NCG Plastic-reconstructive-surgery-guidelines 2.pdf

National Cancer Grid
Plastic & Reconstruction Guidelines 2024
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NCG Plastic and Reconstructive Surgery
Guidelines 2024

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INDEX
No Modalities Page Number
1 Breast recon algorithm 3
2 Buccal Mucosa 5
3 Chest and abdominal wall 7
4 Lower limb reconstruction 11
5 Mandible reconstruction 13
6 Maxilla reconstruction 16
7 Pharyngeal reconstruction 18
8 Skull base 20
9 Tongue reconstruction 22
10 Upper Limb 24

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Legends-
Surgery
Partial breast
reconstruction
Small breast and
no ptosis = WLE
+/- delayed
lipofilling
Large breast and
ptosis =
Oncoplastic
mammaplasty
Volume
displacement
techniques
Volume
replacement
techniques
Flaps
Moderate
resection
<150
grams
ICAP
TDAP
Thoraco-epigastric flaps
Large
resection
>150
grams
LD flaps
Free flaps
Total breast
reconstruction
No
radiothera
py
Implant
Skin
sparing
No ptosis
1.
Expander
2. Implant
Skin
sparing
Ptosis
Wise pattern
reduction with
dermal skin
Direct to
implant
Nipple
sparing
Direct to
implant
radiothera
py
Autologus (Nipple
or skin sparing)
Adequate
abdomen
DIEP flap
Inadequate
abdomen
Bipedicled
/
Stacked
DIEP
DIEP with
lipofilling
DIEP with
implants
TUG
LAP
GAP
LTP
Multiple
flaps
Breast Reconstruction

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ICAP- Inter-coastal artery perforator
TDAP- Thoracodorsal artery perforator
LD- Latissimus dorsi
DIEP- Deep inferior epigastric artery perforator
TUG- Transverse upper gracilis
LAP- Lumbar artery perforator
GAP- Gluteal artery perforator
LTP- Lateral thorasic perforator
• Breast Reconstruction

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- Green signifies best/preferred option, Blue signifies- resource based options, Red signifies salvage options
- 1- FRAFF/FALT/TDAP/MSAP – depending on thickness and pliability of donor site. Flap should provide adequate bulk
Buccal Mucosa
cancer
Anterior Buccal
Mucosa defect
Thin Free flaps 1
Nasolabial
flap/Submental
flap
-Forehead flap/TP
fascia flap
Retromolar trigone defect
(only STSG leads to
trismus after RT
Only Buccal
mucosa
Thin Free Flap 1
Tongue flap/
Submental flap
Forehead
flap/Buccal fat
pad/ Masseteric
flap
Buccal mucosa +
Marginal
Mandebulectomy
Free Flaps1
Submental flap
PMMC
flap/Forehead flap
Buccal Mucosa +
Marginal
mandibulectomy+ skin
Free Flap 1
PMMC+/-DP flap /
Forehead flap
Buccal Mucosa
+Infratemporal fossa
clearance
Free Flap 1
Location
Buccal Mucosa cancer

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References
1. Chin-Yen Chien ,Chung-Feng Hwang, Hui-Ching Chuang , Seng –Feng Jeng, Chih-Ying Su .Comparision of radial forearm free flap , pedicled
buccal fat pad flap and split –thickness skin graft in reconstruction of buccal mucosa defect . Oral Oncol.2005Aug;41(7):694-7 .
2. Schonauer F, Di Martino A, Nele G, Santoro M, Dell'Aversana Orabona G, Califano L. Submental flap as an alternative to microsurgical flap in
intraoral post-oncological reconstruction in the elderly.
Int J Surg. 2016;33 Suppl 1:S51-S56.
3. Fairouz Chouikh The Buccal Fat Pad Flap .Oral Maxillofacial Surg Clin N Am 33 (2021) 177–184 .
4.Vijay Kumar,Sourabh Mukherjee, Naseem Akhtar , Siv Rajan ,Arun Chaturvedi,Sameer Gupta ,Puneet Prakash,Satyabrata Das. Tongue flap
reconstruction in carcinoma of oral cavity :An institutional experience J.Maxillofac.Oral Surg.(july -Sept2019)18(3);428-43 .
5. Shao-Liang Chen , Chien –ChihYu,Meing-Chang,Shou-ChenDengYueng-Shiang and Tim-Mo Chen .Medial sural artery perforator flap for
intraoral reconstruction following cancer ablation .Ann Plast Surg 2008;61:274-279)
6.D.S.Soutar,L.R.Scheker,N.S.B.Yanner and I.A.McGregor .The radial forearm flap : A versatile method for intra-oral reconstruction
British journal of plastic surgery (1983)36,1-8
7. Roberto Squaquara,Karen F .Kim Evans,Stefano Spaniodi Spilimbergo,and Samir Mardini .Intraoral reconstruction using local and regional flaps
;Semin Plat Surg 2010;24:198-211
8. Hemant Nemade , Naren Bollineni Sagar Mortha , G Jonathan,Sravan Kumar , LMCS Rao, Subramanyeshwar Rao .Marginal mandibulectomy
defect reconstruction with pectoralismajor myucutaneous (PMMC) flap in cases of carcinoma buccal mucosa ; Experience from tertiary cancer
institute
Indian Journal of Surgical Oncology (September 2020 ) 11(3):482-485
9. Song M,Chen Fj, Guo ZM ,Zhang Q , Yang AK : Application of various flaps to intraoral recontruction of buccal defect after resection of buccal
mucosa carcinoma Ai Zheng 2009, 28 ;663-667
10. Arik Zaretski , Fu –Chan Wei and Christopher Glenn Wallace . Anterolateral thigh perforator flaps in head and neck reconstruction ;Semin
Plast Surg 2006;20:2;64-72 .

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1. Options for rigid fixation- Mesh cement sandwich, titanium mesh, titanium plate, autograft, allograft
CHEST
WALL
DEFECTS
ADEQUATE
SOFT TISSUE
Primary
closure
INADEQUAT
E SOFT
TISSUE
Skin and
subcuteneo
us
Anterior
defect
Intercostal
artery
perforator
flap,
Latisismus
Dorsi falp,
Rectus
abdominis
flap,
Omentum
flap
Posterior
defect
Latisismus
Dorsi falp,
Intercostal
based flap,
perforator
flap, local
flaps, free
flap
Lateral
defect
Perforator/T
ransposition
flap,
Latisismus
Dorsi falp,
TDAP flap,
free flap
Forequarter
amputation
Fillet flap,
Free flap,
Spare part
surgery
Midline
defects
Latissimus
dorsi flap,
Pectoralis
major flap,
Omentum
flap, VRAM
flap, free
flap
Full
thickness
Anterior
defects
defect > 2
ribs/ 5 cm
Rigid
fixation1 +
soft tissue
flap
defect < 2
ribs/ 5 cm
prolene
mesh + soft
tissue flap
Posterior
defects
Defect > 10
cm
Prolene
mesh with
soft tissue
flap
defect < 10
cm
Soft tissue
flap only
CHEST WALL DEFECTS

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2. Split thickness skin graft is an option if the bed is graftable and adjuvant radiation is not required
REFERENCES –
1. Cohen M, Ramasastry SS. Reconstruction of complex chest wall defects. The American journal of surgery. 1996 Jul 1;172(1):35-40.
2. Chang RR, Mehrara BJ, Hu QY, Disa JJ, Cordeiro PG. Reconstruction of complex oncologic chest wall defects: a 10-year experience.
Annals of plastic surgery. 2004 May 1;52(5):471-9.
3. Sanna S, Brandolini J, Pardolesi A, Argnani D, Mengozzi M, Dell’Amore A, Solli P. Materials and techniques in chest wall reconstruction: a
review. Journal of visualized surgery. 2017;3.
4. Mathes SJ. Chest wall reconstruction. Clinics in plastic surgery. 1995 Jan 1;22(1):187-98.
5. Di Candia M, Wells FC, Malata CM. Anterolateral thigh free flap for complex composite central chest wall defect reconstruction with
extrathoracic microvascular anastomoses. Plastic and Reconstructive Surgery. 2010 Nov 1;126(5):1581-8.
6. Dingman RO, Argenta LC. Reconstruction of the chest wall. The Annals of Thoracic Surgery. 1981 Aug 1;32(2):202-8.
7. Volpe CM, Peterson S, Doerr RJ, Karakousis CP. Forequarter amputation with fasciocutaneous deltoid flap reconstruction for malignant
tumors of the upper extremity. Annals of Surgical Oncology. 1997 Jun;4(4):298-302.
8. Tukiainen E. Chest wall reconstruction after oncological resections. Scandinavian Journal of Surgery. 2013 Mar;102(1):9-13.
9. Matros E, Disa JJ. Uncommon flaps for chest wall reconstruction. Semin Plast Surg. 2011 Feb;25(1):55-9. doi: 10.1055/s-0031-1275171.
PMID: 22294943; PMCID: PMC3140228.
10. Ayyala HS, Mohamed OM, Therattil PJ, Lee ES, Keith JD. The forearm fillet flap: 'spare parts' reconstruction for forequarter amputations.
Case Reports PlastSurg Hand Surg. 2019 Sep 20;6(1):95-98. doi: 10.1080/23320885.2019.1666718. PMID: 31595221; PMCID:
PMC6764346.
11. Sanna S, Brandolini J, Pardolesi A, Argnani D, Mengozzi M, Dell'Amore A, Solli P. Materials and techniques in chest wall reconstruction: a
review. J Vis Surg. 2017 Jul 26;3:95. doi: 10.21037/jovs.2017.06.10. PMID: 29078657; PMCID: PMC5638032.

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1. Biological or synthetic mesh is used for rectus defects.
Legends-
TDAP flap- thoracodorsal artery perforator flap
VRAM flap- Vertical rectus abdominis muscle falp
LD- latissimus dorsi flap
Abdominal wall
defects
Adequate skin
Synthetic/ Biological
mesh + Primary closure
+/- component
seperation
Inadequate skin1
Upper 1/2
Pedicled VRAM ,Extended LD flap,
Paraumbilical perforator flap,
Free flap
Lower 1/2
Pedicled Anterolateral thigh
flap, VRAM, Tensor fascia lata
flap, Paraumbilical perforator
flap, Free flap
Total
Free flap

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References
1. Houston GC, Drew GS, Vazquez B, Given KS. The extended latissimus dorsi flap in repair of anterior abdominal wall defects.
PlastReconstr Surg. 1988 Jun;81(6):917-24. doi: 10.1097/00006534-198806000-00015. PMID: 2967516.
2. Tamai M, Nagasao T, Miki T, Hamamoto Y, Kogure T, Tanaka Y. Rotation arc of pedicled anterolateral thigh flap for abdominal
wall reconstruction: How far can it reach? J PlastReconstrAesthet Surg. 2015 Oct;68(10):1417-24. doi:
10.1016/j.bjps.2015.06.010. Epub 2015 Jun 25. PMID: 26188402.
3. Contedini F, Negosanti L, Pinto V, Tavaniello B, Fabbri E, Sgarzani R, Tassone D, Cipriani R. Tensor fascia latae perforator flap:
An alternative reconstructive choice for anterolateral thigh flap when no sizable skin perforator is available. Indian J Plast Surg.
2013 Jan;46(1):55-8. doi: 10.4103/0970-0358.113707. PMID: 23960306; PMCID: PMC3745122.
4. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plastic and
Reconstructive Surgery. 1999 Apr;103(4):1191-1197. DOI: 10.1097/00006534-199904040-00014. PMID: 1008850

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Inguinal region
Thigh
Primary closure
Pedicled ALT
Pedicled perforator flaps
Pedicled rectus abdominis flap
Free flaps
Other locoregional flaps
Knee
Fasciocutaneous local flaps
Gastrocnemius flap
Free flaps
Standard sural flap
Others locoregional flaps
Pedicled
Leg
Fasciocutaneous local flaps
Gastrocnemius flap/ soleus flap
Reversed sural artery flap
Free flaps
Others locoregional flap
Soft tissue Defects 1
Exposed Bone
Exposed joints
Exposed Neurovascular bundles
Exposed tendons
Weight bearing areas
Possibility of Radiotherapy
NO
YES
Primary
closure
Local flaps
SSG
Foot2
Reversed sural artery flap
Medial plantar artery flap
Peroneus brevis muscle flap
Free flaps
Other local flaps
LOWER LIMB RECONSTRUCTION
ALGORITHM

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• If long segmental loss of nerve or muscle compartment resection resulting in loss of function then tendon transfer, nerve transfer or
functional muscle transfer can be considered
• STSG can be considered in instep area. Flap should be first choice in weight bearing areas
• Non vascularized bone graft may be used in defects < 6 cms in which bed vascularity is good. To be avoided if wound bed is
infected/radiated or likely to receive radiation
Bone defects
Long bone
FFOCF
FFOCF + Allograft( Capana)
Tibialization of fibula
Nail cement spacer
Prosthesis
Cryo/irradiated bone graft
Nonvascularised bone
graft3
Foot
Ank;le Mortis
Arthrodesis
1st, 2nd and 5th
metatarsal
FFOCF
3rd and 4th
metatarsal
Amputation
Involving articular
surface
Epiphyseal
transfer( Pediatric
age group)
Prosthesis
Bone defects

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Mandible
reconstruction
Type I and II
(Bone defect with or without buccal
mucosa)
Central /
Arch defect
Free fibula flap 1
Lateral
Defect (Part
of ramus or
condyle
preserved)
Free fibula flap 1
Soft tissue
flap/PMMC flap
Posterior defects
(entire ramus with
condyle
removed)/Hemima
ndibulectomy
defect
Free fibula flap/
Soft tissue free
flap
PMMC flap
Type III
(compound –
three tissue layers)
Central / Arch
defect
Free fibula
osteo-
cutaneous flap1
Free fibula
osteo-
cutaneous flap
+ soft tissue
free flap2
Free fibula
osteo-
cutaneous flap
+ regional flap
Lateral
Defect (Part of
ramus or
condyle
preserved)
Free fibula flap
1/ Soft tissue
free flap
PMMC flap+- DP
flap
Posterior defects (entire
ramus with condyle
removed)/Hemimandibulec
tomy defect
Soft tissue free
flap
Free fibula
osteo-
cutaneous flap1
Free fibula
osteo-
cutaneous flap
+ soft tissue
free flap2
PMMC flap+- DP
flap
Mandible
reconstruction

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1. Free fibula osteocuteneous flap is first and preferred choice for bone reconstruction.Although depending upon surgeon’s preference, donor site
availability and defect, other bone flaps can also be an option such as
A) Free scapular parascapular flap
B) DCIA flap
2. If skin defect requirement is huge and one flap is not enough to provide the skin paddle, different combinations are possible such as two free flaps, or one
free flap and one regional flap. In salvage situations plate with free flap or regional flaps is also an option.
3. Legends-
A) PMMC- Pectoralis major myocutaneous flap
B) DP flap- deltopectoral flap
References:
1. Takushima, A., Harii, K., Asato, H., Momosawa, A., Okazaki, M., & Nakatsuka, T. (2005). Choice of osseous and osteocutaneous flaps for mandibular
reconstruction. International Journal of Clinical Oncology, 10(4), 234–242.
2. Lavertu P, Wanamaker JR, Bold EL, Yetman RJ. The AO system for primary mandibular reconstruction. Am J Surg 1994; 168:503.
3. Kademani, D., Mardini, S., & Moran, S. (2008). Reconstruction of Head and Neck Defects: A Systematic Approach to Treatment. Seminars in Plastic
Surgery, 22(03), 141–155.
4. Sharma, Shobhit, &SudiptaBera. "Oromandibular reconstruction with free fibula osteocutaneous flap after oncologic resection: retrospective analysis
of surgical experience and operative outcome of 56 cases." International Surgery Journal [Online], 6.10 (2019): 3674-3680
5. Goh, B. T., Lee, S., Tideman, H., &Stoelinga, P. J. W. (2008). Mandibular reconstruction in adults: a review. International Journal of Oral and
Maxillofacial Surgery, 37(7), 597–605.
6. Wei FC, Celik N, Chen HC, Cheng MH, Huang WC. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in
reconstruction of extensive composite mandibular defects. PlastReconstr Surg. 2002 Jan;109(1):45-52.
7. Chung JH, Kim DS, Yoon ES. Reconstruction of Extensive Oromandibular Defect With Simultaneous Dual Free Flap Transfer. J Craniofac Surg. 2022 May
1;33(3):867-869.
8. Gibber MJ, Clain JB, Jacobson AS, et al. Subscapular system of flaps: an 8-year experience with 105 patients. Head Neck 2015;37:1200-6.
9. Bansal AP, Buchakjian MR. Subscapular system free flaps for oromandibular reconstruction. PlastAesthet Res 2021;8:59.
10. Boyd JB, Mulholland RS, Davidson J, Gullane PJ, Rotstein LE, Brown DH, Freeman JE, Irish JC. The free flap and plate in oromandibular reconstruction:
long-term review and indications. PlastReconstr Surg. 1995 May;95(6):1018-28.
11. Yadav, Prabha& Ahmad, Quazi&Shankhdhar, Vinay Kant &Nambi, G.I.. (2012). Reconstruction of oncological oro-mandibular defects with double skin
paddled-free fibula flap: A prudent alternative to double flaps in resource-constrained centres. Journal of cancer research and therapeutics. 8. 91-5.
10.4103/0973-1482.95181.

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Revised James Brown classification-
Classification of vertical and horizontal maxillectomy and midface defect
Vertical classification: I—maxillectomy not causing an oronasal fistula; II—not involving the orbit; III—involving the orbital adnexae with
orbital retention; IV—with orbital enucleation or exenteration; V—orbitomaxillary defect; VI—nasomaxillary defect. Horizontal classification:
a—palatal defect only, not involving the dental alveolus; b—less than or equal to 1/2 unilateral; c—less than or equal to 1/2 bilateral or
transverse anterior; d—greater than 1/2 maxillectomy. Letters refer to the increasing complexity of the dentoalveolar and palatal defect,
and qualify the vertical dimension.
Reference- Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol. 2010
Oct;11(10):1001-8. doi: 10.1016/S1470-2045(10)70113-3. PMID: 20932492

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Maxilla (Midface) Reconstruction
(Modified James brown classification)
Type I
Maxillectomy not
causing oronasal
fistula
FFOCF1
Thin pliable
soft tissue flap
Local flap2(For
very limited
defects)
Type II
Orbital plate preserving
maxillectomy
FFOCF1,3
Thick soft tissue
free flap
Palatal
obturator
Forehead flap
Temporalis flap
Type III
Total maxillectomy
with orbital retention
FFOCF
Thick Soft tissue free
flap + orbital floor
reconstruction4
Other bone flaps5
Double free flap(
Bone +soft tissue)
Forehead flap
Temporalis flap
Prosthesis
Type IV
Total maxillectomy with
orbital enucleation or
exenteration
Thick soft tissue free
flap
Temporalis muscle
Forehead flap
Type V
Orbitomaxillary defect
not involving
alveolus/palate
Soft tissue free
flap
Temporalis
Muscle flap
Type VI
Nasomaxillary
defect not
involving
alveolus/palate
Treat as total
nasal
reconstruction
(Preferred
choice FRAFF)
Maxilla (Midface)
Reconstruction

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1. When defect is crossing midline, FFOCF is preferred over soft tissue flaps
2. If defect is posterior to canine, soft tissue flap is preferred
3. Local flap options – Nasolabial, palatal flap, temporalis flap
4. Other bone flaps can also be considered depending on surgeon preference- eg DCIA flap, Scapular flap
5. Options for orbital floor reconstruction- Non vascularized bone graft (Autograft), Titanium mesh etc
Legends-
1. FFOCF- free fibula osteocutaneous flap
2. FRAFF- free radial artery forearm flap

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Pharyngeal
Defects
lower extent of
disease above
clavicle
Partial defects
Residual Mucosa >
3.5 cm
Primary Closure
Residual Mucosa <
3.5 cm
FRAFF/FALT
PMMC
Supraclavicular
falp
Circumferential
defects
FALT
JEJUNUM
Tube PMMC flap
lower extent of
disease below
clavicle*
Gastric pull
up/Colonic
Transposition
Pharyngeal
Defects

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Page 19 of 26
References:
1. Yabe, T. , Ashford, B. . Reconstruction of Pharyngeal Defects. In: Sun, H. (. , editor. Surgical Management of Head and Neck Pathologies [Internet].
London: IntechOpen; 2020 [cited 2022 Nov 11]. Available from: https://www.intechopen.com/chapters/73654 doi: 10.5772/intechopen.94191
2. Yu, P., Hanasono, M.M., Skoracki, R.J., Baumann, D.P., Lewin, J.S., Weber, R.S. and Robb, G.L. (2010), Pharyngoesophageal reconstruction with the
anterolateral thigh flap after total laryngopharyngectomy. Cancer, 116: 1718-1724.
3. Denewer, A., Khater, A., Hafez, M.T. et al.Pharyngoesophageal reconstruction after resection of hypopharyngeal carcinoma: a new algorithm after
analysis of 142 cases. World J SurgOnc12, 182 (2014).
4. Balasubramanian D, Subramaniam N, Rathod P, Murthy S, Sharma M, Mathew J, et al. Outcomes following pharyngeal reconstruction in total
laryngectomy – institutional experience and review of the literature. Indian J PlastSurg 2018;51:190-5.
5. Raghbir M, Brown JS, Mehanna H. Reconstructive considerations in head and neck surgical oncology: United Kingdom national multidisciplinary
guidelines. The Journal of Laryngology & Otology (2016), 130 (Suppl. S2), S191–S197.
Legends-
FALT- Free anterolateral thigh flap
PMMC- Pectoralis Major myocutaneous flap

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Classification:
Yano T, Okazaki M, Tanaka K, Iida H, Aoyagi M, Tsunoda A, Kishimoto S. A new concept for classifying skull base defects for reconstructive
surgery. J NeurolSurg B Skull Base. 2012 Apr;73(2):125-31. doi: 10.1055/s-0032-1301402. PMID: 23543797; PMCID: PMC3424621

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1. Defects involving orbital contents or skin involvement, free flap is the preferred reconstructive choice
Skull base defects
Anterior/ Central
defects
Localized (Ia,IIa)
Paramedian
forehead flap
Pericranial flap
Inferior turbinate/
Nasoseptal flap
Non vascular grafts2
Vertically extending
to sinonasal cavity
(Ic)/ vertically
extending to
maxillary sinus or
epipharynx1 (IIc)
Paramedian
forehead flap
Pericranial flap
Inferior turbinate/
Nasoseptal flap
Non vascular grafts2
Horizontally
extending to orbital
roof (Ib)/
Horizontally
extending to
pterygoid muscle or
mandible (IIb)
Free flaps to fill
cavity
Lateral/ Posterior
defects
Around parotid
region
Free flap
PMMC flap
Submental flap
With ITF clearance
Free flap
Skull base Defects

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2. Non vascularized grafts should be avoided if post operative radiation is anticipated

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Tongue Defects
Superficial / < 30
% loss
Leave Raw STSG Primary closure
30-50 % loss
Thin pliable Free
Flap
Submental flap
Infrahyoid flap
FAMM flap
PMMF
>50 % loss
Thick Free Flap PMMC
Tongue Defects

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Page 24 of 26
References:
1. Vincent, Aurora et al. “Free-Flap Reconstruction of the Tongue.” Seminars in plastic surgery vol. 33,1 (2019): 38-45. doi:10.1055/s-0039-
1677789
2. 2. Hsiao, H. T., Leu, Y. S., & Lin, C. C. (2003). Tongue reconstruction with free radial forearm flap after hemiglossectomy: a functional
assessment. Journal of reconstructive microsurgery, 19(3), 137–142. https://doi.org/10.1055/s-2003-39824
3. Chang, E.I., Yu, P., Skoracki, R.J. et al. Comprehensive Analysis of Functional Outcomes and Survival After Microvascular Reconstruction
of Glossectomy Defects. Ann SurgOncol 22, 3061–3069 (2015). https://doi.org/10.1245/s10434-015-4386-6
4. Gangiti, K. K., Gondi, J. T., Nemade, H., Sampathirao, L. M., Raju, K. V., & Rao, T. S. (2016). Modified pectoralis major myocutaneous flap
for the total glossectomy defects: Effect on quality of life. Journal of surgical oncology, 114(1), 32–35. https://doi.org/10.1002/jso.24260
5. Daar DA, Abdou SA, Cohen JM, Wilson SC, Levine JP. Is the Medial Sural Artery Perforator Flap a New Workhorse Flap? A Systematic
Review and Meta-Analysis. PlastReconstr Surg. 2019;143(2):393e-403e. doi:10.1097/PRS.0000000000005204
Legends
STSG- Split thickness skin graft
FAMM- Facial artery myomucosal flap
PMMF- pectoralis major muscle flap
PMMC- pectoralis major myocutaneous flap

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UPPER LIMB RECONSTRUCTION
ALGORITHM
Axilla/Shoulder
Arm
Primary closure
Pedicled LD
Free flaps
Others
Pedicled
Elbow
Pedicled Radial artery flap/Ulnar artery
Reverse pedicled Ulnar/Radial
collateral flap
Free flap
Perforator flap
Forearm
Pedicled Radial artery flap/Ulnar
artery7
perforator flaps
Free flaps
Pedicled groin flaps
Abdominal flaps
Pe
Exposed Bone
Exposed joints
Exposed Neurovascular
bundles
Exposed tendons
Weight bearing areas
Possibility of Radiotherapy
Primary
closure
Local flaps
SSG
Digits,Hand
&Wrist
Reverse Radial artery flap/Ulnar
artery/posterior interosseous
Pedicled groin flaps
Abdominal flap-pedicled/staged
Free flaps
Pedicled
Soft tissue Defects1
NO
YES

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Page 26 of 26
-
If long segmental loss of nerve or muscle compartment resection resulting in loss of function then tendon transfer, nerve transfer or functional
muscle transfer can be considered
Non-vascularized bone graft may be used in defects < 6 cms in which bed vascularity is good. To be avoided if wound bed is infected/radiated or
likely to receive radiation
Bone defects
Long bone
FFOCF
Nail cement
spacer
Prosthesis
Cryo/irradiated
bone graft
Nonvascularised
bone graft2
Hand
Carpal bones
Arthrodesis in 30°
extension
Fingers
Options include
Pollicisation, Toe
transfers
Involving articular
surface
Epiphyseal
transfer( Pediatric
age group)
Prosthesis

NCG Plastic-reconstructive-surgery-guidelines 2.pdf

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NCG Plastic-reconstructive-surgery-guidelines 2.pdf