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Dariush Nikkhah
Jeremy Rawlins
Georgios Patanis
Editors
Core Techniques in
Flap Reconstructive
Microsurgery
A Stepwise Guide
123
Core Techniques in Flap Reconstructive
Microsurgery
Dariush Nikkhah • Jeremy Rawlins
Georgios Patanis
Editors
Core Techniques in Flap
Reconstructive Microsurgery
A Stepwise Guide
Editors
Dariush Nikkhah
Department of Plastic, Reconstructive and
Aesthetic Surgery
Royal Free Hospital & University College
London (UCL) Division of Surgical Sciences
London, UK
Georgios Patanis
London Reconstructive Microsurgery Unit
(LRMU), Department of Plastic Surgery,
Emergency Care and Trauma Division (ECAT)
The Royal London Hospital, Barts Health NHS
Trust & University College Hospital London
(UCLH)
London, UK
Jeremy Rawlins
Department of Plastic Surgery
Royal Perth Hospital
Perth, WA, Australia
ISBN 978-3-031-07677-0 ISBN 978-3-031-07678-7 (eBook)
https://doi.org/10.1007/978-3-031-07678-7
© Springer Nature Switzerland AG 2023
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microlms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
This book is dedicated to my patients and to the great mentors I have had in
my training. I must also thank my dearest wife, Mahdis, who supported me
through the editing of this book since 2018 and my wonderful children Rose
and Alborz. I must thank my father and mother, who have given me all the
opportunities throughout my life.
This book is also dedicated to the brave people of Iran and for my dream to
return to a free Homeland.
‘Women, Life, Freedom’
Dariush Nikkhah
Foreword
Reconstructive microsurgery has been developed for decades. However, there are still occasional failures and complications especially when a junior plastic surgeon starts to practice
microsurgery. To minimise pitfalls, a book with concise description of the core free aps stepby- step procedures would be benecial for any plastic surgeon with special interest in reconstructive microsurgery.
It would act as a useful guide before surgery and act as a rapid reading reference for the
procedure’s crucial steps in conjunction with the copious reading from a long and detailed
chapter of a formal textbook. With the accumulation of large experience from world masters,
this book provides a shortcut to the core skillset and theoretical knowledge required for the
competent and condent beginners in reconstructive microsurgery. It can also serve as an aidememoire for surgeons in training or even for senior surgeons that do not perform specic aps
routinely in their daily practice or they may not be familiar with the challenges entailing a
particular ap.
Georgios Patanis (‘Gio’) has been working with us as a microsurgery fellow, and he is
very keen to make each ap perfect. Dariush Nikkhah demonstrated his deep insights in microsurgery during his visit to our department. Their efforts in providing this step-by-step guidebook to reconstructive microsurgery literature are an attempt to simplify and empirically
dissect ap raising to provide an easy, but also an insightful, reminder to the key characteristics, the critical anatomy and nomenclature and the challenges that each core ap entails.
Our vast experience, at China Medical University Hospital, with major trauma and oncological reconstruction and the large number of patients requiring microsurgery, such as replantation, peripheral nerve repair and free tissue transfer reconstruction, allowed us to formulate
a training pathway for young surgeons with safe and robust framework for the patient. The loss
of a free ap or function is a disaster. The direction to improve the function and appearance
instead of just achieving survival is a major motivation to publish this book. I hope it is very
helpful for both surgeons and patients, also hope that this book can be expanded to more topics
for reconstruction of acute and chronic problems in the future.
Plastic Surgery
Hung-ChiChen
China Medical University
Taichung City, Taiwan
International Medical Service Center
China Medical University Hospital
Taichung City, Taiwan
vii
Preface
Thou shalt make a Plan (Sir Harold Gillies) [1]
Microsurgery is a powerful tool that enables the Plastic Surgeon to reconstruct any defect with
free tissue transplantation. In the early days there was no understanding of the blood supply of
the body and surgeons like Gillies popularised tube pedicle aps. It was not until McGregor
and Jackson popularised the pedicled groin ap based on an axial blood supply that pushed the
eld of ap surgery forward [2]. This culminated in the rst free tissue transplant performed in
the west by Taylor and his subsequent landmark work on the Angiosomes of the human body
[3]. These disruptions led to great innovations in the eld that has led us to this book.
My experience in reconstructive microsurgery started at the Queen Victoria Hospital, East
Grinstead, one of the modern powerhouses of plastic surgery where the rst great toe transplant was performed in 1968 by Cobbett [4]. This hospital was the centre of Burns and Plastic
surgery during the second world war and was purposefully built outside the capital. The epicentre of what is complex trauma is now in central London at the Major Trauma Centres.
Royal Perth where I did my fellowship offered a unique experience in the full spectrum of
reconstructive microsurgery, extremity, head and neck, breast reconstruction, trauma and perineal reconstruction. The free tissue transplants I performed under the guidance of surgeons in
that unit form the basis of much of my philosophy as a Consultant Plastic Surgeon in London.
Replace like with like, take care of the donor site, preserve recipient vessels if you can and do
not sacrice major vessels. Another important point is that plastic surgeons are often the surgeons’ surgeon and in many scenarios solve surgical problems for other specialities.
This book is a guidebook to the junior microsurgeon and provides a succinct, stepwise
guide to workhorse aps for the plastic surgeon in training and those who want to refresh their
memories on more obscure aps. Some of the cases have videos demonstrating pertinent steps
in ap elevation or long-term outcomes. Each ap also has a discussion of the key papers and
selected texts from the literature discussing the origins, pitfalls and technical renements of
those aps. We have also managed to draw experts from a truly international stage, the UK,
Australia, USA, South Korea, Japan, China, Europe to name a few.
In my career I have tried to rene and improve techniques in ap elevation; simplicity is the key
to a successful operation. Complexity can invite failure unless meticulous planning for the case is
undertaken. In this book the microsurgeon can be carried through steps with clinical illustrations.
The book covers everything from microsurgical anastomosis, management of ap complications
to stepwise description of fasciocutaneous and muscle aps. I do hope over the course of my
career this book will have many editions and be a useful guide to the Plastic Surgeon.
References
1. Gillies SH, Millard DR.The principles and art of plastic surgery. Boston, MA; Toronto, ON: Little, Brown
& Co; 1957.
2. McGregor IA, Jackson IT.The groin ap. Br J Plast Surg. 1972;25(1):3–16.
ix
x
3. Taylor GI, Palmer JH.The vascular territories (angiosomes) of the body: experimental study and clinical
applications. Br J Plast Surg. 1987;40(2):113–41.
4. Cobbett JR.Free digital transfer: report of a case of transfer of a great toe to replace an amputated thumb. J
Bone Joint Surg (Br). 1969;51:677–9.
London, UK DariushNikkhah
Preface
Acknowledgements
The editors and the publisher especially acknowledge the collaboration of the following
authors: Doctor Yelena Akelina for Chap. 1, Doctor Sandra Shurrey for Chap. 2, Doctor Petr
Vondra for Chap. 29, and also thank Doctor Georgios Patanis for Chaps. 1–4, 15, 17, 23, 31
and 35, as well as Doctor Dariush Nikkhah for Chap. 22. Without their unwavering commitment, this work would not have been possible.
xi
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