Principles of Microsurgery

Introduction

Microsurgery uses the operating room microscope or high-powered loupe magnification to aid in the techniques of microvascular surgery to anastomose small vessels and nerves.¹ Microsurgical reconstruction is used for complex reconstructive surgery problems when other options such as primary closure, healing by secondary intention, skin grafting, or local or regional flap transfer, are not adequate.

Microsurgery may not be the best solution for all reconstructive dilemmas and usually is not the first choice in the reconstructive ladder. However, it can offer the reconstructive surgeon an important tool to achieve complex reconstruction by proceeding with free tissue transfer from distant sites. Free tissue transfer includes flaps such as isolated transfers, composite tissue transfers, functioning free muscle transfers, vascularized bone grafts, and toe transplantation. In addition, specific tissue transfers such as neural grafts or vein grafts are also considered free tissue transfer. In specific cases, such as large defects of the face after tumor resection, free tissue transfer may be the best option for closure of the defect.

This article outlines the basics of microsurgery, preoperative planning, specific operative techniques, and postoperative care. In addition, this article highlights some of the most common flaps used for microsurgical reconstruction.

History of the procedure

The field of microsurgery began with the introduction of the operating microscope when Jacobson and Suarez described the anastomosis of blood vessels. In the 1960s, as microsurgical techniques were perfected, increasing success was seen with digital artery repairs and finger replantation. This laid the foundation for microsurgical composite tissue transfer, which became popular in the 1970s.

In the 1980s, an emphasis was placed on improved function with autologous tissue transplantation, which is exemplified in mandibular reconstructions for cancer. Composite grafts consisting of soft tissue and bone aided in stabilizing the mandible, assisted with mastication, and allowed for reliable coverage during the postoperative period, when radiation usually was required. Today, microsurgical techniques have become an integral part of the armamentarium for plastic surgeons, allowing for soft tissue coverage and function after trauma or oncologic resections.

Indications

The indications for tissue transfer utilizing microsurgical techniques include the need to cover exposed vital structures such as joint surfaces, tendons, vessels, and bone denuded of periosteum; the need to restore shape, such as in the breast after mastectomy; and the need to restore function, such as in the muscles of the face. Finger reimplantation or transfer may represent another aspect of this technique. Microsurgery may also be used as a new approach to achieve lymphatic drainage in cases of lymphedema.²

The indications for microsurgical reconstruction and the type of flap used depend on the type of tissue required and the size and location of the defect. Defects can be an isolated tissue type, such as soft tissue defects on the dorsum of the hand, or some combination of skin, subcutaneous tissue, nerves, muscle, tendons, cartilage, bone, and mucosa.

Free flaps can be categorized into 2 different types of transplants. Isolated tissue transplants include skin, fascia, muscle, nerve, or bone individually. The more common composite tissue transplant represents a more complex flap and provides more than one type of tissue. Such flaps include myocutaneous, osteocutaneous, or innervated myocutaneous flaps.

Historically, reconstruction of a defect was based on a reconstructive ladder, with local and simple procedures being performed prior to more extensive procedures or distant tissue transfers. Today, the use of free tissue transfer is no longer seen as the apex of the reconstructive ladder. Instead, it is a generalized tool for complex or composite tissue transfers, for treating wounds with poor healing or inflow, and for situations in which postoperative radiation may play a factor in wound healing. See the table below for examples of free tissue transfer.

Free Tissue Transfer

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Table

Defect Type	Tissue Defect	Common Flaps
Coverage of exposed structures	Open tibial fractures in the distal third of the leg	Latissimus dorsi muscle free flap; gracilis muscle free flap
Dead space	Obliteration of maxilla defect after maxillectomy for cancer	Rectus abdominus muscle free flap
Tissue defect	Breast reconstruction	Transverse rectus abdominus myocutaneous (TRAM) free flap; deep inferior epigastric perforator (DIEP) flap; superior gluteal artery perforator (SGAP) free flap
Bone and soft defect	Mandible reconstruction	Fibula osteocutaneous free flap
Bone and soft defect	Infraorbital and maxillary defect	Parascapular osteocutaneous free flap
Facial muscle denervation	Facial paralysis with muscular atrophy	Gracilis muscle free flap
Digital amputation	Thumb amputation	Great toe composite free flap
Digestive tract defect	Esophageal reconstruction	Jejunum free flap; anterior lateral thigh (ALT) free flap

Defect Type	Tissue Defect	Common Flaps
Coverage of exposed structures	Open tibial fractures in the distal third of the leg	Latissimus dorsi muscle free flap; gracilis muscle free flap
Dead space	Obliteration of maxilla defect after maxillectomy for cancer	Rectus abdominus muscle free flap
Tissue defect	Breast reconstruction	Transverse rectus abdominus myocutaneous (TRAM) free flap; deep inferior epigastric perforator (DIEP) flap; superior gluteal artery perforator (SGAP) free flap
Bone and soft defect	Mandible reconstruction	Fibula osteocutaneous free flap
Bone and soft defect	Infraorbital and maxillary defect	Parascapular osteocutaneous free flap
Facial muscle denervation	Facial paralysis with muscular atrophy	Gracilis muscle free flap
Digital amputation	Thumb amputation	Great toe composite free flap
Digestive tract defect	Esophageal reconstruction	Jejunum free flap; anterior lateral thigh (ALT) free flap

Contraindications

Contraindications for microsurgical free tissue transfer fall into 2 categories: patient issues and surgical issues.

Patient issues

Contraindications associated with the patient include any condition that may put the patient’s life in danger or significantly increase the probability of postoperative flap loss. The time required to harvest and insert a flap is relatively long. Therefore, any medical condition that inhibits the patient’s ability to withstand prolonged anesthesia, such as severe respiratory disease, is an absolute contraindication. Microsurgical free tissue transfer is absolutely contraindicated in patients who are critically ill, have ongoing sepsis, or have uncontrolled coagulopathy.

Relative contraindications include any condition that increases the risk of intraoperative or postoperative complications. Common conditions that are not contraindications but can increase the risk of complications include cardiovascular disease, diabetes mellitus, Raynaud syndrome, scleroderma, other collagen vascular diseases, smoking, radiation, and ongoing infections. In general, a thorough review of the patient’s medical history and current conditions is critical when formulating a treatment algorithm and timing for a patient.

Surgical issues

Surgical issues include the lack of a properly trained surgeon or surgical team (this is usually not an issue today because microsurgery is common and a major part of most plastic surgery training programs). Other surgical issues include limited resources that might inhibit the staff from properly caring for the patient intraoperatively or postoperatively or the lack of access to specialized microsurgical instruments.

Workup

Preoperative planning includes finding the optimal donor site and designing the flap to maximize soft tissue coverage, functionality, and appearance and to minimize complications. In oncologic cases, the timing of free flap reconstruction should be coordinated with the oncology team, taking into consideration chemotherapy and radiation treatments.

History and physical examination

Preoperative assessment of the patient should include an in-depth review of the patient’s current conditions, past medical history, past surgical history, previous history with anesthesia, and current medications. The social history is important to identify possible issues with substance or tobacco use as well as to better understand the patient’s support network for postoperative care. The physical examination is used to identify the current defect or to anticipate a presumed defect (in the case of an oncologic procedure). The ability to anticipate the operative defect and plan for appropriate reconstructive repair is imperative for a successful restoration of form and function.

Lab studies

Because of the possible long operative and fluid shifts associated with microsurgical cases, a complete blood count, type and screen or type and cross, coagulation panel to rule out either coagulopathy or a hypercoagulable state, and basic chemistries are routinely ordered preoperatively. ECG and chest radiography are also a part of the routine preoperative workup. Additional laboratory studies and tests such as pulmonary function tests are necessary, depending on the general health and age of the patient.

Imaging studies

Imaging studies are an important part of the preoperative workup for specific defects and reconstructive procedures. However, imaging studies are not performed routinely in every case. Computed tomography (CT) scans of the head and neck may be useful in understanding the expected defect. In mandibular reconstruction, 3-dimensional CT scans may help visualize the anticipated defect in 3 dimensions. In lower extremity reconstruction, angiography is useful to determine the zone of vessel injury and the location of recipient vessels. Lower extremity angiography is also useful prior to free fibula harvest in patients who have peripheral vascular disease.

Common Flaps

After the decision has been made to proceed with a microsurgical reconstruction, the optimal flap must be chosen. This decision is based on the size of the defect, the type(s) of tissue required for the repair (bone, muscle, fascia, tendon, nerve, skin), the length of vascular pedicle, and the reliability of the flap.

Perforator flaps involve the dissection of terminal blood vessels into a tissue segment. These flaps have not only gained significant popularity in the last decade as a result of a better understanding of the anatomy and blood supply to specific tissue territory but have revolutionized the field of microsurgery. By dissecting the blood vessels to the flap and sparing the surrounding tissue, large flaps can be harvested with minimal functional loss to the patient. Three perforator flaps are described in this article: the anterior lateral thigh (ALT) flap, the superior gluteal artery perforator (SGAP) flap, and the deep inferior epigastric artery perforator (DIEP) flap.

The following is a list of common, reliable flaps that are used in reconstructive surgery.

Anterior lateral thigh flap

The anterior lateral thigh (ALT) flap is a fasciocutaneous flap that has become popular in recent years. The flap is located over the middle third of the thigh anterior and lateral to the rectus femoris and the vastus lateralis muscles. Although the flap is supplied by musculocutaneous perforators 85% of the time, it can be raised as a perforator flap, allowing for minimal disruption of the underlying musculature. It is usually used for coverage of defects when a relatively thin flap is required but can be harvested with parts of the vastus lateralis muscle when a flap with more volume is required.

• Type - Fasciocutaneous
• Dominant pedicle - Septocutaneous branches of the descending branch of the lateral circumflex femoral artery and venae comitantes
• Innervation - Sensory derived from the lateral femoral cutaneous nerve (L2-3)

Radial forearm flap

This is a useful and versatile flap with a long vascular pedicle and thin, pliable skin that was widely used in China before becoming popular in the western literature. The flap is based on the radial artery and can achieve a pedicle length of 20 cm and a diameter of 2.5 mm. The flap size can reach an area of 10 X 40 cm².

Raising this flap sacrifices a major artery to the hand; therefore, before harvesting this flap, check that the perfusion to the hand is preserved through the ulnar vascular system. The osteocutaneous flap risks radius fracture if not carefully harvested. In addition, exposure of the flexor tendons must be avoided by careful preservation of the paratenon and coverage of tendons with surrounding muscle bellies prior to skin grafting.

• Type- Fasciocutaneous or osteocutaneous
• Dominant pedicle - Radial artery, venae comitantes and cephalic vein
• Innervation - Medial and lateral antebrachial cutaneous nerves (sensory)

Lateral arm flap


The flap can be harvested as a fasciocutaneous, innervated fasciocutaneous, or de-epithelialized subcutaneous fascial flap. The flap is supplied by the posterior radial collateral vessels. The flap does not sacrifice a major vessel in the arm and may be harvested in the same upper extremity that requires reconstruction. The flap may be bulky, and the pedicle may be short (up to 7 cm). The posterior brachial cutaneous nerve (C5-6) innervates the flap when it is harvested as a sensate flap. The donor site may be closed, if laxity is present in the upper arm, or skin grafted. In either case, the donor scar may be conspicuous.

• Type - Fascial or fasciocutaneous
• Dominant pedicle - Posterior radial collateral artery and venae comitantes (branch of profunda brachii artery)
• Innervation - Posterior cutaneous nerve of the arm (sensory); additional sensory from the posterior antebrachial cutaneous nerve

Scapular flap


The pedicle for this flap is long and reliable. It is a thin, sometimes hairless, skin flap from the upper back and can be de-epithelized and used as subcutaneous fascial flap, pedicled flap, or free flap. However, this flap has several drawbacks. The patient must be positioned in either the lateral decubitus position or prone position for harvest; the sensory innervation is not reliable; and the skin may be too bulky, depending on the body habitus of the patient.

• Type - Fascial, fasciocutaneous, or osteocutaneous
• Dominant pedicle - Circumflex scapular artery and vein
• Innervation - Lateral and posterior cutaneous nerves of third to fifth intercostal nerves (sensory)

Groin flap


The groin flap can provide a large skin and subcutaneous tissue territory based on the superficial circumflex iliac artery and vein. It is particularly helpful when thin tissue coverage is required. The flap can be as large as 10 X 25 cm². A tissue expander can be placed under the deep groin fascia, which can expand the flap and allow for direct donor site closure. The small diameter of the superficial circumflex iliac artery and variable vascular anatomy make this flap less popular compared to other free tissue transfers.

• Type - Fasciocutaneous
• Dominant pedicle - Superficial circumflex iliac artery and venae comitantes and superficial circumflex iliac vein

Superior gluteal perforator flap

The superior gluteal artery perforator (SGAP) flap is a perforator flap used mainly for breast reconstruction. The abdomen is the most common harvest site for autologous breast reconstruction; however, in some cases, such as patients who have excessive scarring or are very thin, the abdomen is not an option as a donor site. The gluteal region and the SGAP flap offer alternatives when the abdomen is unavailable as a donor site.

• Type - Fasciocutaneous
• Dominant pedicle - Superior gluteal artery perforators

Latissimus dorsi flap

This flap is a very reliable flap with large muscle mass that can be harvested with or without a skin paddle. The primary vascular pedicle can be as long as 8 cm. If additional tissue is needed, the latissimus dorsi muscle may be raised with the serratus anterior muscle and/or scapular flap on one pedicle. One drawback is the need for positioning the patient in a lateral decubitus position for harvests.

• Type - Muscle or musculocutaneous
• Dominant pedicle - Thoracodorsal artery and vein
• Minor pedicle - Perforators from the posterior intercostal arteries and 7 lumbar artery and venae comitantes
• Innervation - Thoracodorsal nerve (motor)

Rectus abdominis flap


This is a reliable flap with a large muscle mass and skin paddle. The vertically oriented muscle extends between the costal margin and the pubic region and is enclosed by the anterior and posterior rectus sheaths. It has 2 dominant pedicles, based on the superior epigastric artery and vein and the inferior epigastric artery and vein.

The pedicle is large and reliable. The flap may be harvested with the patient in a supine position. One drawback to this flap is the possibility of abdominal hernia after sacrifice of one of the rectus abdominus muscles. Careful closure of the layers of the abdominal wall is critical to prevent this occurrence. In recent years, the perforator flap based on the inferior epigastric artery and vein (DIEP) has become popular as a donor site for breast reconstruction. Its main advantage is the decreased morbidity to the abdominal wall.

• Type - Muscle or musculocutaneous (TRAM, VRAM, muscle sparing TRAM)
• Dominant pedicles - Deep inferior and superior epigastric arteries and veins
• Innervation - Seventh to twelfth intercostal nerves (motor) and lateral cutaneous nerves from seventh to twelfth intercostal nerves (sensory)

Gracilis flap

The gracilis muscle has a dominant pedicle and several minor pedicles. It is a thin and flat muscle that lies between the adductor longus and sartorius muscles anteriorly and the semimembranosus muscle posteriorly. The dominant pedicle is the ascending branch of medial circumflex femoral artery and the venae comitantes. This flap is useful for reanimation of facial paralysis or for extremity muscle function. The vascular pedicle is usually short, and the vessels are small. The skin paddle is typically unreliable.

• Types - Muscle or musculocutaneous
• Dominant pedicle - Ascending branch of medial circumflex femoral artery and vein
• Innervation - Anterior branch of obturator nerve (motor) and anterior femoral cutaneous nerve (sensory)

Tensor fascia lata flap

The tensor fascia lata (TFL) flap has one dominant vascular pedicle, which is the ascending branch of the lateral circumflex femoral artery from the profunda femoris and venae comitantes. The size of the muscle is up to 15 X 5 cm², and the skin flap can achieve a size of 7-9 X 22-26 cm².

• Type - Muscle, musculocutaneous, musculofascial, or musculofasciocutaneous
• Dominant pedicle - Ascending branch of the lateral circumflex femoral artery

Omental flap


The omental flap allows for a large volume of pliable tissue; however, this flap harvest requires a laparotomy. The omentum flap is ideal for obliteration of irregular dead space cavities or when thin coverage is required over an exposed tissue such as bone.

The omentum is considered a visceral structure containing fat and blood vessels within a thin membrane. It extends from the stomach to beyond the transverse colon and covers the anterior aspect of the peritoneal contents. It has 2 dominant pedicles, the right gastroepiploic artery and vein and a left gastroepiploic artery and vein. Prior intra-abdominal surgery, which can create extensive omental inflammatory adhesions, may preclude use of the omental flap.

• Type - Vascularized fat
• Dominant pedicle - Right or left gastroepiploic artery and vein

Jejunal flap

This flap is reserved for pharyngeal or esophageal reconstruction. The intestinal mucosa does not tolerate ischemia; therefore, revascularization must proceed immediately. Postoperative monitoring may be performed with a sentinel loop of intestine that is exteriorized.

• Types - Vascularized intestine
• Dominant pedicle - Jejunal artery and accompanying vein

Fibula flap

This flap offers a large segment of bone that may be recontoured by osteotomies with or without a skin paddle. In patients with abnormal distal extremity pulses, an angiography or magnetic resonance angiography (MRA) of the lower extremity is indicated. The skin paddle is reliable when care is taken to preserve the fasciocutaneous perforators.

• Type - Osseous long bone or osteocutaneous
• Dominant pedicle - Peroneal artery and vein
• Innervation - Superficial peroneal nerve (sensory)

Great toe flap

The great toe flap can be used to reconstruct part of the thumb or as a neurosensory flap. This flap allows composite tissue reconstruction for loss of the thumb without significant loss of function to the foot. However, some patients may not wish to sacrifice a great toe for aesthetic reasons.

• Type - Composite (bone, tendon, nerve, skin, nail) or fasciocutaneous
• Dominant pedicle - First dorsal metatarsal artery and vein
• Minor pedicle - First plantar metatarsal artery and vein
• Innervation - Digital nerves (sensory), dorsal cutaneous nerves from superficial peroneal nerve, deep peroneal nerve

Surgical Principles

Because of the complexity of microsurgical procedures, following guidelines can help achieve a high success rate.

Preoperative details

• The patient needs to be able to tolerate a surgery that lasts 8 hours or longer.
• The flap should be planned based on the size and type of tissue needed, and an alternative flap should be considered as a lifeboat.
• The recipient vessel should be planned outside the zone of injury.
• The patient and the family must understand the extent of the procedure as well as all risks and possible complications, including the possible devastating complication of flap loss.

Intraoperative details

• The surgical plan should be discussed with the operating team, including the anesthesiologists and the circulating and scrub nurses. This should include the length of the procedure, the positioning of the patient and any need to change position, and the indication and contraindication of use of specific pharmacological agents.
• Outline the plan to the circulating nurses and scrub nurses. If 2 surgical teams are to operate simultaneously, ensure that adequate nurses are available.
• Prepare the proper equipment.
  • Operating microscope
  • Microsurgical instruments
  • Microsutures (9-0 and 10-0 nylon)
  • Vein coupler
  • Sterile Doppler
• Position the patient properly.
  • Padding of all pressure points
  • Prevention of nerve traction or compression
  • Foley catheter
  • Sequential compression devices on legs to prevent deep venous thrombosis
  • Sterile preparation of donor and recipient sites as well as sites as needed for harvesting of vein grafts, nerve grafts, or skin grafts
• Surgical details are as follows:
  • Surgery always begins with resection of the tumor or the diseased area and proper exploration and preparation of the recipient site.
  • Control of infection and adequate debridement are necessary prior to flap transfer.
  • The need for free flap reconstruction should be re-evaluated intraoperatively. In some instances, reconstruction may be performed using skin grafts or local flaps based on the reconstructive ladder.
  • Doppler ultrasonography is useful to localize recipient vessels. The recipient artery and vein must be critically evaluated, and the surgeon must be satisfied with inflow and outflow prior to embarking on flap harvest. A common pitfall is remaining within the zone of injury on a traumatized or irradiated vessel for microanastomosis, thus resulting in higher rates of vessel thrombosis.
  • The dimensions and tissue needs of the defect are determined, and the choice of flap is made. An important issue is the orientation and the length of the vascular pedicle. The surgeon must measure the length of pedicle needed to reach the recipient vessels and compare that to the pedicle length available.
  • Microsurgical anastomoses are performed using meticulous technique and the following principles:
    • The recipient vessels and the match between the size of the recipient and pedicle vessels must be carefully assessed.
    • Preparation of vessels to healthy untraumatized tissue (ie, their pretraumatized state), removal of intravascular clots and debris, and irrigation with heparinized saline (100 U/mL)
    • Vessel side branches are examined and legated to prevent hematoma.
    • Either end-to-end or end-to-side anastomoses may be performed, depending on the recipient vessel, the orientation of the flap, and the match between the size of the vessels.
    • Avoidance of vessel tension, kinking, and twisting is important.
    • If tension is excessive, vein grafting is preferred.
    • Once flow is established, the anastomotic sites are bathed with warm irrigation and papaverine to relieve vasospasm.
    • Vascular anastomoses are finally examined, and the vascular strip test is performed to check flow. The strip test is performed by gently occluding the vessel distal to the anastomosis with a microforceps and "stripping" the vessel with another microforceps proximally across the anastomosis. Brisk blood flow should then be observed to return across the anastomosis when the proximal microforceps are released.
  • The vein coupler is becoming more popular and is a useful tool for anastomosing the vein. In the right hands, the coupler is efficient and can help decrease the total operative time.
  • Final inset of the flap is performed with care to prevent compression of the vascular anastomoses. Occasionally (eg, in head and neck cases), the inset of the flap is done prior to the anastomosis.
  • While the patient is under anesthesia, final assessment of flap viability is made by clinical observation, and vascular flow is confirmed with Doppler examination. The location of Doppler signal in the flap is marked with a stitch for postoperative monitoring. Internal Doppler probes are used when the flap is completely buried under the skin.
  • Loose dressings are applied, with a portion of the flap exposed for postoperative monitoring. Splints, if needed, should also be free of compression. Particular attention should be given to the position of the patient to avoid compression or pulling on the pedicle.

Postoperative details

• The postoperative ward must be staffed with nurses who are familiar with free flap monitoring and general care for patients who have undergone microsurgery.
• Pain is well controlled to prevent pain and anxiety leading to vasoconstriction.
• Adequate fluid hydration and body temperature are maintained.
• The location of the free flap is elevated to promote venous drainage and minimize swelling.
• Anticoagulation may be used, depending on the operation and surgeon preference. Possible anticoagulant choices include the following:
  • Dextran 40
  • Heparin
  • Lovenox
  • Aspirin
• Free flap monitoring depends on the operation and surgeon preference. The criterion standard for monitoring remains careful clinical examination that consists of skin color, capillary refill, and flap turgor. Pricking the flap with a needle should result in bright red blood.³ Methods of monitoring the flap include the following:
  • Surface Doppler ultrasound
  • Temperature monitoring
  • Implantable Doppler ultrasound
  • Pulse oximetry
  • Intravenous fluorescein
• Vascular compromise includes congestion or ischemia of the flap, and it may develop very quickly or more slowly. When a vascular compromise occurs suddenly, the patient needs to be taken immediately to the operating room for exploration of the anastomotic site. When the signs of vascular compromise occur more gradually, the following measures should be immediately undertaken:
  • Reposition the patient to relieve possible vascular pedicle compression.
  • Remove compressive dressings.
  • Release tight sutures.
  • Assess hydration.
  • If these simple maneuvers at the bedside are not successful, immediate re-exploration in the operating room is critical.

Complications

Postoperative complications include the following:

• Flap compromise due to vein or artery thrombosis
• Flap congestion
• Fat necrosis
• Hematoma with pedicle compromise and need for transfusion
• Infection
• Wound breakdown
• Wound complication associated with the donor site
• Systemic complications associated with anesthesia
• Deep vein thrombosis and pulmonary emboli (Click here to complete a Medscape CME activity on the risk of venous thrombosis in elderly persons.)

Conclusions

Reconstructive microsurgery is now in a new stage. Because of continued developments in technology, as well as a better understanding of the anatomy, anastomosis of very small vessels (0.3 mm) is now possible. These highly challenging procedures are referred to in the literature as supermicrosurgery. They allow anastomosis of perforator flaps such as the medial plantar flap to perforator recipient vessels.⁴ Additional applications include complex digit reimplantation and lymphatic anastomosis.

Although microsurgery continues to develop, the basic principles of microsurgery, as follow, remain the same:

• Select patients carefully.
• Develop a careful preoperative plan.
• Use a well-defined workhorse flap.
• Obtain full patient consent.
• Pay attention to intraoperative details.
• Perform meticulous microsurgical technique.
• Remain vigilant during postoperative care.

Keywords

principles of microsurgery, microsurgery, free flap reconstruction, free tissue transfer, replantation, composite flaps, flap harvest radial forearm flap, lateral arm flap, latissimus dorsi flap, scapular flap, serratus anterior, rectus abdominis flap, omental flap, jejunal flap, groin flap, anterior lateral thigh, gracilis flap, fibula flap, great toe flap, dorsalis pedis flap, flap monitoring