CHIMERIC GROIN FREE FLAPS: DESIGNAND CLINICAL APPLICATION

WAI-NANG CHAO, M.D.,1,2,3 PO-HUI WANG, M.D., Ph.D.,1 BING-REN CHEN, M.D.,4 and SHIUAN-CHIH CHEN, M.D., Ph.D.1,5*

Background: Reconstruction of composite extremity defects or through-and-through oral defects remains challenging for surgeons. Chi-meric flaps are ideal for repairing these lesions. In this article, we report the design of various chimeric groin free flaps for the reconstruc-tion of both complex oral and extremity defects in 18 patients. Methods: Between 2010 and 2014, 18 patients with composite tissuedefect or two defects in the extremities or head and neck region, underwent reconstruction with cutaneous–cutaneous, musculo-cutaneous, or osteo-cutaneous chimeric groin free flaps. The size and pedicles length of the chimeric groin flaps based on the superficialcircumflex iliac artery (SCIA) were tailored to the lesions. Patient-reported post-operative outcomes at the out-patient department wereevaluated. Results: The types of chimeric groin free flaps included cutaneous–cutaneous (n 5 12), musculo-cutaneous (n 5 1), andosteo-cutaneous (n 5 5) flaps. Three to four SCIA branches (mean: 3.33) could be used for flap design. The cutaneous flap size rangedfrom 1.5 cm 3 6 cm to 11 cm 3 30 cm, and the bone flap size ranged from 1 cm 3 1.5 cm to 2.5 cm 3 6 cm. All flaps survived, and nosignificant complications developed at recipient or donor sites. Functional recovery after reconstruction was satisfactory in most patientsafter a mean of 17.27 months (ranging 2–42 months) of follow-up. Conclusion: The innovative flap technique presented herein hasadvantages including greater reliability, as well as the ability to tailor the dimensions and flap paddles to specific lesions and reconstructtwo defects or one composite defect using only one (chimeric) flap. VC 2015 Wiley Periodicals, Inc. Microsurgery 36:206–215, 2016.

A groin flap, which can be used as either a pedicle or a

free flap, is an effective option for reconstruction of the

extremities,1–6 and the head and neck region.7–9 It can

also be used as a lymph node flap for the treatment of

lymphedema.10 The advantages of this type of flap

include good pliability, relatively hairless skin, and an

inconspicuous donor site. The reconstruction of multiple

or complex defects in the head and neck region, and the

extremities after trauma, remains challenging to surgeons.

Although double flap or combined flap transfers may be

options in such cases, both require significant effort,

operative time, and surgical skill.11–13 In contrast, chi-

meric groin flap is often an excellent choice for one-

stage reconstruction for these complicated defects,

although it has rarely been reported.

Here, we present a novel chimeric groin free flap

design as well as our experience of its application in the

reconstruction of multiple or complex defects in the head

and neck region and extremities.

PATIENTS AND METHODS

This retrospective study was approved by the institu-

tional review board of our hospital. From February 2010

to April 2014, 18 patients underwent reconstruction of

either the extremities (n 5 13) or head and neck region

(n 5 5) using chimeric groin free flaps based on the

superficial circumflex iliac artery (SCIA). There were 17

were men and 1 woman, mean age was 47 years (range

from 20 to 80 years). Furthermore, 13 patients had

lesions (two defects: n 5 7, composite defect: n 5 5,

degloving lesion: n 5 1) in the extremities due to trauma,

while 5 had composite defects in the head and neck

region following carcinoma excision. Patient-reported

outcomes were evaluated after reconstruction. We used

the Outcomes of Plastic Surgery Hand/arm Questionnaire

(including symptoms, limitation of daily activities, func-

tional and cosmetic appearance, and patient satisfaction)

to assess the outcomes of upper extremity surgery, and

the Face-Questionnaire (including satisfaction with

appearance and process of care, quality of life, and nega-

tive sequelae) to evaluate the outcomes of head and neck

reconstruction.

Operative Technique

On the basis of the anatomy of the groin region

and the theory of axial flap design, different types of

chimeric groin flaps, including cutaneous–cutaneous,

musculo-cutaneous, and osteo-cutaneous, were designed

and harvested for reconstruction (Fig. 1). The patient was

placed in the supine position under general or local anes-

thesia. Before flap harvesting, the recipient vessels were

prepared for vascular anastomosis, and the size of the

defect was evaluated. The course of the inguinal ligament

1Institute of Medicine & School of Medicine, Chung Shan Medical University,Taichung, Taiwan2Division of Plastic Surgery, Department of Surgery, Changhua ChristianHospital, Changhua, Taiwan3Chienkuo Technology University, Changhua, Taiwan4Division of Plastic Surgery, Department of Surgery, Liouying Chi-MeiHospital, Tainan, Taiwan5Department of Family and Community Medicine, Chung Shan MedicalUniversity Hospital, Taichung, Taiwan

*Correspondence to: Shiuan-Chih Chen, M.D., Ph.D., Faculty of Medicine,Institute of Medicine and School of Medicine, Chung Shan Medical Univer-sity, 110, Section 1, Jianguo N. Rd., Taichung 40201, Taiwan. E-mail:witson999@gmail.com

Received 2 September 2014; Revision accepted 10 May 2015; Accepted28 May 2015

Published online 3 July 2015 in Wiley Online Library(wileyonlinelibrary.com). DOI: 10.1002/micr.22442

� 2015 Wiley Periodicals, Inc.

was subsequently drawn from the anterior superior iliac

spine to the pubic tubercle. For chimeric flap design, we

identified the branches of the SCIA using a 3–5 cm inci-

sion �3 cm inferior to the middle portion of the inguinal

ligament (Fig. 2). Typically, three to four branches from

the SCIA were found during supra-fascia dissection. In

our series, vascular branches with visible pulsation from

the SCIA were deemed suitable for chimeric flap design.

The dimensions of the chimeric flaps were then designed

along the direction of vascular pedicles, according to

each patient’s lesions (Fig. 3). A small, soft tissue cuff

could be included with the vascular pedicle for protection

during both retrograde and antegrade flap dissection. We

harvested either a thicker flap by including the fascia and

muscle tissue, or a thinner flap by trimming the sur-

rounding fatty tissue from the vascular course. A pedicle

�1–2 cm wide was preserved to attach the flap for safe

blood supply during flap thinning procedure. An acoustic

Doppler probe was sometimes used to identify the vascu-

lar course. In addition, a longer vascular pedicle from a

chimeric groin flap could be tailored by antegrade and

retrograde dissection, as well as by designing the flap

more distally along the SCIA branch. Maintaining a

warm environment during flap harvest and transfer was

essential; one such method used was irrigation with

warm 0.2% xylocaine solution, followed by packing with

warm, moist gauze to prevent vascular spasm. To meet

the goal of primary donor wound closure, three cutane-

ous flap directions including the superior, lateral, and

inferior to the SCIA course, were used for chimeric or

triple chimeric flap design (Figs. 3 and 4). In addition to

chimeric type, three-paddle and even four-paddle groin

flaps could be designed and harvested for the reconstruc-

tion of complex wounds (Fig. 5). After flap transfer and

vascular anastomosis, donor wounds could be directly

closed if they were <11 cm wide.

RESULTS

The clinical data from our study are shown in Table

1. Two to three flap paddles were used in this case

series, including cutaneous–cutaneous (n 5 12), musculo-

cutaneous (n 5 1), osteo-cutaneous (n 5 4), and osteo-

cutaneous-cutaneous (n 5 1) flaps. The number of SCIA

Figure 1. Schematic drawing showing the anatomy of the groin region and the types of chimeric groin flaps. A: Anatomy of the groin. AL,adductor longus muscle; ASIS, anterior superior iliac spine; C-C, cutaneous–cutaneous; FA, femoral artery; FV, femoral vein; G, gracilismuscle; IL, inguinal ligament; M-C, musculo-cutaneous; O-C, osteo-cutaneous; PT, pubic tubercle; RF, rectus femoris muscle; S, Sartoriusmuscle; SCIa, superficial circumflex iliac artery; SEa, superficial epigastric artery; TFL, tensor fasciae latae muscle; VL, vastus lateralismuscle. B: The types of chimeric groin flaps.

Chimeric Groin Free Flaps 207

Microsurgery DOI 10.1002/micr

Figure 2. The location of the initial incision for vascular exploration. A: Schematic drawing shows how to design the initial incision. ASIS,

anterior superior iliac spine; PT, pubic tubercle. B: The initial incision during flap harvest.

Figure 3. Schematic drawing and picture both shows how to design an axial chimeric or triple-paddle groin flap along the vascularbranches of the SCIA. The dimensions of flaps could be tailored (designed) according to lesions. The pedicle of flaps could also be tai-lored by antegrade and retrograde dissection or designing the flap more distally along the SCIA branch. A: Vascular exploration and flapdesign. B: Chimeric flap was designed along the direction of vascular branches. FA, femoral artery; FV, femoral vein.

208 Chao et al.

Microsurgery DOI 10.1002/micr

branches used in the axial flap design with a mean of

3.33 (ranged from 3 to 4). Among these chimeric flaps,

the cutaneous components ranged from 1.5 cm 3 6 cm

to 11 cm 3 30 cm and the bone components ranged

from 1 cm 3 1.5 cm to 2.5 cm 3 6 cm. All chimeric

groin free flaps survived postoperatively. There were no

significant complications at recipient or donor sites,

except for three flaps with mild bulkiness, which were

treated with de-bulking. Mean follow-up was 17.27

months (ranged from 2 to 42 months). Regarding the out-

comes at the end of follow-up, 94% and 78% satisfied

function and appearance, respectively.

CASE REPORTS

Case 1

A 66-year-old man suffering from oral cancer with

mandible invasion had undergone wide excision of the

anterior mouth floor, segmental mandible bone, and left

lower lip resulting in a 4.5 cm 3 7.5 cm and 3 cm 3

5 cm through and through composite defect (Fig. 6A).

After reconstructive plate fixation, we harvested a 5 cm

3 8 cm by 3.5 cm 3 5 cm cutaneous–cutaneous chi-

meric groin flap for lower lip and mouth floor reconstruc-

tion (Fig. 6B). The pedicle was anastomosed to the right

facial artery and vein. The flap survived well postopera-

tively, with no significant complications at donor site and

recipient site (e.g., oral trismus and drooling) at 22

months of follow-up (Figs. 6E and 6F). The patient was

satisfied with his oral function and appearance.

Figure 4. Schematic drawing and pictures shows the ability to directly close a donor wound after chimeric or triple-paddle groin flap har-

vest. A: The hollow yellow arrows showed the directions of wound tension. B: Chimeric flap was dissection. C: Primarily wound closure at

donor site.

Figure 5. The four-paddle groin flap, based on four vascular

branches of the SCIA, harvested for reconstruction.

Chimeric Groin Free Flaps 209

Microsurgery DOI 10.1002/micr

Tab

le1.

Patients

’D

em

ogra

phic

Data

Case

Sex/A

ge

(years

)C

ause/L

esio

n(w

ound

type)

Fla

p

type

Fla

psiz

e

(cm

)

Bra

nches

of

SC

IA

Recip

ient

vesse

ls

Fla

p

surv

ival

Com

plic

atio

n

Secondary

pro

cedure

Follo

w-u

p

(month

s)

Outc

om

es

1M

/31

Tra

um

a/H

and

(Tw

odefe

cts

)C

-CC

1:

2.5

36

4D

MC

a/v

Yes

No

No

42

Funct

ion:

Satisfied

C2:

23

6A

ppeara

nce:

Satisfied

2M

/57

Oncolo

gic

/Ora

l(C

om

posi

te)

O-C

O:

23

63

STa/v

Yes

No

No

40

Funct

ion:

Satisfied

C:

93

13

Appeara

nce:

Satisfied

3M

/55

Oncolo

gic

/Ora

l(C

om

posi

te)

C-C

C1:

73

10

3S

Ta/v

Yes

No

No

36

Funct

ion:

Satisfied

C2:

43

5A

ppeara

nce:

Acce

pta

ble

4M

/70

Oncolo

gic

/Ora

l(C

om

posi

te)

C-C

C1:

3.5

35

3F

a/v

Yes

No

No

32

Funct

ion:

Satisfied

C2:

33

5A

ppeara

nce:

Satisfied

5M

/20

Tra

um

a/H

and

(Tw

odefe

cts

)C

-CC

1:

23

93

Ra/v

Yes

No

No

2F

unct

ion:

Satisfied

C2:

23

8A

ppeara

nce:

Satisfied

6M

/46

Oncolo

gic

/Ora

l(C

om

posi

te)

C-C

C1:

63

74

STa/v

Yes

No

No

28

Funct

ion:

Satisfied

C2:

63

8A

ppeara

nce:

Satisfied

7M

/66

Oncolo

gic

/Ora

l(C

om

posi

te)

C-C

C1:

53

83

Fa/v

Yes

No

No

22

Funct

ion:

Satisfied

C2:

3.5

35

Appeara

nce:

Satisfied

8M

/26

Tra

um

a/T

hum

b(C

om

posi

te)

O-C

O:

13

1.5

4D

a/D

Dv

Yes

No

No

16

Funct

ion:

Satisfied

C:

23

4.5

Appeara

nce:

Satisfied

9M

/80

Tra

um

a/L

eg

(Com

posite)

M-C

M:

43

83

ATa/v

Yes

No

No

15

Funct

ion:

Satisfied

C:

11

330

Appeara

nce:

Satisfied

10

M/4

6Tra

um

a/F

ingers

(Tw

odefe

cts

)C

-CC

1:

23

73

Da

/DD

vYes

No

No

14

Funct

ion:

Satisfied

C2:

1.5

36

Appeara

nce:

Satisfied

11

M/3

1Tra

um

a/T

hum

b(C

om

posi

te)

O-C

O:

13

1.5

3D

a/D

Dv

Yes

No

Fla

pde-b

ulk

y14

Funct

ion:

Accepta

ble

C:

43

5A

ppeara

nce:

Acce

pta

ble

12

M/6

0Tra

um

a/W

rist

(Com

posi

te)

O-C

-CO

:2.5

36

3R

a/v

Yes

No

No

12

Appeara

nce:

Satisfied

C1:

10

318

Waitin

gfo

rto

eto

hand

transpla

nta

tion

C2:

83

10

13

M/6

6Tra

um

a/T

hum

b(C

om

posi

te)

O-C

O:

13

1.5

4D

a/D

Dv

Yes

No

No

11

Funct

ion:

Satisfied

C:

3.5

35

Appeara

nce:

Satisfied

14

M/6

3Tra

um

a/H

and

(Tw

odefe

cts

)C

-CC

1:

10

315

3R

a/v

Yes

No

No

8F

unct

ion:

Satisfied

C2:

53

7A

ppeara

nce:

Satisfied

15

M/2

2Tra

um

a/T

hum

b(D

eglo

vin

g)

C-C

C1:

33

54

Ra/v

Yes

No

Fla

pde-b

ulk

y5

Funct

ion:

Accepta

ble

C2:

33

8A

ppeara

nce:

Acce

pta

ble

16

M/3

0Tra

um

a/H

and

(Tw

odefe

cts

)C

-CC

1:

53

63

Ra/v

Yes

No

No

5F

unct

ion:

Satisfied

C2:

63

8A

ppeara

nce:

Satisfied

17

M/5

6Tra

um

a/H

and

(Tw

odefe

cts

)C

-CC

1:

11

316

3R

a/v

Yes

No

Fla

pde-b

ulk

y5

Funct

ion:

Satisfied

C2:

83

22

Appeara

nce:

Acce

pta

ble

18

F/2

3Tra

um

a/A

rm(T

wo

defe

cts

)C

-CC

1:

93

15

4R

Ca/v

Yes

No

No

4F

unct

ion:

Satisfied

C2:

83

17

Appeara

nce:

Satisfied

Mean

Age:

47.1

3.3

317.2

7

Ata

/v,

ante

rior

tibia

lart

ery

/vein

;B

r.of

PTa,

bra

nch

of

poste

rior

tibia

art

ery

;C,

cuta

neous;

Da

/DD

v,dig

ital

art

ery

/dors

al

dig

ital

vein

;D

MC

a/v

,dors

al

meta

carp

al

art

ery

/vein

;D

Pa/v

,dors

alis

pedis

art

ery

/vein

;F

a/v

,fa

cia

lart

ery

/vein

;C

-C.

Cuta

neous-C

uta

neous;

M-C

,m

usculo

-cuta

neou

s;

O-C

,oste

o-c

uta

neous;

Ra/v

,ra

dia

lart

ery

/vein

;R

Ca/v

,ra

dia

lre

curr

ent

art

ery

/ve

in;

SC

IA,

superfi

cia

lcircum

flex

iliac

art

ery

;S

Ta/v

,superi

or

thyro

idart

ery

/vein

.

210 Chao et al.

Microsurgery DOI 10.1002/micr

Case 2

A 22-year-old man was the victim of machine crush-

ing accident, resulting in a circumferential degloving

injury of the left thumb with 6 cm 3 7 cm skin and sub-

cutaneous defect (Fig. 7A). A wrap-around, toe-to-thumb

reconstructive procedure was initially suggested; how-

ever, the patient was unwilling to sacrifice any of his

toes. After discussion with the patient and his family, we

harvested a 3 cm 3 5 cm by 3 cm 3 8 cm cutaneous–

cutaneous chimeric groin free flap for reconstruction of

the left thumb (Fig. 7B). The distal flap paddle was used

for volar thumb reconstruction, while the other was used

for dorsal thumb repair. In order to prevent a gliding

“pulp,” a portion of dermal and subcutaneous tissue of

the flap was sutured to the distal phalangeal bone and

periosteum (Figs. 7C and 7D). Using an incisional subcu-

taneous tunnel, the common vascular pedicle of the flap

was anastomosed to the radial artery and vein at the ana-

tomical snuffbox. The chimeric flap survived unevent-

fully, and the patient returned to work 2 months

postoperatively. After 16 months of follow-up, he was

satisfied with the function and appearance of his new

Figure 6. Case 1: A: After wide excision of the malignant tumor, oral defects involving the anterior mouth floor, segmental mandible bone,

and left lower lip were observed. B: A cutaneous–cutaneous type of chimeric groin flap was harvested. C: Chimeric groin flap inset with

one cutaneous paddle for inner oral reconstruction and another for lower lip repair. D–F: Appearance of the donor site and recipient site

at 22-month examination.

Chimeric Groin Free Flaps 211

Microsurgery DOI 10.1002/micr

thumb, although it appeared slightly bulky (Figs. 7E and

7F).

Case 3

A 56-year-old male experienced a severe machine

crushing injury, resulting in near total destruction of his

right hand, with the exception of his index, middle, and

ring fingers (Figs. 8A and 8B). We implanted these three

fingers to the right anterolateral thigh after aggressive

debridement because of concerns about wound contami-

nation and an unclear injury zone at the stump (Fig. 8C).

Three digital arteries and veins each, isolated from the

amputated fingers, were subsequently anastomosed to

the branches of the lateral circumflex femoral vessels in

the operation. At the third postoperative week, the flap

delay procedure was performed to enhance blood supply

from the inferior branch of the SCIA (Fig. 8D). A cuta-

neous–cutaneous chimeric groin flap (11 cm 3 16 cm by

8 cm 3 22 cm) with skin connections to the anterolateral

thigh flap including the replanted fingers was harvested

for hand reconstruction at the fourth week (Fig. 8E). In

addition, the toe-to-thumb surgical procedure was per-

formed at the seventh week (Fig. 8F). After rehabilitation

and minor flap revision, the patient could do most of

daily works with his hands, and was satisfied with the

appearance and function of his reconstructed hand at 5

months of follow-up (Figs. 9A and 9B). No significant

Figure 7. Case 2: A: Preoperative view of a degloving injury to the left thumb. B: A chimeric cutaneous free flap with 10-cm pedicle was

harvested. C: Partial dermis and subcutaneous tissue of flap were sutured to the distal phalangeal bone and periosteum to prevent a glid-

ing “pulp.” D: After flap inset and vascular anastomosis, the flap showed good circulation. E, F: The appearance and function of the new

thumb at 2-month follow-up.

212 Chao et al.

Microsurgery DOI 10.1002/micr

complications were found at donor sites including groin,

thigh, and foot.

DISCUSSION

The groin flap has played a major role in the history

of flap surgery: it was the first free cutaneous flap, which

was reported by Daniel and Taylor in 1973.14 There are

several reasons for its past popularity, including its capa-

bility of being used for both pedicle and free type recon-

struction, good pliability, ability to conceal the donor site

scar, and large skin surface area. However, it is less pop-

ular today because of its noted shortcomings, including

arterial anatomical variation, bulkiness, and short pedicle.

When determining how best to enhance the clinical

applications of the groin flap, it is important to promote

its advantages while simultaneously improving upon its

faults, necessitating innovation.

To overcome the bulkiness and short pedicle of the

groin flap, Kimura advocated a free, microdissected, thin

groin flap design with an extended vascular pedicle.15

Similarly, we introduced the SCIA perforator flap to

address the aforementioned shortcomings.16 In this report,

the thickness and pedicle length of the chimeric groin

Figure 8. Case 3: A, B: A severe machine crushing injury, resulting in near total damage of right hand. C: The index, middle, and ring fin-

gers were implanted to the right anterolateral thigh. D: At the third week after surgery, the flap delay procedure was performed for

enhancement of blood supply from the inferior branch of SCIA. E: A very large chimeric groin flap with skin connection to the anterolateral

thigh flap—including the replanted fingers—was harvested for hand reconstruction in the fourth week. F: The toe-to-thumb surgical proce-

dure was performed.

Chimeric Groin Free Flaps 213

Microsurgery DOI 10.1002/micr

flap was adjusted according to each patient’s lesions. We

were able to either harvest a thicker flap by including the

fascia and muscle tissue, or a thinner flap by trimming

the surrounding fatty tissue from the vascular course. In

addition, a longer vascular pedicle of the chimeric groin

flap could be tailored by antegrade and retrograde dissec-

tion, as well as by designing the flap more distally along

the SCIA branch.

Hallock defines a chimeric flap as a flap having sepa-

rate components with separate vascular supplies that are

attached to a common vascular pedicle; its components

may comprise be either similar or different tissues, such as

skin, muscle, and bone.13,17 The main advantages of the

chimeric flap are the independent mobility of each separate

paddle and ability to perform one-stage reconstruction.

Different types of chimeric flap used in reconstructive sur-

gery have been reported, such as peroneal artery perforator

chimeric flap for the reconstruction of composite defects in

extremities,18 anterolateral thigh (ALT) chimeric flap for

head and neck as well as extremity reconstruction,19–21

and chimeric lateral supramalleolar artery perforator fibula

free flap for the reconstruction of composite head and neck

defects.22 Therefore, the chimeric flap is a good surgical

method for extensive, complex, and three-dimensional

defects.23

In the present series, we typically found three to four

branches arising from the SCIA. We were also able to

harvest different types of chimeric groin flaps including

cutaneous–cutaneous, musculo-cutaneous, and osteo-

cutaneous flaps depending upon the defects in question.

To ensure greater reliability of flap circulation, we

selected the two largest vascular branches with visible

pulsation for axial chimeric flap design. Moreover, we

were able to design the chimeric groin flap by including

more than two vascular branches. In addition to chimeric

type, three-paddle and even four-paddle groin flaps could

be designed for the reconstruction of complex wounds.

As at least one vascular branch maintained independent

blood supply in each paddle of the chimeric groin flap,

there were no cases of obviously insufficient circulation

in flaps or partial flap loss. Accordingly, an axial design

of the chimeric groin flap is the key to improving flap

circulation and reliability.

In the modern era of reconstructive surgery, it is vital

to determine how to minimize donor site morbidity. On

the basis of the good skin pliability and axial design of

the chimeric groin flap, donor wounds can be directly

closed after harvesting large flaps. In our series, each

donor wound could be primarily sutured; no skin grafts

were required, even in cases in which very large chi-

meric flaps were harvested.

It is also crucial to understand how to increase the

reliability of large groin chimeric flaps. We previously

demonstrated that a dominant perforator of the deep

branch arising from the SCIA is sufficient to nourish a

relatively large groin flap.16 Sinna et al. found that the

mean skin surface area that can be supplied by a single

dominant perforator arising from the deep branch of the

SCIA was 162 cm2 (maximum: of 375 cm2).24 Their

cadaveric findings are concordant with our clinical appli-

cations: we selected either the larger vascular branch or

multiple vascular branches together for a larger flap pad-

dle design, allowing us to ensure sufficient blood supply

to each flap component. Thus, a reliable large chimeric

flap can be harvested, and the donor wound can be pri-

marily closed if it is less than 11 cm wide.

Different types of flaps have various strengths and

weaknesses. Vascular variation is a major disadvantage

of groin flap application. However, our innovative chi-

meric groin flap design overcomes this problem, because

the branches arising from the SCIA can be exposed for

axial flap design. At least one vascular branche, inferior

Figure 9. After rehabilitation and minor flap revision, the patient was satisfied with the appearance and function of his reconstructed hand.

A: Appearance of hands. B: Gradual recovery of hand function during rehabilitation.

214 Chao et al.

Microsurgery DOI 10.1002/micr

to the course of the SCIA, is typically revealed as a supply

source for the upper anterolateral thigh. At present, the ana-

tomic characteristics of the SCIA can be considered an

advantage of the groin flap. Capitalizing on this advantage,

we successfully used a very large conjoined flap containing

both the groin and anterolateral thigh flaps in a complex

hand reconstruction in case 3.

The diameter of the SCIA is typically somewhat

smaller than that of the pedicles of other flaps, (e.g.,

anterolateral thigh and thoracodorsal flaps). Given the

limitations of the groin flap, it is essential to maintain a

warm environment and employing gentle dissection dur-

ing flap harvesting. Although the vascular pedicle of the

groin flap is not large, it can be anastomosed to recipient

vessels at the extremities, and head and neck region

without obvious lumen discrepancy or technical

problems.

CONCLUSIONS

The chimeric groin free flap offers many new advan-

tages including improved flap reliability by owing to its

axial design, more freedom and opportunity for precise

tailoring of the flap size and component tissue according

to individual lesions, and the ability to reconstruct two

defects or a composite defect with a single (chimeric)

flap in a single stage. Thus, this flap may be an option

for reconstructing simple or complex wounds in the

extremities or head and neck region.

REFERENCES

1. Hahn SB, Kim HK. Free groin flaps in microsurgical reconstructionof the extremity. J Reconstr Microsurg 1991;7:187–195.

2. Chuang DC, Colony LH, Chen HC, Wei FC. Groin flap design andversatility. Plast Reconstr Surg 1989;84:100–107.

3. Chuang DCC, Jeng SF, Chen HT, Chen HC, Wei FC. Experience of73 groin flaps. Br J Plast Surg 1992;45:81–85.

4. Hough M, Fenn C, Kay SP. The use of free groin flaps in children.Plast Reconstr Surg 2004;113:1161–1166.

5. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Urushibara K,Inagawa K, Hamasaki T, Moriguchi T. Superficial circumflex iliacartery perforator flap for reconstruction of limb defects. PlastReconstr Surg 2004;113:233–240.

6. Zhu Y-L, Wang Y, He X-Q, Zhu M, Li F-B, Xu Y-Q. Foot andankle reconstruction: An experience on the use of 14 different flapsin 226 cases. Microsurgery 2013;33:600–604.

7. Koshima I, Nanba Y, Tsutsui T, Itoh S. Sequential vascularized iliacbone graft and a superficial circumflex iliac artery perforator flapwith a single source vessel for established mandibular defects. PlastReconstr Surg 2004;113:101–106.

8. Matsumine H, Sakurai H, Nakajima Y, Kubo K, Higuchi R, NozakiM. Use of a bipedicled thin groin flap in reconstruction of postburnanterior neck contracture. Plast Reconstr Surg 2008;122:782–785.

9. Muresan C, Dorafshar AH, Rodriguez ED. A reappraisal of the freegroin flap in aesthetic craniofacial reconstruction. Ann Plast Surg2012;68:175–179.

10. Zhang H, Chen W, Mu L, Chen R, Luan J, Mu D, Liu C, Xin M.The distribution of lymph nodes and their nutrient vessels in thegroin region: An anatomic study for design of the lymph node flap.Microsurgery 2014;34:558–561.

11. Wei FC, Demirkan F, Chen HC, Chen IH. Double free flaps inreconstruction of extensive composite mandibular defects in headand neck cancer. Plast Reconstr Surg 1999;103:39–47.

12. Wei FC, Celik N, Chen HC, Cheng MH, Huang WC. Combinedanterolateral thigh flap and vascularized fibula osteoseptocutaneousflap in reconstruction of extensive composite mandibular defects.Plast Reconstr Surg 2002;109:45–52.

13. Hallock GG. The complete nomenclature for combined perforatorflaps. Plast Reconstr Surg 2011;127:1720–1729.

14. Daniel RK, Taylor GI. Distant transfer of an island flap bymicrovascular anastomoses. Plast Reconstr Surg 1973;52:111–117.

15. Kimura N, Saitoh M. Free microdissected thin groin flap designwith an extended vascular pedicle. Plast Reconstr Surg 2006;117:986–992.

16. Hsu WM, Chao WN, Yang C, Fang CL, Huang KF, Lin YS, LeeTH. Evolution of the free groin flap: The superficial circumflex iliacartery perforator flap. Plast Reconstr Surg 2007;119:1491–1498.

17. Hallock GG. Simultaneous transposition of anterior thigh muscleand fascia flaps: An introduction to the chimera flap principle. AnnPlast Surg 1991;27:126–131.

18. Chai YM, Wang CY, Zeng BF, Chen ZG, Cai PH, Kang QL, RuanHJ. Peroneal artery perforator chimeric flap for reconstruction ofcomposite defects in extremities. Microsurgery 2010;30:199–206.

19. Peng F, Chen L, Han D, Xiao C, Bao Q, Wang T. Reconstruction oftwo separate defects in the upper extremity using anterolateral thighchimeric flap. Microsurgery 2013;33:631–637.

20. Jiang C, Guo F, Li N, Huang P, Jian X, Munnee K. Tripaddledanterolateral thigh flap for simultaneous reconstruction of bilateralbuccal defects after buccal cancer ablation and severe oral submucousfibrosis release: A case report. Microsurgery 2013;33:667–671.

21. Canhua J, Feng G, Ning L, Wen L, Tong S, Xinqun C, Lian Z,Xinchun J. Multipaddled anterolateral thigh chimeric flap for re-construction of complex defects in head and neck. PLos One 2014;9:e106326.

22. Massarelli O, Gobbi R, Biglio A, Soma D, Tullio A. Chimericlateral supramalleolar artery perforator fibula free flap in thereconstruction of composite head and neck defects. Plast ReconstrSurg 2014;133:130–136.

23. Huang WC, Chen HC, Wei FC, Cheng MH, Schnur DP. Chimericflap in clinical use. Clin Plast Surg 2003;30:457–467.

24. Sinna R, Hajji H, Qassemyar Q, Perignon D, Benhain T, Havet E.Anatomical backgound of the perforator flap based on the deepbranch of the superficial circumflex iliac artery (SCIP Flap): Acadaveric study. Eplasty 2010;10:e11.

Chimeric Groin Free Flaps 215

Microsurgery DOI 10.1002/micr