Basic Sciences - Flaps

Question 1

Draw me a rhomboid flap?

Answer 1

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Question 2

Tell me about the square peg/round hole modification of the rhomboid flap?

Answer 2

Modification described by A Quaba & B Sommerlad (BJPS 1987)

• two main differences to classic rhomboid flap
  1. lesion is excised as required without conversion into a rhomboid (usually circular)
  2. flap is designed ~2/3 size of defect

Main advantages:

• tissue is not unnecessarily sacrificed to produce a rhomboid defect
• more flexibility in choosing a donor site i.e. unlimited choice rather than 4 standard options
• position of transposed flap is not predetermined and can be manipulated to distribute tension most evenly
• flap is made smaller than the defect which facilitates donor site closure allowing for use in larger defects and/or areas without differential skin laxity e.g. scalp, forehead, back
• also smaller size flap may reduce risk of pincushioning

Question 2

Describe the deltopectoral flap

Answer 2

Axial flap based on perforating vessels of the internal mammary artery
Can include a random pattern segment distally if delayed
Traditionally a workhorse flap in H&N

How to raise:
Based on first 2-3 perforators from IMA
Perforators emerge ~2cm from sternal edge
Superior border is line marked along inferior border of clavicle
Inferior line drawn parallel below 2nd/3rd interspace as required
(Keep above breast in female)
NB. Broader base will limit rotation
Flap tip usually just over anterior deltoid
Incise down through skin and pectoral fascia
Raise lateral to medial taking fascia with flap
Care to preserve cephalic vein as cross deltopectoral groove
Protect perforators as approach medial aspect of flap
Close primarily if possible - usually needs SSG
Bridge segment may be returned following division of flap