal artery perforator flaps for reconstruction of sacral pressure sores [32]. Superior gluteal artery perforator flaps can be used in soft tissue reconstruction of locoregional defects as well as in breast reconstruction when used as free flaps [33]. However, for use in breast reconstruction, they are usually indicated in those whom abdominal flaps are risky or cannot be used [31]. Usually, three perforators supply superior gluteal artery perforator flaps [31]. Superior gluteal artery perforators are found one-third of the distance along the line drawn from the posterior superior iliac spine to the greater trochanter [31]. After the localization of the pedicle using a handheld Doppler, the flap may be centered on that pedicle or may be designed eccentrically. After the incisions have been made and the perforator supplying the flap has been found, intramuscular dissection toward the sacrum is performed in order to elongate the flap pedicle (Figure 3). Dissection of a single perforator is adequate to supply the flap. However, one can dissect more than one

Figure 2. (a) An exposed pacemaker is seen over the left pectoral region. The operative plan is to excise the infected skin and reconstruct the defect using a thoracodorsal artery perforator flap. Flap planning is seen. A 9 9 cm defect is formed after excision and flap dimensions are 20 9 cm. (b) The thoracodorsal artery perforator flap has been elevated. (c) Patient

Perforator flaps have evolved as a result of better understanding of the dynamics of the vascular supply and drainage as well as the vascular microanatomy of flaps. Perforator flaps are a step forward in reconstruction of soft tissue defects; they have opened a new era in Goktekin Tenekeci

Address all correspondence to: dr\_tenekecig@hotmail.com

Department of Plastic, Reconstructive and Aesthetic Surgery, Mersin University Hospital, Mersin, Turkey

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[18] Boyd BJ, Markland B, Dorion D, Pang CY, Morris S. Surgical augmentation of skin blood flow and viability in a pig musculocutaneous flap model. Plastic and Reconstructive Surgery. 1990;86:731-738

References

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1378-1383

[1] Engel H, Lin CH, Wei FC. Role of microsurgery in lower extremity reconstruction. Plastic

[2] Blondeel P, Hallock G, Morris SF, Neligan PC. Perforator Flaps: Anatomy, Technique &

[3] Koshima I, Soeda S. Inferior epigastric artery skin flap without rectus abdominis muscle.

[4] Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The "gent" consensus on perforator flap terminology: Preliminary definitions. Plastic and Reconstructive Surgery. 2003;112(5):

[5] Blondeel PN, Van Landuyt K, Hamdi M, Monstrey SJ. Perforator flap terminology:

[6] Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: Vascular anatomy and clinical implications. Plastic and Reconstructive Surgery. 2009;124(5):1529-1544 [7] Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: Development of the concept and designing

[8] Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: Experimental study and clinical applications. British Journal of Plastic Surgery. 1987;40:113-141

[9] Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: Clinical results and vascular anatomy. Plastic and Reconstructive Surgery. 2010;126(5):1589-1603

[10] Taylor GI, Corlett RJ. The cutaneous vascular territories in pig and man. Paper Presented

[11] Callegari PR, Taylor GI, Caddy C, et al. An anatomic review of the delay phenomenon: I.

[12] Morris SF, Taylor GI. Predicting the survival of experimental skin flaps based on a knowledge of the vascular architecture. Plastic and Reconstructive Surgery. 1993;92:1352-1371

[13] Dhar S, Taylor GI. The delay phenomenon: The story unfolds. Plastic and Reconstructive

[14] Taylor GI, Corlett RJ, Caddy CM, Zelt RG. An anatomic review of the delay phenomenon: II. Clinical applications. Plastic and Reconstructive Surgery. 1992;89:408-416

[15] Taylor GI. The delayed TRAM flap for breast reconstruction: Why, when and how.

[17] Shin IS, Lee DW, Rah DK, Lee WJ. Reconstruction of pretibial defect using pedicled

Operative Techniques in Plastic and Reconstructive Surgery. 1999;6:74-82

[16] Chan Wei F. Flaps and Reconstructive Surgery. China: Elsevier; 2009

perforator flaps. Archives of Plastic Surgery. 2012;39(4):360-366

Experimental studies. Plastic and Reconstructive Surgery. 1992;89:397-407

Clinical Applications. St. Louis: Quality Medical Publishing Inc; 2006

safe flaps. Plastic and Reconstructive Surgery. 2011;127(4):1447-1459

at: ASPRS Meeting. New York, NY: Surgical Forum No. 67; 1981

Surgery. 1999;104:2079-2091

and Reconstructive Surgery. 2011;127(1S):228S-238S

Update 2002. Clinics in Plastic Surgery. 2003;30:343-346

British Journal of Plastic Surgery. 1989;42:645


**Chapter 4**

**Provisional chapter**

**Application of Free Flow‐Through Anterolateral Thigh**

**Flap for the Reconstruction of an Extremity Soft Tissue** 

**Application of Free Flow**‐**Through Anterolateral Thigh** 

DOI: 10.5772/intechopen.69404

**Flap for the Reconstruction of an Extremity Soft Tissue**

Patients with severe injury or vasculopathy of the extremities often require resurfacing of tissue defects as well as preservation of functional blood flow to distal areas. In conventional free flap transfer, the recipient vessel is sacrificed to facilitate pedicle anastomosis. On the other hand, a flow‐through flap can provide blood flow to distal tissues. In this chapter, we present cases of successful salvage and reconstruction of the extremities using free flow‐through flaps and highlight their advantages and applications. Free flow‐through flap use should be a good option in the following cases: (1) Gustilo‐ Anderson IIIC type open fracture, (2) chronic ulcer resurfacing in the less vascularized extremities, and (3) additional blood supply for an ischemic flap. This flap facilitates not only the reconstruction of soft tissue defects, but also restores the functional vascular anatomy and maintains the original blood flow by interposing the T‐portion of the ves‐ sel. This technique enables both vascular and soft tissue reconstructions simultaneously with minimal donor site problems. The anterolateral thigh flap is recommended as a free flow‐through‐type flap due to its advantages, including the variety of flap sizes, adequate

calibers of the vascular pedicle, and the lack of a need for position changing.

**Keywords:** reconstruction of the extremity, soft tissue defects, revascularization, free

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

The disadvantage of traditional methods for reconstruction of soft tissue deficits using pedicle flaps is the need for multiple stages. In addition, donor site morbidity may be another disad‐ vantage [1]. Following recent trends to overcome these problems, microsurgical flap trans‐ fer has revolutionized the reconstruction of soft tissue defects and has become a standard

**Defect Requiring Vascularization**

**Defect Requiring Vascularization**

Additional information is available at the end of the chapter

flow‐through flap, anterolateral thigh flap

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69404

Masaki Fujioka

**Abstract**

**1. Introduction**

Masaki Fujioka

**Provisional chapter**

#### **Application of Free Flow‐Through Anterolateral Thigh Flap for the Reconstruction of an Extremity Soft Tissue Defect Requiring Vascularization Flap for the Reconstruction of an Extremity Soft Tissue Defect Requiring Vascularization**

**Application of Free Flow**‐**Through Anterolateral Thigh** 

DOI: 10.5772/intechopen.69404

Masaki Fujioka Masaki Fujioka Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69404

#### **Abstract**

Patients with severe injury or vasculopathy of the extremities often require resurfacing of tissue defects as well as preservation of functional blood flow to distal areas. In conventional free flap transfer, the recipient vessel is sacrificed to facilitate pedicle anastomosis. On the other hand, a flow‐through flap can provide blood flow to distal tissues. In this chapter, we present cases of successful salvage and reconstruction of the extremities using free flow‐through flaps and highlight their advantages and applications. Free flow‐through flap use should be a good option in the following cases: (1) Gustilo‐ Anderson IIIC type open fracture, (2) chronic ulcer resurfacing in the less vascularized extremities, and (3) additional blood supply for an ischemic flap. This flap facilitates not only the reconstruction of soft tissue defects, but also restores the functional vascular anatomy and maintains the original blood flow by interposing the T‐portion of the ves‐ sel. This technique enables both vascular and soft tissue reconstructions simultaneously with minimal donor site problems. The anterolateral thigh flap is recommended as a free flow‐through‐type flap due to its advantages, including the variety of flap sizes, adequate calibers of the vascular pedicle, and the lack of a need for position changing.

**Keywords:** reconstruction of the extremity, soft tissue defects, revascularization, free flow‐through flap, anterolateral thigh flap

#### **1. Introduction**

The disadvantage of traditional methods for reconstruction of soft tissue deficits using pedicle flaps is the need for multiple stages. In addition, donor site morbidity may be another disad‐ vantage [1]. Following recent trends to overcome these problems, microsurgical flap trans‐ fer has revolutionized the reconstruction of soft tissue defects and has become a standard

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

technique for the resurfacing of wounds, because it facilitates not only the safe coverage of large tissue defects, but also yields a cosmetically acceptable appearance [2–4]. Regarding hand and leg salvage and reconstruction after trauma and oncologic resection, surgeons often need to ensure both soft tissue coverage and blood flow supply to the distal extremities. Free tissue transfer can be superior to pedicle flap coverage for the resurfacing of a large tissue defect, as it reduces infection, induces bony healing, and optimizes limb salvage [5–7].

was first described by Soutar et al. [9] using a radial forearm flap, many investigators have described the application of flow‐through flaps for extremity reconstruction; latissimus dorsi musculocutaneous, rectus abdominis musculocutaneous, fibula osteomyocutaneous, and anterolateral thigh (ALT) flaps have been diversely used [9–12]. The ALT flap, in particular, can provide a large skin paddle yet with minimal donor site morbidity; thus, it is ideal for

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The musculofasciocutaneous ALT flap is supplied by the descending branch of the lateral femoral circumflex artery. Thus, it can be harvested as a fasciocutaneous or myocutaneous flap [17]. The descending branch traverses downward in the intermuscular septum between the rectus femoris and vastus lateralis muscle [18]. The rectus femoris muscle is retraced medi‐ ally to expose the vascular bundle of the descending branch, and the length and diameter are examined. It proceeds downward, while sending perforators to supply the skin and muscles around the anterolateral aspect of the thigh (**Figure 2**). Usually, the descending branch has an external diameter of more than 2 mm at the proximal end with a pedicle of more than 8 cm in length (**Figure 3**) [18, 19]. When a larger flap is required, more than two perforator arteries

**Figure 2.** Vascular anatomy of the descending branch of the lateral femoral circumflex artery. The descending branch of

the lateral femoral circumflex artery (marked in the illustration) is used as an interposing vessel.

extremity reconstruction [10, 13–16].

**3. Surgical procedure of free flow‐through ALT flap**

should be preserved between the flap and pedicle.

However, in conventional free flap transfer, the recipient vessel is sacrificed to facilitate ped‐ icle anastomosis, a procedure which may reduce the distal blood flow. Especially, patients with vascular injury or chronic vasculopathy of the extremities require resurfacing of tissue defects as well as preservation of functional blood flow to distal areas. The concept of flow‐ through circulation in free flaps is using a one‐staged technique for wound coverage and the revascularization of ischemic extremities [8].

In this chapter, several cases of successful salvage and extremity reconstruction using free flow‐through flaps are presented; their advantages and applications are highlighted.

## **2. Surgical principle of free flow‐through flap**

In the flow‐through flap concept, both the proximal and distal ends of the vascular pedicle of a free flap are anastamosed to provide blood flow to distal tissues (**Figure 1**). Since the concept

**Figure 1.** Schematic representation of the conventional and flow‐through‐type free flap. (a) Conventional free flap transfer. Major blood vessels are sacrificed; consequently, blood flow to the distal area is reduced. (b) Free flow‐through flap transfer. Flow‐through anastomosis preserves the recipient arterial flow, and the flaps are anatomically consistent.

was first described by Soutar et al. [9] using a radial forearm flap, many investigators have described the application of flow‐through flaps for extremity reconstruction; latissimus dorsi musculocutaneous, rectus abdominis musculocutaneous, fibula osteomyocutaneous, and anterolateral thigh (ALT) flaps have been diversely used [9–12]. The ALT flap, in particular, can provide a large skin paddle yet with minimal donor site morbidity; thus, it is ideal for extremity reconstruction [10, 13–16].

## **3. Surgical procedure of free flow‐through ALT flap**

technique for the resurfacing of wounds, because it facilitates not only the safe coverage of large tissue defects, but also yields a cosmetically acceptable appearance [2–4]. Regarding hand and leg salvage and reconstruction after trauma and oncologic resection, surgeons often need to ensure both soft tissue coverage and blood flow supply to the distal extremities. Free tissue transfer can be superior to pedicle flap coverage for the resurfacing of a large tissue

defect, as it reduces infection, induces bony healing, and optimizes limb salvage [5–7].

revascularization of ischemic extremities [8].

52 Issues in Flap Surgery

**2. Surgical principle of free flow‐through flap**

However, in conventional free flap transfer, the recipient vessel is sacrificed to facilitate ped‐ icle anastomosis, a procedure which may reduce the distal blood flow. Especially, patients with vascular injury or chronic vasculopathy of the extremities require resurfacing of tissue defects as well as preservation of functional blood flow to distal areas. The concept of flow‐ through circulation in free flaps is using a one‐staged technique for wound coverage and the

In this chapter, several cases of successful salvage and extremity reconstruction using free

In the flow‐through flap concept, both the proximal and distal ends of the vascular pedicle of a free flap are anastamosed to provide blood flow to distal tissues (**Figure 1**). Since the concept

**Figure 1.** Schematic representation of the conventional and flow‐through‐type free flap. (a) Conventional free flap transfer. Major blood vessels are sacrificed; consequently, blood flow to the distal area is reduced. (b) Free flow‐through flap transfer. Flow‐through anastomosis preserves the recipient arterial flow, and the flaps are anatomically consistent.

flow‐through flaps are presented; their advantages and applications are highlighted.

The musculofasciocutaneous ALT flap is supplied by the descending branch of the lateral femoral circumflex artery. Thus, it can be harvested as a fasciocutaneous or myocutaneous flap [17]. The descending branch traverses downward in the intermuscular septum between the rectus femoris and vastus lateralis muscle [18]. The rectus femoris muscle is retraced medi‐ ally to expose the vascular bundle of the descending branch, and the length and diameter are examined. It proceeds downward, while sending perforators to supply the skin and muscles around the anterolateral aspect of the thigh (**Figure 2**). Usually, the descending branch has an external diameter of more than 2 mm at the proximal end with a pedicle of more than 8 cm in length (**Figure 3**) [18, 19]. When a larger flap is required, more than two perforator arteries should be preserved between the flap and pedicle.

**Figure 2.** Vascular anatomy of the descending branch of the lateral femoral circumflex artery. The descending branch of the lateral femoral circumflex artery (marked in the illustration) is used as an interposing vessel.

extremities and after malignant tumor resection, as these often cause blood vessel loss associ‐ ated with soft tissue defects. Extremity reconstruction in vasculopathy patients also requires primary preservation of functional blood flow to distal areas. In such cases, one‐stage recon‐

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Free flow‐through flap use should be a good option for soft tissue reconstruction in the fol‐

The author presents some cases of successful salvage and reconstruction of the extremities

Gustilo‐Anderson IIIC type fracture requires both vascular and soft tissue repair immediately [21]. For reconstruction, flow‐through flap use is beneficial, because blood flow of the dis‐ tal extremity can be maintained, while the soft‐tissue‐insufficient wound can be resurfaced

*Case 1*. Due to a traffic accident, a 64‐year‐old man sustained a Gustilo‐Anderson Type IIIC bone‐exposing fracture to the left fibula and tibia with wide skin abrasion and involvement of the anterior tibial muscles (**Figure 4 (a, b)**). Circulation of the left foot had ceased because three main arteries in the leg (peroneal, posterior tibial, and anterior tibial arteries) had been ruptured with subsequent flow interruption (**Figure 5**). After the crushed bones had under‐ gone external fixation, the bone‐exposing wound was repaired with a free flow‐through ALT flap. The T‐portion of the descending branch of the ALT flap was interposed to the defect of the anterior tibial artery (**Figures 6**, **7**). Subsequently, the interrupted anterior tibia artery resumed normal blood flow. The viability of the flap was favorable without infection or

Chronic ulcer resurfacing, especially reconstruction after oncologic resection, in the less vas‐ cularized extremities is a challenge, because single artery scarification can cause amputation [22]. Free flow‐through flap use is beneficial as it can maintain the distal blood flow [6].

*Case 2*. A 65‐year‐old man suffered from a chronic right leg ulcer, which rapidly enlarged and developed a fungating wound over a 6‐month duration (**Figure 9**). Histological analysis of

necrosis (**Figure 8**). The patient could walk without canes 1 year after surgery.

**5.2. Chronic ulcer resurfacing in the less vascularized extremities**

struction using a free flow‐through flap may be an absolute application.

(1) severe trauma (for example, Gustilo‐Anderson IIIC type open fracture);

(2) chronic ulcer resurfacing in the less vascularized extremities; and

**5.1. Severe trauma (Gustilo‐Anderson IIIC type open fracture)**

(3) additional blood supply for an ischemic flaps.

lowing three cases:

using free flow‐through flaps.

**5. Case presentation**

simultaneously.

**Figure 3.** The harvested TFL flap and descending branch of the lateral femoral circumflex artery.

After the ALT flap has been harvested with an elliptical skin island from the thigh in the usual manner, the T‐portion of the descending branch is interposed with the defect of the recipient artery (**Figure 1 (b)**). After confirming the vascular flow in the distal extremity, two veins are connected by end‐to‐end anastomosis. Vessel size mismatch has not been an issue because the caliber of the descending pedicle is considered to be consistently maintained throughout its course down the upper half to two‐thirds of the vastus lateralis [20]. Generally, venous anasto‐ mosis does not have to be performed using the flow‐through technique, except in re‐plantation surgery for amputated limbs. Consequently, the interrupted recipient artery resumes normal blood flow, while the flap is vascularized via the perforator vessels of the descending branch.

## **4. Indication of free flow‐through flap**

Maintaining distal blood supply is important at all times for preventing the development of many diseases due to ischemia or peripheral circulation disorders (including frostbite, a contaminated leg ulcer, peripheral arterial disease, and skin and soft tissue problems associ‐ ated with diabetes mellitus). Therefore, free flow‐through flap use can be recommended in any case when combined free flap reconstruction and preservation/restoration of distal blood flow are required. In this fact indicating that the absolute indication of free flow‐through flap use may be limited. However, additional indications include severe trauma involving the extremities and after malignant tumor resection, as these often cause blood vessel loss associ‐ ated with soft tissue defects. Extremity reconstruction in vasculopathy patients also requires primary preservation of functional blood flow to distal areas. In such cases, one‐stage recon‐ struction using a free flow‐through flap may be an absolute application.

Free flow‐through flap use should be a good option for soft tissue reconstruction in the fol‐ lowing three cases:


The author presents some cases of successful salvage and reconstruction of the extremities using free flow‐through flaps.

## **5. Case presentation**

**Figure 3.** The harvested TFL flap and descending branch of the lateral femoral circumflex artery.

**4. Indication of free flow‐through flap**

54 Issues in Flap Surgery

After the ALT flap has been harvested with an elliptical skin island from the thigh in the usual manner, the T‐portion of the descending branch is interposed with the defect of the recipient artery (**Figure 1 (b)**). After confirming the vascular flow in the distal extremity, two veins are connected by end‐to‐end anastomosis. Vessel size mismatch has not been an issue because the caliber of the descending pedicle is considered to be consistently maintained throughout its course down the upper half to two‐thirds of the vastus lateralis [20]. Generally, venous anasto‐ mosis does not have to be performed using the flow‐through technique, except in re‐plantation surgery for amputated limbs. Consequently, the interrupted recipient artery resumes normal blood flow, while the flap is vascularized via the perforator vessels of the descending branch.

Maintaining distal blood supply is important at all times for preventing the development of many diseases due to ischemia or peripheral circulation disorders (including frostbite, a contaminated leg ulcer, peripheral arterial disease, and skin and soft tissue problems associ‐ ated with diabetes mellitus). Therefore, free flow‐through flap use can be recommended in any case when combined free flap reconstruction and preservation/restoration of distal blood flow are required. In this fact indicating that the absolute indication of free flow‐through flap use may be limited. However, additional indications include severe trauma involving the

#### **5.1. Severe trauma (Gustilo‐Anderson IIIC type open fracture)**

Gustilo‐Anderson IIIC type fracture requires both vascular and soft tissue repair immediately [21]. For reconstruction, flow‐through flap use is beneficial, because blood flow of the dis‐ tal extremity can be maintained, while the soft‐tissue‐insufficient wound can be resurfaced simultaneously.

*Case 1*. Due to a traffic accident, a 64‐year‐old man sustained a Gustilo‐Anderson Type IIIC bone‐exposing fracture to the left fibula and tibia with wide skin abrasion and involvement of the anterior tibial muscles (**Figure 4 (a, b)**). Circulation of the left foot had ceased because three main arteries in the leg (peroneal, posterior tibial, and anterior tibial arteries) had been ruptured with subsequent flow interruption (**Figure 5**). After the crushed bones had under‐ gone external fixation, the bone‐exposing wound was repaired with a free flow‐through ALT flap. The T‐portion of the descending branch of the ALT flap was interposed to the defect of the anterior tibial artery (**Figures 6**, **7**). Subsequently, the interrupted anterior tibia artery resumed normal blood flow. The viability of the flap was favorable without infection or necrosis (**Figure 8**). The patient could walk without canes 1 year after surgery.

#### **5.2. Chronic ulcer resurfacing in the less vascularized extremities**

Chronic ulcer resurfacing, especially reconstruction after oncologic resection, in the less vas‐ cularized extremities is a challenge, because single artery scarification can cause amputation [22]. Free flow‐through flap use is beneficial as it can maintain the distal blood flow [6].

*Case 2*. A 65‐year‐old man suffered from a chronic right leg ulcer, which rapidly enlarged and developed a fungating wound over a 6‐month duration (**Figure 9**). Histological analysis of

**Figure 4.** *Case 1*. The photographs show a Gustilo‐Anderson IIIC type bone‐exposing fracture to the left fibula and tibia with severe abrasion of the skin and anterior tibial muscles.

**Figure 6.** A harvested flow‐through ALT flap.

within the defect of the posterior tibia artery.

**Figure 7.** The intra‐operative photograph shows the T‐portion of the descending branch of the ALT flap interposed

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**Figure 5.** Contrast‐enhanced CT reveals that circulation of the left foot had ceased because peroneal, posterior tibial, and involvement of anterior tibial arteries had been interrupted.

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**Figure 6.** A harvested flow‐through ALT flap.

**Figure 5.** Contrast‐enhanced CT reveals that circulation of the left foot had ceased because peroneal, posterior tibial, and

**Figure 4.** *Case 1*. The photographs show a Gustilo‐Anderson IIIC type bone‐exposing fracture to the left fibula and tibia

involvement of anterior tibial arteries had been interrupted.

with severe abrasion of the skin and anterior tibial muscles.

56 Issues in Flap Surgery

**Figure 7.** The intra‐operative photograph shows the T‐portion of the descending branch of the ALT flap interposed within the defect of the posterior tibia artery.

**Figure 8.** The postoperative photograph shows the resurfacing of all of bone‐exposing wound and assumption of circulation to the foot.

a biopsy specimen indicated squamous cell carcinoma. The peripheral side of his lower leg was perfused only by the posterior tibial artery, because both the anterior tibial and peroneal arteries had been interrupted due to a trauma suffered 40 years previously (**Figure 10**).

After the complete removal of the tumor (**Figure 11**), the bone‐exposing wound was resur‐ faced with a free flow‐through ALT flap with a 22.0 × 8.0‐cm elliptical skin island (**Figure 12**). The T‐portion of the descending branch of the lateral circumflex femoral vessel was interposed

**Figure 9.** *Case 2*. The photograph shows a chronic right leg ulcer, which developed a fungating wound.

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**Figure 9.** *Case 2*. The photograph shows a chronic right leg ulcer, which developed a fungating wound.

a biopsy specimen indicated squamous cell carcinoma. The peripheral side of his lower leg was perfused only by the posterior tibial artery, because both the anterior tibial and peroneal arteries had been interrupted due to a trauma suffered 40 years previously (**Figure 10**).

**Figure 8.** The postoperative photograph shows the resurfacing of all of bone‐exposing wound and assumption of

circulation to the foot.

58 Issues in Flap Surgery

After the complete removal of the tumor (**Figure 11**), the bone‐exposing wound was resur‐ faced with a free flow‐through ALT flap with a 22.0 × 8.0‐cm elliptical skin island (**Figure 12**). The T‐portion of the descending branch of the lateral circumflex femoral vessel was interposed

**Figure 10.** Contrast‐enhanced CT revealed that the lower leg was solely being perfused by the posterior tibial artery.

within the divided posterior tibial artery. Two veins were connected to the accompanying posterior tibial veins by end‐to‐end anastomosis (**Figure 13**). The viability of the skin flaps was favorable without infection or necrosis (**Figure 14**). Contrast‐enhanced computed tomog‐ raphy of the reconstructed leg 1 month after surgery demonstrated successful revasculariza‐ tion at the vascular anastomotic sites, which maintained effective circulation of the right foot (**Figure 15**). Six months later, the patient showed a favorable outcome of the lower leg without recurrence (**Figure 16**).

**Figure 11.** Intraoperative picture after the complete tumor removal showing the large bone‐exposing wound.

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**Figure 11.** Intraoperative picture after the complete tumor removal showing the large bone‐exposing wound.

within the divided posterior tibial artery. Two veins were connected to the accompanying posterior tibial veins by end‐to‐end anastomosis (**Figure 13**). The viability of the skin flaps was favorable without infection or necrosis (**Figure 14**). Contrast‐enhanced computed tomog‐ raphy of the reconstructed leg 1 month after surgery demonstrated successful revasculariza‐ tion at the vascular anastomotic sites, which maintained effective circulation of the right foot (**Figure 15**). Six months later, the patient showed a favorable outcome of the lower leg without

**Figure 10.** Contrast‐enhanced CT revealed that the lower leg was solely being perfused by the posterior tibial artery.

recurrence (**Figure 16**).

60 Issues in Flap Surgery

**Figure 12.** A harvested flow‐through ALT flap.

*Case 3*. A 57‐year‐old male had developed a diabetic ulcer on the medial malleolus, which had enlarged over a 1‐year period. He had non‐controlled diabetes mellitus for more than 7 years. There was evidence of peripheral circulatory disturbance. The chronic ulcer reached the fibula and osteomyelitis occurred (**Figure 17**). He underwent debridement that included infected bone. To maintain peripheral circulation, the defect after resection was resurfaced

**Figure 13.** Intraoperative picture showing the T‐portion of the descending branch interposed within the divided

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posterior tibial artery. The arrows indicate the microsurgical anastomosis points.

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**Figure 13.** Intraoperative picture showing the T‐portion of the descending branch interposed within the divided posterior tibial artery. The arrows indicate the microsurgical anastomosis points.

*Case 3*. A 57‐year‐old male had developed a diabetic ulcer on the medial malleolus, which had enlarged over a 1‐year period. He had non‐controlled diabetes mellitus for more than 7 years. There was evidence of peripheral circulatory disturbance. The chronic ulcer reached the fibula and osteomyelitis occurred (**Figure 17**). He underwent debridement that included infected bone. To maintain peripheral circulation, the defect after resection was resurfaced

**Figure 12.** A harvested flow‐through ALT flap.

62 Issues in Flap Surgery

**Figure 14.** A postoperative photograph showing the resurfacing of all of the bone‐exposing wound, and immediate resumption of foot circulation.

**Figure 15.** Contrast‐enhanced CT demonstrated sufficient circulation of both the transferred flap and right foot.

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**Figure 15.** Contrast‐enhanced CT demonstrated sufficient circulation of both the transferred flap and right foot.

**Figure 14.** A postoperative photograph showing the resurfacing of all of the bone‐exposing wound, and immediate

resumption of foot circulation.

64 Issues in Flap Surgery

**Figure 17.** *Case 3*. This photograph shows a diabetic ulcer on the medial malleolus associated with osteomyelitis.

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**Figure 18.** A harvested flow‐through ALT fasciocutaneous flap.

**Figure 16.** A 6‐month postoperative view. The viability of both the leg and flap was favorable, without tumor recurrence.

with a free flow‐through ATL fasciocutaneous flap (**Figure 18**). The T‐portion of the descend‐ ing branch was interposed within the posterior tibial vessel. The viability of the skin flaps was favorable without infection or necrosis (**Figure 19**). This flap was thin enough to enable him to wear shoes (**Figure 20**).

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**Figure 17.** *Case 3*. This photograph shows a diabetic ulcer on the medial malleolus associated with osteomyelitis.

**Figure 18.** A harvested flow‐through ALT fasciocutaneous flap.

with a free flow‐through ATL fasciocutaneous flap (**Figure 18**). The T‐portion of the descend‐ ing branch was interposed within the posterior tibial vessel. The viability of the skin flaps was favorable without infection or necrosis (**Figure 19**). This flap was thin enough to enable him

**Figure 16.** A 6‐month postoperative view. The viability of both the leg and flap was favorable, without tumor recurrence.

to wear shoes (**Figure 20**).

66 Issues in Flap Surgery

**Figure 19.** A 6‐month post‐operative view. The viability of both the leg and flap was favorable, there was no ulcer recurrence.

> *Case 4***.** A 53‐year‐old man underwent resection of a malignant melanoma presenting at the distolateral plantar weight‐bearing region of the right foot (**Figure 21**). The defect after resec‐ tion of the melanoma was repaired with a reversed island median plantar flap (**Figure 22**). However, the flap became ischemia as the reversed blood flow was insufficient to maintain adequate circulation. Thus, the instep donor defect was covered with a free anterolateral thigh

> **Figure 20.** A 6‐month post‐operative view. The ALT fasciocutaneous flap was thin enough to enable the patient to wear

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shoes.

#### **5.3. Additional blood supply for ischemic flap**

As a flow‐through flap can supply circulation for distal areas, it may be utilized to improve blood flow to other distally‐based ischemic flaps, which show poor circulation [7, 23].

Application of Free Flow‐Through Anterolateral Thigh Flap for the Reconstruction of an Extremi... http://dx.doi.org/10.5772/intechopen.69404 69

**Figure 20.** A 6‐month post‐operative view. The ALT fasciocutaneous flap was thin enough to enable the patient to wear shoes.

*Case 4***.** A 53‐year‐old man underwent resection of a malignant melanoma presenting at the distolateral plantar weight‐bearing region of the right foot (**Figure 21**). The defect after resec‐ tion of the melanoma was repaired with a reversed island median plantar flap (**Figure 22**). However, the flap became ischemia as the reversed blood flow was insufficient to maintain adequate circulation. Thus, the instep donor defect was covered with a free anterolateral thigh

**5.3. Additional blood supply for ischemic flap**

recurrence.

68 Issues in Flap Surgery

As a flow‐through flap can supply circulation for distal areas, it may be utilized to improve

**Figure 19.** A 6‐month post‐operative view. The viability of both the leg and flap was favorable, there was no ulcer

blood flow to other distally‐based ischemic flaps, which show poor circulation [7, 23].

**Figure 22.** Intraoperative photograph of the wound after complete resection of the tumor.

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71

**Figure 23.** Schematic representation of the instep donor defect coverage with a free flow‐through ALT flap.

**Figure 21.** *Case 4*. This photograph shows a malignant melanoma on the distolateral plantar weight‐bearing region of the right foot.

Application of Free Flow‐Through Anterolateral Thigh Flap for the Reconstruction of an Extremi... http://dx.doi.org/10.5772/intechopen.69404 71

**Figure 22.** Intraoperative photograph of the wound after complete resection of the tumor.

**Figure 23.** Schematic representation of the instep donor defect coverage with a free flow‐through ALT flap.

**Figure 21.** *Case 4*. This photograph shows a malignant melanoma on the distolateral plantar weight‐bearing region of

the right foot.

70 Issues in Flap Surgery

flap, while the T‐portion of the descending branch of the lateral circumflex femoral vessel was interposed within the transected medial plantar vessel providing additional blood supply to the ischemic flap (**Figures 23** and **24**). Consequently, ischemia of the reversed median plantar flap improved, because the interrupted medial plantar vessel resumed normal blood flow (**Figure 25**). The patient could walk without tumor recurrence 1 year after surgery (**Figure 26**).

**Figure 24.** A harvested flow‐through ALT flap.

**6. Discussion**

recurrence.

coverage [24].

site [25, 26].

Reconstruction of soft tissue defects in areas of the extremities with no or impaired circula‐ tion is one of the most difficult challenges. Surgeons must reconstruct the defect as well as maintain the peripheral circulation, or patients will lose their limbs. A flow‐through flap may be utilized in an effort to reconstruct the vasculature as well as provide soft tissue

**Figure 26.** A 12‐month postoperative view. The viability of both the leg and flap was favorable; there was no tumor

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73

The author believes that this flap is useful not only for establishing arterial blood supply to the peripheral tissue, but also for preserving venous return, especially in legs with venous stasis. This is particularly so, because it does not sacrifice the valuable deep venous return system. Furthermore, several investigators have reported that flow‐through arterial anas‐ tomosis leads to a higher patency rate than conventional end‐to‐end and end‐to‐side arte‐ rial anastomosis, and even promoted more favorable blood flow through the anastomotic

**Figure 25.** The T‐portion of the descending branch was interposed within the transected medial plantar vessel. Subsequently, ischemia of the reversed median plantar flap improved.

Application of Free Flow‐Through Anterolateral Thigh Flap for the Reconstruction of an Extremi... http://dx.doi.org/10.5772/intechopen.69404 73

**Figure 26.** A 12‐month postoperative view. The viability of both the leg and flap was favorable; there was no tumor recurrence.

## **6. Discussion**

flap, while the T‐portion of the descending branch of the lateral circumflex femoral vessel was interposed within the transected medial plantar vessel providing additional blood supply to the ischemic flap (**Figures 23** and **24**). Consequently, ischemia of the reversed median plantar flap improved, because the interrupted medial plantar vessel resumed normal blood flow (**Figure 25**). The patient could walk without tumor recurrence 1 year after surgery (**Figure 26**).

**Figure 25.** The T‐portion of the descending branch was interposed within the transected medial plantar vessel.

Subsequently, ischemia of the reversed median plantar flap improved.

**Figure 24.** A harvested flow‐through ALT flap.

72 Issues in Flap Surgery

Reconstruction of soft tissue defects in areas of the extremities with no or impaired circula‐ tion is one of the most difficult challenges. Surgeons must reconstruct the defect as well as maintain the peripheral circulation, or patients will lose their limbs. A flow‐through flap may be utilized in an effort to reconstruct the vasculature as well as provide soft tissue coverage [24].

The author believes that this flap is useful not only for establishing arterial blood supply to the peripheral tissue, but also for preserving venous return, especially in legs with venous stasis. This is particularly so, because it does not sacrifice the valuable deep venous return system. Furthermore, several investigators have reported that flow‐through arterial anas‐ tomosis leads to a higher patency rate than conventional end‐to‐end and end‐to‐side arte‐ rial anastomosis, and even promoted more favorable blood flow through the anastomotic site [25, 26].

## **7. Conclusion**

The principal advantage of the flow‐through flap is that it allows a single‐stage composite reconstruction of both soft tissue and vascular defects, making it particularly useful in the reconstruction of ischemic extremities and defects resulting from oncologic ablations.

[9] Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial forearm flap: A versatile method for intra‐oral reconstruction. British Journal of Plastic Surgery. 1983;**36**(1):1‐8 [10] Koshima I, Fujitsu M, Ushio S, Sugiyama N, Yamashita S. Flow‐through anterior thigh flaps with a short pedicle for reconstruction of lower leg and foot defects. Plastic and

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75

[11] Miyamoto S, Kayano S, Umezawa H, Fujiki M, Sakuraba M. Flow‐through fibula flap using soleus branch as distal runoff:. A case report. Microsurgery. 2013;**33**(1):606‐602.

[12] Garvey PB, Clemens MW, Rhines LD, Sacks JM. Vertical rectus abdominis musculo‐ cutaneous flow‐through flap to a free fibula flap for total sacrectomy reconstruction.

[13] Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapular‐tho‐ racodorsal arterial system: study of 100 cadaver dissections. British Journal of Plastic

[14] Xu DC, Zhong SZ, Kong JM, Wang GY, Liu MZ, Luo LS, Gao JH. Applied anatomy of the anterolateral femoral flap. Plastic and Reconstructive Surgery. 1988;**82**:305‐310

[15] Ceulemans P, Hofer SO. Flow‐through anterolateral thigh flap for a free osteocutaneous fibula flap in secondary composite mandible reconstruction. British Journal of Plastic

[16] Ao M, Nagase Y, Mae O, Namba Y. Reconstruction of posttraumatic defects of the foot by flow‐through anterolateral or anteromedial thigh flaps with preservation of posterior

[17] Wong CH, Wei FC. Anterolateral thigh flap. Head and Neck. 2010;**32**(4):529‐540. DOI:

[18] Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft‐tis‐ sue flap? An experience with 672 anterolateral thigh flaps. Plastic and Reconstructive

[19] Gokhan M, Ulusal AE, Atik A, Sargin S, Ulusal B, Sukru Sahin M. Descending branch of the lateral circumflex femoral artery as a recipient vessel for vascularized fibular grafts:

[20] Haffey TM, Lamarre ED, Fritz MA. Auto flow‐through technique for anterolateral Thigh Flaps. JAMA Facial Plastic Surgery. 2014;**16**(2):147‐150. DOI:10.1001/jamafacial.2013.2263

[21] Fujioka M, Hayashida K, Murakami C. Artificial dermis is not effective for resur‐ facing bone‐exposing wounds of Gustilo‐Anderson III fracture. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2013;**66**(4):e119‐121. DOI: 10.1016/j.bjps.2012.12.005

[22] Kells AF, Broyles JM, Simoa AF, Lewis VO, Sacks JM. Anterolateral thigh flow‐through

Clinical case series. Microsurgery. 2014;**34**(8):633‐637. DOI: 10.1002/micr.22299

Reconstructive Surgery. 2005;**115**(1):155‐162. DOI:10.1055/s‐2008‐1040770

Microsurgery. 2013;**33**(1):32‐38. DOI: 10.1002/micr.21990

Surgery. 2004;**57**(4):358‐361. DOI:10.1016/j.bjps.2004.02.013

tibial vessels. Annals of Plastic Surgery. 1997;**38**:598‐603

10.1002/hed.21204. DOI:10.1002/hed.21204

flap in hand salvage. Eplasty. 2013;**13**:e19

Surgery. 2002;**109**:2219‐2226

DOI:10.1002/micr.22043

Surgery. 1984;**37**:574‐576

## **Author details**

Masaki Fujioka

Address all correspondence to: mfujioka@nagasaki‐mc.com

Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Ohmura City, Japan

## **References**


[9] Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial forearm flap: A versatile method for intra‐oral reconstruction. British Journal of Plastic Surgery. 1983;**36**(1):1‐8

**7. Conclusion**

74 Issues in Flap Surgery

**Author details**

Masaki Fujioka

**References**

DOI:10.1055/s‐2008‐1064498

North America. 1994;**27**(1):1731‐1794

Surgical Oncology. 1995;**11**(3):208‐220

2014;**53**:324‐327. DOI: 10.1053/j.jfas.2013.12.012

185. DOI: 10.1007/BF01152186

The principal advantage of the flow‐through flap is that it allows a single‐stage composite reconstruction of both soft tissue and vascular defects, making it particularly useful in the

reconstruction of ischemic extremities and defects resulting from oncologic ablations.

Department of Plastic and Reconstructive Surgery, Clinical Research Center, National

[1] Clymer MA, Burkey BB. Other flaps for head and neck use: Temporoparietal fascial free flap, lateral arm free flap, omental free flap. Facial Plastic Surgery. 1996;**12**(1):81‐89.

[2] Shindo ML, Sullivan MJ. Soft‐tissue microvascular free flaps. Otolaryngologic Clinics of

[3] Coleman JJ 3rd. Reconstruction of the pharynx and cervical esophagus. Seminars in

[4] Baker SR. Microvascular free flaps in soft‐tissue augmentation of the head and neck.

[5] Saint‐Cyr M, Langstein HN. Reconstruction of the hand and upper extremity after tumor resection. Journal of Surgical Oncology. 2006;**94**:490‐503. DOI:10.1002/jso.20486

[6] Fujioka M, Hayashida K, Murakami C. Emergent free flow‐through anterolateral thigh flaps for Gustilo‐Anderson III fracture of the upper extremity. Journal of Emergencies,

[7] Fujioka M, Hayashida K, Senju C. Reconstruction of lateral forefoot using reversed medial plantar flap with free anterolateral thigh flap. Journal of Foot and Ankle Surgery.

[8] Costa H, Cunha C, Conde A, Barsdley A, McGrouther DA. The flow‐through free flap in replantation surgery: A new concept. European Journal of Plastic Surgery. 1997;**20**(4)181‐

Archives of Otolaryngology‐‐Head & Neck Surgery. 1986;**112**(7):733‐737

Trauma and Shock. 2014;**7**(1):53‐55. DOI: 10.4103/0974‐2700.125642

Address all correspondence to: mfujioka@nagasaki‐mc.com

Hospital Organization Nagasaki Medical Center, Ohmura City, Japan


[23] Oberlin C, Accioli de Vasconcellos Z, Touam C. Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect. Plastic and Reconstructive Surgery. 2000;**106**:874‐877

**Chapter 5**

**Provisional chapter**

**Emergent or Early Flap Resurfacing Is Required for**

**Emergent or Early Flap Resurfacing Is Required for** 

**IIIC Fractures**

**IIIC Fractures**

Masaki Fujioka

**Abstract**

procedure.

**1. Introduction**

Masaki Fujioka

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70147

**Bone-Exposing Wounds of Gustilo-Anderson IIIB and**

Background: The wound treatment has progressed owing to the development of new medicine, instruments. Following these trends, can the bone-exposing wounds of severe open fractures be resurfaced without using flaps but only skin grafting? We evaluated a new medicine and instrument, for the resurfacing of bone-exposing complex wounds of Gustilo-Anderson IIIB and C fractures. Patients and methods: Patients with Gustilo-Anderson IIIB (five cases) and C (two cases) open fractures who underwent open reduction and external fixation were evaluated. Bone-exposing wounds were resurfaced with artificial dermis, and basic fibroblast growth factor was sprayed. We investigated the course and outcome. Result: In all of seven cases, abundant granulation tissue did not develop on the bone-exposing wound surface during 2–5 weeks, and 4 patients developed osteomyelitis. Subsequently, all cases required flap surgery to resurface the wound. All patients could walk; however, required a longer period for the complete union of bones. Conclusion: This study showed that it was impossible to prepare a favorable wound bed on the bone when the fracture was severe. Thus, early flap surgery was a recommendable resurfacing option. Furthermore, emergent bone resurfacing with flap, while performing rigid bone fixation with an internal fixation plate, was an ideal

**Bone-Exposing Wounds of Gustilo-Anderson IIIB and** 

DOI: 10.5772/intechopen.70147

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Gustilo-Anderson type III fracture is defined as an open fracture with extensive soft-tissue laceration, damage, or loss or an open segmental fracture, and type IIIB as a severe that open

**Keywords:** emergent reconstruction, free flow-through flap, anterolateral thigh flap,

Gustilo-Anderson IIIB and C fractures, vascular repair


#### **Emergent or Early Flap Resurfacing Is Required for Bone-Exposing Wounds of Gustilo-Anderson IIIB and IIIC Fractures Emergent or Early Flap Resurfacing Is Required for Bone-Exposing Wounds of Gustilo-Anderson IIIB and IIIC Fractures**

DOI: 10.5772/intechopen.70147

Masaki Fujioka Masaki Fujioka

[23] Oberlin C, Accioli de Vasconcellos Z, Touam C. Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect. Plastic and Reconstructive Surgery.

[24] Hidalgo DA. Aesthetic improvements in free‐flap mandible reconstruction. Plastic and

[25] Kim JT, Kim CY, Kim YH. T‐anastomosis in microsurgical free flap reconstruction: An overview of clinical applications. Journal of Plastic, Reconstructive & Aesthetic Surgery.

[26] Miyamoto S, Okazaki M, Ohura N, Shiraishi T, Takushima A, Harii K. Comparative study of different combinations of microvascular anastomoses in a rat model: end‐to‐ end, end‐to‐side, and flow‐through anastomosis. Plastic and Reconstructive Surgery.

2000;**106**:874‐877

76 Issues in Flap Surgery

Reconstructive Surgery. 1991;**88**:574‐585

2008;**61**:1157‐1163. DOI:10.1016/j.bjps.2008.03.048

2008;**122**:449‐455. DOI:10.1097/PRS.0b013e31817d62c5

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70147

#### **Abstract**

Background: The wound treatment has progressed owing to the development of new medicine, instruments. Following these trends, can the bone-exposing wounds of severe open fractures be resurfaced without using flaps but only skin grafting? We evaluated a new medicine and instrument, for the resurfacing of bone-exposing complex wounds of Gustilo-Anderson IIIB and C fractures. Patients and methods: Patients with Gustilo-Anderson IIIB (five cases) and C (two cases) open fractures who underwent open reduction and external fixation were evaluated. Bone-exposing wounds were resurfaced with artificial dermis, and basic fibroblast growth factor was sprayed. We investigated the course and outcome. Result: In all of seven cases, abundant granulation tissue did not develop on the bone-exposing wound surface during 2–5 weeks, and 4 patients developed osteomyelitis. Subsequently, all cases required flap surgery to resurface the wound. All patients could walk; however, required a longer period for the complete union of bones. Conclusion: This study showed that it was impossible to prepare a favorable wound bed on the bone when the fracture was severe. Thus, early flap surgery was a recommendable resurfacing option. Furthermore, emergent bone resurfacing with flap, while performing rigid bone fixation with an internal fixation plate, was an ideal procedure.

**Keywords:** emergent reconstruction, free flow-through flap, anterolateral thigh flap, Gustilo-Anderson IIIB and C fractures, vascular repair

#### **1. Introduction**

Gustilo-Anderson type III fracture is defined as an open fracture with extensive soft-tissue laceration, damage, or loss or an open segmental fracture, and type IIIB as a severe that open

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

fracture with extensive soft-tissue loss. The severest open fracture is called type IIIC; it is associated with an arterial injury requiring immediate repair [1]. The resurfacing of boneexposing complex wounds of this type of fracture remains challenging. Previous conventional wound management involved leaving wounds open after debridement; this might have been because antibiotics and surgical debridement did not prevail, and soft-tissue reconstructive techniques had not been developed [2–5].

Recent technological advances of wound management have made the healing of complex chronic wounds earlier and easier [6, 7]. The development of new medicines, instruments, and techniques, including artificial dermis, angiogenic cytokines, and negative pressure wound treatment device, has allowed bone-exposing wounds to heal more quickly [8, 9]. Among these, artificial dermis is beneficial for the resurfacing of wounds with exposed tendons or bone. Its unique granular regeneration promoting characteristic even on bare bone may allow resurfacing with a free skin graft. Thus, it may replace flap surgery for the treatment of several bone-exposing wounds including deep burns, postabrasion of neoplasms, and skin defects due to trauma (**Figures 1**–**3**) [10, 11].

It is generally felt difficult to prepare a favorable wound bed on the bone when the open fracture is too severe and complex, such as those classified as Gustilo-Anderson IIIB and C. This work is divided into three sections. In the first section, we present and discuss the outcome of resurfacing Gustilo-Anderson IIIB and C bone-exposing wounds, subjected to late treatment using artificial dermis. In the second section, we describe and discuss cases of successful

salvage and reconstruction of Gustilo-Anderson IIIC extremity fractures, highlighting the advantage of emergent free flow-through flap resurfacing. In the third section, we introduce and discuss the "fix and flap" concept, a new radical concept for the treatment of severe open

**Figure 2.** The wound was covered with granulation tissue 4 weeks after injury; thus, a full-thickness skin graft could be

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**Figure 3.** Photograph at 3 months postinjury showing the resurfacing of all of the bone-exposing wound.

**2. Disadvantages of conventional late resurfacing for Gustilo-Anderson** 

Conventional options to treat Gustilo-Anderson IIIB and C bone-exposing injuries are primary surgery including debridement and cleansing, vascular repair, bone reduction/external fixation, and secondary wound resurfacing surgery by skin graft and pedicle or free flap transfer (**Figures 4**–**8**) [12–14]. Ideally, all procedure should be performed immediately; however, the resurfacing of wound tends to be performed late, because of concerns over the development of wound infection or shortage of surgical staff for emergent surgery. In these cases,

fractures.

performed.

**IIIB and C bone-exposing wounds**

**Figure 1.** Case 1. This picture shows a forehead injury with a skin defect exposing frontal bone. Artificial dermis was applied to the wound.

Emergent or Early Flap Resurfacing Is Required for Bone-Exposing Wounds of Gustilo-Anderson... http://dx.doi.org/10.5772/intechopen.70147 79

fracture with extensive soft-tissue loss. The severest open fracture is called type IIIC; it is associated with an arterial injury requiring immediate repair [1]. The resurfacing of boneexposing complex wounds of this type of fracture remains challenging. Previous conventional wound management involved leaving wounds open after debridement; this might have been because antibiotics and surgical debridement did not prevail, and soft-tissue reconstructive

Recent technological advances of wound management have made the healing of complex chronic wounds earlier and easier [6, 7]. The development of new medicines, instruments, and techniques, including artificial dermis, angiogenic cytokines, and negative pressure wound treatment device, has allowed bone-exposing wounds to heal more quickly [8, 9]. Among these, artificial dermis is beneficial for the resurfacing of wounds with exposed tendons or bone. Its unique granular regeneration promoting characteristic even on bare bone may allow resurfacing with a free skin graft. Thus, it may replace flap surgery for the treatment of several bone-exposing wounds including deep burns, postabrasion of neoplasms, and skin defects

It is generally felt difficult to prepare a favorable wound bed on the bone when the open fracture is too severe and complex, such as those classified as Gustilo-Anderson IIIB and C. This work is divided into three sections. In the first section, we present and discuss the outcome of resurfacing Gustilo-Anderson IIIB and C bone-exposing wounds, subjected to late treatment using artificial dermis. In the second section, we describe and discuss cases of successful

**Figure 1.** Case 1. This picture shows a forehead injury with a skin defect exposing frontal bone. Artificial dermis was applied

techniques had not been developed [2–5].

78 Issues in Flap Surgery

due to trauma (**Figures 1**–**3**) [10, 11].

to the wound.

**Figure 2.** The wound was covered with granulation tissue 4 weeks after injury; thus, a full-thickness skin graft could be performed.

**Figure 3.** Photograph at 3 months postinjury showing the resurfacing of all of the bone-exposing wound.

salvage and reconstruction of Gustilo-Anderson IIIC extremity fractures, highlighting the advantage of emergent free flow-through flap resurfacing. In the third section, we introduce and discuss the "fix and flap" concept, a new radical concept for the treatment of severe open fractures.

## **2. Disadvantages of conventional late resurfacing for Gustilo-Anderson IIIB and C bone-exposing wounds**

Conventional options to treat Gustilo-Anderson IIIB and C bone-exposing injuries are primary surgery including debridement and cleansing, vascular repair, bone reduction/external fixation, and secondary wound resurfacing surgery by skin graft and pedicle or free flap transfer (**Figures 4**–**8**) [12–14]. Ideally, all procedure should be performed immediately; however, the resurfacing of wound tends to be performed late, because of concerns over the development of wound infection or shortage of surgical staff for emergent surgery. In these cases,

**Figure 4.** Case 2. Conventional treatment of Gustilo-Anderson IIIC fracture. The patient sustained an open fracture to the right leg.

**Figure 6.** After reduction and external fixation, the posterior tibial artery was repaired with an interposition of vein graft.

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81

**Figure 7.** Three weeks later, the wound was resurfaced by local skin flap and free skin graft.

The wound was covered temporarily with artificial dermis.

pending secondary surgery, the wound is dressed temporarily with wet gauze, several wound dressing materials, or artificial dermis. Our practice has been to apply artificial dermis on the bone, expecting granulation. In this section, we present the outcome of resurfacing Gustilo-Anderson IIIB and C wounds, which had been treated with artificial dermis.

**Figure 5.** The X-ray image shows both tibia and fibula fractures.

Emergent or Early Flap Resurfacing Is Required for Bone-Exposing Wounds of Gustilo-Anderson... http://dx.doi.org/10.5772/intechopen.70147 81

**Figure 6.** After reduction and external fixation, the posterior tibial artery was repaired with an interposition of vein graft. The wound was covered temporarily with artificial dermis.

**Figure 7.** Three weeks later, the wound was resurfaced by local skin flap and free skin graft.

pending secondary surgery, the wound is dressed temporarily with wet gauze, several wound dressing materials, or artificial dermis. Our practice has been to apply artificial dermis on the bone, expecting granulation. In this section, we present the outcome of resurfacing Gustilo-

**Figure 4.** Case 2. Conventional treatment of Gustilo-Anderson IIIC fracture. The patient sustained an open fracture to

Anderson IIIB and C wounds, which had been treated with artificial dermis.

**Figure 5.** The X-ray image shows both tibia and fibula fractures.

the right leg.

80 Issues in Flap Surgery

**4. Results**

In all of the seven cases, abundant granulation tissue did not develop on the bone-exposing wound surface during 2–5 weeks after applying the artificial dermis to the bone. Four patients developed osteomyelitis and required continuous irrigation. Among them, two underwent sequestrectomy (**Figures 9**–**12**). Subsequently, all cases required local flap transfer to resurface the bone-exposing wound (**Figures 13**–**16**). One patient developed malunion and required bone grafting. Patients suffering from complications required a longer period for the complete union of bones, a fact which prolonged the fixation period (11–18 months). Finally,

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**Figure 9.** Case 3. The unpleasant course of Gustilo-Anderson IIIB fracture treated with conventional late wound

**Figure 10.** After reduction and external fixation, the wound was covered temporarily with artificial dermis. The picture

resurfacing. The patient sustained an open fracture to the right leg.

shows osteomyelitis 2 weeks later.

all patients could walk after removal of the external fixation (**Figures 17** and **18**).

**Figure 8.** The X-ray image months later shows favorable bone union.

## **3. Patients and method**

A total of seven patients with Gustilo-Anderson III B (five cases) and C (two cases) open fracture were treated in the National Organization Nagasaki Medical Center in 2011 and 2012 (**Table 1**). All patients underwent open reduction and Ilizarov external fixation. Artificial dermis (TerudermisR, Orimpas-Terumo Co., Ltd., Tokyo, Japan) and ointment-impregnated gauze were applied to the wounds.


**Table 1.** Cases of patients with Gustilo-Anderson IIIB and C open fracture who were treated with artificial dermis.

## **4. Results**

**3. Patients and method**

82 Issues in Flap Surgery

**Figure 8.** The X-ray image months later shows favorable bone union.

**Gustilo-Anderson classification**

IIIC (PTA reconstruction)

reconstruction)

gauze were applied to the wounds.

**Age sex Site of open fracture**

1 74 M Rt. tibia and fibula

2 58 M Rt. tibia and fibula

3 32 M Rt. tibia and fibula

4 68 M Rt. tibia and fibula

5 44 M Rt. tibia and fibula

7 74 M Rt. tibia and fibula

6 56 M Rt. tibia IIIC (PTA

PTA: Posterior tibial artery, FSG: Free skin grafting

A total of seven patients with Gustilo-Anderson III B (five cases) and C (two cases) open fracture were treated in the National Organization Nagasaki Medical Center in 2011 and 2012 (**Table 1**). All patients underwent open reduction and Ilizarov external fixation. Artificial dermis (TerudermisR, Orimpas-Terumo Co., Ltd., Tokyo, Japan) and ointment-impregnated

**Complication Surgical resurfacing** 

**week)**

IIIB Osteomyelitis Sequestration (2 W),

IIIB Osteomyelitis Sequestration, local

**Table 1.** Cases of patients with Gustilo-Anderson IIIB and C open fracture who were treated with artificial dermis.

**(postinjury period,** 

IIIB – Local flap (3 W) – Walk/6

local flap (5 W)

IIIB Osteomyelitis Local flap (W) Bone grafting Walk/11

IIIB – Local flap (W) – Walk/10

flap (2 W)

– Local flap (5 W) – Walk/4

Osteomyelitis Local flap (4 W) – Walk/11

**Additional surgery**

**Prognosis/ external fixation period**

months

months

months

months

months

months

months

Sequestrectomy Walk/13

Sequestrectomy Walk/18

In all of the seven cases, abundant granulation tissue did not develop on the bone-exposing wound surface during 2–5 weeks after applying the artificial dermis to the bone. Four patients developed osteomyelitis and required continuous irrigation. Among them, two underwent sequestrectomy (**Figures 9**–**12**). Subsequently, all cases required local flap transfer to resurface the bone-exposing wound (**Figures 13**–**16**). One patient developed malunion and required bone grafting. Patients suffering from complications required a longer period for the complete union of bones, a fact which prolonged the fixation period (11–18 months). Finally, all patients could walk after removal of the external fixation (**Figures 17** and **18**).

**Figure 9.** Case 3. The unpleasant course of Gustilo-Anderson IIIB fracture treated with conventional late wound resurfacing. The patient sustained an open fracture to the right leg.

**Figure 10.** After reduction and external fixation, the wound was covered temporarily with artificial dermis. The picture shows osteomyelitis 2 weeks later.

**Figure 11.** After sequestrectomy and continuous wound irrigation, the wound was cleansed. Next, the wound was resurfaced by local skin flap and free skin graft 3 weeks later.

**Figure 14.** The wound was covered temporarily with artificial dermis. The picture shows absence of granulation growth

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**Figure 15.** A local skin flap and a free skin were planned to resurface the wound. The picture shows the design of the flap.

on the bone 3 weeks later.

**Figure 12.** The picture shows the appearance of the injured leg. The patient took 6 months to walk.

**Figure 13.** Case 4. The patient sustained a Gustilo-Anderson IIIB open fracture to both tibia and fibula.

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**Figure 14.** The wound was covered temporarily with artificial dermis. The picture shows absence of granulation growth on the bone 3 weeks later.

**Figure 15.** A local skin flap and a free skin were planned to resurface the wound. The picture shows the design of the flap.

**Figure 13.** Case 4. The patient sustained a Gustilo-Anderson IIIB open fracture to both tibia and fibula.

**Figure 12.** The picture shows the appearance of the injured leg. The patient took 6 months to walk.

**Figure 11.** After sequestrectomy and continuous wound irrigation, the wound was cleansed. Next, the wound was

resurfaced by local skin flap and free skin graft 3 weeks later.

84 Issues in Flap Surgery

fibroblasts and better growth of connective tissue strands and epithelium [10]. However, bone-exposing wounds in our patients with Gustilo-Anderson IIIB and C fractures had not improved with this treatment, and required conventional flap surgery. The main problem might have been the total absence or extreme deficiency of blood flow to bone fragment or fractured stumps, which had led to sequestration and osteomyelitis, prolonging the period of external fixation. Although the wounds might not have developed infection, a favorable wound bed could not have developed with poor vascularity. We conclude that, at the present stage of its development, artificial dermis is not a recommendable resurfacing option for patients with Gustilo-Anderson IIIB and C fractures, because it does not help improve poor bone circulation, a fact which may result in osteomyelitis. Thus, immediate primary

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skin closure is desired for patients with Gustilo-Anderson IIIB and C fractures [15].

**6. Application of free flow-through anterolateral thigh (ATL) flap for** 

The vascular injury associated with extremity trauma primarily requires open vascular repair immediate after injury, such as direct anastomosis, an interposition vein graft, or a bypass graft, to restore blood flow to distal area of injured extremities [13] (**Figure 17**). Since the development of concept of the flow-through flap, in which both the proximal and distal ends of the vascular pedicle of a free flap are anastomosed to restore blood flow to distal tissues, many investigators have described the application of flow-through flaps for reconstruction of the extremities [16–19] (**Figure 18**). Instead of conventional interposing vein graft to replace the injured artery, microsurgical free flow-through type flaps use has the added benefit of restoring blood flow to the distal extremities normally, whilst simultaneously immediately reconstructing soft-tissue defects in soft-tissue-deficient wounds. Furthermore, exploring the recipient vasculature for purpose of anastomosing the flap vessels is usually straightforward when reconstructive surgery is performed immediately after injury [20].

These special flaps require a T-shaped branching system of the pedicle vessel with proper diameters. Surgeon can choose several kinds of flow-through type flaps, including latissimus dorsi musculocutaneous, rectus abdominis musculocutaneous, fibula osteomyocutaneous, and anterolateral thigh (ALT) flaps [20–22]. Among all of the above, the ALT flap can provide a large skin paddle and long and suitable pedicle; thus, it is ideal for extremity reconstruction with minimal donor site morbidity [23]. In this article, we present cases of successful salvage and reconstruction of the extremities using free flow-through ALT flaps.

**6.2. Case presentations of Gustilo-Anderson IIIB and C limb fractures reconstructed**

Case 7. Having been caught in a harvester, a 62-year-old man sustained a Gustilo-Anderson type IIIC ulnar fracture to the left elbow with wide abrasion of the skin and flexor muscles (**Figure 19**)

**Gustilo-Anderson IIIB and C bone-exposing wounds**

**6.1. Advantage of flow-through type flaps**

 **with free ALT flow-through type flaps**

**Figure 16.** The picture shows a postoperative view. The bone-exposed wound was covered with flap, the remaining wound received a free skin graft.

**Figure 17.** Schematic representation of the conventional procedure of vascular repair for Gustilo-Anderson IIIC fracture. This method requires additional flap surgery for wound coverage.

**Figure 18.** Schematic representation of the flow-through free flap procedure of vascular repair for Gustilo-Anderson IIIC fracture. This method makes both vascular repair and immediate wound resurfacing possible.

#### **5. Discussion and conclusion**

It is widely known that artificial dermis is used for the reconstruction of wounds with exposed tendons or bone, because it promotes early infiltration of mononuclear cells and fibroblasts and better growth of connective tissue strands and epithelium [10]. However, bone-exposing wounds in our patients with Gustilo-Anderson IIIB and C fractures had not improved with this treatment, and required conventional flap surgery. The main problem might have been the total absence or extreme deficiency of blood flow to bone fragment or fractured stumps, which had led to sequestration and osteomyelitis, prolonging the period of external fixation. Although the wounds might not have developed infection, a favorable wound bed could not have developed with poor vascularity. We conclude that, at the present stage of its development, artificial dermis is not a recommendable resurfacing option for patients with Gustilo-Anderson IIIB and C fractures, because it does not help improve poor bone circulation, a fact which may result in osteomyelitis. Thus, immediate primary skin closure is desired for patients with Gustilo-Anderson IIIB and C fractures [15].

## **6. Application of free flow-through anterolateral thigh (ATL) flap for Gustilo-Anderson IIIB and C bone-exposing wounds**

#### **6.1. Advantage of flow-through type flaps**

**5. Discussion and conclusion**

This method requires additional flap surgery for wound coverage.

wound received a free skin graft.

86 Issues in Flap Surgery

It is widely known that artificial dermis is used for the reconstruction of wounds with exposed tendons or bone, because it promotes early infiltration of mononuclear cells and

**Figure 18.** Schematic representation of the flow-through free flap procedure of vascular repair for Gustilo-Anderson IIIC

fracture. This method makes both vascular repair and immediate wound resurfacing possible.

**Figure 16.** The picture shows a postoperative view. The bone-exposed wound was covered with flap, the remaining

**Figure 17.** Schematic representation of the conventional procedure of vascular repair for Gustilo-Anderson IIIC fracture.

The vascular injury associated with extremity trauma primarily requires open vascular repair immediate after injury, such as direct anastomosis, an interposition vein graft, or a bypass graft, to restore blood flow to distal area of injured extremities [13] (**Figure 17**). Since the development of concept of the flow-through flap, in which both the proximal and distal ends of the vascular pedicle of a free flap are anastomosed to restore blood flow to distal tissues, many investigators have described the application of flow-through flaps for reconstruction of the extremities [16–19] (**Figure 18**). Instead of conventional interposing vein graft to replace the injured artery, microsurgical free flow-through type flaps use has the added benefit of restoring blood flow to the distal extremities normally, whilst simultaneously immediately reconstructing soft-tissue defects in soft-tissue-deficient wounds. Furthermore, exploring the recipient vasculature for purpose of anastomosing the flap vessels is usually straightforward when reconstructive surgery is performed immediately after injury [20].

These special flaps require a T-shaped branching system of the pedicle vessel with proper diameters. Surgeon can choose several kinds of flow-through type flaps, including latissimus dorsi musculocutaneous, rectus abdominis musculocutaneous, fibula osteomyocutaneous, and anterolateral thigh (ALT) flaps [20–22]. Among all of the above, the ALT flap can provide a large skin paddle and long and suitable pedicle; thus, it is ideal for extremity reconstruction with minimal donor site morbidity [23]. In this article, we present cases of successful salvage and reconstruction of the extremities using free flow-through ALT flaps.

#### **6.2. Case presentations of Gustilo-Anderson IIIB and C limb fractures reconstructed with free ALT flow-through type flaps**

Case 7. Having been caught in a harvester, a 62-year-old man sustained a Gustilo-Anderson type IIIC ulnar fracture to the left elbow with wide abrasion of the skin and flexor muscles (**Figure 19**) defect in the ulna, with subsequent opening of the elbow joint cavity (**Figure 20**). The circulation of the left forearm had ceased due to interruption of the brachial artery (**Figure 21**). Immediate reconstruction using a free ALT flow-through type flap was performed. After debridement and external fixation of the elbow joint, the T portion of the descending branch of the lateral circumflex femoral

artery was interposed within the defect of the brachial artery. Two veins were connected to the cutaneous veins by end-to-end anastomosis (**Figures 22** and **23**). The defect of elbow joint capsule was reconstructed with the fascia of the ALT flap, and the bone- and joint-exposing wound was

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**Figure 21.** Contrast-enhanced computed tomography showed that circulation of the left forearm had ceased due to

**Figure 22.** The picture shows a harvested flow-through ALT flap. Arrows indicate the distal and proximal ends of the

interruption of brachial artery.

descending branch.

**Figure 19.** Case 5. The picture shows Gustilo-Anderson IIIC fracture to the left elbow with abrasion of the skin and flexor muscles.

**Figure 20.** An X-ray photograph shows bone defect of ulna, which caused opening of elbow joint cavity.

artery was interposed within the defect of the brachial artery. Two veins were connected to the cutaneous veins by end-to-end anastomosis (**Figures 22** and **23**). The defect of elbow joint capsule was reconstructed with the fascia of the ALT flap, and the bone- and joint-exposing wound was

defect in the ulna, with subsequent opening of the elbow joint cavity (**Figure 20**). The circulation of the left forearm had ceased due to interruption of the brachial artery (**Figure 21**). Immediate reconstruction using a free ALT flow-through type flap was performed. After debridement and external fixation of the elbow joint, the T portion of the descending branch of the lateral circumflex femoral

**Figure 19.** Case 5. The picture shows Gustilo-Anderson IIIC fracture to the left elbow with abrasion of the skin and flexor

**Figure 20.** An X-ray photograph shows bone defect of ulna, which caused opening of elbow joint cavity.

muscles.

88 Issues in Flap Surgery

**Figure 21.** Contrast-enhanced computed tomography showed that circulation of the left forearm had ceased due to interruption of brachial artery.

**Figure 22.** The picture shows a harvested flow-through ALT flap. Arrows indicate the distal and proximal ends of the descending branch.

resurfaced with the vastus lateralis overlying skin island. The blood flow to the hand and forearm through the interposed descending branch was restored, while that to the flap was also favorable (**Figure 24**). The patient could flex his elbow 3 months after surgery (**Figures 25**).

**Figure 23.** The intraoperative photograph shows the descending branch interposed within the interrupted brachial artery. Arrows indicate the areas of anastomosis.

Case 8: Due to a traffic accident, a 32-year-old man sustained a Gustilo-Anderson IIIC type bone-exposing fracture to the left fibula and tibia with severe abrasion of the skin and anterior tibial muscles (**Figure 26**). Circulation of the left foot had ceased because three main arteries

**Figure 26.** Case 6. This photograph shows a Gustilo-Anderson IIIC fracture to the left fibula and tibia with severe

**Figure 25.** View of the reconstructed forearm 3 month after surgery showing favorable resurfacing and successful

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functional outcome.

abrasion of the skin and anterior tibial muscles.

**Figure 24.** Contrast-enhanced computed tomography 2 weeks after surgery showing reestablishment of circulation to the hand and forearm through the interposed descending branch, and blood flow to the flap. The arrows indicated the points of anastomosis.

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resurfaced with the vastus lateralis overlying skin island. The blood flow to the hand and forearm through the interposed descending branch was restored, while that to the flap was also favorable

**Figure 23.** The intraoperative photograph shows the descending branch interposed within the interrupted brachial

**Figure 24.** Contrast-enhanced computed tomography 2 weeks after surgery showing reestablishment of circulation to the hand and forearm through the interposed descending branch, and blood flow to the flap. The arrows indicated the

artery. Arrows indicate the areas of anastomosis.

90 Issues in Flap Surgery

points of anastomosis.

(**Figure 24**). The patient could flex his elbow 3 months after surgery (**Figures 25**).

**Figure 25.** View of the reconstructed forearm 3 month after surgery showing favorable resurfacing and successful functional outcome.

Case 8: Due to a traffic accident, a 32-year-old man sustained a Gustilo-Anderson IIIC type bone-exposing fracture to the left fibula and tibia with severe abrasion of the skin and anterior tibial muscles (**Figure 26**). Circulation of the left foot had ceased because three main arteries

**Figure 26.** Case 6. This photograph shows a Gustilo-Anderson IIIC fracture to the left fibula and tibia with severe abrasion of the skin and anterior tibial muscles.

in the leg (peroneal, posterior tibial, and anterior tibial arteries) had ruptured, and flow had been interrupted. After the crushed bones had been reconstructed and fixed externally, the bone-exposing wound was repaired with a free flow-through ALT flap (**Figures 27** and **28**). The T portion of the descending branch of the ALT flap was interposed to the defect of the anterior tibia artery, and two veins were connected to the cutaneous veins by end-to-end anastomosis. The interrupted anterior tibia artery resumed normal blood flow (**Figure 29**). The viability of the flap was favorable without infection and necrosis. The patient could walk without canes 1 year after surgery (**Figures 30** and **31**).

#### **6.3. Discussion and conclusion**

A flow-through flap is utilized when the flap inflow arterial system not only provides perfusion to the transported flap but also provides a vascular link between the obliterated arteries [24, 25]. Especially, this flap is useful for patients suffering from Gustilo-Anderson IIIC complex injuries, which present with both large soft-tissue defects and main artery defects with compromised circulation of a distal extremities. The flow-through flap transfer can be superior to conventional flaps for achieving the resurfacing of a large tissue defect and vascular repair immediately, a process which reduces infection, induces bony healing, and optimizes limb salvage [23].

**Figure 28.** A The postoperative photograph showing resurfacing with flap and skin graft; circulation of the foot resumed

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**Figure 29.** Computed tomography angiography reveals that the descending branch of the ALT flap was interposed into

the defect of the anterior tibia artery, which supplied blood flow to the foot.

immediately.

**Figure 27.** This picture shows a harvested flow-through ALT flap.

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in the leg (peroneal, posterior tibial, and anterior tibial arteries) had ruptured, and flow had been interrupted. After the crushed bones had been reconstructed and fixed externally, the bone-exposing wound was repaired with a free flow-through ALT flap (**Figures 27** and **28**). The T portion of the descending branch of the ALT flap was interposed to the defect of the anterior tibia artery, and two veins were connected to the cutaneous veins by end-to-end anastomosis. The interrupted anterior tibia artery resumed normal blood flow (**Figure 29**). The viability of the flap was favorable without infection and necrosis. The patient could walk

A flow-through flap is utilized when the flap inflow arterial system not only provides perfusion to the transported flap but also provides a vascular link between the obliterated arteries [24, 25]. Especially, this flap is useful for patients suffering from Gustilo-Anderson IIIC complex injuries, which present with both large soft-tissue defects and main artery defects with compromised circulation of a distal extremities. The flow-through flap transfer can be superior to conventional flaps for achieving the resurfacing of a large tissue defect and vascular repair immediately, a process which reduces infection, induces bony healing, and optimizes

without canes 1 year after surgery (**Figures 30** and **31**).

**Figure 27.** This picture shows a harvested flow-through ALT flap.

**6.3. Discussion and conclusion**

limb salvage [23].

92 Issues in Flap Surgery

**Figure 28.** A The postoperative photograph showing resurfacing with flap and skin graft; circulation of the foot resumed immediately.

**Figure 29.** Computed tomography angiography reveals that the descending branch of the ALT flap was interposed into the defect of the anterior tibia artery, which supplied blood flow to the foot.

**7.2. Case presentation of fix and flap procedure for Gustilo-Anderson IIIB fracture**

A 32-year-old man sustained Gustilo-Anderson IIIB type both tibia and fibula fractures to the right leg with abrasion of the skin and hamstring muscles (**Figures 32** and **33**). After immediate cleansing, reduction, and temporary external fixation, the secondary "fix and

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**Figure 32.** Case 7. This photograph shows a Gustilo-Anderson IIIB type bone-exposing fracture to the right leg with

abrasion of the skin and hamstring muscles.

**Figure 33.** An X-ray photograph shows both tibia and fibula fractures.

**Figure 30.** The patient could walk without canes1 year after surgery.

**Figure 31.** An X-ray photograph shows favorable bone union.

## **7. "Fix and flap," a new radical concept for the treatment of severe open fractures**

#### **7.1. Concept of "fix and flap" procedure for open fracture**

Wound closure of severe open fractures has been delayed with the aim to minimize the risk of infection. However, development of systemic antibiotics, advanced debridement methods, and improvement of surgical techniques have reduced surgical infection. As recent studies have reported that infections after treatment of open fractures are not caused by initial contamination but often are acquired later, emergent or early wound resurfacing for open fractures has been recommended [26–29]. On the other hand, a new radical concept for the treatment of severe open fractures so-called "fix and flap" is recommended as this method also reduces infection [30–32].

#### **7.2. Case presentation of fix and flap procedure for Gustilo-Anderson IIIB fracture**

A 32-year-old man sustained Gustilo-Anderson IIIB type both tibia and fibula fractures to the right leg with abrasion of the skin and hamstring muscles (**Figures 32** and **33**). After immediate cleansing, reduction, and temporary external fixation, the secondary "fix and

**Figure 32.** Case 7. This photograph shows a Gustilo-Anderson IIIB type bone-exposing fracture to the right leg with abrasion of the skin and hamstring muscles.

**Figure 33.** An X-ray photograph shows both tibia and fibula fractures.

**7. "Fix and flap," a new radical concept for the treatment of severe open** 

Wound closure of severe open fractures has been delayed with the aim to minimize the risk of infection. However, development of systemic antibiotics, advanced debridement methods, and improvement of surgical techniques have reduced surgical infection. As recent studies have reported that infections after treatment of open fractures are not caused by initial contamination but often are acquired later, emergent or early wound resurfacing for open fractures has been recommended [26–29]. On the other hand, a new radical concept for the treatment of severe open fractures so-called "fix and flap" is recommended as this method

**7.1. Concept of "fix and flap" procedure for open fracture**

**Figure 31.** An X-ray photograph shows favorable bone union.

**Figure 30.** The patient could walk without canes1 year after surgery.

**fractures**

94 Issues in Flap Surgery

also reduces infection [30–32].

flap" surgery including internal bone fixation, fasciocutaneous frap transfer, and free skin graft was performed 5 days later (**Figure 34**). The wound was healed 10 days later, the patient could walk 1 month after secondary surgery without cane because rigid intramedul-

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Surgeons are recommended to perform early closure of the wound after rigid bone fixation. These "fix and flap" procedures improve postsurgical problems such as infection, and accelerate the rehabilitation, a process which speeds up patients' recovery and improve their qual-

**Figure 36.** View of the reconstructed leg 1 month after surgery, showing favorable resurfacing.

Department of Plastic and Reconstructive Surgery, Clinical Research Center, National

lary fixation system conferred steady stability to the broken leg (**Figures 35** and **36**).

**8. Conclusion**

ity of life [30–32].

**Author details**

Masaki Fujioka

Address all correspondence to: mfujioka@nagasaki-mc.com

Hospital Organization Nagasaki Medical Center, Nagasaki, Japan

**Figure 34.** Late "fix and flap" surgery including internal bone fixation, local frap transfer; a free skin graft was performed 5 days later.

**Figure 35.** An X-ray photograph showing ridged fixation of the broken tibia using intramedullary fixation system.

flap" surgery including internal bone fixation, fasciocutaneous frap transfer, and free skin graft was performed 5 days later (**Figure 34**). The wound was healed 10 days later, the patient could walk 1 month after secondary surgery without cane because rigid intramedullary fixation system conferred steady stability to the broken leg (**Figures 35** and **36**).

**Figure 36.** View of the reconstructed leg 1 month after surgery, showing favorable resurfacing.

## **8. Conclusion**

**Figure 34.** Late "fix and flap" surgery including internal bone fixation, local frap transfer; a free skin graft was performed

**Figure 35.** An X-ray photograph showing ridged fixation of the broken tibia using intramedullary fixation system.

5 days later.

96 Issues in Flap Surgery

Surgeons are recommended to perform early closure of the wound after rigid bone fixation. These "fix and flap" procedures improve postsurgical problems such as infection, and accelerate the rehabilitation, a process which speeds up patients' recovery and improve their quality of life [30–32].

## **Author details**

Masaki Fujioka

Address all correspondence to: mfujioka@nagasaki-mc.com

Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan

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[16] Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial forearm flap: A versatile method for intra-oral reconstruction. British Journal of Plastic Surgery. 1983;**36**(1):1-8

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[19] Garvey PB, Clemens MW, Rhines LD, Sacks JM. Vertical rectus abdominis musculocutaneous flow-through flap to a free fibula flap for total sacrectomy reconstruction.

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[24] Hidalgo DA. Aesthetic improvements in free-flap mandible reconstruction. Plastic and

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**Section 3**

**Special Situations**


**Section 3**

**Special Situations**

[29] Siwach R, Singh R, Arya S, Gupta R. Treatment of 78 type II and type IIIa open fractures by primary closure on suction drain: A prospective study. Journal of Orthopaedic Trauma.

[30] DeLong Jr WG, Born CT, Wei SY, et al. Aggressive treatment of 119 open fracture

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**Chapter 6**

**Provisional chapter**

**Reconstruction for Mandibular Implant Failure**

**Reconstruction for Mandibular Implant Failure**

DOI: 10.5772/intechopen.70166

Mandibular defects may result from tumor ablations, trauma, or radiation necrosis. Significant segmental mandibular loss or hemimandibular loss may sometimes be replaced with mandibular implants by ENT surgeons/oral surgeons/head and neck surgeons. However, this may bring about mandibular implant failure in long-term followup. Mandibular implant failures usually manifest as: soft tissue atrophy, mandibular implant extrusion, infection, facial nerve involvement, facial asymmetry, derangement of occlusion and mastication, orocutaneous fistula, etc. Over 30 years, the authors have treated 102 patients with mandibular implant failure. Reconstruction may involve removal of the mandibular implant and immediate replacement of the mandibular defect with a piece of vascularized bone flap, not only to compensate for bone loss but also to replace neighboring soft tissue and possible skin defects. Frequently used flaps have been vascularized iliac bone (89/102) or vascularized fibula grafts (13/102). During follow-up, iliac bone flap reconstruction has yielded more favorable results due to its ample bone bulk and adequate soft tissue coverage. Fibula flaps with osteotomies have been associated with an increasing incidence of malunion/nonunion and subsequent

**Keywords:** mandibular reconstruction, implant failures, vascularized iliac bone flap,

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Shih-Heng Chen, Hao-Chih Tai, Tai-Ju Cheng, Hung-Chi Chen, An-Ta Ko, Tyng-Luan Roan,

Shih-Heng Chen, Hao-Chih Tai, Tai-Ju Cheng, Hung-Chi Chen, An-Ta Ko, Tyng-Luan Roan,

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Yo-Shen Chen and Yueh-Bih Tang

Yo-Shen Chen and Yueh-Bih Tang

http://dx.doi.org/10.5772/intechopen.70166

**Abstract**

easy deformation.

vascularized fibula bone flap, finesse

**Provisional chapter**

## **Reconstruction for Mandibular Implant Failure**

**Reconstruction for Mandibular Implant Failure**

DOI: 10.5772/intechopen.70166

Shih-Heng Chen, Hao-Chih Tai, Tai-Ju Cheng, Hung-Chi Chen, An-Ta Ko, Tyng-Luan Roan, Yo-Shen Chen and Yueh-Bih Tang Hung-Chi Chen, An-Ta Ko, Tyng-Luan Roan, Yo-Shen Chen and Yueh-Bih Tang Additional information is available at the end of the chapter

Shih-Heng Chen, Hao-Chih Tai, Tai-Ju Cheng,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70166

#### **Abstract**

Mandibular defects may result from tumor ablations, trauma, or radiation necrosis. Significant segmental mandibular loss or hemimandibular loss may sometimes be replaced with mandibular implants by ENT surgeons/oral surgeons/head and neck surgeons. However, this may bring about mandibular implant failure in long-term followup. Mandibular implant failures usually manifest as: soft tissue atrophy, mandibular implant extrusion, infection, facial nerve involvement, facial asymmetry, derangement of occlusion and mastication, orocutaneous fistula, etc. Over 30 years, the authors have treated 102 patients with mandibular implant failure. Reconstruction may involve removal of the mandibular implant and immediate replacement of the mandibular defect with a piece of vascularized bone flap, not only to compensate for bone loss but also to replace neighboring soft tissue and possible skin defects. Frequently used flaps have been vascularized iliac bone (89/102) or vascularized fibula grafts (13/102). During follow-up, iliac bone flap reconstruction has yielded more favorable results due to its ample bone bulk and adequate soft tissue coverage. Fibula flaps with osteotomies have been associated with an increasing incidence of malunion/nonunion and subsequent easy deformation.

**Keywords:** mandibular reconstruction, implant failures, vascularized iliac bone flap, vascularized fibula bone flap, finesse

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

## **1. Introduction**

Mandibular defects may result from tumor ablations, trauma, or radiation necrosis. Significant segmental mandibular loss or hemimandibular loss may be replaced with mandibular implants by head and neck surgeons or oral surgeons in order to terminate surgery quickly [1]. However, mandibular implant failure may ensue on long-term follow-up.

The cause of mandibular implant failure may be related to high functional demands on mastication, speech, yawning, and singing. The force and pressures imposed on the mandible by chewing, yawning, and mouth opening make mandibular implants liable to extrusion sooner or later.

Complications of mandibular implant include infection, loosening, deformation, soft tissue wasting, extrusion, capsular contracture, and sometimes the development of a skin defect owing to infection with subsequent scar contracture (**Table 1**).


**Figure 1.** Soft tissue wasting.

Reconstruction for Mandibular Implant Failure http://dx.doi.org/10.5772/intechopen.70166 105

**Figure 2.** Immediate after operation.

**Figure 3.** Angulation deformity 1 year after operation.

**Table 1.** Mandibular implant failures.

## **2. Manifestations**

	- **a.** Soft tissue wasting (**Figure 1**)
	- **b.** Deformation (**Figures 2** and **3**)
	- **c.** Deviation of mandible and chin (**Figure 4**)

**Figure 1.** Soft tissue wasting.

**1. Introduction**

104 Issues in Flap Surgery

or later.

Infection Extrusion Malocclusion

Soft tissue wasting Loosening of implant Facial nerve involvement Deformation of lower face

**2. Manifestations**

**Table 1.** Mandibular implant failures.

**1.** Facial deformities

**3.** Infection (**Figure 6**)

**a.** Soft tissue wasting (**Figure 1**) **b.** Deformation (**Figures 2** and **3**)

**c.** Deviation of mandible and chin (**Figure 4**)

**2.** Extrusion of mandibular implant (**Figure 5**)

Mandibular defects may result from tumor ablations, trauma, or radiation necrosis. Significant segmental mandibular loss or hemimandibular loss may be replaced with mandibular implants by head and neck surgeons or oral surgeons in order to terminate surgery quickly

The cause of mandibular implant failure may be related to high functional demands on mastication, speech, yawning, and singing. The force and pressures imposed on the mandible by chewing, yawning, and mouth opening make mandibular implants liable to extrusion sooner

Complications of mandibular implant include infection, loosening, deformation, soft tissue wasting, extrusion, capsular contracture, and sometimes the development of a skin defect

**4.** Orocutaneous fistula (**Figure 7(a)**: extrusion of mandibular implant intraorally, (7b): man-

dibular implant at symphysis, **Figure 7(c)**: orocutaneous fistula)

[1]. However, mandibular implant failure may ensue on long-term follow-up.

owing to infection with subsequent scar contracture (**Table 1**).

**Figure 2.** Immediate after operation.

**Figure 3.** Angulation deformity 1 year after operation.

**3. Patients and methods**

further treatments (**Table 2**) [2].

**a.** Soft tissue wasting (**Figure 8**)

**2.** Extrusion of mandibular implant

**4.** Orocutaneous fistula (**Figure 12**)

ous fistula, which never healed.

**b.** Deviation of mandible and chin (**Figure 9**)

Removal of implant 36 Total 32 Partial 4 Retention of implant 66

Vascularized iliac bone 83 Vascularized fibula 19

The manifestations were

**1.** Facial deformities

**3.** Infection

Reconstruction with

**Table 2.** Method.

During the past 35 years, 102 patients with mandibular implant failures had been referred for

**Figure 7.** (a) Extrusion of mandibular implant intraorally. (b) Mandibular implant at symphysis. (c) Orocutaneous fistula.

Reconstruction for Mandibular Implant Failure http://dx.doi.org/10.5772/intechopen.70166 107

Significant facial deformities usually brought the patients to seek plastic surgeons.

Infection ensued with or without extrusion of mandibular implant (**Figure 11(a)** and **(b)**)

Orocutaneous fistula occurred when intraoral extrusion of the implant brought saliva passing by the implant, causing infection. This was soon supervened with an orocutane-

Extrusion occurred intraorally (**Figure 10(a)**) or extraorally (**Figure 10(b)**)

**Figure 4.** Deviation of mandible and chin.

**Figure 5.** Extrusion of mandibular implant.

**Figure 6.** Mandibular implant extrusion with infection.

**Figure 7.** (a) Extrusion of mandibular implant intraorally. (b) Mandibular implant at symphysis. (c) Orocutaneous fistula.

## **3. Patients and methods**

During the past 35 years, 102 patients with mandibular implant failures had been referred for further treatments (**Table 2**) [2].

The manifestations were

**1.** Facial deformities

**Figure 4.** Deviation of mandible and chin.

106 Issues in Flap Surgery

**Figure 5.** Extrusion of mandibular implant.

**Figure 6.** Mandibular implant extrusion with infection.

Significant facial deformities usually brought the patients to seek plastic surgeons.


Extrusion occurred intraorally (**Figure 10(a)**) or extraorally (**Figure 10(b)**)

**3.** Infection

Infection ensued with or without extrusion of mandibular implant (**Figure 11(a)** and **(b)**)

**4.** Orocutaneous fistula (**Figure 12**)

Orocutaneous fistula occurred when intraoral extrusion of the implant brought saliva passing by the implant, causing infection. This was soon supervened with an orocutaneous fistula, which never healed.


**Table 2.** Method.

**Figure 8.** Soft tissue wasting at left side lower face.

**Figure 9.** Deviation of mandible and chin.

**4. Strategy of treatment**

**Figure 12.** Orocutaneous fistula.

**I.** Removal of mandibular implant when the implant became extruded or got infected [3]. **II.** Immediate reconstruction of missing mandibular segment or hemimandible with vascularized bone, incorporating soft tissue and skin flap for intraoral mucosal lining/external skin defect reconstruction/replacement of soft tissue defect. The vascularized bone can be

an iliac bone flap or fibula flap [4, 5]. Selection of vascularized bone (**Table 3**)

With implant retained *in situ* in patients without implant extrusion.

**A.** Hemimandibular defect: vascularized iliac bone [2, 6–8].

**Figure 11.** (a) Left mandibular implant. (b) Extrusion of mandibular implant with infection.

Reconstruction for Mandibular Implant Failure http://dx.doi.org/10.5772/intechopen.70166 109

With implant removed in patients with implant extrusion.

**Figure 10.** (a) Extrusion of mandibular implant intraorally. (b) Extrusion of mandibular implant extraorally.

**Figure 11.** (a) Left mandibular implant. (b) Extrusion of mandibular implant with infection.

**Figure 12.** Orocutaneous fistula.

**Figure 8.** Soft tissue wasting at left side lower face.

108 Issues in Flap Surgery

**Figure 9.** Deviation of mandible and chin.

**Figure 10.** (a) Extrusion of mandibular implant intraorally. (b) Extrusion of mandibular implant extraorally.

#### **4. Strategy of treatment**

	- **A.** Hemimandibular defect: vascularized iliac bone [2, 6–8].

With implant retained *in situ* in patients without implant extrusion.

With implant removed in patients with implant extrusion.

**B.** Segmental defect

Iliac bone flap was more preferable than fibular flap due to more bony height with ample soft tissue and skin paddle [7–10].

**5. Problems of reconstruction with implant failure and removal of the** 

Reconstruction for Mandibular Implant Failure http://dx.doi.org/10.5772/intechopen.70166 111

**3.** Lack of a clear plane to expand the pocket to accommodate a vascularized bone mimicking

**5.** Placement of incision should be carefully designed since there had been soft tissue atrophy

**A.** Hemimandibular reconstruction with mandibular tray implant (**Figure 14**(**a**–**d**)).

**2.** Immediate hemimandibular reconstruction with vascularized iliac bone flap.

**Figure 13.** (a) Thinning of skin overlying mandibular implant. (b) Reconstruction with iliac bone flap with upper neck

**3.** Fascia lata sling operation to hold the mandibular body to temporal muscle and fascia.

**B.** Facial asymmetry after resection of mandibular ameloblastoma and mere reconstruction

**C.** Young man, aged 25 years, suffered from soft tissue wasting 1 year after sole mandibular implant insertion and his status after subcondylar mandibular reconstruction

**D.** Young man, aged 28 years, suffered from soft tissue wasting and chin deviation 6 months after resection of a left side mandibular ameloblastoma and subsequent reconstruction with

**4.** Possibility of facial nerve injury or traction during dissection or expansion.

**1.** Scarring and capsule formation around the implant.

and thinning of skin (**Figure 13(a)** and **(b)**).

**2.** Difficulty in dissecting and approaching the glenoid fossa.

**implant**

the ascending ramus.

**6. Case presentations**

transverse incision.

(**Figure 16**(**a**–**d**)).

**1.** Removal of mandibular implant.

**4.** Facial recontouring, soft tissue, and bone.

with mandibular reconstruction plate (**Figure 15(a)** and **(b)**).


Banked external skin flap could be moved intraorally after the subsidence of tissue swelling.

**IV.** Reshaping of bony contour

After bony union, some imperfect bony contour may be reshaped [4].



With implant retained *in situ*

With implant removed ( total or partial)

(B) Segmental defect:

Iliac bone flap is more preferable than fibular flap due to more bony height

(C) Anterior mandibular defect:

Vascularized iliac bone

(D) Lateral segment defect:

Fibula flap

**III.** Reposition of skin flap

Banked external skin flap can be moved inwardly with subsidence of tissue swelling

**IV.** Reshaping of bony contour

After bony union, some imperfect bony contour may be reshaped

**Table 3.** Summary of operation technique.

**I.** Removal of Mandibular implant when the implant become or got in fected.

**II.** Immediate reconstruction of missing mandibular segment.

## **5. Problems of reconstruction with implant failure and removal of the implant**

**1.** Scarring and capsule formation around the implant.

**B.** Segmental defect

**III.** Repositioning of skin flap

**IV.** Reshaping of bony contour

**V.** Removal of the mandibular plate

swelling.

110 Issues in Flap Surgery

(A) Hemimandibular defect: Vascularized iliac bone

(B) Segmental defect:

Fibula flap

With implant retained *in situ*

(C) Anterior mandibular defect: Vascularized iliac bone (D) Lateral segment defect:

**III.** Reposition of skin flap

**IV.** Reshaping of bony contour

**Table 3.** Summary of operation technique.

With implant removed ( total or partial)

ample soft tissue and skin paddle [7–10].

**D.** Lateral segment defect: fibula flap [5]

**C.** Anterior mandibular defect: vascularized iliac bone

**I.** Removal of Mandibular implant when the implant become or got in fected.

Iliac bone flap is more preferable than fibular flap due to more bony height

Banked external skin flap can be moved inwardly with subsidence of tissue swelling

After bony union, some imperfect bony contour may be reshaped

**II.** Immediate reconstruction of missing mandibular segment.

After bony union, some imperfect bony contour may be reshaped [4].

Iliac bone flap was more preferable than fibular flap due to more bony height with

Banked external skin flap could be moved intraorally after the subsidence of tissue

**VI.** For nearly hemimandibular reconstructions, overzealous removal of the reconstruction plate for further reconstruction might jeopardize the overlying facial nerve which had already been surrounded by fibrosis and might have assumed a nonanatomical path. Thereafter, surgical manipulation in this area to create space might stretch the facial nerve overlying the implant and might lead to its inadvertent injury. For this reason, the plate was either partially removed or not removed at all as long as it had not been already become extruded or infected; instead, it was overlaid with a piece of vascularized bone flap.


**Figure 13.** (a) Thinning of skin overlying mandibular implant. (b) Reconstruction with iliac bone flap with upper neck transverse incision.

## **6. Case presentations**

	- **1.** Removal of mandibular implant.
	- **2.** Immediate hemimandibular reconstruction with vascularized iliac bone flap.
	- **3.** Fascia lata sling operation to hold the mandibular body to temporal muscle and fascia.
	- **4.** Facial recontouring, soft tissue, and bone.

titanium mandibular reconstruction plate (**Figure 18**(**a**–**c**)). Removal of anterior segment mandibular implant and reconstruction with an iliac bone flap resulted in satisfactory

Reconstruction for Mandibular Implant Failure http://dx.doi.org/10.5772/intechopen.70166 113

**Figure 16.** (a) Mandibular implant only, subcondylar hemimandibular reconstruction. (b) Soft tissue wasting 1 year after mandibular implant only subcondylar mandibular reconstruction. (c) Removal of reconstruction plate and replacement with vascularized iliac bone flap. (d) Postoperative photograph, s/p removal of reconstruction plate and replacement

**Figure 17.** (a) Soft tissue wasting with deviation of chin. (b) Reconstruction was performed with retention of implant by onlaying a vascularized iliac bone flap on the reconstruction plate with osteosynthesis at the medial extreme. (c) Postoperative photography. (d) 15 years after left hemimandibular reconstruction by onlaying vascularized iliac bone flap on reconstruction plate, no soft tissue atrophy, wasting noticed. Occlusion was satisfactory with symmetric facial expression.

bone union and facial contour (**Figure 18(d)**).

with vascularized iliac bone flap.

**Figure 14.** (a) Extrusion of mandibular implant with infection, soft tissue wasting and facial deformity. (b) Preoperative roentgenography. (c) Postoperative roentgenography after reconstruction with vascularized iliac bone flap. (d) Postoperative photo showing satisfactory facial contour.

**Figure 15.** (a) Deformation of right side mandibular implant with deviation of chin. (b) Reconstruction with iliac bone flap, regained more symmetric facial contour.

mandibular reconstruction plate only (**Figure 17(a)**). He received mandibular reconstruction with retention of implant by onlaying a vascularized iliac bone flap on the reconstruction plate with osteosynthesis at the medial end of the mandibular section margin (**Figure 17(b)** and **(c)**). Picture 15 years after left hemimandibular reconstruction by an onlaying vascularized iliac bone flap on the reconstruction plate. No soft tissue atrophy or wasting was noticed. Occlusion was satisfactory with symmetric facial expression (**Figure 17(d)**).


titanium mandibular reconstruction plate (**Figure 18**(**a**–**c**)). Removal of anterior segment mandibular implant and reconstruction with an iliac bone flap resulted in satisfactory bone union and facial contour (**Figure 18(d)**).

**Figure 16.** (a) Mandibular implant only, subcondylar hemimandibular reconstruction. (b) Soft tissue wasting 1 year after mandibular implant only subcondylar mandibular reconstruction. (c) Removal of reconstruction plate and replacement with vascularized iliac bone flap. (d) Postoperative photograph, s/p removal of reconstruction plate and replacement with vascularized iliac bone flap.

mandibular reconstruction plate only (**Figure 17(a)**). He received mandibular reconstruction with retention of implant by onlaying a vascularized iliac bone flap on the reconstruction plate with osteosynthesis at the medial end of the mandibular section margin (**Figure 17(b)** and **(c)**). Picture 15 years after left hemimandibular reconstruction by an onlaying vascularized iliac bone flap on the reconstruction plate. No soft tissue atrophy or wasting was noticed. Occlu-

**Figure 15.** (a) Deformation of right side mandibular implant with deviation of chin. (b) Reconstruction with iliac bone

**Figure 14.** (a) Extrusion of mandibular implant with infection, soft tissue wasting and facial deformity. (b) Preoperative roentgenography. (c) Postoperative roentgenography after reconstruction with vascularized iliac bone flap. (d)

**E.** This 24-year-old lady suffered from left side facial wasting after sub-hemimandibular reconstruction with reconstruction plate only (**Figure 18(a)**). She received mandibular reconstruction with an onlaying vascularized iliac bone flap with retaining the

**F.** A 66-year-old lady suffered from soft tissue wasting, deformation with impending extrusion of the implant 1 year after reconstructing a segmental symphyseal defect with a

sion was satisfactory with symmetric facial expression (**Figure 17(d)**).

titanium reconstruction plate (**Figure 18**(**b**–**d**)).

Postoperative photo showing satisfactory facial contour.

112 Issues in Flap Surgery

flap, regained more symmetric facial contour.

**Figure 17.** (a) Soft tissue wasting with deviation of chin. (b) Reconstruction was performed with retention of implant by onlaying a vascularized iliac bone flap on the reconstruction plate with osteosynthesis at the medial extreme. (c) Postoperative photography. (d) 15 years after left hemimandibular reconstruction by onlaying vascularized iliac bone flap on reconstruction plate, no soft tissue atrophy, wasting noticed. Occlusion was satisfactory with symmetric facial expression.

**G.** This 27-year-old young man received a hemimandibular implant reconstruction after resection of an ameloblastoma. However, it was complicated with infection and extrusion and ended up with implant removal, leaving a significant facial deformity (**Figure 19(a)**). The lateral segment mandibular defect was reconstructed with a fibula flap imcorporating with a titanium mandicular condyle (**Figure 19(b)** and **(c)**) [5].

**A.** Hemimandibular reconstruction with implant (**Figure 20**(**a**–**d**)).

**B.** Soft tissue wasting above the left mandibular implant area (**Figure 21**(**a**–**c**)).

**C.** Secondary resurfacing of the lower sulcus with a banked iliac bone skin flap with revolving door technique to facilitate denture fitting and restoration of chin profile (**Figure 23**(**a**–**f**)).

Reconstruction for Mandibular Implant Failure http://dx.doi.org/10.5772/intechopen.70166 115

**Figure 20.** (a) Mandibular implant extrusion with infection. (b) Removal of mandibular implant and reconstruction with vascularized iliac bone flap. Sagging down of the reconstructed mandible was noticed due to lack of holding power of the temporal muscle to coronoid process. (c) Fascial at a sling operation was performed to hold the reconstructed

**Figure 21.** (a) Retention of mandibular implant and onlaying with a vascularized iliac bone flap. (b) Vascularized iliac bone osteocutaneous flap, placed overlying the mandibular implant with osteosynthesis. (c) Postoperative result: soft tissue

wasting and atrophy ceased with long term follow up.

mandible to the temporalis muscle. (d) Post-op front view with adequate mouth opening shown.

**Figure 18.** (a) Reconstruction plate only for reconstruction of symphyseal defect after resection of mandibular ameloblastoma. (b) Impending extrusion of symphyseal reconstruction plate. (c) Panex at 1 year post operation showing deformation of mandibular reconstruction plate. (d) Removal of anterior segment mandibular implant and reconstruction with iliac bone flap resulted in satisfactory bone union and facial contour.

**Figure 19.** (a) This 27-year-old young man received hemimandibular reconstruction with implant after resection of ameloblastoma, however, complicated with infection and extrusion, ended up with removal of implant, leaving significant facial deformity. (b) The lateral segment mandibular defect was then reconstructed with fibula flap 1 year later. (c) Postoperative photos showing regain of facial contour and symmetricity after reconstruction with fibula flap.

#### Ancillary procedures:

Ancillary procedures are always required to achieve satisfactory functional and aesthetic results are shown in (**Table 4**) and (**Table 5**).

**A.** Hemimandibular reconstruction with implant (**Figure 20**(**a**–**d**)).

**G.** This 27-year-old young man received a hemimandibular implant reconstruction after resection of an ameloblastoma. However, it was complicated with infection and extrusion and ended up with implant removal, leaving a significant facial deformity (**Figure 19(a)**). The lateral segment mandibular defect was reconstructed with a fibula flap imcorporat-

**Figure 18.** (a) Reconstruction plate only for reconstruction of symphyseal defect after resection of mandibular ameloblastoma. (b) Impending extrusion of symphyseal reconstruction plate. (c) Panex at 1 year post operation showing deformation of mandibular reconstruction plate. (d) Removal of anterior segment mandibular implant and

reconstruction with iliac bone flap resulted in satisfactory bone union and facial contour.

Ancillary procedures are always required to achieve satisfactory functional and aesthetic

**Figure 19.** (a) This 27-year-old young man received hemimandibular reconstruction with implant after resection of ameloblastoma, however, complicated with infection and extrusion, ended up with removal of implant, leaving significant facial deformity. (b) The lateral segment mandibular defect was then reconstructed with fibula flap 1 year later. (c) Postoperative photos showing regain of facial contour and symmetricity after reconstruction with fibula flap.

ing with a titanium mandicular condyle (**Figure 19(b)** and **(c)**) [5].

Ancillary procedures:

114 Issues in Flap Surgery

results are shown in (**Table 4**) and (**Table 5**).


**Figure 20.** (a) Mandibular implant extrusion with infection. (b) Removal of mandibular implant and reconstruction with vascularized iliac bone flap. Sagging down of the reconstructed mandible was noticed due to lack of holding power of the temporal muscle to coronoid process. (c) Fascial at a sling operation was performed to hold the reconstructed mandible to the temporalis muscle. (d) Post-op front view with adequate mouth opening shown.

**Figure 21.** (a) Retention of mandibular implant and onlaying with a vascularized iliac bone flap. (b) Vascularized iliac bone osteocutaneous flap, placed overlying the mandibular implant with osteosynthesis. (c) Postoperative result: soft tissue wasting and atrophy ceased with long term follow up.


**Figure 22.** (a) Retention of mandibular implant and overlying with vascularized iliac bone flap can achieve not only good functional result, but also satisfactory aesthetic outcome. (b) Post-op result: soft tissue wasting and atrophy ceased with

Reconstruction for Mandibular Implant Failure http://dx.doi.org/10.5772/intechopen.70166 117

**Figure 23.** (a) Pre-op. (b) Harvesting of iliac bone osteomyocutaneous flap. (c) Insetting of flap. (d) Flap transposition with revolving door technique. (e) Anterior sulcus reconstruction was completed by employing revolving door technique. (f) Reconstruction of lower sulcus by mobilizing the banked skin flap inward with revolving door technique

can accommodate further denture fitting, resulting in good functional and aesthetic result.

long-term follow-up.

**Table 5.** Aesthetic considerations.

#### **7. Results**

In 102 patients presenting with mandibular implant extrusions, the primary etiologies were mostly ameloblastoma (100/102), fibroma (1/102), and malignant mixed tumor (1/102). Before extrusiom of the implant occurs, the implant may be retained and overlaid with a vascularized bone.

Keeping the mandibular implant and overlaying it with a vascularized iliac bone flap can achieve not only a good functional result (**Table 4**) If extrusion of the implant has occurred, infection will supervene, and inevitably the implant should be removed totally. Reconstruction may involve removal of the mandibular implant and immdiate replacement of the mandibular defect with a piece of vascularized bone flap, not only to compensate for bone loss, but also to replace neighboring soft tissue and possible skin defect. With the night strategy, good functional outcome and satisfactory aesthetic result can always be achieved, but also a satisfactory aesthetic outcome (**Table 5**). Soft tissue wasting and atrophy ceased with long-term follow-up (**Figure 22(a)** and **(b)**).

For reconstruction of anterior segment mandibular defect, vascularized iliac bone grafting associated with external banking of the skin and soft tissue, followed by turning the skin flap and soft tissue intraorally with revolving door technique, can resurface the anterior vestibule and augment the chin profile, a procedure that also facilitate fitting lower denture fitting (**Figure 23**(**a**–**f**)).

**Figure 22.** (a) Retention of mandibular implant and overlying with vascularized iliac bone flap can achieve not only good functional result, but also satisfactory aesthetic outcome. (b) Post-op result: soft tissue wasting and atrophy ceased with long-term follow-up.

**7. Results**

Mouth opening Oral competence

116 Issues in Flap Surgery

Osseointegration

temporo-mandibular joint function Deepening of buccogingival sulcus Feasibility in fixation of denture

**Table 4.** Functional considerations.

Recontouring of mandibular margin

Fascial sling operation for hemimandibular reconstruction

Myectomy of contralateral lower lip depressors

Soft tissue repositioning Sliding genioplasty

Z-plasty, W-plasty on scars

**Table 5.** Aesthetic considerations.

Reduction of bulk Commissuroplasty Fat graft, fascial graft

ized bone.

(**Figure 22(a)** and **(b)**).

(**Figure 23**(**a**–**f**)).

In 102 patients presenting with mandibular implant extrusions, the primary etiologies were mostly ameloblastoma (100/102), fibroma (1/102), and malignant mixed tumor (1/102). Before extrusiom of the implant occurs, the implant may be retained and overlaid with a vascular-

Keeping the mandibular implant and overlaying it with a vascularized iliac bone flap can achieve not only a good functional result (**Table 4**) If extrusion of the implant has occurred, infection will supervene, and inevitably the implant should be removed totally. Reconstruction may involve removal of the mandibular implant and immdiate replacement of the mandibular defect with a piece of vascularized bone flap, not only to compensate for bone loss, but also to replace neighboring soft tissue and possible skin defect. With the night strategy, good functional outcome and satisfactory aesthetic result can always be achieved, but also a satisfactory aesthetic outcome (**Table 5**). Soft tissue wasting and atrophy ceased with long-term follow-up

For reconstruction of anterior segment mandibular defect, vascularized iliac bone grafting associated with external banking of the skin and soft tissue, followed by turning the skin flap and soft tissue intraorally with revolving door technique, can resurface the anterior vestibule and augment the chin profile, a procedure that also facilitate fitting lower denture fitting

**Figure 23.** (a) Pre-op. (b) Harvesting of iliac bone osteomyocutaneous flap. (c) Insetting of flap. (d) Flap transposition with revolving door technique. (e) Anterior sulcus reconstruction was completed by employing revolving door technique. (f) Reconstruction of lower sulcus by mobilizing the banked skin flap inward with revolving door technique can accommodate further denture fitting, resulting in good functional and aesthetic result.

## **8. Discussions**

Mandibular defects may result in significant facial disfigurement. When the defect is associated with inner mucosal defect and/or external skin defect, the situation become even more complicated [11]. Conventional bone grafting can only succeed in less than 5 cm segmental defect or partial thickness defect.

A fascia lata sling operation is always required in hemimandibular reconstruction in patients with the implant failures, in order to hold the reconstructed mandible to an anatomical and

The use of mandibular implants as the sole reconstruction tool for significant mandibular defects should be limited. Since patients suffering from mandibular ameloblastomas are mostly young, it is advised that vascularized bone be the ideal choice in major mandibular

The authors are indebted to Ms. Hsiao-Fang Wei and Ms. Fang-I Chu for their assistance in preparing and finishing this manuscript. Without their endeavor, this chapter would not

, Hung-Chi Chen3

, An-Ta Ko<sup>4</sup>

Reconstruction for Mandibular Implant Failure http://dx.doi.org/10.5772/intechopen.70166 119

,

, Tai-Ju Cheng2

and Yueh-Bih Tang2,4\*

[1] Hidalgo DA. Deep circumflex iliac artery free flaps. In: Shaw WW, Hidalgo DA, editors. Microsurgery in Trauma. Mount Kisco, New York: Futura Publishing Company, Inc;

[2] Chen YB, Chen HC, Hahn LH. Major mandibular reconstruction with vascularized bone grafts: Indications and selection of donor tissue. Microsurgery. 1994;**15**(4):227-237 [3] Boyd JB. Use of reconstruction plates in conjunction with soft-tissue free flaps for oro-

[4] Hidalgo DA. Aesthetic improvements in free-flap mandible reconstruction. Plastic and

mandibular reconstruction. Clinics in Plastic Surgery. 1994;**21**(1):69-77

Reconstructive Surgery. 1991;**88**(4):574-585; discussion 586-587

functional place.

reconstructions.

come out so soon.

**Author details**

Tyng-Luan Roan<sup>4</sup>

**References**

1988

Shih-Heng Chen1,2, Hao-Chih Tai2

, Yo-Shen Chen<sup>4</sup>

1 Chang-Gung Memorial Hospital, Taoyuan, Taiwan 2 National Taiwan University Hospital, Taipei, Taiwan

\*Address all correspondence to: phoebetang0103@gmail.com

3 China Medical University Hospital, Taichung City, Taiwan 4 Far-Eastern Memorial Hospital, New Taipei City, Taiwan

**Acknowledgements**

Mandibular implants made of different materials (titanium, vitellium, etc.) and having different brands have been used by many head and neck surgeons to reconstruct segmental mandibular defects or hemimandibular defects. However, they are fraught with miscellaneous miserable complications [12].

In this article, we have presented many kinds of failures resulting from mandibular reconstructions with implants.

Reconstructions problems associated with implant failure include:


The choice of bone flap for reconstructions is iliac bone flap for anterior mandibular, segmental and hemimandibular reconstructions while, for lateral mandibular defect, fibular flap in preferred.

## **9. Conclusions**

The fate of various reconstructive modes for major mandibular defects has been presented. Selecting the ideal modes of reconstruction for significant mandibular defects is of paramount importance if an uncomplicated outcome and excellent functional result without facial disfigurement are to be achieved.

Secondary mandibular reconstruction after implant failure may cause facial nerve injury due to scarring which result in difficulty in approaching the glenoid fossa.

When mandibular reconstruction with implant fails, extrusion and infection may ensue and necessitate removal of the implant. In this situation, soft tissue wasting, fibrosis, and contracture will supervene. The overlying facial nerve will be endangered during further reconstruction consequent upon creating additional space to accommodate a vascularized bone flap.

A fascia lata sling operation is always required in hemimandibular reconstruction in patients with the implant failures, in order to hold the reconstructed mandible to an anatomical and functional place.

The use of mandibular implants as the sole reconstruction tool for significant mandibular defects should be limited. Since patients suffering from mandibular ameloblastomas are mostly young, it is advised that vascularized bone be the ideal choice in major mandibular reconstructions.

## **Acknowledgements**

**8. Discussions**

118 Issues in Flap Surgery

defect or partial thickness defect.

miserable complications [12].

structions with implants.

preferred.

**9. Conclusions**

urement are to be achieved.

Mandibular defects may result in significant facial disfigurement. When the defect is associated with inner mucosal defect and/or external skin defect, the situation become even more complicated [11]. Conventional bone grafting can only succeed in less than 5 cm segmental

Mandibular implants made of different materials (titanium, vitellium, etc.) and having different brands have been used by many head and neck surgeons to reconstruct segmental mandibular defects or hemimandibular defects. However, they are fraught with miscellaneous

In this article, we have presented many kinds of failures resulting from mandibular recon-

• lack of a clear plane to expand the pocket in order to accommodate a vascularized bone

• Careful planning of the incision should be elaborated because of soft tissue atrophy and

The choice of bone flap for reconstructions is iliac bone flap for anterior mandibular, segmental and hemimandibular reconstructions while, for lateral mandibular defect, fibular flap in

The fate of various reconstructive modes for major mandibular defects has been presented. Selecting the ideal modes of reconstruction for significant mandibular defects is of paramount importance if an uncomplicated outcome and excellent functional result without facial disfig-

Secondary mandibular reconstruction after implant failure may cause facial nerve injury due

When mandibular reconstruction with implant fails, extrusion and infection may ensue and necessitate removal of the implant. In this situation, soft tissue wasting, fibrosis, and contracture will supervene. The overlying facial nerve will be endangered during further reconstruction

consequent upon creating additional space to accommodate a vascularized bone flap.

to scarring which result in difficulty in approaching the glenoid fossa.

• possibility of facial nerve injury or traction during dissection or expansion.

Reconstructions problems associated with implant failure include:

• scarring and capsule formation around the implant,

• difficulty in dissecting and approaching the glenoid fossa,

graft camouflaging the ascending ramus, resulting in

thinning of skin on top of the mandibular implant.

The authors are indebted to Ms. Hsiao-Fang Wei and Ms. Fang-I Chu for their assistance in preparing and finishing this manuscript. Without their endeavor, this chapter would not come out so soon.

## **Author details**

Shih-Heng Chen1,2, Hao-Chih Tai2 , Tai-Ju Cheng2 , Hung-Chi Chen3 , An-Ta Ko<sup>4</sup> , Tyng-Luan Roan<sup>4</sup> , Yo-Shen Chen<sup>4</sup> and Yueh-Bih Tang2,4\*


## **References**


[5] Roan TL, et al. New modified free chimeric fibular flap design for head and neck reconstruction. Head & Neck. 2013;**35**(8):E231-E233

**Chapter 7**

**Provisional chapter**

**Hand Coverage**

**Hand Coverage**

Francisco Martinez Martinez,

Francisco Martinez Martinez, M. Llanos Guerrero Navarro,

http://dx.doi.org/10.5772/intechopen.74152

Alberto Gimenez Ros and Alba Izquierdo Robledano

Alba Izquierdo Robledano

**Abstract**

defect

**1. Introduction**

tissue problems.

a higher chance of infection.

M. Llanos Guerrero Navarro, Juan Garcia Navarro,

Juan Garcia Navarro, Alberto Gimenez Ros and

DOI: 10.5772/intechopen.74152

Hand and finger soft tissue defects have always represented a surgical challenge at any accident and emergency department. Techniques may vary from just direct closure of the wound to free tissue transfer. Knowledge of the main locoregional hand flaps is paramount to solve most of the soft tissue defects at this level. Flaps vary depending on their blood supply and design. Their vascularity might be at random, they can be pedicled with anterograde or reversed flow or they can rely on simple or complex free tissue transfer whose blood flow depends on vascular anastomosis. This article reviews all the main

soft tissue local or locoregional reconstructive techniques for hands and fingers.

**Keywords:** hand coverage, hand reconstruction, fingertip reconstruction, soft tissue

Soft tissue coverage represents an essential part of the treatment of a traumatic hand. Conservative approach of soft tissue loss may lead to irreversible stiffness and in some cases

The design of different flaps for the hand has been the result of an improvement in the knowledge of hand neurovascular anatomy as well as their hemodynamic behaviour. This has allowed the development of an immense variety of regional flaps to fit a wide range of soft

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter


#### **Chapter 7 Provisional chapter**

#### **Hand Coverage Hand Coverage**

[5] Roan TL, et al. New modified free chimeric fibular flap design for head and neck recon-

[6] Boyd JB. The place of the iliac crest in vascularized oromandibular reconstruction.

[7] Chen SH, et al. Reconstruction for osteoradionecrosis of the mandible: Superiority of free iliac bone flap to fibula flap in postoperative infection and healing. Annals of Plastic

[8] Taylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Annals

[9] Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plastic and Reconstructive Surgery. 1979;**64**(5):595-604 [10] Chen YB, Chen SH, Chen HC. Finesse in Aesthetic Facial Recontouring. Oral Cancer,

[11] Chen SH, et al. Features of oral cancers in Taiwanese females with free tissue transfers: Based on NTUH data. Plastic and Reconstructive Surgery R.O.C. 2009;**18**(4):311-320 [12] Chen YB, Hahn LJ, Yao YT. Long-term survival of patients with mandibular osteosar-

coma. Journal of the Formosan Medical Association. 1999;**98**(11):773-777

struction. Head & Neck. 2013;**35**(8):E231-E233

Microsurgery. 1994;**15**(4):250-256

120 Issues in Flap Surgery

Surgery. 2014;**73**(Suppl 1):S18-S26

of Plastic Surgery. 1982;**9**(5):361-376

InTech Open Science, Croatia, 2012

Francisco Martinez Martinez, M. Llanos Guerrero Navarro, Juan Garcia Navarro, Alberto Gimenez Ros and Alba Izquierdo Robledano Francisco Martinez Martinez, M. Llanos Guerrero Navarro, Juan Garcia Navarro, Alberto Gimenez Ros and Alba Izquierdo Robledano

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.74152

#### **Abstract**

Hand and finger soft tissue defects have always represented a surgical challenge at any accident and emergency department. Techniques may vary from just direct closure of the wound to free tissue transfer. Knowledge of the main locoregional hand flaps is paramount to solve most of the soft tissue defects at this level. Flaps vary depending on their blood supply and design. Their vascularity might be at random, they can be pedicled with anterograde or reversed flow or they can rely on simple or complex free tissue transfer whose blood flow depends on vascular anastomosis. This article reviews all the main soft tissue local or locoregional reconstructive techniques for hands and fingers.

DOI: 10.5772/intechopen.74152

**Keywords:** hand coverage, hand reconstruction, fingertip reconstruction, soft tissue defect

#### **1. Introduction**

Soft tissue coverage represents an essential part of the treatment of a traumatic hand. Conservative approach of soft tissue loss may lead to irreversible stiffness and in some cases a higher chance of infection.

The design of different flaps for the hand has been the result of an improvement in the knowledge of hand neurovascular anatomy as well as their hemodynamic behaviour. This has allowed the development of an immense variety of regional flaps to fit a wide range of soft tissue problems.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Before all this knowledge, flaps were harvested at random, and a 2:1 width to length relation was a necessary condition in order to ensure the survival of a flap. This represented an important limitation to solve the different soft tissue challenges.

hand physiotherapy. This is even more the case, when partial-thickness skin grafts have been

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http://dx.doi.org/10.5772/intechopen.74152

Split-thickness skin grafts have to be harvested with the help of a dermatome and must be 0.25– 0.3 mm wide. Thicker grafts may lead to a non-healing donor site plus a less chance of graft taking. They are often meshed in order to increase their size and to allow exudate to escape.

Full-thickness skin grafts are usually used in finger coverage. One of the reasons is that the amount of the skin to cover a defect in fingers is small enough to be easily obtained from the groin, the wrist or even the anterior skin of the arm or forearm. Also, this type of graft tends

The dorsal skin of the hand is particularly elastic, and different local flaps can be performed in order to cover small defects. The blood supply is mostly at random in these flaps. They might be useful when small to moderate defects are approached and mostly if bone or tendons are exposed. The palmar skin of the hand can be considered the opposite in these terms. Local

Cuadrangular skin advancements and rotational flaps are simple and allow stable coverage

Limberg or Dufourmentel (**Figure 2**) flaps are local cuadrangular transposition flaps. These

are mostly performed in elective surgery such as excisional removal of lesions [2].

to contract less that the split one allows a better functional and cosmetic result.

used. This type of graft is more prone to contract after having taken.

**3. Local flaps for the dorsum of the hand**

flaps will not usually solve any coverage difficulty.

with optimal rates of survival.

**Figure 2.** Limberg's and Dufourmentel's flaps.

The description of pedicled flaps importantly increased the possibilities of coverage. The first neurovascular pedicled island flap was described by Littler [1]. Reverse-flow pedicled flap was first described by Foucher [3] based on the distal anastomotic connections with the dorsal metacarpal arteries, which were found in anatomy studies. Besides, the later description of perforator flaps also simplified the reconstructive techniques, avoiding the sacrifice of important vascular structures. Pollicisation of the index finger, already performed in congenital hand cases, was also applied in traumatic loss of the thumb. Eventually, the development of microsurgical advanced techniques such as toe to finger transfer for partial or complete amputation of a finger was an important asset in cosmesis and function.

Currently, our effort has also been focused not merely on coverage but also on reducing donor site morbidity; techniques leading to incapacitating neuralgias or scars have to be avoided. In some patients, this type of pain may represent a more serious problem than stiffness itself.

There are different possibilities of coverage depending on the tissue exposed and its location. This chapter will only deal with locoregional basic flaps.

## **2. Split- and full-thickness skin grafts**

This type of technique (**Figure 1**) can only be used when bones or tendons are not exposed. Due to inevitable contracture after the graft has taken, most patients will need some sort of

**Figure 1.** Skin grafts: (a) full-thickness skin grafts applied to the dorsum of the hands, (b) donor site of split-thickness skin grafts, (c) split-thickness skin graft meshed and (d) split-thickness skin graft.

hand physiotherapy. This is even more the case, when partial-thickness skin grafts have been used. This type of graft is more prone to contract after having taken.

Split-thickness skin grafts have to be harvested with the help of a dermatome and must be 0.25– 0.3 mm wide. Thicker grafts may lead to a non-healing donor site plus a less chance of graft taking. They are often meshed in order to increase their size and to allow exudate to escape.

Full-thickness skin grafts are usually used in finger coverage. One of the reasons is that the amount of the skin to cover a defect in fingers is small enough to be easily obtained from the groin, the wrist or even the anterior skin of the arm or forearm. Also, this type of graft tends to contract less that the split one allows a better functional and cosmetic result.

## **3. Local flaps for the dorsum of the hand**

Before all this knowledge, flaps were harvested at random, and a 2:1 width to length relation was a necessary condition in order to ensure the survival of a flap. This represented an impor-

The description of pedicled flaps importantly increased the possibilities of coverage. The first neurovascular pedicled island flap was described by Littler [1]. Reverse-flow pedicled flap was first described by Foucher [3] based on the distal anastomotic connections with the dorsal metacarpal arteries, which were found in anatomy studies. Besides, the later description of perforator flaps also simplified the reconstructive techniques, avoiding the sacrifice of important vascular structures. Pollicisation of the index finger, already performed in congenital hand cases, was also applied in traumatic loss of the thumb. Eventually, the development of microsurgical advanced techniques such as toe to finger transfer for partial or complete

Currently, our effort has also been focused not merely on coverage but also on reducing donor site morbidity; techniques leading to incapacitating neuralgias or scars have to be avoided. In some patients, this type of pain may represent a more serious problem than stiffness itself. There are different possibilities of coverage depending on the tissue exposed and its location.

This type of technique (**Figure 1**) can only be used when bones or tendons are not exposed. Due to inevitable contracture after the graft has taken, most patients will need some sort of

**Figure 1.** Skin grafts: (a) full-thickness skin grafts applied to the dorsum of the hands, (b) donor site of split-thickness

skin grafts, (c) split-thickness skin graft meshed and (d) split-thickness skin graft.

tant limitation to solve the different soft tissue challenges.

122 Issues in Flap Surgery

This chapter will only deal with locoregional basic flaps.

**2. Split- and full-thickness skin grafts**

amputation of a finger was an important asset in cosmesis and function.

The dorsal skin of the hand is particularly elastic, and different local flaps can be performed in order to cover small defects. The blood supply is mostly at random in these flaps. They might be useful when small to moderate defects are approached and mostly if bone or tendons are exposed. The palmar skin of the hand can be considered the opposite in these terms. Local flaps will not usually solve any coverage difficulty.

Cuadrangular skin advancements and rotational flaps are simple and allow stable coverage with optimal rates of survival.

Limberg or Dufourmentel (**Figure 2**) flaps are local cuadrangular transposition flaps. These are mostly performed in elective surgery such as excisional removal of lesions [2].

**Figure 2.** Limberg's and Dufourmentel's flaps.

## **4. Coverage of the palm of the hand**

#### **4.1. Radial fasciocutaneous flap**

Described by Yang [4] in 1981 as a free flap for the hand, this is a fasciocutaneous island flap based on the radial artery. Currently, it is not considered the first surgical option due to inevitable sacrifice of the radial artery and possible donor site morbidity. Allen's test is performed before surgical planning (**Figure 3**).

has also been described. In this case a small portion of the radius diaphysis is taken along with the artery. This type of reconstruction has been widely used as a free flap and not much as a

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A perforator radial flap has also been described based on about ten existent perforating vessels (0.3–0.5 mm in diameter) located 2–4 cm proximal to the radial styloid process. To raise an adipofasciocutaneous flap, the territory will be marked over the proximal or middle third of the volar aspect of the forearm, with the pivot point about 2–4 cm proximal to the radial styloid. The proximal perforators can be ligated leaving the distal ones intact. The flap can be

Orbay et al. [6] described a flap based on a superficial cutaneous branch of the radial artery at

The superficial palmar arch is mainly formed by the ulnar artery, less so the superficial branch of the radial artery emerges 1–2 cm proximal to the wrist fold before dividing into superficial

The superficial radial branch courses underneath the palmar fascia and irrigates the thenar eminence before proceeding under the adductor and opponens muscles. At the level of the insertion of the FCR, the cutaneous branch of the superficial radial artery perforates the palmar

**Figure 4.** Reverse-flow flap based on the anastomosis of the superficial palmar branch of the radial artery with the

vascular palmar arches. Notice the 180° arc of rotation of the flap.

and dorsal branches (the latter one eventually enters Guyon's canal).

pedicled flap.

**4.2. Glabrous skin flap**

the thenar eminence (**Figure 4**).

also potentially raised as an adipofascial flap [5].

When the objective is palm coverage, the design of the paddle starts in the middle third of the forearm between the brachioradialis (BR) and the flexor carpi radialis (FCR). The dissection can be performed suprafascially, but once the septum in between the two muscles is reached, the fascia along with the septum and the artery has to be included. The peritenons of the FCR and BR must not be injured. The cephalic vein is usually necessary when harvesting a free flap but not in the case of a reverse-flow type, in which only concomitant veins are needed. The artery will be ligated at the proximal aspect of the flap. The arterial blood flow to the radial artery occurs through the distal ulnar artery connections in the vascular palmar arches; thus, this will then be considered a reverse-flow island flap.

The same flap can also be raised as an adipofascial flap in order to reduce morbidity of the donor site, but then again the flap itself will have to be grafted. An osteocutaneous radial flap

**Figure 3.** Fasciocutaneous radial flap: (a) retrograde fasciocutaneous radial flap, (b) radial perforator flap and (c) clinical case of a retrograde fasciocutaneous radial flap for a defect of the palm of the hand.

has also been described. In this case a small portion of the radius diaphysis is taken along with the artery. This type of reconstruction has been widely used as a free flap and not much as a pedicled flap.

A perforator radial flap has also been described based on about ten existent perforating vessels (0.3–0.5 mm in diameter) located 2–4 cm proximal to the radial styloid process. To raise an adipofasciocutaneous flap, the territory will be marked over the proximal or middle third of the volar aspect of the forearm, with the pivot point about 2–4 cm proximal to the radial styloid. The proximal perforators can be ligated leaving the distal ones intact. The flap can be also potentially raised as an adipofascial flap [5].

#### **4.2. Glabrous skin flap**

**4. Coverage of the palm of the hand**

this will then be considered a reverse-flow island flap.

Described by Yang [4] in 1981 as a free flap for the hand, this is a fasciocutaneous island flap based on the radial artery. Currently, it is not considered the first surgical option due to inevitable sacrifice of the radial artery and possible donor site morbidity. Allen's test is performed

When the objective is palm coverage, the design of the paddle starts in the middle third of the forearm between the brachioradialis (BR) and the flexor carpi radialis (FCR). The dissection can be performed suprafascially, but once the septum in between the two muscles is reached, the fascia along with the septum and the artery has to be included. The peritenons of the FCR and BR must not be injured. The cephalic vein is usually necessary when harvesting a free flap but not in the case of a reverse-flow type, in which only concomitant veins are needed. The artery will be ligated at the proximal aspect of the flap. The arterial blood flow to the radial artery occurs through the distal ulnar artery connections in the vascular palmar arches; thus,

The same flap can also be raised as an adipofascial flap in order to reduce morbidity of the donor site, but then again the flap itself will have to be grafted. An osteocutaneous radial flap

**Figure 3.** Fasciocutaneous radial flap: (a) retrograde fasciocutaneous radial flap, (b) radial perforator flap and (c) clinical

case of a retrograde fasciocutaneous radial flap for a defect of the palm of the hand.

**4.1. Radial fasciocutaneous flap**

124 Issues in Flap Surgery

before surgical planning (**Figure 3**).

Orbay et al. [6] described a flap based on a superficial cutaneous branch of the radial artery at the thenar eminence (**Figure 4**).

The superficial palmar arch is mainly formed by the ulnar artery, less so the superficial branch of the radial artery emerges 1–2 cm proximal to the wrist fold before dividing into superficial and dorsal branches (the latter one eventually enters Guyon's canal).

The superficial radial branch courses underneath the palmar fascia and irrigates the thenar eminence before proceeding under the adductor and opponens muscles. At the level of the insertion of the FCR, the cutaneous branch of the superficial radial artery perforates the palmar

**Figure 4.** Reverse-flow flap based on the anastomosis of the superficial palmar branch of the radial artery with the vascular palmar arches. Notice the 180° arc of rotation of the flap.

fascia; this level corresponds to a point 0.5–1 cm radial to the cutaneous thenar fold. A distal perforating vessel from the profundus or the superficial arch emerges at the confluency of Kaplan's line with the second webspace axis. The flap can then be raised based on the proximal cutaneous perforator and down to the radial superficial artery. Thus raised, the flap can be used as a free flap. Based on the distal perforators, it can also be designed to be a retrograde flap and can be used to solve first web contractures. In this case the superficial radial branch must be ligated proximal to the skin paddle.

The design of the posterior interosseous flap starts with the marking of the cutaneous island. A line is drawn between the lateral humeral epicondyle and the distal radioulnar joint. The island must be outlined in between the proximal and distal thirds of the forearm. The main posterior interosseous cutaneous branch emerges 9 centimetres distal to the lateral epicondyle in the same line; this can also be easily identified with a Doppler

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The vascular anastomosis between the two interosseous arteries can be found 2 cm proximal

The interosseous posterior artery is found at the septum between the extensor carpi ulnaris (ECU) and the extensor digiti minimi (EDM). This septum and the anastomosis are easily identified distally, which is the reason why many surgeons prefer to first identify the anastomosis and the posterior interosseous artery and eventually raise the flap. The posterior interosseous artery is closely related with the posterior interosseous nerve. This condition might

Donor site may be close directly or with a split skin graft depending on the width of the cuta-

**Figure 6.** Dorsoulnar fasciocutaneous flap: (a) anatomy of the distal dorsal branch of the ulnar artery and elevation of the flap based on the distal anastomosis of the ascending branch with the dorsal radial arch and the cutaneous ulnar branch needs to be ligated in order to perform a retrograde flap (black line) and (b) clinical case of dorsoulnar fasciocutaneous

to the radiocarpal joint at the proximal border of the pronator quadratus.

represent a challenge in the hands of an inexperienced surgeon.

ultrasound.

neous island.

flap to cover a defect of the palm.

## **5. Coverage of the dorsum of the hand**

#### **5.1. Posterior interosseous fasciocutaneous flap**

Described by Zancolli and Angrigiani [7] in 1988 for the dorsal coverage of the hand, this flap is based on the existence of an anastomosis between the posterior interosseous artery and the dorsal branch of the anterior interosseous artery at the dorsal aspect of the wrist. The posterior interosseous artery will be ligated, and the blood flow will course retrogradely from the anterior interosseous artery to the posterior interosseous pedicle (**Figure 5**).

**Figure 5.** Interosseous posterior flap: (a) defect located on the dorsum of the hand and markings of the flap, (b) septum between the fifth and sixth extensor compartment where a cutaneous perforator can be visualized, (c) the flap harvested and (d) the final outcome.

The design of the posterior interosseous flap starts with the marking of the cutaneous island. A line is drawn between the lateral humeral epicondyle and the distal radioulnar joint. The island must be outlined in between the proximal and distal thirds of the forearm. The main posterior interosseous cutaneous branch emerges 9 centimetres distal to the lateral epicondyle in the same line; this can also be easily identified with a Doppler ultrasound.

fascia; this level corresponds to a point 0.5–1 cm radial to the cutaneous thenar fold. A distal perforating vessel from the profundus or the superficial arch emerges at the confluency of Kaplan's line with the second webspace axis. The flap can then be raised based on the proximal cutaneous perforator and down to the radial superficial artery. Thus raised, the flap can be used as a free flap. Based on the distal perforators, it can also be designed to be a retrograde flap and can be used to solve first web contractures. In this case the superficial radial branch

Described by Zancolli and Angrigiani [7] in 1988 for the dorsal coverage of the hand, this flap is based on the existence of an anastomosis between the posterior interosseous artery and the dorsal branch of the anterior interosseous artery at the dorsal aspect of the wrist. The posterior interosseous artery will be ligated, and the blood flow will course retrogradely from the

**Figure 5.** Interosseous posterior flap: (a) defect located on the dorsum of the hand and markings of the flap, (b) septum between the fifth and sixth extensor compartment where a cutaneous perforator can be visualized, (c) the flap harvested

anterior interosseous artery to the posterior interosseous pedicle (**Figure 5**).

must be ligated proximal to the skin paddle.

126 Issues in Flap Surgery

**5. Coverage of the dorsum of the hand**

**5.1. Posterior interosseous fasciocutaneous flap**

and (d) the final outcome.

The vascular anastomosis between the two interosseous arteries can be found 2 cm proximal to the radiocarpal joint at the proximal border of the pronator quadratus.

The interosseous posterior artery is found at the septum between the extensor carpi ulnaris (ECU) and the extensor digiti minimi (EDM). This septum and the anastomosis are easily identified distally, which is the reason why many surgeons prefer to first identify the anastomosis and the posterior interosseous artery and eventually raise the flap. The posterior interosseous artery is closely related with the posterior interosseous nerve. This condition might represent a challenge in the hands of an inexperienced surgeon.

Donor site may be close directly or with a split skin graft depending on the width of the cutaneous island.

**Figure 6.** Dorsoulnar fasciocutaneous flap: (a) anatomy of the distal dorsal branch of the ulnar artery and elevation of the flap based on the distal anastomosis of the ascending branch with the dorsal radial arch and the cutaneous ulnar branch needs to be ligated in order to perform a retrograde flap (black line) and (b) clinical case of dorsoulnar fasciocutaneous flap to cover a defect of the palm.

#### **5.2. Dorsoulnar fasciocutaneous flap**

This is a flap that is based on the distal branch of the ulnar artery which emerges 2–5 cm proximal to the pisiform bone. This branch courses between the flexor carpi ulnaris (FCU) and the ECU and then reaches the cutaneous skin crossing between the ulnar nerve and the FCU distally. It then divides into descending and ascending branches. The descending branch anastomoses with skin perforators of the dorsal arch (**Figure 6**).

This distal branch can be identified with Doppler ultrasound. The flap can then be raised as a propeller flap (rotating the fasciocutaneous island around this branch) or as a reversed flap based on the anastomosis with the descending branch. This second option allows further advancement. This flap reaches the fourth and the fifth metacarpophalangeal joints.

Bertelli and Pagliei [8] have made an anatomic description of an osteocutaneous flap based on the ulnar periosteal branches of the ascending branch.

## **6. Finger coverage**

#### **6.1. Cross-finger flap**

The cross-finger flap is a two-stage flap reconstruction that was first described by Cronin in 1951 [9] (**Figure 7**).

This flap can be easily raised due to the fact that it does not require the dissection of vascular pedicles. It is a transposition flap based on the subcutaneous dorsal branches of a proper palm digital artery (PDA).

from the ring finger. This flap is not a good option for the coverage of the tip of the middle finger, because the ring or the index medial phalanges are more proximally located and the

**Figure 7.** Cross-finger flap: (a and b) defect and markings of the flap and (c, d and e) clinical case; always preserve the

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This flap has also been described for the reconstruction of the tip of the long fingers. This is

The skin is taken from the radial aspect of the thenar eminence, proximal to the metacarpophalangeal fold. Despite of its name, scars at the thenar eminence should be avoided above all

The base of the flap can be cranially or caudally located. The donor site needs to be grafted.

This triangular advancement flap was described by Tranquili [10] and popularised by Atasoy [11]. This flap is indicated in the case of transverse or dorsally oblique amputation of the tip

middle finger needs to be forced into flexion in order to fit next to them.

not only a simple technique but also needs a two-step procedure (**Figure 8**).

the weight-bearing central axis of the thenar eminence.

peritenon to be able to apply a skin graft on the donor digit.

**6.2. Thenar flap**

**6.3. V to Y Atasoy flap**

of the fingers (**Figure 9a**).

The fact that this is a two-stage surgical technique is the main disadvantage.

This flap is frequently designed over the dorsal skin of a medial phalanx in order to cover a distal phalanx or a medial phalanx of a contiguous finger. The limits of flap dissection are always represented by the finger folds. The vascular base of the flap is located at the mediolateral line of the donor finger that is directly opposite to the defect on the adjacent finger. In the case of volar skin loss, the flap has to be raised based on the dorsal skin of the medial phalanx of the donor finger. In case of dorsal skin loss, the coverage will be performed based on the volar aspect instead.

Dissection must include the skin and subcutaneous tissue, and the tendon sheath should not be exposed. The donor site has to be covered with a full-thickness skin graft.

The donor and recipient finger should be buddy splinted for 2 weeks. The second surgical step is then performed and the syndactyly is released. Hand physiotherapy will be necessary after the surgical procedure has been completed.

This type of coverage is particularly interesting for the triphalangeal fingers. The middle finger acts as a proper donor for the index and ring fingers. Little finger injuries require the skin

**Figure 7.** Cross-finger flap: (a and b) defect and markings of the flap and (c, d and e) clinical case; always preserve the peritenon to be able to apply a skin graft on the donor digit.

from the ring finger. This flap is not a good option for the coverage of the tip of the middle finger, because the ring or the index medial phalanges are more proximally located and the middle finger needs to be forced into flexion in order to fit next to them.

#### **6.2. Thenar flap**

**5.2. Dorsoulnar fasciocutaneous flap**

geal joints.

128 Issues in Flap Surgery

**6. Finger coverage**

**6.1. Cross-finger flap**

1951 [9] (**Figure 7**).

digital artery (PDA).

on the volar aspect instead.

after the surgical procedure has been completed.

This is a flap that is based on the distal branch of the ulnar artery which emerges 2–5 cm proximal to the pisiform bone. This branch courses between the flexor carpi ulnaris (FCU) and the ECU and then reaches the cutaneous skin crossing between the ulnar nerve and the FCU distally. It then divides into descending and ascending branches. The descending

This distal branch can be identified with Doppler ultrasound. The flap can then be raised as a propeller flap (rotating the fasciocutaneous island around this branch) or as a reversed flap based on the anastomosis with the descending branch. This second option allows further advancement. This flap reaches the fourth and the fifth metacarpophalan-

Bertelli and Pagliei [8] have made an anatomic description of an osteocutaneous flap based on

The cross-finger flap is a two-stage flap reconstruction that was first described by Cronin in

This flap can be easily raised due to the fact that it does not require the dissection of vascular pedicles. It is a transposition flap based on the subcutaneous dorsal branches of a proper palm

This flap is frequently designed over the dorsal skin of a medial phalanx in order to cover a distal phalanx or a medial phalanx of a contiguous finger. The limits of flap dissection are always represented by the finger folds. The vascular base of the flap is located at the mediolateral line of the donor finger that is directly opposite to the defect on the adjacent finger. In the case of volar skin loss, the flap has to be raised based on the dorsal skin of the medial phalanx of the donor finger. In case of dorsal skin loss, the coverage will be performed based

Dissection must include the skin and subcutaneous tissue, and the tendon sheath should not

The donor and recipient finger should be buddy splinted for 2 weeks. The second surgical step is then performed and the syndactyly is released. Hand physiotherapy will be necessary

This type of coverage is particularly interesting for the triphalangeal fingers. The middle finger acts as a proper donor for the index and ring fingers. Little finger injuries require the skin

The fact that this is a two-stage surgical technique is the main disadvantage.

be exposed. The donor site has to be covered with a full-thickness skin graft.

branch anastomoses with skin perforators of the dorsal arch (**Figure 6**).

the ulnar periosteal branches of the ascending branch.

This flap has also been described for the reconstruction of the tip of the long fingers. This is not only a simple technique but also needs a two-step procedure (**Figure 8**).

The skin is taken from the radial aspect of the thenar eminence, proximal to the metacarpophalangeal fold. Despite of its name, scars at the thenar eminence should be avoided above all the weight-bearing central axis of the thenar eminence.

The base of the flap can be cranially or caudally located. The donor site needs to be grafted.

#### **6.3. V to Y Atasoy flap**

This triangular advancement flap was described by Tranquili [10] and popularised by Atasoy [11]. This flap is indicated in the case of transverse or dorsally oblique amputation of the tip of the fingers (**Figure 9a**).

**Figure 8.** Thenar flap: (a and b) schema and (c and d) clinical case.

This flap is one of the most frequently performed in the emergency department but can be advanced only up to 7 to 8 mms. If higher expectations are sought, this flap would not be suitable. Inexperienced surgeons may tend to skeletonize the base of the flap or suture it under tension; any of these situations lead to inevitable flap necrosis.

The design of the flap is marked on the volar aspect of the affected distal phalanx down to the distal fold. The subcutaneous tissue can be fully elevated from the tendon sheath. The skin will only be incised superficially (i.e. until the subcutaneous tissue appears). Once dissected, the distal aspect of the flap is fixed with the help of a small needle rather than direct sutures, because direct suturing may damage the nail bed. The skin must be closed in a V to Y fashion in order to advance the flap.

As a main drawback, this flap leaves an unpleasant longitudinal linear scar at the tip of the

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This flap was described by Venkataswami and Subramanian [13] in 1980; it is mostly suitable for oblique fingertip amputations. The flap is based on the vascular pedicle opposite

finger.

**6.5. Homodigital pedicled island flaps**

**Figure 9.** (a) Atasoy's flap and (b) Kutler's flap.

*6.5.1. Oblique triangular neurovascular flap*

#### **6.4. Bilateral V to Y Kutler's flap**

This bilateral flap was described by Kutler [12] in 1930; it is based on the same principles as the V to Y flap (**Figure 9b**).

The Vs are marked at both sides of the defect, taking into account that they will be irrigated by the small branches of the proper palmar digital arteries.

**Figure 9.** (a) Atasoy's flap and (b) Kutler's flap.

This flap is one of the most frequently performed in the emergency department but can be advanced only up to 7 to 8 mms. If higher expectations are sought, this flap would not be suitable. Inexperienced surgeons may tend to skeletonize the base of the flap or suture it under

The design of the flap is marked on the volar aspect of the affected distal phalanx down to the distal fold. The subcutaneous tissue can be fully elevated from the tendon sheath. The skin will only be incised superficially (i.e. until the subcutaneous tissue appears). Once dissected, the distal aspect of the flap is fixed with the help of a small needle rather than direct sutures, because direct suturing may damage the nail bed. The skin must be closed in a V to Y fashion

This bilateral flap was described by Kutler [12] in 1930; it is based on the same principles as

The Vs are marked at both sides of the defect, taking into account that they will be irrigated

tension; any of these situations lead to inevitable flap necrosis.

**Figure 8.** Thenar flap: (a and b) schema and (c and d) clinical case.

by the small branches of the proper palmar digital arteries.

in order to advance the flap.

130 Issues in Flap Surgery

the V to Y flap (**Figure 9b**).

**6.4. Bilateral V to Y Kutler's flap**

As a main drawback, this flap leaves an unpleasant longitudinal linear scar at the tip of the finger.

#### **6.5. Homodigital pedicled island flaps**

#### *6.5.1. Oblique triangular neurovascular flap*

This flap was described by Venkataswami and Subramanian [13] in 1980; it is mostly suitable for oblique fingertip amputations. The flap is based on the vascular pedicle opposite the amputated side. The base of the triangular flap lies adjacent to de amputated side. A vertical incision is performed in the midlateral line of the finger down to the periosteum, and the pedicle of the finger is visualised and fully raised avoiding skeletonization. A partial thickness oblique incision is then performed; only the fibrous septa are divided to allow flap advancement (**Figure 10**).

The apex of the triangle is usually marked at the PIP joint. Small islands will tend to contract in time. Therefore, the island should never be small in size.

Unlike most unipedicled digital flaps, it contains the digital nerve of the flap and branches of the contralateral digital nerve. It cannot be considered as a true island flap but the first step just before that.

In case the advancement provided is insufficient, decision has to be made as to whether a true island flap is needed.

#### *6.5.2. Homodigital neurovascular anterograde unipedicled island flap*

This was described by Littler [1] although as a heterodigital flap. The design of the flap is subject to the location of the lesion. Despite of that, Brunelli described some considerations as to which donor site is more advisable in order to leave intact the dominant hemipulp. Advisable donor sites are the ulnar aspect of the index and middle fingers as well as the radial aspect of the ring and little fingers (**Figures 11** and **12**).

improved by releasing the pedicle down to the base of the finger. Brunner or hemi-Brunner

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A splint is advisable in the first week to prevent tension of the pedicle; the MCP joints should be kept flexed and the DIP and PIP joints extended. Hand physiotherapy is paramount to

This flap is not suitable for patients with peripheral vascular disease or in digits nourished

Described in 1966 by Hueston [14], this flap is meant to be advanced and rotated to reach the defect. It is based on one of the neurovascular pedicles and is eligible for transverse defects. Further dissection of the pedicle down to the base of the finger is not performed (**Figures 13**

The island paddle is outlined at the midaxial lateral line of the less affected side, or in case of a complete transverse amputation, the lateral line transected will correspond to the nondominant side. Therefore, this flap will be based on the dominant neurovascular pedicle. The flap is elevated and the tendon sheath will be left intact. The flap will then be advanced and rotated

The proximal end will be closed in a V to Y fashion or with a skin graft if needed.

incisions are then performed to avoid scar contractures in the future.

fully recover function.

*6.5.3. Homodigital quadrangular flap*

**Figure 11.** Homodigital anterograde neurovascular flap.

to cover the area of defect.

by a single vessel.

and **14**).

A full-thickness skin graft is hardly ever necessary to cover the donor site.

A U-shaped flap is marked, proximal to the defect, apex based at the PIP joint. The vertical incision reaches the periosteum, and once again, the pedicle must be visualised and not skeletonized to preserve a suitable venous drainage. The oblique incision also reaches the tendon sheath, and the flap would finally only be attached by its pedicle. The advancement can be

**Figure 10.** Neurovascular island flap and Venkataswami's flap.

**Figure 11.** Homodigital anterograde neurovascular flap.

the amputated side. The base of the triangular flap lies adjacent to de amputated side. A vertical incision is performed in the midlateral line of the finger down to the periosteum, and the pedicle of the finger is visualised and fully raised avoiding skeletonization. A partial thickness oblique incision is then performed; only the fibrous septa are divided to allow flap

The apex of the triangle is usually marked at the PIP joint. Small islands will tend to contract

Unlike most unipedicled digital flaps, it contains the digital nerve of the flap and branches of the contralateral digital nerve. It cannot be considered as a true island flap but the first step

In case the advancement provided is insufficient, decision has to be made as to whether a true

This was described by Littler [1] although as a heterodigital flap. The design of the flap is subject to the location of the lesion. Despite of that, Brunelli described some considerations as to which donor site is more advisable in order to leave intact the dominant hemipulp. Advisable donor sites are the ulnar aspect of the index and middle fingers as well as the radial aspect of

A U-shaped flap is marked, proximal to the defect, apex based at the PIP joint. The vertical incision reaches the periosteum, and once again, the pedicle must be visualised and not skeletonized to preserve a suitable venous drainage. The oblique incision also reaches the tendon sheath, and the flap would finally only be attached by its pedicle. The advancement can be

in time. Therefore, the island should never be small in size.

*6.5.2. Homodigital neurovascular anterograde unipedicled island flap*

the ring and little fingers (**Figures 11** and **12**).

**Figure 10.** Neurovascular island flap and Venkataswami's flap.

advancement (**Figure 10**).

just before that.

132 Issues in Flap Surgery

island flap is needed.

improved by releasing the pedicle down to the base of the finger. Brunner or hemi-Brunner incisions are then performed to avoid scar contractures in the future.

A full-thickness skin graft is hardly ever necessary to cover the donor site.

A splint is advisable in the first week to prevent tension of the pedicle; the MCP joints should be kept flexed and the DIP and PIP joints extended. Hand physiotherapy is paramount to fully recover function.

This flap is not suitable for patients with peripheral vascular disease or in digits nourished by a single vessel.

#### *6.5.3. Homodigital quadrangular flap*

Described in 1966 by Hueston [14], this flap is meant to be advanced and rotated to reach the defect. It is based on one of the neurovascular pedicles and is eligible for transverse defects. Further dissection of the pedicle down to the base of the finger is not performed (**Figures 13** and **14**).

The island paddle is outlined at the midaxial lateral line of the less affected side, or in case of a complete transverse amputation, the lateral line transected will correspond to the nondominant side. Therefore, this flap will be based on the dominant neurovascular pedicle. The flap is elevated and the tendon sheath will be left intact. The flap will then be advanced and rotated to cover the area of defect.

The proximal end will be closed in a V to Y fashion or with a skin graft if needed.

**Figure 12.** Clinical case of a homodigital anterograde neurovascular flap: (a) distal amputation, (b) flap dissection, (c) result at the end of the surgery and (d) the final outcome.

#### *6.5.4. Homodigital neurovascular retrograde unipedicled flap*

Described by Lai [15] in 1989, this flap is outlined on the lateral nondominant border of the base of the affected digit. The availability of the skin paddle is larger than the one for the anterograde flap (**Figure 15**).

**Figure 13.** Hueston's flap: (a) schema of the flap for a thumb defect and (b) schema of the flap for a triphalangeal finger.

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**Figure 14.** Clinical case of homodigital cuadrangular flap after necrosis of the tip of the middle finger.

Elevation is carried out from proximal to distal until enough length of the pedicle is obtained. The vascularity of this flap is dependent on transverse commissural arteries found at the PIP and DIP joints. Therefore, dissection should not proceed more than 1 cm proximal to the DIP joint. During dissection the proper digital nerve (PDN) is gently separated from the vascular pedicle, and the digital vessel is ligated proximally. The artery must be raised along with a cuff of fat and again never skeletonised the pedicle.

A full-thickness skin graft is used to close the secondary defect at the donor site.

The flap described is a non-sensate flap, and the PDN is left buried under a skin graft, which in some cases may be the cause of scar donor site dysaesthesias.

A retrograde sensate flap has also been described, including the PDN along with the artery. Once the flap reaches the defect, the nerve needs to be sutured to the amputated contralateral nerve in order to achieve sensation.

**Figure 13.** Hueston's flap: (a) schema of the flap for a thumb defect and (b) schema of the flap for a triphalangeal finger.

*6.5.4. Homodigital neurovascular retrograde unipedicled flap*

result at the end of the surgery and (d) the final outcome.

cuff of fat and again never skeletonised the pedicle.

in some cases may be the cause of scar donor site dysaesthesias.

anterograde flap (**Figure 15**).

134 Issues in Flap Surgery

nerve in order to achieve sensation.

Described by Lai [15] in 1989, this flap is outlined on the lateral nondominant border of the base of the affected digit. The availability of the skin paddle is larger than the one for the

**Figure 12.** Clinical case of a homodigital anterograde neurovascular flap: (a) distal amputation, (b) flap dissection, (c)

Elevation is carried out from proximal to distal until enough length of the pedicle is obtained. The vascularity of this flap is dependent on transverse commissural arteries found at the PIP and DIP joints. Therefore, dissection should not proceed more than 1 cm proximal to the DIP joint. During dissection the proper digital nerve (PDN) is gently separated from the vascular pedicle, and the digital vessel is ligated proximally. The artery must be raised along with a

The flap described is a non-sensate flap, and the PDN is left buried under a skin graft, which

A retrograde sensate flap has also been described, including the PDN along with the artery. Once the flap reaches the defect, the nerve needs to be sutured to the amputated contralateral

A full-thickness skin graft is used to close the secondary defect at the donor site.

**Figure 14.** Clinical case of homodigital cuadrangular flap after necrosis of the tip of the middle finger.

**Figure 15.** Homodigital retrograde neurovascular flap. The vascular conections of the proper palmar digital arteries are represented on the left image.

The main drawback is the fact that the stump of the donor nerve might turn into a neuroma and neuralgic pain may be quite invalidating.

dorsoulnar branch of the thumb which anastomoses with the thumb proper ulnar artery at the neck of the proximal phalanx. The dorsoulnar artery needs to be ligated proximal to the island paddle, and dissection is performed from distal to proximal (**Figures 17** and **18**).

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The flap can potentially include radial sensory branches found near the dorsoulnar branch which can then be sutured to the proper digital nerve to attempt a sensate type of flap.

A similar flap has been described based on the dorsoradial artery of the thumb [19]. However,

Otherwise, this flap will not provide sensation to the tip of the thumb.

the dorsoulnar branch is considered more dominant and constant.

**Figure 16.** Möberg's flap.

**Figure 17.** Brunelli's flap.

#### *6.5.5. Homodigital bipedicled island flap for the thumb*

Moberg [16] first described this flap in 1964, which consisted of undermining of the volar skin from the dorsal aspect along the midaxial lines of the thumb, starting proximal to the defect. The quadrangular advancement of the volar skin includes the two proper digital arteries and nerves. The arterial supply of the thumb differs from other fingers. Whereas the volar side of the thumb is supplied by two palmar collateral arteries which are branches of the princeps pollicis artery, the dorsal skin is predominantly supplied by ulnar and radial dorsolateral arteries and branches of the dorsal branch of the radial artery. Due to this particular vascularity, this flap can be raised to cover distal defects of the thumb but can potentially cause dorsal skin necrosis in triphalangeal fingers. The IP joint of the thumb should be kept flexed at 15–20° for a week, and later on hand physiotherapy is advised (**Figure 16**).

O'Brien [17] modified this flap in order to avoid flexion contractures. He added a skin incision distal to the MCP fold. Both pedicles are visualised and left intact with surrounding the subcutaneous tissue. This technique allows further advancement of the flap. A graft is then placed to cover this secondary defect.

#### *6.5.6. Homodigital unipedicle retrograde island flap for the thumb*

This flap was described by Brunelli [18]. The skin paddle is designed over the dorsoulnar aspect of the first metacarpal distal to the emergence of the dorsal branch of the radial artery in the first webspace. Dorsoulnar and dorsoradial arteries for the thumb branch out directly from the radial artery or from the first dorsal interosseous artery. This axial flap carries the

**Figure 16.** Möberg's flap.

The main drawback is the fact that the stump of the donor nerve might turn into a neuroma

**Figure 15.** Homodigital retrograde neurovascular flap. The vascular conections of the proper palmar digital arteries are

Moberg [16] first described this flap in 1964, which consisted of undermining of the volar skin from the dorsal aspect along the midaxial lines of the thumb, starting proximal to the defect. The quadrangular advancement of the volar skin includes the two proper digital arteries and nerves. The arterial supply of the thumb differs from other fingers. Whereas the volar side of the thumb is supplied by two palmar collateral arteries which are branches of the princeps pollicis artery, the dorsal skin is predominantly supplied by ulnar and radial dorsolateral arteries and branches of the dorsal branch of the radial artery. Due to this particular vascularity, this flap can be raised to cover distal defects of the thumb but can potentially cause dorsal skin necrosis in triphalangeal fingers. The IP joint of the thumb should be kept flexed

O'Brien [17] modified this flap in order to avoid flexion contractures. He added a skin incision distal to the MCP fold. Both pedicles are visualised and left intact with surrounding the subcutaneous tissue. This technique allows further advancement of the flap. A graft is then

This flap was described by Brunelli [18]. The skin paddle is designed over the dorsoulnar aspect of the first metacarpal distal to the emergence of the dorsal branch of the radial artery in the first webspace. Dorsoulnar and dorsoradial arteries for the thumb branch out directly from the radial artery or from the first dorsal interosseous artery. This axial flap carries the

at 15–20° for a week, and later on hand physiotherapy is advised (**Figure 16**).

*6.5.6. Homodigital unipedicle retrograde island flap for the thumb*

and neuralgic pain may be quite invalidating.

represented on the left image.

136 Issues in Flap Surgery

placed to cover this secondary defect.

*6.5.5. Homodigital bipedicled island flap for the thumb*

dorsoulnar branch of the thumb which anastomoses with the thumb proper ulnar artery at the neck of the proximal phalanx. The dorsoulnar artery needs to be ligated proximal to the island paddle, and dissection is performed from distal to proximal (**Figures 17** and **18**).

The flap can potentially include radial sensory branches found near the dorsoulnar branch which can then be sutured to the proper digital nerve to attempt a sensate type of flap. Otherwise, this flap will not provide sensation to the tip of the thumb.

A similar flap has been described based on the dorsoradial artery of the thumb [19]. However, the dorsoulnar branch is considered more dominant and constant.

**Figure 17.** Brunelli's flap.

**Figure 18.** Clinical case of homodigital dorsoulnar retrograde flap for the tip of the thumb.

Cavadas [20] described a modification that included a small portion of the first metacarpal diaphysis. This was presented as an option for complex injuries with a severe bone defect at the distal phalanx.

#### **6.6. Heterodigital flaps**

#### *6.6.1. Littler neurovascular island flap*

Currently, this type of reconstruction has lost popularity. The previously described anterograde homodigital flaps and microsurgical procedures such as toe to pulp transfer have limited its use. It is still interesting in case of a spare skin paddle and corresponding neurovascular pedicle of an otherwise nonsalvageable digit. This can then be used to reconstruct other injured digits but mainly for thumb reconstruction (**Figure 19**).

**6.7. Metacarpal artery island flaps**

*6.7.1. First dorsal metacarpal artery flap*

The so-called cerf-volant was described by Foucher and Braun [21] and has been considered

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Based on the first dorsal metacarpal artery (FDMA), which is a branch of the dorsal radial artery of the hand, it courses parallel to the first metacarpal bone and superficial to the first dorsal interosseous muscle fascia although some fibres may cover the vessel at its course. The

The island paddle is outlined at the dorsal skin of the proximal phalanx. It extends from the PIP joint to the MCP joint. Laterally, it can extend from the radial midline to the ulnar midline of the finger. Dissection has to be carried out subfascially in order not to damage the pedicle.

FDMA has vascular connections with the PDA at the level of the metacarpal neck.

the main workhorse in thumb reconstruction (**Figures 20** and **21**).

**Figure 19.** Littler's flap and heterodigital hemipulp neurovascular flap.

The selected donor site is the ulnar aspect of the middle and ring fingers. The skin paddle is marked; it extends from the volar midline until the dorsal midline. The pedicle dissection must be continued until the superficial palmar arch has been reached. A cuff of perivascular tissue needs to be preserved; after releasing the natatory fibres of the palmar fascia, the proper digital artery of the adjacent finger is ligated at the bifurcation of the common palmar digital artery, and the dissection of the pedicle is then accomplished up to the superficial arch. Brunner and hemi-Brunner types of incisions in both zone II and zone III have to be done in order to reach the proper pedicle length. The island flap has to be transferred without tension, kinking or compression through a subcutaneous tunnel to the thumb.

The sensory integration of the flap is variable, and the older the patient is, the less recognition will take place. However, this is not essential to reach adequate function.

The donor site needs skin grafting.

**Figure 19.** Littler's flap and heterodigital hemipulp neurovascular flap.

#### **6.7. Metacarpal artery island flaps**

Cavadas [20] described a modification that included a small portion of the first metacarpal diaphysis. This was presented as an option for complex injuries with a severe bone defect at

Currently, this type of reconstruction has lost popularity. The previously described anterograde homodigital flaps and microsurgical procedures such as toe to pulp transfer have limited its use. It is still interesting in case of a spare skin paddle and corresponding neurovascular pedicle of an otherwise nonsalvageable digit. This can then be used to reconstruct

The selected donor site is the ulnar aspect of the middle and ring fingers. The skin paddle is marked; it extends from the volar midline until the dorsal midline. The pedicle dissection must be continued until the superficial palmar arch has been reached. A cuff of perivascular tissue needs to be preserved; after releasing the natatory fibres of the palmar fascia, the proper digital artery of the adjacent finger is ligated at the bifurcation of the common palmar digital artery, and the dissection of the pedicle is then accomplished up to the superficial arch. Brunner and hemi-Brunner types of incisions in both zone II and zone III have to be done in order to reach the proper pedicle length. The island flap has to be transferred without tension,

The sensory integration of the flap is variable, and the older the patient is, the less recognition

other injured digits but mainly for thumb reconstruction (**Figure 19**).

**Figure 18.** Clinical case of homodigital dorsoulnar retrograde flap for the tip of the thumb.

kinking or compression through a subcutaneous tunnel to the thumb.

will take place. However, this is not essential to reach adequate function.

the distal phalanx.

138 Issues in Flap Surgery

**6.6. Heterodigital flaps**

*6.6.1. Littler neurovascular island flap*

The donor site needs skin grafting.

#### *6.7.1. First dorsal metacarpal artery flap*

The so-called cerf-volant was described by Foucher and Braun [21] and has been considered the main workhorse in thumb reconstruction (**Figures 20** and **21**).

Based on the first dorsal metacarpal artery (FDMA), which is a branch of the dorsal radial artery of the hand, it courses parallel to the first metacarpal bone and superficial to the first dorsal interosseous muscle fascia although some fibres may cover the vessel at its course. The FDMA has vascular connections with the PDA at the level of the metacarpal neck.

The island paddle is outlined at the dorsal skin of the proximal phalanx. It extends from the PIP joint to the MCP joint. Laterally, it can extend from the radial midline to the ulnar midline of the finger. Dissection has to be carried out subfascially in order not to damage the pedicle.

A lazy S incision is performed from the MCP joint to the anatomic snuffbox. The pedicle is then released until its emergency at the dorsal radial artery. Subcutaneous veins and sensory

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A tunnel is dissected from the first interosseous webspace to the defect at the tip of the thumb, and the flap and its pedicle are transferred and sutured. The pedicle must not be compressed

The dorsal metacarpal arteries (DMA) are branches of the dorsal arch supplied by the radial artery. They course underneath the extensor tendons, included in the epimysial lining of the

Due to the vascular connections with the deep palmar arch through recurrent cutaneous branches, this flap can be raised retrogradely. These connections are found distal to the junc-

Early and Milner [22] developed a reverse-flow island flap, based on the dorsal metacarpal arteries. This flap includes the whole course of the metacarpal artery; at the proximal end, the artery is ligated. The dissection must leave the peritenon of the extensor tendon intact

**Figure 22.** Dorsal metacarpal flaps of reverse flow: (a) position of the skin paddles (ellipses) and pivotal points (red dots);

(b) the pedicle includes the fascia of the dorsal interosseous muscle.

branches of the radial nerve are identified and can be included in the flap.

under the tunnel, and the flap should be sutured tension-free.

*6.7.2. Reverse-flow dorsal metacarpal flaps*

turae tendinum.

dorsal interosseous muscles (**Figures 22** and **23**).

**Figure 20.** Cerf-volant Foucher's flap, based on the first dorsal interosseous artery.

**Figure 21.** Clinical case of a defect of the tip of the thumb treated with a Foucher's flap.

A lazy S incision is performed from the MCP joint to the anatomic snuffbox. The pedicle is then released until its emergency at the dorsal radial artery. Subcutaneous veins and sensory branches of the radial nerve are identified and can be included in the flap.

A tunnel is dissected from the first interosseous webspace to the defect at the tip of the thumb, and the flap and its pedicle are transferred and sutured. The pedicle must not be compressed under the tunnel, and the flap should be sutured tension-free.

#### *6.7.2. Reverse-flow dorsal metacarpal flaps*

**Figure 21.** Clinical case of a defect of the tip of the thumb treated with a Foucher's flap.

**Figure 20.** Cerf-volant Foucher's flap, based on the first dorsal interosseous artery.

140 Issues in Flap Surgery

The dorsal metacarpal arteries (DMA) are branches of the dorsal arch supplied by the radial artery. They course underneath the extensor tendons, included in the epimysial lining of the dorsal interosseous muscles (**Figures 22** and **23**).

Due to the vascular connections with the deep palmar arch through recurrent cutaneous branches, this flap can be raised retrogradely. These connections are found distal to the juncturae tendinum.

Early and Milner [22] developed a reverse-flow island flap, based on the dorsal metacarpal arteries. This flap includes the whole course of the metacarpal artery; at the proximal end, the artery is ligated. The dissection must leave the peritenon of the extensor tendon intact

**Figure 22.** Dorsal metacarpal flaps of reverse flow: (a) position of the skin paddles (ellipses) and pivotal points (red dots); (b) the pedicle includes the fascia of the dorsal interosseous muscle.

**Figure 23.** Clinical case of skin defect on the proximal interphalangeal joint of the middle finger; the second dorsal metacarpal artery flap is performed.

**Figure 25.** Clinical case of a volar defect at the medial phalanx: a Quaba Davison's flap was used since many of the

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**Figure 26.** Dorsal commissural flaps: (a) location of the skin paddles (ellipses); (b) the flap reaches the distal interpha-

adjacent digits had been amputated.

langeal joints and the distal phalanx.

**Figure 24.** Quaba Davison's flaps: (a) location of the skin paddles (ellipses) and pivotal points (red dots); (b) the flap does not include the fascia of the dorsal interosseous muscle, and the pivotal point is immediately distal to the juncturae tendinum.

**Figure 25.** Clinical case of a volar defect at the medial phalanx: a Quaba Davison's flap was used since many of the adjacent digits had been amputated.

**Figure 23.** Clinical case of skin defect on the proximal interphalangeal joint of the middle finger; the second dorsal

**Figure 24.** Quaba Davison's flaps: (a) location of the skin paddles (ellipses) and pivotal points (red dots); (b) the flap does not include the fascia of the dorsal interosseous muscle, and the pivotal point is immediately distal to the juncturae tendinum.

metacarpal artery flap is performed.

142 Issues in Flap Surgery

**Figure 26.** Dorsal commissural flaps: (a) location of the skin paddles (ellipses); (b) the flap reaches the distal interphalangeal joints and the distal phalanx.

The knowledge of the neurovascular anatomy is paramount in order to understand and per-

Most local flaps provide adequate sensation and cosmesis using locoregional skin. However, local flaps obviously have limited indications, and larger or complex cases need a microsurgical approach instead of or even further amputation if considered nonsalvageable. Surgeons

\*, M. Llanos Guerrero Navarro2

[1] Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand.

[2] Lister GD, Gibson T. Closure of rhomboid skin defects: The flaps of Limberg and

[3] Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the

[4] Yang G, Chen B, Gao Y. The forearm free skin flap transplantation. National Medical

[5] Medalie DA. Perforator-based forearm and hand adipofascial flaps for the coverage of

[6] Orbay JL, Rosen JG, Khouri RK, et al. The glabrous palmar flap: The new free or reversed pedicled palmar fasciocutaneous flap for volar hand reconstruction. Techniques in Hand

[7] Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. Journal of Hand

[8] Bertelli JA, Pagliei A. The neurocutaneous flap based on the dorsal branches of the ulnar artery and nerve. A new flap for extensive reconstruction of the hand. Plastic and

difficult dorsal hand wounds. Annals of Plastic Surgery. 2002;**48**(5):477-483

The Journal of Bone and Joint Surgery. American Volume. 1956;**38**:917

Dufourmentel. British Journal of Plastic Surgery. 1972;**25**(3):300-314

thumb. Plastic and Reconstructive Surgery. 1979;**63**(3):344-349

& Upper Extremity Surgery. 2009;**13**(3):145-150

Reconstructive Surgery. 1998;**101**(6):1537-1543

Surgery British. 1988;**13**(2):130-135

and Alba Izquierdo Robledano1

2 Hospital General Universitario Santa Lucia, Cartagena, Murcia, Spain

, Juan Garcia Navarro1

http://dx.doi.org/10.5772/intechopen.74152

,

Hand Coverage

145

should recognize which indication is correct in every case.

\*Address all correspondence to: fmtnez@gmail.com

Journal of China. 1981;**61**:139

1 Hospital Universitario Virgen de la Arrixaca, Murcia, Spain

form these flaps.

**Author details**

Alberto Gimenez Ros1

**References**

Francisco Martinez Martinez1

**Figure 27.** Clinical case of soft tissue defect on the medial phalanx where a dorsal commissural flap was obtained.

and include the interosseous fascia. The juncturae must be released, and dissection has to end at the level of the metacarpal neck. Dorsal sensory branches and possible veins must be included in the flap. The island paddle extends from the MCP joint to the wrist crease. The arc of rotation of this flap (180°) allows the coverage of the proximal phalanx and PIP joint up to the middle phalanx.

Quaba and Davidson [23] described the same flap without incorporating the DMA (**Figures 23** and **24**). Dissection of the flap proceeds suprafascially, and it is based only on the recurrent cutaneous branch. The flap can also extend from the MCP joint to the wrist crease. The flap is then easier to elevate and provides a thinner coverage (**Figures 25** and **26**).

Eventually, anatomic studies confirmed the existence of vascular connections at different levels of the proximal phalanx and medial phalanx between the PDA and cutaneous braches of the DMA. Karacalar and Özcan [24] described a modified version of this flap based on these anatomic findings. This is a reverse-flow flap with the skin paddle outlined on the second and third webspaces (**Figure 27**). The arc of rotation reaches the distal phalanx, and the pivot point is found at the neck of the proximal phalanx (**Figures 25** and **26**).

#### **7. Summary**

Local hand flaps offer excellent coverage of soft tissue loss when a skin graft is not eligible and when the defect is small or moderate.

The knowledge of the neurovascular anatomy is paramount in order to understand and perform these flaps.

Most local flaps provide adequate sensation and cosmesis using locoregional skin. However, local flaps obviously have limited indications, and larger or complex cases need a microsurgical approach instead of or even further amputation if considered nonsalvageable. Surgeons should recognize which indication is correct in every case.

## **Author details**

Francisco Martinez Martinez1 \*, M. Llanos Guerrero Navarro2 , Juan Garcia Navarro1 , Alberto Gimenez Ros1 and Alba Izquierdo Robledano1

\*Address all correspondence to: fmtnez@gmail.com

1 Hospital Universitario Virgen de la Arrixaca, Murcia, Spain

2 Hospital General Universitario Santa Lucia, Cartagena, Murcia, Spain

## **References**

and include the interosseous fascia. The juncturae must be released, and dissection has to end at the level of the metacarpal neck. Dorsal sensory branches and possible veins must be included in the flap. The island paddle extends from the MCP joint to the wrist crease. The arc of rotation of this flap (180°) allows the coverage of the proximal phalanx and PIP joint up to

**Figure 27.** Clinical case of soft tissue defect on the medial phalanx where a dorsal commissural flap was obtained.

Quaba and Davidson [23] described the same flap without incorporating the DMA (**Figures 23** and **24**). Dissection of the flap proceeds suprafascially, and it is based only on the recurrent cutaneous branch. The flap can also extend from the MCP joint to the wrist crease. The flap is then

Eventually, anatomic studies confirmed the existence of vascular connections at different levels of the proximal phalanx and medial phalanx between the PDA and cutaneous braches of the DMA. Karacalar and Özcan [24] described a modified version of this flap based on these anatomic findings. This is a reverse-flow flap with the skin paddle outlined on the second and third webspaces (**Figure 27**). The arc of rotation reaches the distal phalanx, and the pivot point

Local hand flaps offer excellent coverage of soft tissue loss when a skin graft is not eligible and

easier to elevate and provides a thinner coverage (**Figures 25** and **26**).

is found at the neck of the proximal phalanx (**Figures 25** and **26**).

the middle phalanx.

144 Issues in Flap Surgery

**7. Summary**

when the defect is small or moderate.


[9] Cronin TD. The cross finger flap: A new method of repair. The American Surgeon. 1951; **17**(5):419-425

**Chapter 8**

**Provisional chapter**

**Omental Flap in Breast Reconstruction**

and technique of omental flap for breast reconstruction.

**Keywords:** breast, reconstruction, omental flap, mastectomy

tion rate and good esthetic outcome.

**Omental Flap in Breast Reconstruction**

DOI: 10.5772/intechopen.70115

**Objectives:** The use of omental flap for breast reconstruction was reported by the Romanian surgeon Kiricuta in 1963, since that time some surgeons tried to use the omentum either pedicled or free for breast reconstruction. It can be used after partial or total

**Aims:** The aim of this chapter is to address indications, limitations, contraindications,

**Technique:** This flap could be retrieved by either a small midline laparotomy or preferably by laparoscopic harvesting. Details of retrieval, tips and tricks are highlighted in

**Conclusions:** Omental flap is a strong working horse in breast reconstruction after partial or skin sparing mastectomy (SSM). It can be free or pedicled. It could be retrieved by minilaparotomy or preferably by laparoscopic harvesting omental flap (LHOF). It is a simple, safe, and reliable flap that mimics the natural contour of the breast. In about 30% with volume insufficiency it can be used with an implant as a cover with low complica-

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

The omentum is not just an abdominal structure, it is an unique organ with a peculiar location, shape, attachments, supply, and function. The omentum has a mechanical function as a barrier or sealant. It has an immune function and an endocrinal function through secreting many cytokines, growth factors, and hormones [1, 2]. Surgeons aimed to use this organ in many reconstructive procedures. The first use of a pedicled omental flap was reported by Senn in

Ashraf Khater, Adel Fathi and Hosam Ghazy

Additional information is available at the end of the chapter

Ashraf Khater, Adel Fathi and Hosam Ghazy

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70115

**Abstract**

mastectomy.

this chapter.

**1. Historical background**


**Provisional chapter**

## **Omental Flap in Breast Reconstruction**

**Omental Flap in Breast Reconstruction**

Ashraf Khater, Adel Fathi and Hosam Ghazy Ashraf Khater, Adel Fathi and Hosam Ghazy Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70115

#### **Abstract**

[9] Cronin TD. The cross finger flap: A new method of repair. The American Surgeon. 1951;

[10] Tranquilli-Leali E. Reconstruzione del apice falangi vaguali mediante autoplástica

[11] Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction of the amputated finger tip with a triangular volar flap. Journal of Bone and Joint Surgery. 1970;**52**:921-926

[12] Kutler W. A new method for fingertip amputation. Journal of the American Medical

[13] Venkataswami DR, Subramanian N. Oblique triangular flap: A new method of repair for oblique amputations of the fingertip and thumb. Plastic and Reconstructive Surgery.

[14] Hueston JT. Local flap repair of fingertip injuries. Plastic and Reconstructive Surgery.

[15] Lai CS, Ling SD, Yang CC. The reverse digital artery flap for fingertip reconstruction.

[16] Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. The

[17] O'Brien B. Neurovascular island pedicle flaps for terminal amputations and digital scars.

[18] Brunelli F, Vigasio A, Valenti P, Brunelli GR. Arterial anatomy and clinical application of the dorsoulnar flap of the thumb. Journal of Hand Surgery. 1999;**24**(4):803-811

[19] Bakhach J, Sentucq-Rigal J, Mouton P, Boileau R, Panconi B, Guimberteau JC. The dorsoradial flap: A new flap for hand reconstruction. Anatomical study and clinical applica-

[20] Cavadas P. Reverse osteocutaneous dorsoulnar thumb flap. Plastic and Reconstructive

[21] Foucher G, Braun J. A new island flap transfer from the dorsum of the index to the

[22] Early MJ, Milner RH. Dorsal metacarpal flaps. British Journal of Plastic Surgery. 1987;

[23] Quaba AA, Davidson PM. The distally-based dorsal hand flap. British Journal of Plastic

[24] Karacalar A, Özcan M. A new approach to the reverse dorsal metacarpal artery flap.

Journal of Bone and Joint Surgery. American Volume. 1964;**46**:817-825

tions. Annales de Chirurgie Plastique et Esthétique. 2006;**51**(1):53-60

thumb. Plastic and Reconstructive Surgery. 1979;**62**(3):344-349

Journal of Hand Surgery American. 1997;**22**(2):307-310

volare pedunculata per scorimento. Infort Traum Lavoro. 1935;**1**:186-193

**17**(5):419-425

146 Issues in Flap Surgery

Association. 1947;**133**(1):29-30

Surgery. 2003;**111**(1):326-329

Surgery. 1990;**43**(1):28-39

**10**:333-341

Annals of Plastic Surgery. 1989;**22**(6):495-500

British Journal of Plastic Surgery. 1968;**21**(3):258-261

1980;**66**(2):296-300

1966;**37**(4):349-350

**Objectives:** The use of omental flap for breast reconstruction was reported by the Romanian surgeon Kiricuta in 1963, since that time some surgeons tried to use the omentum either pedicled or free for breast reconstruction. It can be used after partial or total mastectomy.

DOI: 10.5772/intechopen.70115

**Aims:** The aim of this chapter is to address indications, limitations, contraindications, and technique of omental flap for breast reconstruction.

**Technique:** This flap could be retrieved by either a small midline laparotomy or preferably by laparoscopic harvesting. Details of retrieval, tips and tricks are highlighted in this chapter.

**Conclusions:** Omental flap is a strong working horse in breast reconstruction after partial or skin sparing mastectomy (SSM). It can be free or pedicled. It could be retrieved by minilaparotomy or preferably by laparoscopic harvesting omental flap (LHOF). It is a simple, safe, and reliable flap that mimics the natural contour of the breast. In about 30% with volume insufficiency it can be used with an implant as a cover with low complication rate and good esthetic outcome.

**Keywords:** breast, reconstruction, omental flap, mastectomy

#### **1. Historical background**

The omentum is not just an abdominal structure, it is an unique organ with a peculiar location, shape, attachments, supply, and function. The omentum has a mechanical function as a barrier or sealant. It has an immune function and an endocrinal function through secreting many cytokines, growth factors, and hormones [1, 2]. Surgeons aimed to use this organ in many reconstructive procedures. The first use of a pedicled omental flap was reported by Senn in

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

1888 when he used it for protection of intestinal anastomosis [3]. More recently, the omentum was revisited by Knazozovicky in 1929 when he used the pedicled omentum after arthroplasty [4]. Due to its immune function, it was used for coverage of deep sternal and infected wounds as well as to protect anastomoses [5, 6]. The Romanian surgeon, Kiricuta described the use of the pedicled omental flap for repair of vesicovaginal fistula and for breast reconstruction after mastectomy [7, 8]. He reported on 10 cases of breast reconstruction after subcutaneous mastectomy with 40% pure omental reconstruction without any need for implants. This opened the gate for use of pedicled omental flap in breast reconstruction. The main two problems with this flap were the unpredictable volume [9, 10] and the requirement of laparotomy for retrieval. The latter was associated with potential morbidity especially in regards to the occurrence of incisional hernia [11]. Some researchers tried to extract this flap through a minilaparotomy; yet incisional hernia still remained a complication [12]. For this reason Saltz described omental flap retrieval through a laparoscopic approach [13]. Later on, there was a shift toward the laparoscopic retrieval with great success. The largest series was reported by Hisamitsu Zaha who performed around 200 cases of laparoscopically harvested omental flap (LHOF) with minimal complications and satisfactory aesthetic results [14]. Subsequently, to avoid any traction over the pedicle with added length of the pedicle to the total flap volume, a trend emerged toward usage of free omental flaps extracted through a small abdominal incision to avoid any traction over the pedicle with added length of the pedicle to the total flap volume [15, 16]. The first free omental flap was performed in an emergent basis to cover a large defect in the scalp after avulsion [15]. After that, its indications were widened and it was applied to several locations [17]. In this work, we shall try to answer the following question: is there a role for omental flap in breast reconstruction in the era of oncoplastic surgery?

**8.** Great adaptability to any cavities.

increases in obese women.

ally of lesser amount.

rupture are rare [12].

incision.

**9.** Great malleability with ease in reshaping to mimic the breast mound.

**10.** It is a good reconstructive tool in obese women (its volume increases with weight gain) and can be retrieved with the laparoscope without major complications. On the other hand, obesity is a relative contraindication for TRAM flap and its ischemic complications

Omental Flap in Breast Reconstruction http://dx.doi.org/10.5772/intechopen.70115 149

**11.** Long pedicle which can be transferred easily to the mastectomy bed through an epigastric

**13.** It has a characteristic absorptive power, so seroma is less evident and drain output is usu-

**14.** It is the only flap that shows a unique phenomenon of size gain, which is completed by the end of the sixth month. Other flaps (or lipofilling) usually undergo size decrease with

**18.** Surprisingly, if it is used as a cover for the silicone implants, capsular contracture, and

**15.** It has an immune function and good tissue adherence, so it can cover ischemic areas.

**12.** The flap is bipedicled and can be divided to work for both breasts simultaneously.

progress of time due to either muscle atrophy or adipose tissue loss [19].

**16.** It is suitable for all ages, stages, body weights, and controllable comorbidities.

**17.** It has a very good tolerance for postoperative radiotherapy.

**Figure 1.** Mammographic view of the right breast reconstructed with an omental flap.

#### **2. Advantages of the omental flap**

We can list several advantages of the omental flap [11, 12, 18]:


**8.** Great adaptability to any cavities.

1888 when he used it for protection of intestinal anastomosis [3]. More recently, the omentum was revisited by Knazozovicky in 1929 when he used the pedicled omentum after arthroplasty [4]. Due to its immune function, it was used for coverage of deep sternal and infected wounds as well as to protect anastomoses [5, 6]. The Romanian surgeon, Kiricuta described the use of the pedicled omental flap for repair of vesicovaginal fistula and for breast reconstruction after mastectomy [7, 8]. He reported on 10 cases of breast reconstruction after subcutaneous mastectomy with 40% pure omental reconstruction without any need for implants. This opened the gate for use of pedicled omental flap in breast reconstruction. The main two problems with this flap were the unpredictable volume [9, 10] and the requirement of laparotomy for retrieval. The latter was associated with potential morbidity especially in regards to the occurrence of incisional hernia [11]. Some researchers tried to extract this flap through a minilaparotomy; yet incisional hernia still remained a complication [12]. For this reason Saltz described omental flap retrieval through a laparoscopic approach [13]. Later on, there was a shift toward the laparoscopic retrieval with great success. The largest series was reported by Hisamitsu Zaha who performed around 200 cases of laparoscopically harvested omental flap (LHOF) with minimal complications and satisfactory aesthetic results [14]. Subsequently, to avoid any traction over the pedicle with added length of the pedicle to the total flap volume, a trend emerged toward usage of free omental flaps extracted through a small abdominal incision to avoid any traction over the pedicle with added length of the pedicle to the total flap volume [15, 16]. The first free omental flap was performed in an emergent basis to cover a large defect in the scalp after avulsion [15]. After that, its indications were widened and it was applied to several locations [17]. In this work, we shall try to answer the following question: is there a role for omental flap in breast reconstruction in the era of oncoplastic surgery?

**2. Advantages of the omental flap**

learning curve.

148 Issues in Flap Surgery

**3.** Minimal blood loss.

complications and fat necrosis.

We can list several advantages of the omental flap [11, 12, 18]:

**1.** Easy harvest which is not technically demanding, and that is characterized by a short

**4.** Can be retrieved simultaneously with mastectomy by two teams with neither need for

**6.** This flap is fatty in nature, so it mimics the normal breast and you can hardly differentiate

**7.** Reliability of its axial blood supply with less common ischemic complications transverse rectus abdominis myocutaneous flap (TRAM) is a perforator flap with common ischemic

**2.** Minimal donor site morbidity especially with the use of laparoscopic harvesting.

extra time nor for changing patient′s position for staged operations.

in between even with the use of mammography (**Figure 1**).

**5.** Fast recovery with early discharge especially with laparoscopic harvesting.


**Figure 1.** Mammographic view of the right breast reconstructed with an omental flap.

## **3. Limitations**


#### **3.1. Contraindications**

**1.** The main contraindication is the presence of omental malignant nodules, omental cake, or malignant ascites [11].

**Figure 2.** Layers and attachment of the greater omentum.

Omental Flap in Breast Reconstruction http://dx.doi.org/10.5772/intechopen.70115 151

**Figure 3.** Arterial supply of the greater omentum.


#### **4. Anatomic considerations**

The greater omentum is attached inferiorly to the transverse colon after making a loop over itself forming a four layer loop. Superiorly, it is attached to the greater curve of the stomach (**Figure 2**) [20–22].

It has the advantage of having a dual blood supply from both gastroepiploic arteries (right epiploic from gastroduodenal and left from the splenic). Both form anterior and posterior epiploic arcades (**Figure 3**) and gives rise to anterior, posterior, and accessory epiploic arteries.

The flap pedicle can be based on either the right or the left gastroepiploic arteries (commonly the right) after dividing the contralateral artery (**Figure 4**). However, if a free flap is used, both vascular pedicles can be anastomosed to the branches of the axillary artery through a microvascular anastomosis.

Moreover, the flap can be lengthened by dividing the anterior epiploic arteries keeping the anterior and posterior omental arcades (**Figure 5**).

**Figure 2.** Layers and attachment of the greater omentum.

**3. Limitations**

150 Issues in Flap Surgery

**3.1. Contraindications**

malignant ascites [11].

**1.** The main drawback of this flap is the unpredictable volume, however if volume is insuf-

**4.** It is considered an abdominal operation with all hazards of laparoscopic use as bleeding,

**1.** The main contraindication is the presence of omental malignant nodules, omental cake, or

The greater omentum is attached inferiorly to the transverse colon after making a loop over itself forming a four layer loop. Superiorly, it is attached to the greater curve of the stomach

It has the advantage of having a dual blood supply from both gastroepiploic arteries (right epiploic from gastroduodenal and left from the splenic). Both form anterior and posterior epiploic arcades (**Figure 3**) and gives rise to anterior, posterior, and accessory epiploic

The flap pedicle can be based on either the right or the left gastroepiploic arteries (commonly the right) after dividing the contralateral artery (**Figure 4**). However, if a free flap is used, both vascular pedicles can be anastomosed to the branches of the axillary artery through a

Moreover, the flap can be lengthened by dividing the anterior epiploic arteries keeping the

**6.** Presence of peritoneal metastases or omental deposits may preclude flap retrieval.

ficient [9, 11], it can be used safely as a cover for an implant.

visceral injuries, and complications of laparoscopy.

**5.** Presence of adhesions may be a limiting factor.

**2.** If omentectomy was done for any reason.

**4.** Contraindications of laparoscopy.

**4. Anatomic considerations**

(**Figure 2**) [20–22].

microvascular anastomosis.

anterior and posterior omental arcades (**Figure 5**).

arteries.

**2.** It is not suitable for cases in which the whole breast with its skin is removed.

**3.** It may be deficient in thin women (implant can be used as an adjunct).

**3.** Presence of marked abdominal adhesions that make retrieval difficult.

**Figure 3.** Arterial supply of the greater omentum.

**5. Technique**

retraction if it has a large volume (**Figure 7**).

Ligasure as this device can control sizable vessels (**Figure 9**).

**Figure 6.** Omental flap retrieved through a small epigastric minilaparotmy.

alization of the right gastroepiploic artery within a fold (**Figure 10**).

The omentum may be retrieved through a small epigastric minilaparotomy (**Figure 6**) or through laparoscopy. Laparoscopic ports are usually infra‐umbilical; a 12 mm port just below the umbilicus for the camera and two 5 mm lateral ports for handling and dissection. Optional one or two 5 mm ports may be used in the upper right or left hypochondrium for omental

Omental Flap in Breast Reconstruction http://dx.doi.org/10.5772/intechopen.70115 153

In laparoscopic harvest, it is preferable to start dissection with separation of the omentum from the colonic attachment to preserve the flap suspended from the greater curve (**Figure 8**). Then working in a counterclockwise direction, dissection is extended toward the left gastroepiploic artery which is sealed and divided either by harmonic scalpel or preferably by

Then, we start dividing the attachment to the greater curvature of the stomach up to the visu-

The last step is a creation of an epigastric incision through the lower mastectomy flap, then a 12 mm trocar is introduced to grasp the distal tip of the freed omentum which is widened to

2–3 fingers width to allow transmission of the flap to the mastectomy bed (**Figure 11**).

**Figure 4.** Pedicled omental flap based on the right gastroepiploic artery.

**Figure 5.** Lengthened omental flap (dotted division line).

## **5. Technique**

**Figure 4.** Pedicled omental flap based on the right gastroepiploic artery.

152 Issues in Flap Surgery

**Figure 5.** Lengthened omental flap (dotted division line).

The omentum may be retrieved through a small epigastric minilaparotomy (**Figure 6**) or through laparoscopy. Laparoscopic ports are usually infra‐umbilical; a 12 mm port just below the umbilicus for the camera and two 5 mm lateral ports for handling and dissection. Optional one or two 5 mm ports may be used in the upper right or left hypochondrium for omental retraction if it has a large volume (**Figure 7**).

In laparoscopic harvest, it is preferable to start dissection with separation of the omentum from the colonic attachment to preserve the flap suspended from the greater curve (**Figure 8**).

Then working in a counterclockwise direction, dissection is extended toward the left gastroepiploic artery which is sealed and divided either by harmonic scalpel or preferably by Ligasure as this device can control sizable vessels (**Figure 9**).

Then, we start dividing the attachment to the greater curvature of the stomach up to the visualization of the right gastroepiploic artery within a fold (**Figure 10**).

The last step is a creation of an epigastric incision through the lower mastectomy flap, then a 12 mm trocar is introduced to grasp the distal tip of the freed omentum which is widened to 2–3 fingers width to allow transmission of the flap to the mastectomy bed (**Figure 11**).

**Figure 6.** Omental flap retrieved through a small epigastric minilaparotmy.

**Figure 7.** Laparoscopically retrieved omental flap with port sites demonstrated.

**Figure 8.** Separation of the greater omentum from the colonic attachment.

When the flap is transferred to the bed, it could be molded to fit to the breast envelope, then the flap should be fixed by few nonabsorbable sutures to the underlying muscles to avoid flap retraction into the abdomen. Care should be exercised to avoid injury of the vascular pedicle by these sutures. We prefer carrying mastectomy through a hidden inframammary incision close to the epigastrium. This allows delivery of the flap through the subcutaneous tunnel and enables us to obtain a very good cosmetic outcome "scarless procedure" (**Figure 12**). The problem with this incision is the relative higher ischemic complications, these can be avoided

Omental Flap in Breast Reconstruction http://dx.doi.org/10.5772/intechopen.70115 155

**Figure 11.** Grasping of the flap distal end to be transmitted into the mastectomy bed.

**Figure 10.** Division of attachments to the greater curvature.

**Figure 9.** Division of the left gastroepiploic artery.

**Figure 10.** Division of attachments to the greater curvature.

**Figure 7.** Laparoscopically retrieved omental flap with port sites demonstrated.

154 Issues in Flap Surgery

**Figure 8.** Separation of the greater omentum from the colonic attachment.

**Figure 9.** Division of the left gastroepiploic artery.

**Figure 11.** Grasping of the flap distal end to be transmitted into the mastectomy bed.

When the flap is transferred to the bed, it could be molded to fit to the breast envelope, then the flap should be fixed by few nonabsorbable sutures to the underlying muscles to avoid flap retraction into the abdomen. Care should be exercised to avoid injury of the vascular pedicle by these sutures. We prefer carrying mastectomy through a hidden inframammary incision close to the epigastrium. This allows delivery of the flap through the subcutaneous tunnel and enables us to obtain a very good cosmetic outcome "scarless procedure" (**Figure 12**). The problem with this incision is the relative higher ischemic complications, these can be avoided

**7. Pedicled versus free flaps**

**8. Evaluation of flap integrity**

**9. The aesthetic outcome**

**Figure 14.** Duplex assessment showing an intact vascularity.

A free omental flap is recommended if remote coverage is required such as scalp avulsion, however there are advantages for free omental flap transfer in breast reconstruction, such as making benefit of the length of pedicle when added to the flap [16], ridding the patient of epigastric discomfort or pain due to passage of the pedicle through the tunnel, and finally minimal incidence of epigastric hernia consequent upon avoidance of the epigastric wound. This is especially so, if the omental flap is retrieved through a small Pfannenstiel incision or

Omental Flap in Breast Reconstruction http://dx.doi.org/10.5772/intechopen.70115 157

Some authors leave a small window for this purpose, however the best way is to perform an

As reported by many authors, more than 80% of patients express an excellent aesthetic outcome [14]. **Figures 15** and **16** show cases of skin sparing mastectomy (SSM) reconstructed with a pedicled omental flap. In **Figure 15**, retrieval was done through a minlaparotomy and in **Figure 16** it was through a laparoscopic harvesting (LHOF) with a nearly scarless procedure.

intraoperative Doppler study and postoperative Duplex assessment (**Figure 14**).

even through an epigastric wound which is completely closed.

**Figure 12.** Inframammary incision to make a scarless procedure and to ease flap retrieval through the epigastric incision.

by testing its vascularity by either simple pricking, peripheral cutting or through dye techniques. However, any ischemia could be easily managed in the outpatient clinic with a very satisfactory cosmetic outcome.

## **6. Volume insufficiency**

In the largest reported series by the Japanese surgeon Hisamitsu Zaha that included 200 cases, volume insufficiency was around 30%; in such case, a silicone implant could be used as an adjunct with a very good aesthetic outcome (**Figure 13**) [14].

**Figure 13.** Silicone implant as an adjunct with omental flap.

## **7. Pedicled versus free flaps**

A free omental flap is recommended if remote coverage is required such as scalp avulsion, however there are advantages for free omental flap transfer in breast reconstruction, such as making benefit of the length of pedicle when added to the flap [16], ridding the patient of epigastric discomfort or pain due to passage of the pedicle through the tunnel, and finally minimal incidence of epigastric hernia consequent upon avoidance of the epigastric wound. This is especially so, if the omental flap is retrieved through a small Pfannenstiel incision or even through an epigastric wound which is completely closed.

## **8. Evaluation of flap integrity**

by testing its vascularity by either simple pricking, peripheral cutting or through dye techniques. However, any ischemia could be easily managed in the outpatient clinic with a very

**Figure 12.** Inframammary incision to make a scarless procedure and to ease flap retrieval through the epigastric incision.

In the largest reported series by the Japanese surgeon Hisamitsu Zaha that included 200 cases, volume insufficiency was around 30%; in such case, a silicone implant could be used as an

adjunct with a very good aesthetic outcome (**Figure 13**) [14].

**Figure 13.** Silicone implant as an adjunct with omental flap.

satisfactory cosmetic outcome.

156 Issues in Flap Surgery

**6. Volume insufficiency**

Some authors leave a small window for this purpose, however the best way is to perform an intraoperative Doppler study and postoperative Duplex assessment (**Figure 14**).

**Figure 14.** Duplex assessment showing an intact vascularity.

#### **9. The aesthetic outcome**

As reported by many authors, more than 80% of patients express an excellent aesthetic outcome [14]. **Figures 15** and **16** show cases of skin sparing mastectomy (SSM) reconstructed with a pedicled omental flap. In **Figure 15**, retrieval was done through a minlaparotomy and in **Figure 16** it was through a laparoscopic harvesting (LHOF) with a nearly scarless procedure.

**3.** Local sepsis that may end up with necrotizing fasciitis especially in poorly controlled dia-

Omental Flap in Breast Reconstruction http://dx.doi.org/10.5772/intechopen.70115 159

**4.** Hemorrhage, either in the mastectomy bed or intra‐abdominal after flap retrieval. The most common abdominal sources are, the sealed left gastroepiploic vessels, short gastric

**5.** Epigastric discomfort or hernia due to passage of the pedicle through the epigastric tunnel.

**7.** Seroma which is less common than with mastectomy alone due to the absorptive power

This flap is ideal to solve the problem of volume replacement of medial quadrant volume replacement in cases of partial mastectomy for tumors in the medial quadrant. Moreover, it is a very good choice for total breast reconstruction after skin sparing mastectomy (SSM) especially in women with body mass index above the age of 30 years. This is particularly so, even if the volume is not adequate, because in such case it can be used to cover a silicone implant

Omental flap is a strong working horse in breast reconstruction after partial or skin sparing mastectomy. It can be free or pedicled. It could be retrieved by a minilaparotomy or preferably by laparoscopic harvesting (LHOF). It is a simple, safe, and reliable flap that mimics the natural contour of the breast. In about 30% of cases with volume insufficiency, it can be used with an implant as a cover with low complication rate and good aesthetic

1 Department of Surgical Oncology, Faculty of Medicine, Mansoura Oncology Center (OCMU),

2 General Surgery Department, Mansoura University Hospital, Mansoura University, Egypt

**11. Place of the omental flap in the era of oncoplastic surgery**

and Hosam Ghazy<sup>2</sup>

\*Address all correspondence to: dr.ashrafkhater@yahoo.com

betics; this may be another cause of flap loss.

vessels, or sealed vessels along the greater curve.

to avoid the capsular contracture and implant rupture.

**6.** Port site hernia after laparoscopic retrieval.

of this flap.

**12. Conclusion**

outcome.

**Author details**

Mansoura University, Egypt

\*, Adel Fathi1

Ashraf Khater1

**Figure 15.** SSM which is reconstructed with pedicled omental flap through minilaparotomy.

**Figure 16.** SSM which is reconstructed with laparoscopically harvested omental flap (LHOF).

## **10. Complications**

#### **10.1. General**


#### **10.2. Specific**


## **11. Place of the omental flap in the era of oncoplastic surgery**

This flap is ideal to solve the problem of volume replacement of medial quadrant volume replacement in cases of partial mastectomy for tumors in the medial quadrant. Moreover, it is a very good choice for total breast reconstruction after skin sparing mastectomy (SSM) especially in women with body mass index above the age of 30 years. This is particularly so, even if the volume is not adequate, because in such case it can be used to cover a silicone implant to avoid the capsular contracture and implant rupture.

#### **12. Conclusion**

**10. Complications**

**2.** Chest complications.

dates surgical resection).

**2.** Traumatic fat necrosis.

**1.** Those of laparoscopy, as complications of the access, visceral injury, gas embolism, etc.

**1.** Flap loss which may be either total or partial (partial loss may be minor or major that man-

**3.** Deep venous thrombosis (DVT) and pulmonary embolism.

**Figure 15.** SSM which is reconstructed with pedicled omental flap through minilaparotomy.

**Figure 16.** SSM which is reconstructed with laparoscopically harvested omental flap (LHOF).

**10.1. General**

158 Issues in Flap Surgery

**10.2. Specific**

Omental flap is a strong working horse in breast reconstruction after partial or skin sparing mastectomy. It can be free or pedicled. It could be retrieved by a minilaparotomy or preferably by laparoscopic harvesting (LHOF). It is a simple, safe, and reliable flap that mimics the natural contour of the breast. In about 30% of cases with volume insufficiency, it can be used with an implant as a cover with low complication rate and good aesthetic outcome.

## **Author details**

Ashraf Khater1 \*, Adel Fathi1 and Hosam Ghazy<sup>2</sup>

\*Address all correspondence to: dr.ashrafkhater@yahoo.com

1 Department of Surgical Oncology, Faculty of Medicine, Mansoura Oncology Center (OCMU), Mansoura University, Egypt

2 General Surgery Department, Mansoura University Hospital, Mansoura University, Egypt

## **References**

[1] Smitka K, Marešová D. Adipose tissue as an endocrine organ: An update on pro‐ inflammatory and anti‐inflammatory microenvironment. Prague Medical Report. 2015;**116**:(2):87‐111

[15] McLean DH, Buncke HJ. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plastic and Reconstructive Surgery. 1972;**49**(3):268‐274 [16] Gomez JA, Pascal SG, Michel S, Mitchel H, Richard L. Free omental flap for skin‐sparing breast reconstruction harvested laparoscopically. Plastic & Reconstructive Surgery.

Omental Flap in Breast Reconstruction http://dx.doi.org/10.5772/intechopen.70115 161

[17] Losken A, Carlson GW, Culbertson JH, Scott Hultman C, Kumar AV, Jones GE, Bostwick 3rd J, Jurkiewicz MJ. Omental free flap reconstruction in complex head and neck defor-

[18] Costa SS, Blotta RM, Mariano MB, Meurer L, Edelweiss MIA. Laparoscopic treatment of Poland's syndrome using the omentum flap technique. Clinics Sao Paulo.

[19] Costa SS, Blotta RM, Meurer L, Edelweiss MIA. Adipocyte morphometric evaluation and angiogenesis in the omentum transposed to the breast: A preliminary study. Clinics

[20] Skandalakis JE, Colborn GL, Weidman TA, Foster Jr RS, Kingsnorth AN, et al. Surgical Anatomy: The Embryologic and Anatomic Basis of Modern Surgery. Chapter 10. Peritoneum, Omenta, and Internal Hernias. Athens, Greece: Paschalidis Medical

[21] Nakao K, Miyata M, Ito T, et al. Omental transposition and skin graft in patients for advanced or recurrent breast cancer. The Japanese Journal of Surgery. 1986;**16**:112 [22] Samson R, Pasternak BM. Current status of surgery of the omentum. Surgery, Gynecology

2002;**110**(2):545‐551

2010;**65**(4):401‐406

Publications; 2004

& Obstetrics. 1979;**149**:437

Sao Paulo. Feb 2011;**66**(2):307‐312

mities. Head & Neck. Apr 2002;**24**(4):326‐331


[15] McLean DH, Buncke HJ. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plastic and Reconstructive Surgery. 1972;**49**(3):268‐274

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2015;**116**:(2):87‐111

2006;**50**:216‐229

Médicale. 1963;**5**:15‐17

Surgical Endoscopy. 2010;**24**:103‐107

1156‐1163

2014;**38**:482

[1] Smitka K, Marešová D. Adipose tissue as an endocrine organ: An update on pro‐ inflammatory and anti‐inflammatory microenvironment. Prague Medical Report.

[2] Fonseca‐Alaniz MH. Takada J. Alonso‐Vale MI, Lima FB. The adipose tissue as a regulatory center of the metabolism. Arquivos Brasileiros de Endocrinologia & Metabologia.

[3] Senn N. An experimental contribution to intestinal surgery, with special reference to the treatment of intestinal obstruction (concluded). Annals of Surgery. 1888;**7**:421‐430

[4] Lieberman‐Meffert D, White H. The Greater Omentum: Anatomy, Physiology, Pathology,

[5] Irons GB, Witzke DJ, Arnold PG, Wood MB. Use of the omental free flap for soft‐tissue

[6] Parissis H, Al‐Alao B, Soo A, Orr D, Young V. Risk analysis and outcome of mediastinal wound and deep mediastinal wound infections with specific emphasis to omental trans-

[7] Kiricuta I. The use of the great omentum in the surgery of breast cancer. La Presse

[8] Kiricuta I, Goldstein AM. The repair of extensive vesicovaginal fistulas with pedicled

[9] Cothier‐Savey I, Tamtawi B, Franck D, et al. Immediate breast reconstruction using laparoscopically harvested omental flap. Plastic and Reconstructive Surgery. 2001;**107**:

[10] Zaha H, Inamine S, Naito T, Nomura H. Laparoscopically harvested omental flap for immediate breast reconstruction. The American Journal of Surgery. Oct 2006;**192**(4):556‐558

[11] Zaha H, Inamine S. Laparoscopically harvested omental flap: Results for 96 patients.

[12] Khater A. Erratum to: Evaluation of pedicled omental flap delivered through a minilaparotomy for immediate breast reconstruction in obese patients. Aesthetic Plastic Surgery.

[13] Saltz R, Stowers R, Smith M, Gadacz TR. Laparoscopically harvested omental free flap to cover a large soft tissue defect. Annals of Surgery. 1993;**217**(5):542‐546; discussion 6‐7

[14] Zaha H, Abe N, Sagawa N, Unesoko M. Oncoplastic surgery with omental flap reconstruction: A study of 200 cases. Breast Cancer Research and Treatment. Jan 24,

2017;**162**(2):267‐274. DOI: 10.1007/s10549‐017‐4124‐9. [Epub ahead of print]

omentum: A review of 27 cases. The Journal of Urology. 1972;**108**:724‐727

Surgery, with a Historical Survey. New York: Springer; 1983

reconstruction. Annals of Plastic Surgery. 1983;**11**(6):501‐507

position. Journal of Cardiothoracic Surgery. Sep 2011;**6**:111


**Chapter 9**

**Provisional chapter**

**An Overview of Hypospadias Surgery**

**An Overview of Hypospadias Surgery**

DOI: 10.5772/intechopen.69924

Performed by urologists and paediatric surgeons, hypospadias procedures go unnoticed in many classical treatises of plastic surgery. Hypospadias is a very common malforma‐ tion that occurs in nearly 1 in 250 male births. It consists of an abnormal opening of the urethral meatus at some point of its dorsal aspect. It is associated with an incomplete, semi‐circumferential foreskin and in nearly half of the patients it may be accompanied with a curvature of the penile shaft called chordee. Most classifications differentiate between distal, middle and proximal presentations. Different techniques have been proposed for its treatment; some of the most usual ones are briefly revised. Continued improvement in surgical management has made currently practised one‐stage repairs possible. We provide an introduction to the current techniques, as well as operative tips and an overview of the most common pitfalls the surgeon must bear in mind when treat‐

**Keywords:** hypospadias, microsurgery, urethra, penoscrotal transposition, child, paediatrics,

Derived from the Greek prefix *hypo* (under) and *spadon* (gap, cleft), the word hypospadias refers to a congenital condition in which the urethral meatus appears proximal to its usual

perineum. The foreskin lacks an inferior portion in a way that the remaining semi‐circumferential

Note that the embryological dorsal aspect of the urethra is named as *ventral* or *anterior* in many texts. This confusion probably derives from the surgeon's view of an exposed operative field on the table. A defect on the embryological ven‐

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

surface of penis, scrotum or even

and reproduction in any medium, provided the original work is properly cited.

Wenceslao M. Calonge and Gianluca Sapino

Additional information is available at the end of the chapter

Wenceslao M. Calonge and Gianluca Sapino

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69924

**Abstract**

ing this condition.

location at the tip of the penis.

1

urology, congenital malformations

**1. Introduction and classification**

The urethral orifice may lie at any level on the *embryologic* dorsal1

tral surface of the urethra corresponds to the condition known as epispadias.

**Provisional chapter**

## **An Overview of Hypospadias Surgery**

**An Overview of Hypospadias Surgery**

Wenceslao M. Calonge and Gianluca Sapino Wenceslao M. Calonge and Gianluca Sapino Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69924

#### **Abstract**

Performed by urologists and paediatric surgeons, hypospadias procedures go unnoticed in many classical treatises of plastic surgery. Hypospadias is a very common malforma‐ tion that occurs in nearly 1 in 250 male births. It consists of an abnormal opening of the urethral meatus at some point of its dorsal aspect. It is associated with an incomplete, semi‐circumferential foreskin and in nearly half of the patients it may be accompanied with a curvature of the penile shaft called chordee. Most classifications differentiate between distal, middle and proximal presentations. Different techniques have been proposed for its treatment; some of the most usual ones are briefly revised. Continued improvement in surgical management has made currently practised one‐stage repairs possible. We provide an introduction to the current techniques, as well as operative tips and an overview of the most common pitfalls the surgeon must bear in mind when treat‐ ing this condition.

DOI: 10.5772/intechopen.69924

**Keywords:** hypospadias, microsurgery, urethra, penoscrotal transposition, child, paediatrics, urology, congenital malformations

#### **1. Introduction and classification**

Derived from the Greek prefix *hypo* (under) and *spadon* (gap, cleft), the word hypospadias refers to a congenital condition in which the urethral meatus appears proximal to its usual location at the tip of the penis.

The urethral orifice may lie at any level on the *embryologic* dorsal1 surface of penis, scrotum or even perineum. The foreskin lacks an inferior portion in a way that the remaining semi‐circumferential

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

<sup>1</sup> Note that the embryological dorsal aspect of the urethra is named as *ventral* or *anterior* in many texts. This confusion probably derives from the surgeon's view of an exposed operative field on the table. A defect on the embryological ven‐ tral surface of the urethra corresponds to the condition known as epispadias.

tissue resembles of a hood. The glans itself may be slightly flattened. Moreover, many cases of hypospadias may present with a curvature named chordee (from Latin *chorda*, string) between glans and meatus. This chordee is usually produced by an excess of fibrous tissue.

In order to evaluate the location of the urethral meatus, it should be examined under mild retraction of the foreskin and the skin surrounding the orifice. Though there is no total con‐ sensus, most urological texts describe the level of the urethral meatus as follows (**Figure 1**):


All observations should include the degree of curvature. This is usually expressed by the angle between the main axis from basis and the main axis from the apex of the glans (**Figure 2**).

treatment proposals followed along the next centuries. The Portuguese Amatus Lusitanus (1511–1568) is usually credited as the first to carve a tunnel between the glans and the ectopi‐ cal meatus. An illustrious patient was King Henry II of France, who presented with a chordee and underwent some kind of procedure in the hands of royal surgeon Jean Fernel. During the eighteenth century, Morgagni compared the condition to the penile groove of turtles and

An Overview of Hypospadias Surgery http://dx.doi.org/10.5772/intechopen.69924 165

The bulk of current techniques derive from conceptual improvements of the nineteenth cen‐ tury. Bouisson proposed a scrotal skin flap to create the inferior wall of the missing urethral segment in 1861. In 1869, Thiersch described tubularised skin grafts as a means to create a neourethra in epispadias (another unrelated urethral malformation). In 1874, Théophile Anger adapted this technique to obtain a successful correction of a penoscrotal hypospadias. In 1880, Duplay described a two‐stage repair that included the correction of chordee as the first stage and the urethral reconstruction by means of local flaps from the penile ventral skin as a second stage. Nove‐Josserand was the first surgeon to describe free skin grafts to create a

Former milestones to be cited usually include the works by Matthieu (a flap from proximal skin with parallel sutured lines, 1932), Nesbitt (a technique to treat congenital curvature using fundoplication of the tunica albuginea, 1941), Mustardé (a large flap of perimeatal skin combined with a 'V' incision of the glans, 1965), Duckett [Meatal advancement and glanuloplasty (MAGPI) procedure—1981], Koyanagi (a technique for the more complex

questioned an association between hypospadias and infertility.

neourethra in scrotal hypospadias in 1897.

**Figure 2.** Measurement of the angle of penile curvature.

**Figure 1.** Classification of hypospadias according to level of the urethral meatus.

#### **2. Historical notes**

Most historical studies [1–3] refer to Heliodorus and Antyllus, two alexandrine surgeons who proposed total amputation of the penis distal to the orifice. The first description of hypo‐ spadias, however, is attributed to Galen (129‐ca.199 AD). Several isolated observations and

**Figure 2.** Measurement of the angle of penile curvature.

tissue resembles of a hood. The glans itself may be slightly flattened. Moreover, many cases of hypospadias may present with a curvature named chordee (from Latin *chorda*, string) between

In order to evaluate the location of the urethral meatus, it should be examined under mild retraction of the foreskin and the skin surrounding the orifice. Though there is no total con‐ sensus, most urological texts describe the level of the urethral meatus as follows (**Figure 1**):

All observations should include the degree of curvature. This is usually expressed by the angle between the main axis from basis and the main axis from the apex of the glans (**Figure 2**).

Most historical studies [1–3] refer to Heliodorus and Antyllus, two alexandrine surgeons who proposed total amputation of the penis distal to the orifice. The first description of hypo‐ spadias, however, is attributed to Galen (129‐ca.199 AD). Several isolated observations and

glans and meatus. This chordee is usually produced by an excess of fibrous tissue.

• Distal or anterior (glandular and coronal)

• Proximal or posterior (penoscrotal, scrotal and perineal).

**Figure 1.** Classification of hypospadias according to level of the urethral meatus.

• Middle (penile)

164 Issues in Flap Surgery

**2. Historical notes**

treatment proposals followed along the next centuries. The Portuguese Amatus Lusitanus (1511–1568) is usually credited as the first to carve a tunnel between the glans and the ectopi‐ cal meatus. An illustrious patient was King Henry II of France, who presented with a chordee and underwent some kind of procedure in the hands of royal surgeon Jean Fernel. During the eighteenth century, Morgagni compared the condition to the penile groove of turtles and questioned an association between hypospadias and infertility.

The bulk of current techniques derive from conceptual improvements of the nineteenth cen‐ tury. Bouisson proposed a scrotal skin flap to create the inferior wall of the missing urethral segment in 1861. In 1869, Thiersch described tubularised skin grafts as a means to create a neourethra in epispadias (another unrelated urethral malformation). In 1874, Théophile Anger adapted this technique to obtain a successful correction of a penoscrotal hypospadias. In 1880, Duplay described a two‐stage repair that included the correction of chordee as the first stage and the urethral reconstruction by means of local flaps from the penile ventral skin as a second stage. Nove‐Josserand was the first surgeon to describe free skin grafts to create a neourethra in scrotal hypospadias in 1897.

Former milestones to be cited usually include the works by Matthieu (a flap from proximal skin with parallel sutured lines, 1932), Nesbitt (a technique to treat congenital curvature using fundoplication of the tunica albuginea, 1941), Mustardé (a large flap of perimeatal skin combined with a 'V' incision of the glans, 1965), Duckett [Meatal advancement and glanuloplasty (MAGPI) procedure—1981], Koyanagi (a technique for the more complex scrotal cases, 1984) and Snodgrass (an incision of the tubularised urethral plate, 1994). A great number of surgeons have contributed to this field in order to achieve an acceptable correction to any kind of hypospadias and any claim for 'a new concept' is difficult to prove.

**4. General surgical principles**

bullying and comparison with peers [14].

tions and it is indispensable in infants and toddlers.

before planning an ultimate corrective operation.

Technical advances allow operating earlier than in previous decades. Many surgeons advo‐ cate intervening in the first 2 years of life for minor distal forms. On the other hand, because increased penile size minimises the risk of producing undesired damage, complicated prox‐ imal forms are usually postponed. There is broad consensus to have all procedures done before compulsory school age at 4–5 years with the aim of avoiding psychosocial issues as

An Overview of Hypospadias Surgery http://dx.doi.org/10.5772/intechopen.69924 167

Most surgeons think of magnification loupes as a minimal requisite for this kind of surgery; some of them even favour the use of the surgical microscope. Magnification makes the sur‐ geon aware of the importance of minor vessels. In any case, it minimises the rate of complica‐

Many of the instruments used in hypospadias surgery (Castroviejo needle holders, palpe‐ bral retractors, microsurgical pincettes) are similar to the ones used in ophthalmic surgery. Depending on centres and individuals, there are some variations but most surgeons apply absorbable polyglactin, polyglycolic acid or monofilament polydioxanone sutures for closing of the neourethra. Nylon or polypropylene are only used in skin sutures and removed after

Introduced in the 1970s [15], the injection of saline solution facilitates correct appreciation of the chordee during the procedure. Some surgeons use it as an ancillary diagnostic procedure

Also starting in the 1970s [16], several techniques have been described to add an extra protec‐ tive layer of tissue: de‐epithelised skin, external spermatic fascia, Buck's fascia, tunica vagi‐ nalis or most usually dartos fascia flaps. These procedures decrease significatively the rate of postoperative fistulas [17]. Mobilisation of the dartos muscle over the repair allows 'water‐

As a precaution to prevent undesired burns of the thin penile structures, most surgeons

10–14 days. Surgical calibre of these materials usually varies between 5/0 and 7/0.

**4.5. Interposed tissue between skin suture and urethra and biological adhesives**

proofing'. Some surgeons use fibrin glue before suturing the final skin layer.

**4.1. Age for intervention**

**4.2. Optical magnification**

**4.3. Instruments and sutures**

**4.4. Artificial erection**

**4.6. Haemostasis**

favour bipolar diathermy.

## **3. Incidence, aetiology and associated malformations**

Hypospadias is a common congenital malformation. A nationwide study from Taiwan [4] for the period from 1997 to 2008 has shown a mean incidence of 3.38 per 1000 live male births. A recent series from Sweden [5] has shown an increase from 4.5 cases per 1000 live male births (1973–1989) to 8 per 1000 live male births (1990–2009).

Fortunately, there is a higher incidence of the less severe variants of the condition. Thus, a Dutch series [6] has shown how 59% of hypospadias are anterior (glanular and coronal), 29% are middle (penile) and 12% are posterior (penoscrotal, scrotal and perineal).

Urethral closing is controlled by androgen receptors that bind to dihydrotestosterone. 5‐alpha reductase II catalyses the conversion from testosterone to dihydrotestosterone. Most authors men‐ tion a multifactorial aetiology and a putative influence on genes that control androgen metabo‐ lism. Endocrine disruptors as anti‐androgenic substances, hormones or environmental pollutants are heavily suspected as important factors in the pathogenesis of hypospadias in the prenatal period [7]. It is difficult to extrapolate the findings from animals to human beings, however.

Though some genes have been pointed out as causative factors of hypospadias, not many of them have been examined to the point of allowing unequivocal conclusions. There are con‐ tradicting studies about the effects of particular drugs on humans, such as the anti‐epileptic valproate or the anti‐hystaminic loratadine [8].

Hypospadias is more frequent among children of men who themselves have had hypospa‐ dias. The risk also rises for the brothers of children with hypospadias [9, 10].

Undescended testis in variable degrees and inguinal hernia are the most common anomalies seen in boys with hypospadias. The more proximal the hypospadias, the more frequent these anomalies.

Diverticula of the prostatic portion of the urethra are seen in severe proximal forms. Infection is a frequent complication of this kind of diverticula and is usually addressed with antibiotic treatment. However, some centres still advise routine explorations of the upper urinary tract in proximal forms [11].

Discovery of intersex states is extremely rare but a karyotype is recommended in case of total cryptorchidism, micropenis, penoscrotal transposition (PST) or biphid scrotum [12].

Imperforate anus and myelomeningocele may be associated with hypospadias. Finally, hypospadias may be part of some complex entities such as McKusick‐Kaufman syn‐ drome, Brachmann‐de Lange syndrome, Fryns syndrome, Pallister‐Hall syndrome, Smith‐Lemli‐Opitz syndrome, Rapp‐Hodgkin syndrome, Marden‐Walker syndrome or fronto‐facio‐nasal dysplasia [13].

## **4. General surgical principles**

#### **4.1. Age for intervention**

scrotal cases, 1984) and Snodgrass (an incision of the tubularised urethral plate, 1994). A great number of surgeons have contributed to this field in order to achieve an acceptable correction to any kind of hypospadias and any claim for 'a new concept' is difficult to prove.

Hypospadias is a common congenital malformation. A nationwide study from Taiwan [4] for the period from 1997 to 2008 has shown a mean incidence of 3.38 per 1000 live male births. A recent series from Sweden [5] has shown an increase from 4.5 cases per 1000 live male births

Fortunately, there is a higher incidence of the less severe variants of the condition. Thus, a Dutch series [6] has shown how 59% of hypospadias are anterior (glanular and coronal), 29%

Urethral closing is controlled by androgen receptors that bind to dihydrotestosterone. 5‐alpha reductase II catalyses the conversion from testosterone to dihydrotestosterone. Most authors men‐ tion a multifactorial aetiology and a putative influence on genes that control androgen metabo‐ lism. Endocrine disruptors as anti‐androgenic substances, hormones or environmental pollutants are heavily suspected as important factors in the pathogenesis of hypospadias in the prenatal period [7]. It is difficult to extrapolate the findings from animals to human beings, however.

Though some genes have been pointed out as causative factors of hypospadias, not many of them have been examined to the point of allowing unequivocal conclusions. There are con‐ tradicting studies about the effects of particular drugs on humans, such as the anti‐epileptic

Hypospadias is more frequent among children of men who themselves have had hypospa‐

Undescended testis in variable degrees and inguinal hernia are the most common anomalies seen in boys with hypospadias. The more proximal the hypospadias, the more frequent these

Diverticula of the prostatic portion of the urethra are seen in severe proximal forms. Infection is a frequent complication of this kind of diverticula and is usually addressed with antibiotic treatment. However, some centres still advise routine explorations of the upper urinary tract

Discovery of intersex states is extremely rare but a karyotype is recommended in case of total

Imperforate anus and myelomeningocele may be associated with hypospadias. Finally, hypospadias may be part of some complex entities such as McKusick‐Kaufman syn‐ drome, Brachmann‐de Lange syndrome, Fryns syndrome, Pallister‐Hall syndrome, Smith‐Lemli‐Opitz syndrome, Rapp‐Hodgkin syndrome, Marden‐Walker syndrome or

cryptorchidism, micropenis, penoscrotal transposition (PST) or biphid scrotum [12].

are middle (penile) and 12% are posterior (penoscrotal, scrotal and perineal).

dias. The risk also rises for the brothers of children with hypospadias [9, 10].

**3. Incidence, aetiology and associated malformations**

(1973–1989) to 8 per 1000 live male births (1990–2009).

valproate or the anti‐hystaminic loratadine [8].

anomalies.

166 Issues in Flap Surgery

in proximal forms [11].

fronto‐facio‐nasal dysplasia [13].

Technical advances allow operating earlier than in previous decades. Many surgeons advo‐ cate intervening in the first 2 years of life for minor distal forms. On the other hand, because increased penile size minimises the risk of producing undesired damage, complicated prox‐ imal forms are usually postponed. There is broad consensus to have all procedures done before compulsory school age at 4–5 years with the aim of avoiding psychosocial issues as bullying and comparison with peers [14].

#### **4.2. Optical magnification**

Most surgeons think of magnification loupes as a minimal requisite for this kind of surgery; some of them even favour the use of the surgical microscope. Magnification makes the sur‐ geon aware of the importance of minor vessels. In any case, it minimises the rate of complica‐ tions and it is indispensable in infants and toddlers.

#### **4.3. Instruments and sutures**

Many of the instruments used in hypospadias surgery (Castroviejo needle holders, palpe‐ bral retractors, microsurgical pincettes) are similar to the ones used in ophthalmic surgery. Depending on centres and individuals, there are some variations but most surgeons apply absorbable polyglactin, polyglycolic acid or monofilament polydioxanone sutures for closing of the neourethra. Nylon or polypropylene are only used in skin sutures and removed after 10–14 days. Surgical calibre of these materials usually varies between 5/0 and 7/0.

#### **4.4. Artificial erection**

Introduced in the 1970s [15], the injection of saline solution facilitates correct appreciation of the chordee during the procedure. Some surgeons use it as an ancillary diagnostic procedure before planning an ultimate corrective operation.

#### **4.5. Interposed tissue between skin suture and urethra and biological adhesives**

Also starting in the 1970s [16], several techniques have been described to add an extra protec‐ tive layer of tissue: de‐epithelised skin, external spermatic fascia, Buck's fascia, tunica vagi‐ nalis or most usually dartos fascia flaps. These procedures decrease significatively the rate of postoperative fistulas [17]. Mobilisation of the dartos muscle over the repair allows 'water‐ proofing'. Some surgeons use fibrin glue before suturing the final skin layer.

#### **4.6. Haemostasis**

As a precaution to prevent undesired burns of the thin penile structures, most surgeons favour bipolar diathermy.

It is generally accepted that using a transient tourniquet to operate in an almost bloodless field eases visualisation and shortens procedure time. (Needless to say, the surgical team must pay attention not to forget tourniquet removal before dressing at the end of the operation.)

#### **4.7. Intraoperative local anaesthesia**

A penile block before the end of the operation, using bupivacaine, diminishes pain and the risk of dangerous manipulations of the dressing. Moreover, due to the extensive use of penile block, some minor procedures can be performed as ambulatory day‐surgery.

#### **4.8. Catheter drainage**

Catheters divert the pressure on the suture zone during the immediate postoperative period. They allow bladder voiding in case of clotting or spasm. As they should be least reactive, silicone is the most favoured catheter or stent material. Catheters and stents provide a priceless protec‐ tion in middle and proximal hypospadias. Bladder spasm can be reduced by using oxybutynin.

#### **4.9. Dressings**

Confection of a mildly compressive dressing deserves special attention at the end of the pro‐ cedure. A certain degree of pressure is needed to maintain haemostasis and diminish local oedema. A modern trend promotes abstention of any kind of dressing [18]. In any case, all eventual dressings should be non‐adhesive to prevent unwanted tearing at the moment of removal.

## **5. Common surgical procedure**

More than 300 techniques have been described for the correction of the diverse types of hypo‐ spadias. This great number probably reflects that no single technique can provide an answer to all situations. The average hypospadias surgeon concentrates on mastering a basic arse‐ nal with a certain number of flexible options. Complicated presentations may need complex grafts of mucosa collected from the bladder (introduced by Memmelaar in 1947 [19]) or buccal cavity (first performed by Sapezhko in the nineteenth century [20]).

**5.2. Meatal advancement and glanuloplasty (MAGPI)**

**Figure 3.** Dissection of a chordee without hypospadias.

(**Figure 4**).

(**Figure 5**).

**5.3. Mathieu procedure**

The MAGPI technique was described by Duckett in 1981 [22]. It may be useful in the more distal types of hypospadias without chordee that present good skin quality. After liber‐ ating the ventral skin, the surgeon performs a triangular suprameatal incision from the point where the new meatus is intended. The centre of the hypospadic meatus is sutured to the vertex of the triangle in order to achieve ascension. The preputial frenulum is simu‐ lated by suturing in an inverted 'V', the edges of the missing balanopreputial groove

An Overview of Hypospadias Surgery http://dx.doi.org/10.5772/intechopen.69924 169

Though described by Mathieu in 1932 [23], it bears a strong resemblance to previous oper‐ ations and has undergone subtle modifications and refinements by surgeons as Gibbons, Devine, Horton, Barcat or van der Meulen to adapt to diverse situations. When the meatus lies subcoronal (or even in the most distal third of the penile shaft), this technique uses a flap of the perimeatal skin to create the missing wall of the urethra in a tubularised way

#### **5.1. The chordee**

Correction of chordee should precede any hypospadias surgery to estimate the real length of the straightened urethra (**Figure 3**). A common classification includes four types. Type I is an 'easy' skin tethering. Type II includes a fibrotic fascia. Type III involves corporal dispro‐ portion. Type IV consists of a true urethral tethering [21]. The chordee may appear isolated without hypospadias. All fibrous vestiges running along the penile shaft from glans to meatus must be carefully dissected to avoid damage to the urethral plate and the cavernous bodies. Many surgeons prefer a two‐stage repair in cases of hypospadias with severe chordee.

**Figure 3.** Dissection of a chordee without hypospadias.

#### **5.2. Meatal advancement and glanuloplasty (MAGPI)**

The MAGPI technique was described by Duckett in 1981 [22]. It may be useful in the more distal types of hypospadias without chordee that present good skin quality. After liber‐ ating the ventral skin, the surgeon performs a triangular suprameatal incision from the point where the new meatus is intended. The centre of the hypospadic meatus is sutured to the vertex of the triangle in order to achieve ascension. The preputial frenulum is simu‐ lated by suturing in an inverted 'V', the edges of the missing balanopreputial groove (**Figure 4**).

#### **5.3. Mathieu procedure**

It is generally accepted that using a transient tourniquet to operate in an almost bloodless field eases visualisation and shortens procedure time. (Needless to say, the surgical team must pay attention not to forget tourniquet removal before dressing at the end of the operation.)

A penile block before the end of the operation, using bupivacaine, diminishes pain and the risk of dangerous manipulations of the dressing. Moreover, due to the extensive use of penile

Catheters divert the pressure on the suture zone during the immediate postoperative period. They allow bladder voiding in case of clotting or spasm. As they should be least reactive, silicone is the most favoured catheter or stent material. Catheters and stents provide a priceless protec‐ tion in middle and proximal hypospadias. Bladder spasm can be reduced by using oxybutynin.

Confection of a mildly compressive dressing deserves special attention at the end of the pro‐ cedure. A certain degree of pressure is needed to maintain haemostasis and diminish local oedema. A modern trend promotes abstention of any kind of dressing [18]. In any case, all eventual dressings should be non‐adhesive to prevent unwanted tearing at the moment of

More than 300 techniques have been described for the correction of the diverse types of hypo‐ spadias. This great number probably reflects that no single technique can provide an answer to all situations. The average hypospadias surgeon concentrates on mastering a basic arse‐ nal with a certain number of flexible options. Complicated presentations may need complex grafts of mucosa collected from the bladder (introduced by Memmelaar in 1947 [19]) or buccal

Correction of chordee should precede any hypospadias surgery to estimate the real length of the straightened urethra (**Figure 3**). A common classification includes four types. Type I is an 'easy' skin tethering. Type II includes a fibrotic fascia. Type III involves corporal dispro‐ portion. Type IV consists of a true urethral tethering [21]. The chordee may appear isolated without hypospadias. All fibrous vestiges running along the penile shaft from glans to meatus must be carefully dissected to avoid damage to the urethral plate and the cavernous bodies. Many surgeons prefer a two‐stage repair in cases of hypospadias with severe chordee.

cavity (first performed by Sapezhko in the nineteenth century [20]).

block, some minor procedures can be performed as ambulatory day‐surgery.

**4.7. Intraoperative local anaesthesia**

**5. Common surgical procedure**

**4.8. Catheter drainage**

168 Issues in Flap Surgery

**4.9. Dressings**

removal.

**5.1. The chordee**

Though described by Mathieu in 1932 [23], it bears a strong resemblance to previous oper‐ ations and has undergone subtle modifications and refinements by surgeons as Gibbons, Devine, Horton, Barcat or van der Meulen to adapt to diverse situations. When the meatus lies subcoronal (or even in the most distal third of the penile shaft), this technique uses a flap of the perimeatal skin to create the missing wall of the urethra in a tubularised way (**Figure 5**).

Warren Snodgrass introduced a substantial variation [25] that is now becoming the most usual procedure in any kind of hypospadias. He proposed a longitudinal incision of the ure‐ thral plate all along the midline. This incision allows easier approaching of the edges of the

An Overview of Hypospadias Surgery http://dx.doi.org/10.5772/intechopen.69924 171

**Figure 7.** Longitudinal transection of the urethral plate in the Snodgrass procedure.

open urethral plate (**Figure 7**).

**Figure 6.** Different stages of the Byars procedure.

**Figure 4.** The initial stage and four different phases in the MAGPI technique.

#### **5.4. Byars procedure and Snodgrass adaptation**

As described in 1955 [24], this technique is still used on penoscrotal or proximal third types. It is inspired by the concepts of Thiersch and Duplay. The incised edges of the open urethral plate are sewn together and tubularised (**Figure 6**). As usual, there are many variations to this technique.

**Figure 5.** The Mathieu technique.

**Figure 6.** Different stages of the Byars procedure.

**5.4. Byars procedure and Snodgrass adaptation**

170 Issues in Flap Surgery

**Figure 4.** The initial stage and four different phases in the MAGPI technique.

**Figure 5.** The Mathieu technique.

As described in 1955 [24], this technique is still used on penoscrotal or proximal third types. It is inspired by the concepts of Thiersch and Duplay. The incised edges of the open urethral plate are sewn together and tubularised (**Figure 6**). As usual, there are many variations to this technique.

Warren Snodgrass introduced a substantial variation [25] that is now becoming the most usual procedure in any kind of hypospadias. He proposed a longitudinal incision of the ure‐ thral plate all along the midline. This incision allows easier approaching of the edges of the open urethral plate (**Figure 7**).

**Figure 7.** Longitudinal transection of the urethral plate in the Snodgrass procedure.

#### **5.5. Island flap techniques**

These are delicate procedures that involve the crafting of a new urethra by using the foreskin [26, 27]. The vascularisation of the preputial flap stems from the basis of the penis and must be preserved to avoid flap necrosis and failure (**Figure 8**). The size of the flap is precisely mea‐ sured having in sight an undesired retraction (when too short) or diverticula (when too wide). There are different available options for the pedicle.

Surgical correction is challenging and is usually performed around the 15th–18th month of birth. The size of the phallus and its potential to develop into a sexually satisfactory penis at puberty should be carefully evaluated before surgery. Reassignment to female gender may even be a prudent therapeutic option in a small number of extreme penoscrotal trans‐ position cases due to the unsatisfactory results obtained with penile repositioning and

An Overview of Hypospadias Surgery http://dx.doi.org/10.5772/intechopen.69924 173

Repairs of penoscrotal transposition rely on the creation of rotational flaps to mobilise the scrotum downwards or transpose the penis to a neo meatus created in the skin of the mons pubis. All procedures entail a complete circular incision around the root of the penis. This usually results in severe and massive oedema of the penile skin, which delays correction of the associated hypospadias and increases the incidence of complications. The skin vascularity

Several surgical techniques are described in the literature for the incomplete PST. The modified Glenn‐Anderson [31] techniques are commonly used. In these techniques, the two halves of the scrotum are completely mobilised as a rotational flap and relocated in the right position. The penis can be transposed to a neo hole created in the skin of the mons pubis. To reduce the incidence of oedema of the penile skin consequent upon a circular incision around the root of the penis, Saleh suggests to maintain the penile skin connected to the skin of the lower abdomen by a small strip of skin (**Figure 10**); thus, aids in obtaining

and lymphatics may be impaired by the designed incision.

**Figure 9.** A moderate degree of complete penoscrotal transposition.

reconstruction [30].

a good outcome [32].

**Figure 8.** Different stages in the Duckett island flap procedure.

## **6. Penoscrotal transposition**

Penoscrotal transposition (PST) represents a rare congenital abnormality of external geni‐ talia in which the scrotum is positioned superiorly or anteriorly in relation to the penis (**Figure 9**). It includes a large spectrum of anomalies, ranging from the mild bifid scro‐ tum form to the complete penoscrotal transposition (CPST) where the scrotum is located cephalic to the penis [28].

Usually patients present other associated anomalies. Hypospadias, chordee and renal dyspla‐ sia as well as anal abnormalities are frequently associated in most patients. Cardiac, gastroin‐ testinal, craniofacial, skeletal and central nervous system malformations have to be ruled out in most severe cases of CPST. Aetiology remains uncertain. A genetic background finds the largest consensus in literature. It is probably linked to an abnormal genital tubercle develop‐ ment around the fifth to sixth week of gestation which might affect the migration and fusion of the scrotum.

Prenatal diagnosis of PST is difficult but it should be considered in the differential diagnosis when ambiguous genitalia or a major urogenital abnormality is suspected on the ultrasound [29].

**Figure 9.** A moderate degree of complete penoscrotal transposition.

**5.5. Island flap techniques**

172 Issues in Flap Surgery

**6. Penoscrotal transposition**

**Figure 8.** Different stages in the Duckett island flap procedure.

cephalic to the penis [28].

of the scrotum.

There are different available options for the pedicle.

These are delicate procedures that involve the crafting of a new urethra by using the foreskin [26, 27]. The vascularisation of the preputial flap stems from the basis of the penis and must be preserved to avoid flap necrosis and failure (**Figure 8**). The size of the flap is precisely mea‐ sured having in sight an undesired retraction (when too short) or diverticula (when too wide).

Penoscrotal transposition (PST) represents a rare congenital abnormality of external geni‐ talia in which the scrotum is positioned superiorly or anteriorly in relation to the penis (**Figure 9**). It includes a large spectrum of anomalies, ranging from the mild bifid scro‐ tum form to the complete penoscrotal transposition (CPST) where the scrotum is located

Usually patients present other associated anomalies. Hypospadias, chordee and renal dyspla‐ sia as well as anal abnormalities are frequently associated in most patients. Cardiac, gastroin‐ testinal, craniofacial, skeletal and central nervous system malformations have to be ruled out in most severe cases of CPST. Aetiology remains uncertain. A genetic background finds the largest consensus in literature. It is probably linked to an abnormal genital tubercle develop‐ ment around the fifth to sixth week of gestation which might affect the migration and fusion

Prenatal diagnosis of PST is difficult but it should be considered in the differential diagnosis when ambiguous genitalia or a major urogenital abnormality is suspected on the ultrasound [29].

Surgical correction is challenging and is usually performed around the 15th–18th month of birth. The size of the phallus and its potential to develop into a sexually satisfactory penis at puberty should be carefully evaluated before surgery. Reassignment to female gender may even be a prudent therapeutic option in a small number of extreme penoscrotal trans‐ position cases due to the unsatisfactory results obtained with penile repositioning and reconstruction [30].

Repairs of penoscrotal transposition rely on the creation of rotational flaps to mobilise the scrotum downwards or transpose the penis to a neo meatus created in the skin of the mons pubis. All procedures entail a complete circular incision around the root of the penis. This usually results in severe and massive oedema of the penile skin, which delays correction of the associated hypospadias and increases the incidence of complications. The skin vascularity and lymphatics may be impaired by the designed incision.

Several surgical techniques are described in the literature for the incomplete PST. The modified Glenn‐Anderson [31] techniques are commonly used. In these techniques, the two halves of the scrotum are completely mobilised as a rotational flap and relocated in the right position. The penis can be transposed to a neo hole created in the skin of the mons pubis. To reduce the incidence of oedema of the penile skin consequent upon a circular incision around the root of the penis, Saleh suggests to maintain the penile skin connected to the skin of the lower abdomen by a small strip of skin (**Figure 10**); thus, aids in obtaining a good outcome [32].

observed after tubulised free grafts. The most common causes of fistulisation include isch‐ aemia, infection, intolerance to the suture material, distal obstruction to the urine outflow and poor surgical technique. Most teams prefer a waiting period of 6 months before any reopera‐ tion. A little number of small early fistulas seems to heal spontaneously. When repairing a

An Overview of Hypospadias Surgery http://dx.doi.org/10.5772/intechopen.69924 175

Most cases of narrow urethra may be treated by dilation in the first preoperative months.

Complicated cases may require a new operation that may involve mucosal grafts.

fistula, a well‐vascularised layer should cover the area (**Figure 11**).

\* and Gianluca Sapino<sup>2</sup>

1 Department of Surgery, Établissements Hospitaliers du Nord Vaudois, Switzerland

[1] Hauben DJ. The history of hypospadias. Acta Chirurgica Plastica. 1984;**26**:196‐199

2 Department of Plastic, Reconstructive and Aesthetic Surgery, Azienda Ospedaliero–Universitaria

\*Address all correspondence to: wcalonge@yahoo.es

**Figure 11.** Closing of urethral fistula with a rotating flap.

**7.4. Stenosis**

**Author details**

di Modena, Italy

**References**

Wenceslao M. Calonge<sup>1</sup>

**Figure 10.** Design of scrotal flaps in a modified Glenn‐Anderson procedure.

## **7. Complications**

Many years ago, operating on hypospadias was said to be a sure way to ruin one's reputation in a paediatric department. Complications such as fistulas are unavoidable but fortunately there is remarkable improvement in this area when the above‐mentioned general principles are routinely applied [33, 34]. Diverticula are less frequent when appropriate planning is car‐ ried out. Skin flap (or even glans!) necrosis and persistent chordee are becoming very rare complications.

#### **7.1. Infection**

Perioperative antibiotics may help to reduce the risk of infection, especially with indwelling catheters and adult patients.

#### **7.2. Haemorrhage in the early postoperative period**

Usually, it may be prevented with appropriate dressings and non‐adherent materials. Instructing the parents and a correct postoperative analgesia would prevent the child to scrub the area.

#### **7.3. Fistulas**

Urethrocutaneous fistulas arise from the suture line of the crafted neourethra in all series but their proportion is reported to be from 3 to 20%. Fortunately, this incidence is far from the high values (as much as 45%) observed 40 years ago [35, 36]. Higher fistulisation rates are observed after tubulised free grafts. The most common causes of fistulisation include isch‐ aemia, infection, intolerance to the suture material, distal obstruction to the urine outflow and poor surgical technique. Most teams prefer a waiting period of 6 months before any reopera‐ tion. A little number of small early fistulas seems to heal spontaneously. When repairing a fistula, a well‐vascularised layer should cover the area (**Figure 11**).

#### **7.4. Stenosis**

**7. Complications**

174 Issues in Flap Surgery

complications.

**7.1. Infection**

the area.

**7.3. Fistulas**

catheters and adult patients.

**7.2. Haemorrhage in the early postoperative period**

**Figure 10.** Design of scrotal flaps in a modified Glenn‐Anderson procedure.

Many years ago, operating on hypospadias was said to be a sure way to ruin one's reputation in a paediatric department. Complications such as fistulas are unavoidable but fortunately there is remarkable improvement in this area when the above‐mentioned general principles are routinely applied [33, 34]. Diverticula are less frequent when appropriate planning is car‐ ried out. Skin flap (or even glans!) necrosis and persistent chordee are becoming very rare

Perioperative antibiotics may help to reduce the risk of infection, especially with indwelling

Usually, it may be prevented with appropriate dressings and non‐adherent materials. Instructing the parents and a correct postoperative analgesia would prevent the child to scrub

Urethrocutaneous fistulas arise from the suture line of the crafted neourethra in all series but their proportion is reported to be from 3 to 20%. Fortunately, this incidence is far from the high values (as much as 45%) observed 40 years ago [35, 36]. Higher fistulisation rates are Most cases of narrow urethra may be treated by dilation in the first preoperative months. Complicated cases may require a new operation that may involve mucosal grafts.

**Figure 11.** Closing of urethral fistula with a rotating flap.

## **Author details**

Wenceslao M. Calonge<sup>1</sup> \* and Gianluca Sapino<sup>2</sup>

\*Address all correspondence to: wcalonge@yahoo.es

1 Department of Surgery, Établissements Hospitaliers du Nord Vaudois, Switzerland

2 Department of Plastic, Reconstructive and Aesthetic Surgery, Azienda Ospedaliero–Universitaria di Modena, Italy

## **References**

[1] Hauben DJ. The history of hypospadias. Acta Chirurgica Plastica. 1984;**26**:196‐199


[16] Smith D. A de‐epithelialized overlap flap technique in the repair of hypospadias. British

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[17] Gapany C, Grasset N, Tercier S, Ramseyer P, Frey P, Meyrat BJ. A lower fistula rate in hypo‐

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[21] Donnahoo KK, Cain MP, Pope JC, Casale AJ, Keating MA, Adams MC, Rink RC. Etiology, management and surgical complications of congenital chordee without hypo‐

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[24] Byars LT. A technique for consistently satisfactory repair of hypospadias. Surgical

[25] Snodgrass WT. Tubularized incised plate hypospadias repair. In: Frank D, Gearhart JP, Snyder HM, editors. Operative Pediatric Urology. London: Churchill Livingstone; 2002.

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[28] Avolio L, Karmarkar SJ, Martucciello G. Complete penoscrotal transposition. Urology.

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[7] Wolf C, Lambright C, Mann P, Price M, Cooper RL, Ostby J, Gray LE. Administration of potentially antiandrogenic pesticides (procymidone, linuron, iprodione, chlozolinate, p,p′‐DDE, and ketoconazole) and toxic substances (dibutyl‐ and diethylhexyl phthal‐ ate, PCB 169, and ethane dimethane sulphonate) during sexual differentiation produces diverse profiles of reproductive malformations in the male rat. Toxicology and Industrial

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178 Issues in Flap Surgery

Clinics of North America. 1981;**8**:223‐236

## *Edited by Sherif Amr*

The development of flap surgery parallels the increasing complexity of soft-tissue defects needing reconstruction. Random and pedicled flaps as well as free muscle and fasciocutaneous flaps have helped to reconstruct single soft-tissue defects. The multiplicity of defects needing reconstruction and donor-site morbidity in addition to tailored reconstruction have called for a revision of flap concepts in favor of perforator flaps. Unfortunately, we are faced with increasingly complex reconstructive issues. New reconstructive techniques, such as the Ilizarov method, have made orthopedic reconstruction after high energy and complex trauma possible. Revision surgeries after tumor resection and plastic surgery have brought about soft-tissue defects associated with extensive fibrosis and necrosis. As a result, previously nonsalvageable limbs have been salvaged. The reconstructive surgeons are faced with the following situations: multiple soft-tissue defects, extensive fibrosis, possibility of major vessel loss, and possibility of damage of several perforators.

Published in London, UK © 2018 IntechOpen © zizulhalmi / iStock

Issues in Flap Surgery

Issues in Flap Surgery