Practical Plastic Surgery - part 10 ppsx

101 603 Reflex Sympathetic Dystrophy Intravenous alpha-Adrenergic Blockade Bier block administration of intravenous phentolamine, an alpha-adrenergic re- ceptor antagonist, should produce sympathetic blockade. If the signs and symptoms are sympathetically-mediated as in the case of RSD, they should diminish in re- sponse to this infusion. It is important to administer saline in a blinded fashion to eliminate the placebo effect. Classification • Lankford classified RSD into five categories: • Minor causalgia: A mild form of RSD seen after injury to a sensory nerve in the forearm, hand or fingers. • Major causalgia: The more severe form of causalgia in which pain and dys- function are prominent. It occurs as a result of injury to mixed motor and sensory nerve. • Minor traumatic dystrophy: Mild RSD with an inciting trauma, but no known nerve injury. • Major traumatic dystrophy: The form most commonly thought of when the term RSD is used. Seen after trauma or fracture of the upper extremity, without specific nerve involvement. • Shoulder and hand syndrome: RSD due to remote injury such as an MI or cervical spine injury. Symptoms begin in the shoulder and spread to the hand, sparing the elbow. • SMPS can be classified into Type I and II: • Type I: What is thought of when the term RSD is used. Pain follows and inciting event and is out of proportion to the exam. The other findings typi- cally associated with RSD are usually present. • Type II: This type of SMPS describes causalgia, similar to the definition given in the Lankford classification. Staging • RSD can also be thought of in terms of its stage: early, established or late. • Early RSD: Defined as the first three months of symptoms. Pain is often burning and can be caused be even light touch. Discoloration, hyperhydrosis, and increased temperature are often present. • Established RSD: Defined as the period between three and twelve months of symptoms. Pain is still the dominant feature. Skin dryness, joint stiffness, contractures and osteoporosis are common. The temperature of the hand gradu- ally goes from warm seen in early RSD to cold, as compared to the other side. • Late RSD: Defined as the final stage of RSD, twelve months or longer after onset of symptoms. The pain may become less severe during this stage, how- ever flare-ups can occur. Stiffness and joint contracture are the most promi- nent features of late RSD. The skin can become thickened and nodular, and severe osteoporosis is not uncommon. Treatment The overriding goal of treatment for RSD is elimination of persistent sources of pain. Simple measures such as relieving pressure points or elevation of the extremity can be very helpful. Local and regional nerve blocks help neutralize sensory nerves as well as providing a chemical sympathectomy. 101 604 Practical Plastic Surgery The stellate ganglion block is the most effective regional nerve block. It has been demonstrated to provide some degree of relief; however results are variable. Numerous studies have been published with good results ranging from zero to 100%. However, little long-term data is available, and few studies are randomized. A satis- factory block is indicated by warming of the upper extremity and a Horner’s sign (unilateral pupillary constriction, ptosis, anhydrosis and facial flushing). Conven- tional stellate blocks are done with lidocaine or bupivicaine. Good results have been obtained with narcotic blocks (e.g., fentanyl) in refractory cases. Usually repeated biweekly blocks are required. For patients unable to tolerate weekly treatments, a continuous stellate block for 3 to7 days has been used successfully. Although not widely used in the U.S., sympathetic inhibition can also be achieved using an intravenous regional block with anti-adrenergic agents such as bretylium, guanethidine or reserpine. These agents are infused intravenously into an extremity using the Bier block technique to isolate the upper extremity. Other drugs such as steroids and NSAIDs have been used as well. Good long-term pain relief has been demonstrated with this technique. A variety of oral medications have been used to treat RSD. Several drug regi- mens, such as a short course of oral corticosteroids, nightly amitryptyline, and select calcium channel blockers have met with good success. Oral phenoxybenzamine and other anti-adrenergic drugs have been used with mixed results. Calcitionin and pheny- toin have been used to relieve symptoms of RSD; however their use has met with mixed results. Physical therapy should consist of active range of motion of all joints from the shoulder to the DIP joints. Hand therapy should not be done while the patient is actively in pain. It can be performed immediately following sympathetic blocks when substantial pain relief has been achieved. Progressive stress loading without joint motion is also recommended. It involves the use of active traction and compression exercises. Static splints can be used to keep the hand in the intrinsic plus position. Adjunctive treatments can be helpful in dealing with RSD that does not re- spond to traditional sympathetic blocks and hand therapy. Biofeedback, psycho- therapy, smoking cessation, and transcutaneous electrical nerve stimulation have all been attempted. Surgical sympathectomy should be reserved for severe, prolonged cases, and those that are refractory to other treatment modalities. The procedure consists of transection of the upper thoracic sympathetic chain via an extrapleural, axillary ap- proach. The T2 and T3 sympathetic nerves must be completely transected. Success rates up to 90% have been reported. More recently, sympathectomies have been performed under video-assisted thoracoscopic surgery (VATS). Long-Term Outcomes Very few studies have addressed the sequelae of patients successfully treated for RSD. Overall, long-term results have been disappointing. At one year post-treatment, roughly half of patients have cold intolerance or pain with cold weather. Trophic changes persist in about a third of patients. Joint swelling and stiffness, as well as decreased grip strength are also common complaints. In sum- mary, RSD and SMPS are still poorly understood. The diagnosis of these condi- tions can be challenging, and their treatment even more so. Active and future research will undoubtedly shed greater light on these syndromes and offer prom- ise for those who suffer from them. 101 605 Reflex Sympathetic Dystrophy Pearls and Pitfalls 1. It is important for the treating physician to realize that almost any injury can be the inciting cause for RSD. The earlier the inciting injury is recognized, the more likely treatment is to be successful. 2. Pain free movement is probably the best therapeutic modality against RSD. Nerve blocks and oral analgesics combined with physical therapy is a treatment goal. 3. The extremity surgeon treating this condition is a coach or motivator for the patient, more so for this disease process than almost any other. The patient needs frequent counseling about the disease process and the expected length of treatment. Suggested Reading 1. Dzwierzynski WW, Sanger JR. Reflex sympathetic dystrophy. Hand Clin 1994; 10:29. 2. Lankford LL. Reflex sympathetic dystrophy. In: Hunter JM et al, eds. Rehabilitation of the Hand-Surgery and Therapy. 3rd ed. St. Louis: CV Mosby, 1990. 3. Nath RK, Mackinnon SE, Stelnicki E. Reflex sympathetic dystrophy. The controversy continues. Clin Plast Surg 1996; 23:435. 4. Zyluk A. The sequelae of reflex sympathetic dystrophy. J Hand Surg (Br) 2001; 26:151. Appendix I Part A: Important Flaps and Their Harvest Zol B. Kryger and Mark Sisco Groin Flap The groin flap is a fasciocutaneous Type A flap based on the superficial cir- cumflex iliac system. The skin is innervated from the T12 lateral cutaneous nerve. This flap is used primarily as a rotational flap for coverage in the abdominal wall and perineum; it can also be used as a free flap for distant coverage. The skin of the lateral groin is elevated along an axis parallel and 3 cm inferior to the inguinal ligament (Fig. AI.1). The skin flap can measure up to 25 x 10 cm. The pedicle originates from the femoral artery roughly in the femoral canal. The main vein drains into the saphenous vein just distal to the fossa ovalis. The skin is incised down to the fascia. The flap is elevated distal to proximal in the plane superficial to tensor fascia lata, which serves as the distal extent of the flap. It is dissected free from the anterior superior iliac spine (ASIS), inguinal ligament and external oblique fascia. The deep fascia that envelops the sartorius is included in the flap. The pedicle is dissected to the medial edge of the sartorius muscle—the proximal limit of the flap. If the skin is elevated as an island flap, the pedicle should be identified in the femoral triangle through a transverse incision, before the skin island incision is made. The flap is elevated from distal to proximal as described above, until the dissection meets the pedicle. Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©2007 Landes Bioscience. Figure AI.1. The groin flap and HS blood supply. AI 608 Practical Plastic Surgery Table AI.1. Fasciocutaneous and perforator flaps Flap Type* Size (cm) Blood Supply (D=dominant, M=minor) Common Uses Forehead A 22 x 7 D: Superficial temporal a. Middle and inferior face, oral cavity, M: Supratrochlear a. nose, frontal and maxillary sinus M: Supraorbital a Nasolabial C 2 x 5 D: Angular a. Nose, lips, floor of mouth M: Alar branches of superior labial a. Temporoparietal fascia A 12 x 9 Superficial temporal a. Scalp, upper and middle face, ear, free flap Deltopectoral C 10 x 20 D: Perforators 1-3 of IMA Middle and inferior face, neck, M: Perforators 4-5 of IMA oral cavity, esophagus Gluteal thigh A 12 x 30 D: Superior gluteal a. Sacrum, ischium, perineum D: Inferior gluteal a. M: Branches of lateral circumflex femoral a. M: 1st perforator of profunda femoris Scapula B 20 x 7 D: Circumflex scapular a. Neck, axilla, shoulder, back, Radial forearm B 10 x 40 D: Radial a. free flap (mandible) M: Musculocutaneous branches of radial Forearm, elbow, wrist, hand, recurrent a. and inferior cubital a. free flap Groin A 25 x 10 D: Superficial circumflex iliac Upper extremity, abdominal wall, perineum, free flap Lateral thigh B 7 x 20 D: 1st-3rd perforators of profunda femoris Ischium, greater trochanter, free flap Medial plantar B 12 x 6 D: Medial plantar a. Plantar foot, ankle, free flap M: Musculocutaneous perforators from (contralateral foot) medial plantar a. Anterolateral thigh (ALT) B, C 12 x 20 D: Septocutaneous branches of descending Trunk, abdomen, groin, thigh, branch of lateral circumflex a. free flap M: Musculocutaneous branches of descending branch of lateral circumflex a. Deep Inferior epigastric D: Perforator from deep inferior Free flap (breast) perforator (DIEP) epigastric a. Thoracodorsal perforator (TAP) D: Perforator from thoracodorsal a. Free flap (breast, extremity) Superior gluteal perforator (SGAP) D: Perforator from superior gluteal a. Sacrum, ischium, lower back, free flap *Mathes-Nahai classification of fasciocutaneous flaps. Type A, direct cutaneous pedicle. Type B, septocutaneous pedicle. Type C, musculocutaneous pedicle AI 609 Appendix I Table AI.2. Muscle and musculocutaneous flaps Flap Type* Size (cm) Blood Supply (D = dominant, M = minor) Common Uses Temporalis III 10 x 20 D: Anterior deep temporal a. Facial reanimation, orbit, palate, mandible D: Posterior deep temporal a. M: Branches of middle temporal a. Pectoralis major V 15 x 25 D: Pectoral branch of thoracoacromial a. Face, chest, neck, shoulder, axilla, sternum, M: Pectoral branch of lateral thoracic a. upper extremity S: Internal mammary (1-6) and intercostal (5-7) perforators Gluteus maximus III 24 x 24 D: Superior gluteal a. Sacrum, ischium, trochanter, vagina, free flap D: Inferior gluteal a. M: Branches of lateral circumflex femoral M: 1st perforator of profunda femoral Latissimus dorsi V 25 x 35 D: Thoracodorsal Scalp, neck, trunk, breast, abdomen, upper extremity, S: Posterior intercostal perforators and lumbar perforators free flap Rectus III 25 x 6 D: Superior epigastric a. Breast, trunk, abdomen, groin, perineum, abdominis D: Deep inferior epigastric a. pelvic floor, free flap M: Subcostal and intercostal a. Serratus III 15 x 20 D: Lateral thoracic a. Head, thorax, axilla, posterior trunk, intrathoracic, D: Branch of thoracodorsal a. free flap Gracilis II 6 x 24 D: Ascending branch of medial circumflex femoral a. Perineum, groin, penis, vagina, free flap M: 1-2 branches of SFA Hamstring II 15 x 45 D: 1st-3rd perforators of profunda femoris Ischium M: Branch of inferior gluteal a. M: Superior lateral genicular a. Tensor fascia lata I 5 x 15 D: Ascending branch of lateral circumflex femoral a. Abdomen, groin, perineum, trochanter, ischium, free flap Vastus lateralis I 10 x 25 D: Descending branch of lateral circumflex femoral a. Ischium, trochanter, groin, perineum, knee, abdomen M: Transverse branch of lateral circumflex femoral a. M: Posterior branch from profunda femoris M: Superficial branch of lateral superior genicular a. Gastrocnemius I 20 x 8 D: Medial sural a. Knee, lower thigh, upper leg D: Lateral sural a. M: Anastomotic vessels from sural a. Soleus II 8 x 28 D: Muscular branches of popliteal Middle and lower leg D: First 2 branches of posterior tibial a. D: First 2 branches of peroneal a. M: Segmental branches of posterior tibial a. Fibula V 3 x 40 D: Nutrient branches of peroneal a. Tibia, free flap (mandible) M: Periosteal and muscular branches of peroneal a. *Mathes-Nahai classification of muscle and musculocutaneous flaps. Type I, one pedicle. Type II, dominant and minor pedicles. Type III, two dominant pedicles. Type IV, segmental pedicles. Type V, one dominant pedicle and secondary segmental pedicles. AI 610 Practical Plastic Surgery Table AI.3. Visceral flaps Blood Supply Flap Type* Size (cm) (D = dominant, M = minor) Common Uses Omentum III 40 x 60 D: Right gastroepiploic a. Head and neck, trunk, intrathoracic, D: Left gastroepiploic a. abdomen, groin, perineum, free flap Jejunum I 7-25 D: Jejunal a. (from SMA) Free flap (esophagus) *See classification in Table AI.2. AI 611 Appendix I Rectus Abdominis Flap The rectus abdominis flap can be harvested as either a muscle or musculocuta- neous, Type III flap. The two dominant pedicles are the superior and deep infe- rior epigastric arteries. Minor pedicles include the intercostals and subcostal arteries, with the T8 subcostal artery usually being the largest. The muscle and overlying skin are innervated by segmental motor and cutaneous intercostal (7-12) nerves, re- spectively. It is an extremely useful flap used in breast, perineal and vaginal recon- struction, and as coverage in the thorax, abdomen, posterior trunk and groin. For these purposes, it is primarily used as a rotational flap or island pedicle flap. It is also an extremely versatile free flap based on the deep inferior epigastric vessels. Contraindications for use of the rectus abdominus flap include: • Unilateral subcostal incision (Kocher incision) for an ipsilateral flap based on the superior pedicle • Bilateral subcostal incisons (Chevron incision) for any flap based on the superior pedicle • Low transverse incison (Pfannenstiel incision) for any muscle flap based on the inferior pedicle (exception: a deep inferior epigastric perforator flap) • Any portion of the skin island that is lateral to a prior skin incision should not be used • Prior use of the internal mammary artery is a relative contraindication for a superiorly based flap • History of major external iliac vascular surgery is a relative contraindication for an inferiorly based flap, unless angiography confirms otherwise. For harvesting a muscle flap, either a longitudinal paramedian or low transverse skin incision is used. For the musculocutaneous flap, the skin island can be marked in multiple horizontal or vertical patterns. A transverse (horizontal) skin island can be up to 21 x 8 to 21 x 14 cm in size. This skin can be divided into zones: zone 1 is over the ipsilateral rectus; zone 2 is over the contralateral rectus; zone 3 is lateral to the ipsilateral rectus; zone 4 (least reliable skin) is lateral to the contralateral rectus. After the skin paddle is marked, the inferior border is incised down to the ante- rior rectus sheath. The skin and subcutaneous fat are elevated from lateral to medial off the fascia. The dissection is slowed several centimeters lateral to the midline where the musculocutaneous perforators are encountered. The superior border of the skin island should be incised only after confirming that the donor skin will close without excessive tension. Alternatively, the superior incision can be made first, followed by the inferior incision once it is clear that the abdominal skin will come together without undue tension. The anterior rectus sheath is opened sharply in a longitudinal direction exposing the rectus muscle (Fig. AI.2). The muscle is dissected free from its sheath, with care taken not to violate the posterior sheath. For the inferiorly-based flap, the muscle is divided at or near the costal margin. The superior epigastric artery and vein are divided at the medial border of the muscle. For the superiorly-based flap, the muscle is divided at the level of the pubis symphysis. The deep inferior epigastric artery and vein can be dissected for several centimeters prior to division. This can serve as an alternative pedicle for microvascular anastomosis if the superior pedicle is insuffi- cient. Care must always be taken to avoid injuring the musculocutaneous perfora- tors feeding the skin paddle. AI 612 Practical Plastic Surgery If only a muscle flap is required, the abdominal skin and subcutaneous fat are elevated off the anterior abdominal wall. The rectus sheath can then be opened as described above without concern for the musculocutaneous perforators. Once the rectus muscle is harvested, the donor site is closed. The anterior rectus sheath can be closed primarily using a running or interrupted permanent suture. If the fascial edges are frayed or primary closure will create under undue tension, a synthetic mesh can be used to replace the missing segment. If necessary, small tears in the fascial edges during primary fascial closure can be reinforced with an overly- ing piece of mesh. Fibula Composite Flap The fibula free flap can be harvested as either an osseous or osseofasciocutaneous (composite), Type V flap. In addition, cuffs of muscle are usually incorporated in order to protect the blood supply. The dominant pedicle is the nutrient branch of the peroneal artery. The minor pedicles are the periosteal and muscular branches of the peroneal artery. The sensory nerve supply is from the superficial peroneal nerve. This flap is used primarily as a free flap for mandibular reconstruction or for reconstruction of the ipsilateral tibia and femur. If an osseous flap is needed, a longitudinal incision is made along the posterior border of the fibula from the head of the fibula to the lateral malleolus. If an osseofasciocutaneous flap is used, the skin territory should be marked as a vertical ellipse over the middle third of the fibula. The skin island can span from 6 cm below the fibular head to 8 cm above the distal fibula, and it can measure up to 5 x 15 cm. The width of the skin island can be extended; however closure will require a skin graft. For harvesting the osseous flap, the lateral compartment is opened, and the pero- neus longus and brevis are detached from the fibula leaving a small cuff of muscle attached. The common and superficial peroneal nerves are identified and preserved. Figure AI.2. The rectus abdominus musculocu- taneous flap and its dual blood supply. [...]... 213 Alloplastic framework 345, 346 Alpha-hydroxy acid 441, 443, 448 Alveolar closure 350 Amputation 43, 80, 8 2-8 4, 111, 123, 136, 289, 318, 319, 322, 485, 492, 49 3-4 96, 531, 537, 548, 549, 56 1-5 63, 595 revision 549 Anastomosis 27, 5 7-6 0, 85, 97, 98, 109 , 111, 26 8-2 72, 297, 464, 466, 494, 530, 611 technique end-to-end 57, 58, 543, 550 end-to-side 57, 58 Anesthesia 29, 3 1-3 6, 3 8-4 1, 74, 86, 128, 210, 245,... 276, 277, 297, 410, 411, 415, 416, 421 reduction 38, 271, 287, 28 8-2 93, 41 3-4 16 circumareolar 289, 41 8-4 20 free nipple graft See Grafts, free nipple inferior pedicle 28 8-2 91, 293, 415, 421, 611 medial pedicle 28 8-2 90, 292, 293, 421 Practical Plastic Surgery patterns 28 8-2 91, 293 vertical scar 28 8-2 90, 292, 41 8-4 20 Wise pattern 28 8-2 91, 293, 419, 420 Browlift 229, 37 7-3 81 coronal 37 8-3 80 direct 379... 499, 510, 56 6-5 73 Carpenter syndrome 337, 338 Carpometacarpal (CMC) joint 462, 463, 470, 479, 51 5-5 17, 554, 587, 593 Cartilage 7, 44, 97, 121, 127, 128, 147, 160, 163, 16 9-1 75, 177, 18 3-1 85, 188, 19 0-1 92, 198, 214, 216, 234, 243, 246, 302, 341, 34 4-3 46, 348, 35 0-3 55, 38 2-3 85, 39 4-3 99, 502, 599 costal 175, 190, 234, 263, 264, 296, 302, 34 4-3 46 framework 34 4-3 46 637 Cast, thumb spica 503, 504, 508, 510, ... 473, 479, 482, 492, 493, 49 5-4 97, 50 0-5 08, 510, 51 2-5 17, 526, 529, 53 4-5 36, 539, 54 3-5 45, 54 7-5 50, 552, 55 4-5 56, 559, 56 1-5 64, 568, 574, 576, 578, 590, 592, 593, 601, 602, 613 635 crib 213 fixation 493, 514 nonvascularized 212, 213, 506 palatine 231, 359 pisiform 46 2-4 64, 478, 503, 508, 510, 526, 564, 568 scan 83, 92, 295, 503, 507, 602 triphasic 602 Botulinum toxin 45 1-4 53 Bowen’s disease 126, 314,... nipple-areolar complex (NAC) 63, 260, 283, 28 8-2 93, 406, 409, 412, 415, 41 7-4 22 nipple-areola reconstruction (NAR) 271, 28 3-2 87 nipple-areolar necrosis 286, 288, 421 periareolar incision 260, 409, 416, 419 pseudo-ptosis 419 ptosis 260, 278, 279, 289, 290, 406, 410, 41 7-4 22 grade 41 8-4 20 reconstruction 47, 61, 66, 25 9-2 61, 263, 266, 267, 269, 271, 272, 274, 275, 278, 283, 284, 300, 620 delayed 26 0-2 62,... 60, 61, 63, 64, 6 8-7 0, 76, 7 9-8 1, 83, 97, 101 , 104 , 109 , 113, 114, 118, 134, 142, 149, 166, 169, 187, 203, 206, 209, 215, 225, 227, 228, 236, 238, 242, 253, 255, 26 0-2 62, 267, 269, 271, 272, 274, 277, 286, 287, 294, 297, 299, 304, 309, 312, 313, 336, 346, 366, 372, 375, 376, 380, 381, 385, 391, 392, 396, 398, 399, 40 9-4 11, 415, 416, 421, 42 3-4 25, 42 9-4 32, 436, 440, Practical Plastic Surgery 444, 445,... implants 66, 280, 40 6-4 08, 412, 417 Index Index 636 Index Breast 7, 38, 39, 43, 47, 61, 63, 66, 67, 79, 25 8-2 63, 266, 267, 26 9-2 72, 27 4-2 80, 28 3-2 85, 28 8-2 93, 300, 40 6-4 22, 608, 609, 611, 615, 620 saline 39, 66, 67, 278, 280, 281, 407, 411, 412 silicone 6 6-6 8, 278, 281, 412 inframammary crease 275, 276, 407, 418, 420 mammaplasty 28 8-2 93, 40 6-4 12, 422 mastopexy 38, 260, 271, 406, 409, 412, 41 7-4 22 vertical... 169, 170, 176, 178, 179, 181, 182, 18 5-1 87, 190, 196, 199, 201, 203, 206, 20 8-2 10, 257, 263, 269, 270, 275, 280, 28 4-2 86, 292, 293, 29 5-3 00, 30 3-3 05, 307, 30 9-3 11 Cocaine 29, 31, 32, 245 Collagen 2, 3, 16, 20, 22, 62, 84, 96, 117, 119, 145, 15 1-1 53, 220, 368, 389, 412, 421, 435, 437, 438, 444, 445, 44 8-4 50, 456, 539, 544, 597 type I 539 Collagenase (Novuxol®) 22, 103 , 599 Collateral ligament 463, 474,... Cellulitis 70, 72, 83, 143, 294, 410, 482, 483 Central slip 466, 533, 537, 538, 557, 558 Centric relation 328, 333, 401 Cephalogram 32 8-3 30, 332, 340, 367 Cephalometric analysis 32 7-3 29, 332, 333, 400, 401 Cervical spine injury 245, 603 Charcot foot 81, 91 Chemical peel 435, 436, 44 0-4 45 Baker-Gordon 441, 444 deep 44 0-4 45 glycolic acid 440, 441, 44 3-4 45 medium-depth peel 440, 44 3-4 45 phenol peel 441, 444,... 352, 35 6-3 67, 404 fistula 366 lengthening 362 V-Y pushback 362 plane 329, 330 primary palate 350, 356, 359 repair 352, 360, 361, 366, 367, see also Flaps, mucoperichondrial Clonidine 39, 41, 372 Closed reduction 241, 245, 25 1-2 54, 256 Index Index 638 Index Closure 3, 4, 6, 8, 9, 11, 12, 14, 16, 22, 24, 46, 52, 59, 60, 62, 63, 7 0-7 2, 75, 78, 8 4-8 6, 92, 97, 104 , 107 , 11 4-1 16, 129, 133, 144, 147, 15 0-1 53, . the pedicle. Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©2007 Landes Bioscience. Figure AI.1. The groin flap and HS blood supply. AI 608 Practical Plastic Surgery Table. superior pedicle is insuffi- cient. Care must always be taken to avoid injuring the musculocutaneous perfora- tors feeding the skin paddle. AI 612 Practical Plastic Surgery If only a muscle flap. section of the leg showing the compartments of the leg and the anterior and posterior approaches to the deep posterior compartment. AI 614 Practical Plastic Surgery Pectoralis Major Flap The