V2Chung OT in Flaps in Plastic and Reconstructive Surgery 97

^ȈŒɛɵࢲǦȠࢲØȈŒɵʂǦƀࢲŒȠƊࢲßƝƀȰȠɵʂɥʗƀʂǦʴƝࢲèʗɥLjƝɥˁ `xæðüࢱD5xüx´£ࢱ ßʞŷȋǩɻǞƟƌࢱŸŒˈࢱ߿߽߾ ࠆ ࢱ

Visit ȈʸʸࡰƀȰࡰʗȂࢲࢲ for more information

SAMPLE CHAPTER PREVIEW

ĦǕƚȘ ʿȩʕ Ǖŏʲƚ ɾȩ ųƚ ɟǞǃǕɾ

`ȋŒɠɻࢱǩȣࢱßȋŒɻʉǩƁࢱŒȣƌࢱæƟƁȴȣɻʉɫʞƁʉǩʻƟࢱðʞɫNJƟɫˈ

`xæðüࢱD5xüx´£ࢱ

x SBN ߤߣߥ ࡷ ߝ ࡷ ߝߡߣߥ ࡷ ߥߠߥߞ ࡷ ߝ ÚɟǞżƚ ࢪ ࡕߜߜࡏߡߥߝ ࢛ ߜߜࡏߜߞߞ

Úŏɟɾ ȩǀ ɾǕƚ ųƚɯɾࡷɯƚȀȀǞȘǃ °ɔƚɟŏɾǞʲƚ ÷ƚżǕȘǞɛʕƚɯ ɯƚɟǞƚɯ ࡈ °ɔƚɟŏɾǞʲƚ ÷ƚżǕȘǞɛʕƚɯ ǞȘ ÚȀŏɯɾǞż ëʕɟǃƚɟʿ ɔɟȩʲǞƇƚɯ ɯʕɔƚɟųȀʿ ǞȀȀʕɯɾɟŏɾƚƇ ࡈ ŏʕɾǕȩɟǞɾŏɾǞʲƚ ǃʕǞƇŏȘżƚ ȩȘ ȩɔƚɟŏɾǞʲƚ ɾƚżǕȘǞɛʕƚɯ ŏȀȩȘǃ ʶǞɾǕ ŏ ɾǕȩɟȩʕǃǕ ʕȘƇƚɟɯɾŏȘƇǞȘǃ ȩǀ Ǖȩʶ ɾȩ ɯƚȀƚżɾ ɾǕƚ ųƚɯɾ ɔɟȩżƚƇʕɟƚ ࡈ Ǖȩʶ ɾȩ ŏʲȩǞƇ żȩȒɔȀǞżŏɾǞȩȘɯ ŏȘƇ ʶǕŏɾ ȩʕɾżȩȒƚɯ ɾȩ ƚʾɔƚżɾ ࡏ ÷ǕǞɯ ɯɾŏȘƇࡷŏȀȩȘƚ ųȩȩǺ ȩǀǀƚɟɯ ǀȩżʕɯƚƇ ࡈ ƚŏɯʿࡷɾȩࡷǀȩȀȀȩʶ żȩʲƚɟŏǃƚ ȩǀ ǀȀŏɔɯ ǀȩɟ ŏȀȀ ŏȘŏɾȩȒǞż ɟƚǃǞȩȘɯ ࡈ ɾŏǺƚȘ ƇǞɟƚżɾȀʿ ǀɟȩȒ ɾǕƚ Ȁŏɟǃƚɟ ɾƚʾɾ ࡏ vɾ żȩʲƚɟɯ ȘƚŏɟȀʿ ŏȀȀ ǀȀŏɔ ɾƚżǕȘǞɛʕƚɯ Ǖŏɾ ŏɟƚ ǞȘ żʕɟɟƚȘɾ ʕɯƚ ࡈ ŏȘƇ Ǟɯ ǞƇƚŏȀ ǀȩɟ ɟƚɯǞƇƚȘɾɯ ŏȘƇ ɔǕʿɯǞżǞŏȘɯ ǞȘ ƇŏǞȀʿ ɔɟŏżɾǞżƚ ࡏ

Features include: ðʞƁƁǩȣƁʉࢱʉƟˇʉࡪࢱŷʞȋȋƟʉƟƌࢱɠȴǩȣʉɻࡪࢱŒȣƌࢱɧʞǩƁȅ࢙ɫƟLJƟɫƟȣƁƟࢱʉŒŷȋƟɻࢱŒȋȋȴʿࢱˈȴʞࢱʉȴࢱɫƟʻǩƟʿࢱǩȣLJȴɫȝŒʉǩȴȣࢱ ɧʞǩƁȅȋˈࢱŒȣƌࢱʞȣƌƟɫɻʉŒȣƌࢱŷƟɻʉࢱɠɫŒƁʉǩƁƟɻࢱŒȣƌࢱɠȴʉƟȣʉǩŒȋࢱɠɫȴŷȋƟȝɻࢱLJȴɫࢱƟŒƁǞࢱɠɫȴƁƟƌʞɫƟࡱ

ßƟɫLJƟƁʉࢱLJȴɫࢱŒࢱɧʞǩƁȅࢱɠɫƟȴɠƟɫŒʉǩʻƟࢱɫƟʻǩƟʿࢱȴLJࢱʉǞƟࢱɻʉƟɠɻࢱȴLJࢱŒࢱɠɫȴƁƟƌʞɫƟࡱ

oʞȣƌɫƟƌɻࢱȴLJࢱLJʞȋȋ࢙ƁȴȋȴɫࢱǩȣʉɫŒȴɠƟɫŒʉǩʻƟࢱɠǞȴʉȴNJɫŒɠǞɻࢱŒȣƌࢱǩȋȋʞɻʉɫŒʉǩȴȣɻࡪࢱŒɻࢱʿƟȋȋࢱŒɻࢱȣʞȝƟɫȴʞɻࢱǞǩNJǞ࢙ ɧʞŒȋǩʉˈࢱʻǩƌƟȴɻࡪࢱƁŒɠʉʞɫƟࢱɠɫȴƁƟƌʞɫƟɻࢱɻʉƟɠࢱŷˈࢱɻʉƟɠࢱŒȣƌࢱǞƟȋɠࢱˈȴʞࢱǩȝȝƟƌǩŒʉƟȋˈࢱŒɠɠȋˈࢱˈȴʞɫࢱȅȣȴʿȋƟƌNJƟࡱ

+ȴȝɠɫƟǞƟȣɻǩʻƟȋˈࢱƁȴʻƟɫɻࢱƁɫŒȣǩȴLJŒƁǩŒȋࢱŒȣƌࢱLJɫȴȣʉŒȋࢱɻǩȣʞɻࢱLJȋŒɠɻࡶࢱǞƟŒƌࢱŒȣƌࢱȣƟƁȅࢱLJȋŒɠɻࡶࢱ LJȋŒɠɻࢱLJȴɫࢱŷɫƟŒɻʉࢱɫƟƁȴȣɻʉɫʞƁʉǩȴȣࡶࢱʉɫʞȣȅࢱɫƟƁȴȣɻʉɫʞƁʉǩȴȣࢱŒȣƌࢱŷȴƌˈࢱƁȴȣʉȴʞɫǩȣNJࢱLJȋŒɠɻࡶࢱ LJȋŒɠɻࢱǩȣࢱǞŒȣƌࢱɻʞɫNJƟɫˈࡶࢱLJȋŒɠɻࢱʞɻƟƌࢱǩȣࢱȋȴʿƟɫࢱȋǩȝŷࢱɫƟƁȴȣɻʉɫʞƁʉǩȴȣࢱŒȣƌࢱŒȝɠʞʉŒʉǩȴȣࡶࢱŒȣƌࢱ LJȋŒɠɻࢱʞɻƟƌࢱǩȣࢱɠƟƌǩŒʉɫǩƁࢱLJŒƁǩŒȋࢱɫƟŒȣǩȝŒʉǩȴȣ

ßʞŷȋǩɻǞƟƌࢱŸŒˈࢱ߿߽߾ ࠆ ࢱ ëŏȒɔȀƚ +Ǖŏɔɾƚɟ ÚɟƚʲǞƚʶ

ĦǕƚȘ ʿȩʕ Ǖŏʲƚ ɾȩ ųƚ ɟǞǃǕɾ

Contributors

Kevin C. Chung, MD, MS Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Charles B. G. de Nancrede Professor of Surgery Professor of Plastic Surgery and Orthopaedic Surgery Assistant Dean for Faculty Affairs Associate Director of Global REACH University of Michigan Medical School Ann Arbor, Michigan Mark W. Clemens, MD, FACS Associate Professor Department of Plastic Surgery MD Anderson Cancer Center University of Texas Houston, Texas Zachary J. Collier, MD Division of Plastic & Reconstructive Surgery Department of Surgery USC Keck School of Medicine Los Angeles, California Brendan Collins, MD Attending Physician and Microsurgical Fellowship Director Kasandra Dassoulas, MD Richmond Aesthetic Surgery Midlothian, Virginia Joseph H. Dayan, MD Division of Plastic & Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, New York J. Rodrigo Diaz-Siso, MD Postdoctoral Research Fellow Hansjörg Wyss Department of Plastic Surgery New York University Langone Health New York, New York Mercy Medical Center Baltimore, Maryland

Edward I. Chang, MD, FACS Associate Professor Department of Plastic Reconstructive Surgery University of Texas MD Anderson Cancer Center Houston, Texas Hung-Chi Chen, MD, PhD, FACS China Medical University Hospital International Medical Service Center China Medical University Taichung, Taiwan Pierre M. Chevray, MD, PhD Houston Methodist Institute for Reconstructive Surgery Associate Professor Professor of Plastic Surgery Department of Plastic and Reconstructive Surgery Michael V. Chiodo, MD Plastic Surgery Resident Hansjörg Wyss Department of Plastic Surgery New York University Langone Medical Center New York, New York Ernest S. Chiu, MD, FACS Associate Professor of Plastic Surgery Director, Kimmel Hyperbaric and Advanced Wound Healing Center NYU Langone Health New York, New York Carrie K. Chu, MD, MS Assistant Professor Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, Texas Michael W. Chu, MD Kaiser Permanente Medical Group Department of Plastic & Reconstructive Surgery Los Angeles, California Weill Cornell Medical College Adjunct Associate Professor Baylor College of Medicine Program Director Houston Methodist Plastic Surgery Residency Houston, Texas

Mouchammed Agko, MD Assistant Professor Section of Plastic Surgery Department of Surgery Medical College of Georgia at Augusta University Augusta, Georgia Jeffrey A. Ascherman, MD Thomas S. Zimmer Professor of Reconstructive Surgery at CUMC Site Chief Division of Plastic Surgery Columbia University Medical New York, New York Fadi Bakal, MD Plastic Surgery Department Brussels University Hospital Vrije Universiteit Brussel Brussels, Belgium Maureen Beederman, MD Resident Section of Plastic and Reconstructive Surgery Department of Surgery The University of Chicago Medicine Chicago, Illinois Robert Beinrauh, MD Head of Craniofacial Surgery Plastic and Reconstructive Surgery Department Kaiser-Permanente Hospital Downey, California Lawrence E. Brecht, DDS NYC Prosthodontics New York, New York Charles E. Butler, MD, FACS Professor and Chairman Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, Texas Chris A. Campbell, MD, FACS Associate Professor Department of Plastic Surgery University of Virginia

Charlottesville, Virginia Bernard W. Chang, MD Chief of Plastic Surgery Mercy Medical Center Baltimore, Maryland

vii

Chung-Flaps1e9781975129491-FM.indd 7

3/8/2019 9:00:14 PM

viii

Contributors

Matthew M. Hanasono, MD Professor and Fellowship Program Director Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, Texas

Ravi Garg, MD Chief Resident Plastic and Reconstructive Surgery University of Wisconsin Madison, Wisconsin Brian R. Gastman, MD Professor Cleveland Clinic Lerner College of Medicine Staff in Plastic Surgery/Taussig Cancer Center Melanoma–Soft Tissue Cancer–Head and Neck Cancer Cleveland Clinic Cleveland, Ohio Finny George, MD Long Island Plastic Surgical Group Garden City, New York David Gerth, MD Plastic Surgery MOSA Surgery Miami Beach, Florida Amir M. Ghaznavi, MD Staff Department of Plastic & Reconstructive Surgery Cleveland Clinic Florida Weston, Florida Deepak M. Gupta, MD Clinical Assistant Professor of Plastic Surgery Santa Clara Valley Medical Center and Stanford University School of Medicine San Jose, California Larissa Habib, MD Clinical Fellow in Ophthalmic Plastic and Reconstructive Surgery Department of Ophthalmology Harvard Medical School Massachusetts Eye and Ear Infirmary Boston, Massachusetts Nicholas Haddock, MD Associate Professor Department of Plastic Surgery University of Texas Southwestern Dallas, Texas Eric G. Halvorson, MD Halvorson Plastic Surgery Asheville, North Carolina Moustapha Hamdi, MD, PhD Professor and Chairman of Plastic Surgery Department Brussels University Hospital–Vrij Universiteit Brussel Brussels, Belgium

Joseph J. Disa, MD, FACS Vice Chair of Clinical Activities Department of Surgery Attending Surgeon Memorial Sloan Kettering Cancer Center Professor of Surgery Weill Medical College of Cornell University New York, New York Gregory A. Dumanian, MD Lucille and Orion Stuteville Professor of Surgery Chief of Plastic Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois Kate Elzinga, MD, FRCSC Plastic Surgeon Department of Surgery University of Calgary Calgary, Alberta, Canada John G. Fernandez, MD, FACS Director of Plastic and Reconstructive Surgery Cancer Treatment Centers of America Philadelphia, Pennsylvania Michael W. Findlay, MBBS, PhD, FRACS, FACS Program Director–Plastic Surgery The Peter MacCallum Cancer Centre Plastic, Reconstructive and Hand Surgeon The Canberra Hospital Surgical Lead Plastic, Reconstructive and Hand Surgery Australasian Clinical Trials Network Director Program for Molecular and Cellular Innovation in Surgery Senior Lecturer Department of Surgery Melbourne, Australia Sean M. Fisher, MD Plastic and Reconstructive Surgery Resident University of Washington Seattle, Washington Jordan D. Frey, MD Resident Hansjörg Wyss Department of Plastic Surgery NYU Langone Health New York, New York Brad M. Gandolfi, MD Craniofacial Plastic and Reconstructive Surgeon Paramus, New Jersey Royal Melbourne Hospital The University of Melbourne

Ahmed M. Hashem, MD Professor of Plastic Surgery Division of Plastic Surgery

Department of General Surgery Kasr Al-Ainy, Faculty of Medicine Cairo University Cairo, Egypt Mahmoud Hassouba, MD Craniofacial and Pediatric Plastic Surgery Fellow Plastic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio Peter Henderson, MD, MBA Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai New York, New York David L. Hirsch, MD, DDS, FACS Chief, Oral-Maxillofacial Surgery Department of Otolaryngology–Head & Neck Surgery Lenox Hill Hospital New York, New York Michael A. Howard, MD Clinical Associate Professor of Surgery Section of Plastic Surgery Pritzker School of Medicine Clinical Fellow, Aesthetic and Reconstructive Breast Surgery Division of Plastic and Reconstructive Surgery Massachusetts General Hospital/ Harvard Medical School Boston, Massachusetts Amir Inbal, MD Section of Plastic and Reconstructive Surgery Department of Surgery University of Chicago Medical Center Chicago, Illinois Adam Jacoby, MD University of Chicago Northbrook, Illinois John Hulsen, MD

NYU Langone Health New York, New York

Chung-Flaps1e9781975129491-FM.indd 8

3/8/2019 9:00:14 PM

ix

Contributors

Jamie P. Levine, MD Associate Professor of Plastic Surgery Hansjörg Wyss Department of Plastic Surgery Chief of Microsurgery Microsurgery Fellowship Director NYU Langone Medical Center New York, New York Sean S. Li, MD Resident Division of Plastic and Reconstructive Surgery University of California, San Diego San Diego, California John R. Lien, MD Assistant Professor Section of Plastic Surgery Department of Orthopaedic Surgery University of Michigan Health System Ann Arbor, Michigan Xiangxia Liu, MD, PhD Associate Professor and Associate Chief Division of Plastic Surgery First Affiliated Hospital Sun Yat-sen University Guangzhou, Guangdong, China Jeffrey R. Marcus, MD, FAAP, FACS Professor and Chief Director Duke Cleft and Craniofacial Center Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery Duke University Durham, North Carolina Brian P. Marr, MD Director Ophthalmic Oncology Service Professor College of Physicians and Surgeons Columbia University New York-Presbyterian Hospital/ Columbia University Medical Center Department of Ophthalmology Edward S. Harkness Eye Institute Columbia University Medical Center Department of Oncology Herbert Irving Comprehensive Cancer Center New York, New York Evan Matros, MD, MMSc, MPH Associate Member Memorial Sloan Kettering Cancer Center Associate Professor Weill Cornell Medical College New York, New York

Ulrich Kneser, MD Professor of Plastic and Hand Surgery University of Heidelberg Medical School Director Department of Hand, Plastic and Reconstructive Surgery Burn Unit BG Trauma Center Ludwigshafen Ludwigshafen, Germany Petro Konofaos, MD, PhD Assistant Professor of Plastic Surgery and Neurology Director of Microsurgery and Research Department of Plastic Surgery University of Tennessee Health Science Center Memphis, Tennessee Ann Arbor, Michigan Thomas Kremer, MD Professor of Plastic and Aesthetic Surgery, Hand Surgeon Department of Plastic and Hand Surgery Burn Center Leipzig, Germany Theodore A. Kung, MD Assistant Professor of Surgery Section of Plastic and Reconstructive Surgery University of Michigan Michigan Medicine Ann Arbor, Michigan Brian I. Labow, MD, FACS, FAAP Associate Professor of Surgery Jeffrey H. Kozlow, MD, MS Associate Professor (Clinical Track) Section of Plastic Surgery University of Michigan

Jeffrey E. Janis, MD, FACS Professor of Plastic Surgery, Neurosurgery, Neurology, and Surgery Chief of Plastic Surgery University Hospitals Ohio State University Wexner Medical Center Columbus, Ohio Sahil K. Kapur, MD Assistant Professor Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, Texas Ibrahim Khansa, MD Division of Plastic and Maxillofacial Surgery Children’s Hospital Los Angeles Los Angeles, California Matthew S. Kilgo, MD Plastic Surgeon Long Island Plastic Surgical Group Garden City, New York Jeff J. Kim, MD Resident Physician PGY6 Section of Plastic and Reconstructive Surgery Department of Surgery The University of Chicago Medical Center Chicago, Illinois So Young Kim, MD, PhD Assistant Professor Department of Plastic and Reconstructive Surgery Inje University Sanggye Paik Hospital Inje University School of Medicine Seoul, South Korea Michael J. A. Klebuc, MD Associate Clinical Professor of Plastic and Neurosurgery Weill Medical College Cornell University Director Center for Facial Reanimation

Harvard Medical School Boston Children’s Hospital Boston, Massachusetts Brock Lanier, MD

Clinical Instructor in Microsurgery Division of Plastic and Reconstructive Surgery

and Functional Restoration Houston Methodist Hospital Houston, Texas Jennifer A. Klok, MD, MSc Associate Staff Division of Plastic Surgery Department of Surgery Peterborough Regional Health Centre Peterborough, Ontario, Canada

Stanford University Stanford, California Amber R. Leis, MD

Assistant Clinical Professor Director of Hand Surgery Assistant Program Director University of California–Irvine Orange, California

Chung-Flaps1e9781975129491-FM.indd 9

3/8/2019 9:00:14 PM

x

Contributors

Brenton R. Robinson, MD Resident Physician Department of Surgery Presence Saint Joseph Hospital– Chicago Chicago, Illinois Eduardo D. Rodriguez, MD Chair Hansjörg Wyss Department of Plastic Surgery Helen L. Kimmel Professor of Reconstructive Plastic Surgery NYU Langone Medical Center New York, New York Pierre Saadeh, MD Vice Chair of Education Residency Program Director Chief of Plastic and Hand Surgery Bellevue Hospital Department of Plastic Surgery School of Medicine New York University New York, New York Christopher J. Salgado, MD Professor and Interim Chief of Plastic Surgery Division of Plastic Surgery Medical Director of the LGBTQ Center for Wellness Gender and Sexual Health Department of Surgery School of Medicine/Jackson Memorial Hospital System University of Miami Miller Miami, Florida Hani Sbitany, MD, FACS Associate Professor of Surgery Division of Plastic and Reconstructive Surgery University of California, San Francisco San Francisco, California Subhro K. Sen, MD Clinical Associate Professor Plastic and Reconstructive Surgery Farooq Shahzad, MBBS, FACS, FAAP Assistant Professor of Plastic Surgery Ann & Robert H Lurie Children’s Hospital of Chicago Feinberg School of Medicine Northwestern University Chicago, Illinois Stanford University Palo Alto, California

Peter Neligan, MB, FRCS(I), FRCSC, FACS Professor of Surgery Director, Center for Reconstructive Surgery University of Washington Medical Center Seattle, Washington Ajani G. Nugent, MD Assistant Professor Division of Plastic and Reconstructive Surgery Department of Surgery Miller School of Medicine University of Miami Miami, Florida Adrian S. H. Ooi, MBBS, MMed (Surgery), MRCS, FAMS (Plastic Surgery) Consultant Plastic Surgeon Department of Plastic, Reconstructive and Aesthetic Surgery Singapore General Hospital SingHealth Head & Neck Disease Center SingHealth Singapore, Singapore Julie E. Park, MD Assistant Professor Section of Plastic & Reconstructive Surgery University of Chicago Medical Centre Department of Surgery The University of Chicago Medicine & Biological Sciences Chicago, Illinois Julian J. Pribaz, MD, FRCS(Edin), FRACS(Plastics) Professor of Surgery Morsani College of Medicine University of South Florida Plastic Surgeon Moffitt Cancer Center Plastic Surgeon Tampa General Hospital Tampa, Florida Lee L. Q. Pu, MD, PhD, FACS Professor of Surgery Division of Plastic Surgery University of California Davis Medical Center

Babak J. Mehrara, MD Chief Plastic and Reconstructive Surgery Service Member Memorial Sloan Kettering Cancer Center New York, New York Alexander F. Mericli, MD Assistant Professor Department of Plastic Surgery MD Anderson Cancer Center University of Texas Houston, Texas Lauren M. Mioton, MD Resident Physician Division of Plastic and Reconstructive Surgery Northwestern University Chicago, Illinois Arash Momeni, MD Assistant Professor of Surgery Director, Clinical Outcomes Research Ryan-Upson Scholar in Plastic and Reconstructive Surgery Division of Plastic & Reconstructive Surgery Stanford University Medical Center Palo Alto, California Adeyiza O. Momoh, MD Associate Professor of Plastic Surgery Program Director Integrated Plastic Surgery Residency University of Michigan Ann Arbor, Michigan Mark Morris, MD Joseph H. Boyes Hand Surgery Fellow University of Southern California Los Angeles, California Afshin Mosahebi, MBBS(Lon), FRCS, FRCS(Plast), PhD(Lon), MBA(Warwick) Professor of Plastic Surgery Royal Free Hospital University College London London, United Kingdom Goo-Hyun Mun, MD, PhD Professor Department of Plastic Surgery Samsung Medical Center Sungkyunkwan University Seoul, South Korea Rahim Nazerali, MD, MHS, FACS Clinical Assistant Professor of Surgery Division of Plastic & Reconstructive Surgery

Sacramento, California Chad A. Purnell, MD Resident Physician

Ashkaun Shaterian, MD Plastic Surgery Resident

Division of Plastic Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois

Department of Plastic Surgery University of California, Irvine Orange, California

Stanford Healthcare Palo Alto, California

Chung-Flaps1e9781975129491-FM.indd 10

3/8/2019 9:00:14 PM

xi

Contributors

Katie E. Weichman, MD Assistant Professor of Surgery Department of Surgery Albert Einstein School of Medicine/ Montefiore Medical Center Bronx, New York Alex Wong, MD, FACS Associate Professor of Surgery Director, Basic, Translational, and Clinical Research Director, Microsurgery Fellowship and Medical Student Education Division of Plastic and Reconstructive Surgery Keck School of Medicine of USC Los Angeles, California Kyong-Je Woo, MD, PhD Assistant Professor Department of Plastic Surgery College of Medicine Ewha Womans University Ewha Womans University Medical Center Seoul, Korea

Amir H. Taghinia, MD, MPH, MBA Assistant Professor of Surgery Harvard Medical School Staff Surgeon Department of Plastic and Oral Surgery Boston Children’s Hospital Boston, Massachusetts Simon Talbot, MD Attending Plastic Surgeon Brigham and Women’s Hospital Associate Professor Harvard Medical School Boston, Massachusetts Vishal Thanik, MD Assistant Professor, Plastic Surgery Associate Program Director, Residency Program Chief of Microsurgery, Bellevue Hospital Hansjörg Wyss Department of Plastic Surgery New York University Langone Medical Center New York, New York Sergey Y. Turin, MD Resident Physician Division of Plastic and Reconstructive Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois Joseph Upton, MD Clinical Professor for Surgery Harvard Medical School Chestnut Hill, Massachusetts John van Aalst, MD, MA, FACS, FAAP Professor and Director Division of Pediatric and Craniofacial Plastic Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio Robert D. Wallace, MD Professor and Chair Residency Program Director Department of Plastic Surgery University of Tennessee Health Sciences Center Memphis, Tennessee Robert L. Walton, MD, FACS Professor of Surgery Division of Plastic & Reconstructive Surgery Feinberg School of Medicine

Deana Shenaq, MD Resident Section of Plastic & Reconstructive Surgery Department of Surgery University of Chicago Medical Centre Section of Plastic and Reconstructive Surgery The University of Chicago Medicine & Biological Sciences Chicago, Illinois John W. Siebert, MD Professor Division of Plastic and Reconstructive Surgery University of Wisconsin Hospital and Clinics Private Practice Chicago, Illinois David H. Song, MD, MBA, FACS Physician Executive Director MedStar Health Plastic & Reconstructive Surgery Professor and Chairman Department of Plastic Surgery Georgetown University Washington, District of Columbia Dhivya R. Srinivasa, MD Resident Plastic and Reconstructive Surgery University of Michigan Ann Arbor, Michigan John T. Stranix, MD Chief Resident Hansjörg Wyss Department of Plastic Surgery NYU Langone Health New York, New York Ahmed Suliman, MD Associate Professor University of California San Diego, California Section Chief, Veterans Healthcare Administration Division of Plastic & Reconstructive Surgery University of California San Diego Section of Plastic & Reconstructive Surgery Veterans Healthcare Administration University of California, San Diego Medical Center San Diego, California Madison, Wisconsin Sammy Sinno, MD

Liza C. Wu, MD, FACS Chief of Microsurgery PENN Plastic Surgery Professor of Surgery University of Pennsylvania Philadelphia, Pennsylvania

George Xipoleas, MD, FACS The Long Island Plastic Surgical Group, PC Garden City, New York Essie Kueberuwa Yates, MD Plastic & Reconstructive Surgeon Yates Institute of Plastic Surgery Lauderdale, Florida

Peirong Yu, MD, FACS Professor Division of Surgery Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Bellaire, Texas Michael R. Zenn, MD, MBA, FACS Zenn Plastic Surgery

Raleigh, North California Adjunct Professor of Plastic Surgery University of North Carolina at Chapel Hill Chapel Hill, North Carolina

Northwestern University Chief of Plastic Surgery Department of Surgery Saint Joseph Hospital Chicago, Illinois

Chung-Flaps1e9781975129491-FM.indd 11

3/8/2019 9:00:14 PM

xii

Contributors

Terri A. Zomerlei, MD Clinical Instructor House Staff Columbus, Ohio

Barry M. Zide, MD, DMD Professor of Plastic Surgery Hansjörg Wyss Department of Plastic Surgery

Toni Zhong, MD, MHS, FRCS(C) Associate Professor Departments of Surgery and Surgical Oncology University of Toronto Fellowship Director Division of Plastic and Reconstructive Surgery University of Toronto Plastic Surgeon–Scientist Belinda Stronach Chair of UHN Breast Cancer Reconstructive Surgery Director of the UHN Breast Reconstruction Program University Health Network Mount Sinai Hospital Toronto, Ontario, Canada

NYU Langone Health New York, New York

Yasmina Zoghbi, MD Resident Division of Plastic Surgery Department of Surgery Icahn School of Medicine at Mount Sinai New York, New York

Chung-Flaps1e9781975129491-FM.indd 12

3/8/2019 9:00:14 PM

Preface

I want to applaud all the authors for sharing their expertise generously. I am grateful for your interest in applying the con- cept of this textbook in the care of your patients. Kevin C. Chung, MD, MS Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Charles B. G. de Nancrede Professor of Surgery Professor of Plastic Surgery and Orthopaedic Surgery Assistant Dean for Faculty Affairs

Since the introduction of the angiosome concept, surgeons have embraced the unique vascular anatomy that supplies various anatomic regions of the body. Flap designs have progressed from muscles flaps to perforator flaps with vessels traveling through the muscle to supply the overlying cutaneous terri- tory. The introduction of propeller flaps and chimeric flaps adds even more possibility to reconstruct complex defects to achieve similar tissue-type reconstruction. This textbook is a clinically based technique product that presents an exhausting list of flaps for all anatomic regions. Quite a few flap books are currently available, but this book presents the indications and applications in a step-by-step organization that provides expedient reference to achieve safe and predictable outcomes.

Associate Director of Global REACH University of Michigan Medical School Ann Arbor, Michigan

xiii

Chung-Flaps1e9781975129491-FM.indd 13

3/8/2019 9:00:14 PM

Contents

8 Lateral Mandible Reconstruction With Soft Tissue Flaps 72 Afshin Mosahebi, Evan Matros, and Babak J. Mehrara SECTION IV LIP 9 Repair of Lip Commissure Defects with Estlander Flaps 77 Simon G. Talbot and Julian J. Pribaz 10 Repair of Lip Defects With Karapandzic Flaps 81 Simon G. Talbot and Julian J. Pribaz 11 Repair of Lip Defects With the Abbe Flap 85 Robert Beinrauh and Joseph H. Dayan 12 Lower Lip Reconstruction With the Nasolabial Flap 90 George Xipoleas and Matthew S. Kilgo 13 Lip Reconstruction With Radial Forearm Free Flap 95 Vishal Thanik SECTION V EYELID 14 Tenzel Semicircular Rotational Flap 100 John Nguyen and Aaron Fay 15 Eyelid Reconstruction With the Hughes Flap or Cutler-Beard Flap 105 Larissa Habib and Brian P. Marr 16 Lower Eyelid Reconstruction With Palatal Grafts 110 Farooq Shahzad, Babak J. Mehrara, and Aaron Fay Based Cervicofacial Flap 115 Sammy Sinno and Barry M. Zide 18 Cheek Reconstruction With Free Radial Forearm Flap 121 John G. Fernandez SECTION VII EAR 19 Antia-Buch Flaps for Ear Reconstruction 127 Amir M. Ghaznavi and Brian R. Gastman SECTION VI CHEEK 17 Cheek Reconstruction With Laterally or Medially

Contributors vii Preface xiii PART 1 CRANIOFACIAL

SECTION I MANDIBULAR SURGERY 1 Osteocutaneous Parascapular Flap for Mandibular Reconstruction 2 Ravi K. Garg and John W. Siebert SECTION II FRONTAL SINUS 2 Pericranial Flap Harvest for Frontal Sinus Obliteration 10 Mahmoud Hassouba and John A. van Aalst

PART 2 HEAD AND NECK RECONSTRUCTION

SECTION I SCALP AND CALVARIUM 1 Scalp Reconstruction With Rotation Flaps 16 Finny George and Evan Matros 2 Scalp Reconstruction With Free Flaps 20 Finny George and Evan Matros SECTION II SKULL BASE AND MIDFACE 3 Free Fibula Flap for Midface Reconstruction 26 J. Rodrigo Diaz-Siso and Eduardo D. Rodriguez 4 Soft Tissue Flaps for Maxillary Reconstruction 36 Ahmed M. Hashem and Brian R. Gastman SECTION III MANDIBLE 5 Mandible Reconstruction With Fibula Free Flap Using CAD/CAM Techniques 47 Jamie Levine, David Hirsch, and Lawrence Brecht 6 Mandible Reconstruction With Fibula Flap With Templates 55 Eric G. Halvorson 7 Mandible Reconstruction With Scapula Flap 62 Mouchammed Agko and Hung-Chi Chen

xiv

Chung-Flaps1e9781975129491-FM.indd 14

3/8/2019 9:00:14 PM

xv

Contents

20 Postauricular Flap for Ear Reconstruction 131 Matthew M. Hanasono

2 Local Flaps in Partial Breast Reconstruction 230 Moustapha Hamdi and Fadi Bakal

SECTION VIII NOSE 21 Nasal Reconstruction With Banner Flaps, Bilobed

SECTION II LATISSIMUS FLAP BREAST RECONSTRUCTION 3 Latissimus Flap 240 Peter Henderson and Joseph J. Disa SECTION III ABDOMINAL FLAP BREAST RECONSTRUCTION 4 TRAM 244

Flaps, and Nasolabial Flaps 136 Michael V. Chiodo and Pierre Saadeh 22 Nasal Reconstruction With Paramedian Forehead Flap 144 Robert D. Wallace and Petros Konofaos 23 Septal Flaps for Nasal Lining 155

Peter Henderson, Jeffrey A. Ascherman, and Joseph J. Disa

Jordan D. Frey, John T. Stranix, and Pierre Saadeh

24 Radial Forearm Flap for Nasal Lining Reconstruction 161

5 Free TRAM 250

Jennifer A. Klok and Toni Zhong 6 Muscle-Sparing Free Transverse Rectus Abdominis Myocutaneous (TRAM) Flap 259 Arash Momeni and Liza C. Wu 7 DIEP Flap Breast Reconstruction 265 Pierre M. Chevray 8 Abdominal Breast Reconstruction Using a SIEA Flap Approach 274 Adrian S. H. Ooi, Deana Shenaq, Julie E. Park, and David H. Song 9 Recipient Vessel Exposure—Internal Mammary and Thoracodorsal 283 Theodore A. Kung and Adeyiza O. Momoh 10 Inferior Gluteal Artery Perforator Flap Breast Reconstruction 288 Katie E. Weichman 11 Superior Gluteal Artery Perforator Flap Breast Reconstruction 295 Katie E. Weichman SECTION IV OTHER FREE FLAPS 12 Profunda Artery Perforator Flap for Breast Reconstruction 300 Katie E. Weichman and Nicholas Haddock 13 Transverse Upper Gracilis Flap for Breast Reconstruction 305 Adeyiza O. Momoh 14 Skate Flap for Nipple Reconstruction 312 Katie E. Weichman 15 C-V Flap for Nipple Reconstruction 318 Katie E. Weichman 16 Nipple Reconstruction 321 Kasandra Dassoulas, Brendan Collins, and Bernard W. Chang

Robert L. Walton and Brenton R. Robinson

25 V-Y Advancement Flaps for Nasal Reconstruction 170 Julian J. Pribaz and Simon G. Talbot

SECTION IX CAVITY AND PHARYNX 26 Facial Artery Perforator Flap 175 Julian J. Pribaz and Simon G. Talbot 27 Facial Artery Musculo-Mucosal (FAMM) Flap 180 Julian J. Pribaz and Simon G. Talbot 28 Free Flap for Hemi-Tongue Reconstruction 185 Carrie K. Chu and Periong Yu 29 Jejunum Flap for Pharyngeal Reconstruction 196 Farooq Shahzad and Babak J. Mehrara 30 Anterolateral Thigh Flap for Pharyngoesophageal Reconstruction 203 Edward I. Chang and Matthew M. Hanasono 31 Pectoralis Major Flap for Pharyngeal Reconstruction 210 Michael A. Howard and Babak J. Mehrara 32 Supraclavicular Island Flap for Oropharyngeal Reconstruction 216 Michael W. Chu and Ernest S. Chiu

PART 3 PLASTIC SURGERY OF THE BREAST

SECTION I BREAST RECONSTRUCTION FOR PARTIAL MASTECTOMY DEFECTS 1 Partial Breast Reconstruction With Local Tissue Rearrangement 224 Moustapha Hamdi

Chung-Flaps1e9781975129491-FM.indd 15

3/8/2019 9:00:14 PM

xvi

Contents

PART 4 TRUNK RECONSTRUCTION AND BODY CONTOURING

15 Vertical Rectus Abdominis Flap for Perineal Reconstruction 422 Dhivya R. Srinivasa and Jeffrey H. Kozlow 16 Gracilis Flap for Perineal and Vaginal Reconstruction 428 Ajani G. Nugent, Yasmina Zoghbi, and Christopher J. Salgado SECTION IV RECONSTRUCTION OF PRESSURE INJURIES 17 Gluteal Flaps for Sacral Pressure Injuries 434 Terri A. Zomerlei and Jeffrey E. Janis 18 Posterior Thigh and Hamstring Flaps for Ischial Ulcers 441 John Hulsen and Jeffrey E. Janis 19 Tensor Fascia Lata Flaps for Trochanteric Ulcers 451 Terri A. Zomerlei and Jeffrey E. Janis 20 Repair of Flank and Lumbar Defects 457 Sergey Y. Turin, Chad A. Purnell, and Gregory A. Dumanian SECTION V POSTERIOR TRUNK RECONSTRUCTION 21 Erector Spinae (Paraspinous) Muscle Flap 463 Lauren M. Mioton and Gregory A. Dumanian 22 Trapezius Muscle Flap 466 Lauren M. Mioton and Gregory A. Dumanian 23 Superior Gluteal Artery Perforator Flap 470 Lauren M. Mioton and Gregory A. Dumanian 24 Keystone Flaps 474 Theodore A. Kung and Peter Neligan PART 5 HAND SURGERY SECTION I FLAPS AND MICROSURGERY 1 Flap Coverage of Fingertip Injuries 482 Kate Elzinga and Kevin C. Chung 2 Flap Coverage of Thumb Defects 491 Kate Elzinga and Kevin C. Chung 3 Reverse Flow Radial Forearm Flap 500 Kate Elzinga and Kevin C. Chung 4 Ulnar Artery Perforator Flap 506 Kate Elzinga and Kevin C. Chung 5 Posterior Interosseous Artery Flap 512 Kate Elzinga and Kevin C. Chung 6 Free Lateral Arm Flap 520 John R. Lien and Kevin C. Chung

SECTION I RECONSTRUCTION OF THE CHEST WALL 1 Pectoralis Flap for Chest Wall Reconstruction 328 Jeff J. Kim and David H. Song 2 Sternal Debridement and Application of Muscle Flaps 336 Sean M. Fisher, Jeff J. Kim, and David H. Song 3 Rectus Abdominis Flap for Thoracic Reconstruction 342 Maureen Beederman and David H. Song 4 Omental Flap for Thoracic Reconstruction 346 Amir Inbal and David H. Song 5 Latissimus Dorsi Flap for Chest Wall Defects 357 Essie Kueberuwa Yates and David H. Song 6 Serratus Anterior Flap for Chest Wall Reconstruction 361 Zachary J. Collier and David H. Song SECTION II RECONSTRUCTION OF THE ABDOMINAL WALL 7 Hernia Repair With Open Component Separation 370 Ibrahim Khansa and Jeffrey E. Janis 8 Ventral Hernia: Component Separation Technique 377 Mark W. Clemens and Charles E. Butler 9 Rectus Femoris Flap for Abdominal Wall Reconstruction 386 Alexander F. Mericli and Charles E. Butler 10 Lower Abdominal Wall Reconstruction With Lateral Thigh-Based Flaps 394 Dhivya R. Srinivasa and Jeffrey H. Kozlow SECTION III RECONSTRUCTION OF PERINEAL DEFECTS 11 Vertical Rectus Abdominis Myocutaneous Flap for Perineal Reconstruction 402 Sahil K. Kapur and Charles E. Butler 12 Gluteal Thigh Flap for Perineal Reconstruction 407 David Gerth and Christopher J. Salgado 13 Omental Flap for Pelvic Floor Reconstruction 410 Carrie K. Chu and Charles E. Butler 14 Posterior Labial Artery Flap for Vulvar and Vaginal Reconstruction 418 Chris A. Campbell

Chung-Flaps1e9781975129491-FM.indd 16

3/8/2019 9:00:14 PM

xvii

Contents

7 Pedicled and Free Groin Flap 523 Mark Morris and Kevin C. Chung 8 Free Anterolateral Thigh Flap 530 John R. Lien and Kevin C. Chung 9 Second Toe to Thumb Transfer 533 John R. Lien and Kevin C. Chung 10 Index Finger Pollicization for Hypoplastic Thumb 541

SECTION II KNEE 7 Soft Tissue Coverage of the Knee: Gastrocnemius Muscle Flap 598 Hani Sbitany 8 Soft Tissue Coverage of the Knee: Free Flaps 602 Goo-Hyun Mun and So Young Kim 9 Soft Tissue Coverage of the Thigh—Pedicled Rectus Flap 609 Brock Lanier and Alex Wong 10 Soft Tissue Coverage of Thigh—Free Flaps 614 Ulrich Kneser and Thomas Kremer 11 Keystone and Related Perforator Flaps 621 Michael W. Findlay SECTION III BURNS 12 Reconstruction of Contractures: Z-Plasty, Skin Grafting, and Flaps 628 Xiangxia Liu 13 Soft Tissue Reconstruction With Propeller Flaps 638 Adam Jacoby, John T. Stranix, and Pierre Saadeh PART 7 PEDIATRICS SECTION I FACIAL REANIMATION 1 Motor Branch of Masseter for Innervation of Free Muscle Flap 644 Michael J. A. Klebuc 2 Masseter-to-Facial Nerve Transfer 649 Michael J. A. Klebuc 3 Pediatric Facial Reanimation Using a Functional Gracilis Muscle Transfer 657 Brad M. Gandolfi, Jeffrey R. Marcus, and Michael R. Zenn Index 667

Amir H. Taghinia, Brian I. Labow, and Joseph Upton

SECTION II CONGENITAL HAND DISORDERS 11 Second Toe-to-Thumb Transfer for Hypoplastic Thumb 548 Amir H. Taghinia, Brian I. Labow, and Joseph Upton

PART 6 LOWER LIMB RECONSTRUCTION AND AMPUTATION

SECTION I FOOT, ANKLE, AND LOWER LEG 1 The Medial Plantar Flap 558 Arash Momeni and Subhro K. Sen 2 Reconstruction of Heel and Plantar Defects: Free Flap 563 Goo-Hyun Mun and Kyong-Je Woo 3 The Reverse Sural Artery Flap for Lower Extremity Reconstruction 573 Ashkaun Shaterian and Amber Leis 4 Ankle Reconstruction With Free Flap 577 Sean S. Li, Ahmed Suliman, and Deepak M. Gupta 5 Soft Tissue Coverage of Lower Leg—Free Flap 585 Goo-Hyun Mun and Kyong-Je Woo 6 Soft Tissue Coverage of Lower Leg—Soleus Flap 593 Rahim Nazerali and Lee L. Q. Pu

Chung-Flaps1e9781975129491-FM.indd 17

3/8/2019 9:00:14 PM

Video Clips

PART 1 Chapter 1

Chapter 7 Rib Graft Harvest Chapter 12 Osteocutaneous Scapular Flap

Injection of Botulinum Toxin into the Glabellar Region

PART 4 Chapter 5

PART 2 Chapter 2

Transgender Breast Chapter 13 Delayed Tissue Expander

Cranial Vault Expansion

Chapter 9 Monobloc Distraction Chapter 23 Segmental Le Fort I Advancement: Two and Three Piece Chapter 29 Secondary Alveolar Bone Grafting of the Cleft Alveolar Defect in Cleft Palate

Chapter 17 Direct to Implant Breast Reconstruction Chapter 20 Free TRAM Flap: Fascial and Intramuscular Dissection

PART 5 Chapter 7

Minimally Invasive Anterior Components Separation Anterior Components Release Technique Ventral Hernia Repair

PART 3 Chapter 1

Infraorbital Nerve Block

Chapter 9

Chapter 6

Calvarial Graft Harvest

xviii

Chung-Flaps1e9781975129491-FM.indd 18

3/8/2019 9:00:14 PM

1 C H A P T E R

Section I: Mandibular Surgery

Osteocutaneous Parascapular Flap for Mandibular Reconstruction

Ravi K. Garg and John W. Siebert

DEFINITION

Axillary artery

■ The parascapular osteocutaneous free flap serves as a ver- satile reconstructive option for composite head and neck defects involving the mandible. ■ The lateral border and angle of the scapula are the most commonly used osseous flap components, although harvest of the medial scapular border has also been described. ■ Soft tissue elements that may be incorporated into the flap include skin, fat, fascia, muscle such as the serratus and latissimus, and nerves, including the thoracodorsal nerve. ANATOMY ■ The parascapular osteocutaneous free flap is based on the subscapular system emerging from the distal third of the axillary artery. ■ The circumflex scapular artery branches from the subscap- ular artery and serves as the primary blood supply to the parascapular osteocutaneous flap. ■ The circumflex scapular artery can be reliably identified in the triangular fossa, which is bound by the teres major and minor muscles as well as the long head of the triceps ( FIG 1 ). ■ The thoracodorsal artery also branches from the subscapu- lar artery and sends a branch to the scapular angle either directly or as a side branch of the serratus muscle branch. ■ The angular artery can be useful for augmenting the blood supply of the scapular border or can be used to harvest the scapular angle as a separate osseous flap. PATIENT HISTORY AND PHYSICAL FINDINGS ■ Determine if the patient has had previous head and neck surgery that would limit recipient vessel options or donor sites for microsurgical reconstruction. ■ Assess the patient’s level of function and which donor site will result in the least morbidity. ■ A scapular flap may be advantageous for older patients with compromised mobility who will have greater difficulty ambu- lating after surgery if a lower extremity donor site is chosen. 1 ■ Inspect the patient’s dental occlusion and determine whether any diseased dentition needs to be managed perioperatively and whether dental rehabilitation will be performed. 2 IMAGING ■ Preoperative CT angiography may be useful to exclude lower extremity flap options such as the fibular flap in a patient with claudication and suspected peripheral vascular disease. ■ Virtual surgical planning may be helpful for complex head and neck reconstruction. A three-dimensional reconstruction

Cutaneous branch

Subscapular artery Circumflex scapular artery

Scapular flap

Thoracodorsal artery

Latissimus dorsi muscle

of the recipient and scapula donor sites can be produced using CT imaging. Osteotomy sites at both the recipient and donor scapula locations may be planned preoperatively and a cutting jig developed to facilitate scapular contouring and inset. 3 SURGICAL MANAGEMENT ■ The parascapular osteocutaneous flap is particularly use- ful for composite tissue defects with a large soft tissue component. ■ Multiple skin paddles and muscle flaps, including the latissi- mus and serratus, can be transferred with scapular bone based on the circumflex scapular artery, 2,4 enabling reconstruction of some of the most complex three-dimensional defects. ■ This flap is unique among other choices used for man- dibular reconstruction including fibula, iliac crest, and radial forearm free flaps, because the lateral scapular bone FIG 1 • Demonstration of the cutaneous branch of the circumflex scap- ular artery exiting the triangular fossa defined by the teres major, teres minor, and long head of triceps. The versatility of the scapular osteocu- taneous flap relates to the multiple soft tissue elements including skin, fat, fascia, and the latissimus and serratus muscles that can be elevated with the flap based on the subscapular system. Additionally, the lateral scapular border is perfused by both the circumflex scapular and angular arteries, enabling separate bone flaps to be harvested.

Chung-Flaps1e9781975129491-P1-ch001.indd 2

2/19/2019 3:11:06 PM

3

Chapter 1 Osteocutaneous Parascapular Flap for Mandibular Reconstruction

is vascularized by a circumflex scapular pedicle branch independent from the branch supplying the skin paddle. ■ The bone can be inset into segmental defects of the mandi- ble or used as a mandibular onlay, whereas the skin paddle can be safely rotated up to 180 degrees in relation to the bone. Preoperative Planning ■ Determine the anticipated length of the bony deficit at the recipient site and whether a scapula flap will provide suf- ficient bone to reconstruct the defect. ■ Discuss with the patient and surgical team the functional goals of the reconstruction. Most male patients will be able to accommodate osteointegrated implants into their scapula flaps, although some female patients will have insufficient bone stock. 5 ■ Decide whether a two-team approach will be possible based on the positioning needs of the team working at the head and neck prior to transfer of the microsurgical free flap. Positioning ■ The patient is placed in the supine position for induction of general anesthesia. ■ A bump is placed under the shoulder ipsilateral to the flap harvest site. This provides sufficient exposure of the upper back, and no beanbag is required for immobilization. ■ Following flap harvest, the bump may be removed, enabling a simple transfer to the supine position.

■ A Z-arm is placed on the side of the operating table opposite the back ( FIG 2A ). The patient’s arm will be suspended to this following sterile preparation and draping. ■ The arm ipsilateral to the flap harvest site is prepped and draped in addition to the upper back. ■ A Mayo stand cover is placed over the Z-arm, and this is wrapped with two rolls of gauze ( FIG 2B ). ■ A sleeve is placed over the prepped arm past the level of the elbow ( FIG 2C ). The sleeve is secured with a roll of gauze wrapped from the hand up. ■ Two Kocher clamps are then used to suspend the patient’s arm to the Z-arm ( FIG 2D ). ■ This technique avoids any areas of concentrated pressure on the arm and minimizes the risk of peripheral nerve injury. ■ The back is then draped with sterile towels and sheets. Approach ■ The operative approach to raising the osteocutaneous para- scapular flap depends upon the design of the skin paddle. We tend to design the skin paddle on the back along the axis of the arm so that the donor-site scar will be hidden under the arm. However, the skin paddle can be oriented in any direction around the triangular fossa. ■ Once the skin paddle has been designed, we approach flap elevation and pedicle identification by raising the flap from caudad to cephalad. However, the flap pedicle may also be approached by raising the skin paddle from its lateral or medial aspect.

FIG 2 • A. The patient is positioned with a bump under the back on the side of flap harvest. The arm is elevated and will be suspended to a Z-arm that crosses the patient’s body. B. The goal of the setup is to minimize pressure on the forearm and avoid complications of neurapraxia and nerve palsy. A sterile Mayo stand cover is placed over the Z-arm and secured in place with two rolls of gauze. C. A sterile arm sleeve is placed over the arm after it has been sterilely prepared. D. The sleeve is secured to the arm with a gauze roll, and then, the gauze is secured to the Z-arm using two Kocher clamps. This strategy provides plenty of cushioning for the forearm without creating any areas of focal pressure that could result in nerve injury.

Chung-Flaps1e9781975129491-P1-ch001.indd 3

2/19/2019 3:11:09 PM

4

Operative Techniques in Plastic Surgery: Flaps

T E C H N I Q U E S ■ Flap Elevation Flap Design

■ If additional flap bulk is desired, a subfascial dissec- tion may be desirable and may incorporate a fascial extension beyond the borders of the skin paddle. ■ Paralyzing agents are used to facilitate electrocautery dissection. ■ As the superior border of the teres major is approached, a tenotomy is used to expose the border of the muscle until the cutaneous perforator to the skin paddle is identified. ■ The cutaneous perforator is followed proximally to the main trunk of the circumflex scapular vessels. ■ As the vessels are traced, distinct branches will be identified that directly penetrate the lateral scapular border or that travel closely along the muscle and fas- cia overlying the lateral scapular border ( TECH FIG 2B ). ■ Usually, the circumflex scapular artery sends two or three branches directly to the lateral scapular bone ( TECH FIG 2C ). ■ A transverse branch investing the overlying scapular mus- cle and fascia supplies the medial scapular border and may serve as the basis for a medial scapular osteocutaneous flap. ■ We tie this branch off and prefer to use the lateral bor- der of the scapula for reconstruction. ■ Distinct, descending branches of the circumflex scapu- lar vessels travel along the lateral border of the scapula and are identified and preserved ( TECH FIG 2D ). ■ At this point, the remainder of the skin paddle is elevated cephalad to the cutaneous branches of the circumflex scapular vessels. ■ The skin paddle is now completely free and perfused only by these cutaneous branches ( TECH FIG 2E ). This enables the skin to be moved back and forth to facili- tate exposure of the lateral scapular border. ■ The skin paddle can be rested on a stack of green tow- els to help expose the scapular border while minimiz- ing tension on the circumflex scapular vessels. ■ The teres minor and portions of the teres major and infraspinatus muscles are dissected off the lateral border of the scapula in order to prepare the bone for osteotomy. ■ A thin cuff of muscle is left on the lateral bone in order to preserve its periosteal blood supply.

■ Landmarks: lateral scapular border, teres major, teres minor, long head of triceps ■ The skin paddle of the flap is designed around the trian- gular fossa through which the circumflex scapular artery passes. ■ A depression superior to the teres major can usually be palpated and used to identify the triangular fossa ( TECH FIG 1A ). ■ The teres major measures two fingerbreadths wide and runs almost parallel to the lateral scapular border. ■ If the muscle cannot be palpated, then the lateral bor- der of the scapula may be identified and traced just proximal to the glenohumeral joint. ■ The triangular fossa is located two fingerbreadths medial to this junction of the lateral scapular border and glenohumeral joint. ■ Confirmation can be performed with a pencil Doppler. ■ A skin paddle 5 to 10 cm in width and 16 to 46 cm in length can be harvested and enable primary closure ( TECH FIG 1B ). ■ Cadaver studies have demonstrated that branches of the circumflex scapular artery emerge radially from the triangular fossa and even perfuse the anterior chest wall at least as far as the anterior axillary line. 6 The implication is that a long skin paddle can be harvested and followed into the inframammary fold to keep the donor site discrete. ■ Once the patient is prepped and draped in a sterile fash- ion, skin cuts are made along the outline of the elliptical skin paddle. ■ The skin paddle is elevated from caudad to cephalad using electrocautery ( TECH FIG 2A ). ■ Elevation can be performed in a subfascial or supra- fascial manner.

Soft Tissue Dissection

TECH FIG 1 • A. The triangular fossa, where the cutaneous branch of the circumflex scapular artery emerges, can be identified on physical examination. The teres major is pinched cephalad to the latissimus. The depression superior to the teres major is where the cutaneous branch emerges and can be confirmed with Doppler. B. The skin paddle to be elevated is outlined based on the course of the circumflex scapular artery. The scapula is palpated and the lateral border is marked.

Chung-Flaps1e9781975129491-P1-ch001.indd 4

2/19/2019 3:11:10 PM

9

Chapter 1 Osteocutaneous Parascapular Flap for Mandibular Reconstruction

POSTOPERATIVE CARE

■ If multiple osteotomies are being planned, incorporation of both the circumflex scapular and angular arteries to the lat- eral scapular bone may be considered to augment the blood supply and reduce the risk of distal bone ischemia. 1 REFERENCES 1. Urken ML, Bridger AG, Zur KB, Genden EM. The scapular osteofas- ciocutaneous flap: a 12-year experience. Arch Otolaryngol Head Neck Surg. 2001;127:862-869. 2. Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular surgery. Semin Surg Oncol. 2000;19:226-234. 3. Parthasarathy J. 3D modeling, custom implants and its future perspec- tives in craniofacial surgery. Ann Maxillofac Surg. 2014;4:9-18. 4. Valentini V, Gennaro P, Torroni A, et al. Scapula free flap for complex maxillofacial reconstruction. J Craniofac Surg. 2009;20:1125-1131. 5. Frodel JL Jr, Funk GF, Capper DT, et al. Osseointegrated implants: a comparative study of bone thickness in four vascularized bone flaps. Plast Reconstr Surg. 1993;92:449-455. 6. Siebert JW, Longaker MT, Angrigiani C. The inframammary extended circumflex scapular flap: an aesthetic improvement of the parascapular flap. Plast Reconstr Surg. 1997;99:70-77. 7. Robb GL. Free scapular flap reconstruction of the head and neck. Clin Plast Surg. 1994;21:45-58. 8. Gibber MJ, Clain JB, Jacobson AS, et al. Subscapular system of flaps: an 8-year experience with 105 patients. Head Neck. 2015;37:1200-1206. 9. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg. 1986;77:530-545. 10. Hyman J, Disa JJ, Cordiero PG, Mehrara BJ. Management of salivary fistulas after microvascular head and neck reconstruction. Ann Plast Surg. 2006;57:270-273.

■ Shoulder movement is permitted as tolerated after surgery. ■ As patients progress, they may work on rebuilding shoulder strength and range of motion. ■ An occupational therapist can be very helpful for creating a graduated program for the patient.

OUTCOMES

■ Swartz is widely regarded as the first surgeon to popularize the osteocutaneous scapula flap for mandible reconstruction. 9 ■ In his series of 26 patients, 21 patients underwent man- dibular reconstruction and there was a 100% flap sur- vival rate. ■ The senior author has also had 100% survival of the osteo- cutaneous scapular flap. ■ The soft tissue elements of the subscapular system carry a robust blood supply. However, if soft tissue ischemia occurs, local debridement and wound care may be necessary. ■ Orocutaneous fistulas may occur and can usually be man- aged with local wound care. 10 ■ When scapular osteotomies are performed, there is a risk of ischemia involving the distal scapula bone beyond the osteot- omy site. Swartz described two patients who experienced non- union due to bone loss beyond the scapular osteotomy site. 9 COMPLICATIONS

Chung-Flaps1e9781975129491-P1-ch001.indd 9

2/19/2019 3:11:30 PM