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Local Flaps in the Head and Neck: Forehead, FAMM, Submental, Nasolabial and Cervicofacial Flaps

Introduction Over the years, numerous local flaps have been utilized for closure of facial defects. Owing to the robust blood supply of the facial soft tissues, many local flaps have been based on the dermal and subdermal capillary circulation and simply represent the geometric repositioning of the skin and soft tissues. Other flaps, such as the paramedian forehead flap and the nasolabial flap, are based on…

Reconstructive Options Following Flap Failure

Introduction A failed free flap is a challenge for every microsurgeon no matter how experienced. When a flap is lost, the patient and family are disappointed, and disturbed over the need for additional surgery. The clinical support staff share a sense of responsibility and discouragement. The surgeon must make difficult clinical decisions. There are often several reconstructive surgical options, the array seems confusing – simpler methods…

Postoperative Care

Introduction Microsurgical reconstruction with free tissue transfer has become standard practice for plastic surgeons around the world with varied uses and applications. However, perioperative management of these complex patients is diverse. As the understanding of flap physiology and refinement of microsurgical techniques has evolved, both pedicled flaps and free tissue transfer have become reliable and effective methods of producing sound functional and aesthetic reconstructive outcomes. The…

Flap Re-exploration and Salvage

Introduction Achieving success in microvascular free tissue transfers requires more than the technical ability to proficiently perform microvascular anastomoses. Preoperative planning, choice of recipient vessels, intraoperative execution of dissection, elevation and insetting, along with postoperative monitoring are all equally important to a successful outcome. Although having a free flap survive may be a prerequisite for success, a truly successful outcome is being able to achieve the…

Avoiding Complications

Introduction It is something of a dent to personal pride to be singled out among so many internationally distinguished contributors to write a chapter on complications in microsurgery. How did the editors know we were so experienced in complications? We would like to be able to make the same boast as an esteemed surgical mentor who, when asked to speak on complications, warmed to the subject…

Thinning and Tailoring

Purposes of Skin Flap Surgery The purposes of flap transfer are classified into four categories: surface coverage; volume restoration; framework creation; and functional reconstruction. Category one is surface coverage of the defect without the need for significant thickness. In clinical situations, since every flap has some degree of thickness, surface coverage inevitably is associated with provision of volume (category two). The third category is reconstruction of…

Vessels

Introduction It is more than a century since Alexis Carrel introduced the techniques of vessel repair in 1906. The triangulation technique founded by him was used for the repair of major vessels. The origin of modern microvascular practice is credited to Jacobson and Suarez, who borrowed the use of the operating microscope from their otolaryngology colleagues in the 1950s. With time, the diameter of the vessels…

Nerves

Introduction and Historical Notes The peripheral nervous system (PNS) embodies unique anatomical structure and function that contributes immensely to human quality of life. Through the ages, the importance of the PNS has been recognized, but function and structure were often misinterpreted or considered mystical. The Alexandrians, specifically Herophilus of Chalcedon (335–280 bc ) and Erasistratus of Chios (310–250 bc ) are credited with differentiating nerves from…

Functional Muscle Transfers for Various Purposes

Introduction Whereas in the past, reconstructive microsurgery mainly consisted of defect coverage by free tissue transfer, today this technique allows a continual integration of improved aesthetic appearance and functional reconstruction. Thus, the main goal of functional reconstructive surgery is to optimally address both functional and aesthetic requirements. Sophistication in surgical techniques has enabled the surgeon to address a wide variety of individual exigencies with one or…

Lower Extremity Reconstruction

Introduction In this chapter we present the topic of reconstruction of soft tissue and bone defects in the lower extremity. We present the multiple indications for lower extremity reconstruction and review the decision-making process for proceeding with limb amputation versus salvage for cases of severe lower extremity trauma or major oncologic resection. We also discuss the likely postoperative sequelae and secondary challenges that arise after major…

Adult Brachial Plexus Injury (A-BPI) Reconstruction

Introduction The surgical management of adult brachial plexus injury (A-BPI) reconstruction has evolved substantially over the last century. The advancement of the operative microscope and surgical loupe magnification, micro-instruments and stitches, nerve stimulators, chemistry, molecular biology, and pharmacology has enabled a far deeper understanding of the internal anatomy of the nerves and pathophysiology of nerve degeneration and regeneration. As a result of more accurate preoperative diagnosis,…

Upper Extremity Reconstruction

Introduction The many specialized structures of the hand and upper extremity work in intimate synchrony to provide a harmonious interplay of precision motor biomechanics with fine tactile senses. Our hands are subject to many common occupational and domestic injuries, including fingertip trauma, tendon lacerations, neurovascular compromise, fractures, and soft tissue loss. Every extremity trauma has its own unique characteristics that offer challenges for soft tissue coverage.…

Pelvic and Urogenital Reconstruction

Introduction Perineal and urogenital reconstruction has particular challenges due to the anatomic and functional complexity and differences between the male and female genitalia. Furthermore, genital defects and abnormalities are associated with psychological and social implications, which must be considered by the reconstructive surgeon. The complexity of genital anomalies requires a multidisciplinary approach with close cooperation between the reconstructive surgeon and the urologist or gynecologist. Pertinent functions…

Abdominal Wall Reconstruction

Introduction The need for soft tissue coverage in abdominal wall reconstruction implies a lack of tissue beyond the availability of local tissue to be recruited to resurface the defect. As the majority of abdominal wall defects can be reconstructed with the redundant tissue from the torso, these defects represent a more complex subset of abdominal wall reconstructions. Indications for flap coverage vary by etiology of defect,…

Chest and Back Reconstruction

Introduction The structure of the chest and back serves multiple functions that are important to be aware of and maintain during reconstruction. The chest and back protect the vital heart, lungs, great vessels, and spine, and provide a pressure environment for inspiration and expiration. This structure also serves as the foundation for upper limb movement and support of the head and trunk. Chest and back defects…

Breast Reconstruction

Introduction Autologous options for breast reconstruction have greatly expanded since the initial descriptions of the latissimus dorsi musculocutaneous flap and the transverse rectus abdominis musculocutaneous (TRAM) flap. In many ways, these two flaps have provided the cornerstone for many of the autologous options that are currently available. Through ingenuity and innovation, plastic surgeons have pioneered a variety of flaps that are currently in use in order…

Facial Reanimation: Evolution and Refinements

Introduction and Historic Review Facial paralysis (FP) is a devastating condition which strips the human face from all emotional expressivity, leading to severe consequences in the quality of life, interpersonal communication, and psychological development of the afflicted patient ( Fig. 15.1 ). The most important advances in the treatment of FP during the last century included the introduction of restorative microsurgery with atraumatic manipulation of injured…

Head and Neck Reconstruction

Introduction The head and neck is a unique anatomic region of the human body with specialized function. The sophisticated arrangement of multiple tissue types comprises unique physical traits from individual to individual. Regions of the head, face, and neck are responsible for multiple high functioning mechanisms, including mastication, swallowing, phonation, articulation, respiration, vision, periorbital protective mechanisms, audition, and olfaction, all of which have been characteristic in…

Clinical Anatomy and Recipient Vessel Selection and Exposure in the Lower Extremity

Introduction The reconstructive microsurgeon is often consulted for management of lower extremity bone and soft tissue defects. Defects can arise from multiple causes, including trauma, oncologic resection, infection, or pre-existing vascular disease. By far, trauma is the most common etiology for lower extremity defects that require microsurgical reconstruction. This chapter delineates clinically relevant anatomy in the lower extremity and provides anatomic and technical descriptions of exposing…

Clinical Anatomy and Recipient Vessel Selection in the Upper Extremity

Introduction Reconstructive microsurgery of the upper extremity requires detailed knowledge of the regional anatomy of the arm, forearm and hand. Specific familiarity with the anatomy of the neurovascular structures allows safer, more expeditious flap elevation and recipient vessel exposure. This chapter reviews anatomy pertinent to upper extremity reconstruction, and describes the anatomy of common recipient vessel approaches. Anatomy of the Arm The arm is divided into…