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47 Head and Neck Recipient Vessels Access
Table 47.2 Proposed algorithm for vessel selection in head and neck reconstruction
Recipient Vessels for Head and Neck (H&N) Defect
Upper H&N Lower H&N
471
1º: SuTA
2º: FA
3º: Other Vessels
H&N - Head and Neck
SuTa - Superficial Temporal Artery
FA - Facial Artery
RT - Radiotherapy
ECA - External Carotid Artery
LA - Lingual Artery
STA - Superior Thyoid Artery
Simultaneous Lympth-nodes neck dissection/Radiotherapy (RT)
No/Yes
1: FA (if no RT)
2º: SuTA (if RT)
3º: End-to-side to ECA
Ipsilateral Vessels
47.8 Selected Readings
• Chummun S, McLean NR, Ragbir M.Surgical education:
neck dissection. Br J Plast Surg. 2004;57(7):610–23.
https://doi.org/10.1016/j.bjps.2004.05.011. PMID:
15380694.
• Kushida-Contreras BH, Manrique OJ, Gaxiola-García
MA.Head and neck reconstruction of the vessel-depleted
neck: a systematic review of the literature. Ann Surg
Oncol. 2021;28(5):2882–95. https://doi.org/10.1245/
s10434- 021- 09590- y. Epub 2021 Feb 6. PMID:
33550502.
• Chia HL, Wong CH, Tan BK, Tan KC, Ong YS.
An algorithm for recipient vessel selection in
microsurgical head and neck reconstruction. J Reconstr
Microsurg. 2011;27(1):47–56. https://doi.org/
10.1055/s- 0030- 1267829. Epub 2010 Oct 25. PMID:
20976669.
• Tessler O, Gilardino MS, Bartow MJ,
St Hilaire H, Womac D, Dionisopoulos T, Lessard
L.Transverse cervical artery: consistent anatomical landmarks and clinical experience with its use as a recipient
artery in complex head and neck reconstruction.
Plast Reconstr Surg. 2017;139(3):745e–51e.
https://doi.org/10.1097/PRS.0000000000003085. PMID:
28234854.
Previous Neck Disscetion with ligation of IJV
Contralateral Vessels
No
No/No
1º: STA
2º: FA or LA
3º: End-to-side to ECA
1º: FA
2º: STA
3º: Other Vessels or
Vein grafting
Ye s
References
1. Tessler O, etal. Transverse cervical artery: consistent anatomical
landmarks and clinical experience with its use as a recipient artery
in complex head and neck reconstruction. Plast Reconstr Surg.
2017;139(3):745e–51e.
2. Yagi S, et al. Recipient vessel selection in head and neck reconstruction based on the type of neck dissection. Yonago Acta Med.
2016;59(2):159–62.
3. Nahabedian MY, et al. Recipient vessel analysis for microvascular reconstruction of the head and neck. Ann Plast Surg.
2004;52(2):148–55; discussion 156–7.
4. Chia HL, et al. An algorithm for recipient vessel selection in
microsurgical head and neck reconstruction. J Reconstr Microsurg.
2011;27(1):47–56.
5. Ahmadi I, et al. End-to-end versus end-to-side microvascular
anastomosis: a meta-analysis of free ap outcomes. J Reconstr
Microsurg. 2017;33(6):402–11.
6. Yu P.The transverse cervical vessels as recipient vessels for previously treated head and neck cancer patients. Plast Reconstr Surg.
2005;115(5):1253–8.
7. Yazar S.Selection of recipient vessels in microsurgical free tissue reconstruction of head and neck defects. Microsurgery. 2007;27(7):588–94.
8. Christianto S, etal. One versus two venous anastomoses in microsurgical head and neck reconstruction: a cumulative meta-analysis.
Int J Oral Maxillofac Surg. 2018;47(5):585–94.
9. Prim MP, etal. Patency and ow of the internal jugular vein after
functional neck dissection. Laryngoscope. 2000;110(1):47–50.
10. Wax MK, etal. Internal jugular vein patency in patients undergoing
microvascular reconstruction. Laryngoscope. 1997;107(9):1245–8.
11. Dancey A, Blondeel PN. Technical tips for safe perforator vessel dissection applicable to all perforator aps. Clin Plast Surg.
2010;37(4):593–606, xi-vi.
Upper Limb Recipient Vessels Access
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ZhiYangNg, CalumHoneyman, AmirSadr,
andDariushNikkhah
48
48.1 Indications
The requirement for upper limb microsurgery is varied and
includes reconstruction following trauma, burns, infection,
neoplasia and congenital differences for both elective free
tissue transfers, and emergency cases such as replantation,
revascularisation, fasciotomies and amputations. Selection
of the most appropriate recipient vessels depends on the size
and composition of the defect to be addressed, osteosynthesis required (e.g. external xator), quality of vessels (particularly veins) and the pedicle length available; vein and nerve
grafts may also be needed and should be marked out at the
start of the case on the same limb.
It is also important to consider the long-term reconstructive plan for patients from the outset. In the upper extremity,
staged reconstruction to optimise function is commonly
required. The addition of future free functioning muscle or
toe transfers should be carefully planned when choosing
recipient vessels to prevent burning future bridges.
This chapter details the relevant clinical anatomy of the
most commonly used recipient vessels in upper limb free tissue transfer, up to and including the antecubital fossa proximally. In addition, the pre-operative work up, surgical
approach and technical pearls and pitfalls are discussed, with
the aim of maximising functional and aesthetic outcomes for
this highly challenging group of patients.
48.2 Anatomy
48.2.1 Antecubital Fossa
The boundaries of the antecubital fossa are the brachioradialis (BR) muscle laterally, the pronator teres muscle medially
and a theoretical line between the medial and lateral epicondyles proximally. The oor is made up of the brachialis and
supinator muscles, and the roof by skin, fat, fascia, the
median cubital vein and the bicipital aponeurosis (lacertus
brosus). The brachial artery, a continuation of the axillary
artery, originates at the distal edge of the teres major muscle,
where it is generally accompanied by two sizeable venae
comitantes. Numerous subcutaneous veins are encountered
when accessing the antecubital fossa from the medial side,
including the large basilic vein, which runs supercial and
medial to the brachial artery, accompanied by the medial
antebrachial cutaneous nerve (MABCN) in the subcutaneous
plane. Ultimately, the brachial artery divides into the radial
and ulnar arteries approximately 2cm distal to the exion
crease of the elbow (Fig. 48.1). This bifurcation occurs
medial to the insertion of the biceps tendon, and lateral to the
median nerve (Fig.48.2). While anatomical variations of the
brachial artery have been described that include an accessory
brachial artery, trifurcation and even complete absence [1],
this is usually not of clinical signicance.
48.2.2 Forearm/Wrist
Z. Y. Ng
Oxford Deanery, Oxford, UK
C. Honeyman
Canniesburn Plastic Surgery and Burns Unit, Glasgow Royal
Inrmary, Glasgow, UK
A. Sadr . D. Nikkhah (*)
The Royal Free Hospital NHS Foundation Trust, London, UK
e-mail: d.nikkhah@nhs.net
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_48
In the proximal third of the forearm, the radial artery is usually located in a plane deep to the BR (but can be supercial
to BR [2]) and exor carpi radialis (FCR) muscle bellies.
At this level, the ulnar artery lies in a plane on top of the
brachialis and exor digitorum profundus muscles (FDP)
and beneath the muscle bellies of pronator teres (PT), FCR
and exor digitorum supercialis (FDS) arising from the
common exor origin. In the distal third of the forearm, the
473
474
Z. Y. Ng et al.
Fig. 48.1 Bifurcation of the brachial artery (BA) into the radial (RA)
and ulnar (UA) arteries approximately 2cm distal to the exion crease
of the elbow. Triangle represents the boundaries of the antecubital fossa
Fig. 48.2 Median nerve (MN) lies medial to the brachial artery (BA)
at the antecubital fossa; basilic vein (BV) retracted
radial artery continues in the lateral intermuscular septum,
easily accessed between the tendons of the FCR muscle
ulnarly and brachioradialis radially. The ulnar artery
courses on the medial side of the ulnar nerve, in a plane
between the FCU tendon ulnarly and FDS radially, sitting
on top of the FDP tendons before entering Guyon’s canal at
the wrist.
The cephalic vein (3 mm or more) has a suprafascial
course along the radial aspect of the forearm (Fig.48.3) and
crosses the anatomical snuffbox distally in the wrist.
Correspondingly, the basilic vein can be found on the medial
aspect of the arm before joining the median cubital vein in
the antecubital fossa and extends distally along the ulnar
aspect of the forearm. Both radial and ulnar arteries are commonly accompanied by a pair of venae comitantes (around
1.5mm each) (Fig.48.4).
48.2.3 Hand
The ulnar artery exits the wrist on the radial side of the
pisiform and distal FCU tendon, entering Guyon’s canal
Fig. 48.3 Reverse radial forearm ap (RFF) based on retrograde ow
through the radial artery (RA) (note accompanying pair of venae comitantes) and cephalic vein (CV)
Fig. 48.4 Ulnar artery with accompanying venae comitantes; The FDS
and FDP are retracted radially while FCU is retracted ulnarly. Note dorsal branch of ulnar artery i.e. perforator used for Becker ap arborising
into the skin
with the ulnar nerve located ulnarly. Guyon’s canal is
approximately 4cm in length and sits on top of the transverse carpal ligament bounded by the pisiform and pisohamate ligament ulnarly and the hamate radially. Ultimately,
the ulnar artery becomes the supercial palmar arch in 39%
of cases, or anastomoses with the supercial palmar branch
of the radial artery in 35% of cases to form the supercial
palmar arch [2] at the level of Kaplan’s line, with other anatomical variations comprising the rest. Correspondingly,
the radial artery leaves the distal wrist and enters the anatomical snuff box between the tendons of abductor pollicis
longus (APL), extensor pollicis brevis (EPB) and extensor
pollicis longus (EPL); deep to the fascia of the snuff box,
the radial artery and its two venae comitantes are found
coursing obliquely in the space on top of the rst and second metacarpals. The supercial palmar branch of the
radial artery is also supercial to the exor tendons and
common digital nerves from the median nerve but deep to
the supercial palmar fascia.
Three common digital arteries then arise from the supercial palmar arch and subsequently bifurcate into proper
palmar digital arteries around 1cm proximal to the webspaces. The proper digital arteries continue into the digits
deep to the digital nerves (Fig.48.5), and are covered by
Grayson’s ligaments volarly, and Cleland’s ligaments dor-
48 Upper Limb Recipient Vessels Access
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475
sally [3]. Ultimately, these form an arch at the level of the
pulp, which is distal to the distal interphalangeal joint
before terminating in the central artery of the pulp. Of note,
the thumb is unique in that it has a palmar (proper digital
arteries) and dorsal blood supply (variable origins from
rst dorsal metacarpal artery to the dorsal branch of radial
artery) [4].
An abundant network of highly variable veins is present
on the dorsum of the hand and ngers which ultimately drain
into the basilic and cephalic veins. Supercially, the cephalic
vein and supercial radial nerve branches are encountered in
the snuffbox. Small volar veins are also present in the digits
and can be used as recipient outow for distal replants and in
bespoke super microsurgical nger free aps.
a
48.3 Pre-operative Investigation
Careful pre-operative clinical examination of the upper
extremities prior to microsurgical intervention is essential to
ascertain signs of neurovascular compromise, associated
functional decits, size and composition of potential defects
and the true extent of the zone of injury, if applicable.
Observation for signs of intravenous drug use or in situ or
previous venous and arterial lines is also important.
Physical examination typically requires documentation of
the results from Allen’s test, especially when raising aps
based on the radial or ulnar artery, to avoid subsequent hand
ischaemia. This occurs when colour (i.e. perfusion) fails to
return during an Allen’s test, suggesting that the blood sup-
b
c
Fig. 48.5 (a) Ring avulsion injury (Urbaniak Class II) of the little
nger, demonstrating an intact ulnar digital nerve (UDN) and microsurgical repair (with vein graft, not shown) of the radial digital artery
(RDA). (b) Reperfused digit after reversed interpositional vein graft
taken from distal forearm. (c) Outcome after salvage
476
Z. Y. Ng et al.
ply to the palmar arch is incomplete (e.g. blood ow from the
ulnar artery is compromised if the radial artery is compressed
and pallor persists, and vice versa). Interestingly, head and
neck reconstruction studies based on the radial forearm free
the surgical plan may change. Finally, colour Doppler
ultrasound is increasingly being used to map out perforators arising from both the radial [6] and ulnar [7]
arteries.
ap have suggested an incidence of a variant, supercial
ulnar artery in 0.43% of cases, which suggests radial dominance based on Allen’s test although true gures are believed
to be much higher [5].
48.4 Recipient Vessel Access (A Figure
withSurface Markings)
Of note, the superficial location of the cephalic and
basilic veins is such that both can be lost as a result of
trauma. Therefore, there has been increasing argument
for CT angiography to assess both the arterial and venous
systems, especially in paediatric patients where clinical
findings may be equivocal, or in mutilating injuries, as
Typical incisions for access to the (a) brachial artery and
bifurcation into radial and ulnar arteries; (b) radial artery
along the proximal, middle or distal forearm; within the anatomical snuffbox (c); and (d) ulnar artery along the middle or
distal forearm, and (e) wrist (Fig.48.6).
ab
cd
e
Fig. 48.6 Typical incisions for exposure of the (a) brachial artery and
bifurcation, radial artery along the forearm (b) and within the anatomical snuffbox (c), and the ulnar artery along the forearm (d) and in the
hand/wrist (e). (Modied from Strauch, B. and Yu, H., 2006. Atlas of
Microvascular Surgery. NewYork: Thieme)
48 Upper Limb Recipient Vessels Access
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477
48.5 Recipient Vessel Dissection:
AStep- by- Step Guide
Following general or regional anaesthesia, patients are typically positioned supine with their arm outstretched on a hand
table and an upper arm tourniquet applied. Figure48.6 shows
classical placement of skin incisions for access to the main
recipient vessels of the upper limb; the accompanying venae
comitantes are usually sufcient for microsurgery. However,
in trauma, infection and oncology, the nal soft tissue defect
may be far more extensive following debridement or R0
resection and may incorporate or even be “joined up” with
these incisions.
48.5.1 Brachial Artery: Antecubital Fossa
(Fig.48.6a)
NB: To access the brachial artery in the arm, a removable
sterile tourniquet or pre-operative subcutaneous administration of local anaesthetic with adrenaline can be useful.
1. Palpate the brachial artery (BA) in the distal arm by roll-
ing your ngers medially and deep to the biceps tendon.
2. Place the skin incision slightly medial to the artery begin-
ning 4–5 cm proximal to the elbow crease. Extend the
incision distally, crossing the exion crease of the elbow
at 90° before terminating the incision into the forearm to
permit access to the bifurcation of the BA into the radial
and ulnar arteries as required.
3. When approaching the BA from medial to lateral, the fol-
lowing structures will be encountered and should be preserved: the MABCN, the median nerve (larger than the
MABCN and just medial to the BA), the basilic vein, the
median cubital vein and, nally, the BA.
4. Incise the deep fascia overlying the BA.
5. Further exposure of the bifurcation, if required, can be
achieved by incising the bicipital aponeurosis (lacertus
brosus) and retracting the pronator teres and
brachioradialis.
3. Incise the deep fascia over the RA and insert a West selfretaining retractor to optimise exposure.
48.5.3 Radial Artery: Anatomical Snubox
(Fig.48.6c)
1. A curvilinear incision is placed over the radial side of the
snuffbox to expose the EPL and APL/EPB; the supercial
branch of the radial nerve and the cephalic vein run supercial to the fascia and should be identied and preserved.
2. Incision of the deep fascia between EPL and APL/EPB
followed by blunt dissection exposes the radial artery
(Fig.48.7).
48.5.4 Ulnar Artery: Distal Forearm
(Fig.48.6d, e)
1. Place skin incision radial to the FCU to expose the antebrachial fascia medially and the FCU ulnarly.
2. Incision of the fascia exposes the ulnar artery which lies
deep to the FCU. If necessary, further distal exposure
can be achieved with a curvilinear incision across the
wrist crease placed between the pisiform and hook of
hamate.
3. The volar carpal ligament (which forms the roof of
Guyon’s canal) and palmaris brevis are then divided with
bipolar cautery with further extension into the proximal
palm (Fig.48.8). At this level the ulnar nerve continues to
lie laterally so due care must be taken to avoid the deep
branch of the ulnar nerve when accessing this area.
48.5.2 Radial Artery; Distal Forearm
(Fig.48.6b)
1. Palpate and identify the radial artery (RA) in the distal
forearm between the tendons of FCR and BR
(radially).
2. A curvilinear skin incision is made directly over the RA.
Fig. 48.7 Exposure of the radial artery (RA) and accompanying venae
comitantes (VC) within the anatomical snuff box
478
Fig. 48.8 Skin incision radial to the FCU for exposure of the ulnar
artery and accompanying venae comitantes, with distal, zig-zag extension across the wrist crease into the proximal palm
48.6 Core Surgical Techniques inRecipient
Vessel Harvest
Generally, using one or two West self-retaining retractors
helps to maximise recipient vessel exposure and frees up the
assistant(s) to help with preparing for microsurgical anastomosis. Identify and preserve the important and relevant neurovascular structures encountered with vessel loops; vessel
side branches can be ligated with electrocautery alone, clips
alone, or a combination of both (with heatsink technique) so
that adequate recipient vessel length can be achieved. Dissect
and clip supercial veins encountered during access incisions in the upper limb as potential venous outow options.
48.6.1 Brachial Artery
1. Use tenotomy scissors or knife to progress through subcutaneous tissue proximal to the antecubital fossa (Step
#2 above).
2. Distal to the elbow exion crease, following dissection
and preservation of key neurovascular structures (Steps
#3 and #4 above), preserve any sizeable cutaneous nerves
(potential nerve graft donor) that run along with the
basilic vein.
3. Use microsurgical Acland clamps for proximal and distal
control and microsurgical scissors for cutting back
trimmed ends and/or making an arteriotomy for ETS
anastomosis.
48.6.2 Radial Artery
1. This is usually of sufcient calibre at the distal forearm to
permit ETS anastomosis to preserve distal perfusion to
Z. Y. Ng et al.
Fig. 48.9 Supercial palmar branch of radial artery seen entering thenar eminence (Demonstrated by tenotomy forceps). This serves as the
basis for the free thenar ap, it can also be used as a recipient vessel
the hand (Step #2 above) to avoid potential sequelae
including cold intolerance and pain.
2. When the dissection is extended more distally (but
proximal to the wrist crease), the supercial palmar
branch (variable calibre, 0.8–3.0 mm) of the radial
artery may be identied and can be used for ETE anastomosis (Step #3); distal to the wrist crease, careful
blunt dissection in the rst dorsal compartment will
expose the radial artery at the base of the snuffbox
(Step #4) (Fig.48.9).
48.6.3 Ulnar Artery
1. It is usually radial and supercial to the ulnar nerve at the
wrist although in a small number of cases, it can be suprafascial and at risk of inadvertent injury.
2. Further dissection under palmaris brevis into the palm for
distal exposure can be performed (Step #4).
3. After Guyon’s canal is opened, the hook of the hamate is
identied by palpation, the ulnar neurovascular bundle
retracted medially, and the deep motor branch of the ulnar
nerve is identied and preserved after dissection of the
proximal edge of the hypothenar muscles with tenotomy
scissors.
48 Upper Limb Recipient Vessels Access
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48.7 Pearls andPitfalls
479
Pearls
• Consider preservation of perforators from the brachial artery around the elbow to permit end-to-end
(ETE) anastomosis (e.g. perforator to perforator)
instead of end-to-side (ETS) to the brachial artery.
• Following the radial artery distally after exposure of
the bifurcation leads to several branches including
the recurrent radial artery, and also the supercial
palmar branch of the radial artery both of which can
also be used for ETE anastomosis.
• Release of the brachioradialis from the distal radius
may occasionally be necessary for adequate vessel
exposure.
• The main blood supply to the hand is usually from
the ulnar artery. ETS anastomosis to the ulnar artery
is preferable or perforator to perforator ETE
anastomosis.
• CT angiogram can be helpful in planning microsurgical anastomosis in free tissue transfer to the upper
extremity, with identication of perforators and
suitable recipient vessels.
Pitfalls
• Under the operating microscope, assess for intimal
damage, particularly in the case of digital revascularisation for avulsion injuries.
• In extremity replantation dissect back outside the
zone of injury under the operating microscope.
• Check for good proximal ow before microsurgical
anastomosis (Fig. 48.10a).
• Prepare extra donor sites in the lower limb (e.g.
saphenous vein, which will need to be reversed in
direction, and sural nerve for cable grafting) and/or
the volar forearm for potential vein or nerve grafts
for digital revascularisation (posterior interosseous
nerve, MABC nerve) (Fig. 48.10b).
• Wherever possible do not sacrice the main vessels
(radial artery and ulnar artery) in the upper extremity when performing free tissue transfer, ETS anastomosis or ETE perforator to perforator anastomosis
should be considered rst.
a b
Fig. 48.10 (a) Acland clamp released demonstrating good proximal ow from digital. (b) Harvest of a supercial cutaneous vein from the volar
forearm for interpositional vein grafting in a case of a ring avulsion injury as demonstrated in gure 48.5
480
Z. Y. Ng et al.
48.8 Selected Readings
• Bogdan MA, Klein MB, Rubin GD, McAdams TR,
Chang J. CT angiography in complex upper extremity
reconstruction. J Hand Surg Br. 2004;29:465–9.
• Over 20 months, 17 outpatient contrast-enhanced CT
angiograms were performed in 14 patients. While intraoperative ndings corroborated CT ndings, two patients
required a change in surgical plan due to pre-operative
imaging results.
• Hsu CS, Hellinger JC, Rubin GD, Chang J.CT angiography in pediatric extremity trauma: preoperative evaluation prior to reconstructive surgery. Hand (N Y).
2008;3:139–45.
• In paediatric patients with suspected, traumatic extremity
vascular injuries (n= 5 each for upper and lower limb)
requiring reconstruction, ndings from CT angiography
were conrmed intra-operatively with no complications
at up to a mean of 28 months’ follow-up post-operatively.
• Unal C, Yasar EK, Sarisoy TH.The role of preoperative
radiological assessment of vascular injury on surgical
decision making in mutilating injuries of the upper
extremity. Ann Plast Surg. 2013;70:289–95.
• Pre-operative digital subtraction angiography (DSA) and
CT angiography were performed in seven adult patients
with upper extremity injuries. This led to the change in
ap type that was planned for in ve patients, and the
anastomosis plan had to be revised in seven.
• Nasr AY.The radial artery and its variations: anatomical
study and clinical implications. Folia Morphol (Warsz).
2012;71:252–62.
• Cadaveric dissection of 100 upper limbs (30 men) showed
different branching patterns and 3 modes of termination.
Most importantly, the diameters at 1cm distal to its origin, and at 2cm proximal to the styloid process, ranged
between 3.1 and 3.3mm in both males and females, conrming adequacy for microsurgical anastomoses.
• Ozkus K, Peştelmaci T, Soyluoğlu AI, Akkin SM, Ozkus
HI. Variations of the supercial palmar arch. Folia
Morphol (Warsz). 1998;57:251–5.
• Cadaveric dissection of 80 hands demonstrated variation
in radial and ulnar artery contribution to the supercial
palmar arch; 17.5% was formed by the ulnar artery
alone. This supports the importance of pre-operative
Allen’s test prior to ap design based on the radial or
ulnar artery.
References
1. Funk GF, Valentino J, McCulloch TM, Graham SM, Hoffman
HT.Anomalies of forearm vascular anatomy encountered during
elevation of the radial forearm ap. Head Neck. 1995;17:284–92.
2. Strauch B, Yu HL.Forearm region. In: Atlas of microvascular surgery anatomy and operative techniques. 2nd ed. NewYork: Thieme;
2006. p.40–108.
3. de-Ary-Pires B, Valdez CF, Shecaira AP, de Ary-Pires R, Ary PiresNeto M.Cleland’s and Grayson’s ligaments of the hand: a morphometrical investigation. Clin Anat. 2007;20:68–76.
4. Earley MJ. The arterial supply of the thumb, rst web and index
nger and its surgical application. J Hand Surg Br. 1986;11:163–74.
5. Bell RA, Schneider DS, Wax MK.Supercial ulnar artery: a contraindication to radial forearm free tissue transfer. Laryngoscope.
2011;121:933–6.
6. Onode E, Takamatsu K, Shintani K, etal. Anatomical origins of
radial artery perforators evaluated using color Doppler ultrasonography. J Reconstr Microsurg. 2016;32:594–8.
7. Ishiko M, Yano K, Onode E, Takamatsu K.Identication of ulnar
artery perforators using color Doppler ultrasonography. J Reconstr
Microsurg. 2020;36:667. https://doi.org/10.1055/s- 0040- 1713601.
Lower Limb Recipient Vessels Access
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YezenSheena, GeorgiosPatanis, DariushNikkhah,
EdmundFitzgeraldO’Connor, and JeremyRawlins
49
49.1 Indications
Lower limb reconstruction by free tissue transfer is required
in a variety of settings and not uncommonly after trauma,
infection, or oncological resections. In general, limb-salvage
is the aim, and the only absolute contraindication is when the
patient’s life is threatened by achieving this. The defect location, size, composition and availability of donor sites are
important when considering the best ap and recipient vessels. It is useful, particularly in trauma, to obtain angiographic
imaging to conrm the anatomy and condition of leg vessels.
By communication with the patient and colleagues, the
microsurgeon must anticipate the whole reconstructive and
rehabilitation journey tailoring a dynamic approach to staged
orthopaedic treatment, integrating complication management
(keeping ‘lifeboats’ without ‘burning bridges’) towards
returning the patient to normal ambulatory function.
49.2 Anatomy
Reviewing lower limb vascular anatomy is relevant and a
summary is provided here with brief details on the approach,
to access common recipient vessels for microsurgery to fol-
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 3- 031- 07678- 7_49].
Y. Sheena (*)
Royal Perth Hospital, Perth, WA, Australia
G. Patanis ∙ E. F. O’Connor
Guys & Thomas’ and Kings College Hospital NHS Foundation
Trusts, London, UK
D. Nikkhah
The Royal Free Hospital NHS Foundation Trust, London, UK
J. Rawlins
Department of Plastic and Reconstructive Surgery, Royal Perth
Hospital, Perth, WA, Australia
low. The femoral artery, a continuation of the external iliac
artery distal to the inguinal ligament, provides the main
blood supply to the lower limb. At its origin within the femoral triangle it gives off the profunda femoris artery. This
courses posteriorly and distally giving off three main
branches: (1) Lateral femoral circumex—crosses anterior
femur supplying lateral thigh muscles and skin; (2) Medial
femoral circumex—wraps round posterior femur supplying the bone’s head and neck; (3) Perforators supplying
adductor magnus. The Supercial Femoral Artery (SFA)
descends from the femoral triangle, entering the adductor
canal supplying the anterior thigh muscles, and becomes the
Popliteal Artery (PA) as it leaves this canal via the adductor
(magnus) hiatus. The PA gives off genicular branches supplying the knee joint, then descends through and exits the
popliteal fossa between gastrocnemius and popliteus muscles where it terminates by dividing into the Anterior Tibial
Artery (ATA) and Tibio-Peroneal Trunk. The latter bifurcates into the Posterior Tibial Artery (PTA) and Peroneal or
Fibular Artery (FA). The FA descends posterior to the bula
in the posterior leg giving off perforators supplying the lateral leg muscles. The PTA descends in the deep posterior leg
compartment entering the foot via the tarsal tunnel where it
bifurcates into medial and lateral plantar arteries (contributing to the sole of the foot and toes via the deep plantar arch).
The ATA is conducted anteriorly through a gap in the interosseous membrane between tibia and bula and descends
the anterior compartment of the leg becoming the Dorsalis
Pedis Artery (DPA) beyond the ankle to supply the dorsal
foot and joins the lateral plantar artery forming the deep
plantar arch.
49.3 Pre-operative Investigation
Beyond a thorough pre-operative clinical examination of the
lower limb’s injury and neurovascular status, the majority of
microsurgeons utilise some form of imaging to dene the
recipient lower limb vascular anatomy. Anatomical land-
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_49
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