PART IX
TRUNK AND LOWER EXTREMITY
CHAPTER 92 • CHEST WALL RECONSTRUCTION
JOSEPH N. CAREYt LBO R. OTAKEt ANTHONY E.CHOt AND GORDON K. LEE.
lnSTORY
Chest wall reconstruction became more formalized as a result
of reconstructing mastectomy defects. T ansini is credited
with the first latissimus dorsi flap for reconstruction of a
mastectomy defect in 1896. He developed fasciocutaneous,
muscle, and musculocutaneous flaps for radical mastectomy
defects. The surgical treatment of breast cancer at the time
included resection of the breast, the pectoralis major, and the
axillary contents. Halsted, who first performed the procedure
in 1882, proposed skin graft closure or healing by secondary
intention. Tansini's experiments with random fasciocutane-
ous, muscle, and eventually pedicled musculocutaneous flaps
gave him experience with partial and full flap necrosis. His
tribulations led him to describe the concepts of blood flow in
flaps and to conclude that the musculocutaneous latissimus
flap was the most reliable method of reconstructing a mas-
tectomy defect.
Tansini's concept of mastectomy closure was lost for many
years, as the Halsted method of breast cancer treatment was
adopted, and admonitions about the use of flaps in cancer
treatment were heeded. As the use of muscle and myocutane-
ous flaps was popularized in the 1970s by Mathes and Nahai
and Bostwick, however, the superiority of flaps in the closure
of mastectomy defects was demonstrated.
Similarly, as the surgical treatment of thoracic diseases
evolved, large chest wall defects were created, present·
ing reconstructive challenges. Arnold and Pairolero in the
1970s and 1980s made substantial contributions using sev-
eral muscle flaps (including the external oblique, pectoralis
major, and latissimus dorsi) and omentum for chest wall
reconstruction.
Modem-day chest wall reconstruction uses the gamut of
the reconstructive armamentarium, including negative pres-
sure wound therapy (Chapter 3),local flaps, pedicled flaps,
and free tissue transfers. Alloplastic and prosthetic materials
are also frequently used and their use has increased in recent
years with the advent of biological prosthetic materials. This
chapter focuses on the desaipti.on of chest wall wounds, and
the algorithm and materials available to the reconstructive
surgeon to solve the problems associated with ablative sur-
geryt traum&t and infection of the chest walL
CHESTWALLANATOMY AND
FUNCTION
The chest wall consists of muscle, cartilage, and bone arranged
in a conical fashion and consisting of an apex and a base
(Figure 92.1}. The junction of the first thoracic vertebrae, the
first ribs, and the manubrium forms the apex or "thoracic out·
let." The base is formed by the diaphragm and its attachments
to the inferior ribs, the xiphoid process, and the spine. The
anterior surface of the chest wall consists of the sternum and
its cartilaginous attachments to the anterior ribs. The chest
wall is connected to the upper extremities anteriorly via the
sternoclavicular joint and posteriorly through the soft tissue
attachments of the scapulae.
The arterial supply to the chest wall consists primarily
of paired intercostal arteries that originate from the aorta
posteriorly, run through the intercostal spaces, and join the
internal mammary arteries. The secondary arterial supply
originates from the subclavian and axillary arteries via tho-
racoacromial, lateral thoracic, and thoracodorsal branches.
The venous drainage parallels the arterial supply, however,
in the posterior mediastinum the intercostal veins termi·
nate in the azygous system. Paired intercostal nerves cor-
responding to the anterior rami of the T1 to T11 thoracic
nerves travel with the neurovascular bundles in the inter·
costal spaces and provide motor innervation to the inter·
costal muscles as well as sensation to the overlying skin
(Chapter 4).
The functions of the chest wall include (1) sturdy protec·
tion of the thoracic viscera; (2) assistance with respiratory
function via muscular contraction and structural stability; (3)
symmetric attachment of the upper extremity musculature and
stabilization of the shoulder joint; and (4) symmetric attach-
ment of the breasts.
Respiratory function depends on chest wall muscula-
ture and the stability of the rib cage. The chest wall muscles
are arranged in three layers similar to the abdominal wall.
Contraction narrows the intercostal spaces and changes the
thoracic volume to change the intrathoracic pressure to effect
air movement.
ETIOLOGY OF CHEST WALL
DEFECTS
Chest wall deformities occur from a variety of causes, includ-
ing trauma, tumor extirpation, infection, and iatrogenic inju-
ries such as radiation. The origin of the defect, the age of the
patient, and concomitant comorbidities all affect the recon·
structive decisions.
Trauma. The most common cause of chest trauma in the
United States is blunt trauma associated with motor vehicle
accidents (MVAs). An estimated 7% of MVAs result in seri-
ous thoracic injury and 20% of all trauma deaths involve tho-
racic injury. In addition, penetrating, blast, or bum injuries
may necessitate chest wall reconstruction.
Tumor. Tumor extirpation results in chest wall defects
that range from small to massive. Among the most common
neoplastic causes for chest wall resection are breast carcinoma
and soft tissue sarcoma. However, extrathoracic extension
of thoracic visceral tumors and primary bone and cartilage
tumors are also causes of large chest wall defects. The specific
921
922 Pan IX: Tl'Wik and Lower h:tremity
Costo-
chondrel
)unction
Costal
cartilage
A B
FIGURE !12.1. Chest wall rmatomy. A. Su:mum and rib cage. B. Anterior view. C. Posterior view.
adjuvant treatments for each type of tumor are taken into con-
sideration, including the potential need for chemotherapy and
radiation.
Infection. lnfeaions involving the chest wall and thoracic
cavities are common indications for reconstruction. Origins
of intrathoracic infections include empyema, bronchopleural
fistula, pneumonia, and surgical site infections following tho-
racic surgery. Mediastinal sepsis and sternal osteomyelitis may
occur following heart surgery and require prompt and com-
plete debridement and coverage.
Radiation. Radiation treatment of tumors in the chest wall,
most commonly breast cancers, results in difficult to manage
wounds that require resection and coverage with vascularized
tissue. Osteoradionecrosis of ribs and the stemum may occur
years following treatment of carcinomas and lymphomas, and
results in recurrent infection and drainage.
Congenital. Congenital chest wall defects requiring recon-
struction are most commonly pectus excavatum, pectus
carinatum, and Poland's syndrome (Chapkr 64). Other condi-
tions include lymphatic and vascular malformations.
Trauma of the Chest Wall
Rib fractures indicate significant chest trauma and may be
associated with intrathoracic and intra-abdominal injury.
Fractures of three adjacent ribs in two or more places may
result in a flail chest and paradoxical motion, and may lead
to respiratory compromise. Blast and electrical injuries may
induce zones of injury not immediately apparent in the acute
setting and require close cardiac and respiratory monitoring.
Treatment. After stabilization of life-threatening injuries,
patients with flail chest may require operative stabilization of
rib fractures. While the mainstay treatment of rib fractures is
nonoperative, rib plating systems are currently available for
the stabilization of rib fractures in a flail chest segment. Rigid
fixation systems contain a standard plate and screws, as well
as intramedullary rods.
In traumatic wounds, coverage after debridement of nonvi-
able tissues is approached similarly to infections and tumor
defms (see below).
Tumors of the Chest Wall
Primary malignancies of the chest wall may be classified
into eight main categories: muscular, vascular, fibrous and
fibrohistiocytic, peripheral nerve, osseous and cartilaginous,
Outline of
heart
-r lnfer1or margin
of lung
--Inferior margin
of pleura
Costo-
diaphragmatic
recess c
adipose, hematologic, and cutaneous. The diversity of malig-
nancies and attendant surgical extirpation may result in sig-
nificant defects. Reconstruction must also take into account
postoperative oncologic therapy such as radiation.
Treatment. Ai.te.r extirpation of the tumor, the dimensions
and components of the chest wall requiring reconstruction
are evaluated. Restoration of pleural cavity integrity as well
as protection of intrathoracic structures may be required.
Classic; te:u:hing recommends skeletal rec;onstruc:ti.on for
defects involving four or more ribs or greater than 5 an in
diameter; however, this varies depending on the loc:ation of
the defect.
An option for skeletal reconstruction includes the so-called
methylmethacrylate and synthetic mesh "sandwich." The
methylmethacrylate is molded into the desired shape of the
defect, and Marlex or Prolene mesh is placed on each side of
the construct and sutured together. The methylmethacrylate
and mesh sandwich can be sutured to the surrounding struc-
tures. Some patients experience pain with respiration since the
methylmethacrylate is much more rigid than the chest wall.
This method of skeletal reconstruction provides protection
to the underlying cardiac and pulmonary structures and can
be used for even large defects in tandem with soft tissue flaps
(Figure 92.2).
Posterior and superior chest wall defects may not aff«t
ventilation as muc;h as anterior defec:ts. In these cases, skeletal
reconstruction may not be necessary; therefore, a variety of
other products, both synthetic and biologic, may be appropri-
ate. Synthetic products such as Gore-Tex, Marlex, and Prolene
mesh may be used for smaller lateral defeca. Synthetic mesh
can be problematic in the lower chest wall since the mesh may
come into contact with the intra-abdominal contents and lead
to bowel adhesions or even fistulae (Chapter 93). Biological
products, such as human allograft dermis and xenograft der-
mis, ofEer other options for reconstruction where rigid stabil-
ity is not mandatory. They are not likely to cause adhesions
with the viscera and may tolerate bacterial contamination
better than a synthetic product since they may become revas-
cularized by the surrounding host tissue. Although the discus-
sion of biologic materials is beyond the scope of this chapter,
surgeons have continued to expand applications in complex
defms and wounds. Both biologic and synthetic mesh do not
provide the same level of rigidity as methylmethacrylate or
titanium mesh, but they do provide additional stability to the
chest by spanning the defect.
 Chapter 92: Chest Wall Reoonstr'Uetion 923

Infections of the Chest Wall and Thorax Treatment

Empyema and Bronchopleural Fistula. A broncho-
pleural fistula and pleural empyema (pus in the pleural cav-
ity) are complications of pneumonectomy that carry signif-
icant morbidity and mortality. As a first step, drainage of
the infectious empyema is performed, and depending on its
severity, may nec:essitate a delay in the reconstruction. Often
the thoracic surgeon manages the empyema and requests
help from a plastic surgeon for the transfer of flaps to rein-
force the bronchial stump closure or to obliterate the pleural
cavity.
Eloesser Flap. To adequately drain the empyema cavity, a
variety of procedures have been described. The Eloesser flap,
originally described in 1935 for the drainage of tuberculous
empyemas, externalizes the empyema. A 2-inch random-pat·
temed fasciocutanous flap is created on the chest wall at the
level of the empyema, a segment of rib is reseaed, and the flap
is sewn to the pleural lining (Figure .92.3A). This allows for
continual drainage of the empyema.
Clagett Procedure. The dagett procedure involves creation
of a window thoracotomy and the packing of the wound with

~----------------------------------~ 8

FIGURE 92.2. Dermatofibrosarcoma protuberans. A. Patient with large dermatofibrosarcoma protuberans of chest wall. B. Post resection with
exposed pericardium aod chest wall de!ect. C. Matlex mesh sandwich tailored for support of recoosttuct:ioo. D. Application of methylmethac-
rylate to mesh. E. Soft tissue coverage with pedicled latissimus dorsi/serratus chimaera, omeotumlsk.io graft, aod free tensor fascia lata flaps.
(4) Gordon Lee,. M.D.t.
924 Pan IX: Tl'Wik and Lower h:tremity
FIGURE !n.l. (Continuedt
antibiotic-soaked dressings that are changed every 48 hours.
Once the pleural space contains healthy granulation tissue,
the cavity is completely filled with antibiotic solution and the
chest wall is closed in layers.
Thoracoplasty. Obliteration of the pleural space is necessary
if the remaining lung does not fill the hemithorax. A post-
pneumonectomy syndrome of tracheal deviation, inspiratory
stridor, and exertional dyspnea may develop. Historically, a
thoracoplasty was performed, where the skeletal support was
removed, leading to the external collapse of the hemithorax
(Figure 92.3B). While this procedure addressed the dead space
from the pneumonectomy, it was quite morbid and disfiguring.
Flap Transposition. Regional flap transposition is the pre-
ferred method to fill intrathroacic dead space and to patch
A B
FIGURE 92.3. Eloesser flap and thoracoplasty. A. Schematic of Plower flap. B. Radiograph post-thoracoplasty.
a bronchial stump. To seal ol£ bronchopleural fistula, extra-
thoracic flaps are transposed through a second thoracotomy
and sewn to the bronchial stump. Often a 7 to 10 an seg-
ment o£ rib will require resection to allow patsage o£ dle £lap
into the pleural space. The following flaps are commonly
used: latissimus dorsi, serratus anterior, intercostal muscle,
pectoralis major, and rectus abdominis, and omentum. For
larger intrathoracic defects, a musculocutanous flap such as
the transverse rectus abdominis myocutaneous (TRAM) and
vertical rectus abdominis myocutaneous (VRAM) can be used.
If regional flaps are not available, free tissue transfer can be
performed to bring in healthy tissue.
Adult Sternal Wounds. Historically, sternal wound
infections were associated with a 70% mortality rate. In the
1.960s, debridement and closure over an antibiotic irrigation
system improved mortality rate to 20%. Then in the 1.970s,
the concept of utilizing flaps to cover the defects following the
debridement of nonviable bone and cartilage brought the mor-
tality rate into single digits. The incidence of sternal wound
infections is on the order of 0.4% to 5% of all sternotomies
performed. There is an increased risk of sternotomy infections
associated with internal mammary artery (IMA) harvest, dia-
betes mellitlls, and multiple reoperations. The risk of mediasti-
nitis is particularly high when both internal mammary arteries
are harvested for coronary artery bypass grafting. This occurs
because the sternum does not contain separate nutrient ves·
sels and relies solely on the segmental sternal branches of the
IMA to supply the periosteal plexus for its nutrients. When
both IMAs are used, the sternal vascularity is decreased sig·
nificantly and is vulnerable to nonunion and infection.
Classification. Sternal wound infections are clatsified into
three categories: Class 1 infections occur 1 to 3 days postop-
eratively, are manifested by serous drainage, and cultures are
sta:ile. Class 2 infed:ions occur 1 to 3 weeks postoperatively,
are manifested by purulent mediattinitis, and ailtares are pos-
itive for bacterial pathogens. Clats 3 infections oc:au months
to years after the initial surgery, are manifested by a chronic
draining sinus trac:t, and cultures are positive for pathogens.
Treatment. Initial treatment consists of debridement. Class 1
infections are treated with minimal debridement, irrigation,

and re-wiring of the sternum. Class 2 and 3 infections require a
thorough debridement, antibiotics, and flap coverage.
While it may be common to perform multiple debride-
ments of the wound prior to flap con:rag~ it has been shown
that a single-stage radical debridement and concomitant flap
coverage has a similar success rate. Multiple surgical debride-
ment is to allow the wound to demarcate and may help the
surgeon adequately debride the nonviable tissue, which may
not have been evident at the initial surgery. The condition of
the patient and the specific nature of the wound dictates the
appropriate debridement.
Negative pressure wound therapy has provided another
treatment modality for sternal wounds. The greatest benefit
occurs after the initial debridement. Since the negative pres-
sure wound dressing is only changed every 2 to 3 days, it
drastically reduces the frequency, pain, and inconvenience of
dressing changes. In addition, the wound contracts, thereby
reducing the tissue required for coverage. In some cases, nega-
tive pressure wound therapy may result in complete closure
and obviate the needs for any flaps.
Median sternotomy wound closure is usually success·
ful with soft tissue flaps only and skeletal stabilization is
not required. On occasion, these patients complain of pain
because of motion of the sternum or rib segments, which has
led to the devdopment of sternal plating systems. The need for
rigid fixation, however, remains controversial.
Within the past decade, the concept of rigid skeletal fixa-
tion of the sternum following median sternotomies and of
the ribs following traumatic injuries has been revisited. The
traditional sternal closure consists of wire cerclage to reap-
proximate the sternal margins. Titanium sternal plating sys-
tems may be best reserved for high-risk patients with multiple
comorbidities, and in re-operative patients with sternal insta-
bility, fracture, and poor bone quality. By adhering to the
osteosynthesis principles for rigid skeletal fixation, reduction
of micromotion across the bone fragments enables bone heal-
ing and decreases infection. Early results demonstrate that the
titanium sternal plating systems in these high-risk populations
may decrease or even prevent the incidence of mediastinitis.
Complications from titanium sternal plating system include
plate fracture, infection, and seromas.
Pectoralis Major Flap. The pectoralis major muscle
inserts onto the prox.imalliumerus and is attached broadly to
the anterior chest wall from the clavicle and ribs one through
six. It receives blood supply from the thoracoacromial vessels,
branches of the lateral thoracic artery, and from perforators of
the internal mammary and intercostal arteries. Motor innerva-
tion is from the medial and lateral pectoral nerves.
The pectoralis major flap is the workhorse flap for ster-
nal reconstruction due to its dose proximity. This flap is
commonly based on the thoracoacromial artery and rotated
toward the sternotomy defect (Figure 92.4). The insertion on
the humerus can be divided to allow better mobilization. The
limitation of this flap is the inability to cover the lower third
of the sternum. If the IMA on that side was not harvested, the
pectoralis major muscle flap can be based on the IMA perfo-
rators and used as a turnover flap, which allows coverage of
the lower sternum. As a turnover flap, the pectoralis major
muscle can be split to provide coverage to the superior and
inferior sternum. For sternal dehiscence without a deep cavity,
the two pectoralis major muscles can simply be advanced to
each other.
Rectus Abdominis Flap. The rectus abdominis muscle
flap is a potential option for sternal wound coverage. For the
purpose of chest wall reoonstruction, the flap is based on the
superior epigastric artery, a continuation of the IMA, and
can provide coverage over the lower sternum (Figure .92.S).
A skin paddle can be harvested with the muscle in the form
of a VRAM flap or a TRAM flap if additional volume or skin
Chapter 92: Chest Wall Reoonstruetion 925
coverage is needed. In cases where the IMA has b«n har-
vested, the flap can still be transferred on the eighth intercos-
tal vessels from the mosadophrenic artery. In this sc:enario,
the skin paddle and the distal muscle may be unreliable.
Omentum Flap. The omentum is a large and versatile flap
for sternal wound reconstruction. An upper laparotomy inci-
sion is needed for access into the peritoneal cavity. After divid-
ing the shon gastric arteries, this flap can be based on the left
or right gastroepiploic artery; however, the left gastroepiploic
artery offers the greatest flap length (Figure 92.6). This flap
has the benefit of having a large surface area and being rda-
tively thin, which allows it to be easily contoured. lt can eas-
ily cover the entire length of the sternal wound, wrap around
vascular grafts in the chest, fill any small cavity around the
wound, and even can be skin grafted. Previous abdominal
surgery limits the use of the flap due to adhesions. The draw-
backs of the omentum flap include a possible epigastric her·
nia, bowd obstruction, bawd adhesions, and the insult of a
laparotomy on a sick patient.
Latissimus Dorsi Flap. The latissimus dorsi muscle is a
broad, fan-shaped muscle that has attachments to the back
along the fascia of the paraspinous muscles, and the lum-
bar fascia. It has insertions onto the proximal humerus and
is involved in adduction and internal rotation of the arm. Its
blood supply is from the thoracodorsal artery, which origi·
nates from the subscapular system, as well as thoracolumbar
perforators. Motor innervation is from the thoracodorsal
nerve, which runs along with the blood supply.
The latissimus dorsi muscle flap is not the first choice of
flaps for sternal wound reconstruction, but it may be used in
occasional circumstances. The flap is based on the thoracodor-
sal artery from the subscapular system (Figure 92.7). The flap
is harvested in the lateral or prone position, necessitating posi·
tion changes during surgery. While the distal portion of the
flap may reach the sternum, the blood supply may be tenuous.
The latissimus dorsi muscle flap is best reserved for coverage
of lateral or anterolateral chest wall defects.
Pediatric Sternal Wounds. Pediatric sternal wounds pres-
ent some subtle differences. While the debridement of the
wound should be thorough, excessive debridement of the ster-
num and the costal cartilages should be avoided. Since ossi-
fication of the skeletal structures is not complete in a young
pediatric patient, over-resection of these structures may occur.
Second, the pectoralis major muscle is smaller relative to the
size of the patient and will definitely not reach the lower half
of the sternum. Furthermore, devation of a pectoralis flap in a
female patient may damage the devdoping breast and inhibit
breast development in the future. Finally, the pediatric omen-
tum is thin and may not provide adequate bulk for sternal
coverage. The rectus abdominis muscle is a better option,
especially in infants since this muscle is rdatively wide, thin,
and long.
Left Ventricular Assist Device Pocket Infe<:tions. When
first developed, left ventricular assist devices (LVADs) were
large devices with proportionately large power units for
patients with heart failure awaiting a heart transplantation.
As the devices have become more compact and longer lasting
battery packs have been developed, their use for destination
therapy has become more common. Patients who were previ-
ously confined to a hospital setting awaiting a heart transplant
are now able to return to their previous lives with the newer
LVADs. As with any prosthetic implant, infections can occur.
Treatment. Infections usually occur around the drivdine
or the LVAD pocket. The infection is ideally treated with
removal of the LVAD; however, unless the patient's heart
failure has improved or a donor heart is available, device
removal is not an option. The LVAD and its pocket, however,
926 Pan IX: Tl'Wik and Lower h:tremity

C D
FIGURE ,1.4. Pectoralis major flap. A. Stemal wound after debridement; B. closure with bilateral advancement pectoralis major flaps;
C. thoracoacromial pedicle; D. turnover flap with intercostal perforators. (A, B: e Gordon Lee, MD).

do require debridement. Once the LVAD pocket is dean and
there are signs of granulation. regional flaps are used to cover
the device. The omentum or rectus abdominis muscles are the
most readily available flaps due to their close proximity to
the defect and their ability to cover a large surface area. It
should be noted that the driveline for the LVAD is usually
placed though one of the rectus abdominis muscles, which can
potentially damage the vascular pedicle and preclude transfer
of that muscle.
Congenital Chest Wall Defects
Pectus Carinatum and Pectus Excavatum. Pectus cari-
natum is a protrusion of the sternum secondary to a deformity
of the costal cartilages. Overall prevalence is 0.6% with a male
preponderance and genetic association both in isolation and as
a component of a syndrome. Pectus excavatum, a concavity of
the sternum and adjacent costal cartilages, has an overall inci-
dence of 1:400 to 1:1,500 births with a 3:1 male preponder·
ance; it is also associated with Marfan's and Ehler-Danlos syn·
dromes. In severe cases, these chest wall deformities can cause
physiological disturbances, including measured dea:eases in
forced expiratory volume, cardiac stroke volume, and output.
Surgical correction can improve exercise tolerance.
Treatment. Indications for surgical correction of pectus
deformities include cardiopulmonary impairment and pro-
gression of the deformity with age. Correction of pectus
carinatum involves bilateral resection of deformed costal
cartilages, osteotomy, and repositioning of the sternum with
reapproximation of the distal sternum to the xyphoid. The
pectoralis major muscles are reapproximated over the ster·
noplasty. A variation of this procedure, including pectoralis
muscle splitting without detachment,. cartilage resection with
bioabsorbable plating, and postoperative external compres-
sion splinting, has been described.
Mild pectus excavatum deformities can be disfigured with
custom sternal implants or to some extent with breast implants
in female patients. Two options for surgical correction of pec-
tus excavatum have been described: the "open" Ravitx:h proce-
dure and the "closed" Nuss procedure. In the former, deformed
cartilages are removed, the xyphostemal articulation is divided,
and a transverse osteotomy of the sternum is performed at
the superior limit of the deformity. The corrected position
is maintained using autologous or synthetic mesh support
(Figure 92.8A). In the closed Nuss procedure, a convex metal
bar is introduced under thoracoscopic guidance across the chest
in a substernal tunnel and rotated to force the sternum ante-
riorly (Figure 92.8B); the bar is left in place for up to 5 years.
 Chapter 92: Chest Wall Reoonstruetion 927

Internal
thoracic
artery

Eighth
intercostal
artery

FIGURE 92.5. Reaus abdominis Sap pedicled on superior epipsuic:

and eighth ina:rc:ostal amries. A. Su:mal wound aftu debridement;
B. rec:tus abdominis muscle Sap; C. c:losure of sa:rnal. wound and Sap
donor site. (A-C: e Gordon Lee, MD). D. Schematic illustration of
rectus abdominis flap pedicled on the superior epigastric and eighth
intercostal arteries. D
928 Pan IX: Tl'Wik and Lower h:tremity
Recontouring of the chest wall after these corrective proce-
dures may be required. Autologous cartilage grafting has been
described for the correction of minor chest wall deformities or
for "fine tuning,. of the result. Breast augmentation for female
patients is an alternative.
Poland Syndrome. Poland syndrome is a rare condition
occurring in 1:16,500 births as a constellation of symptoms,
including hypoplasia of the pectoralis major, hypoplasia of
the bone and cartilage of the ipsilateral upper extremity and
trunk, as well as hypoplasia/agenesis of the latissimus dorsi. In
addition, hypoplasia or absence of the breast and nipple may
be present (Chapter 64).
Treatment. Reconstruction of the male chest has been
described using customized silicone implants. Reconstruction
of the female breast is dependent upon the degree of breast
hypoplasia. An algorithm developed by Freitas et al., in 2007,
describes the use of silicone prosthetic versus tissue expander/
c
silicone prosthetic reconstruction for mild and severe
presentations of breast hypoplasia, respectivdy, and describes
the use of implantAatissimus dorsi myocutaneous .Bap recon-
struction for more severe cases involving hypoplastic pecto-
ralis muscles (Figure 92.9). The latissimus dorsi muscle flap
helps recreate the anterior axillary fold, which is deficient in
these patients and is difficult to reconstruct otherwise. In the
event of hypoplasia or absence of the latissimus dorsi muscle,
free tissue transfer techniques may be employed, including
perforator flaps. More recently, fat transfer techniques have
been applied to the correction of the female breast defo.rmity
in Poland syndrome.
Alternative Flaps for Chest Reconstruction
Pedicled Perforator Flaps. Perforator-based fasciocutane-
ous flaps have rea:ntly been applied to chest wall reconstruc-
tion. The use of the deep inferior epigastric artery perforator
flap in breast reconstruction decreases donor-site morbidity,
FIGURE 92.6. Omentum flap pedicled on right or left gastrcepiploic
arteries. A. Stemal wound after debridement; B. omentum flap raised
prior to inset; C. coverage with omentum flap and split thickness skin
graft. (A-C: ~ Qlrdon Lee, MD). D. Schematic illustration of cmen-
tum Sap pedicled on the right gastrccpiploic am:ry.
 Chapter 92: Chest Wall Reoonstruetion 929

Right and Left

gastroepiploic artery -=:::,....--.,----:=..;.---il

D
FIGUJlE 92.6. (Continued)

FIGURE 92.7. Latissimus dorsi flap. A. Planned latissimus dorsi {LD)

flap; B. skinislandraited with LD flap; C. infra-axillary subcutaneous twl-
nel for passage of £lap to anterior chest wall. (A-C: e Gordon Lee, :MD).
D. Schematic illustration of latissimus dor&i Sap pedicled on the thora-
codorsal artery.
930 Pan IX: Tl'Wik and Lower h:tremity

Thoracodoraal
arts~--~-----------+~~

Branch to
serratus muscfe - - -----\:-- - - - - - - ----.--'---1

D FIGURE fJ2.7. (Continued)

and this concept has been applied to the IMA, thoracoacro·
mial artery, the thoracodorsal artery, and most other axial
vessels in the body. The IMA perforator flap is a transversely
oriented fasciocutaneous skin paddle up to 7 X 26 em based
on an eccentric perforating vessel of the internal mammary
system. Flaps have been effectively designed on perforators
from the second to the eighth intercostal space. The flaps are
then rotated up to 180°. Intercostal artery perforator flaps are
useful in a variety of settings to cover sternal wounds and par·
tia1 breast defects.
Free Tissue Transfer. The abundance of local and regional
flap options usually makes free flaps for chest wall reconstruc·
tion unnecessary. However, situations do exist where local
and regional flaps are not available or reliable. Free flaps
may be indicated in the manubrial region, or other central
sternal defects, or when the pectoralis muscles are unavail-
able due to resection or debridement. A free flap may also
be the best option in a radiated chest wall where a latissimus
flap has already been used. Various free flaps for chest wall
reconstruction have been described, including the anterolat·
eral thigh, vastus lateralis, tensor fascia lata, latissimus, and
free abdominal flaps. The choices of commonly used recipi·
ent vessels include the internal mammary, thoracodorsal, or
transverse cervical arteries. In the case of the vessel-depleted
patient, arteriovenous loops can be created using the cephalic
and thoracoacromial vessels.
SUMMARY
When managing patients with chest wall defects, the plastic
surgeon takes into account the nature of the defect, the indica-
tion for surgery (fo.rm and/or function), and the condition of
the patient. If multiple ribs and/or sternum are missing, skeletal
reconstruction is considered with methylmethacrylate, titanium
mesh, plate and screw fixation, or mesh only (synthetic or bio·
logic). Options for soft tissue coverage include the pectoralis
major, rectus abdominis, latissimus dorsi muscles, omentum,
or free tissue transfer. A multidisciplinary approach between
the thoracic surgeon and plastic surgeon yields the best results.

A
FIGURE 92.8. Nuss and Ravitch proa:dw:es for correction of pectus exc:avatum deformity. A. Dlusuation of the Ravitch procedure with excision
of costal cartilages and elevation of the sternum. B. Illutttation of the NuSll procedure with placement of retrostemal bar.
 Chapter 92: Chest Wall Reoonstruetion 931

Seconcl costal
cartilage
clivicled

•---=-•-~t:::::::§--,-':---lnteroostal buncllss
Costal cartilage dMded
exclaed -----ta~....-

"~-=,I!:"T""~:-""::W:...._:r.--- Finger to
free
pericardium and
pleural reftactions

B FIGURE 92.8. (Continued)

B
FIGURE 92.9. Poland syndrome and deformity correction. A. Illutttation of a patient with Poland syndrome. Note the severe hypoplasia of right
breast, nipple-areola complex, and pe<:teralis major. B. Correction of deformity with combination of right tissue expansion with second-stage
exchange for silicone prosthesis under latissimut dorsi ftap reconstruction. Reprinted with permission from Freitas Rda S, o Tolaui AR. Martins
VD, Knop BA, Graf RM, Cruz GA. Poland's s)'Ddrome: different cliDic:al. pl'C5CDtations and surgical reconstruc:tions in 18 case&. Authetic Plast
SUI'g. 2007 M.ucll-April;31(2):140-146.
932 Pan IX: Tl'Wik and Lower h:tremity
Suggested Readings
Arnold PG, Pairoleto PC. Cheat-wall reconstruction: SID. account of SOO COil·
secuti,-e patiellts. Pl.tu:t R«.omtr SNrg. 1llll6 Octobet;li8(S):804-810.
BIID.ic A, Rjs HB, l!mi D, Striffeler H. Flu latittimus dorsi flap for chest wall
repair after complete resectioll of ill.ft.cted tttmum . .Ntn Thonre ~rg. 1JIJIS
Octobet;60(4):1028-1032.
BroWll. Rl!, McCall TI!, Neumeister MW. Use of free-tiaue tr.IID.der ill the
tteatmellt of m.edilul. stemotomy wound infections: retrospective review.
J Recotl&#' Miao&Nrg. lllllll April;1S(3}:171-17S.
Colemall JJ 3rd, Bostwick J. Rectus abdomillia muscle-musculocut.IID.e-
out flap ill chett-wall reconstructioll. SNrg Clin Nonh Am. tllllll
Octobet;6li(S):1007-1027.
Del Frari B, Schwabeggrer AH. Te~~.-yeu experieli.Ce with the muscle tplit tech-
ll.ique, bioabtorbable platet, IID.d pottoperatiTe bracill.g for correction of
pectus cuill.atum: the IM.sbruck protocol J Thor<~e CMtliovtue SNrg. 2011
}Ull.e;141(6):1403-140ll.
Delay R, Si~~.na R., Cb.ekaroua K, Delaporte T, Garton S, Toussoun G.
Lipomodeli.llg of Poland's syndrome: a new treatment of the thoracic defor-
mity. Alf&thetit: Pl.ut SNrg.lOlO April;34(l}:l18-l2S. Bpub lOOJI Nov 10.
BDgd H, Pelzer M, 5.wetbier M, Germalm G, HeitmiiD.ll. C. All ill.no'fllli,-e ttestt-
mell.t ooncept fur free flap terollll~ll of oomplex central cheat wall defects-
the cephali.c-l:horacomial (CfA) loop. Mia'o.lwrgt"PY. 2007;27(5):481-486.
Freitas Rda S, o Toltuzi AR, Martins VD, K.nop BA, Grd RM, Cruz GA.
PoliiD.d'• syndrome: di.fftrell.t clinic.tal ptetelltatioliS .llll.d surgical recolllltfUC-
tiollll in 18 catet. Alf&thetit: Pl.tut SNrg.2007 Mar~April;31 (2):140-146.
Gonfiotti A, Salltini PF, Campanacci D, et al. Malip~~D.t primary chett-wall.
tumours: tedl.lliques of teeoll.ttfUction and tutvival. Ellr J Ctvdiothof'tu:
Slwg. 2010 July;38(1):3li-4S.
Hallock GG. The ial.ud thoracoacromial artery mutcle perforator flap• .Ntn
Pl.tu:t SNrg.l011 February;66(2}:168-171.
Hamdi M, Van LIID.duyt K, U1ell.t S, VIID. Hedellt E, Roche N, Monstrey S.
Clinical applications of the superior epigutric artery perforator (SEAP)
flap: anatomical studies and preoperatift perforator mappill.g with multide-
tector cr. JPltut RetloMtl' Amhet SNrg. 2009 September;62(9):1127-1134.
Kelly RE, Gotettky MJ, Obermeyer R, et al. Twemy...,ne yeart experience wilh
minimally invati•e repair of pectus excuatum by the Nuss procedure in
1215 patiell.t$. Ann Slwg. 2010 December;2S2(6):1072-1081.
Lec:ours C, Saillt-Cyr M, Wo~~g C, Bernier C, Mailhot E, Tardif M, Chollet
A. Fl'l!estyle pedide pert'orator flaps: cliDi<:al. rmdts and .,asc:u.~ar anatomy.
P£ut ~ SNrg. 2010 Nomnber;126(5):1S8.9-1603.
Lee CH, Hsien JH, Tang YB,. eben HC. Reconstruction for sternal osteomy-
elitis at the lower third of sternum. J Pla.u R_,n.ur Aeuhtn Swg. 2010
April;63(4):633-641.
Lee CJ, 1Gm CW, Kwik IH, Gil MS, lWig YH, Lee SL The use of omentum as
a free flap to recoll.5truct the upper portion of the mediastinum without a
mbsterual. tract. Ann Plmlt Sl.rg. 2001 Julr.47(1):93-95.
Maia M, Oll.i G, Wong C, Saint-Cyr M. All.terior chest wall recoliStruction with
a low skin paddle pedicled latissimus dorti. flap: a no•el flap design. PList
Recomtr Swg. 2011 March;127{3):1206-1211.
Maxwell GP. ft:inio T llli5W and the origin of the latissimus doni mii'ICII.!ow.ta-
l!eOUS flap. Pltut Reronttl' Sin-g. 1980 Mar,65(5):686-692.
Pereira LH, SabatO'ri~h 0, Santall.a KP, Piw:~~ R., Sterodimu A. Surgical cor-
reclioll of Poland's syndrome in malew. purposely designed implant. J PList
Recomtr Aauun Sttrg. 61(4):3ll3-3llll. Epub 2007 }IID.uary 31.
Reichellbetger MA, Harenberg PS, Pel2er M, et al. Arterio•enous loops in
microsurgical free tissue transfer iD. recollsttu~oll of czntral sterDal. defects.
JThor#.C C.dio!IIUC Sl.rg. 2010 DKelllber;140(6):1283-1287.
R.oa:o G, Fazioli F, La Manna C, et al. Omental tlap and titanium plates pro-
vide structural stability and protection of the mediastinum after exten.si.e
sternoc:ostal mection. .Ntn Thowu: Swg. 2010 July;JIO(l):e14-e16.
Villa MT, Chang DW. Muscle and omental flapt lor chest wall reconstruction
(,Review]. Thome SNrg C1in. 2010 No-.ember-,.20(4):543-550.
Woug C, Maia M, Saint-Cyr M. Lateral iD.te~stal artery perforator tlap iD.
combination with thora~oabdomillal. ad•an~t flap for ~orrection of
contour defortnities following autologous breast reconstruction. Pl.tut
Recomtr Swg. 2011 June;127{6):1S6e-1S8e.
Yang H, Lee H. Sua:esslul. use of squeezed-fat grafts to correct a breast affected
by Poland syndrome. Ae~rhl!tic Pltut S'"f. 2011 }lllle;35(3):418-42S. Epub
2010 October 17.
CHAPTER 93 • ABDOMINAL WALL
RECONSTRUCTION
GREGORY A. DUMANIAN
INTRODUCTION
Abdominal wall reconstruction (AWR) is a proving ground for
the principles of plastic surgery. It requires a thorough knowl-
edge of anatomy, an understanding of the physiology of the
intra-abdominal viscera, the manipulation of multiple tissue
types, the handling of alloplastic makrials, and wound care.
The quality of the reconstruction is judged both by the dura-
bility of the abdominal muscle repair and on the aesthetics of
the final draping of skin and soft tissues over the abdominal
wall. According to the Cochrane database, as many as 11%
to 53% of all midline laparotomies will result in a hernia.
Challenges facing surgical management of hernias include the
obesity epidemic and the advent of minimally invasive proce·
dures that have eroded the familiarity of other surgery disci-
plines with large open procedures and complex wounds.
This chapter attempts to provide the reader a framework
for the management of all types of abdominal wall situations,
including wounds, fistulae, and hernias. Management of the
abdominal wall depends on:
1. An understanding of abdominal wall physiology and the
forces on the abdominal wall that lead to hernia forma·
tion.
2. Strategies to deal with complex abdominal wall wounds
and fistulae.
3. An appreciation of factors, such as prior surgical history,
bowel issues, and nutrition, that play a role in the timing
and sequence of operative procedures.
4. The attention to skin vascularity during hernia repair.
FORCES ON Tim
ABDOMINAL WALL
The abdomen can be conceptualized as a pressurized cylinder.
The posterior one-third of the cylinder is rigid. With inspi-
ration or for motion of the upper body and arms, a combi-
nation of diaphragm descent and abdominal wall muscle
contraction causes an immediate rise in intra-abdominal
pressure. In a healthy abdominal wall, the increased internal
abdominal pressure is matched by an increase in the tone of
the abdominal wall muscles. Where there is a local imbal-
ance of intra-abdominal pressure and muscle tone, a bulge
becomes apparent. Examples of bulges include the linea alba
with the condition of rectus diastasis after childbirth and the
lateral bulges seen not infrequendy after flank incisions. What
is important is the uniformity of the abdominal wall coun·
terpressure. When this uniformity of abdominal wall coun-
terpressure is lost7t bulges and hernias emerge. Episodic high
peaks of intra-abdominal pressure caused by chronic coughing
and periodic lifting of heavy objects hasten the deformation
of the weak area of the abdominal wall by the mobile inter-
nal viscera. Whereas bulges are comprised of some aspects of
intact (though weakened, partially reseaed, or denervated)
abdominal wall, true hernias are contained only by scar. The
physiologic importance of this difference is understood by
observing the cross-sectional appearance of bulges that are
smooth curves, in comparison to the omega shape of ven-
tral hernias. Bowel can become caught and strangulate on
the lip of a hernia, while there are no risks of incarceration
with bulges. While the medical indication to repair hernias
is the prevention of bowel obstruc:tion and the improvement
of lOC'.llllized pain, the indication to repair bulges rests solely
on the issues of pain that can occar with tissue stretching.
Hernias typically expand with time, due to the tendency of
scar to stretch and deform, and therefore often do not reach
a steady state. Bulges, on the other hand, can reach a steady
state in size when the inelasticity of the tissue is matched to the
decrease in abdominal wall pressure that would accompany
an increase in intra-abdominal volume.
Obesity plays a role in two ways-first, there is an
increased amount of tissue inside the abdominal wall raising
baseline intra-abdominal pressure. Second, the abdominal
wall must support a greater amount of weight above the dia-
phragm, increasing both the intensity and number of peaks of
high intra-abdominal pressure. Each peak of pressure causes
stress at the suture-tissue interface.
ABDOMINAL MUSCLE
PHYSIOLOGY
In a normal abdomen without a hernia, downward descent
of the diaphragms and abdominal muscle contraction creates
elevated intra-abdominal pressure. The Valsalva maneuver is
but one example of the body using elevated intra-abdominal
pressure to brace and make more rigid the torso for effective
use of the upper body and arms for lifting. Abdominal mus·
cle contraction in this instance is predominantly isometric-
meaning that the muscle fibers increase their tone but without
sarcomere shortening. In cases of large hernias, abdominal
muscle contraction no longer increases intra-abdominal
pressure, because the viscera can escape out into the hernia.
The abdominal wall muscles now shorten (isotonic contrac-
tion) rather than simply increase in tension. This increases
the work of the abdominal wall, because isotonic contrac·
tion consumes more energy than does isometric contraction.
Additionally, the diaphragm and upper torso no longer can
"push off" against a pressurized abdomen, creating dys·
function between the chest and abdominal compartments.
The more massive the hernia, the larger the derangement of
abdominal wall physiology.
Another concept useful in understanding the forces of
the abdominal wall musculature and the utility of AWR is
abdominal wall compliance. Compliance is measured by the
change in volume for a given change in intra-abdominal pres-
sure. As abdominal compliance increases, more volume can
be accommodated for the same increase in pressure. If the
compliance of the abdominal wall is improved, it follows that
during a hernia repair, the contents of a hernia sac (volume
"outside" the abdomen) can be more easily reduced back into
the abdomen. Indeed, it has been shown that experimental
hernia repairs are more successful when the abdominal wall
is compliant than when it is stiff. Causes of abdominal wall
stiffness include lateral incisions, large abdominal meshes
from prior hernia repair, and intraperitoneal sepsis and scar
formation. 1 An emphasis on the forces on the abdominal wall
is more important for surgically induced ventral hernias than
for spontaneous abdominal wall defects, where deficiencies in
extracellular matrix may play a prime pathologic role.2
933
934 Pan IX: Tl'Wlk and Lower Extremity
The Effect of Repair on Abdominal
WaD Forces
-----------------
The goal of a hernia ~pair is to reestablish uniform abdomi-
nal wall counterpressure against the viscera, improving the
counterpreuure where it is weak, and if necessary, weaken-
iJJg the abdominal wall where it is strong. In suture repairs
(also known as direct repairs), the abdominal wall is approxi-
mated primarily. Th~ is no change in the abdominal wall
compliance, and the greatest tension is at the site of the repair.
•un1upported" direct repairs (those without 1ome type
of mesh) rely solely on sutures to hold the abdominlll wllll.
•supported• direct repairs attempt to distribute the forces
on the repair over a luger area by adding mesh to the repair
site. Another type of hernia repair is with a piece of mesh that
spans across an open defect of the abdominal wall. In these
types of "bridged" repairs, sutured mesh acts like a cap or lid,
replacing the weak area of the abdominal wall. 1bis avoids an
increase in focal forces on the abdominal wall where the tis-
sues have previously failed. The strength of the mesh to resist
outward deformation depends on the strength of the circum-
ferential attachment of the mesh to the normally innervated
abdominal wall. The larger the hernia, the further the mesh
center is from innervated abdominal wall, and the greater will
be the eventration.
The prime ~ason for hernia recurrence is suture pulling
through the tissues over time like a wire cutting through ice.
Improved force distribution over the hernia construct with
decreased tension experienced by each stitx:h will lead to lower
suture pull-through. Direct supported repairs use mesh as a
load-sharing manner as opposed to a load-bearing manner for
bridged repairs. Improved force distribution and decreased
pull-through are the primary reasom that supported repairs
have lower failure rates than primary repairs or bridged
repairs. Obesity and lateral abdominal wall noncompliance
increase the forces felt by each stitch-an explanation for
higher failure rates in theae situatiom.
A final manner of repairing the abdominal wall is with the
components separation technique for midline defects. Releases
of the external oblique muscle and fascia from its attachment
to the rectus abdominis muscles allows for a repair of the rec-
tus muscles in the midline while simultaneously improving the
abdominal wall compliance on the sides. Components' sepa·
ration repairs can be either "unsupported" or "supported"
depending on the clinical situation.
CLOSING THE WOUND
When patients are ill, wounds are inflamed, and nutrition is
poor, open abdominal wounds should be treated with simple
procedures that have high chances for succc:ss. Patients who
are packed open after a laparotomy can often be closed pri-
marily after bowel swelling bas resolved. For those patients
that cannot have their fascia closed due to persistent visceral
swelling or intra-abdominal sepsis, early wound closure in the
simplest manner possible provides multiple benefits, includ-
ing patient comfort, euc: of wound care, and a deaeascd inci-
dence of enteroc:utaneous fistul.ae.J To devise a wound closure
plan, the following questiODB must be answered: Are the vis-
cera "frozen, • and what are the chances for an evisceration?
Do bowel contenb need to be controlled? What are the loca·
tion, size:. and characteristics of the wound? Should the sur-
rounding skin be modified to bdp achieve wound closure?
Open Wounds and Evisceration
Bowel found outside the skin are surgical emergencies that
require immediate evaluation and thoughtful treatment in the
operating room. Much depends on the cause of the loss of the
abdominal wall integrity. Pure technical problems of broken
suture and untied .knots do occur, but are uncommon. When
detected quic.kly, these patients at exploration have pristine
wounds and can simply be reclosed. H sutures are noted to
have tom out of weak fascia, the conversion to a direct sup-
ported repair or the use of retention sutures is successful with-
out repeat disruption SS% of the time.4 Mass closures with
retention sutures can be successful, but the sutures can cause
skin and tissue necrosis.
More commonly, the patient has an ileus and the bowel
is swollen. These are usually contaminated wounds and
th~ is often an underlying septic intra-abdominal process.
Therefore, the goal of surgery is to replace the intestines
back into the abdomen and to prevent a second eviscera-
tion. Necrotic tissue is debrided, intra-abdominal fluid col·
lectiODB are allowed to drain, and a compartment syndrome
from swollen bowd is avoided. For these sick patients, a
temporary mesh-typically absorbable polyglycolic acid-is
placed using a running absorbable monofilament suture to
"close" the abdominal wall and to keep the viscera in their
proper domain (Figure 93.1A). The bridging nature of the
mesh across the fascial defect increases the intra-abdominal
volume. Secondary dehisa:ru.:e is unusual because the lateral
abdominal muscles are now shortened and cannot generate
a maximal contraction during coughing and movement. The
porous nature of the closure allows intra-abdominal fluid
to drain into the overlying gauze or a subatmospheric pres-
sure dressing. When the patient has stabilized, skin closure is
performed by delayed primary closure, by skin grafts, or by
secondary intention. When the skin gapes widdy and several
months would be required for closure by secondary intention,
skin grafting provides the simplest and most reliable closure as
discussed below.
An alternative to closure with a temporary porous mesh
is patching the open fascial defect with a human or porcine
bioprosthetic mesh. Bioprosthetic meshes haYt: been touted for
their toleran~ of inflamed 6dds, resistance to infection, and
ability to restore abdominal wall continuity, at least tempo-
rarily. While this may be true, granulation of the bioprosthetic
meshes may lead to a rapid loss of teDBile strength of the bio·
material. Disadvantages of these products include their high
cost, and relative impermeability to intra-abdominal fluid in
comparison to polyglactin mesh. These disadvantages would
be less important if a later AWR could be avoided, but this
has not yet been borne out in the literature. Finally, repair of
these fascllll defects with permanent mesh wa tried and aban-
doned in the earliest papers on A WR. The heavywtight poly-
propylene wa auociated with fierce adhesions, extrusions,
enterocutaneous fistulae, and occasional mortality.
While eviscerations with exposed bowel require operative
intervention, the treatment of open wounds after laparotomy
requires a more thorough history, physical examination, and
radiologic evaluation. Open wounds after laparotomy may
represent simple skin wounds, but they may also harbor fas·
cial defects with exposed viscera at their base. dues for fucial
dehiscence include loose abdominal sutures at the base of the
wound, a history of a "seroma" (a clue that intra-abdominal
fluid is emerging through the open abdominal wall), or a com-
puted tomography (Cf) scan demonstrating superlicial bowel
loops. The timing from the latest abdominal exploration is
also a critical factor in the evaluation of a potential eviscera-
tion. Open wounds with a £tidal dehiscence less than 1 week
from the lut exploration are at high risk for eviJceration and
should probably be aplored to prevent an even larger dehis-
cence leading to a surgical ernergenc;y. Wounds with fucial
dehiscence over 2 weeks from laparotomy usually have enough
intra-abdominlll adhesions to avoid an evisceration and QUI
usually be maniiBed u standard wounds. Wounds between
7 and 14 days require judgment to decide whether the explo-
ration would have a higher chance of causing a bowel injury
than it would prevent an evisceration. Patient factors such as
age, previous presence of adhesions, and wound healing issues
such as steroids play into the decision. Patients on steroids

c
may require up to 3 weeks before adhesions between bowel
loops are strong enough to avoid an evisceration.
For the patients with open wounds, unknown fascial integ-
rity, and a low chance for evisceration, informed consent is
important. Patients with open abdominal wounds after a lapa-
rotomy have a high incidence of later hernia formation. These
patients should be informed that surgical treatment of open
abdominal wounds have a risk of creating an enterocutaneous
fistula, and that with or without treatment, there is a high risk
of a ventral hernia. The patients are informed that "conser-
vative" treatment with dressing changes is also not without
risk, as the intense local inflammation may cause an open-
ing at a bowel suture line or site of a previous serosal tear.
All things considered, early wound closure inc:reases patient
Chapter 93: Abdominal Wall Reconstruction 935
FIGURE 93.1. Open abdomen after treatment for pancreatitis.
A. Evisceration was prevented with P1'FE mesh, which was sewo to
the edges of the abdominal wall with running sutures. Intra-abdominal
fluid drained easily onto the dressings, which c:an be seen overlying
the mesh. B. 'l1u:ee weeks afu:.r the definitive laparotomy, the PTFE
mesh was removed and the wound gcndy debrided. Skin grafts were
placed for early wound closure. C. The skin grafted hernia de:fed: with
laterally displaced skin and rectus muscles.
comfort, reduces the chances for bowel injury, and is the first
step in AWR. The most reliable method of wound closure is
with skin grafts (Figure 93.1B and C). The "two-dimensional"
healing of skin grafts is not dependent on the patient's nutri-
tion, unlike the "three-dimensional" healing required for
sutured skin flaps, and may proceed despite suboptimal nutri-
tion parameters.
Skin Grafting for Early Wound
Closure-Technique
At the time of surgery, the overhanging skin edges are sau-
cerized to create a flat surface for grafting. Skin bridges
are divided. If polyglactin mesh had been used to prevent
936 Pan IX: Tl'Wik and Lower h:tremity
evisceration. a viNal clue that the open abdomen is ready for
skm grafting is that individual bowd loops are no longer dis-
cemable amidst the sea of granulation tissue. A second visual
clue is that polyglactin mesh also wrinkles as bowel edema
recedes. After removal of the polyglactin mesh, the thick layer
of granulation tissue overlying the bowel is bluntly debrided
using a large periosteal elevator. As long as only the surface of
the bowel mass, and not individual bowel loops, is debrided
prior to skin grafting, the loops stay matted to the undersur·
face of the abdominal wall and to each other. The grafts are
fixed with lateral staples and central chromic sutures, and a
moist dressing applied. Moist dressing changes on the graft
itself are initiated 2 to S days after the placement of the graft.
Unlike the base of the wound, the sidewalls take skin graft
poorly. probably due to poor vascularity and significant
motion on the sides of the skin flaps. Therefore, the side walls
need not be grafted.
Fistulae
Every tube placed percutaneously into the bowel is a fistula.
The difference between the controlled fistulae seen on a gen-
eral surgery service and the fistulae in the midst of an open
abdominal wound is a lack of overlying soft tissue. When a
percutaneous tube is removed, the overlying integument con-
tracts around the tract. When a fistula occurs in the center of
a wound, there is no overlying soft tissue to help the fistula
to seal. Bowel rest, nasogastric decompression, and octreotide
help decrease the flow of succus entericus across the fistula and
aid in wound management. Frustratingly, the granulation tis-
sue surrounding the fistula prevents adherence of an ostomy
device to catt:h the fluid. The way to stop the fistula is to per·
form a bowel resection and repair, but this type of patient is
generally a poor candidate for an intra-abdominal prooedure.
The open abdominal wound, associated tissue edema, and fri-
ability are setups for difficult operations and recurrent fistula
formation. An alternative is wound closure with skin grafts to
convert the fistula into an ostomy, allowing for patient com-
fort and cleanliness, and to delay definitive surgery. Skm grafts
take well on tissue surrounding the fistula, but it is essential
to keep the surgical site free of succus for the first 24 to 48
hours after graft placement to encourage skiD. graft adherence.
Suction is applied to a rubber catheter placed into the fistula to
remove succus. Attention to detail is critical to keep this tube
functioning early after surgery. After 48 hours, moist dressings
are begun to the entire ~ area for cleanliness and to aid
epithelialization. After 14 to 21 days, the skin graft is strong
enough to withstand placement of an ostomy bag. 1hree to six
months are usually required for inflammation to subside and
the wound to soften before definitive reconstruction.s
Wound Shape and Location
In the infraumbilical area of the obese patient, some wounds
are so deep and/or contain so much fat necrosis that local
wound care will not achieve closure in a timely manner. ln
these selected patients, a panniculectomy encompassing the
necrotic tissue is helpful to change the shape of the wound.
Even if part of the wound is left open intentionally, a trans·
versely oriented wound closes much more quickly than a ver-
tically oriented wound. Prior to panniculectomy, a CT scan
may be obtained to confirm the position of the bowel to avoid
an iatrogenic injury.
RECONSTRUCTION OF
THE ABDOMINAL WALL AND
SOFT TISSUES
Much like fracture healing, healthy soft tissue coverage is
required for primary healing after laparotomy. In the ideal
case, the patient has a stable closed wound with soft pliable
tissues over the hernia sac. If not, a plan to manage the soft
tissues is just as important as the plan to repair the abdominal
wall. The timing for AWR is also important. An easy rule to
remember: if the hernia is expanding, it is ready for repair.
An expanding hernia implies that bowel adhesions and scar
attaching the bowel to the abdominal wall has significantly
softened and will be straightforward to dissect.
Midline Abdominal Wall Defects with
Stable Soft Tissues
When the skin and subcutaneous tissues are pliable, no
wounds are present, and no gastrointestinal surgery is
planned, many options exist for hernia repair. For small her-
nias less than 3 em across, a direa suture repair is often per-
formed. However, given the surprisingly high recurrence rate,'
mesh may be added to the fascial closure to achieve a direct
supported repair. Laparosc:opic; mesh repairs can be ideal for
hernias greater than 3 em by CT scan. These repairs have been
shown in the literature to have recurrence rate in the 3% to
4% range, low incidences of infeaions, short hospitalizations,
and quick recoveries.7•8 The hernias should not have a neck
greater than 6 to 8 em to facilitate the placement and maneu·
vering of trocars and to avoid eventration of the central non-
supported aspect of the mesh. Other options for treatment of
hernias with stable soft tissues include open mesh repairs and
closure with the components separation technique.
In open hernia mesh repairs, the quality of the attachment
of the mesh to the abdominal wall is paramount. When mesh
repairs fail. it is typically due to lack of a durable attachment
of the mesh to the abdominal wall. Compliance mismatches
between the mesh and the lateral aspect of the abdominal wall
stiffened over time by the presence of the hernia leads to high
stress zones and possible failure/suture pull-through. Hdpful
techniques include placing the mesh intra-abdominally and
ensuring an overlap of at least 3 em between the mesh and the
abdominal wall. Intra-abdominal mesh placement maximizes
the attachment of the mesh to the abdominal wall because the
pressure of the viscera pushes the mesh against the abdomi·
nal wall. A wide zone of contact greater than 3 em smooths
out compliance issues between the mesh and the abdominal
wall. The "Goldilocks principle" guides the number of sutures
required; enough are needed to prevent the herniation of a
bowel loop between stitA:hes, but too many can cause ischemic
necrosis of the edge of the abdominal wall, and in tum lead
to a poor mesh attachment. Components separation repairs of
midline defects have certain advantages and will be discussed
subsequently.
Types of Mesh
Mesh materials have distinctive properties and compositions
that result in different complication profiles. Permanent mesh
materials retain their properties over time and are generally
formulated from either weaves of polypropylene, polyester,
or expanded polytetrafluoroethylene (PTFE). These types
of mesh are characterized by their porosity: the greater the
porosity, the more the mesh is incorporated into the soft tis-
sues. Mesh incorporation may be associated with a lower
infection rate. Shrinkage can occur in some types of mesh
material over time, so that the mesh no longer covers the
same surface area of abdominal wall as when it was originally
placed.' PTFE meshes tend to become encapsulated rather
than integrated into tissues, and this leads to a rdatively high
shrinkage rate.10• The tendency of the mesh to form adhesions
to the viscera is another troublesome property. PTFE. tends
to form the fewest adhesions due to its smooth. nonporous
nature. Coatings on the !lll'face of permanent mesh are touted
to decrease the chance of problematic adhesions to bowel. A
general rule of thumb is that permanent meshes are incom-
patible with grossly contaminated wounds and are relatively
contraindicated in mildly contaminated fields.

The physicomechanical properties of the mesh are impor-
tant to its handling in the operating room, and the ease of
placement without wrinkles. Wrinkled mesh may be a prime
cause of extrusion (a pressure sore through the skin), adhe-
sions, and enterocutaneous fistulae (caused by a pressure sore
into the bowel).11 Commonly used heavy weight mesh is far
stronger and stiffer than the native abdominal wall; light-
weight and midweight polypropylene weaves have been devel-
oped to improve biomechanical compatibility with the soft
tissues.
Bioprosthetic meshes are novel treatments of either human
or porcine dermis that have initial strengths greater than the
abdominal wall. Therefore, they may be ideal materials for
abdominal wall repair. Comprised of the skeleton of dermis or
fibrous submucosa of bowel, the materials allow for ingrowth
of fibrous tissue and incorporation in a manner different from
permanent mesh. As the materials are replaced by the body's
own tissues over time, they may be more resistant to infec-
tion, and therefore may tolerate mildly contaminated fields.
Bioprosthetic mesh has been found to form fewer adhesions
to bowel than permanent mesh in laboratory studies.11 The
long-term durability of these materials is uncertain. There
seems to be a relationship between the rate of bioprosthetic
mesh incorporation and eventual loss of structural integrity,
i.e., the more the integration, the greater the loss of integrity
over time. Human dermis may be integrated more quickly
than porcine products, leading to eventual loss of support of
the abdominal wall. Enzymatic preparation of porcine mesh
reduces antigenicity and permits fibrous ingrowth. However,
collagen cross-linking of porcine dermis, designed to produce
a longer-lasting material, may also limit ingrowth and cause
encapsulation rather than integration of the bioprosthetic.
Widely varying recurrence rates have been reported when
biomaterials are utilized in direc:t supported repairs of the
abdominal wall.13•14
Lateral Abdominal Wall Defects with Stable
Soft Tissues
ln contrast to midline hernias that tend to be large, lateral
abdominal wall defects tend to be smaller and with good soft
tissue cover. The hernia can typically be repaired using mesh,
placed either laparoscopically or using the open technique.
CT scans often demonstrate dehiscence of the transversus
abdominis and internal oblique muscles, with continuity of
the external oblique. These true hernias can be improved with
direct supported repairs of the abdominal wall. On occasion,
for larger non-midline hernias where there has been a mild
loss of domain, a contralateral release of the opposite external
oblique (described in the following section) is performed to
give the hernia contents more room in the abdominal cavity
and to improve overall abdominal compliance.
More troublesome are the lateral bulges that are associ-
ated with some degree of denervation injury to the abdominal
musculature. These bulges occur not infrequently after flank
incisions for exposure of the spine and the retroperitoneum.
Informed consent on operative management of these lateral
bulges is aiti~ because surgery generally improves but does
not completely resoln: the bulge, and patients are generally
not satisfied with •some improvement... Exposure of the
abdominal bulge with wide elevation of skin flaps, imbrica-
tion of the abdominal musculature while flexing the operating
table to take tension off the sutures, and a large mesh overlay
generally improve the bulge by only SO%.
Midline Defects with Unstable Soft Tissues
and/or Contaminated Fields
When both skin and abdominal wall are deficient in the mid-
line, the procedure of choice is A WR using bilateral myo-
fascial rectus abdominis flaps. Referred to as "components
Chapter 93: Abdominal Wall Reconstruction 937
separation" and "separation of paru," the operation described
by Ramirez moves the laterally displaced skin and rectlls mus-
cles toward the midline. u
The surgical procedure involves radical removal of tissue
between the medial aspects of the rectus abdominis muscles.
Thin atrophic hernia skin cover, wounds, infected mesh,
draining stitch abscesses, and fistulae are removed, leaving
only unscarred tissue for the eventual closure.1' The releases
of the external oblique muscle and fascia may be performed
through bilateral transverse 6 em incisions located at the infe-
rior border of the rib cage (Figure 93.2). Alternatively, the
external oblique muscle may be visualized by elevating skin
flaps from the midline incision. Tissues over the semilunar line
are elevated by blunt dissection. The external oblique muscle
and fascia are then divided under direct vision from above the
rib cage to the level near the inguinal ligament. The inferior
aspect of the release is completed under a small tunnel that
joins the lower aspect of the midline laparotomy incision with
the lateral dissection. The external oblique is then bluntly dis-
sected off of the internal oblique, allowing the muscles to slide
relative to each other. The use of the lateral skin incisions
avoids wide skin undermining and preserves the blood supply
to the skin from rectus abdominis muscle perforators. This
approach has been shown to decrease wound healing prob-
lems that may a«ur with skin undermining. Ai.ter approxi-
mation of the fascial edges. the midline closure is similar to a
standard laparotomy incision. The significantly improved soft
tissue vascularity gives the operative team the confidence to
perform simultaneous bowel surgery without an increase in
soft tissue infectionsF
The hernia rate of an unsupported component release
repair is approximately 24% at 10 months compared with
0% at 13 months for repairs supported by soft polypropylene
mesh.11• The preservation of skin perforators decreases wound
complications, but it also prevents the placement of large
overlay meshes. However, an intra-abdominal mesh underlay
can be used to augment the midline closure and to distribute
tension away from the suture line (Figure 93.2B and C). Direct
supported repairs using components separation augments the
central strength of the repair, while simultaneously improving
the lateral abdominal wall compliance. Lateral releases also
serve to increase the intra-abdominal volume, and so reduce
the chance of an abdominal compartment syndrome from the
loss of domain found in these large hernias.19 The mesh, either
prosthetic or bioprosthetic, may be placed intra-abdominally
or immediately behind the rectus muscles (retrorectus). based
on the preference of the surgeon.
An analysis of factors that make hernias easy or difficult
to close is helpful when approaching a patient with a large
hernia. Significant weight loss since the last laparotomy. a her·
nia centered on the umbilicus, no previous use of retention
sutures, a compliant lateral abdominal wall from pregnancy,
and the absence of previous stomas all make the hernia repair
more straightforward. Conversely, an upper abdominal her·
nia, scarred rectus muscles, stomas, lateral abdominal wall
stiffness due to previous lateral incisions, and a history of
severe intra-abdominal sepsis all make the repair more diffi-
cult. Previous mesh repairs make the dissection more difficult,
but make the repair easier, because the mesh typically keeps
the rectus muscles medialized and the hernia small. By CT
scan measurement, simple releases of the external oblique have
allowed each of the rectus muscles to be moved 8 to 10 em
medially. In the majority of cases. releases of the external
oblique muscle and fascia alone will allow the recreation of
the linea alba without any bridging or spanning mesh in direct
supported components release repairs. Releases of additional
components of the abdominal wall, including the transversa·
lis fascia or the internal oblique, can be performed, but run
the risk of significant weakness along the semilunar line par-
ticularly if the rectus abdominus muscle is denervated. This
maneuver is unnecessary and should generally be avoided.
938 Pan IX: Tl'Wik and Lower h:tremity
AL-----------------~====~----~
FIGURE !13.2. (A-C) CompoDents separation. A. Technique for components separation hernia repair with law:al incisions for the .n:.lease. B. Dir«:t
supported repair with iD.tta-abdominal midM:ight polypropylene mesh. C. Four years following the repair of a midline hernia with direct sup-
pom:d compoDents separation n:chnique.
Perforator preservation and medial mobilization of the rec-
tus muscles will bring well-vascularized skin to the midline.
Healthy soft tissue coverage allows for the radical excision
of the scarred and contaminated midline hernia sac. It also
provides protection of bridging mesh when used in truly mas-
sive hernias. This situation arises when, despite components
separation, the rectus muscles do not meet in the midline and
the underlying mesh is not completely covered by the muscle
repair. With perforator preservation, the skin and subcutane-
ous tissue covering the mesh are more robust and there is a
markedly reduced risk of mesh exposure.
Obese patients with large pannuses and infraumbilical
hernias may be addressed through a panniculectomy inci-
sion.zo The panniculectomy addresses the heavy thick skin
while simultaneously exposing the fascial edges of the hernia.
Releases of the external oblique can be performed through
narrow tunnels elevated from within the surgical wound.
Increased complications, including hernia recurrence and
wound complications, have been encountered with increas-
ing body mass index, and when a "T,.-shaped incision is
employed to elevate tissues above the umbilicus.
Combined Non-Midline Abdominal Wall and
Soft Tissue Defects
Patients with missing abdominal wall and overlying soft tis-
sues due to tumor reseaion, chronic inflammation, necrotiz-
ing infection, and trauma represent true surgical challenges.
Bowel fistula can be located in the center of these defects.
Surgery planning rests on the decisions of two independent
but related questions: How best to replace the abdominal wall
and how best to replace the skin~
For repair of the soft tissues, decision making depends on
the shape, size, and location of the defea. Narrow transverse
defeas of skin can often be repaired with wide undermining,
flexion of the patient on the operating table, and closure like
an abdominoplasty. A preoperative "pinch" test will deter-
mine the suitability of this plan. Narrow vertical defects are
similarly treated, though the wide undermining required may
lead to skin necrosis of the midline. Circular defects require
more ingenuity and planning. Tissue expansion of good qual-
ity lateral tissue is one option. The largest size tissue expanders
are placed, with access incisions oriented in the direction of the
eventual movement of the tissue. Flaps based on periumbilical
perforators are useful and moved as propellers (Figure 93.3).
The location of these perforators can be seen on routine CI'
scans and confirmed by Doppler. The orientation of these
flaps should be paralld to a line drawn between the umbili-
cus and the tip of the scapula. Lower abdominal defects can
be covered with pedicled vastus lateralislanterolateral thigh
flaps. Increased reach of the flap is attained by passing the flap
deep to the rectus femoris with division of the rectus pedicle
to more generously cover the abdomen.21 This myocutaneous
thigh flap may carry more soft tissue and be of greater width
than the tensor fascia lata flap. In the upper abdomen, tissue
expansion with the expanders located on the rib cage is effec-
tive. Upper abdominal soft tissues can be covered by steal-
ing from the lower abdomen with rectus myocutaneous flaps.
Perforator flaps based on external oblique or latissimus blood
supply can cover the lateral abdominal wall. Free flaps are
solutions for the largest circular defects not coverable using
thigh- or latissimus-based flaps. If necessary, skin grafting of
granulated bioprosthetic mesh can delay the final AWR to
another day.

B
The quality of the soft tissue repair and its dependability
will dictate how the abdominal wall is reconstructed. A direct
repair of the abdominal wall is unlikely when the soft tissues
have wide defects. After components releases of the rectus
muscles, the abdominal wall wmpliance will be improved, but
the size of the defea may require bridging of the abdominal
wall. A clean surgical field with minimal contamination. no
serosal tears of the bowel. and reliable soft tissue flaps permits
the use of prosthetic mesh to bridge the defect. Conversely, the
presence of intraabdom.inal suture lines contamination, radia-
tion, or persistence of inflamed tissue are all indications for
bioprosthetic mesh. Should there be any concern for potential
exposure of the abdominal wall repair due to the unpredict-
ability of a reliable soft tissue envelope, a bioprosthetic mesh
should be strongly considered.
CONCLUSION
Abdominal wall hernias are challenging and recalcitrant prob-
lems. Without a thoughtful preoperative strategy, recurrence
and further morbidity is guaranteed. Understanding abdomi-
nal wall physiology and wound healing is essential. Whenever
possible, scarred tissues should be discarded and healthy uns-
carred tissues mobilized for repairs. Individualizing the opera-
tive plan based on the unique features, hernia, soft tissues, and
the overall health of the patient is required for success.
1. Dubay DA, Choi W, Urbancbek MG, et al. Incisional. herniation ind~~Ces
dec~ abdominal. wall compliance via oblique m:wcle atrophy and fibre>
sis. Ann Surg. 2007;245:140-146.
Chapter 93: Abdominal Wall Reconstruction 939
FIGURE 93.3. (A-C) Radiated inflamed hernia and associated
ente.rocutaneous fistula that had failed two previoUll repairs through
a midline incision. A. The star represents a periumbilical pe.rforator
from the left deep inferior epigastric: arw:y. The large abdominal wall
defect e:x:tl:Dds from near the right stoma to the level of this star. The
proposed propeller Sap is marW and will cover the c:irc:ular soft tis-
sue defec:t. B. Afu:r radic:al removal of sc:ar and small bowel reKc-
tion, the abdominal wall is repaired with a large sheet of bioprosthetic
mesh. Bioprosthetic mesh is chosen due to the history of radiation, the
presence of a bowel suture liDe, and the contaminat!ld nature of the
procedure. C. The healed wound 3 weeb after turge.ry.
2. FriWl MG. The biologr of hernia fo:nnation. Sftrg Clin N Am. 2008;88:
1-15.
3. Sukbr SM,.I>wlwlian GA, Szaerb11. SM, Telle)l MG. Ch•llenging ll.bdomi-
!W wall defects. Am J Srwg. 2001;181:115-121.
4. Abbott DE, Dwlwlian GA.,. Halverson AL Me.qeme11t of Llpuotomy
wound dehiscellce. Am Sftrg. 2007;73{12):1224-1227.
S. Dumanian GA. llull R, Lot2:e MT, Ramasastry SS. Grero R, Edington H.
Abdominal wall dehiscence with enterocutaneous fistulae: temporizing
wound Dlllllll&ement with split thickness skin grd'u. Am J Sflfg. 1!1.!16;172:
332-334.
6. Che~~g H, Rupprecl!t F, Jacbon D, Berg T, Seelig MH. Decision ~W~lytis
model of incisio!W hernia after open 11.bdominal swgery. Ht:l'llill. 2007;11(2):
12.!1-137.
7. S,Qjid MS. Boldwi SA, Mallick AS, Cheek 1!, Baig MK. Laparoscopic ver-
sus open repair of i~~eisionallventral hernia: 11. met/1.-.analytis. Am J Stwg.
200.!1;1.!17{1):64-72.
8. Shumll. A, Mehrotra M,. Khulbr R. et al Lapuosc:opic veDtrallincisional.
hernia repair: 11. single centre experience of 1,.242 patients Ol'er a period of
13 years. Hemitl.. 2011;15(2):131-13!1.
!1. Schoenmaeckers BjP, l'an der Valk SBA,. van den Hout HW, ~ymakers
JFTJ, Rik.ic S. Computed tomogr11.phic measurements of mall shrinkage
after Llparosoopic l'entral incisional. hernia repair with an expanded polytet-
rafluoroethylene mesh. Sl.fg Eru/0/IC. 200.!1;23(7):162~1623.
10. Deeken CR., Abdo MS. Frisella MM, Matthews BD. Physicomec:hanical
evaluation of polypropylene, polyester, and polytetrailuoroethylme ~
for inguinal bemia l'l!pair. JAm Co11 Slnl(. 2011;212:6'8-7.9.
11. Dumanian GA. Dimusion: adipose tissue-deri'Rd stem cells euhance hie-
prosthetic: mesh repair of nmral hernias. Pltut R«-arutr Slnl(. 2010;126:
855-857.
12. BIIZlls NK,Jaffari MV, R.ios CN', Mathur AB, Butler CB. Non-cro•liDbd
porcine ac:ellular dermal matri<:es for abdominal. wall reconstruction. Pbut
ReWMtr Stwg. 2010;125{1):16'7-176.
13. £,pinosa -<le-los-Monteros A, de Ia Torre JI, Marrero I, Andrades P, Davis
MR., Vasconez LO. Utilization of human cadaveric: ac:elllllar dermis for
abdominal. hemia reconstruction. Ann Pltut Stwg. 2007;.58:26'4-267.
14. Ko JH. Salny DM,. Paul BC, Wang EC. Dumanian GA. Soft polypropyl-
me mesh, but not cadaveric: dermis, significantly improfts the outcome of
midline hemia repairs using the components separation technique. Pltut
ReWMtr Stwg. 2009;124:836'-847.
940 Part IX: Trunk and Lower Extremity
15. Ramirez OM, Ruas E, Dellon AL. ~Components separation" method for
closure of abdominal wall defects: an anatomic and clinical study. PltUt
Reromtr Surg. 1990;86:519.
16. Szczerba SR, Sukkar SM, Dwnanian GA. Definitive surgical treatment of
infected or exposed mesh. Ann StMrg. 2003;237:437-441.
17. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preser-
vation significantly reduces superficial wound complications in "separation
of pans• hernia repairs. Pwt ~t:onstr S~Mrg. 2002;109:2275-2280.
18. Ko JH, Wang EC, Salvay DM, Paul BC, Dumanian GA. Abdominal wall
reconstruction: lessons learned from 200 ~components separation" proce-
dures. Art:h StMrg. 2009;144(11):1047-1055.
19. Agnew SP, Small W Jr, Smith LJ, Hada I, Wang E, Dumanian GA.
Prospective measurements of intra-abdominal volume and pulmonary func-
tion after repair of massive ventral hernias with the components separation
technique. Ann StMrg. 201 0;251:981-988.
20. Reid RR, Dumanian GA. Panniculectomy and the separation of parts hernia
repair: a solution for the large infraumbilical hernia in the obese patient.
Pwt Reronm SMrg. 2005;116:1006-1012.
21. Spyriounis PK. The extended approach to the vascular pedicle of the antero-
lateral thigh perforator flap. Pwt Recomtr StMrg. 2006;117:997-1 001.
CHAPTER 94 • LOWER EXTREMITY
RECONSTRUCTION
ARMEN K. KASABIAN AND NOLAN S. KARP
The lower extremity has a mechanical component and must
bear weight. These functional requirements make an effecive
reconstruction difficult. The mechanism of lower extremity
defects includes trauma, diabetes and vascular disease, cancer
ablation, and other disease processes. Reconstruction of the
lower extremity requires the knowledge of all plastic surgi-
cal tools, such as skin grafting. local flaps, perforator flaps,
muscle flaps, microvascular free flaps, and arterial, nerve, and
bone repair.
LOWER EXTREMITY TRAUMA
Treatment of high-energy lower extremity trauma with soft-
tissue and bone injuries remains a formidable problem. These
injuries often occur in the multiply injured trauma patient.
making management even more difficult. Initial motor vehicle
air bag designs reduced mortality and the incidence of facial
fractures, but did not offer adequate protection of the lower
extremities. Newer designs with multiple airbags now protect
the lower extremities. Pedestrian motor vehicle accidents, falls
from heights, and sporting injuries result in open tibial frac-
tures that require the management of complex bone and soft-
tissue injuries and may be associated with vascular and nerve
injuries.
The management of lower extremity trauma has evolved to
the point that many extremities, except for severely mangled
extremities, are now routinely salvaged. Treatment requires a
team approach consisting of orthopedic, vascular, and plastic
surgeons. Fracture management utilizes techniques of exter-
nal fixation, intermedullary rodding, and internal plating.
Bone grafting now includes vascularized bone grafts, llizarov
bone lengthening, artificial bone matrix and bone growth fac-
tors, and nonvascularized bone grafts. Soft-tissue manage-
ment includes microvascular free tissue transkrs, local muscle
flaps, fasciocutaneous and perforator flaps, and skin grafts.
Tedmiques of vascular and nerve repair have been further
refined.
The goal in the tteatment of open tibial fractures and lower
exttemity salvage is to preserve a limb that will be more func-
tional than if it were amputated. If the exttemity c:annot be
salvaged, the goal is to maintain the maximum func:tional
length. The management of these injuries is a topic of debate
in the literature. A severely mangled extremity may require
multiple operative procedures and it may be months to years
before it can be used for weight bearing and the patient can
return to employment.
In a review of 72 patients with Gustilo grade lliB open tib-
ial fractures, Francel et al. found that despite a 93% successful
limb salvage rate, a majority of patients had problems with
ankle motion or leg edema. Only 28% returned to work after
42 months of mean follow-up compared with 68% of patients
who had a below-knee amputation.1 Similarly, Georgiadis et
al. compared 27 patients who had attempted limb salvage
with 18 patients who had primary below-knee amputation.
They found that patients who had limb salvage took longer
to achieve full weight bearing, were less willing to return to
work, and had higher hospital charges than those who had
primary amputation.2
Other reviews have shown more successful outcomes with
extremity salvage. Laughlin et al. reviewed the functional
outcome in eight patients with grade DIB and six with grade
me injuries. He found that despite a long recovery period,
eight of nine patients returned to work.3 In a series of 128
patients tteated at Bellevue Hospital for open tibial fractures,
66 were available for follow-up for at least 5 years. More than
60% of the patients returned to work after extremity salvage.
For some patients, the delay in returning to work was as long
as 10 years after the original injury. A significant cause for the
delay to return to work was social factors, such as pending
litigation. No patients required further reconstruction more
than S years after their microvascular free tissue ttansfer. All
but three patients were satisfied with their reconstructions and
would do it again if they had the chance. Of the three who
were dissatisfied, none were willing to convert the reconstruc-
tion to an amputation.4 In a series of 42 patients, Rodriguez
et al found that of 42 patients who had lower exttemity sal-
vage with free flaps, 93% of the patients would go through
the limb salvage process again to avoid amputation.s
These results appear to be favorable compared with aver-
age return to work rates of 66% for patients after lower limb
amputation, with only 22% to 67% of these returning to the
same occupation and the remainder changing their occupa-
tion as reported in the literature in a review by Burger et al.6
Although McKenzie et al. found that outcomes based on the
Sickness Impact Profile (SIP) was equivalent at 2 and 7 years
for amputees versus salvage patients/•' 20% of patients with
lower extremity fractures, not extremity salvage procedures,
were not working at 30 months post injury despite low SIP
scores/ lhis indicates that return to work rates and SIP scores
are not accurate in determining the value of lower exttemity
salvage. Objecti.ve functional studies need to be done to com-
pare outcomes.
Extremity salvage is a long, complicated process. Patients
must be made aware of the expected course and the antici-
pated functional outcome. Patient selecti.on is an important
variable in evaluating the final outcome. Although normal
function is rarely achieved, most patients are grateful for their
salvaged limb.
History
Amputation was practiced early in the history of man. One of
the earliest writings is that of Hippocrates (460-370 Be), who
described amputation as the method of last resort when faced
with ischemic gangrene.
Ambroise Pare (1509-1590) described the basic rules of
amputation still followed today. He recommended amputa-
tion through viable tissue and closure of amputation stumps
to fit prostheses. He went on to describe phantom pain and
stump revision.
The concept of immobilization was inttoduced by Oilier
(1825-1900), who introduced the plaster cast. During the
U.S. Civil War, the mortality of lower extremity injuries was
50%, secondary to sepsis. The advent of antiseptics and anti-
biotics deaeased this mortality rate through World War I.
The "closed plaster technique" for open tibial fractures
was introduced by On. It was further advanced during the
Spanish Civil War by Trueta, who performed surgical debride-
ment prior to placement in plaster.
During World War U, no new techniques were developed.
However, improvement in aseptic technique and antibiotics
941
942 Part IX: Trunk and Lower Extremity
decreased the mortality of wound complications from 8%
in World War I to 4.5% in World War II. Nonetheless, the
increased destructive capacity of military equipment in World
War II resulted in a 5.3% amputation rate compared with 2%
in World War I. The incidence of postfracture osteomyelitis
decreased from 80% in World War I to 25% in World War II.
The next major advance in lower extremity salvage came
during the Korean conflict. Lower extremity injuries during
this war involved injuries to the major arteries in 59% of the
cases. The concept of artery repair as opposed to artery liga-
tion was introduced. This practice decreased the amputation
rate from 62% at the beginning of the war to 13% at the end
of the war, with wound mortality dropping to 2.5%.
In the late 1960s, plastic surgeons discovered the trans-
fer of regional flaps to cover soft-tissue defects of the lower
extremity. With the advent of microsurgery in the 1970s,
improved techniques of bone coverage with soft tissue and
of nerve repair further advanced the ability to salvage trau-
matic lower extremity injuries. Rates of osteomyelitis have
been decreased by up to 95% in most series. The free fibular
flap also solved the problem of bone gaps in these devastating
injuries. The concept of bone lengthening was discovered by
Codivilla much earlier and advanced by Uizarov. It was popu-
larized in the Western world only in the 1980s. This concept
provided additional techniques to solve both bone and soft-
tissue deficiencies.
The concept of negative pressure dressings was introduced
in the 1990s by Argenta et aJ.1° It was found that negative
pressure on a wound would decrease edema, decrease bacte-
rial count, promote contraction of the wound, and, with the
help of a sponge dressing, promote granulation.
Perforator flaps have become more effective in covering
many defects of the lower extremity which once required
microvascular free flaps. Many wounds that were difficult
to manage now were easier to manage and enabled sim-
pler reconstructions. Management of many lower extremity
wounds requires careful evaluation to use the simplest and
most effective methods.
Anatomy
The leg has several characteristics that make it unique.
Humans are bipedal, thus full weight bearing in the erect
position is on the two lower extremities. The full force of
the weight of the body is transmitted through the legs. The
muscles of the leg provide ankle function with plantarflexion,
dorsiflexion, eversion, and inversion. Additional leg muscle
functions include toe flexion, knee extension, and knee flex-
ion. If the ankle were fused, the functional needs of the leg
muscles are greatly unnecessary. Therefore, significant muscle
loss of the leg can be tolerated with maintenance of bipedal
ambulation. Consequently, muscle loss of the leg is not a con-
traindication to reconstruction and salvage.
The hydrostatic pressures imposed on the leg increase the
incidence of edema, deep venous thrombosis, and venous sta-
sis problems. These problems are rare in the upper extrem-
ity, but common in the lower extremity. The lower extremity
is also much more commonly afflicted with atherosclerosis
than the upper extremity. Therefore, both venous and arterial
problems are more common in the lower extremity and must
be considered when developing a reconstructive plan.
The anteromedial portion of the tibia is covered by the skin
and subcutaneous fat only. This relatively unprotected anat-
omy leads to many instances of bone exposure, which require
specialized soft-tissue coverage.
Because the full force of the body is transmitted to the feet,
sensibility on the plantar aspect of the foot is necessary for
normal ambulation. Normal sensibility is required for tactile
sensation, position sensation, and protection of the vulner-
able pressure-bearing portion of the body. Loss of the tibial
nerve, with loss of sensibility on the plantar aspect of the foot,
is a relative contraindication for lower extremity salvage.
However, many patients with peripheral neuropathy are able
to ambulate. They must remain cognizant of the potential
problems; motivated patients can reasonably enjoy normal
ambulation without soft-tissue breakdown. Thus, in selected
patients, loss of sensation of the plantar aspect of the foot
may not be an absolute contraindication for lower extremity
salvage.
Bones
The bones of the leg are the tibia and the fibula. The tibia pro-
vides 85% of the weight-bearing capacity of the leg, whereas
the fibula serves as a structure for muscle and fascial attach-
ments and as a significant structural portion of the ankle joint.
The tibia is the second longest bone in the body. It articu-
lates with the femur at the knee joint on two condyles and
joins the fibula to articulate with the talus to form the ankle
joint. It articulates with the fibula proximally at the tibiofibu-
lar joint and distally at the tibiofibular syndesmosis. The tibia
is connected to the fibula in its midportion with the interosse-
ous membrane. It is a classic long bone with a diaphyseal shaft
with a thick cortical bone surrounding a marrow cavity. The
tibia is wide proximally where it articulates with the femur
and narrows to the shaft. The diaphyseal portion is usually
described as three surfaces: medial, lateral, and posterior. The
medial border is subcutaneous, and thus most prone to expo-
sure during injury. The lateral surface is one of the origins of
the tibialis anterior muscle and is protected by the anterior
compartment muscles. The posterior surface is well protected
by the soleus and gastrocnemius muscles.
The fibula is the smaller bone of the leg. It originates
slightly posterior and distal to the tibia and it articulates with
the posterolateral tibia. The shaft of the fibula serves as the
origin of many of the muscles of the leg. Distally, it articu-
lates with the talus and forms the lateral malleolus. Because
the fibula is not weight bearing and is in a relatively protected
position, it is of less concern in trauma, except when the lat-
eral malleolus is involved. Only the proximal and distal por-
tions of the fibula are required, and because of an independent
blood supply from the peroneal artery, the central portion of
fibula is an excellent source of vascularized long bone and can
be sacrificed readily.
Compartments
The anatomy of the leg is best understood by dividing it into
its four muscle compartments: anterior, lateral, posterior, and
deep posterior. The deep fascia of the leg forms discrete areas
or compartments (Table 94.1 and Figure 94.1).
The anterior compartment is comprised of four muscles:
the tibialis anterior, the extensor hallucis longus, the extensor
digitorum longus, and the peroneus tertius. All four muscles
dorsiflex the foot, but the primary dorsiflexor is the tibialis
anterior, which also inverts the foot. The extensor hallucis lon-
gus primarily extends the great toe; further contraction causes
foot dorsiflexion. The extensor digitorum longus extends the
phalanges of the lateral four toes and dorsiflexes the foot. The
peroneus tertius dorsiflexes and everts the foot. All four mus-
cles are innervated by the deep peroneal nerve, and their blood
supply is from muscular branches of the anterior tibial artery.
The lateral compartment is comprised of the peroneus lon-
gus and peroneus brevis muscles. Both muscles plantarflex
and evert the foot. They are both innervated by the peroneal
nerve. The vascular supply of the peroneus longus is the mus-
cular branches of the anterior tibial and peroneal arteries. The
vascular supply of the peroneus brevis is muscular branches
from the peroneal artery.
The superficial posterior compartment is comprised of the
gastrocnemius, soleus, plantaris, and popliteus muscles. They
are all innervated by the tibial nerve. The gastrocnemius mus-
cle plantarflexes the foot and flexes the knee. Its blood supply
 Chapter 94: Lower Extremity RecoDBtruc:tion 943

COMPARTMENTS OF THE LEG

• .COMPARTMENT • MUSCLB FUNCTION
Anterior tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Lateral peroneus longus
Peroneus brevis
Superficial posterior
Gastrocnemius
Soleus
Plantaris
Popliteus
Deep posterior
Flexor hallucis longus
Flexor digitorum profundus
Tibialis posterior
• NERVB
Dorsiflex foot, invert foot Deep peroneal nerve
Extend great toe, dorsiflex foot Deep peroneal nerve
Extend toes 11-V, dorsiflex foot Deep peroneal nerve
Dorsiflex foot, evert foot Deep peroneal nerve
Plantarfl.ex and evert foot Superficial peroneal nerve
Plantarflex and evert foot Superficial peroneal nerve
Plantarfl.ex foot, flex knee Tibial nerve
Plantarflex foot Tibial nerve
Plantarflex foot Tibial nerve
Flex knee, rotate tibia Tibial nerve
Flex great toe, flex foot Tibial nerve
Flex toes 11-V, flex foot Tibial nerve
Plantarfl.ex, invert foot Tibial nerve
• ARTBRY
Anterior tibial artery
Anterior tibial artery
Anterior tibial artery
Anterior tibial artery
Anterior tibial and peroneal
artery
Peroneal artery
Popliteal artery, sural branches
Posterior tibial, peroneal, sural
Sural
Popliteal, genicular branches
Peroneal artery
Posterior tibial artery
Peroneal artery

is from sural branches of the popliteal artery. The soleus
muscle plantarflexes the foot and is supplied by the muscular
branches of the posterior tibial, peroneal, and sural branches
of the popliteal artery. The plantaris muscle plantarflexes the
foot and is supplied by the sural branches of the popliteal. The
pDpliteus flexes the knee and rota~ the tibia and is supplied
by genicular branches of the poplitul.
The deep posterior compartment is comprised of the flexor
hallucis longus, flexor digitorum longus, and tibialis posterior
muscles. They are all innervated by the tibial nerve. The flexor
hallucis longus flexes the great toe and aids in plantarflexion
of the foot. It is !Npplied by muscular branches of the peroneal
artery. The flexor digitorum longus flexes the phalanges of
the lateral four toes and aids in plantarflexion of the foot. It
is supplied by the branches of the posterior tibial artery. The
tibialis posterior plantarflexes and inverts the foot. It is sup-
plied by muscular branches from the peroneal artery.
Compartment Syndrome
Compartment syndrome is an increase in interstitial fluid
pressure within an osseofasc:ial compartment of sufficient
FIBULA
TIBIA
ANTERIOR
Tibialis Mterior
Extensor hallucis longws
DEEP POSTE RIOIR Extensor digilorum longus
Peroneus tenias
Flexor halluc is longus
LATERAL
Flexor dig itorum profundu
nbialis posterior Peroneus longus
Peroneus brevis
POSTERIOR
Gastrocnemius
Soleus
Plantaris
Popliteus
FIGURE 94.1. Cross-sectional anatomy of the leg. Note the paucity
of soft tissue over the anteromedial. tibia.
magnitude to cause a compromise of the mic:rociradation,
leading to myoneural nea:osis. Any crush injury to a closed
compartment may lead to compartment syndrome. The litera-
ture indica~ an incidence of compartment syndrome of 6%
to 9% in open tibial fractures. It is important to realize that
a laceration with an open fracture may not provide adequate
decompression to prevent compartment syndrome.
The cardinal signs of compartment syndrome are pain dis-
proportionate to the injury, pain on passive flexion or exten-
sion, and palpably swollen or tense compartments. Loss of
pulses is a late sign and the presence of pulses does not rule
out compartment syndrome. The definitive diagnosis is made
by measuring the compartment pressure.
Various methods have been used to measure the inter-
compartmental pressure, including slit catheters and saline
injection techniques. Although commercially produced units
are available, an 18G needle flushed with saline and con-
nected to a transducer is usually adequate. The threshold
for fasciotomy is controversial. Some surgeons consider a
pressure >30 mm Hg in any compartment as an indication
for fasciotomy. Allen et al. considered fasciotomy when the
compartment pressure was >40 mm Hg for 6 hours or was
>50 mm Hg for any length of time.u Four-compartment
fasciotomy should be performed when there is any index of
suspicion of compartment syndrome, as the morbidity of a
fasciotomy is far less than the morbidity of ischemic necrosis
of the lower extremity secondary to an untreated compart-
ment syndrome.
Fracture Classification
Classification of open tibial fractures in relation to fracture
pattern and soft-tissue injury is useful in describing injuries
and prognosis. The most commonly quoted classification for
open fractures is that of Gustilo (Table 94.2).
A grade rnA injury is an open fracture with soft-tissue
damage. Be<:ause it is classified as having adequate soft-tissue
coverage of the fracture, it rarely requires complex plastic sur-
gical procedures. These injuries are usually treated with local
wound care, debridements, skin grafts, or simple local flaps.
A grade lliB injury involves an open fracture with periosteal
stripping and bone exposure. A grade me injury is an open
944 Pan IX: Truuk and Lower Extremity

GUSTILO CLASSIFICATION OF OPEN FRACTURES

OF THE TIBIA

• TYPE • DBSCRIPTION
Open fracture with a wound <1 an
D Open fracture with a wound >1 an without
extensive soft-tissue damage
m Open fracture with extensive soft-tissue damage
rnA m with adequate soft-tissue coverage
DIB m with soft-tissue loss with periosteal stripping
and bone exposure
DIB m with arterial injury requiring repair

fracture associated with an arterial injury requiring repair.

Although this is the most commonly quotl!d classification. it
remains woefully inadequate to describe the injury or to eval-
uate the prognosis of an open tibial fracture for which the
plastic surgeon is involved. An open tibial .fractllre with 3 em
of periosteal stripping and exposed bone (Figure 94.2A) is not
the same as an open tibial fracture with an 8-cm bone gap,
12 em of exposed bone, and neaosis of 16 em in all four-<:am-
partment muscles (Figure 94.2B), though they would be both
classified as grade DIB injuries. Similarly, the phrase "arterial
injury requiring repair" in the classification of a grade me
injury is ambiguous. Some surgeons may believe it is necessary
to repair a second vessel in a one-vessel leg. whereas others
believe that a single vessel is an adequate blood supply to the
foDt. In the first case, the injury would be classified as grade
me; in the secDnd case, as grade DIB. The classification does
not tale nerve injury into consideration, which is crucial in the
assessment of prognosis.
In an attempt at a better classification, the Mangled
Extremity Syndrome Index, Mangled Extremity Severity
ScDre, Predictive Salvage Index, and Limb Salvage Index were
creatx:d. Even these indices have proved imperfect in predict-
ing outcome.12 A more precise classification system awaits
develDpment to predict the outcome of salvage efforts for
mangled extremities.
MANAGEMENT OF Tim
MANGLED EXTREMITY
Management of the mangled extremity requires the combined
expertise Df the trauma, vascular, and plastic surgeons. For
the management of the mangled extremity, we use the proto-
col presentx:d in Figure 94.3 at Bellevue Hospital.
Initial Evaluation
High-energy lDwer extremity injuries are usually associated
with other life-threatening injuries. The priority in multisys-
tem injuries is to salvage the li.fi:: of the patient, not necessarily
to salvage or treat the limb. The advanced trauma and life
support guidelines are followed prior to fracture management.
The priDrities are the ABes: airway, breathing, and circula-
tion. If the patient has other life-threatening injuries, treatment
of the extremity injury should be limited to stabilization of the
extremity and control of bleeding. Amputation of a mangled
extremity in a clinically unstable patient may be more prudent
than an extensive reconstructive course and should be consid-
ered in the initial evaluation of the patient.
Once the patient's other injuries have been addressed, an
assessment is made to determine if the extremity is salvage-
able. Limb viability is assessed by examining the wound and
then assessing vascular, bone, soft-tissue, and nerve injuries.
FIGURE J-4.2. Grade lllB fracture~ vary ttemendously in severity.
A. Grade DIB open tibial fracture with periosa:al. stripping and soft-
tissue defect. B. Grade !DB open tibial frac::tul'e with e:xt:eDaive bone
and soft-tissue lose.
Vascular examination includes evaluation of the pulses,
color, temperature, and turgor of the foot. One must realize that
an ischemic limb does not necessarily indicate a vascular injury.
The vessels may be in spasm or may be kinked secondary to
the injury. Pulses may return after fracture reduction. Doppler
examination of the vessels may help to evaluate patency when
pulses are not palpable. Angiograms are usually performed if the
extremity remains ischemic or requires a free-flap .reconstJ:Uction.
Bony evaluation is made by visual examination of the open
wound. Radiographs are mandatory for evaluation of the
.fractllre. More thorough evaluation of the fracture .fragments
and accurate assessment of bone loss. fragment vascularity,
and periosteal stripping of the bone require assessment in the
operating room.
Soft-tissue evaluation includes examination of the skin
subCiltaneous tissue, muscle. and periosteum. Avulsed and
crushed soft tissues can be assessed in the emergency room,
but soft-tissue and muscle viability usually cannot be evalu-
ated except in the operating room during the debridement. In
complicated cases, even experienced surgeons have difficulty
assessing soft-tissue viability. Serial debridements may be nec-
essary to make that determination.
Neurologic evaluation includes motor and sensory evalua-
tion of the peroneal and tibial nerves. Significant nerve injury
is a relative contraindication for extremity salvage, as nerve
repair in the lower extremity has poor functional results, and a
below-knee amputation may be preferable to an insensate foot.
The initial assessment determines if the limb is salvageable,
if the extremity revascularization is necessary, if a .free flap will
likely be required, if there is bone loss. and if there is nerve
injury and if so, if it precludes a functional limb. If the extrem-
ity is unsalvageable, an amputation is indicated. If the extrem-
ity is salvageable, the reconstructive protocol is followed.

Unsalvageable
Quick
Angio
Access
Reconstructive Plan
Alter the patient is stabilized and the decision for limb sal-
vage has been made, the first issue to address is whether or
not there is a vascular injury. If so, a decision is made as to
whether an angiogram should be obtained in the angio suite or
in the operating room. If there is quick access to a high-quality
angiogram.. that is prekrable. If there may be a several-hour
wait for the angio suite, the patient is taken to the operating
room and an on-table angiogram is obtained.
In general, the skeleton is stabilized first. If the extrem-
ity requires revascularization. the stabilization is performed
quickly or temporary vascular shunts are placed until stabi-
lization is achieved. Once the bone is stabilized, the vascular
injury is repaired if indicated. Significant ischemia may result
from spasm, which can be corrected by fracture reduction. If
the foot is viable, there may be adequate collateral circula-
tion. or a single intact vessel to the foot may be adequate for
extremity viability. If revascularizati.on is performed, fasciot-
omy to prevent compartment syndrome is always nec:essary.
Once bony stability and vascular integrity are established,
all nonviable tissue is debrided. If blood vessels are exposed
and an adequate debridement has been performed, immediate
Chapter 94: Lower Extremity Reconstruction 945
Ampuuuion l
FIGURE ~.3. Algorithm for the treatment of lower
e:x:trcmity trauma.
soft-tissue coverage is indicated with a microvascular soft-
tissue transfer. If there are no vital structures exposed and/or
the zone of injury is not dear, the patient is brought back for
a second, or even a third, debridement before definitive soft-
tissue coverage is achieved. Most authors agru that early soft-
tissue coverage is associated with a lower complication rate.
Byrd et al. found that the overall complication rate of wounds
closed within the first week of injury was 18% compared with
a SO% complication rate for wounds closed in the subacute
phase of 1 to 6 weeks.13 In a review of Godina's work, closure
of wounds within the first 72 hours after injury was associ-
ated with the lowest complication rate and highest success
rate (Table 94.3),14 Yaremchuk. et al. believe that serial, com-
plete debridement is more important than the absolute timing
of soft-tissue coverage. u Platelet counts ina-ease nearly four-
fold in the subac:ute phase after injury, which may play a role
in the increased compliution rate seen during this period.1'
Recent reviews have had conflicting results. Although Steirt
et al found that the free flap coverage of open fractures could
be delayed by initial treatment with vacuum-assisted closure
(VAC) therapy without significantly increased complication
rates,17 Hou et al. found that the VAC therapy decreased
flap size requirements but use beyond 7 days showed higher
946 Pan IX: Truuk and Lower Extremity
HOW TIMING OF FREE FLAP COVERAGE AFFECTS OUTCOME IN THE TREATMENT OF OPEN FRACTURES, FROM GODINA
• TIMING • FAU.URB RATB • INFBCTION RATB
<72h 1% 2%
72 h to 3 wk 12% 18%
>3wk 10% 6%
infection and amputation risks.11 The surgeon is best guided
by the principle that early complete debridement and early
soft-tissue coverage improve the results of extremity salvage.
Special Problems
Soft-Tissue Avulsion. Soft-tissue avulsion is a unique con-
dition. Massive areas of skin and subcutaneous fat may be
avulsed that initially appear viable, and it is tempting to suture
the avulsed tissue back in place. This avulsed tissue is always
injured much more extensively than initially appreciated and
progressive thrombosis of the subdermal plexus ensues, fol-
lowed by neaosis of nearly the entire flap of soft tissue. lt is
more prudent to remove the entire avulsed soft tissue, remove
the skin as a skin graft. and reapply it to the soft-tissue defect.
lt always seems radical at the time, but nothing is more waste-
ful than necrosis of the entire flap with its skin, requiring addi-
tional donor defects for later skin grafting.
Vascular Injuries. Injury to the popliteal vessels or vessels
more proximal requires immediate repair or reconstruction.
Posterior dislocations of the knee are prone to disruption
of the popliteal vessels and represent a vascular emergency.
The best treatment for more distal injuries is somewhat more
controversial. Certainly, if all three vessels distal to the tri-
furcation are injured, reconstruction of at least one vessel is
indicated. lf one vessel is injured, then ligation of that vessel
may be more prudent than the atrempted repair. If two ves-
sels are injured, it is usually preferable to repair at least one
vessel. There are, however, no studies that demonstrate any
difference in outcome whether or not a second vessel is recon-
structed. Sound surgical judgment is necessary to determine
whether the extremity will benefit from a second distal vessel
and whether the morbidity of the additional surgery to recon-
struct the second vessel is warranted.
Vascular injury is initially assessed with physical examina-
tion of palpable pulses, color, capillary refill, and turgor of
the extremity. Doppler examination is added for equivocal
physical examinations. An angiogram is indicated for mas-
sive injuries, an ischemic injury that will probably require
reconstruction, or an injury that may require microvascular
reconstruction. In the ischemic extremity, angiography must
be done emergendy, with reconstruction to follow. Often, if a
vascular bypass is required to revascularize the extremity, an
immediate microvascular free flap may be required to cover
the bypass graft. further complicating the emergent treatment
of the wound. lf the extremity is not ischemic, angiography
may be delayed after initial treatment of fracture fixation and
wound debridement followed by delayed soft-tissue coverage.
If pulses are palpable, recent studies show that preoperative
angiography may not be necessary prior to microvascular free
tissue transfer.
Nerve Injury. Injuries to the lower extremity often have
associated nerve injuries. Although microvascular m:hniques
allow for nerve repair and nerve grafting, the results of nerve
reconstruction in the lower extremity are poor. These poor
results are in part a result of the long distance from the spi-
nal cord to the motor endplates, the complex distribution of
nerve fascicles, and the long distance required for the nerve to
• BONE HBALING TIME • HOSPITAL TIME
68mo 27d
123mo 130d
2.9mo 256d
grow to the motor endplate, resulting in end-organ atrophy.
Recent experience with nerve grafting shows some promising
results in selected patients. Trumble found an average return
of strength of 11% and protective sensation in all of nine
patients treated with nerve grafts for repair of the peroneal
and sciatic nerves." However, most of these patients were in
the pediatric age group.
Disruption of the peroneal nerve results in foot drop and
loss of sensation on the dorsum of the foot. Although not crip-
pling, lifelong foot splinting or tendon transfers are required
to offset the foot drop. The loss of sensation of the dorsum
of the foot does not cause much morbidity. The loss of the
tibial nerve is more devastating. lt results in the loss of plan-
tarflexion of the foot, a .function that facilitates the step off
in ambulation. The most devastating loss is that of sensibil-
ity of the plantar aspect of the foot; which results in the loss
of some position sense and in chronic injury and wounding
of the plantar aspect of the foot. Atrophy and vasomotor
changes complicate the injury and often result in amputation.
Although not an absolute indication for amputation, it is cer-
tainly a relative contraindication and is not much different
from the foot of the patient with diabetic neuropathy.
Nerve injuries to the lower extremity should be repaired at
the time of injury, if primary repair can be achieved. If nerve
grafts are necessary to bridge nerve gaps, they are perhaps
best delayed until a healthy soft-tissue bed is established. The
prognosis of nerve repair is guarded at best, and most patients
require tendon transfers or lifetime splinting.
FRACTURE MANAGEMENT
Before vascular or nerve repair can be performed or adequate
debridement attempted, a stable framework must be con-
structed. lt is the basis for early fracture management. If a
vascular anastomosis is performed prior to fracture fixation,
the maneuvering during fracture reduction may disrupt the
anastomosis, or the interposition grafts may be found to be
too short or redundant after fracture reduction. Consequendy.
our protocol is to perform fracture .fixation first.
The techniques available for fracture fixation include trac-
tion, casting/splinting, intramedullary nailing, internal fixa-
tion, and external fixation.
Traction .fixation is rarely used, when the patient is too
sick to undergo fracture stabilization. lt necessitates immobi-
lization of the entire patient and does not rigidly fix the frag-
ments. Traction is employed more commonly in the upper leg;
however, it may be used in the lower leg as a temporary mea-
sure for the unstable patient until the patient's medical condi-
tion allows more stable fixation.
Cast immobilization is appropriate for closed leg injuries or
for open tibial fractures once the wound is stable, but it pro-
vides poor fracture immobilization and difficulty with wound
care if there is an active wound. Although the uclosed plaster
technique" was introduced by Orr and popularized by Trueta,
newer techniques are currendy available. Occasionally. an
open plaster technique is used. A window is cut in the cast to
allow for dressing changes and wound debridement. This open
cast technique can be used until wound control is achieved
and definitive wound management is approached.

Intramedullary nailing with reamed or nonreamed nails has
many advantages in fracture fixation. Reamed nails provide
rigid fixation by providing a tight fit in the medullary canal
with proximal and distal fixation. Rt:amed nails allow early
ambulation. Intramedullary nails, however, can only be used
for minimally comminuted fractures without significant bone
loss. The disadvantage of this technique is the obliteration of
the entire endosteal blood supply by stripping out the med-
ullary canal. In bone that already has a compromised blood
supply, devascularization of the injured bone may re!iult; thus,
the technique is not indicated for the massively traumatized
lower extremity.
Nonreamed nails do not take up the entire intramedullary
canal and do not require complete stripping of the endosteal
blood supply. They share the advantage of relatively stable
fixation and allow early mobilization. They also require rela-
tively stable fracture patterns. When used for Gustilo grade
DIB or me injuries, immediate coverage of the exposed bone
and hardware is required. Exposure of the hardware runs
the risk of a progressive, rapid infection up the intramedul-
lary canal. Consequently, serial debridements and delayed
soft-tissue coverage are contraindicated with this technique.
Although it is generally agreed that nonreamed locked nails
are effective in open grades I, II, and niA tibial fractures,
their use in grade mB fractures is less clear. Trabulsf0 and
Tornetta21 showed that nonreamed locked nails combined
with early soft-tissue coverage and early bone grafting were
more effective than external fixation.
Internal fixation of diaphyseal tibial long bone injuries with
plates and screws provides relatively rigid fixation. Application
of the fixation devices, however, requires extensive soft-tissue
and periosteal stripping and introduces a significant amount
of foreign body into the wound. Compromised tissue may be
further devasculari.zed. The plates and screws must be covered
immediately with soft tissue using local or free flaps. Again,
serial debridement and delayed .flap coverage are not indicated
once the hardware has been introduced.
External fixation is the fixation of choice in the most
severely traumatized lower extremities with massive soft-tis-
sue and bone injury. External fixation allows rigid fixation
without additional soft-tissue trauma and bone devasculariza-
tion and allows access to the wound for additional debride-
ment. External fixators may obstruct microvascular surgery
however. Such problems can be limited with proper planning
of pin and rod placement. In addition to the disadvantage of
bulkiness, another potential complication is pin tract infec-
tions. External fixators can be used with the Ilizarov technique
for bone lengthening in situations of bone gaps, or they may
be left in place after cancellous or vascularized bone grafting
until additional stability of the fracture is obtained. Because
of the wide zone of injury in grade BIB and me injuries and
contamination at the fracture site, external fix.ation is usually
the fiDtion of choice.
Management of Bone Gaps
For managing bone gaps, three techniques are available: non-
vascularized cancellous bone grafts, Dizarov bone lengthen-
ing, and vascularized bone grafts. The timing of bone grafting
remains controversial. At the time of soft-tissue coverage,
bone gaps may be filled with antibiotic beads or cancellous
bone grafts. Early bone grafting relies on adequate debride-
ment and soft-tissue coverage with adequate vascularity to
support the bone grafting. Many surgeons prefer to get wound
control prior to bone grafting, avoiding the risk of losing valu-
able bone stock. We prekr to postpone bone grafting until6 to
12 weeks after soft-tissue wound coverage has been achieved.
Nonvascularized cancellous bone grafts are best used for
nonunions or small bone gaps of less than a few centimeters.
In well-vascularized beds, union rates >90% can be achieved
with nonvascularized bone grafts in these limited situations.
Chapter 94: Lower Extremity Reconstruction 947
With larger bone gaps, the success of nonvascular-
ized bone grafts decreases, and vascularized bone grafb or
Uizarov bone lengthening is required. The Dizarov technique
uses the concept of distraction osteogenesis to fill bone gaps
(see Chapter 24). The Dizarov technique can theoretically
bridge gaps of large dimensions, but for practical purposes,
it is best used for gaps of 4 to 8 em. Two strategies are pos-
sible. The gap can be obliterated with bone graft and then
lengthened subsequently, or the bone gap can be left as is
and distraction osteogenesis is employed to distract one or
both segments to meet at the fracture site. The former, short-
ening of the bone and later lengthening, offers the advan-
tage of easier soft-tissue management. When the bones are
left out to length, soft-tissue coverage by microvascular
free flaps followed by distraction osteogenesis is also pos-
sible. Complications include leg-length discrepancies, axial
deformities, refracture, pin track infections, and incomplete
"docking" requiring secondary bone grafting.
Vascularized fibular grafts can bridge gaps of ~4 em. In
harvesting the fibula, it is necessary to preserve the proxi-
mal and distal 6 em of fibula in the donor leg in order not
to interfere with knee or ankle function; thus, the limit of
fibula harvest is the native fibular length minus 12 em. The
use of the fibula assumes the availability of the contralateral
fibula as a donor and of a recipient vessd in the injured leg.
The fibula will never achieve the strength of the original tibia
bt:(;ause of its markedly smaller mass. The fibula is prone
to fracture, but after healing, the fibula hypertrophies and
increases in strength. Weiland reported an 87.5% success
rate in 32 free fibular grafts, with average time to full weight
bearing of 15 months. 21 Fyajima et al. reduced the time to
weight bearing to 6 months by the use of a twin-barreled
vascularized fibular graft.23
Soft-Tissue Management
The choice of soft-tissue coverage of open tibial fractures
depends on the extent and the location of the injury.
Split-Thickness Skin Grafts. Split-thickness skin grafb
will cover exposed muscle or soft tissue, and occasionally they
can be used to cover the bone with healthy periosteum or ten·
don with healthy paratenon. In most circumstances, however,
subcutaneous tissue or muscle is recommended to cover ves-
sels, nerves, bone, and tendon, even with healthy periosteum
or paratenon. Skin grafts may be adequate to cover Gustilo
grade IDA open tibial fractures, but they are inadequate cover-
age alone for Gustilo grade DIB or me injuries.
Local Flaps. Local fasciocutaneous or muscle flaps are use-
ful for small to moderate defects of bone-exposed vessels or
tendons. It is generally accepted that local £laps are available
in the proximal or middle third o£ the leg, but local flaps in the
lower third of dle leg do not exist. The defec:ts of the lower
third of the leg nearly always require free tissue trans£er.
Fasciocutaneous flaps may be proximally based and cover
small defects of the bone, exposed vessels, or tendons; how-
ever, general principles of rotation flaps must be considered.
A small defect will require a large flap and the donor site will
always require a split-thickness skin graft. In a series of 67
fasciocutaneous flaps to the lower extremity, Hallock found
an 18.5% complication rate. Distally based .flaps had a 37.5%
complication rate, although wound closure was ultimately
achieved in 97% of patienu.24 Local fasciocutaneous .flaps are
usually not available in Gustilo grade mB or me injuries in
which the local soft tissue is within the zone of injury and
unavailable for transkr.
With better understanding of the blood supply to the
skin and subcutaneous tissue, pedicled perforator .flaps have
become more popular as local soft-tissue flaps and represent a
new era for reoonstruction of the lower extremity. ln a series
by El-Sabbagh et al., 32 of 34 perforator .flaps to the lower
948 Pan IX: Tl'Wik and Lower h:tremity
extremity survived completely. One flap failed and one had
tip necrosis. There were 13 peroneal artery perforator flaps,
16 posterior tibial artery perforator flaps, and 5 medial sural
artery perforator flaps in their series.zs
Local muscle flaps are quite useful to cover defects of
exposed bone, artery, nerve, or tendon in the proximal or mid-
dle third of the leg. The lateral or medial gastrocnemius flap is
useful for defects of the proximal third of the leg (Figure .94.4).
Defects of the knee can be covered easily. The middle third
can be covered by the soleus flap (Figure .94.5). A hemiso-
leus muscle can be taken, preserving function of the remaining
haH of the soleus muscle. Again, it is important to note that
large flaps are required to cover even small defects because
of the arc of rotation. A considerable donor-site defect that
requires sk.in grafting may be encountered. Functional defi·
cits of muscle harvest are real, but have not been adequately
studied. Smaller de&:cts may be covered by the tibialis anterior
muscle or other muscles of the anterior and lateral compart-
ments; however, these muscles have a less reliable blood sup·
ply and may be less readily expendable. The tibialis anterior,
for example, is an important muscle for dorsiflexion of the
ankle. lt should be transferred as a bipedicle flap for small
defects. The main problem with the use of local muscle flaps is
that they are usually in the zone of injury of high-energy grade
nm or me injuries. High-energy injuries may result in bone,
soft-tissue, arterial, nerve, and significant muscle injury. The
muscles in these high-energy injuries with significant associ-
ated aush injury may not be available for local transfer.
Free Tissue Transfer
Microvascular free tissue transfer has revolutionized the treat·
ment of high-energy lower-extremity injuries with the associ-
ated bone, soft tissue, and muscle loss and with exposure of
the bone and vital structures. Once debridement of all devi-
talized tissue has been completed, and if an available recipi·
ent artery is available, abundant. healthy muscle, and soft
tissue can be supplied to cover the exposed vital structures.
The rectus muscle or the latissimus dorsi muscle, or the latissi-
mus dorsi combined with the serratus muscle, can cover large
defects (Figure 94.6). In a review of 304 cases of microvascu-
lar free flap reconstruction of the lower extremity, Khouri and
Shaw reported a .92% success rate.• Reported success rates by
many authors with early wound coverage with microvascular
free flaps have been 85% to 100%. The anterolateral thigh
perforator free flap has recendy become a popular choice for
the coverage of lower extremity defects.
Negative Pressure Dressiogs. Some wounds may be dif-
ficult to manage despite the options of sk.in grafting, local
flaps, or microvascular free tissue transfers. Some patients may
not be candidates for operative procedures. Chronic wounds
may not be amenable to these treatment options because of
poor wound beds and inadequate granulation. Argenta et al.
described a VAC using a foam dressing with controlled nega-
tive pressure on the dressing sponge and thus the wound. This
method of wound care promotes granulation, promotes wound
contracture, and decreases bacterial count. The technique has
been successful in treating even grade UIB open tibial fractures
that may have required a local muscle flap or a microvascular
free tissue transfer.18.2' Surgical debridements are still necessary
as an adjunct to the dressing changes. Though some wounds
may be treated with this technique until complete closure has
occurred, many wounds require additional surgery, such as a
skin graft or flap. The significant improvement in the wound
bed, however, makes the reconstructive procedure easier. This
technique is not effective for ischemic wounds.
Chronic Osteomyelitis
Chronic osteomyelitis after grade m tibial fractures occurs
in approximately 5% of open tibial fractures. Early and
adequate debridement of open fractures is key to prevention
of osteomyelitis. Once osteomyelitis occurs, the mainstay of
treatment is debridement of all devitalized tissue and necrotic
bone (Figure .94.7) and replacement with healthy, well-vas·
cularized tissue, followed by treatment of the bone defect.
Anthony et al. treated 34 patients with chronic osteomyelitis
with debridement and immediate muscle flap coverage and
antibiotics. They had an overall success rate of 96%.27 May
FIGURE ~.4. Open knee wound with necrotic patella. A. Pre-op
appearance. B. The wound covered with a gasttelc:nemius rCltatiClD
Sap. C. The healing WClund 6 weeks p<>stoperation.

c
reviewed a 13-year experience with treatment of chronic trau-
matic bone wounds with microvascular free tissue transkr.ll
He had a 95% success rate in his series of 96 patients. The
treatment of choice for chronic osteomyelitis remains radical
debridement of necrotic tissue and coverage with well-vascu-
larized tissue.
Most recent studies also show excellent overall success
rate in the treatment of chronic osteomyelitis with fasciocu·
taneous free flaps. Khan et al. showed a 100% survival and
honey union in 20 patients treated with radial forearm free
flaps.:u Hong et al. showed a 100% success rate in 28 con-
secutive patients with chronic osteomyelitis treated with the
FIGURE ~U. Mangled e:xucmity with severe niB fracture and multiple areas of c::xposed bone. A. Pre-op appearance B. Salvage after multiple
debridemen~. bone grafting and rectus free Sap.
Chapter 94: Lower Extremity Reconstruction 949
FIGURE ~4.5. Middle third tibial fracture. A. PrH>p appearance
B. Hcmisoleus Sap to cover tibial fracture. C. The healing wound 10
days postoperation.
anterolateral thigh flap.3° Musharafieh et al. had success in
21 out of 22 patients treated for chronic osteomyelitis with
free flaps.31 However, Gonzalez et al. had a 22% failure rate
in patient treated for chronic osteomyelitis with free flaps.32
Successful treatment of chronic osteomyelitis of the lower
extremity with free tissue transkr can be expected to be from
80% to9S%.
Salvage of Below-Knee Amputation Stumps
When limb salvage is not possible, every attempt should be
made to preserve as much limb length as possible. This is
950 Pan IX: Tl'Wik and Lower h:tremity
particularly important with respect to the knee joint. If the
knee unit is salvageable, a below-knee amputation is per-
formed. The work of ambulation is significantly reduced in
patients with below-knee amputations when compared with
patients with above-knee amputations. Patients with below-
knee amputations have a more normal gait and a greater
ability to perform more physical activities than patients with
above-knee amputations. The development of microvascular
surgery has allowed salvage of extremities at a more distal
level. This is particularly true when the main problem is inad-
equate soft-tissue coverage.
Advantages of More Distal Amputations. Ambulation
with a below-knee amputation requires 25% more energy
and oxygen consumption than ambulation without an ampu-
tation. Above-knee amputations necessitate 65% more oxy-
gen and energy consumption compared with nonamputees.
Patients with bilateral below-knee amputations have a 45%
FIGURE 94.7. Chronic IIIB tibia fracture with exposed bone.
A. P~p appearance B. Radical debridement of all devitalized bone
and 50ft tissue. C. The wound after exteD.Sive debridement. D. After
coverage with parascapular free flap. E. 24-year follow-up.
increased oxygen and energy consumption requirement for
ambulation when compared with nonamputees. The ampu-
tee will walk more slowly to compensate for the increase in
energy required. The higher the level of the amputation, the
more energy required, and the slower and less effective the
ambulation.
Quality of life is also significantly affected by the level of
amputation. The daily distance walked is significantly less in
above-knee amputation patients as compared to below-knee
amputation patients. More above-knee amputation patients
walk only in the house or do not walk at all. Above-knee
amputation patients have more trouble with stairs and ramps
and often require hand controls to drive.
Free Flap Salvage of Below-Knee Amputation
Stumps. If the distal limb is nonsalvageable but the
knee joint is functional, every attempt should be made
to preserve a below-knee amputation. Although the ideal

below-knee amputation stump has >6 em of tibia below the
tubercle, any length of tibia should be preserved as the ben-
efits of a below-knee amputation are great compared with
above-knee amputation. If adequate soft-tissue coverage is
present, the stump may either be closed primarily or closed
in a delayed fashion. If insufficient soft tissue exists to
cover the bone, free flap reconstruction is considered. If the
foot on the amputated part is uninjured, the plantar sur-
face can be removed and transferred to the stump as a free
flap. If the foot on the amputated part is not usable, then
a standard free flap can be performed shortly thereafter. In
dirty wounds, the free flap is delayed until wound condi-
tions are optimized. Figure 94.8 summarizes the decision-
making tree.
ln a study by JCasabian, 22 patients achieved stable cov-
erage of below-knee amputations with free flap coverage.33
The most common flap was the parascapular flap, used in 11
patients. A foot fillet flap was used in six cases. The other free
flaps employed were the latissimus dorsi,4 lateral thigh,1 ten-
sor fascia lata,1 and groin.1 The patients in the study required
an average of 4.9 operations related to their injury. There
were 1.3 operations after the free flap. Most patients had long
hospitalizations as a result of the combination of their injuries
and their overall situations.
The foot fillet flap offers several advantages over other
flaps. It is the only flap available from the amputated part
and as such has no donor-site morbidity. In addition, sensory
innervation is provided by the tibial nerve, peroneal nerves,
and sural nerves. The tibial nerve is used most commonly and
provides sensibility to the plantar surface of the foot, which is
usually inset at the end of the below-knee amputation stump.
Neurorrhaphy may be accomplished to a proximal nerve
Thwmatlc
Below Knee
Injury
Umb
Reconstruction/ Amputation
Replantation
Knw Functional
Below Knee
Salvage
lnadequ~
Soft Tissue
Primary Below Knee
Reoonstruction Salvage
Dirty / Clean~ Cf98n
Wouo/ Wound~ Wound
Delayua Primary lmme<late
Closure Closure Free Flap
Foot
Avalfsbl9
Foot Filet
Free Flap
Chapter 94: Lower Extremity Reconstruction 951
stump or the nerve may be left in continuity. Finally, the foot
fillet has glabrous skin that is durable and not prone to ulcer-
ation (Figure 94.9).
Muscle free flaps with skin graft coverage tend to heal
slowly. There are often areas of partial graft survival. In addi-
tion, a the muscle atrophies and the flap shrinks, revisions are
required for both the stump and the prosthesis. The additional
surgical procedures lengthen the time to the fitting a£ the final
erosthesis when compared with patients with fascloc:ataneous
flaps.
Oncologic Lower Extremity Reconstruction
Defects of the lower extremity caused by oncologic resection,
involving bone and soft tissue, can be salvaged in a similar
fashion. Numerous reviews show high success rates in tibial
reconstruction with fibula free flaps as well as soft-tissue
reconstruction with muscle and fasciocutaneous free flaps.
Chen et al. reviewed 25 patients who had reconstruction of
long bone defects with vascularized fibula flaps. All flaps sur-
vived. After 6 months, 11 of 14 patients had uncomplicated
bony union and 13 of 14 patients had bony union after a sec-
ond procedure.34 Moran et al. reviewed reconstruction of long
bone defects salvaged with massive bone allografts and intra-
medullary free fibular flaps. All .Baps survived. Four of seven
patients had primary bone union and the other two had bony
union with a second procedure.3'
Darner-Rasmussen et al. reviewed 75 free flaps for recon-
struction after resection of soft-tissue sarcomas of the leg.
Success rate was 95%. 3' Success rate in reconstruction for
oncological resection remains high. The problem remains dis·
ease free survival after oncologic resection (Figure 94.10).
Aballe Knee
Amputation
Dirty
fNbund
Delsyud
Free Flap
""- Foot Not
""-Avaffab/9
Pa188C8pular FIGURE 94.8. An algorithm for
Free Flap amputation in lower extremity injuries.
952 Pan IX: Tl'Wik and Lower h:tremity

FIGURE ~·'· FC~ot fillet coverage. A. A large zone C~f injury in proxi-
mal tibia area with a lC~ng segment C~f exposed tibia. B. The fC~ot is
.n:latively UDiDju.red. C. FC~ot fillet dissection performed. D and E. The
final result.

FIGURE 94.10. Soft-ti5sue sarcoma of the lowc:.r extremity. A. Pre-<lp appearance. B. After wide e:xc.ision C~f the tumor. C. Tumor specimen.
D. Afu:.r recon~~truction with latissimus flap and skin graft.

FIGURE !14.10. (Continued)
Lower Extremity Reconstruction in
Vascularly Compromised Patients
Numerous authors have shown that lower extremities may
be salvaged even in those patients with severe vascular dis·
ease. Colen showed a success rate of nine free flaps in
10 patients with severe vascular diseaseP Serletti et al. reviewed
30 patients with combined vascular bypass and free flap
reconstruction. Eighteen patients had simultaneous bypass
and flap while 12 had delayed soft-tissue reconstruction.
Eight of the 30 reconstructions were unsuccessful with 3 early
graft and flap failures and S with new areas of ischemia. All
required amputation. But 73% were salvaged.38 Most of these
Chapter 94: Lower Extremity Reconstruction 953
D
salvage attempts were for defects of the foot, which will be
discussed in the next chapter. However, revascularization may
be required for salvage of defects of the leg. Kasabian et al.
described the salvage of a tibial defea: with a microvascular
free flap using simultaneous polytetrafluoroethylene graft for
infiowl' (Figure .94.11).
SUMMARY
Lower extremity reconstruction requires a team approach
that carefully assesses the costs, technical considerations,
functional results, and psychosocial aspects of the treat·
mentplan.
FIGURE 94.11. Ischemic lower extremity with exposed tibia. The
saphenous veins had previously been harvested for coronary bypass
gralu. A. Pre-op appearance. B. Angiogram shows inadequate donor
vessel for hu: flap. C. Simultaneous reva&e:ularization with polytet-
rafluoroethylene graft and r«:ms free flap. D ud E. Postoperative
l'Cllult.
 954 Pan IX: Tl'Wik and Lower h:tremity
D
FIGURE 94.11. (Cotumued)
1. Francel. 1j, V.tU~der Kolk CA., Hoopea ]E, et a!. Microvascular soft-tissue
tr.tUillplantation for reconstruction of acute open tibial frsu:tures: tim-
ing of coverag-e aJ~d long-term fWI.ctiow results. Pl4st R~rcomtr S11rg.
1992;8.9:478-487.
2. Georgiadis GM, BehreiiS FF, joyce MJ, et al. Open tibial fractures with
seven soft-tissue lost. Limb salvage compand with below-the-knfe amputa-
tioll.J Bontt JointS~~rg Am. 19.93;75:1431-1441.
3. Laughlin RT, Smith KL, Russell RC, et a!. Late functional outcome
in patients with tibia frsu:tutes covered with free muscle flaps. J Onhop
TNIIIIIII. 1993;7:123-129.
4. Khouri RK, Shaw WW. Reconstruction of the lower extremity with
mictovascultu free flaps: a 10-year experiell.ce with 304 COIISecutive CS!Se6.
J TNWIIIII. 1989;29:1086.
5. Rodrigun I!D, Bluebond-Langner R, Copeland C, et al. FWI.ctional out-
comes of posttraumatic lower limb salvage: a pilot study of anterolat-
eral thigh perforator flaps versut muscle flaps. J TM~ma. 2009;66{5):
1311-1314.
6. Burger H, Matincek C. Retum to work after lower limb amputatioll.
Di&abil Rmabil. 2007;2.9(17):1323-1329.
7. Bosse Mj, MadCenzie I!J, Kellam jF, et al. AZ1 alllll.ysis of outcomes of
teeoDtttuction or amputation after leg-thnattDiDg injuries. N Eflgl J Mltd.
2002;347(24):1924-1931.
8. Mackenzie I!J, Bosse MJ, Pollak AN, et al Long-term persistence of disabil-
ity following seven lower-limb trauma. Rfsults of a sevm..,.ear follow-up.
J Bone Joint S~~rg Am. 2005;87(8):1901-1909.
9. Butcher jL, MacKenzie I!J, Cushing B, et al. Long-Term outcomes after
lower extttmity trauma.. J TN~~ma. 1996;41(1):+9.
10. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method
for wound control and treatment: clinical experience. Amt Pl4st S..rg.
1997;38(6):563-576.
11. Allen MJ, et a!. Ill.tracompattmental prestun monitoring of leg injuries. AZ1
aid to management. J Bone Joint Slff'g. 1985;67.8:53.
12. Boll.aJIDi P, Rhodes M, Llacke JF. The futility of predictive scoriDg of maJ~·
gled lower atremities. J Trafft114. 1993;34:99-104.
13. Byrd SH, Spicer ET, Cier:uy G m. Management of open tibial fra.ctures.
P£ut kcomtr S~~rg. 1985;76:719.
14. Godina M. Early micrcsurgical reconstruction of complex trauma of the
extremities. Clin P£ut S..rg. 1986;13:619.
15. Yaremch.Wt t.ij", Brumback JJ, Manson PN, et al Acute ud definitive maJ~·
agt!ment of tra~~mt~.tic osteocutaneoull defects of the lO'Iftr extremity. P£ut
ReroJ'J$lr Slff'g. 1982;80:1-14.
16. Clwe m, Ka.ubian KA, Kolker RA, eta!. Thrombocytmis after major lawt!r
extremity trauma: mechanism ud possible role in free flap failure. Ann
P£ut S~~rg. 1996;36:489-494.
17. Steirt AB, Gohritz A, Schreiber TC et al Delayed flap coverage of open
extremity fractures after prmo1111 va.cuum-assisted closure (VAC) therapy-
vrorse or worth? J P£ut R«<OI..Itr ~ht S..rg. 2009 May;62{5):675-6"83.
18. Hou Z, Irgit K, Strohecker KA, et al. Delayed tlap reconstruction with
va.cuum-usisted closure management of the open mB tibial fracture.
J'lhum1a. 2011;71(6):1705-1708.
19. Trumble T, Vuderhooft E. Ne"e grafting for lower-extremity iDjuries.
J PMWr Orthop. 1994;14:161-165.
20. Trabulsy PP, Kerley SM, Hoffman WY. A prospective study of early soft
tissue coverage of grade DIB tibial~ ]1'tafft114. 1994;36:661-668.
21. Tometta P m, Bergman M, Watnik N, et al TtWmellt of grade mB open
1ibw frsu:tutes. A prospective raJ~domized compatiso11. of exter:ual fixati011
and non-reamed locked IW!ing. J 801111 Joint Stwg Br. 1994;76:13-19.
22. WeiW1d AJ, Moor JR. Daniel RK. Vascul.atized bone autografts: experience
with 41 cases. Clin Orthop. 1983;174:87.
23. Fyajima H, Tamai S. Twill.-batteled vascul.atized fibular grafting to the pel-
Yis md lower extremity. Clin Onhop. 1994;303:178-184.
24. Hallock GC. ComplicQ.tioDS of 100 coDSecUti•e local fasciocuta11.eous fhps.
PlMt ~S~~rg.1991;88:264.
25. 1!1-Sabbqb. AH. Skin perforator flaps: aJI algorithm for leg rec011.Stl'uCti011.
J Recomtr MicrO&fll'g. 2011;27(,):511-523.
26. Greer S, Kiw.bian A, Thorne C, et a!. The use of subatmospheric pretOSUre
dteasill.g to salvage a Gustilo grade DIB ope11. tibial fracture with concomi-
taJit osteomyelitis to uert a free flap. Ann PlMt Stwg. 1998;41{6):687.
27. Anthony JP. Mathes Sj, Alpert BS. The muscle fLlp ill. the treatment of
chronic lower extremity osteomyelitis: results in patieu.ts over 5 years after
tteatme11t. Pla.u R.!COIWf'Srwg.1991;88:311.
28. May JW. Jupiter jB, Gallico GG, et a!. Treatment of chronic traumatic
bone woUDds. Microvascular free tissue trti.IISfer: a13-year experimce in 96
patients. Ann Sfwg. 1991;214:241.
29. Khan MA, jose RM, Taylor C, et al Free radial forearm fasciocuWI.eous
flap in the treatment of distal third tibial osteomyelitis. Ann P/4# S..rg.
2012;68(1 ):58-61.
30. Hong JP. Shin HW, Kim .D. et a!. The use of aDterolateral thigh perforator
flaps in chronic 06too:myelitis of the lower extremity. P/4# Reeonur Sl.nJ.
2005;115(1):142-147.
31. Musharafieh R, Osmani 0, Mushatafieh U, et al Efficacy of tllicrosurgical
free-tissue trallllfer in chronic osteomyelitis of the leg and foot: review of 22
CS!Se6. J R&:OIIUf' Micros~~rg. 1999;15(4):239-244.
32. Goii.ZiZle2: MH, Tatandy DI. Troy D, eta!. Free tissue cover.age of cl!rouic trau-
matic woUII:ds of lhe lower leg. Pla.u R~ Sl.nJ. 2002;10!1(2):592-6"00.
33. Kilsabian AI<., Colen SR, Shaw WW, et a!. The role of microvasculat free
flap in salvqing below-knee amputation stumps: a re•iew of 22 ca"'.
J Tf'alml4. 1991;31:495.
34. Chen CM, Diu JJ. Lee HY, et a!. ReCOil.Sttuction of extremity long bou.e
defects after sarcoma resection with •ascularized fibula fLlps: a 10-yea.r
review. Pla.u Recomtr Sfwg. 2007;119(3):915-924.
35. Moran SL, Shin AY, Bishop AT. The use of mam•e bone allograft with
intramedullary free fibular fhp for limb salvage in a pediatric aJ~d adol-
oent populatio11. PlMt R4eo:nslr S~~rg. 2006;118(2)413-419.
36. Bar:uer-Rumussen I, Popov<: P, Bohling T, et aL Micro•ascular recon-
struction after resection of soft tissue ltl.l'coma of the leg. Br J S11rg.
200!1;96(5):482-489.
37. Colen LB. Limb sal•qe in the patient with severe peripheral vasculat di.-
ease: the role of microsurgical free-tissue traJ~sfer. Phl.u R«<ns.tr S11rg.
1987;79(3):389-395.
38. Setletti JM, Deuber MA, Guidera PM, et al Atherosclerosis of the lower
e:x:ttetllity and free-tissue recoD.Structioll. for limb sal..age. Pla.u RecOIWl'
S..rg. 1995;96(5):1136-1144.
39. Kiw.bian AI<., Gw PM, Eidelman Y, eta!. Limb salvage with tllicro..ucular
ttee tlap recoDtttuctionusillg simult.tU~eo\1!1 polytetratluoroethylme graft for
inflow. Ann P£ut S..rg. 1995:35{3):310-315.
CHAPTER 95 • FOOT AND ANKll RECONSTRUCTION
CHRISTOPHER E. ATI1NGBR. AND MARK W. CLEMENS

Functional restoration of the complex and efficient bio-

mechanics of the foot and ankle is a challenge for the
reconstructive surgeon. Trauma, tumor ablation, as well
as changes in sensation, motor function, skeletal stability,
blood supply, and immune status render the foot and ankle
susceptible to breakdown. Inability to salvage the injured
foot has traditionally led to amputation, carrying with it
potentially dramatic morbid sequelae and a lifetime depen-
dence on prosthetic devices. The relative 5-year mortality
rate after major limb amputation in diabetics is greater
than SO%, a startling figure when compared with mortality
rates of lung cancer (86%), colon cancer (39%), and breast
cancer (23%).
Successful foot and ankle reconstruction demands a
team approach consisting of a vascular surgeon skilled in
both endovascular and bypass techniques, a foot and ankle
surgeon skilled in internal and external (Ilizarov) bone sta-
bilization techniques, a soft-tissue surgeon for soft-tissue
reconstruction, an infectious disease specialist, and a medi-
cal specialist to handle the comorbidities such as diabetes,
hypertension, renal failure, and coronary artery disease.1
Surgical goals include a good local blood supply, debride-
ment to a dean base, correction of any biomechanical abnor-
mality, and nurturing the wound until it demonstrates signs
of healing. Reconstruction can be accomplished by simple
techniques 90% of the time and complex flap reconstruc-
tion in 10% of cases. This chapter focuses on the critical
aspects of foot and ankle reconstruction, including anat-
omy, evaluation, diagnosis, and treatment with flap-based
reconstructions.
ANATOMY
Vascular Anatomy
The foot and ankle consists of six angiosomes2: (1) the distal
anterior tibial artery feeds the anterior ankle while its contin-
uation, the dorsalis pedis artery, supplies the dorsum of the
foot; (2) the calcaneal branch of the posterior tibial artery
feeds the medial and plantar heel; (3) the calcaneal branch
of the peroneal artery feeds the lateral and plantar heel; (4)
the anterior perforating branch of the peroneal artery feeds
the anterolateral ankle; (5) the medial plantar artery feeds
the plantar instep; and (6) the lateral plantar artery feeds the
lateral plantar mid- and forefoot (Figure 95.1). Note that the
plantar heel receives dual blood supply from both the calca-
neal branches of the posterior tibial and peroneal arteries.
When the heel develops gangrene, this usually implies severe
vascular disease involving both the peroneal and posterior
tibial arteries.
Because the foot is an end organ, many arterial-arterial
anastomoses provide a duplication of inflow. These arterial-
arterial anastomoses (Figure 95.2) provide a margin of safety
if one of the main arteries becomes occluded. At the ankle, the
anterior perforating branch of the peroneal artery is connected
to the anterior tibial artery via the lateral malleolar artery. At
the Lisfranc joint, the dorsalis pedis artery dives into the first
interspace to connect direaly with the lateral plantar artery.
This vascular loop is critical in determining the direction of
flow within the anterior or posterior tibial arteries, which can
be antegrade or retrograde or both. ln addition, the plantar

FIGURE 9S.1. The angiosomes of the foot and ankle include (A) the anterior ankle fed by the anterior tibial artery and the dorsum of
the foot fed by the dorsalis pedis artery; (B) the medial and plantar heel fed by the calcaneal branch of the posterior tibial artery, the
plantar instep fed by the medial plantar artery, the lateral plantar midfoot and plantar forefoot fed by the lateral plantar artery; and
(C) the anterolateral ankle fed by the anterior perforating branch of the peroneal artery and the lateral heel fed by the calcaneal branch of
the peroneal artery.

9SS
956 Pan IX: Tl'Wik and Lower h:tremity
+--+---Ant. tibial a.
Lateral
tarsal a.
Pro00mal ---+,~~~~
perforating a.
Dorsal
dlgltalaa.
FIGURE 95.2. Am:riaJ. anatomy of the foot and ankle. At the ankle,
the anterior tibial arw:y gives off the lawai malleolar artery at the
level of the latl:.l'al malleolus that anastomoses with the anrerior perfo-
rating branch of the peroneal artery. At the Litfranc joint, the dorsalis
pedis art:~:ry dives deep in the lim inteopace to join the lareral plan-
tar art:~:ry. At the second, third, and founh proximal interspaces, the
proximal perforators link the dorsal and plantar metatarsal arteries.
Not shown is the direct connection betw=n the peroneal and poste-
rior tibial anc:ry deep to the distal A.chilles rendon. (From Attingc:r C.
Vasc:ular anatomy of the foot and ankle. Oper Tech Plast Reconslr
Surg. 1997;4:183, with permission.)
and dorsal metatarsal arteries are linked to one another at the
Lisfranc joint by proximal perforators and at the digital web
spaces by distal perforators. Finally, the posterior tibial artery
and peroneal artery are directly connected deep to the distal
Achilles tendon by one to three connecting arteries. Using a
Doppler ultrasound probe and selective occlusion, one can
determine the patency of these connections as well as the
direction of Bow. This knowledge is critical in designing local
flaps, pedicled flaps, and amputations.3
Motor and Sensory Anatomy
The sciatic nerve divides into the tibial and common pero-
neal nerves proximal to the popliteal fossa. The tibial nerve
runs lateral to the popliteal vessels within the popliteal fossa,
before entering the deep posterior compartment of the leg.
The tibial nerve innervates muscles of the deep and superficial
posterior compartments (except the gastrocnemius muscle)
and trifurcates at the distal inner ankle, deep to the flexor
retinaclllwn, into the calcaneal and medial plantar and lateral
plantar nerves. These nerves provide the motor branches to
the intrinsic muscles of the foot (except the extensor digito·
rum brevis [EDB] muscle). The common peroneal nerve passes
around the lateral aspect of the fibular head before splitting
into the superficial and deep branches. The deep peroneal
Ponrior
Ferrorar
Cut.aneous N
M terlllf
FemOra.a
C UliJntous N,
SapntonOus u
FIGURE 95.3. Sensory innervation of the lower leg. Note that the
SCDSOry distribution of the deep peroneal nuve is limited to the first
web space,. whereas the superfic.ial peroneal nuve provides sc:ns.ibility
to the dorsum of the foot. The posterior tibial tupplies the tole of the
foot and toes.
nerve innervates the extensor muscles in the anterior compart·
ment before exiting the extensor retinaculum to innervate the
EDB muscle. The superficial peroneal branch innervates the
everting peroneal muscles of the lateral compartment before it
pierces the fascia to become subcutaneous and provide ~~ensi·
bility to the lateral lower leg and dorsum of the foot.
The sensory nerves to the foot and ankle (Figure .95.3)
travel more superficially than the motor nerves, and their
degree of function is a useful index to the localization of
trauma. As mentioned. the superficial peroneal nerve (L4.
LS, and S1) supplies the anterolateral skin in the upper third
of the leg while descending within the lateral compartment.
It becomes subcutaneous approximately 10 to 12 em above
the lateral ankle and travels anterior to the extensor retinae·
ulum to supply the dorsum of the foot and skin of all the
toes except the lateral side of the fifth toe (sural nerve) and
the first web space (deep peroneal nerve). The deep peroneal
nerve (L4. LS. and S1) exits the anterior compartment deep
to the extensor retinaculum to supply and ankle and mid-
foot joints, sinus tarsi, and the first web space. The sural
nerve (LS and S1), derived from both the tibial and com-
mon peroneal nerves. descends distal to the popliteal fossa in
the posterior aspect of the calf along the course of the lesser
saphenous vein. It provides sensibility to the posterior and
lateral skin of the leg's distal third, prior to passing between
the anterolateral border of the Achilles tendon and the lat-
eral malleolus in order to supply the skin of the dorsolat·
eral foot and fifth toe. The skin of the medial half of the
lower leg and dorsomedial portion of the foot is innervated
by the saphenous nerve (LS and S1), a cutaneous branch of
the femoral nerve. The dorsum of the foot has communicat·
ing branches between saphenous, sural. superficial. and deep
peroneal nerves, and thus there is often an overlap in their
respective terminal areas of innervation. As mentioned, the
posterior tibial nerve at the distal portion of the tarsal tunnel

divides into three branches that supply the sole of the foot:
the calcaneal branch (S1 and S2) supplies the medial aspect
of the heel pad; the lateral plantar nerve (51 and 52) supplies
the lateral two thirds of the sole and the fifth and lateral
fourth toes; the medial planter nerve (L4 and L5) supplies
the medial one third of the sole and the first; second, third,
and medial fourth toes. The medial and lateral plantar nerve
can have an overlap in their respective zones with the saphe-
nous and sural nerves, respectively.
WOUND COMORBIDITIES
Diabetes
Approximately 24 million or 7.8% of all Americans have
documented diabetes mellitus and 15% of them eventually
develop a foot ulcer during their lifetime. Almost 15% of the
health care budget of the United States goes toward manage-
ment of diabetes, with 20% of hospitalizations and 25% of
diabetic hospital days for the treatment of diabetic foot ulcers.
Two thirds all the major amputations performed per year in
the United States are performed in diabetics. Diabetics battle
numerous complications related to their underlying disease,
but none is more devastating, both psychologically and eco-
nomically, than gangrene of an extremity with the associated
risk of amputation.
Diabetic peripheral polyneuropathy is the major cause of
diabetic foot wounds. More than 80% of diabetic foot ulcers
arise in the setting of neuropathy. The neuropathy is a conse-
quence of chronically elevated blood sugar that causes vascular
and metabolic abnormalities. Elevated intra-neural concentra-
tions of sorbitol, a glucose by-product; are thought to be one
of the principal mechanisms for nerve damage. Further dam-
age can result when the damaged nerve swells within anatomi·
cally tight spaces such as the tarsal tunnel. The combination
of nerve swelling and tight anatomic compartments leads to
the "double crush syndrome," which may sometimes be par-
tially reversed with nerve release surgery.4 Unregulated glu-
cose levels elevate advanced glycosylated end product levels
that may induce microvascular injury by cross-linking colla-
gen molecules. Decreased insulin levels, along with altered lev-
els of other neurotrophic peptides, may decrease maintenance
or repair of nerve fibers. Other potential causative factors of
peripheral neuropathy include altered fat metabolism, oxida-
tive stress, and abnormal levels of vasoactive substances such
as nitric oxide.
Hyperglycemia also affects the body's ability to fight
infection by diminishing the ability of polymorphonuclear
leukocytes, macrophages, and lymphocytes to destroy bac-
teria. In addition, the diabetic's ability to coat bacteria with
antibiotics is diminished, which .further helps shield bacte·
ria from phagocytosis. As a result of this impaired immune
state, diabetics are especially prone to Streptococcus and
Staphylococcus sk.in infections. Deeper infections tend to
be polymicrobial, with gram-positive cocci, gram-nega-
tive rods, and anaerobes present. Postoperative complica-
tion rates correlate directly with the level of postoperative
hyperglycemia.
In patients with neuropathy, non-healing ulcers precede
80% to 95% o£ amputations. Despite attempts to decrease
the number of amputations in the United States by various
strategies from improving glucose control to more wide-
spread saeening exams for impaired sensibility, the num-
ber of amputations has continued to increase from 54,000
in 1990 to 65,700 in 2006. Arterial disease present india-
betic patients is usually located in the infra-popliteal region
and significantly increases the risk of ulceration and possible
amputation. It is present in greater than SO% of diabetic foot
ulcers. So, while peripheral vascular disease is frequently
present, peripheral neuropathy is the primary cause of foot
wounds in the diabetic population.
Chapter 95: Foot and Ankle Recoastruction 957
Neuropathic Changes
The neuropathic changes in the diabetic feet are a result of
the neuropathy in the motor, sensory, and autonomic nervous
systems. The loss of pseudomotor function from autonomic
neuropathy leads to anhydrosis and hyperkeratosis. Fissuring
of the skin results and facilitates bacterial entry with subse-
quent infection. The lack of sensibility over bony prominences
and between the toes often delays the detection of these small
breaks in the skin.
Charcot deformities (neuroarthropathy) of the joints of the
foot occur in 0.1% to 2.5% of the diabetic population. When
present, the tarsometatarsal joints are involved in 30%; the
metatarsophalangeal joints in 30%; the intertarsal joints in
24%; and the interphalangeal joints in 4% of the time. The
explanation for these degenerative changes is widdy debated.
One possible etiology is "neurotraumatic," i.e., joint collapse
from damage that has accumulated because of insensitivity to
pain. A more recent proposed etiology is due to osteopenia
triggered by abnormalities in the RANKIRANK-Iigand/osteo·
protegerin system.
The process probably begins with a ligamentous soft-tissue
injury accompanied by synovitis and effusion. ln the absence
of pain perception, continued use of the extremity exacerbates
the inflammatory process. Eventually distention of the joint
capsule leads to ligament distortion, resulting in joint insta-
bility. Further activity causes articular cartilage erosion, with
debris being trapped within the synovium. These changes are
often accompanied by loss of dorsiflexion of the foot due to
the loss of Achilles tendon flexibility, adding further stress on
the arch of the foot.5 This combination of changes can then
cause a collapse of the medial longitudinal arch, altering the
biomechanics of gait. The no.rmal calcaneal pitch is distorted,
which in tum causes severe strain to the ligaments that bind
the metatarsal, cuneiform, navicular, and other small bones
forming the long arch of the foot. Heterotopic bone formation
and eburnation of load-bearing surfaces frequently result.
These degenerative changes overload specific parts of the
foot rather than allowing the normal weight transition from
heel to midfoot to forefoot. The increased focal stress leads to
ulceration, infection, gangrene, and limb loss if the process is
not halted or compensated for in its early stages. Diagnosis of
a Charcot foot is often missed as it often presents as a swollen
foot that is misdiagnosed as a sprain. Erythema may further
confuse this presentation, leading to a misdiagnosis of cellulitis.
The motor component of the neuropathy further contrib-
utes to Charcot deformities as the intrinsic foot musculature
atrophies and becomes fibrotic. The resulting metatarsopha-
langeal joint extension and interphalangeal joint flexion pro-
duce excessive pressure on the metatarsal heads and the ends
of phalanges. The loss of both the transverse and longitudinal
arches of the foot exacerbates the unfavorable weight distri-
bution across the midfoot and metatarsal heads.
Ischemia
Atherosclerotic disease is a common cause of non-heal-
ing foot ulcers, especially in combination with diabetes.
Hypercholesterolemia, hypertension, and tobacco use are
additional risk factors for atherosclerosis. Other causes
of ischemia in the foot include thromboangiitis obliterans
(Buerger disease, generally seen in young smokers), vasculi-
tis, and thromboembolic disease. The etiology of the ischemia
requires accurate diagnosis before treatment is initiated.
When discussing revascularization plans with the vascular
surgeon, it is important to consider within which angiosome
the ulcer is located. Failure to revascularize the affected angio·
some can lead to a 15% or greater limb loss rate despite a
patent bypass. If the affected angiosome is directly revascular-
ized, wound healing increases by SO% and the risk of major
amputation decreases fourfold.6 For ulcers on the dorsum of
958 Pan IX: Tl'Wik and Lower h:tremity
the ankle or foot, the anterior tibial artery or dorsalis pedis
should be revascularized if possible. If the connection between
the dorsalis pedis and the lateral plantar artery is intact, then
a bypass to the posterior tibial artery is equally successful For
heel ulcers, revascularizing either the posterior tibial artery or
peroneal artery is nec:essary. For mid- and forefoot plantar
wounds, the posterior tibial artery should be chosen, although
revascularizing the dorsalis pedis can be equally effective if the
connection between the dorsalis pedis and the lateral plantar
artery is intact. I£ the ideal vessel is not available, then revas-
~a1ion should prcx:eecl with the understanding that there
is a greater than 1S% chance of failure.
When the patient with significant peripheral vascular dis-
ease presents with gangrene, the timing of revascularization
versus debridement is aitical. If there is stable dry gangrene
without cellulitis, then the revascularization should proceed
promptly but nonurgently. If the patient presents with wet
gangrene with or without cellulitis, the wound should imme-
diately be debrided. Revascularization should then be per-
formed on an urgent basis as progressive gangrene will occur
without new blood flow. After revascularization. wound do-
sure should be initiated only when the wound shows signs
of healing with the appearance of new, healthy granulation
tissue and neoepithelialization. It takes anywhere from 4 to
10 days after a bypass and up to 4 weeks after endovascular
surgery for the wound to develop maximal benefit from the
revascularization.
Connective Tissue Disorders
The connective tissue disorders (e.g., systemic lupus, rheuma-
toid arthritis, and 51Cleroderma) cause difficult-to-treat recalci-
trant va51Culitis ulcers. These ulcers are frequently associated
with Raynaud disease, which causes distal vasospasm and
cutaneous ischemia. Treatment frequently requires immuno-
suppressive drugs such as steroids and immunosuppressive
agents to control the autodestruction of tissue. Until the opti-
mal immunosuppressive regimen is determined, the wound
will not heal. The wound-retarding effects of steroids used
in the immunosuppressive therapy are mitigated with oral
vitamin A (10,000 U/d while the wound is open). The use of
topical vitamin A is also effective. Close coordination with the
rheumatologist is necessary in the management of these most
difficult of wounds.
In addition, almost hal£ of patients with vasculitic ulcers
also suffer £rom a coagulopathy leading to a hypercoagulable
state. The most frequent abnormalities involve antithrombin
m, Lciden factor v, protein c. s,
protein and homocysteine.
Consequently, a coagulation blood panel is obtained on these
patients and if abnormalities exist, they are treated with appro-
priate anticoagulants and/or medications by the hematologist.
The treatment of these ulcers is principally medical. Once
the abnormalities are identified and corrected, wound-healing
adjuncts can help in healing the wound. Cultured skin and
hyperbaric oxygen can be used to stimulate the formation of a
healthy granulation bed. Patience is required in treating these
wounds as less than half go on to heal, which can take as long
as 24 months.7
EVALUATION AND DIAGNOSIS OF
Tim WOUND
The etiology of foot and ankle wounds is often traumatic, with
the underlying pathology complicating the healing process.
Accompanying disease processes include infection, ischemia,
neuropathy, venous hypertension, lymphatic obstruction,
immunologic abnormality, hypercoagulability, vasospasm,
neoplasm, self-induced wound, or any combination of the pre-
ceding. The most frequent systemic comorbidities include dia-
betes, peripheral vascular disease, venous hypertension. and
connective tissue disorders.
Diagnostic Studies
Evaluation of the patient with a foot wound or ulcer begins
with a history and physical examination. Important points in
the history include etiology, duration and previous treatment
of the wound(s), comorbid conditions (diabetes, peripheral
vascular disease, venous insufficiency, atherosclerotic disease,
autoimmune disorders, radiation, coagulopathy, etc.), current
medications, allergies, and nutritional status. It is also impor-
tant to assess the patient's current and anticipated level of
activity. Limb salvage is usually indicated if the patient uses
the leg in any way (inc:luding simple transfers) and if medically
tolerated and tec:hnic:ally feasible. However, if the limb is not
going to be used, then strong consideration should be given
to performing a lmee disarticulation or above-knee amputa-
tion to aare the problem and minimize the risk of recurrent
breakdown.
When performing the physical examination, one should
avoid the temptation to go right to the wound and examine
the entire body. The wound examination includes measuring
the wound (length, width, and depth) and assessment of the
types of tissue involved (i.e., epithelium, dermis, subcutane-
ous tissue, fascia, tendon, joint capsule, and/or bone). The
most accurate way of determining bone involvement is if one
can directly feel bone with a metal probe, which correlates
85% of the time with the existence of osteomyelitis.' Diabetic
ulcers with an area >2 crn2- have a 90% chance of underlying
osteomyelitis regardless of whether the bone is probed at the
base of the wound. The levels of tissue necrosis and possible
avenues of spread of infection via flexor or extensor tendons
are then determined. If cellulitis is present, the border of the
cellulitis is delineated with a marker and the date and time are
noted. This permits the clinician to immediately monitor the
progress of the initial treatment despite the lack of bacterial
culture results.
The vascular supply to the foot is then examined. If pulses
are palpable (dorsalis pedis or posterior tibial artery), there
is usually adequate blood supply for wound healing. If one
cannot palpate pulses, a Doppler should be used. The Doppler
ultrasound probe also allows the surgeon to evaluate the non-
palpable anterior perforating branch and the calcaneal branch
of the peroneal artery. It also helps determine the direction of
flow along the major arteries of the foot to accurately assess
local blood flow when designing a flap or amputation. A tri-
phasic Doppler sound indicates excellent blood £low; a bipha-
sic sound indicates adequate blood flow; and a monophasic;
sound warrants funber investigation by the vascular surgeon.
A monophasic tone does not necessarily reflect inadequate
blood flow as it may reflect lack of vascular tone and absence
of distal resistance.
If the pulses are non-palpable or monophasic, then nonin-
vasive arterial Doppler studies are indicated. It is important to
obtain PVRs (pulse volume recordings) at each level because
arterial bruhial indices are unreliable in patients with calci-
fied vessels (30% of diabetks and all renal failure patients).
Ischemia may be present if the PVR amplitude is <10 mm
Hg. Obtaining arterial toe pressures yields further informa-
tion because digital arteries are less likely to be calcified; if the
toe pressure is <30 mm Hg, ischemia may be present. Tissue
oxygen levels are also helpful in determining whether there
is sufficient blood flow to the extremity. Tissue oxygen pres-
sure levels <40 mm Hg suggest insufficient local blood flow
to heal a wound. Skin perfusion pressure (Vasamed, Eden
Prairie, MN) less than 50 mm Hg also indicates insufficient
blood flow to heal. If the noninvasive tests suggest ischemia,
an arterial imaging study is obtained to evaluate whether a
vascular inflow and/or vascular outflow procedure is required.
While bypass surgery remains the gold standard for revas-
cularization, the less invasive endovascular techniques are
very effective in treating stenosed or obstructed arteries by
dilation, recanalization, or atherectomy with or without

stenting. Combined endovascular and bypass techniques are
also effective.
Sensory examination is performed with a 5.07 Semmes·
Weinstein filament that represents 10 g of pressure. If the
patient cannot feel the filament, protective sensation is
absent, leading to an increased risk of breakdown. ln addi-
tion, one of the following should be used: vibration using
128-Hz tuning fork, pinprick sensation, or ankle reflexes.
Motor function is assessed by looking at the resting position
of the foot and the strength and active range of motion of the
ankle, foot, and toes.
The bone architecture is evaluated by looking at whether
the arch is stable, collapsed, or disjointed. Bone prominence
can occur with collapsed midfoot bones (cuboid or navicu-
lar bone with Charcot destruction of the midfoot), osteophyte
formation, or abnormal biomechanical forces (hallux val-
gus, hammer toe, etc.). An x-ray series of the foot is required
(anteroposterior, oblique, and lateral). The views of the lat-
eral foot should be weight bearing. Calcaneal, sesamoids, and
metatarsal head views may be necessary if local pathology is
suspected. It is important to remember that the x-ray appear-
ance of osteomyelitis lags behind the clinical appearance by
up to 3 weeks. A magnetic resonance imaging (MR.I) scan can
help with earlier detection of osteomyelitis, as well as with
diffi:rentiation between osteomyelitis and Charcot collapse. In
general, bone scans are of no value in evaluation of osteomy-
elitis when there is an ulcer present ~ause the bone under
an ulcer will show increased uptake, regardless of whether or
not osteomyelitis is present. However, if proximal spread of
osteomyelitis along a long bone is to be ruled out, then a nega-
tive bone scan can be very useful.
Finally, the Achilles tendon is evaluated. If the ankle can·
not be dorsiflexed 10° to 15° beyond neutral, the Achilles ten·
don is tight and is placing excessive stress on the arch in the
midfoot and on the plantar forefoot during gait. This needs
to be addressed orthotically or surgically so as to avoid exces-
sive pressure that could lead to Charcot collapse or forefoot
plantar ulceration.
Preparing the Wound for Reconstruction
The goal of treating any type of wound is to promote healing
in a timely fashion. The first step is to establish a dean and
healthy wound base. An acute wound is defined as a recent
wound that has yet to progress through the sequential stages
of wound healing. If the wound is adequately vascularized,
a dean base can be established with simple debridement
and either immediate closure or covering the wound with a
negative-pressure wound closure device for subsequent clo-
sure. A chronic wound is a wound that is arrested in one of
the wound-healing stages (usually the inflammatory stage)
and cannot progress further. Converting a chronic wound
to an acute one requires correction of medical abnormalities
(high blood sugar levels, coagulation abnormalities, chang-
ing or modifying drug therapy, etc.), restoration of adequate
blood flow, administration of appropriate antibiotics if infec-
tion is present, and aggressive debridement of the wound.
The debridement should also include removal of the senes·
cent cells along the edge of the wound (3 to 4 mm of the
wound edge). If the wound has responded to this therapy,
healthy granulation should appear, edema should decrease,
and neoepithelialization should appear at the wound edge.
Negative-pressure wound therapy (NPWT)1 is a useful post·
debridement dressing for the uninfected, well-vascularized
wound because it accelerates the formation of granulation
tissue while decreasing wound edema and keeping the bacte-
rial countdown.
Measuring the wound area weekly is a useful way to
monitor progress, as the rate of normal healing is a 1 0%
to 15% decrease in surface area per week. Assuming
the underlying abnormalities have been corrected (e.g.,
Chapter 95: Foot and Ankle Recoastruction 959
infection, ischemia, and edema) and the healing falls below
the normal healing rate, topical growth factors, cultured
skin, and/or hyperbaric oxygen can be applied alternatively
or in combination.
Surgical debridement is the single most underper£ormed
procedure in treating foot and ankle wounds and ulcers
bec:ause of conc:ems of how to repair the resultant def«t.9
Leaving dead or infected tissue or bone behind because of
concerns about wound closure leads to persistent infection
and further necrosis with the risk of possible amputation.
Biofilm is present in over 90% of chronic wounds. Its pres·
enc:e further complicates the debridement as it penetrates
every aspect of the wound and can be found up to 4 mm
deep to its base because it spreads along the perivascular
plane of arterioles feeding the wound bed. Bio.film can con·
sist of up to 60 different bacteria species, of which a major-
ity are anaerobic. Tissue containing clotted veins or arteries
in dermis or subcutaneous tissue, liquefied fascia or tendon,
and non-bleeding bone should all be debrided. Debridement
should be considered complete only when normal bleeding
tissue remains.
Using colors to guide the debridement is useful to judge
how much to remove. Debriding until onl.y normal red (mus-
cle), yellow (fat), and white (bone, tendon, and fascia) colors
remain is a very useful visual guide. In addition, painting the
base of the wound with blue dye before starting the debride-
ment and making sure that all the blue is removed during the
debridement hdps insure that the entire wound base has been
adequately debrided. Injecting blue dye into a sinus tract or
abscess allows the surgeon to follow the tract and identify the
source of the sinus. The most e.ffeaive debridement technique
consists of removing thin layers of tissue in a sequential fash.
ion until only normal tissue is left behind. This minimizes the
amount of viable tissue sacrificed while ensuring that the tis-
sue left behind is healthy.
The skeleton can usually be stabilized by splinting or cor-
rected by application of an external fixator (monoplanar
frame and lliza.rov frame). The lliza.rov frame provides supe-
rior immobilization, allows for bone transport, and minimizes
the risk of pin track infection because of the thin wire pins. In
addition, the Ilizarov device with footplate hdps avoid jeop-
ardizing any dependent reconstruction (i.e., heel and plantar
foot) by suspending the foot until the reconstructed wound
heals.
Deep uncontaminated tissue cultures pre- and post-
debridement should be obtained during the initial and
subsequent debridements to guide antibiotic therapy (both
intravenous and topical). Effective dressings for wounds
that may still harbor significant bacteria include topical
antibiotics and/or biocides containing acetic acid, bleach,
silver, or iodine. For heavily exudative wounds, an absor-
bent dressing with biocidal ingredients or NPWI' should be
used. For wounds that are dean and well vascularized, a
moist dressing or NPWT can be applied. Debridement is
rescheduled as frequendy as necessary if there is progressive
tissue necrosis or destruction or persistent positive wound
cultures.
Biologic debriding agents such as maggots are useful in
patients too ill for anesthesia or in patients awaiting revas-
cularization. Maggots consume all bacteria including anti-
biotic-resistant bacteria such as VRE. (vancomycin-resistant
enterococci) or MRSA (methicillin-resistant Staphylococcus
aureus) as well as biofilm.
After initial debridement to clean the tissue, it is important
to select a therapeutic option to both prevent a subsequent
bu.ildup of metalloproteases that destroy naturally produced
growth factors and prevent biofilm from reestablishing itsdf.
The baaerial biofilm and proteinaceous debris that form on
the wound sur:lac:e must be removed at regular intervals. This
can be done by scrubbing the wound daily or using wet-to-
dry dressings. Dressings that absorb metalloproteases as well
960 Pan IX: Tl'Wik and Lower h:tremity

as destroy or inhibit biofilm need to be used as intermittent

dressings. There is some evidence that polymerase chain
reaction-guided topical antibiotic gel mixtures accompanied
are also effi:ctive in controlling biofilm.10
If the wound fails to show signs of healing despite
being clean and having adequate blood flow, it can
often be converted into a healing wound by providing
local wound-healing factors to the site. One can apply a
platelet-derived growth factor (Regranex, Ortho-McNeil
Pharmaceutical, Raritan, NJ) daily to the wound or
place a sheet of cultured skin that produces the entire
range of growth factors every 1 to 6 weeks (Apligraf,
Organogenesis, Canton, MA; Dermagraft, Advanced Extensor
Tissue Sciences, La Jolla, CA). The formation of new tis- Dlgilorum
Longus and
sue also can be stimulated by placing a layer of inert der- Peroneus
mis (Integra, Integra LifeSciences, Plainsboro, NJ) over a Tertius 2.1 em --+~ sote:us·s.s em
healthy wound bed and allowing it to revascularize over
the next 10 to 12 days with NPWT or over 3 weeks with-
out NPWT. The newly vascularized dermis can then be
skin grafted with a thin autograft.
Finally, level-one evidence has demonstratld that systemic
hyperbaric oxygen can also be used to convert a non-healing
wound into a healthy granulating wound provided one fol- Peroneus
9revis 4.1
lows approved indications for the procedure.11 Hyperbaric Extensor
oxygen stimulates local angiogenesis in the wound bed, helps Halluc is
in the formation of collagen (cross-linking and extrusion Longus 2.0 em
from the cell), and potentiates the ability of macrophages and
granulocytes to kill bacteria. When healthy granulation tis-
sue appears, the wound can then be closed safely. Failure to
wait until the wound has developed signs of healing (healthy
granulation tissue, neoepitheliali%ation at the skin edge, etc.)
carries a high risk of failure.

RECONSTRUCTIVE TECHNIQUES
Lower Leg, Ankle, and Foot: Muscle and
Fasciocutaneous Flaps
Lower leg, ankle, and foot flaps are described, emphasizing
their vascular supply and their indications. Further details of
individual flap dissection are described in several atlases.11•13
More importantly, repeated cadaver dissection of these flaps,
emphasizing the blood supply, is the most reliable way to
become facile in their use.
Lower Leg and Ankle Flaps
The lower leg muscles make poor pedicled flaps because most
of them are type 4 muscles with segmental minor arterial ped-
ides. As a reilllt, only a small portion of the muscle can safely
be transferred without a delay. Although the bulk of these
muscles is small, the distal portion of some of these type 4 mus-
cles (Figure 95.4) can be used to cover small defects around the
ankle medially, anteriorly, and laterally. To successfully trans-
fer a significant portion of the distal muscle, all the relevant
minor perforators are preserved with the accompanying distal
major artery and depend on retrograde flow. The sacrifice of
a major artery should only be considered if all three arteries
are open and there is excellent retrograde flow. It is impor-
tant to tenodese the distal end of the severed tendon of the
harvested muscle to a muscle with similar function so that the
harvested muscle's function is not lost. For example, if the dis-
tal muscular-tendinous portion of the extensor hallucis longus
(EHL) muscle is harvested, the remaining distal EHL tendon
should be tenodesed to the adjacent extensor digitorum longus
sD that hallux dorsiflexion is not lost. Because the loss of the
anterior tibial tendon is so debilitating, this muscle should not
be ham:sted unless the aokle has been or is being fused.
The EHL muscle can cover small defects that are as dis-
tal as 2 em above the medial malleolus. The extensor digito-
rum longus muscle and peroneus tertius muscle are used for
FIGURE 95.4. The type 4 muscles of the lower leg are DOt only thin
but am only be harve~ted for a distance of 2 ro 3 segmental pe1ficles
and therefore provide very little bulk ro cover lower leg ~. The
figure indicates how fu proximal from the distal medial malleolus
one can expect to find muscle ro actually cover small lower leg defects.
FasciocutaneoUJ flap• actually provide more bulk without affecting
function. For larger defects a free flap ill UJUally a better option. {From
Attinger C. Plastic surgery teclmiques for foot and aukle surgery. In:
Myerson M, ed. Poot and Ankle DisO'fders. Philadelphia, PA: WB
Saunders; 2000:627, with permission.)
small defects as distal as 2 em above the medial malleolus.
The peroneus brevis muscle can be used for small defects as
distal as 4 em above the medial malleolus. The flexor digi-
torum longus muscle can be used for small defects as distal
as 6 em above the medial malleolus. The soleus muscle is the
only type 2 muscle in the distal lower leg and so the minor
distal pedicles can be detached and the muscle can be rotated
with its intact proximal major pedicle rotated to cover large
(10 em X 8 em) anterior lower leg defects as distal as 6.6 em
above the medial malleolus. It can be harvested as a hemiso-
leus for small defects and as an entire soleus for larger defects.
These flaps require skin grafting. ln addition, the ankle has to
be immobilized to avoid dehiscence and ensure adequate skin
graft take. External frames are useful for immobilization and
NPWT assist in skin graft take.
Fasciocutaneous flaps had their origin in 1981 when Ponten
described the medial calf flap. Ftidoaataneous B.aps are use-
ful for reconstruction around the foot and ankle, although
the donor site always requires skin graftmg. The retrograde
peroneal flap is useful for ankle, hed, and proximal dorsal
foot defects. Its blood flow is retrograde and depends on an
intact distal peroneal arterial-arterial anastomosis with either
or both the anterior tibial artery and posterior tibial artery.

The dissection is tedious and it does sacrifice one of the three
major arteries of the leg. A similar retrograde anterior tibial
arte.ry fasciocutaneous flap has been described for coverage in
young patients with traumatic wounds over the same areas.
Because the anterior compartment is the only compartment of
the leg whose muscles depend solely on a single artl\ry, only
the lower half of the artery can be safely harvested as a vas-
cular leash. Both the peroneal and anterior tibial flaps can be
dissected out as perforator flaps obviating the need to sacrifice
a major vessel.
The retrograde sural nerve flap (Figure .95.5) is a versa-
tile neurofasciocutaneous flap that is useful for ankle and
heel defects. The sural artery travels with the sural nerve and
receives retrograde flow from a peroneal perforator S em
above the lateral malleolus. The artery first courses above
the fascia and then penetrates deep to the fascia at mid-
calf while the accompanying lesser saphenous vein remains
suprafascial. The venous congestion often seen with this flap
can be minimized if the pedicle is harvested with 3 em of tis-
sue on either side of the pedicle and with the overlying sldn
intact. Problems with n:nous drainage ~an be further helped
if the flap is delayed, 4 to 10 days earlier, by ligating the
proximal lesser saphenous vein and sural artery. The inset of
the flap is critical to avoid ldnldng of the pedicle. Ingenious
splinting is necessary to avoid pressure on the pedicle while
the flap heals (the Uizarov external frame can be useful in
this regard). The major donor deficit of the flap is the loss of
sensibility along the lateral aspect of the foot. while the skin-
grafted depression in the posterior calf may pose a problem
if the patient subsequently has a below-the-knee amputation.
To minimize donor defect, this flap can be dissected out as a
perforator flap.
The supramalleolar flap can be used for lateral malleo-
lar, anterior ankle, and dorsal foot defects. It can be har-
vested either with the overlying skin or as a fascial layer
that can be skin grafted. When harvested as a fascial flap,
the donor site can be closed primarily. Various local or
perforator flaps can also be designed over the row of per-
forators (Figure .95.6) originating from the posterior tibial
artery medially and the peroneal artery laterally. Although
the reach and size of these flaps are limited, both can be
A B
Chapter .95: Foot and Ankle Recoastruction 961
expanded by applying delay principle. These flaps are
extremely useful in the closure of soft-tissue defects around
the ankle in patients in an Ilizarov frame because accessibil-
ity to pedicled flaps or recipient vessds for free flaps can be
problematic.
Foot Flaps
The muscle flaps in the foot have a type 2 vascular pattern
and are useful for coverage of relatively small defects.l4 The
abductor digiti minimi muscle {Figure .9S.7A) is very useful
for coverage of small mid- and posterior lateral defects of
the sole of the foot and lateral distal and plantar calcaneus.
The dominant pedicle is medial to the muscle's origin at the
calcaneus and the muscle has a thin distal muscular bulk.
The abductor hallucis brevis muscle {Figure .95.7B) is larger
and can be used to cover medial defects of the mid- and
hindfoot, as well as the medial distal ankle. lts dominant
pedicle is at the takeoff of the medial plantar artery. Both
of the above muscles can be used together to cover some-
what larger plantar defects in the midfoot and heel. The
flexor digiti minimi brevis muscle is a small muscle that can
be used to cover defects over the proximal fifth metatarsal
bone. lt receives its dominant pedicle at the lateral plantar
artery takeoff of the digital artery to the fifth toe. The flexor
hallucis brevis muscle has similar vascular anatomy, but can
be harvested on a much longer vascular pedicle as an island
flap on the medial plantar artery to reach defects as far as
the proximal ankle.
The EDB muscle {Figure .95.8) has disappointingly little
bulk but can be used for local defects over the sinus tarsi or
lateral calcaneus. The muscle can be rotated either in a limited
fashion on its dominant pedicle, the lateral tarsal artery, or
in a wider arc if harvested with the dorsalis pedis artery. The
flexor digitorum brevis muscle can be used to cover plantar
heel defects. Because the muscle bulk is small, it works best
if it is used to .fill a deep defect that can then be covered with
plantar tissue.
The most versatile fasaOQltaneous £lap of the foot is the
medial plantar flap, which is the ideal tissue for the cover-
age of plantar defects. It can also reach medial ankle defects.
FIGURE !15.5. Rett()grade sural artery flap. This
flap depends ()n a peroneal perforator 5 an pr()xi.-
mal to the lateral mallwlu&. It also indudes the
lesser saphenous vein. Use of the flap sacrifices
the sural nerve, leaving the lateral foot insensate.
It is useful in covering lower leg, ankle, and hind-
foot defects. A. Flap design. B. Flap dissection
and arc ()£ f()tation. (F.r()m Attinger C. Soft tis-
sue «lverage for lower extremity trauma. Orthop
Clin North Am. 1995;26:3, with permiss.i()n.)
962 Pan IX: Tl'Wik and Lower h:tremity

Anterior tibial
perforators
Posterior --....._
~ tibial Peroneal perforators
Perforating branch , . ~- perforators
of peroneal i. .-f
Anteri;r:;t~ral ---ti"l.· L.<;,;:
l ..~ Anlorior med;al
malleolar · -,. malleolar
~-- - ~ ... ~.,. ' · · f ;.';
Lateral tarsal --~ Medial tarsal
Pbmenor ---~-~~
medial
malleolar

FIGURE 9S.6. Location of the cutaneous perforators is shown. Perlorators are shown as they emanate from the post!lrior tibial atUlry, peroneal
artery, and anterior tibial artery. A flap designed with one of these perforators at its base, located by Doppler ultrasound probe, can encompass
the territory fed by an adjoining perforator. To extend the ftap successfully beyond those boundaries requires a delay procedure. (From Hallock
J. Distal lower leg random Wciocutrmeous flaps. Plast Reconslr Surg. 1990;86:304, with permission.)

The flap can be harvested to a size as large as 6 em x 10 em,
has sensibility, and has a wide arc of rotation if it is taken
with the proximal part of the medial plantar artery whether
distally based on the superficial medial plantar artery or
on the deep medial plantar artery (Figure 95.9). Although
easier to harvest on the deep medial plantar branch, it is
preferable to harvest the flap based on the superficial
branch because there is less disturbance of the inflow to
the remaining foot. When harvested with retrograde flow,
the flap should be based on the deep branch of the medial
plantar artery.
The lateral calameal flap (Figure 95.10) is use£ul £or pot-
tenor calcaneal and distal AdWles de£eas. Its length can be
increased by harvesting it as an L-shaped flap posterior to
and below the lateral malleolus. It is harvested with the lesser
saphenous vein and sural nerve. Because the calcaneal branch
of the peroneal artery lies directly on the periosteum, it is fre·
quently damaged or cut during harvest.

Abc:!liClOt
halllcls
brevis

A Lateral Incision Site B

FIGURE fJS.7. Abductor digiti minimi and abductor hallucis brevis muscle flaps. These muscles have a type 2 vaKUlar pattern, with the domi-
nant pedicle at the level of the distal calcaneus. They are harvested on their dominant proximal pedicles. The distal muscle bulk is often
disappointingly smalL However, these muscles are useful to fill small midfoot, rear-loot, and distal ankle defects. A. Abductor digiti minimi.
B. Abductor halluc:is brevis.

Skin incision
Lateral
tarsal
Extensor artary
(jgttorum
bnMs Dorsalis
muscle -++--- pedis
artary
Extensor
hallucls
brevis
musda
A B
The dorsalis pedis flap can be either proximally or distally
based for coverage of ankle and dorsal foot defects. A flap
wider than 4 em usually requires skin grafting on top of the
extensor tendon paratenon, which deprives the dorsum of the
foot of durable coverage. Because the donor site is vulnerable
£rom both a vascular and tissue breakdown perspective, the
dorsalis pedis flap is now rarely used.
The filet of the toe flap is useful for small forefoot web
space ulcers and distal forefoot problems, even though the
reach of the flap is always less than expeaed. The technique
involves removal of the nail bed, phalangeal bones, extensor
tendons, flexor tendons, and volar plates while leaving the two
digital arteries intact. An elegant variation is the toe island
flap, where a part of the toe pulp is raised directly over the
ipsilateral digital neurovascular bundle and then brought over
to dose a neighboring defi:ct. while its neurovascular pedicle
is buried underneath the intervening tissue.
Treatment Options
Reconstruction is guided by the principle that coverage of a
wound should be performed as quickly and efficiently as pos-
sible. Once the wound is clean and well vascularized, one of
the following reconstructive options is chosen: (a) the defect
is allowed to heal by secondary intention; (b) the wound is
closed primarily; (c) a split- or full-thickness skin graft and!
or neodermis is applied; (d) a local random flap is transposed
or advanced; (e) a pedicled or island flap is transferred; (f)
a microvascular free flap is transferred. BiomC(;hanics are a
critical part of the reconstructive plan and may involve bone
rearrangement, partial joint removal or fusion, or tendon
lengthening or transfer. The method of soft-tissue recon·
struction chosen hinges on the patient's medical condition,
the surgeon's experience, the size of the wound, the vascular
status of the foot. the exposed structures (tendon, joint. and!
or bone}, and the access to the wound (i.e., an Uizarov frame
limits the aa:ess to the foot). Any solution includes resto-
ration of a biomecbanically sound foot to prevent recurrent
breakdown.
Simple coverage (secondary intention, delayed primary
closure, or simple skin graft and/or neodermis) is recom·
mended if there is no tendon, joint, or bone involved. Even
Chapter 95: Foot and Ankle Recoastruction 963
Extensor
dlgltorlum
brevis
E'xtenaor
Hall ucla
brevis
FIGURE 95.8. The extensor digitomm
brevi& mu&cle is a small musc:le based
on the lateral tar&al artery that covers
small defects over the anterior ankle
and sinus tarsi. It can be harvesl!ld on its
short dominant proximal lateral tarsal
artery pedicle. Its reach can be extended
by inc:luding the dorsalis pedis artery
with either antegrade or retrograde flow
depending on the location of the wound.
(From Attinger C. Soft ti&&ue coverage
for lower extremity trauma. Orthop Clin
North Am. 1995;26:3, with permission.)
more complex wounds involving exposed tendon, joint, or
bone that mandated flap reconstruction in the past can now
be treated with simpler methods. For example, wounds over
the Achilles tendon easily develop adequate granulation tis-
sue with good wound care and can be simply covered with a
skin graft and/or neodermis. With NPWT, granulation tissue
forms over tendon, bone, or joints that will heal either by sec-
ondary intention or be skin grafted. With neodermis, with or
without the NPWT, a healthy dermal layer forms over tendon,
bone, or joints that can be skin grafted with a thin autograft
(Figure 9 S.11 ).11 It is critical to immobilize the wound over
a moving joint and to offload the wound to prevent shear·
ing forces from disrupting the healing process. Both NPWI'
and an external fixator can be used to minimize motion at the
wound site, while the Uizarov frame can be used to offload
the wound (i.e., heel and plantar foot). Using these medlods,
more than 85% of all wounds can be dosed by simple tea-
Diques, while less than 15% require £laps.
Wounds will frequently heal by secondary intention with
daily dressing changes, application of the NPWT, and correc-
tion of the biomechanical abnormality. If the resultant scar
might be problematic with nonnal activity (over a joint, plan-
tar foot. and posterior heel), soft-tissue coverage may be the
preferable option. A tight Achilles tendon is the principal cau5e
of forefoot plantar ulceration in diabetics. By lengthening the
tendon and applying a contact cast or equivalent, a plantar
wound usually heals without further treatment over the next 6
weeks (see section on diabetic foot ulcers). The application of
growth factor or cultured skin may hasten the process.
Delayed primary closure can be considered after the edema
and induration of the wound edges have resolved. NPWI' can
be helpful in reducing the edema by absorbing all excess fluid.
After primary closure, one should always check that .relevant
arterial pulses have not diminished because of an excessively
tight closure. If the gap is too large to allow for immediate
closure of the defect, the wound can be closed 5erially or the
remaining gap can be left to heal by secondary intention.
Adequate soft-tissue envelope can also be created by removing
the underlying bone. This occurs in partial foot amputations
where just enough bone is removed to develop adequate soft-
tissue envelopes for delayed primary closure. Correcting the
Charcot collapse of the midfoot arch by removing the arch
964 Pan IX: Tl'Wik and Lower h:tremity

FIGURE 95.9. Medial plantar flap. The most

versatile fasciocutaneous £lap of the foot is the
media.l. plantar £lap. It is ideal for the cover-
age of plantar defed:s. It can be harvested on
the superficial medial plantar artery or on the
deep medial plantar anery. The flap shown is
based on the deep medial plantar artery. A) The
patient has a melanoma resect!ld from hill plan-
tar heel. The medial plantar flap is drawn out
on the plantar instep over the medial plantar
artery. B) The medial plantar flap is dissected
off of the instep. C) The medial plantar flap is
elevated off of the insu:p. D) The healed wound
shows a healed flap covering the plantar heel
and the instep skin grafted.
c

FIGURE 95.10. Lateral calcaneus flap. This fasaoc:utaneous flap can

be extended into an L shape so that it can cover part of the weight-
bearing heel. The donor site is skin grafted. Part A shows the traditional
non extended lateral calcaneal £lap. Pan B shows the design for the
extended lateral calcaneal £lap. (From Attinger C. Soft tissue coverage
for lower extremity trauma. Orthop Clin North Am. 1995;26:3, with
permission.)

A B
and re-fusing the metatarsals to the hindfoot with the help of
the Ilizarov external fixator usually allows for loose approxi-
mation of the plantar soft-tissue ulcer.
Skin grafting can be used to dose most foot and ankle
wounds. A healthy granulating bed is the nea:ssary prereq-
uisite. This can be achieved by the methods delineated above
and include NPWI', cultured skin, growth factor, and/or
hyperbaric oxygen. When there is a healthy granulating bed,
neodermis can be applied to give a more solid construct on
which to skin graft. Successful skin graft take is aided by
removing the granulation bed that contain& bac:terialbiofilm
before placing the skin graft. The wound is then pulse lavaged
and new instruments are used to avoid recontaminating the
wound base. The skin graft can be meshed at a 1:1 ratio to
decrease the risk of seroma or hematoma although we prefer
using an intact skin graft with perforations to allow trapped
fluid to escape. The use of the NPWI' on low continuous suc-
tion as a temporary dressing for the first 3 to 5 days helps
absorb excess fluid and ensure fixation of the skin graft to
the underlying bed and minimizes possible skin graft-recipi-
ent bed disruption from shear forces.' If the skin graft is over
moving muscle or joint, it is critical to immobilize the foot and
ankle by splinting or placement of an external fixator until the
skin graft has completely healed.
Chapter 95: Foot and Ankle Recoastruction 965
FIGURE 9S.11. Ankle ulcer. A. This large ulcer
above the medial ankle was debrided to clean
bleeding tiuue and tibia.. B, C. The wound was
covered with a dermal regeneration template
and NPWT for 10 day&. D. The silicone sheet
was removed off the now va&c:Ularized dermal
template and a thin aurograft was applied.
D
The ideal graft donor site for a plantar wound is the gla-
brous skin from the plantar instep beause the thicker gla-
brous skin graft resists the shear forces applied to the plantar
foot during ambulation. It is harvested at 30/l,OOOth of an
inch, meshed or perforated, and covered with NPWT. The
donor site is, in tum, covered with a skin graft of tSn,oooth
of an inch so that it heals rapidly and holds up better to the
stress of ambulation. For plantar wounds where the patient
is noncompliant either by choice or because of body habitus,
consideration is given to placing an llizarov frame with a pro-
tective footplate until the graft has healed.
The use of any flap requires an accurate assessment of the
blood flow. For local flaps, there should be a Dopplerable per-
forator close to the base of the flap. For pedicled flaps, the
dominant branch to the flap should be patent. For perforator
flaps, the perforator should be identified by Doppler and ide-
ally visualized with duplex ultrasound. For free flaps, there
should be an adequate recipient artery and vein(s). If there is
any question, a duplex scan, cr or .MR.I angiogram, or nor-
mal angiogram is obtained.
Local flaps are useful in coverage of foot and ankle
wounds because they only need to be large enough to cover
the exposed tendon, bone, or joint while the rest of the
wound is skin grafted. This frequently obviates the need for
 966 Pan IX: Tl'Wik and Lower h:tremity
c ;...__ _ _ _ D - - - - - - - - - - - - - - - - -
larger pedicled or free flaps (Figure 95.12). In addition, an
infinite variation of local flaps can easily be done around or
through an Ilizarov external fixator (Figure 95.13) because
the lack of access makes pedicled, perforator, or free flaps
hard to carry out.
Pedicled flaps in the foot and ankle area are often more
difficult to dissect and have a higher perioperative c:omplic:a-
tion rate, although equal. long-term success, as free flaps. 1'
However, free flaps in the foot and ankle carry the highest
failure rate of free flaps in any anatomic loc:ation and should
be planned carefully. One reason for this is that c:omplic:ations
arise when the anastomosis is performed at or near the zone
of injury. In addition, the arteries are often calcified and spe-
cial hardened micro-needles are often required. Anastomoses
should be performed away from the zone of injury, either
proximal or distal to the zone of injury, provided that the
neurovascular bundle is intact. An end-to-side anastomosis
to the recipient artery should be employed whenever possible
to avoid sacrificing one of the main vessels to the foot. Two
venous anastomoses are performed whenever possible to mini-
mize postoperative flap swelling. The use of a coupling device
for vein anastomoses speeds up the procedure.
The choice of free flap depends in large part on the length
of pedicle needed. For long pedicles, the serratus, vastus late·
ralls, anterolateral thigh flap, radial forearm flap, and the rec-
tus kmoris muscles are excellent. It is important to remember
that the pedicle can be extended by further dissection within
the muscle belly. For the dorsum of the foot and ankle, thin
fasciocutaneous and/or perforator flaps work best. For the
plantar foot. skin-grafted muscle flaps and skin graft seem
FIGURE 95.12. V-Y Sap. A, B. A V-Y flap is a V-shaped
flap that, when advancei'l,. forms a Y. C. The V-Y flap
depc:nds on the dir«:t underlying perforators to stay alive.
For that reason, the flap ill dissected down through the fas-
cial layer with no undermining. D. On the plantar aspect of
the foot, the maximum advancem.e:ot ill limit!ld to 1 to 2 an.
to hold up better than fasciocutaneous flaps with the normal
wear and tear of ambulation.
Postsurgical Care
Patients are generally not allowed to bear weight on the
operated foot for 6 weeks if the plantar surface is involved.
Appropriate devices can be prescribed to ofBoad specific parts
of the plantar foot: heel and forefoot. The help of a pedor-
thotist should be sought in cases where off-the-shelf offload-
ing devices are not available. For dorsal wounds, patients are
allowed to ambulate far sooner, provided they are in a dressing
that protects the reconstruction. Because of these limitations,
a patient will often need a course of physical and occupa-
tional rehabilitation to gain the strength and mobility to live
independently at home. Patients should be followed closely in
clinic during the postoperative period and should be seen by a
pedorthotist to get the appropriate shoe to wear once they can
bear weight. When healed, diabetics should return to the care
of a podiatrist for preventive foot care.
RECONSTRUCTIVE OPTIONS BY
LOCATION OF DEFECT
Forefoot Coverage
Toe ulcers and gangrene are best treated with limited ampu-
tations that preserve any viable tissue so that the amputated
toe is as long as possible when closed. Attempts to preserve
at least the proximal portion of the proximal phalanx should
 Chapter 95: Foot and Ankle Recoastruction 967

FIGURE 95.13. Muscle £lap• for ankle defects. Local flap• aze particu-
larly useful around ankle defecu. They need only to be large enough
to cover the portion of the wound that has exposed bone or t!lndoDJ
bc:cause the remainder of the wound c:an be skin grafted. A. B. In this
instance,. the tibio-talaz junction could not be completely covered with a
transposition Sap. C-E. As a result,. a abductor halluc:is muscle flap and
skin graft were harvested to cover the lower half of the wound.

be made so that it can serve as spacer, preventing the toes on
either side from drifting into the empty space. If the hallux
is .involved, attempts should be made to preserve as much as
possible because of its critical role in ambulation.
Ulcers under the metatarsal head(s) occur because biome-
chanical abnormalities place excessive or extended pressure
on the plantar forefoot during the gait cycle. Although ham-
mertoes, long metatarsals, or sesamoids can be contributing
factors, the pr.incipal abnormal biomechanical force is a tight
Achilles tendon that prevents ankle dorsiflexion beyond the
neutral position. If the patient cannot dorsiflex his or her foot
with the knee bent or straight, both the gastrocnemius and
soleus portions of the tendon are tight. In addition, the pos-
terior capsule of the ankle joint may be tight. A percutaneous
release of the Achilles tendon is performed (Figure .95.14A and
B), and if the foot still does not dorsiflex, then a posterior cap-
sular release is performed. If the patient can dorsiflex his or her
foot only when the knee is bent, then the gastrocnemius por-
tion of the Achilles tendon is tight. A gastrocnemius recession
should correct the problem (Figure .95.14C-E). The patient is
kept in a contact cast or cam walker boot for 6 weeks. Because
compliance in diabetics is as low as 28%, a cam walker boot
is reinforced with casting material to ensure that it does not
come off. With the release of the Achilles tendon, the forefoot
968 Pan IX: Tl'Wik and Lower h:tremity
pressure drops dramatically and the ulcer(s), if bone is not
involved, heals simply by secondary intention in less than
6 weeks. The lmgthening of a tight Achilles tendon has deaeased
the nicer reaurena: rate in diabetics by baH at 2 years.s
For patients with normal ankle dorsiflexion who have a
stage 1 to 3 plantar ulcer caused by a plantar-prominent meta-
tarsal head, the affected metatarsal head can be elevated with
preplanned osteotomies and internal fixation. The metatarsal
head is shifted 2 to 3 mm superiorly. Upward movement with
its attendant pressure relief is usually !Ufficient for the under-
lying ulcer to heal by secondary intention. The small, deep
forefoot ulcers, without an obvious bony prominence, can be
allowed to heal by secondary intention or with a local flap.
For larger ulcers where the metatarsal head and distal shaft
are involved, consideration is given to a partial ray amputa·
tion. Resecting the more independent first or fifth metatar·
sal causes less biomechanical disruption than reseaing the
second, third, or fourth metatarsal because the central three
metatarsals operate as a cohesive central unit.
All efforts are made to preserve as much of the metatar-
sals as possible if more than one is compromised because
they are important to normal ambulation. Local tissue is
often insufficient in the forefoot and a microsurgical free
flap is considered. If ulcers are present under several meta-
tarsal heads, or if a transfer lesion from one of the resected
metatarsal heads to a neighboring metatarsal has occurred,
a pan-metatarsal head resection should be considered.
If more than two toes with the accompanying metatarsal
heads have to be resected, then a trans-metatarsal amputa-
tion is performed. The normal parabola, with the second
metatarsal being the longest, is preserved. To avoid the
resultant equinus deformity from the loss of the long and
short toe extensors, the extensor and flexor tendons of the
fourth and fifth toe should be tenodesed with the ankle in
the neutral position and/or the Achilles tendon lengthened.
As much plantar tissue as possible should be preserved to
cover as much of the anterior portion of the amputation
with healthy plantar tissue.

M L M L

M L

D
FIGURE 9S.14. Acl'lilles tendon lengthening. A. Jl both the gastrocnemius and toleuJ portion of the Achilles tendon are tight, the tendon can be
released pera1taneously by making three stab wounds at 2, S, and 8 an above the insertion of the Aclillles into the calcaneus. A no. 1S blade is
inserted into the central raphe of the tendon and the blade is turned 90° to cut half of the tendon at each site. The upper and lower cuts aze in
the medial direction and the a:nu:r c:ut is in the lateral direction. B. Geode doraiflexion preasure is e:xuted on the foot until the tendon releaaes.
C, D. If only the gastrocnemius portion of the Achilles tendon is tight, then a gaatrocnemiua.rea:aaion can be done. The Ac:hillea tendon ia c:ut just
below the mUKle belly of the gastrocmmius mUKles in a linear fashion while the aoleua muacle remains intact. E. If the function of the gaatroc:-
nemius mUKles is to be spared,. then the cut can be made in a tonpe-and-groove fashion.

The most proximal forefoot/distal midfoot amputation is the
Lisfranc amputation where all the metatarsals are removed. The
direction of the blood .Bow along the dorsalis pedis and lateral
plantar artl:ry is evaluated. If both have antq;rade flow, then
the connection between the two can be sacrificed. However,
if only one of the two vessels is providing blood flow to the
entire foot, the connection is preserved. To prevent an equin-
ovaru.s deformity, the anterior tibial tendon should be split and
the lateral aspect inserted into the cuboid bone. In addition, the
Achilles tendon is lengthened. The Lisfranc amputation can be
closed with volar or dorsal .Baps, if there is sufficient tissue. If
there is inadequatx: tissue for coverage, a free muscle flap with
skin graft is used. Postoperatively, the patient's foot is placed in
neutral position until the wound has healed.
Midfoot Coverage
Dekcts on the medial aspect of the sole are non-weight bear-
ing and are best treated with a skin graft. Ulcers on the medial
and lateral plantar midfoot are usually caused by Charcot col-
lapse of the mid foot plantar arch. If the underlying fragmented
bone has healed and is stable (Eichenholz stage 3), then the
excess bone is shaved via a medial or lateral approach while
the ulcer heals by secondary intention or is covered with a gla-
brous skin graft or a local flap. For small defects, useful local
flaps include the V-to-Y flap, the bilobed flap, the rhomboid
flap, and the transposition flap. If a muscle flap is needed, a
pedicled abductor hallucis flap medially or an abductor digiti
minimi flap laterally works well. For slightly larger defects,
large V-to-Y flaps; random, large, medially based rotation
flaps; or pedicled medial plantar fasciocutaneous flap can be
successful. Larger defects should be filled with free muscle
flaps covered by skin grafts. Great care should be taken to
tailor the flap so that it is inset at the same height as the sur-
rounding tissue. If the midfoot bones are unstable (Eichenholz
stage 1 or 2), then they can be excised using a wedge excision
and the arch reconstituted by fusing the proximal metatarsals
to the talus and calcaneus via an Ilizarov frame. The shorten-
ing of the skeletal midfoot usually leaves enough loose soft
tissue to close the wound primarily or with a local flap.
Hindfoot Coverage
Plantar heel defects or ulcers are among the most difficult of
all wounds to treat. If they are the result of the patient being in
a prolonged decubitus position, they usually also reflect severe
vascular disease. A partial calcanectomy (preferably vertical)
may be required to develop enough local soft tissue to cover
the resulting defect. Despite sacrificing the Achilles tendon
insertion, the patient can ambulate with a partially resected
calcaneus provided they use acco.rwnodative foot orthoses.
If there is underlying collapsed bone or bone spur causing a
hindfoot defect, the bone should be shaved. These ulcers are
usually closed with a large, distally based V-to-Y flap or larger
medially based rotation flaps. Plantar heel defects can also
be closed with pedicled flaps that include the medial plantar
fasciocutaneous flap or the flexor digiti minimi muscle flap.
Posterior heel defects are better dosed with an extended lat-
eral calcaneal fasciocutaneous flap or the retrograde sural
artery fasciocutaneous flap. If the defect is large, then a muscle
free flap with skin graft should be used. The flap should be
carefully tailored so that there is no excess tissue and it blends
well with the rest of the heeL Medial or lateral calcaneal
defects usually occur after fracture and attempted repair. If
osteomyelitis develops, the infected bone should be debrided
and the defect filled with antibiotic-containing beads until the
culture retums. Then, the medial defect can usually be covered
with the abductor hallucis muscle flap medially or the abduc-
tor digiti minimi flap laterally. The exposed muscle is then
skin grafted. After 6 or more weeks, the beads can be replaced
with bone graft.
Chapter 95: Foot and Ankle Recoastruction 969
The two hindfoot amputations are the Chopart and Symes
amputations. The Chopart amputation leaves an intact talus
and calcaneus while removing the mid- and forefoot bones of
the foot. To avoid going into equinovarus deformity, a mini-
mum of 2 an of the Achilles tendon has to be resected. When
healed, a calcaneal-tibial rod can be used to further stabilize
the ankle. The Symes amputation should be considered if there
is insufficient tissue to primarily close a Cbopart amputation
and there is insufficient arterial blood supply for a free flap, or
if the talus and calcaneus are involved with osteomyelitis. The
tibia and fibula are cut just above the ankle mortise and the
deboned heel pad is anchored to the anterior portion of the
distal tibia to prevent posterior migration. The large medial
and lateral dog-ears can be carefully trimmed at the initial
operation or 4 to 6 weeks later to yidd a thin, tailored stump
that can fit well into a patellar weight-bearing prosthesis.
Dorsum of the Foot
The defects on the dorsum of the foot are often treated with
simple skin grafts. If the tissue covering the extensor ten-
dons is thin or nonexistent, a dermal regeneration template
(Integra) is applied and, when vascularized, covered with a
thin skin autograft. Local flaps that can be used for small
defects include rotation, bilobed, rhomboid, or transposition
flaps. The EDB muscle .Bap works wdl for sinus tarsi defects
and its reach can be increased by cutting the dorsalis pedis
artery above or below the tarsal artery, depending on the pres-
ence of antegrade and retrograde flow and the location of the
defect. The supramalleolar flap can be used over the lateral
proximal dorsal foot and its reach can be increased by cutting
the anterior perforating branch of the peroneal artery before
it anastomoses with the lateral malleolar artery. For larger or
more distal defects, the most appropriate microsurgical free
flap is a thin fasciocutaneous flap to minimize bulk. The radial
forearm flap is an excellent choice because it is thin, is sen-
sate, and provides a vascularized tendon (palmaris tendon) to
reconstruct lost extensor function. Thin muscle or fascial flaps
with skin grafts are effective options as well.
Ankle Defects
Soft tissue around the ankle is sparse and has minimal flex-
ibility. If there is sufficient granulation tissue, a skin graft will
work well. To encourage the formation of a healthy wound
bed, NPWT, with or without neodermis, can be used. The
Achilles tendon, if allowed sufficient time to form a granulat-
ing bed, will tolerate a skin graft that will hold up well over
time. Local flaps only need to cover the critical area of the
wound including exposed tendon, bone, or joints while the
rest of the wound can be skin grafted (Figure 95.13). Useful
local flaps include rotation or transposition flaps based on
posterior tibial and peroneal arterial perforators. Pedicled
flaps include the supramalleolar flap, the retrograde sural
artery flap, the medial plantar flap, the abductor hallucis mus-
cle flap, the abductor digiti minimi muscle flap, the EHL, and
the EDB muscle flap. Perforator flaps based on the posterior
tibialis or peroneal artery can also be useful. Free flaps can
either be fasciocutaneous or muscle with skin graft but they
must be thin. To ensure good healing, the ankle should be
temporarily immobilized with an external fixator.
CONCLUSION
Treatment of foot wounds requires, at a minimum, the pres-
ence of adequate blood flow, absence of infection, and a sta-
ble skdetal framework. A team approach is required. Once
adequate blood .Bow has been verified or provided, debride-
ment, the platform on which all te(;onstruction begins, is initi-
ated. Debridement is aggressive and repeated as many times
as necessary until the wound is ready for reconstruction.
970 Part IX: Trunk and Lower Extremity
Reconstruction is only considered when the wound demon-
strates signs of healing. Most wounds are closed with simple
surgical techniques, and only a few require sophisticated ana-
tomic knowledge to perform the necessary pedicled, perfora-
tor, or free flaps. Biomechanics are addressed in every patient
so that recurrent breakdown is averted. Finally, when healed,
appropriate orthotics and shoes are ordered to protect the
reconstructed foot.
References
1. Sanders LJ, Robbins JM, Edmonds ME. History of the team approach
to amputation prevention: pioneers and milestones. J Vase StMrg. 2010
September;52(3 suppl):3S-16S.
2. Attinger C, Evans KK, Bulan E, Blwne P, Cooper P. Angiosomes of the
foot and ankle and clinical implications for limb salvage: reconstruction,
incisions, and revascularization. Pla&t Reron&tr Surg. 2006;117:261S-293S.
3. Attinger CE, Cooper P, Blume P, et al. The safest surgical incisions and
amputations using the angiosome concept and Doppler on arterial-arterial
connections of the foot and ankle. Foot Ankle Clin North Am. 2001;6:745.
4. Dellon AL, Mackinnon SE. Chronic nerve compression model for the
double crush hypothesis. Ann Pla&t StMrg. 1991;26:259-264.
5. Mueller MJ, Sinacore DR, Hastings MK, et al. Effect of Achilles tendon
lengthening on neuropathic plantar ulcers, a randomized clinical trial.
J Bone Joint StMrg Am. 2003;85a:1436.
6. Neville RF, Attinger CE, Bulan EJ, Ducic I, Thomassen M, Sidawy AN.
Revascularization of a specific angiosome for limb salvage: does the target
artery matter? Ann Vase SMrg. 2009;23(3):367-373.
7. Shanmugam VK, Price P, Attinger CE, Steen VD. Lower extremity ulcers
in systemic sclerosis: features and response to therapy. Int J Rbe..mtJtol.
2010;2010. doi:pii: 747946. Epub August 18, 2010.
8. Argenta LC, Morykwas MJ. Vacuwn-assisted closure: a new method
for wound control and treatment: clinical experience. Ann Pltut StMrg.
1997;38:563-576.
9. Steed DL, Donohoe D, Webster MW, et al. Effect of extensive debride-
ment and treatment on the healing of diabetic foot ulcers. JAm Coil StMrg.
1996;183:61-64.
10. Dowd SE, Wolcott RD, Kennedy J, Jones C, Cox SB. Molecular diagnos-
tics and personalised medicine in wound care: assessment of outcomes.
J Wound Care. 2011 May;20(5):232, 234-239.
11. Uindahl M, Katzman P, Nilsson A, Hammarlund C. Hyperbaric oxygen
therapy facilitates healing of chronic foot ulcers in patients with diabetes.
Diabetes Care. 2010 May;33(5):998-1003.
12. Strauch B, Vasconez W, Hall-Findlay EJ, Lee BT. Grabb'$ ErJcyClopedia of
Flatu: VoJ..me III: Torso, Pelvis, and Lower &tremitia. Philadelphia, PA:
Lippincott Williams &; Wilkins; 2008.
13. Wei FC, Mardini S. Flap$ tJnd Reconstructive Surgery. London:
Saunders; 2009.
14. Attinger CE, Clemens MW, Ducic I, et al. Chapter 21: The use of local
muscle flaps in foot and ankle reconstruction. In: Dock£ry GD, ed. Lower
Extremity Soft Tissue & CMtaneous Pltutic StMrgl!f")). 2nd ed. Kidlington:
Elsevier Science; 2011.
15. Iorio ML, Goldstein J, Adams M, Steinberg J, Attinger C. Functional limb
salvage in the diabetic patient: the use of a collagen bilayer matrix and risk
factors for amputation. Plast Rero'"tr StMrg. 2011 January;127(1):260-267.
16. Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle
flaps vs. free flaps and the role of diabetes. Plast Recorutr Surg. 2011
July;128(1):173-180.
CHAPTER 96 • RECONSTRUCTION OF
THE PERINEUM
PAUL H. TRAN AND VALERIE LEMAINE
INTRODUCTION
The goals of reconstructive surgery are restoration of both
form and function, and this is especially important when deal-
ing with reconstruction of the perineum. This area presents
complex challenges to the plastic surgeon due to the dose
proximity of several key functional systems, namely the uri-
nary, gynecologic, and gastrointestinal tracts.
The perineum can be conceptualized as a diamond-shaped
space forming the outlet of the pelvis. It is confined within the
following boundaries: (1) anterolaterally, by the inferior mar-
gin of the pubic symphysis and the borders of the ischiopubic
rami; (2) posterolaterally, by the coccyx and the sacrotuber-
ous ligaments (covered by the gluteus maximus muscles); and
(3) laterally, by the two ischial tuberosities. It can be subdi-
vided into two triangles, the urogenital triangle anteriorly and
the anal triangle posteriorly. The perineum is highly vascular
in both males and females. The superficial and deep external
pudendal arteries arise from the femoral artery and provide
the main blood supply to the skin and fascia of the anterior
triangle. They divide into abdominal and perineal branches
approximately 4 to 6 em from the pubic symphysis. The
main pedicle of the posterior triangle is the internal puden·
dal artery, a branch of the internal iliac artery. It gives rise
to the penile (or clitoral) branch and the superficial perineal
artery. The superficial perineal artery divides into medial and
lateral branches and continues into its terminal branches, the
posterior scrotal (or labial) artery. There is also a rich supra-
aponeurotic vascular plexus supplying the labia majora in
women and scrotum in men and surrounding perineal skin
and soft tissue.
Reconstruction of the perineum can be complicated by
prior surgeries and incisions, absent or inadequate muscu-
lature, impaired wound healing from radiation therapy, or
from altered bloody supply. Factors such as smoking, dia-
betes, immunosuppression, atherosclerosis, prior surger-
ies, or advanced age are taken into consideration to avoid
errors in flap selection and to maximize the outcome of the
reconstruction.
GENERAL PRINCIPLES
Etiology of Defects
Perineal reconstruction may be indicated for congenital or
acquired defects. Congenital perineal defects result from
Miillerian or Wolffian aplasia, producing urogenital disor-
ders such as imperforate anus, bladder exstrophy, and vaginal
agenesis or atresia. Acquired perineal defects most commonly
occur following surgical excision of primary or recurrent
colorectal, gynecologic, or urologic malignancies. In this set-
ting, perineal reconstruction frequently requires concomitant
pelvic reconstruction by transferring well-vascularized tissue
of sufficient bulk. Other less common causes of perineal and
genital defects include traumatic injuries and infectious pro-
cesses. Fournier's gangrene is a rare but potentially fatal nec·
rotizing fasciitis of the perineum and abdominal wall, along
with the scrotum and penis in men and the vulva in women.
Fournier's gangrene is a surgical emergency. Skin loss can be
incapacitating, difficult to repair, and may involve a combina·
tion of several techniques to achieve wound closure.
Preoperative Assessment and Surgical Planning
The preoperative evaluation of patients with present or
expected perineal defea:s includes a comprehensive assessment
of the patient's comorbidities and the degree and nature of the
anticipated perineal wound. Communication with the ablative
surgeon is esllential in case adjuvant therapies are planned that
may influence the surgical plan. The anticipated defect of the
external genitalia, the perineal skin, and, in the female patient,
the vagina is evaluated. If partial or total perineal proctec·
tomy is performed with the surrounding skin, it is essential to
anticipate the amount of skin that will be removed. If a pel-
vic exenteration is planned, vascularization of the pelvic floor
musculature may be disrupted. If a cystectomy is planned, pre·
operative discussion with the urologist for planning an ileal
conduit is essential.
RECONS'IRUCTION OF
THE PERINEUM
Perineal reconstruction will ideally result in a healed wound
in a single-stage procedure, with restoration o£ normal or
near-normal func::tion and minimal associated morbidity.
Reconstruction is usually performed with local or regional
flaps from the lower extremity and abdomen, and rarely
requires free tissue transfer. Extensive perineal defects may
require reconstruction with a combination of flaps. A useful
start is the reconstructive ladder, which organizes options by
complexity.
Small defects of the perineum can frequently be dolled pri-
marily. Moderate-sized, superficial defects are amenable to
closure with either healing by secondary intention, skin graft-
ing, or local skin flaps such as a rhomboid flap. Local surveil-
lance in diseases with high recurrence rates, such as Bowen's
disease, may be easier following skin grafting. Skin grafting
and local flap teclmiques may be suboptimal in the setting
of urinary or fecal contamination, or with locally irradiated
tissues. Regional flaps may be more ideal. Large superficial
defects of the perineum (Figure 96.1) may best be downsized
by negative pressure wound therapy, followed by flap or
skin graft coverage. Large defects following abdominoperi-
neal resections or total pelvic exenterations typically require
immediate placement of a vascularized flap into the pelvis
and perineum. Non-rec.onstruaed pelvic cavities may become
filled with iuid and/or intestinal loops, inc:reasing the risk a£
prolonged wound drainage, pelvic abscess, perineal wound
dehiscence, or bowel obstruction and herniation. The trans-
fer of wdl-vascularized flaps to the perineum allows wound
closure without tension, promotes primary wound healing,
decreases postoperative complications, and requires fewer
stages. Communication with the oncologic surgeon is essen-
tial when designing skin incisions and planning the location a£
stomas to preserve potential iap donor sites.
Decisions regarding flap selection include the amount of
soft tissue needed, the adequacy of local blood supply, the
presence of surgical scars at the donor site, patient positioning
during surgery, as well as the operative approach used (i.e.,
laparotomy versus perineal approach). In men, the pdvis is
longer and deeper than in women, so this additional length
should be factored into the flap design.
971
972 Pan IX: Tl'Wik and Lower h:tremity
FIGURE !16.1. A. A 24-year-old male with significant perineum
tiS&ue DeaOsis following infiltration of vasopreS&Ors into his left fem-
oral venous catheter. B. After debridement of necrotic: tissue. C. A
wound vacuum-assisted closure was placed following debridement.
D. One month aftu Split-thickness skin gralt. Couttesy of Brian T.
Carlsen, M.D.
The vertical rectus abdominis myocutaneous (VRAM) £lapt
delivered to the perineum through an intraperitoneal transpel-
vic route, is a workhorse flap for combined pel'ric and perineal
defec:ts.1 The VRAM flap is based on the inferior epigastric
vessels and can be harvested with or without a skin paddle,
depending on the characteristics of the perineal defea. As a
myocutaneous flap, it provides a robust skin paddle to the
perineUD'I., has a reliable vascular supply, and allows transfer
of a large volume of soft tissue to obliterate the pelvic cavity
created by tumor excision.l.llt is extremely versatile, as it can
be used for pelvic reconstruction alone, as well as for recon-
struction of defeas of the anterior or posterior vaginal wall,
or for total vaginal reconstruction. In addition to the vertical
skin paddle design, transverse and large oblique extended skin
paddles have been described for tissue coverage or obliteration
of dead space.4 1mportantconsiderations include: (1) when the
flap is transposed into the pelvis, care must be made to pre-
vent twisting or kinking of the pedicle; (2) the VRAM myocu·
taneous flap skin paddle may be unreliable in obese patients
with thick subcutaneous fat. When compared with thigh flaps,
the VRAM flap following abdominoperineal resec:tion and
pelvic exenteration is associated with fewer major postopera-
tive complications.s
The pedicled greater omental flap is another available
option for reoonstruction of the pelvic floor when a patient
has undergone a laparotomy. This flap is based on the right
or left gastroepiploic vessels and is useful in patients with a
narrow pelvis, in obese patients, or when the VRAM flap is
unavailable. The greater omental flap is sometimes unavail-
able for reconstruction due to insufficient size, presence of

adhesions, or previous surgical removal. Once the greater
omentum has been dissected off the transverse mesocolon and
the greater curvature of stomach, it can be passed to the right
or left midline to bring vascularized tissue into a previously
irradiated pelvis. This improves pelvic lymphatic drainage and
decreases the risk of perineal hernia and bowel obstruction.
The pedicled greater omental flap can also be covered with a
skin graft for vaginal reconstruction.'
The gracilis £lap is another useful flap for reconstruction
of the perineum, due to its versatility and minimal donor site
morbidity. Furthermore, it often lies outside of the radiation
field and does not require a laparotomy. However, it has
a short pedicle and unreliable skin paddle, which can limit
its use for coverage of large defectS. A skin paddle can be
designed over the proximal and middle third of the muscle.
The major pedicle, the ascending branch of the medial cir·
cumflex femoral vessels, is identified as it courses deep to the
adductor longus muscle. During flap harvest; the distal tendon
is divided and the muscle is dissected from distal to proximal,
dividing any perforating vessels. Extended dissection to the
profunda femoris artery provides additional pedicle length.
The flap can then be tunneled into the defect or used as a free
flap (Figure .96.2).
The posterior thigh flap can be useful when the rectus
abdominis myocutaneous flap or the gracilis myocutaneous
flap is unavailable. Based on the inferior gluteal artery, the
posterior thigh flap is designed over the central aspect of the
posterior thigh. Patency of the internal iliac vessels is con-
firmed prior to flap harvest as the inferior gluteal artery is a
terminal branch. The posterior femoral cutaneous nerve inner-
vates the skin of the posterior thigh. The flap is marked over
Chapter 96: Reoonstru.:tion of the Perineum 973
the central axis of the neurovascular pedicle, which exits at
the level of the gluteal crease midway between the greater tro-
chanter and the ischial tuberosity. This flap can be raised with
a patient in the lithotomy position, and the donor site may be
closed primarily or skin grafted. If needed, a large amount of
skin can be harvested, up to 34 em x 15 em. However, to pro-
vide sufficient bulk to obliterate large pelvic defects, this flap
may need to be raised bilaterally7 (Figure .96.3).
The Singapore flap (pudendal thigh flap) is a versatile fas-
ciocutaneous flap often selected for vaginal reconstruction.8 lt
is an axial pattern, sensate flap based on the superficial peri-
neal artery. The pudendal nerve and the posterior cutaneous
nerve of the thigh provide flap innervation. Depending on the
type of perineal defect, the Singapore flap can be designed as
a V-Y fasciocutaneous flap, or as bilateral flaps sewn together
to fo.rm a neovagina.'
Other potential flaps for perineal reconstruction include
the gluteal flap, as weD as fasciocutaneous flaps such as the
medial thigh flap, or perforator flaps. Perforator flaps such
as the pedicled anterolateral thigh (ALT) flap, deep inferior
epigastric perforator flap, and superior gluteal artery perfo·
rator flap have been used successfully to reconstruct perineal
defects/
FUNCTIONAL RESTORATION OF
THE FEMALE PATIENT
The vagina is a cylindrical, muscle-walled strllcture extending
from the vestibule to the uterus. It measures approximately 6
to 7.5 em along its anterior wall and 9 em along its posterior
wall. lt is in close relationship with the fundus of the bladder

FIGURE 96.2. A 26-year-old female with Crohn's disease, status post

abdominoperineal resection. A. Chronic perineal wound. B. Gracilis
muscle flap. C. One-month postoperative result. Couttesy of Molly F.
Walsh, D.O.
974 Pan IX: Tl'Wik and Lower h:tremity
FIGURE 96.3. Pressure sore involving the perineum. A. Preoperative
appearance B. Repair using bilateral V-Y posterior thigh advance-
ment flaps and right gluteal rotation flap. Courtesy of Craig H.
Johnson, M.D.
anteriorly and with the rect:w:n posteriorly. Vaginal defects
result from congenital or acquired causes. The goals of vagi-
nal reconsttuc:tion include primary wound healing, decreased
pelvic dead space, restoration of the pelvic £loor, and the abil-
ity to have sexual interoourse.
Congenital Vaginal Defects
Congenital vaginal agenesis or atresia is frequently associated
with Mayer-Rokitansky-Kuster-Hauser syndrome. This syn-
drome has an estimated incidence of 1 in 4,SOO female births
and is characterized by Mullerian ductal aplasia. Patients
with congenital absence of the vagina typically present with
normal development of secondary sexual characteristics and
normal external genitalia. Associated deformities of the uri·
nary tract and skeletal system are common. Other etiologies
of congenital vaginal defects are those associated with dis-
orders such as gender dysmorphia, bladder exstrophy, and
imperforate anus.
Correction of vaginal agenesis can be accomplished with
nonsurgical or surgical techniques. The Frank method is a
nonsurgical approach that involves tissue expansion of the
vaginal pouch, using vaginal dilators to progressively lengthen
the vagina. It is a painful method with low compliance and
high failure rates among young women. A number of surgi-
cal techniques are available. The most popular is the Abbe-
Mc;lndoe operation involving split-thickness skin grafts that
are molded over a vaginal stent after dissection of a space
be~n the bladder and the rectum. Other available surgical
techniques include intestinal rolpoplasty (e.g., sigmoid colon
flap and jejunal flap) and the modified Singapore flap. When
abdominal or perineal donor sites are unavailable following
previous operative procedures in patients with associated
congenital abnormalities, the gracilis flap or the posterior
thigh flap can be used.
Acquired Vaginal Defects
Acquired vaginal defects can be partial or complete and
most commonly result from surgical treatment of pelvic (i.e.,
colorectal, gynecologic, or urologic) malignancies. Other less
frequent causes of acquired vaginal defects include obstetric
and non-obstetric trauma, infectious processes, and burns.
Small vaginal defects may be closed primarily. Since
regional flaps are usually available. larger vaginal defects
rarely require free tissue transfers. Cordeiro et al.10 have
described a useful classification scheme for acquired vaginal
defects, based on the anatomic location. According to this
classification, partial vaginal deftxts (type I) are separated into
two subtypes. Type IA partial defects involve the anterior and/
or lateral vaginal wall and typically occur following resection
of urinary tract or primary vaginal wall malignancies. The
ideal flap for reoonstruction of this type of defect is the uni-
lateral or bilateral modified Singapore fasciocutaneous flap.
Type mpartial defects are the most common: they are primar·
ily encountered with coloreaal carcinomas extending to the
posterior vaginal wall. The pedicled VRAM flap is ideal for
reconstruction of type mdefects because of its great soft tisrue
bulk (Figure 96.4).
Circumferential vaginal defects (type ll) are also divided
into two subtypes. Type llA vaginal defects involve the upper
two thirds of the vagina, following surgical treatment of uterine
and cervical diseases. They can usually be reconstructed with
a rolled pedicled rectus myocutaneous flap. If the abdominal
donor site is unavailable, an intestinal colpoplasty is another
alternative. Type llB defects are total vaginal defects generally
 Chapter 96: Reoonstru.:tion of the Perineum 975

FIGURE 96.4. A 42-year-old female with recurrent anal cancer

and rectovaginal fistula. A. Defect following resection, includ-
ing the posterior and lateral wa.lls of the vagina. B. A vertical rec-
ms abdominis myocutancous (VRAM) flap inset into the defect.
Cud D. Two-month postoperative result, anterior and posterior view.
E. VRAM donor sin: closure, 2-month postoperative rctult. Courtety of
Molly F. Walsh, D.O.
976 Pan IX: Tl'Wik and Lower h:tremity
resulting from pelvic exenteration, and reconstruction can be
achieved with bilateral gracilis myocutaneous flaps.
Surgical planning of vaginal reconstruction should take
into account the need to restore sexual function. Elderly
patients and patients with significant comorbidities may not
require reconstruction of the vaginal vault. In this setting, a
muscle-only VRAM .flap can be used to fill the pelvic cavity.
When there is concern regarding the viability of the VRAM
flap skin paddle, bilateral modified Singapore flaps may be a
better option for reconstruction of type IB defects. lf a non-
functional vaginal reconstruction is to be achieved, or in the
presence of a type IIA. defect, skin-grafted muscle .flaps can
also be used (e.g., reaus abdominis and gracilis).
Vulvar Defects
Vulvar reconstruction is generally required following surgical
excision of tumors. Squamous cell carcinoma is the most wm-
mon vulvar malignancy. Depending on the characteristics of the
defect, various methods can be used for reconstruction, includ-
ing primary closure, split-thickness skin grafts, or local flaps.
Larger vulvar defects may require coverage with myocutaneous
.flaps from the medial thigh, abdomen, or posterior thigh.
FUNCTIONAL RESTORATION
OF THE MALE PATIENT
Congenital deformities, trauma, in.fi:ctions, lymphatic malfor-
mations, and surgical treatment of malignancies are the most
common causes of male perineal defects.11 Perineal tumor
FIGURE ~.S. A 24-year-old male with idiopathic scrotal and penile lymphedema. A. Preoperative appearance. B and C. Alter debulking of
diseased penile and scrotal skin. D. After application of split-thickness skin gralt harvested from the thigh. The scrotum was dosed primarily.
E. Foam dressing in place to keep the penis at fulllengdl. Couttesy of Craig Johnson, M.D.
resection (e.g., squamous cell carcinoma of the penis, prostate
cancer, and anal cancer) may require radical resection of soft
tissue and subsequent radiation therapy, which can increase
the risk of secondary complications such as perineal fistula
and impaired wound healing.
Functional and aesthetic goals in reconstruction of the male
patient are obviously different from those in female patients.
Sua:essfal reconstruction of the penis takes into consideration
the physiology of the phallus, including {1) a amal for urine
and sperm; (2) ereai.le capability; (3) sufficient length; and (4)
taaile and erogenous sensation.
Surface de:fec::ts of dle penis. Penile skin defects most com·
monly stem from congenital anomalies (e.g., bladder exstro-
phy), infections, trauma, circumcision complications, or
oncologic resection. Surface deformities may also occur in
obese males with a buried penis. Furthermore, idiopathic
lymphedema and radiation-induced lymphedema of the penis
may require therapeutic skin excision and cause surface defects.
Skin coverage can be achieved with various methods
such as mobilization of redundant foreskin in uncircum·
cised patients, scrotal rotation flaps, and local .flaps from the
thigh or abdomen. These, however, are cosmetically inferior
when compared with split-thickness skin grafts. Non-meshed
split-thickness skin grafts (0.010 to 0.015 inch) are preferred
(Figure 96.5). lntracavemosal injec:t:ion to expand the phallus
at maximal length may be helpfal in applying the skin grafts.
Foam dressing or negative pressure wound therapy can be
a useful adjunct to promote successful skin graft healing. In
order to avoid scar contracture and chordee, the suture lines
between the graft edges should run obliquely.

FIGUJlE %.5. (Conlinuedt
Total Penile Reconstruction
Achieving satisfactory cosmetic and functional outcomes in
total penile reconstruction is challenging and may involve sev·
eral Nrgical procedures (Chapter 9.9). Phalloplasty in bladder
exstrophy patients, in female-to-male transsexuals, as well as
in post-traumatic reconstruction is now routinely performed
using microsurgical techniques. Regional flaps (e.g., anterior
lateral thigh flap) have been described for this purpose, but
are associated with a higher incidence of urinary problems
secondary to excessive flap thickness and technical difficul-
ties with urethral reconstruction. The radial forearm free flap
is the preferred method for total penile reconstruction.' The
lateral antebrachial cutaneous nerve can be harvested with
the flap for subsequent neurorrhaphy with the dorsal nerve
of the penis to provide sensory innervation to the neophallus.
Scrotal Reconstruction
Scrotal reconstruction may be required after extensive tis-
sue loss, such as in the case of Fournier's gangrene and sub-
sequent debridements. Hyperbaric oxygen therapy may be
c:onsiderecl as an adjunct to treatment, with a reported sur-
rival advantage. The scrotum is the area most often requir-
ing rec:onstruction. Depending on the size of the defect, the
scrotum can be closed primarily, with local skin flaps or with
sk.in grafts (Figure .96.6). Defects up to SO% can be dosed
primarily, and tissue expansion has been described to achieve
primary closure of defects up to 67%. For extensive wounds,
the testes can be placed in thigh pouches until reconstruction,
or can be managed with repeated wet dressing changes. It is
Chapter 96: Reoonstru.:tion of the Perineum 977
important to keep in mind that long-term exposure to higher
body temperatures in thigh pouches can hinder spermatogen-
esis. Meshed sk.in grafts are ideal for scrotal reconstruction
as long as the tunica vaginalis is intact and are preferred as
they allow exudate to escape, thus improving skin graft take.
The testes will serve as natural tissue expanders, causing them
to descend into an anatomical, dependent position over time.
The spermatic cords should be sewn together before grafting
to prevent a bifid neoscrotum. Skin grafts have the disadvan-
tage of being insensate, and testicular torsion with vascular
compromise in healed grafts has been known to occur. For
extremely large scrotal defects, local flaps such as a pedicled
VRAM flap, a pedicled ALT flap, or a sensate superomedial
thigh fasciocutaneous flap may be considered.7
Penile Replantation
In the setting of penile amputation, replantation can be
achieved at a facility with microsurgical capabilities. Although
macrosc:opic anastamoses can be performed with good erec-
tile function, there is a greater likelihood of skin loss, urethral
strictures, and decreased sensation. Successful microsurgical
replantation has been reported within 6 hours of warm isch-
emia or 16 hours of cold ischemia. The amputated penis should
be rinsed in saline, preserved in saline-soaked gauze, sealed
in a sterile plastic bag, and placed in a bag with crushed ice.
The major steps for microvascular replantation are as follows:
(1) two-layer urethral closure over a catheter with S-0 absorb-
able sutures; (2) minimal dissection of the neurovascular
bundle to identify vessels and nerves; (3) closure of the tunica
albuginea with 3-0 absorbable sutures; (4) microsurgical
 978 Pan IX: Tl'Wik and Lower h:tremity

FIGURE ~.6. A 57-yc:ar-()ld male with angiokuatomas of Fordyce.

A. Preoperative appearance. B. After m:oDStrUc:tion of scrotum with
bilaa:rallocal&aps and .reconstruction of the penis with meshed split-
thickness skin grafts. C. Recurrence of lymphedema of the scrotwn
and right lower extremity 10 years later. D and E. After scrotal reduc-
tion and primary closure. Courtesy of Philip G. Arnold, M.D. and
Samir Mardini, M.D.
c
 Chapter 96: Reoonstru.:tion of the Perineum 979

CONCLUSION
Reconstruction of the perineum remains challenging due to
the complexity of surgical defects, the presence of irradiated
wounds, and the need for functional restoration. The goal of
reconstruction of the perineum is to achieve a healed wound
in a one-stage reconstruction with minimal morbidity. A vari-
ety of reconstructive options are available. Oose communica-
tion with the oncologic surgeons is essential for optimal flap
selection and superior outcomes.

Suggested Readings
1. Buche! EW, Finical S, johnson C. Pelvic recoDStruction using ...ettical
rectus abdomillis musculocuun.eous flaps. Ann Plsut S11rg. 2004;.52:
22-26.
2. Butler Cl!,. RDdriguez-B41a& MA. Pehoic teCOIIStruction after abdominoperi-
ne.al resection: is it worthwhile? Ann Srwg Oneol. 2005;12:91-94.
3. Chessin DB, Hartley J. Cohen AM, et al. Rectus flap reconstruction
decre.ases perineal wound compliu.tioiiS after pell'ic chemoradiJI.tion and
su:gery: a cohort study. Ann Surg O:neol. 2005;12:104-110.
4. Villa M, Saint-Cyr M,. Wong C, et al. Bxtended l'ettical rectus ll.bdomi-
nis myocutaneous flap for pelvic reconstruction: three-dime11sio11al
and four-dimensional computed tomogr11.phy angiographic perfusion
study and clinical outcome analysis. PW:t RiiCon.str S11rg. 2011;127:
200-209.
S. Nelso11 RA. Butler CE. Surgicd outcomes of VRAM ...enus thigh flaps for
immediJI.te reconstruction of pehoic and perilleal CJI.IIcer resectio11 defects.
Pl4.u R8constrSfW8. 2009;123:175-183.
6. Friedman j, Dinh T, Potoclmy J. R.econ.structio11 of the peri~~ewn. St:min
SIWg O:neol. 2000;1lf:282-293.
7. Friedman JD. Reece GR., Bldor L. The utility of the posterior thigh flllp
for complex pell'ic and perined reconstruction. Pltw R~eon.str S11rg.
2010;126:146-155.
8. Woods .JE. Alter G, Meland B, et al. Experience with vaginal reconstruction
utilizing the modified Singapore flap. Pltut Reeon.str SJ~Tg. U92;.90:
270-274.
9. Sinna R, Qusemyar Q. Benhim. T, et al. Pedorator flaps: a 11ew option
iD. peri11ed reoonstr11ction. J Pltut Reron.str Ae3tbet SNrg. 2010;63:
E ~--~---------------- e766-e774.
10. Cordeiro PG, Pluic AL, Disa ,U. A c:bssm<:ation system and reconstruc-
FIGURE 96.6. (Contmuet4 tive al~rithm. for acqllired vaginal ddects. Pltut kroniitr S..rg. 2002;110:
1058-1065.
11. Finical SJ, Arnold PG. Care of the deglond penis and scrotllm: a 25-ye.ar
anastomosis of the dorsal artery with 11-0 nylon and the dorsal e:xperie11ce. Pltut kCO'IIItr s,g. 1999;104:2074-2078.
12. Campbell MF, Wein AJ, KaTolmi LR. Czmpbe11-Wtlhh Urolog)l. lfth ed.
vein with 9-0 nylon or a venous coupler; and (S) epineural Philadelphia, PA: W.B. Salllld.ers; 2007.
repair of the dorsal nerve with 10·0 nylon. The patient should
also receive a suprapubic cystostomy.u
CHAPTER 97 • LYMPHEDEMA: DIAGNOSIS
AND TREATMENT
STEVEN M. LE'V1NEt DAVID W. CHANG, AND BABAK J. MEHRARA
INTRODUCTION
Lymphedema is the accumulation of protein-rich interstitial
fluid in tissues and occurs when the transport capacity of the
lymphatic system is exceeded (Figure .97.1). Lymphedema can
occur secondary to congenital abnormalities of the lymphatic
system (primary lymphedema) or as a result of an acquired con-
dition in which lymphatic channels are injured or obstructed
(secondary lymphedema). In Western countries, lymphedema
occurs most commonly as a complication of cancer treatment
after lymph node excision with breast cancer patients making
up the largest number of patients in the United States. As many
as SO% of patients who undergo axillary lymph node dissec-
tion, and 4% to 7% o£ patients who undergo sentinel lymph
node biopsy, will den:lop lymphedema.1 Lymphedema is also
a common complication of the treatment of other malignan-
cies. A recent meta-analysis of 7,7.90 patients reported a 16%
risk of lymphedema in patients treated for a variety of tumors,
including sarcoma (30%), melanoma (16%), gynecological
(20%), and genitourinary (10%) malignancies. 2 Overall, it is
estimated that 3 to 5 million Americans suffer from lymph-
edema and as many as 25 to 50,000 new cases are diagnosed
FIGURE !17.1. Patient with seven: lymphedema of the right arm.
980
annually. Severe lymphedema is associated with recurrent
infections, disfigurement, pain, secondary malignancies, and
deaeased quality of life, in addition to the financial burden on
the health care system.
Development of effective treatment strategies for lymph-
edema has been hampered by the fact that the etiology of this
disorder remains largely unknown. Although recent stud-
ies have delineated the molecular mechanisms that regulate
lymphatic repair and regeneration, it is still not clear why
lymphadenectomy or lymphatic injury results in lymphedema
in some patients and not in others. Similarly, we cannot accu-
rately predict the disease course for individual patients, their
response to various treatment strategies, or the effectiveness of
preventative options. As a result, treatment for lymphedema
is palliative with a goal of preventing disease progression and
symptomatic relief.
TYPESOFLY~HEDEMA
Lymphedema that arises from a developmental abnormality of
the lymphatic system is termed primaty lymp'Mdema. These
disorders can be present at birth, or more commonly develop
later in life manifesting as unilateral or bilateral limb edema.
Congtmital lympbetkma is clinically evident at birth and
accounts for 10% to 25% of all primary lymphedemas. As
with most forms of primary lymphedema, females are affected
twice as often as males and the lower extremity is involved
three times more commonly than the upper extremity.
A subset of congenital lymphedema patients demonstrates
a familial, sex-linked pattern of inheritance (termed Milroy•s
disease) and accounts for approximately 2% of patients with
congenital lymphedema. Milroy described this hereditary
disorder in 1892 when he traced a single patient's lymph-
edema through six generations. The disease is characterized
histologically by hypoplastic lymphatic channds and variable
degrees of dermal and collecting lymphatic agenesis. Recent
studies have demonstrated that Milroy's disease is caused by
loss of function mutations in the vascular endothelial growth
factor-3 receptor, a key regulator of lymphatic development
and regeneration.
Lymphetkma prauox is the most common form of pri-
mary lymphedema accounting for 65% to 80% of all cases.
Patients with lymphedema praecox usually present with uni-
lateral (70%) limb edema beginning after birth and before
35 years of age as a result of lymphatics that are reduced
in caliber and number. Presentation at puberty is the most
common age and females are affected four times as fre-
quently as males.
Lympht!tkma tartla is a primary form of lymphedema that
manifests clinically after the age of 35 years and accounts for
a relatively small number of cases of primary lymphedema
(10%). Lymphedema tarda most commonly affects the lower
extremity and occurs more commonly in women. The diag-
nosis is made by exclusion of other forms of lymphedema
or causes of limb swelling and often occurs with a familial
pattem. Loss of function mutations of the FOXC2 gene have
been reported in some patients, and histological examina-
tion usually demonstrates hyperplastic, tortuous lymphatics
of increased caliber and number and incompetent or absent
lymphatic valves.
 Chapter .97: Lymphedema: Diagnosis and Treatment
SECONDARY LYMPHEDEMA
Secondary lymphedema is the acquired dysfunction of other-
wise normal lymphatics. Trauma#U: lymphtttkma occurs as
a consequence of scarring or injury following trauma, can·
cer treatment, burn injury, or radiation exposure and is the
most common cause of lymphedema in the United States.
Traumatic lymphedema can also occur after extensive skin
resection performed for a variety of conditions including mas·
sive weight loss. I1f(edioJU lymphetkma is caused by inva·
sion of the lymphatic vessels with a foreign organism. This
is usually the filarial worm, Wuchereria bancrofti, but can
also be other microorganisms such as Mycobacterium tuber-
culosis, Treponema pallidum, or other organisms including
streptococci and fungi. With between 140 and 2SO miUion
cases worldwide, filariasis remains the most common cause
of lymphedema outside of the developed world. lnflammation
resulting from invasion of the lymphatic system by microor·
ganisms leads to progressive fibrosis and lymphatic dysfunc-
tion resulting in lymphedema of massive proportions.
Infiltration and obstruction of the lymphatic system with
malignant cells can result in malignant lymphedema. This
condition should be considered in the differential diagnosis
of patients who present with lymphedema without an obvi-
ous cause. P03t-venous thrombosis lymphetkma can occur
after ligation or thrombosis of a major extremity vein and
is thought to occur as a result of increased venous pressure
diminishing lymphatic return.
DIAGNOSIS OF LY!\-fPHEDEMA
The diagnosis of lymphedema is usually made by clinical his·
tory and physical examination (Figure .97.2).3 Patients typi-
cally present with complaints of limb swelling; tightness in
the skin; functional complaints such as heaviness, fatigue,
and difficulty moving a joint; and a history of recurrent infec-
tions. Limb circumference or volume measurements can be
performed to confirm limb swelling. A difference in limb mea-
surement of greater than 2 em or a 200 m1 increase in volume
when compared with the una.Hected limb is generally consid-
ered clinically significant lymphedema. Most patients will also
have a history of traumatic injury to the lymphatic system
since secondary lymphedema is the most common form of
lymphedema in the United States. Obesity, infections, and a
history of radiation therapy increase the risk of lymphedema
significantly after surgery. Patients with primary lymphedema
may have a family history; however, sporadic forms of pri-
mary lymphedema also occur. In these situations, the diagno·
sis of primary lymphedema is a diagnosis of exclusion.
Rarely, patients with long-standing lymphedema will
present with lymphangiosarcoma, an aggressive tumor with
aS-year surri.val of less than 10% (Figure ..97.3}. This com-
plication was first reported by Stuart and Treves in 1.948
in patients with postmastectomy lymphedema and is also
FIGUJlE ~7.2. Diagnosis of lymphedema. MRI, magnetic rcsonauce imaging; CT, computed tomography; USG, ultrasonography.
981
referred to as Stuart-Treves syndrome. Patients present with
red or purple nodules in the diseased tissues and are most
commonly treated with amputation. Despite aggressive surgi-
cal management, however, the average survival after diagnosis
is only 19 months.
The differential diagnosis of lymphedema includes deep
vein thrombosis, congestive heart failure, malignancy, and
infection. In some cases, additional tests may be required to
diagnose lymphedema. Lymphoscintigraphy is performed by
the injection of radiolabeled colloid into the region of inter·
est and then its transport is followed using a gamma counter.
Although lymphoscintigraphy is helpful in the diagnosis of
lymphedema, the interpretation of these studies is not stan-
dardized making it difficult to compare findings between
studies. The use of the lymphatic transport index has been sug·
gested to standardize these findings but has not been widely
accepted. Lymphoscintigraphy is differentiated from contrast
lymphography, which involves the injection of radio-opaque
dye directly into peripheral lymph vessels with radiological
assessment of lymphatic flow. This test has largely been aban·
doned, however, due to technical difficulties and also because
the contrast dye can injure the remaining lymphatic vessels
resulting in worsening of lymphedema.
Lymphedema diagnosis and quantification can also be
performed with a variety of noninvasive methods, including
perometry, tissue tonometry, bioimpedance spectroscopy, and
radiologic imaging techniques. Perometry is a method to cal-
culate limb volumes and relies on the use of infrared scanning
u:chnology to estimate limb cross-sectional diameters at mul-
tiple intervals. Bioimpedance measures the rate of electrical
current transmission through tissues and can estimate fluid
content in a lymphedematous limb when compared with the
normal limb. This technique is particularly helpful in early
stage lymphedema. Finally, both magnetic resonance imaging
(MRI) and computerized axial tomography (CI') can be used
to assess lymphedema. On both MRI and CT scan, lymph-
edema appears as a subcutaneous honeycomb pattern. Finally,
ultrasound can be used to evaluate lymphedema by correlat-
ing the thiclrness of the subcutaneous tissue with the progres-
sion of lymphedema and fibrosis.
STAGING OF LYMPHEDEMA
Lymphedema can be classified based on its clinical features,
changes in limb volumes, or changes in limb circumference.
Several classification schemes exist, though no single system
has gained universal acceptance. The International Society of
Lymphology stages lymphedema based on changes in the tis-
sues.4 Stage 0 (latent lymphedema) is defined as impaired Buid
transport without evidence of swelling or edema. Stage I is the
early accumulation of protein-rich interstitial Buid, resulting
in measurable swelling with pitting of the skin that decreases
after compression garment treatment. Stage n is character-
ized by limb swelling (non-pitting) that does not decrease with
982 Pan IX: Tl'Wik and Lower h:tremity
FIGURE 97.3. Patient with lymphangiosarcoma of the right arm
after long-standing lymphedema secondary to mastectomy and
axillary lymph node dissection.
compression due to fibrofatty tissue deposition. Stage m (lym-
phostatic elephantiasis) demonstrates severe swelling, fibrosis,
adiposity, and skin changes (hyperkeratosis and acanthosis).
Campisi et aL have proposed a similar staging scheme with
stage I defined as initial or irregular edema, stage ll as per-
sistent lymphedema, stage m as persistent lymphedema with
lymphangitis, stage IV as .fibrolymphedema ("column" limb);
and stage V as elephantiasis.5
Lymphedema can also be classified based on changes in
limb circumference when compared with preoperative mea-
sures or in comparison to the unaffected limb. Increases of
less than 2 em are considered mild lymphedema, 2 to 4 em
moderate lymphedema, and greater than 4 em severe lymph-
edema. Though easy to conceptualize, this classification sys-
tem has two major flaws: the inter-examiner variability of
measurements and the relative nature of the grading scheme
(i.e., a 2 em increase in a thin patient is more noticeable than a
2 em increase in an obese patient). Furthermore, circumfer-
ence measurements may vary significantly due to the use of
compression garments or changes in patient activity.
NONSURGICAL lREATMENT OF
LYMPHEDEMA
Complex Decongestive Therapy
Complex decongestive therapy (CDT) is the mainstay of
lymphedema management and aims to deaease the amount
of fiuid in lymphedematous tissues.'·7 CDT is comprised of
multiple therapies and is usually divided into two phases.
Phase 1 is an intensive treatment regimen typically performed
once or twice daily for 4 to 6 weeks. Patients are treated with
manual lymphatic drainage (MLD), skin care, compression
wraps with short-stretch bandages, and light exercises. MID
is a form of soft tissue massage performed with light strokes
in a directional manner to increase lymphatic fluid flow away
from damaged lymphatics. In phase 2, MLD use is decreased
and patients are primarily treated with compressive garments
and skin care administered indefinitely since lymphedema is
a chronic disease. Some patients are given additional phase 1
treatments if there is evidence of relapse or progression of
disease. In addition, some centers prescribe intermittent pneu-
matic compression (IPC) in this phase.
CDT is effective in most patients; however, this therapy is
time intensive, is expensive, and requires a high level of sophis-
tication on the part of the patient and caregiver. Certified
lymphedema therapists are sometimes difficult to find, and the
costs of long-term care are not always covered by health insur·
ance policies. These difficulties contribute to relativdy high
rates of patient noncompliance.
Compression Therapy
Compression therapy includes a wide range of treatments,
including multilayer bandaging, sdf-adherent wraps, and cus·
tom-made pressure garments. The goal of these treatments is
to restore hydrostatic pressure in the limb and improve lymph
flow. It is important to note that wraps are performed with
low-strett:h bandages rather than high-stretch bandages (e.g.,
Ace bandage). This difference is important since short-stretch
bandages maintain a constant pressure at rest but exert an
increased pressure with exercise. In contrast, high-stretch ban-
dages may exert high pressures at rert thereby causing circula-
tory compromise.
Intermittent Pneumatic Compression
The IPC device is a pneumatic cuH connected to a pump that
simulates the natural pump effea of muscular contraction on
the peripheral lymphatic system. IPC pumps typically cycle
and have pressures in the range of 35 to 180 mm Hg applied
either uniformly or sequentially. Although some studies have
shown that IPC can be effective in patients with secondary
lymphedema, particularly when combined with compression
garments, there is currently no consensus on the use of these
devices and costs of these devices are usually not covered by
insurance plans.
Exercise
For many years, it was thought that patients with lymphedema
or those at risk for devdoping lymphedema should refrain
from vigorous exercise with the affected limb. This concept
was based on the idea that exercise increased blood flow
and hence lymphatic load. More recently, however, multiple
prospective studies have demonstrated significant benefits in
monitored exercise regimens. Although the exact mechanisms
by which exercise improves lymphedema remain unknown, it
is thought that activation of the muscular pump mechanism
helps propd lymphatic fluid in the affected extremity. It is also
possible that exercise improves lymphedema by promoting
weight loss and maintenance of ideal body weight since these
factors have also been shown to decrease the incidence and
severity of lymphedema.
SURGICAL lREAT.MENT OF
LYMPHEDEMA
Although the mainstay of lymphedema treatment is non·
surgical, a number of surgical options have been described.
However, there is currently no consensus on patient selection,
the type of procedure, timing of intervention, or postoperative
management. In most cases, surgery is reserved for patients
with significant symptoms and functional complaints who
have failed conservative management. Some authors, how-
ever, describe their experience with patients who are simply
dissatisfied with compression garments.
The surgical options available for lymphedema can be
broadly divided into physiologic approaches and reductive
techniques (Figure 97.4). Physiological treatments aim to
restore lymphatic flow and include flap transposition, lymph
node transfers, and lymphatic bypass procedures. Reductive
 Chapter 97: Lymphedema: DiagnoJis and Treatment
techniques, such as surgical excision or liposuction, simply
aim to treat the consequences of sustained lymphatic fluid sta-
sis by removing the fibrofatty tissues that has been pathologi-
cally generated.
PHYSIOLOGICAL ME1HODS
Flap Transfer
The first repom:d case of flap transposition for the treatment
of lymphedema is crediml to Gilles who described a two-stage
tubed flap transfer from the arm to the abdomen and ulti-
mately the affected groin. He reported improvement in the
patients' chronic lymphedema and hypothesized that the skin
flap provided a path for lymphatic fluid to bypass the dam-
aged inguinal region. Goldsmith used this same concept and
reported his experience with the use of pedicled omentum flap
transpositions in a series of 22 patients (13 with lower extrem-
ity and 9 with upper extremity). Nearly half of the patients
experienced good results; however, due to the high rates of
complications, including adhesions, abdominal waD hernias
with incarcerated bowel, pulmonary embolus, and wound
healing complications, the procedure failed to gain wide-
spread acceptance. With the advent of modem pedicled and
free flap procedures, several case series and case reports have
been published detailing improvements in lymphedema of the
lower/upper extremity, genitalia, and head and neck after flap
transfer. Unfortunately, the unpredictable outcomes associ-
ated with these procedures have precluded their widespread
clinical application.
Lymphatic Bypass
With the understanding that lymphedema was the result
of lymphatic fluid stasis, in 1908 Harvey attempted to
re-establish lymphatic flow by tunneling silk threads subcuta-
neously from the lymphedematous tissue into adjacent healthy
tissue. Lexer later modified the procedure to use strips of fas-
cia lata instead of silk thread while Walther used rubber tubes.
Although seemingly reasonable from a pathologic standpoint,
none of these procedures produced long-lasting results. In the
1960s, shortly after the introduction of microsurgery, Laine
and Howard and Olsewski and Nielubowicz first reported
on using microsurgical techniques to help restore absent or
scarred lymph basins. Since then, a variety of procedures
have been proposed to bypass obstructed lymphatics either
by connecting obstructed lymphatics to normal lymphatics
(lymphatic-lymphatic bypass) or by connecting lymphatics to
a local or distant vein (lymphaticovenous bypass; Figure 97.5).
Lymphalic-#ymphatU: bypass is performed by transferring
a soft tissue graft containing superficial lymphatics from the
anterior thigh to the affected limb and connecting the col-
lecting lymphatics of the graft to lymphatic channels in the
lymphedematous region. The graft is then tunneled subcuta-
neously into a non-lymphedematous area, and the proximal
983
FIGURE 97.4. Surgical options for lymphedema.
lymphatic vessels in the graft are anastomosed to the local,
healthy lymphatics. Alternatively, vein grafts can be harvested
and several small, transected lymphatic vessels are inserted
into the distal cut end of the vein. The vein graft is then tun·
neled into the neck or distal to the damaged groin lymphatics
and anastomosed to local lymphatic channels.5
Connection of lymphatic vessels to regional veins forms the
basis of lymphtllicowmous procedures. These procedures were
initially described as end-to-side anastomoses to large super·
.ficial veins (e.g., saphenous). However, some authors have
criticized this approach as theorizing that the high pressures
in the veins would impede lymphatic drainage. More recently,
supermicrosurgical techniques have been used to connect col-
lecting lymphatics in an end-to-end manner with subdermal
veins to avoid this issue.
Lymph 1fOtk transfers are performed by harvesting lymph
nodes from an unaffected region (usually the superficial ingui-
nal nodes) and transferring them either as grafts or as a free
flap with microsurgical anastomoses of the artery and vein.
The transplanted lymph nodes may be transferred to the site
of the original lymph node resection or to nonanatomic areas
such as the dorsum of the arm in upper extremity lymph-
edema. Although there have been anC(;dotal reports of success
utilizing these procedures, the rationale for their success, par-
ticularly when lymph nodes are transferred to nonanatomic
sites, is not entirely clear. Furthermore, engraftment of avas-
cular lymph nodes with reconnecti.on to the surrounding lym-
phatic networks has not been verified clinically and occurs at
relatively low rates in animal models, casting further doubt on
the effectiveness of these procedures. Finally, given that even
relatively minor injury to the lymphatic system such as senti-
nel lymph node biopsy can result in lymphedema, it is possible
that harvesting of lymph nodes for transfer may cause lymph-
edema in the donor extremity.
Although there is no general consensus for indications or
timing of lymphatic bypass procedures, most authors agree
that these interventions should be reserved for patients who
have failed conservative management or suffer from recurrent
cellulitis or lymphangitis. Bypass procedures are, in general,
thought to be feasible even years after the onset of lymph-
edema so long as fibrosis and fat hypertrophy in the affected
limb are not severe. Most authors consider patients with early
stage lymphedema (Campisi stage I, n, or early stage m) as
the ideal candidates and it is thought that patients with more
advanced lymphedema are less likely to benefit from lym-
phatic bypass procedures. As a result, many authors consider
extensive soft tissue fibrosis or fatty deposition as relative
contraindications to lymphatic bypass procedures. Similarly,
due to the potential for backflow into the lymphatic system,
venous hypertension is also considered a contraindication to
these procedures by most authors.
Several groups have reported the results of lymphatic
bypass procedures; however, the reported outcomes have been
highly variable with some groups describing excellent results
and others reporting modest or no improvement in either
984 Pan IX: Tl'Wik and Lower h:tremity
\ \
A B
FIGURE fJ"/.S. Schematic of phytiologic procedures for lymphedema. A. Lympholymphatic bypass utilizing lymphatic vessels and soft tiSIUes
harvested from the anterior thigh. B. Lympholymphatic bypass utilizing saphenous vein as conduit. C. Lymph node transfer. D. Lymphovenous
bypass.
objective measures or subjective measures of lymphedema
symptoms (Table 97.1 ). A number of factors amtribute to this
variability. Perhaps, the most significant problem has been the
retrospective nature of analysis and irregular or inadequate
follow-up after surgery.ln addition, there is considerable vari-
ability between studies in how lymphedema is assessed both
objectivdy and subjectively and significant differences in cri-
teria for patient selection, timing of intervention, identifica-
tion of suitable lymphatic vessels, and the type of lymphatic
bypass procedure that is performed. Objective analysis is
particularly problematic with a variety of techniques used by
different groups to estimate the excess volume in the aHected
limb before and after surgery. In addition, most studies have
utilized just one measure (either limb volume or circumfer-
ence, for example} and have not used complementary nonin·
vasive techniques to assess lymphatic flow or changes in tissue
pliability or fluid content. Perhaps most significantly, there is
also wide ranging differences in the use of compression gar-
mentslphysical therapy postoperatively that may alter limb
volumes independently from surgical inkrventions. Subjective
analysis has been particularly problematic with most studies
utilizing non-validated, non-standardized questionnaires to
evaluate patients. Finally, many studies have reported mixed
series of patients with either upper or lower lymphedema or
lymphedema resulting from various etiologies, including can·
cer surgery, trauma, congenital conditions, and filariasis. In
D
fact, these weaknesses cast significant doubt on any conclu-
sions demonstrating a benefit.
Chant reported his early experience in using lymphati·
covenular bypass in 20 patients with upper extremity lymph·
edema related to the treatment of breast cancer. Nineteen
patients (95%) reported that their symptoms improved after
surgery, and 13 patients had quantitative improvement. The
mean reduction in volume differential was 29%, 36%, 39%,
and 35% at 1, 3, 6, and 12 months, respectively.
One recent advance in the lymphovenous bypass operation
has been the use of fluorescence lymphography to image the
lymphatic system during lymphovenous shunt operations and to
diagnose the severity of lymphedema.' Fluorescence lymphogra-
phy allows surgeons to locate a functional lymphatic vessel for
the lymphovenous shunt before making a skin incision. This tech·
nique allows for the prompt identification of the functionallym·
phatic vessels, and thus has the potential to significantly improve
the outwmes of lymphovenous bypass operations (Figure .97.6).
While the benefits of lymphatic bypass procedures are
unverified, complication rates of these procedures appear
low.1•1•10•11 These complications are usually minor (wound
healing, lymphatic fistula, and cdlulitis) and improve sponta·
neously. Further, extended antibiotic use decreases postopera-
tive cellulitis. Interestingly, despite the fact that lymphedema is
a chronic, progressive disease, very few studies have reported
worsening of lymphedema symptoms after surgery.
OUTCOMES AFTER t'HYSrOLOGIC PROCEDURES

• TYPE AND • ADDffiONAL • OUTCOMB

• TYPE • Alfl'HOR • N STAGB • ARBA • INDICATIONS • PROCBDURE • FlU TRBATMBNT MBASURES • RBSULTS
Retro Campisi -t800 to, r UE, LE Failed LVA,LVL Variable t5% continued Volume Volume decreased in 83%
(20t0) conservative Rx gannent LS of patients (average 67%)
Rec:urreot c:ellulitis, Subjective 87% decreased incidmce
pain, dysfunction, ofcelluli~
dissa~faaion I..S improved
Some details not reported
Retro Mukenge 5 r Genital Failed LVA 6.8 ± 0.8 mo None Cfscan 4/5 bad "satisfactory" decrease
(20t0) conservative Rx Lymphangiography in edema and improved
StageR Subjective subjective symptoms
Canc:er free Three patients with 3-5 y
follow-up had 9o-tOO%
resolution of edema
Prosp Chang 20 r UE Stage n or m post LVA ty Compression Volume (peromeuy) 95% subjective improvemmt
(20t0) mastectomy-related (supermicrosurgery) after 4 wk Subjective 65% bad volume decrease
lymphedema (35% decrease in volume)
l 0
,r
- Campisi stage n, m, LVA±LVL to patimts mean decrease in
Reuo Demiuas 78 I.E 13.2mo mevatiou Volume
(20t0) and IV Short-stretch volume = 56.2 ± 22.8%
bandageXtmo r patients mean decrease in
Garment X 6 mo volume= 60.3% ± t8.t%
Reuo Nagase, >80 to, 2o UFILE Failed conservative LVA 4.6y Elevation Circumference 62% of patients had a decrease
Koshhima therapy X 6 mo (supermicrosurgery) Compression of4cm
(2005) bandage Mean decreae = 4.7 an
Prostaglandins (for
lymphatic dilatation)
Reuo O'Brien 134 20 UE,LE Not described LVA (52 pts) 3-6 y mevatiou at night Volume and LVAonly:
(t990) LVA and reduction for3mo circumference 42% improved (44%
(38 pts) Garments Subjective decrease in volume)
Reduction only variable t2% unchanged (6%
(38 patimts) increase in volume)
45% worse (29% increase in
volume)
LVA and reduaion:
60% improved (44%
decrease in volume)
t6% no change (2%
increase in volume)
24% worse (35% increase in
volume)
94% subjective improvemmt
58% decrease cellulitis
Prosp, prmpeccive; Retro, retrospective, 1•12•, primary/&eeondary; UE, upper extremity; I.E, lower extremity; LVA, lympbaticovenous ana.&tomosit.; LVI., lympbacicovenous-lympbacic hypass; LS, lymphoscintigraphy.

I
986 Pan IX: Tl'Wik and Lower h:tremity
defined lymphedema as an increase in volume of 100 cc. 'This
volume is controversial since it is considered to be within the
standard error of volume measurements. AJi, a result, most
previous studies have considered volume changes of more
than 200 cc consistent with lymphedema. In addition, many
patients in a study probably received the benefits of limb ele-
vation, compression therapy, and other noninvasive measures.

REDUCTIVE lviETHODS
Direct Excision
Since the late 19th century, a number of surgical procedures
have been described for debulking of lymphedematous tis-
sues (Figure 97.7). Although occasionally used in cases of
severe lymphedema, direct excision procedures are largely of
historical significance. In the early 20th century, Diffenbach,
Mikulicz, and others were among the first surgeons to
describe their results with surgical excisions of lymphedema-
taus skin and subcutaneous tissue. They achieved temporary

FIGURE ~7.6. A.Jndoc:yaDine green fluorcm:nt lymphography of the

normal upper limb with photos of the limb (color). Arrows indicate
injection sites of indocyanine green. B. Fluorescent lymphography of
the dorsal (/em and volar (right) sides of a lymphedematous upper
limb. Injection sites of indocyanine green (black arrows) identified
collecting lymphatic: vessels (white arrows). (Reprinted with permis-
sion from Suami H, Chang DW, Yamada K, ct al. Use of indocyanine
green fluorescent lymphography for evaluating dynamic: lymphatic:
status. Plast Recotutt' Surg. 2011;127:74e-76e.)

Recent reports have utilized immediate lymphatic bypass

procedures as a means of preventing lymphedema following
axillary lymph node dissection.12 Using a prospective random-
ized clinical trial, one study found that lymphovenous bypass
procedures performed at the time of lymphadenectomy sig-
nificantly decreased the incidence of lymphedema (4.3% vs.
30.4%} 18 months after surgery. In addition, the authors
found that patients treated with bypass procedures had B
increased lymphatic transport capacity as assessed by lympho- FIGURE n.7. Schematic: of excisional prelcedures for lympb.Nema.
scintigraphy. These results should be interpreted with caution A. Charles procedure. B. Sisttwk Clperatieln.
since the trial included relatively few patients and the authors
 Chapter 97: Lymphedema: Diagnolis and Treatment
improvements, though they were unclear whether this was
a result of their operation or the postoperative bed rest and
extremity elevation. Other surgeons attempted to bypass
damaged lymphatics by creating lymphatic bridges between
the superficial and deep systems. Some of these attempts
were clearly misguided such as the procedures proposed by
Lanz in which pedicled strips of fascia lata were buried into
underlying trephined bone. In 1912, Kondoleon popularized
a simpler procedure in which he used a large strip of fascia
lata in the diseased leg as a free graft to form a conneaion
between the sk.in and the underlying muscle. This was based
on the theory that this connection would lead to the forma·
tion of new venous and lymphatic channels thereby bypass-
ing obstructed dermal lymphatics. Around the same time
period, Sir Richard Charles described the treatment of lower
extremity lymphedema with circumferential sk.in and subcu-
taneous tissue excision to the level of the deep fascia and
resurfacing with skin grafts harvested from the discarded
tissue. In 1927, Sistrunk and later Thompson modified this
approach for the treatment of upper extremity lymphedema
in breast cancer survivors by excising an elliptical area of
skin and soft tissues in the medial aspect of the arm and
directly closing the resulting defect. They also attempted to
form new lymphatic connections between the superficial and
deep systems by burying dermal flaps connecting the skin
with the underlying fascia.
The Charles procedure and similar debulk.ing treatments
are still used in extreme cases of extremity lymphedema,
and a number of authors have contributed case series with
varying lengths and follow-up and varying reports of suc-
cess (Table 97.2). A variety of modifications, including
987
the use of split-thickness or full-thickness grafts, allograft,
and negative pressure wound therapy, have been described.
However, these procedures are acknowledged to be inva-
sive and may result in significant morbidity, including pain,
wound healing complications, infections, and lymph fistu-
las. In fact, severe wound healing complications in some
cases have resulted in worsening of lymphedema and limb
amputation.
Liposuction
Since the popularization of liposuction for cosmetic proce-
dures, a number of surgeons have evaluated the use of this
technique for the treatment of upper and lower extremity
lymphedema. Although there is no general consensus regard-
ing indications for this technique, most surgeons reserve
liposuction for the treatment of non-pitting upper extrem-
ity lymphedema that has failed conservative management for
at least 3 months with volume differences of at least 600 cc
when compared with the unaffected limb, absence of active
cancer or metastasis, and no clotting abnormalities or circu-
latory compromise. In addition, some groups consider sub-
jective complaints such as heaviness, pain, and functional
impairments and recurrent infections as indications for treat-
ment. Some authors advocate liposuction as a first-line ther·
apy for lymphedema,U while others reserve it as second-line
treatment when microsurgical treatment is not an option or
has failed. 14
The efficacy of liposuction has been most intensely stud-
ied in patients with breast cancer-related upper extremity
lymphedema. Prospective studies of this patient population

EXCISIONAl PROCEDURES FOR lYMPHEDEMA TREATMENT

• NUMBER. • FOllOW-UP
• LEVEL OF • FIRST AUIHOR, OF • TYPE OF INTERVAL
EVIDENCE DATE PATIBNTS RESURFACING (MEAN) • OUTCOME
IV Mckee (1959) 21 FTSGorSTSG NR Poor results (recurrence,
delayed48 h ulceration, and cellulitis) in seven
patients; fair results in 10 patients;
good results in four patients (all
withFTSG)
IV Dellon (1977) 12 FTSGorSTSG 14-277mo No recurieDc:es, two patients
required scar contracture release
IV Sakulsky (1977) 3 NR 6-96mo Poor result (one); ell:cellent (two)
IV Mavili (1994) 4 STSG 1-3 y No lymphedema recurrence;
hypertrophic: scarring in two
patients
v Dumauian (1996) 1 FTSG (15 y) Good results with uo
(delayed 72 h) recurrence
IV Van derWalt 9 STSG (delayed 27.3mo Additional grafting (three); wound
(2009} for 7 d with VAC) dehiscence (two);
cellulitis {one); 45% increase in
lower extremity func:tioual score
after operation

IV Karri (2011) 27 STSG 1.5-48 mo Cellulitis (five); hypertrophic

(mean 21.6 mo) scarring {two); wound dehis-
cence {two); revision surgery
within 6 mo (sixteen); all patients
reported mobility to be same or
improved at 6 mo
FTSG, faD-thickness skin graft; STSG, split-1hiclcneJis skin graft; NR, not sta~d in the table; VAC, vaca~assisted closure.
988 Pan IX: Tl'Wik and Lower h:tremity
have reported overall favorable and long-lasting results
with significant reductions in limb volumes (on average,
half of the preoperative value) after circumferentiallipo·
suction and continuous use of postoperative compres·
sion garments. Improvements have been noted even as
long as 4 years postoperatively. Several studies have also
reported decreased rates of cellulitis in the affected limb
after liposuction. In addition, although subjective analysis
of lymphedema symptoms was not performed in a system-
atic manner, the majority of patients reported symptomatic
relief.
It is important to note that liposuction is not a cure for
lymphedema but rather a treatment designed to address the
effects of chronic lymphatic insufficiency. This concept is
highlighted by the fact that continued use of postoperative
garments and conservative therapy is critical for the mainte-
nance of volume reductions after upper extremity liposuction.
Without these measures, fluid and fatty tissue re-accumulation
occurs rapidly with only modest improvements in limb mea·
surements 1 year after surgery. Because of this, most groups
that utilize liposuction as a treatment for lymphedema follow
patients closely postoperatively and adjust garments routinely
to maintain a tight fit.
The scientific evidence supporting the use of liposuction
for lower extremity lymphedema is less dear as most reports
have been either case studies or small series. In fact, the ini·
tial reports of lower extremity liposuction were distinctly
disappointing demonstrating very minor improvements in
limb volume if liposuction was used as the only treatment
modality. More recent studies have reported better out-
comes with modem liposuction devices and tumescent tech·
niques. In addition, the use of intraoperative tourniquets has
been helpful in decreasing blood loss associated with these
procedures.
Circumferential liposuction for lymphedema is a safe
technique with few postoperative complications. Most pro-
cedures are performed in the outpatient setting and the major·
ity of patients have no complications. Complications that do
occur tend to be minor and usually resolve spontaneously.
Temporary parasthesias and minor wound healing complica·
tions comprise the majority of these problems. Contrary to
common belief, circumferential liposuction does not appear
to disrupt lymphatic vessels or decrease the already impaired
lymphatic transport capacity of the limb if performed in paral-
lel to the long axis of the extremity.
CONCLUSIONS
Despite the advances in cancer treatment, lymphedema
remains a significant and oommon complication, and treat-
ment of lymphedema remains palliative in nature. Recent
advances in surgical treatment of lymphedema have shown
promise; however, additional studies are required in order to
verify the benefit and define the patient population most likely
to respond. A better understanding of the etiology of lymph·
edema is probably required for these goals.
References
1. MclAughlin SA, Wright MJ, Morris KT, et al. Prevalente of lymphedema in
women with breast QDoer 5 ye.ars alter semiD.el. lymph node biopsy or uil.-
lary dissection: objettive meaS~~Iements. J Clm Oneal. 2008;26:5213-5219.
2. Cormier JN, Askew RL, MIUI{IOTaD. KS, et al. Lymphedema beyond breast
anc:er: a systematic: re'f:iew and meta-anal.yis of anter-related setOndary
lymphedema. Cmar. 2010;116:5138-5149.
3. Warren AG, Brorson H, Bor11d LJ, et aL Lymphed.eiiill: a c:omprehensi•e
re'f:iew. Ann P£ut Sl.rg. 2007;S!M64-472.
4. Bemu MJ, Witte CL, Witte MH. The dillgDosis and treatment of periph-
eral lymphedema: drait re'f:ision of the 1995 Consensus DotlUIIent of the
Intem&tional Society of Lymphology EXK~~tin Committee for disc:umon at
the September 3-7, 2001, XVID International Congress of Lymphology in
Genoa, Italy. Lympbology. 2001;34:84-91.
5. Campisi C, Da'f:ini D, Bellini. C, et al. Lymphatic: mic:rOSIU'gery for the treat-
ment of lymphedema. Microlllf'gt!"''J· 2006;26: 65~9.
6. Szuba A, A~halu R., R.oc:k.son SG. Dec:ongestin lymphatic: therapy for
patients with breast arrinoma-associaud lymphedema. A randomized, pro-
spec:ti,-e study of a role for adjiUic:ti're intermittent pneumatic: tompremon.
Cmar. 2002;95:2260..2267.
7. Szuba A, CookejP, YOliSUfS.et aL De<;:ollplti,-e lymphalittherapyforpatimts
with c:anter-rel&ud or primary lympbedema. Am JM.eJ. 2000;109: 296-300.
8. Chang DW. Lymphatic:onnular bypass for lymphedema manage-
ment in bte~~&t c:ancer patients: a prospecti•e study. Plllst R~consw Stwg.
2010;126:752-758.
9. Suami H, Clwlg DW, Yamada K,. et al. Ute of indocy~Wne gteell. fiuoR*-
cell.t lymphogrAphy for e•aluating dy!WIIic lymphatic swu.s. Pl4# R-.tr
Slwg. 2011;127:74e-76e.
10. KDshima I, wgawa K, Urushibua K, et al. SupermicrOS\IJ."Sicallymphati-
conll.ular JWI.Stomoeis for the treatmell.t of lymphedema ill. the upper
extremities. I RltCOIJSW Mkroslolfl. 2000;16:437-'142.
11. O'Brien BM,. Mellow CG, Khum.chi RK,. et al. Long-term results after
microlymphatioo•eDous IUI.Utomoses for the tteatmeDt of obstl'llctive
lymphedema. Pl4.u RJICOIIUr SU1J. 1990;85:562-572.
12. Boa:udo FM, Olsabo~~a F, Friedman D, et al. Surgical pre..e11tion of ann
lymphedema after breast cancer treatment. Ann Stwg Oneol. 2011;18:
2500-2505.
13. Bl'OI.'SOn H. Sn~~&son H. LipoNction combined wilh COli.trolled compmtioll.
tb.er11P7 teduaes ann lymphedem• more afecti..ely than controlled rompratioll.
tb.er11P7 i!one. Pklu R«Mur S:l.t!J. 1!)98;102:1058-1067; discwotion 1068.
14. O'Brien BM, Khazanchi RK, Kumu PA, et al. Liposuction in the tteatmeDt
oflymphoedema; a preliminaty report. Br I PIAu SU1J. 1989;42:530-533.
CHAPTER 98 • PRESSURE SORES
KAREN L. POWERS AND LINDA G. PHILLIPS
INTRODUCTION
------------------ ------------------
A pressure sore is localized soft-tissue injury resulting from
unrelieved pressure, usually over a bony prominence. Because
areas of tissue pressure depend on patient position, the term
• pressure sore" is preferred, rather than bedsore or decubi-
tus ulcer. Relieving the preasure caused by patient positioning
is the key to prevention and healing. Factors contributing to
the development of pressure SOle$ include decreased mobility,
decreased llensation, spasticity, shearing forces, friction, and
moisture. With so many factors playing a part in pressure sore
development, prevention and treatment frequently require a
multidisciplinary approach, often with the plastic surgeon
consulted for reconstruction of the soft-tissue defect.
The most widely accepted preaaure sore staging system
was revised by the National Pressure Ulcer Advisory Panel
in 2007 to include the original four stages and an additional
two stages regarding deep tissue injury and unstageable pres-
sure sores (Table 98.1). Stage I includes intact skm with non-
blanching erythema, stage II includes partial-thiclcness loss of
dermis, stage m includes full-thickness tissue loss, and stage
IV includes exposed bone, tendon, or muscle.1 Additional clas-
si.fication includes SJI$'f)ec;ted deep tissue in;ury, usually charac-
terized by maroon localized intact skin or blood-filled blister,
and unstageable, which is a full-thickness ulcer with eschar
at the base. Limitations exist in this system; signs like skin
erythema can be present in more than one stage and dark skin
pigmentation can actually obscure the presence of erythema,
necessitating other diagnostic signs like increased skin temper-
ature, edema, and induration, to accurately stage the wound.
Long-standing wounds of the pelvic girdle warrant careful
examination and possible imaging to evaluate for extension
into deeper structures, such as the acetabulofemoral joint.
EPIDEMIOLOGY
------------------ ------------------
The incidence of pressure sore formation is variable but
the patient populations commonly studied include those in
acute care settings, nursing home patients, and paraplegic
NATIONAL PRESSURE ULCER ADVISORY PANEL
STAGING SYSTEM, 2007
• STAGE • DESCRIPTION
Intact akin with non-blanchable rednen of a
localized area
D Partial-thickness loss of dermis presenting as
a shallow open ulcer with a red pink wound
bed
m Pull-thickness tissue loaa. Subcutaneous fat
may be visible but bone, tendoo, and muscle
are not exposed
IV Full-thicknes~
tissue loss with exposed bone,
tendon, or muscle
-----------------
Data &om National Pressure Ul<:er Advbory Panel. NPUAP l'temlle
Ulcer StageS/Categories. bttp:llwww..npoap.org/mourca/educati~
and-cliDkal-mource.afnpuap-pressure-aker-stagetattegorieal
populations. In general, pressure sores develop in approxi-
mately 9% of all hospitalized patients, affecting 2.5 million
people annually.2 For acute and long-term cate facilities, the
overall reported prevalence ranges between 3.5% and 29.5%.'
In addition to causing pain, suffering, and disability, pressure
sores contribute to over 60,000 deaths per year according to
the N ational Pressure Ulcer Advisory Panel.1 Data from the
National Pressure Ulcer Long Term Care Study suggest that
up to 19% of new patients develop a pressure ulcer while
in long-term care and 22% arrive with an existing pressure
ulcer. 4 Beginning in October 2008, The Centers for Medicare
and Medicaid Services ended reimbursement of acute care
facilities for the development of a hospital-acquired stage m
or IV pressure sores, thereby compounding the challenge of
pressure sore prevention with the essential task of documenta-
tion of pressure sores present on admission.
Multiple studies have demonstrated that age, moisture,
immobility, and friction/shear are key risk factors.J Impaired
sensory perception is known to contribute to the development
of pressure sores but the incidence in patients with spinal cord
injuries varies greatly. The Braden Scale, incorporating factors
such as mobility, can be used to predict an individual's pres-
sure sore risk. Stal et al.' cited a 20% incidence in paraplegic
patients and a 26% incidence in patients who were quadriple-
gic. For the majority of patients, wounds develop in either the
supine or seab:d position. Up to 75% of all pressure sores are
located around the pelvic girdle. This is not unex~d, as it
mirrors the distribution of pressure in supine and sitting posi-
tions (Figures 98.1 and 98.2). A study of a large cohort from a
statewide Arkansas registry cited significant risk factors in the
spinal cord-injured patient, including being underweight, use
of pain medications, smoking, suicidal behaviors, history of
incarceration, and alcohol and drug use. 7
PA1HOPHYSIOLOGY
--------------
Compression of soft tissues results in ischemia and, if n ot
relieved, it will progress to necrosis and ulceration, even in
well-vascularized areas (Figure 98.3). What is seen on the
surface is often merely the trp of the iceberg, as confirmed
by pressure measurements taken over bony prominences•
(Figure 98.4). In susceptible patients, progression from exces-
sive pressure to irreversible ischemia and tissue necrosis is
accelerab:d by infection, inflammation, edema, and other fac-
tors that are not yet understood.
Pressure
----------
Ischemia occurs when external pressure exceeds the capillary
pressure, which was shown by Landis9·l0 in the 1930s to be 12
mm Hg on the venous end and 32 mm Hg on the arterial end.
I£ the extemal compressive lorce exceeds capillary bed pres-
sure (32 mm Hg), atpilllll')' perfusion is impaired 11111d ischemia
will ensue. Original dog studies demonstrated an inverse para-
bolic relationship between the amount of pressure and dura-
tion of exposure (Figure 98.5). Early studies demonstrated
that pressure of 70 mm Hg applied over 2 hours was sufficient
to cause pathologic changes in dogs. Dinsdale11 confirmed
these results in a pis model; perhaps just as importantly, he
was also able to demonstrate the absence ol injury if pretsure
could be relieved for as little as 5 minute~, even with pressure~
as hish as 4SO mm liB- Similarly. Daniel et al.12 demonstrated
that pressure of 500 mm Hg applied for 2 hours, or pressure
989
990 Pan IX: Tl'Wik and Lower h:tremity

FIGURE 98.3. Unusual prenure tore of lateral thorax.

heels, buttock, and sacrum. ln the sitting position, pressures

were greatest near the ischial tuberosities.

FIGURE ~.1. Distribution of pressures in a normal man. A. Prone.
B. Sitting. (From Lindan 0, Greenway RM. Piazza JM. Pressure dis-
tribution on the surface of the human body. I. Evaluation in lying and
sitting positions using a "bed of springs and nails." Arch Plrys Med
Rehabil. 1965;46:378.)
Inflammation
Maintenance of soft-tissue integrity requires tightly regulated
interactions between cells, growth factors, their receptors,
extracellular matrix molecules, and a variety of proteases and
their inhibitors. When tissue is injured by causes such as unre-
lieved pressure,. there is a demargination and influx of cells
responsible for inflarwnation. For injuries to heal, a series
of events unfolds, including vasoconstriction/vasodilatation,
c:oagulation, influx of proinflammatory cells like neutrophils
and macrophages, and, finally, matrix formation/maturation.
In chronic wounds, there is a breakdown in this sequence,
leading to a non-healing wound. Altered immune function
has been implicated in the development of pressure sores and

of 100 mm Hg for 10 hours, was sufficient to cause muscle

necrosis. Interestingly, it was not until pressure of 600 mm
Hg was applied for 11 hours that ulceration of the skin could
be seen. Not only did these results c:onfirm. the relationship
between pressure and time, but they also demonstrated that
the initial pathologic c:hanges occurred in the muscle overlying
the bone, followed by the more superficial soft tissue, involv-
ing the skin last.U Several classic st:lldies investigated pressure
and its effects as it relab:s to location, time, and intensity in
humans (Figures 98.1 and 98.2). ln the supine position, the
maximal recorded pressures were 40 to 60 mm Hg near the

Sitting, feet supported Sitting, teet unsupported

FIGURE 98.2. Distribution of pressures in a normal man, sitting.
(From undan 0, Greenway RM. Piazza JM. Pressure distribution on
the surface of the human body. L Evaluation in lying and s.itting pos.i-
tions using a ..bed of springs and nails.,. Arch Phys Med Rehabil.
1965;46:378.)
FIGURE 98.4. Cone-shaped pattern of injury rerulting from unre-
lieved pre55ure. The highest pressure and greatellt injury ill deep,
adjacent to the bone. The cutaneous wound ill only the "tip of the
iceberg..,.

Ill 550
:z:
e soo
E •so
z
o 400
I
...
~ 350
II: 300
•"'
.., 2SO
~ 100
"'
~ 150
Ill
a. 100
5o()
0 ~~2~3~4~5~6 ~~8~9--10~~
11 ~12~
TIME IN HOURS
FIGUJlE ~8.5. Inverse relationship between time and pressure in the
formation o£ pl'CS&ure sores.
molecular evidence points to an imbalance between matrix
metalloproteases (MMPs) and tissue inhibitors of metallo-
proteases (TIMPs). MMPs, especially 1 and 9, are key to cell
signaling and migration, whereas TIMPs, especially 1 and 2,
bind to these proteases and presumably protect uninjured
tissues. Numerous subsequent studies have documented the
presence of elevated levels of various MMPs and decreased
levels of TIMPs in chronic wounds, or an imbalance between
the levels of MMPs and TIMPs.14 In patients with spinal cord
injuries, the loss of sympathetic tone results in vasodilatation
of denervated tissues, which further intensifies this problem.
Edema
Approximately 80% of soft tissue mass is fluid. External
pressure on soft tissue increases plasma extravasation, which
leads to edema formation, a significant factor in pressure sore
formation. Denervation contributes to pressure sore develop-
ment through loss of blood vessel sympathetic tone and its
subsequent vasodilatation, vessel engorgement; and edema.
Circulatory deficiencies, such as heart failure, renal failure,
and venous insufficiency, are risk factors for pressure sore
formation in part due to their propensity to increase edema
in dependent soft tissue. On a molecular level, inflammatory
mediators such as prostaglandin Ez released in response to the
trauma of compression increase leakage through the cell mem-
branes and increase interstitial fluid accumulation.
PREOPERATIVE CARE
As Tchanque-Fossuo et al.s noted in a 2011 review of evi-
dence-based approaches to pressure sores, the goals of man-
agement for a patient with a pressure sore are (1) prevention
of complications, particularly invasive infection, related to
the existing sore; (2) preventing the existing sore from getting
larger; (3) preventing sores in other locations; and, if possible,
(4) closure of the wound. Most authors report high recur-
rence rates after surgical closure of pressure sores. Suc:.c:essful
pressure sore coverage is multifactorial but key components
include resolution of infection, the preoperative/postoperative
relief of pressure, and, for uses of <:hronically non-ambula-
tory patients, the control of spasm and c:ontrac:tures.
Nutrition
The nutritional condition of the patient must be evaluated.
Normal healing potential exists as long as serum albumin is
maintained above 2.0 gldL. In addition to an adequate sup-
ply of micronutrients such as zinc, calcium, iron, copper, and
vitamins A and C, a diet with sufficient protein is required
for optimal healing of pressure sores. The nutritional litera-
ture suggests a requirement of 1.5 to 3.0 glkgld of protein to
restore lost lean body mass, and 25 to 35 callkg of non-protein
Chapter 98: Pressure Sores 991
calories should be delivered daily.U Optimization of nutri-
tional parameters must be balanced against practicality; some
patients will never achieve normal albumin levels until their
huge wounds are closed.
Infection
Compression of soft tissue impairs lymphatic drainage, lead-
ing to edema, ischemia, and other conditions favorable to
colonization and infection by microorganisms. It is known
that bacterial counts increase in compressed areas. Robson
and Krizek1' quantified the effect of pressure on bacterial
count, showing that incisions created in areas of applied pres-
sure and inoculated with known concentrations of organisms
allowed for a 100-fold greater bacterial growth than in areas
not subjected to pressure. The proposed mecllanisms include
impaired immune function, ischemia, and impaired lymphatic
function. Both pulmonary and urinary sources cause seeding
and subsequent infection of pressure sores. Indwelling bladder
catheters or self-catheterization programs can result in urinary
sepsis in one-third of paraplegic patients. If left untreated, uri-
nary .infections can be a constant source of bacteremia.
Pressure sores may or may not present with local infection
(deep or superficial). The removal o£ all nonviable tissue is the
essential first step. After a soft-tissue debridement; a specimen
should be sent to the microbiology laboratory to assess not
only the bacterial types and sensitivities but also for quantita-
tive culture. A result of more than lOS organisms per gram
of tissue is diagnostic for invasive infection and is predictive
of failure of surgical closureP Swab cultures are generally
discouraged because they often represent only surface con-
taminants. Diagnosis of osteomyelitis depends on bone biopsy
to identify the causative organism and magnetic resonance
imaging to determine the extent of involvement. Surgical clo-
sure without eradication o£ bone infection through reseaion
of devitalized bone is associated with a high recurrmce rate.
Osteomyelitis from a pressure sore requires a surgical solu-
tion, not a medical solution.
Appropriate intravenous antibiotics for cellulitis or osteo-
myelitis, along with topical antimicrobials, such as silver sul-
fadiazine, mafenide acetate, and buffered Dakin's solution,
should be used as adjuncts to surgery in the process of clearing
infection. Although Dakin's solution diluted to 0.025% has
been shown to be bactericidal with preservation of fibroblasts,
all topicals should be used for a limited time after debridement
to avoid delayed wound healingP
Relief of Pressure
The relief of pressure both preoperatively and postoperatively
is the key to success, because healing will not occur in the pres-
ence of ischemia and/or neaosis. It is well known that reliev-
ing the pressure over a bony prominence for 5 minutes every
2 hours will allow adequate perfusion and prevent break-
down.11 Patient; family, and medical staff education is para-
mount in this goal, and it must be performed in both supine
and sitting positions. Adjuncts include dynamic and static
pressure-reducing support surfaces, such as foam, wheelchair
cushions, specialized mattresses, cushions, and mattress over-
lays. Surgical staff should use all available means, such as "heel
floating" and intermittent scalp massage by anesthesia staff, in
addition to pressure point relief to minimize development of
pressure sores during procedures in the operating room.
Spasm
Spasticity is common in patients with spinal cord injuries and
is a key contributor in the development of pressure sores,
especially as it relates to shear. In their review of long-term
care patients in Germany, Lahmann et al.11 found that the
presence of friction and shear had the strongest association
with pressure sore formation. The incidence of pressure sores
992 Pan IX: Tl'Wik and Lower h:tremity
varies with the level of spinal cord injury. The more proxi-
mal the lesion, the higher the incidence of spasm: near 100%
in the cervical region, 75% in the thoracic region, and SO%
in the thoracolumbar region.U Treatment of muscle spastic-
ity should be implemented prior to surgery. The most com-
mon medical treatments for muscle spasms include baclofen,
diazepam, and dantrolene. Botulinum toxin is an emerging
treatment for spasticity and has been shown to be effective
in reducing localized spasticity of the upper and lower limbs
with minimal adverse effects.111 The lasting effects of the botu-
linum toxin treatment for muscle spasticity are approximately
3 months. If patients fail to respond to medical therapy, surgi-
cal intervention may be required, including peripheral nerve
blocks, epidural stimulators, baclofen pumps, and rhizotomy.
Rhizotomy, the interruption of spinal roots within the spinal
canal, can be surgical or medical, the latter using subarach-
noid blocks with phenol (phenol rhizotomy).
Contractures
Bedridden patients, especially those with long-standing dener-
vation and!or altered sensorium, tend to develop joint contrac-
tures through tightening of both muscles and joint capsules.
Contractures are common in hip flexors and contribute to the
formation of trochanteric, knee, and ankle ulcers. Patients
with significant hip and/or knee contractures should have
every attempt made to tteat the contraaures prior to surgery
to help prevent rec:urrenc:e. If physical therapy is unsuccess-
ful at relieving the contractures, tenotomies are performed. ln
mobile, wheelchair-bound patients, however, releasing the hip
contractures can lead to a flail extremity, which may interfere
with transfers. u
Comorbidities
Many chronic medical conditions-such as diabetes, smoking,
peripheral vascular disease, and cardiovascular disease-are
known to impair wound healing. In diabetics, glucose lev-
els and hemoglobin Ale should be checked and optimized
because hyperglycemia slows wound healing and increases the
risk of wound dehiscence and infection. Recent work found
that hemoglobin Ale greater than 6% was associated with
both dehiscence and recurrence and that younger age and
hypoalbuminemia were associated with early flap failure.20
Anemia can be an indicator of poor nutrition or chronic blood
loss and should be worked up and corrected. In spinal cord
injury patients, management of fecal soilage of the wound is
necessary through alteration of the bowel routine or a divert-
ing colostomy in selected patients.
SURGICAL TREATMENT PLANNING
When the challenges such as consistent pressure relief, ade-
quate nutrition, eradication of infection, complete debride-
ment, and reliable patient and family education have been
accomplished, consideration can be given to surgical closure.
Because the reaurence rate of pressure sores has been reported
to be as high as 91 %t the goal is to provide soft-tissue cov-
erage of the pressure sore defea, while maintaining as many
options as possible for future use. A number of strategies for
closure have been attempted in the past and in general should
be avoided. The temptation to perform a primary closure
should be resisted even if the tissues seem to rex~ppro:ximate
easily. By definition, a pressure sore has an absolute tissue
deficiency, and simply pulling the tissue together over a bony
prominence will almost surely lead to tension and dehiscence.
Skin grafting bas been attempted with limited success because
of the lack of bulk and poor durability in the face of the pres-
sure and shearing forces. lt is only successful in a patient
where acute illness and immobility will be resolved. More
successful strategies include the use of musculocutaneous and
fasciocutaneous flaps, with each having its advantages. Flaps
that include muscle have significant bulk and excellent blood
supply. They, therefore, can be useful where a significant soft-
tissue defect is present and also where a history of infection is
a consideration. On the downside, muscle is not a good choice
in ambulatory patients, as sacrificing muscle may lead to func-
tional impairments.
Even if the patient is ambulatory, surgical planning for
patients with pressure sores should include deep venous
thrombosis risk stratification and appropriate prophylaxis.
Non-ambulatory spinal cord injury patients have additional
anesthetic risks when compared with non-spinal cord injury
patients of a similar American Society of Anesthesiologists
class. Autonomic dysreflexia can produce bradycardia and
hypotension, or tachycardia and hypertension. This condition,
plus the hyperkalemia that can be caused by the use of suc-
cinylcholine in spinal cord injury patients, must be discussed
preoperatively with the anesthesia team.
For all patients in general and acute spinal cord injury
patients in particular, prevention of pressure sores acquired in
the operating room is paramount through intraoperative pres-
sure relief, which can include such measures as "floating the
heels." Moving and positioning patients with pressure sores
also requires coordination of the surgical, anesthesia, and sup-
port staff. Usually patients are anesthetized on thcir stretchers
and transferred prone to the operating room bed. This process
reversed at the completion of the case as patients are often
positioned onto their freshly transferred tissue for extubation.
OPERATIVE MANAGEMENT
Debridement
Debridement of the pressure sore removes necrotic tissue,
decreases the bacterial count and bio.film, and converts a
chronic wound into an acute wound. The presence or absence
of sensation in the tissues affected by pressure ulceration
becomes an issue most often when sharp debridement is con-
sidered. The pain associated with the adequate removal of
necrotic tissue in sensate patients makes bedside debridement
impossible. ln insensate patients, bedside debridement can be
performed within reason, although the safety and extent is
more often related to the control of hemorrhage. At the start
of the debridement procedure, the cavity can be painted with
a dilute solution of methylene blue and hydrogen peroxide to
help define the cavity and leave a visual guide for excision.
After the removal of the necrotic tissue, specimens of viable tis-
sue should be sent for quantitative culture to aid in postopera-
tive systemic and topical antibiotic coverage. Postoperatively,
the wound is packed and dressings changed every 6 to 8 hours.
Ostectomy
Removal of the bony prominence is an integral but tricky part
of the surgical treatment of pressure sores. Radical ostectomy
should be avoided so as to prevent excessive bleeding, skeletal
instability, and redistribution of pressure points to adjacent
areas. Ischial ulcers best illustrate this as total ischiectomies
often result in the formation of a contralateral ischial ulcer.
Bilateral ischiectomy has also been proposed, but redistrib-
uted pressure has caused perineal ulceration and urethral
fistulas. Therefore, removing the minimum amount of bone
necessary when debriding ischial pressure ulcers is essential.U
Closure
When planning a surgical strategy, the surgeon should consider
not only the present surgery but also the need for subsequent
surgical procedures. The choice of closure strategy depends not
only on the location, size, and depth of the ulcer but also on
the previous surgeries performed. Primary closure, although
tempting, is avoided. These wounds represent an absence of
tissue and primary closure leads to tension, a scar over the

original bony prominence, and dehiscence. Skin grafting has
a low success rate, as grafting ~nds to provide unstable cov-
erage. Musculocutaneous flaps provide blood supply and
bulky padding and are effective in treating infected wounds.
Disadvantages include sensitivity to external pressure, func-
tional deformity in ambulatory patients, and lack of bulk in
the elderly and in spinal cord patients. Fasciocutaneous flaps
offer an adequate blood supply, durable coverage, and mini-
mal potential for a functional deformity, and they more closely
reconstruct the normal anatomic arrangement over bony
prominences. The disadvantages include limited bulk for the
treatment of large ulcers. In a recent reriew of .94 patients with
saaal and ischial pressure wounds, there was no statistical di£-
ference in recurrence, complications, or morbidity between clo-
sure wish fasciocutaneous flap and with myoc:utaneous !aps.:u
Ischial Defects
Ischial pressure sores develop in patients who are seated, often
in wheelchairs, for long periods of time. Because patients
almost always return to sitting after repair of their ischial
pressure sores, the recurrence ra~ traditionally has been high;
Conway and Griffith reported a recurrence rate of 75% to
Medially based tb igh flap
Glu teal island th igh flap
Tensor fascia
lata flap
FIGURE 98.6. Flaps for clofW'e of iKhia1 wounds.
Chapter 98: Pressure Sores 993
77%. R.e«nt work cites recurrence rates as low as 19% to
33% that may be due in part to improved wheelchair cushions
and other modalities.:U Ischial wound location, however, con-
tinues to correlate with late recw:rence.20
Closure of an ischial defect is most commonly achieved
with fasciocutaneous flaps or myocutaneous flaps. Perforator
and free-flap reconstruction have been described but cur-
rently is not a mainstay of ischial pressure sore treatment.
Some of the more commonly used closure strategies are fea-
tured in Figure 98.6. Given the high recurrence rate of pres-
sure wounds. flap design should allow coverage of the ulcer
but should not prevent the use of other flaps in the future.
Important considerations for flap design include size and
depth of the ulcer, quality and pliability of the surrounding
skin, presence of previous surgical scars, and the ambulatory
status of the patient. For example. the inferior gluteal mus-
culocutaneous flap, based on the inferior gluteal artery, uses
only the lower half of the gluteus maxi.mus muscle. This rota-
tion flap does not preclude later use of the posterior thigh flap
and is less debilitating in ambulatory patients.
In the superiorly based gluteal flap (Figure 98.7), care
is taken to avoid incisions over bony prominences when
the patient is in the seated position. The biceps femoris,
V-Y Hamstring advancemem flap
GraciJis
flap
994 Pan IX: Tl'Wik and Lower h:tremity
FIGURE 98.7. Flaps for closure of sacral wounds.
semimembranosus, and semitendinosus musculocutaneous
flaps are said to be effi:ctive for ischial ulcers and they can be
re-advanced. They are most reliably designed as a V-Y pattern,
but do have several disadvantages, including closure is always
under tl:nsion, the scar is directly over the maximal pressure
point, and hip flexion tends to cause dehiscence. The tensor
fascia lata (TFL) flap can occasionally be used to close ischial
ulcers, although the distal aspect of the TFL flap is usually too
thin to offer adequatl: padding, making the TFL flap, in gen-
eral, not the best choice. For more complex, deeper, or larger
wounds, a combination of flaps may need to be employed.
Sacral Defects
Sacral pressure sores occur in patients in the supine position,
most of whom have had an acute illness. Musculocutaneous
FIGURE ~8.8. Glutl:al flap to saaal prc:Mure sore. A. Sacral wound. B. Oosure with gluteal fascioc:utaDeOus flap.
or fasciocutaneous flaps are the mainstays of surgical ther-
apy but the use of perforator and free-flap reconstrllction is
increasing (Figure 98.7). Some groups have published that
their first choice for reconstruction of ischial and sacral pres-
sure sores is free tissue transfer with microvascular anasto·
mosis to the gluteal vessds.23 Other surgeons using pedicled
tissue transfer cite a 21% total recutTence rate after coverage
with any flap of sacral wounds, with a lower (17%) recur-
rence rate after reconstruction with fasciocutaneous flap. 24
The most commonly described musculocutaneous flaps are
based on the gluteus maximus muscle. The gluteal flap can
be based superiorly or inferiorly, part or all of the muscle or
both muscles may be used; it can be constrllcted of muscle or
muscle and skin; and it may be rotated, advanced, or turned
over (Figure 98.8). Other flaps available include the transverse
and vertical lumbosacral flaps, based on lumbar-perforating
 Chapter 98: Pressure Sores 995

FIGUJlE 98.9. Ten&Or fascia lata flap to ischial pressure sore. A. Flap design. B. Flap closure.

vessels, although these have significandy less bulk and, conse- therapy is continued during the perioperative period. The
quendy, are less useful in deeper wounds. antibiotics are modified to fit the sensitivity results of intra-
operative cultures as these results become available. Pressure
Trochanteric Defects relief for the surgical site, usually involving bed rest and a
Trochanteric ulcers develop in patients who lie in the lateral pressure-relief bed, is of utmost importance. The patients are
position, especially in those who have significant hip flexion positioned to avoid pressure on the operative site, with turn-
ing every 2 hours, and use of low-air-loss mattresses when
contractures. Perforator flap reconstruction of trochanteric available. Patients are kept in the postoperative position,
pressure wounds is possible with a pedicled anterolateral thigh
with no pressure allowed on the surgical site for 2 to 3 wedts.
flap. However, the most commonly used flap for treatment of
Before reseating after ischial pressure wound coverage, the
this location is the TFL flap. This highly reliable flap is based
patient's wheelchair should be evaluated to ensure a proper
on the perforating vessels from the TFL muscle, although cau-
fit and pressure distribution. There is no consensus on reseat-
tion is advised as the distal aspect of the flap has a random
blood supply that sometimes necessitates a delay procedure. ing protocols, but it is agreed that reseating must be gradual.
A common protocol starts with 30 minutes the first day and
Sensation from the nerve roots ofLl, 1.2, and L3 by the lateral
then adds a 0.5-hour increment daily if tolerated without
femoral cutaneous nerve makes this a potentially sensate flap compromise of the surgical site.1
in patients with spinal cord injury below L3. Rotation of the
TFL flap results in a T·shaped junction between the flap and
a primary dosed donor site that is prone to dehiscence, often CO?viPLICATIONS
the donor site is skin~ to avoid dehiscence (Figure 98.9).
In addition to the acute complications related to treating pres·
sure sores-hemorrhage, pulmonary and cardiac complica-
Other Considerations tions, and infection-a few long-term complications warrant
Only the most common pressure sores have been discussed discussion.
in this chapter; however, if an anatomical location can serve
as a pressure point, then it has the potential to develop a Recurrence
wound when subjected to unrelieved pressure (Figures 98.1 The reasons for high rates of recurrence are multifactorial.
and .98.2}. Some less common pressure sores, like those at
The underlying medical problems that contributed to ulcer
the ear or scapula, ofb:n can be dosed primarily or with local
tissue rearrangement. Other pressure sores, such as those at
the heels, are difficult to treat (Figure 98.10). In patients who
have multiple pressure sores or who have undergone multi·
ple previous procedures, there may not be any local options
remaining. In extreme cases of pelvic girdle or lower extremity
pressure sores, it may be necessary to consider total thigh flaps
in which the femur is removed and the thigh tissue is used to
close the wound (Figure 98.11).

POSTOPERATIVE CARE
Many of the preoperative care considerations (e.g., nutrition
and management of chronic conditions such as spasm and dia-
betes} continue into the postoperative period. Careful nursing
care is critical to postoperative success. An absorptive non-
occlusive dressing is used in an effort to avoid macerating the
wound. The control of urine and stool is important and in
some cases colostomies are required pre-operatively. Drains
are placed intraoperatively to remove serous fluid and to aid
in apposition of the flaps to the wound bed. Because of prob-
able intraoperative bacteremia, broad-spectrum antibiotic
 996 Pan IX: Tl'Wik and Lower h:tremity
c tissue that can be folded over the wound. D. Closed wound.
formation stiU exist. The presence of spinal cord injury and/
or altered mentation in the elderly persist. The labor-intensive
nursing care issues (turning, local wound care, and avoidance
of urine and fecal contamination) may not have changed from
the preoperative setting. Social issues like the lack of finan-
cial resources, inadequate family and/or community support,
and the use of drugs and alcohol may also be present. Many
studies observed that the first 15 to 22 months are the most
vulnerable time period for recurrence. A recent review by Keys
et al.20 found a 39% recurrence rate of pressure sores after
flap closure, with poor blood glucose control, younger age,
and poor nutritional status (hypoalbuminemia) as significant
risk factors. Patients with multiple risk factors had operative
success rates that approached zero.
Carcinoma
In 1828, Jean Nicholas Marjolin described a tumor that was
present in a chronic wound. The term MarjoUn ulcer is used
to describe carcinoma arising in a ~hroni~ wound. The most
FIGURE ~8.11. Total thigh flap. A. Large recurrent ischial wound.
B. The distal lower extremity was amputated and the femur was
removed with the specimen. C. The thigh tissue provides abundant
~on cell type is squamous ceU carcinoma. In contrast to
most other tumors of this type, these tumors tend to be aggres-
sive with 2-year survival rates varying from 66% to 80%.
Their metastatic rate, as compared with that of Marjolin
ulcers arising in bum scars, is significandy higher at 61% ver-
sus 34%. The time interval of development is also reduced.
The usual time to appearance is 25 years when compared with
more than 30 years in bum-related carcinomas, but it can be
as short as 2 years. Because of the aggressive nature of the dis-
ease, wide surgical excision to clear margins is recommended.
Prophylactic lymph node dissection is not recommended, but
therapeutic node dissection is indicated in the case of clinically
involved nodes. Adjuvant radiation and/or chemotherapy may
be indicated in cases of unresectable tumors or if the patient
refuses surgery.
Nonsurgical Treatment
The ultimate treatment of pressure ulcers is not necessarily
a surgical correction. If proper preoperative assessment and

preparation are performed, there will usually be a period of
time in which the ulcers can be observed. If during this time
period the ulcer appears to be healing significantly, continu-
ation of nonoperative treatment is indicated. Some patients
may never be candidates for surgical correaion because of
significant medical problems. In these cases, avoidance of
unrelieved pressure. control of infection (local and remote),
control of incontinence, and improved nutrition may lead to
successful ulcer closure, or at least may allow for a stable
wound that does not progress.
Debridement of devitalized tissue and wound care remain
the foundation of pressure sore management. Despite a
plethora of available dressings, growth factors, and adjunc-
tive therapies, there is no strong evidence to indicate that
any given wound care regimen is superior, and as a conse-
quence. none has become dominant.4 Enzymatic debridement
ointments have been in use since the 1950s and continue to
be a valuable tool. Negative pressure wound closure devices
increasingly have been used for pressure sores. A recent
Cochrane review, however, found that while the data do
demonstrate a beneficial effect of wound healing, more qual-
ity research is needed before confirming it as a mainstay of
pressure wound treatment.25
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August 7, 1011.
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Ann Pltut Swg.1008;60:631-634.
24. Yamamoto Y, TSilt!llmlida A, Murazumi. M, eta!. ~-tlrm ouu:ome of preJ-
mre sores treall!d with Sap C01'el'ap!. Pltut kconstr Smg. 1997;100:1211--1217.
15. Ubbink. DT, Westerbos SJ, Enns D, eta!. Topic:al. nq:atin press~~re for
trea1iD.g c:hronic woUIIds. Coclmme DIIUI1Me Syst R4!11. 2008;3:CD0018.98.
CHAPTER 99 • RECONSTRUCTION OF THE PENIS
J. JORIS HAGE
INDICATIONS AND REQUIREMENTS
Reconstruction or de novo construction of the penis may be
indicated to treat genital ambiguity or severe micropenis, to
relieve gender dysphoria in female-to-male transsexuals, or to
treat for accidental or (self-) inflicted traumatic loss, oncologi-
cal amputation, or infection of the penis.
Genital Ambiguity
Although masculinization can be extreme in newborns pre-
senting with ambiguous genitalia, genetic females recog-
nized in the neonatal period should be raised as girls as it is
easier to adapt the genitalia toward the female phenotype.1 .1
Although feminine assignment is often favored over condemn·
ing a male patient to a life with an inadequate phallus, it is
no longer necessary to routinely assign the female gender to
all male newborns with ambiguous genitalia. 'Three key issues
are to be taken into consideration when deciding on the more
appropriate gender for such patients. First,. the urologist and
reconstructive surgeon assess the urogenital anatomy to define
the surgical procedures that would be required to construct
functional male external genitalia.t.l Testosterone may be
administered to assess the likelihood of penile growth, thus
excluding androgen insensitivity and possibly facilitating geni-
tal reconstruction. Second, the pattern of pubertal change that
can be expected at the time of adolescence must be considered
by an endocrinologist. A male role is especially preferable if
a male infant has an enzymatic error preventing synthesis of
testosterone, because testicular architeaure is usually normal.
Third. a behavioral scientist assesses the social and cultural
background of the newborn and the views of the parents on
the most appropriate sex for their child. Unbiased sexual ori·
entation is enhanced if the parents show no ambivalence con-
cerning the chosen sex.l
The above considerations apply only to the newborn in
whom genital ambiguity poses an emergency situation. When
the diagnosis is initially established at a later age, all mea-
sures should be direaed toward restoring the concordance of
the phenotype with the sex of rearing.1 Moreover, there are
those patients in whom no (complete) surgical correction was
undertaken even though a proper diagnosis had been made
early in life. Complete endocrinologic and urogenital assess-
ment is routine prior to the initiation of reconstructive surgery
for such disorders, whether they appear in pediatric, adoles·
cent, or adult cases. Therefore, treatment of genital ambigu-
ity disorders should be restricted to multidisciplinary teams
capable of well-balanced individualized recommendations for
each patient.
Gender Dysphoria
The same principles apply to the treatment to female-to-male
transsexuals. Driven by the persistent and unchangeable need
to eliminate the diffi:rence between the physical reality of the
body and gender of the mind, transsexuals seek to adapt their
bodies as optimally as possible to the sex they feel they belong
to. The key issue prior to considering gender-confirming sur-
gery is to establish beyond reasonable doubt that the trans-
sexual feeling is genuine. The diagnosis of gender dysphoria
and the determination of whether sex reassignment surgery
is warranted is primarily the task of a behavioral scientist. In
addition, appropriate assessment of medical conditions and
998
the effi:cts of the hormonal treatment on liver and other organ
systems should he accomplished preoperatively by an endocri-
nologist. Hence, all specialists involved to collaborate closely
as members of a gender team. 3
Penile Loss
In male patients with penile loss as a result of amputation or
infection, the remaining penile stump may prove of insufficient
length causing poor personal hygiene and scrotal excoriation
because of urine, as well as an inability to void when stand-
ing:' Consultation with a behavioral scientist prior to any
reconstructive procedures may prevent postoperative disap-
pointment and frustration of phalloplasty or penile enhance-
ment. In cases where the testes were also lost,. the input of
an endocrinologist is required and in oncologic patients the
urologist has to be involved for proper timing of surgery.
Therefore, again, a multidisciplinary approach is preferred.
SURGICAL TECHNIQUES
Reconstruction or consttuction of the penis should ideally
aim at (a} a reproducible one-stage procedure; (b) aeation
of a competent neourethra to allow urination while stand-
ing; (c;) preservation or restoration of tutile and erogenous
sensibility in the phallus; (d) preservation of erec:tile £unc:-
tion or sufficient bulk to tolerate the insertion of a prosthetic
stiffener; and (e) a result that is aesthetic:ally ac:uptable to
the patient. Additionally, the ideal proc:edure also requires
(f) minimal scarring or disfigurement and (g) no func:tional
loss in the donor area.1
Correction of Genital Ambiguity
In cases where a decision for male gender assignment has been
reached in a child with a small but complete micropenis, sev-
eral surgical techniques to mobilize the cavernous corpora
from the pubic rami, to accentuate the penoscrotal junction,
and to reduce the pubic fat may be chosen in order to make
the small phallus appear more prominent. 1 Gonadal tissue
that is inconsistent with the male se:x should be removed.
Following masculine assignment in a truly intersex patient,
genital correction is similar to that of severe hypospadias.
Complete cordectomy is performed to mobilize the cavernous
corpora and the urethra is lengthened to bring the perineal
urethral orifice to the tip of the glans. Moreover, the ventral
asped: of the glans is reconstructed to give it a normal appear-
ance. This can often be accomplished in a single stage with the
neourethra being constructed proximally from the midportion
of a bifid scrotum meeting a distal rotated vascularized skin
flap from the hooded foreskin. If necessary, a thick non-hir-
sute skin graft can be used to bridge a gap of any length. The
prepenile, or "shawl," scrotum that drapes around the base
of the penis can be transposed caudally at a later stage and
testicular implants may be inserted.1.2
Metaidoioplasty
The techniques mentioned above compare with metaidoio-
plasty, in which a penile substitution with clitoral enlargement
and urethral lengthening is performed in female-to-male trans-
sexuals.~ The term metaidoioplasty is derived from the Greek
with "meta" as the prefix denoting the concept of "after"
or "subsequent to." Aidoio is an archaic combining form

relating to the genitals and -plasty is the suffix derived from
plastos (formed, shaped) meaning shaping. Indeed, androgen
intake may stimulate the growth of the clitoris to the point
where this organ can suffice as a phallus. Although metaid-
oioplasty is performed according to the principles of hypo-
spadias surgery, the female external genitalia actually provide
more tistn~e for surgical construction of a male phallus than a
severe hypospadias patient has available. A:sJ. overdeveloped
clitoris may be distinguished from an underdeveloped penis
by the frenulum on the ventral surface of the phallus. In nor-
mal males there is only a single midline frenulum, whereas
in normal females there are two frenula, each lateral to the
midline. Furthermore, the so-called chordae holding down the
female clitoris represent the conjoined continuation of both
labial spongiosus corpora toward the glans clitoris rather
than solely fibrous strands present in severe hypospadias. The
major labia are anterior in position to the scrotum and are
"transposed" in relation to the penis. The minor labia cor-
respond to the nonfused pendulous urethra and central penis
covering, whereas the female urethral ori1ice is comparable to
the perineal hypospadias situation.
During the single-stage metaidoioplasty, the clitoris is par-
tially released and stretched by resection of the ventral chor-
dae and the urethra is lengthened to the tip of the glans using a
pedicled musculomucosal.flap raised from the anterior vaginal
wall and minor labial skin (Figure 9.9.1). In most patients the
metaidoioplasty is combined with the construction of a bifid
scrotum in which testicular prostheses are implanted, hence
effecting the dorsal transposition of the major labia by bilat-
eral V-Y advancement. Metaidoioplasty allows the base of
the clitoris to be advanced approximately 3 em anteriorly.'-'
Chapter 99: Reoonst:ruction of the Penis 999
If provided with a sufficiently lengthened urethra this clitoris-
penoid will act as a normal and complete penis, albeit a small
one hardly capable of sexual penetration. In female-to-male
transsexuals where the clitoris seems to be large enough to
provide a phallus that will satisfy the patient, this one-stage
procedure is the method of choice.
Phalloplasty
Alternatively, efforts may also be made to construct a phal-
lus de novo. The relevant differences between the female and
male urogenital anatomy represent the surgical goals for
phalloplasty in female-to-male transsexuals (Figure 99.2).
The internal genitalia are superfluous but the urethra requires
lengthening, and some sort of phallus has to be added.
Because the male scrotum has abundant skin as compared
with the female major labia, the labial skin requires aug-
mentation and the insertion of testicular prostheses. Female
erectile tissues are much less developed than their male coun-
terparts and they are ideally replaced by an implant in female-
to-male transsexuals.
Phalloplasty in female-to-male transsexuals can seldom
be achieved in one stage because of the need to create a com-
petent neourethra allowing a urine stream to break cleanly
from the tip of the newly constructed phallus.1 Urethral
construction in a properly situated phallus involves fitting
the phallus with the pendular part of the urinary conduit,
and also advancing the original female urinary orifice to a
more anterior position. Advancement up to the base of the
clitoris may be accomplished by construction of the perineal
part of the neourethra using a flap raised from the anterior

Bladder Vagina Rectum

A B

(\

c D E F
FIGUJ:tE 9!1.1. Metaidoioplasty. A-F. In metaidoioplasty, the clitoris is sttetx:hed to become a phallus and the urethra is lengthened to the tip of
the phallus using an ann:rior vaginal musculomuc:osal flap and labial skin flaps. A. Pre-op. B. Post-op. C. To allow for the release of the clitoral
shaft and to secure neourethrallirliDI and cover, the TC&tibular skin bctweeD. meatus and glans clitoris is incised in a W-like fashion. D. The mid-
line vestibular sldn is undermined toward the glans thereby exposing the spongiorus tissue and chordae. These structures are resecn:d to bare the
ventral aspect of both cavernous corpora. E. After the phallus is stretched, the vaginal mucosa and vestibular skin flaps are rolled onto a cathel!lr
and sutured in a watertight fashion. Both flaps are anastomosed in a beveled fashion to prevent strictures. F. To strengthen the neourethra thus
crea~ the medial aspect of the left minor labium is de-epit:heliali2ed and sutured to cover the pendular part of the neourethra. The lateral sur-
face of the right minor labium is used to cover the periD.eal. fua:d part of the neourethra. (From Hage JJ. Metaidoioplasty-an alternative pbal-
loplasty technique in transsexuals. Plast R.econstr SUTg. 1996;97:161, with permission.)
1000 Pan IX: Tl'Wik and Lower h:tremity
8 u
:Jars
Jendulans
I
I involve the superfluous female internal genitalia like the
I vagina (V) and uterus and ovaries (U). Conversely, the
I
I v
I cient saotal skin. Furthermore, in female-to-male surgery,
I
I the urethra should be lengthened (B, bladder and urethra;
I I
l Pars ·fbca :
vaginal wall. J,9 Construction of this fixed part is often per-
formed separately from phalloplasty but may be combined
with the hysterectomy. Other surgeons construct this pars
fixa using an extra-long urethral part of the flap used for
phalloplasty or, even, free grafts.
A variety of techniques have been used for the recon-
struction of the actual phallus, and the development of
techniques for phalloplasty has paralleled the evolution of
plastic surgery. Randomly vascularized or axial pattern ped-
icled skin flaps and regional myocutaneous flaps, however,
do not provide adequate sensibility to the phallus. Because
such sensibility is a condition sine qua non for use of an
incorporated stiffener prosthesis, I regard these to be tech-
niques with few indications for phalloplasty. Although the
ideal requirements of phalloplasty have not all been met by
any single technique, microsurgical free flap techniques lead
to superior functional and aesthetic: results.5•10 Using free
flaps, it is possible to provide the phallus with protective
sensibility by coapting one of the dorsal clitoral or inguinal
nerves to a cutaneous nerve in the flap. Because no erog-
enous phallic sensibility is to be expected in the neophallus,
the second dorsal clitoral nerve should be left unharmed. To
construct the pendular phallic part of the neourethra, the
technique of a roll-in-a-roll is frequently used (Figure 99.3).
Alternatively, the neourethra may be preconstructed by
burial of a full-thickness skin graft in the flap to be used for
the phalloplasty at a later stage.11
Rigidity techniques should only be performed second·
arily, after sensibility has recurred in the free flap used for
the phalloplasty. A constant rigid phallus may serve as a
source of embarrassment to the patient and, therefore, inflat-
able hydraulic prostheses are to be preferred."·11 Because such
prostheses demonstrate mechanical failure, however, some
authorities have their patients use external devices for erec-
tion, whereas others fully rely on edema, scar fibrosis, or con-
gestion to give sufficient rigidity.
Apart from the need to give the perineum a scrotum-like
appearance, aesthetic considerations require the construction
of a glans-like tip of the neophallus. The Norfolk technique of
coronal ridge and sulcus construction leads to superior results
when a circumcised appearance is desired.5•10 Triangular flaps
at the distal end of the .flap give the phallus a conic glans and
a sagittally slitted aspect of the urethral orifice and prevent
meatal stricture (Figure 99.3).
As surgical techniques have developed, the combination
of pedicled and free flaps, or even of two free flaps, has been
applied. Such sophisticated methods do not always lead to
better results than the use of a single free flap. Microsurgical
techniques allow the surgeon to choose the free-flap donor
site. The most frequently used are the radial forearm flap,S•10
the lateral upper arm flap, and the fibula flap. 11 The donor
R
FIGURE 99.2. A, B. Male n. female anatomy. The rel-
evant differences between female and male representing
the Nrgical goals for phalloplasty in transsexual patients
female body is short of c:m:tile ti&Sues (C), testes, and suffi-
R, rectum). A. Male. B. Female.
site may be chosen in such a way as to prevent obvious
scaring. Still, laborious techniques such as pretransfer tis·
sue expansion and posttransfer correction of the donor site
may be indicated. Consequently, the quest for other free-flap
1----------- -~~~~-~'!'. ---------- ~ -~,_!·~_c_'!'_l
1
: 0.75cm
~
I I I
I
I
: 2.2cm
!
__.__
I
9-10
em
I
I
I
__.__
I
i 1cm
NV VAV VN
FIGURE 99.3. Free flap penile reconstruction. Design of a free flap
allowing the construction of the phallic part of the neourethra by
the tube-within-a-tube roll technique. The 2.S em narrow skin strip
is tubed outside-in to become the neourethra. Next to this strip, the
flap is de-epithelialized over a width of 1 c:m. This allows for the
wider 10 to 11 c:m skin part to be tubed and sutured in a water-
tight fashion around the urethral part to become the outer aspect of
the phallic shaft. Proximally, the urethral skin flap is extended 1 em
beyond the outer flap to reinforce the anastomosu between this phal-
lic part of the neourethra and itt fixed perineal part. Two triangular
flaps at the distal end of the flap give the phallus a conic glans and
a sagittally slitted aspect of the urethral orifice and prevent meatal
stricture. A distally based circumferential skin £lap is dinec!Jld to be
sutured to its own base in order to form the coronal ridge. The donor
site is covered with a split-thickness skin graft to mimic the coronal
sulcus. In cases where a radial. forearm free flap is used, multiple
vessels and nerves may be included (A, artuy; N, nerve; V, vein).
(Modified from Hage Jj, de Graaf FH. Addressing the ideal require-
ments by free flap pballoplasty: some reflections on refinements of
technique. Mict'osurgery. 1993;14:592, with permission.)

donor sites to be used for phalloplasty continues and neo-
phalloplasty remains one of the most challenging procedures
in reconstructive surgery.
Penile Enhancement
Most of the free flap phalloplasty techniques are also applica-
ble in men who have sustained traumatic loss of their penis. In
these patients the loss is often partial, necessitating the recon-
struction of the extracorporal, or pendular, part of the penis
only. ln these patients and oncologic patients alike, combined
suprapubic lipectomy and penile enhancement by uncover-
ing its subcutaneous parts may ofkr a simple and satisfactory
altemati~.4•13 Penile enhancement aims to increase the exter-
nal functional length of the penis by uncovering its subcutane-
ous parts with preservation of erogenous and tactile sensitivity
(Figure 99.4). The non-hirsute skin that was previously used to
cover the amputated corpora is spared to create the neoglans.
and the remaining subcutaneously covered length of the com-
bined corpora cavemosa and corpus spongiosum is dissected.
Care is taken not to injure the dorsal penile neurovascular sys-
tem. Dorsally, this dissection is continued up to the pubic sym-
physis, leaving only the deepest part of the suspensory ligament
intact. To allow the pubic edge of the circumferentially incised
skin to be anchored to the suspensory ligament dorsally, all but
1 em of pubic fat is resected subcutaneously.U Ventrally, the
dissection is extended to bare 1 to 2 em of the fascia of the bul-
bospongiosus muscle. Recessing the saotwn skin edge toward
this muscle will restore the penosaotal angle. Subsequent sutur-
ing of the lateral skin edges to the bared base of the penile shaft
will preserve the entire length of the enhanced penis. A thin
partial-thickness skin graft is used to cover the bare surface of
the shaft because it is more likely to successfully take on the
poorly vascularized tunica albuginea that may even have been
irradiated in oncologic patients. By meshing this graft, the risk
of postoperative edematous bulkiness is further reduced and the
definition of the neoglandular corona is better maintained;'
COMMENTS
ln cases of severe micropenis or genital ambiguity the main
question for the reconstructive surgeon concerns what the
fate of the presented organ will be-can it be made any
Chapter 99: Reoonst:ruction of the Penis 1001
bigger or should gender reassignment be contemplated.1•1
A useful objective criterion for function is the ability to void
standing up through an opened fly. It is surprising how short
a penis can be used to accomplish this task, especially if a
boy is given adequate instruction and trousers with ade-
quate openings. The same applies for male amputees and for
female-to-male transsexuals who had a metaidoioplasty: a
very small penis is compatible with the normal male role.
Thus, the prospect of a very small penis should not, on its
own, be an indication for assignment to the female gender
or phalloplasty.1
Although a small phallus may perform normal urina-
tion, it is more difficult to get away with an abnormal
appearance. Little boys are very conscious of their genita-
lia and only a few men with a micropenis will feel confi-
dent to change clothes or shower in public. No operation
has yet been devised to predictably make the corpora of
the truly small penis longer, but the techniques for phal-
loplasty used for female-to-male gender confirmation can
be applied to male adults. The disadvantage in infants is
that the constructed phallus may not grow. Now that neo·
phallic sensibility and possible rigidity may be secured,
these techniques may be appropriate for the healthy adult
male patient with a small but sexually sensitive penis or
penile stump.
Total sensate phalloplasty including an erectile implant
is not considered an option in the oncologic patient who
is at risk for neophallic lymphedema resulting from ingui-
nal lymph node dissection or adjuvant radiotherapy.•
Moreover, an increasing number of men present after par-
tial penis amputation as organ-saving therapies are gaining
interest among urological oncologists. Still, adhering to a
1.5 to 2 em surgical cancer-free margin often leads to a
phallus width in which voiding in the standing position
and sexual intercourse are impossible, particularly in obese
patients. These patients may be offered penile enhance-
ment to relieve the psychological sequelae of inadequate
penile length.u
Patients presenting for reconstruction or de novo construc-
tion of the penis require tailor-made treatment. The plethora
of techniques for penile (re)construction stresses that various
indications pose different requirements and suggests that not
one technique may pass as a fit-for-all.

~~..
A ...... S
...
I

FIGUJ:tE 9!1.4. Penile enhana:ment aftu partial amputation. Left to right: The skin that was used to cover the am~~a:d corpora cavemosa
(CC) and corpus spongiosum (CS) is iDcised in an oblique ciraunfcrcntial ~shlon to recrcaa: ~ n~~s (~). 1'hl: rema.tDIDS su~eously co'!'-
ered length of the penile shaft is subsequently dissec:a:d deep to Buclc.'s fascia (B). Dorsally, this disse<:tton IS con?Dued up to the pub~c: symphysis
(S) and partly into the deep tuSpensory ligament, whereas, ventrally, it is extended to bare 1 to 2 c:m of the fasw. of the bulbospong~otuS muscle
(MB). Following resection of pubic tulx:utaneous fat, the pubi~ skin is secured to ~e abdoa;ainal wall: -r:ne marked diHf:rence in ~tial
width between the neoglans and the dissected penile corpora IS sutured to the turuc:a albugmea to mmuc the coronal ndge (C). The pub1c: ~d
scrotal skin edges are anchored to the suspensory ligament and bulbospongiotuS fascia (D) and the lateral skin edg,es are anchored to the tumc:a
albuginea. The resulting bare surface of the penile shaft is then covered by a p~-thickness skiD. graft. (Modified ~m Ha~ JJ. Simple,. safe,
and satisfactory secondary penile enhana:mcnt aftu near-total oncologic: amputanon.. Ann Plast Surg. 2009;62:685, wtth penm58.1on.)
1002 Pan IX: Tl'Wik and Lower h:tremity
1. Woodlwuse CRJ. Problems of intenex, g~ender identity and mieropellis. ID:
Woodhouse CRJ, ed. Long-term Pe#Umic Urology. Lcndon: BlukweU;
19.91:176-191.
2. Hrabonzky Z, Hutson JM. Surgi~ treatment of intersex abnormalities:
a review. Sftrgery. 2002;131:92-104.
3. Meyer WM m, Bocltting WO, Cohen-I<i!ttellis P, et al The Han:y Beujamin
Intemational. GeDder Dysphoria AMM:iation's standards of care for gender
identity disorders, si:x:th version. JPttycholl:blrrum &1:11111. 2001;13:1-30.
4. Hage lJ. Simple, safe, and sal'ist'utory sec:ondary pellile enhaneement after
near-total on<:Ologil: amputation. Ann P£ut SIR'g. 200.9;62:685-6'8.9.
5. Ha.ge lJ, de Gra.af FH. Addressing the ideal requirements by free flap
phalloplasty: some reflections on refiDements of techniq~~e. MiawiR'gery.
19.93;14:592-598.
6. Hage JJ. Metaidoioplasty-An altemative phalloplasty technique in trans-
semals. Pltut RecorJ~tr S.rg. 1996;97:161-167.
7. lkge lJ, •an Tumhout AA. Long-term outcome of m.etaidoioplasty in
70 femAle-to-male traii.SSeXWils. Am P/4# Sftrg 2006;.57:312-316.
8. Djordjeric ML, SWiojeric D, Bi.zic M. eta!. Metuidiopluty as a. single stage
sex re.assipme~~t surgery in female transsexuals: Belgrade experience. J s~
M&l. 200.9;6:1306-1313.
.9. R.ohmwm D, jakse G. Urethroplasty in femAle-to-male transsexuals. I!.Mr
Urol. 2003;44:611-614.
10. Monstrey S, Hoebeke P, Sel,-a.ggi G, et a!. Penile reconstruction: is the
radilll. forearm flap really the stll.lldard techllique? Pltut RJiconstr Stwg.
200!1;124:510-518.
11. Hage JJ, Winters HAH, van Lieshout j. Fibula. &ee fla.p phallopluty: modi-
fica.tioll811.1ld r«<mmendations. MicrOIMf'gtny. 1.9.96;17:358-365.
12. Hoebeke P, de Cuypere G, Ceulemans P, Mollltrey S. Obtaining rigid-
ity in total phalloplasty: experience with 35 pa.tients. J Urol. 2003;16.9:
221-223.
13. Horton CB. Dean JA. R.ecoll8truction of tta.wntltically a.cquired defects of
the piWlus. World J Smg. 1.9.90;14:757-762.