Breast Reconstruction: Autologous Flap Techniques

Question 1

Clinical exam remains the standard for postoperative flap
monitoring.

Answer 1

T

Question 2

using autologous tissue, one may obviate the postoperative risks of
morbidity associated with implants including infection, rupture,
capsular contracture, and malposition.

Answer 2

T

Question 3

autologous tissue is generally preferred in patients expecting to receive radiation or with a history of radiation therapy including radiation
previously delivered as part of breast conservation therapy (BCT)

Answer 3

T

Question 4

quality of life in patients undergoing autologous tissue reconstructions is maintained at a high level over time after the completion of
reconstruction

Answer 4

T

Question 5

The need for PMRT, an
absolute contraindication to immediate reconstruction,

Answer 5

F The need for PMRT, though not an
absolute contraindication to immediate reconstruction, tends to be
the predominant reason to consider delayed reconstruction

Question 6

Delayed
reconstruction is typically advocated for multiple reasons including

Answer 6

Avoidance of untoward effects of radiation on the results of an
immediate reconstruction and the potential for delaying oncologic
treatment because of complications from reconstruction

Question 7

A known history of hypercoagulable conditions would be a contraindication to performing a free tissue transfer with an increased risk for vessel thrombosis;

Answer 7

T pedicled flap options would be possible in this
context.

Question 8

Active smoking would be an absolute contraindication for performing any autologous flap procedure with increased risk for wound
dehiscence and delayed wound healing.

Answer 8

F Active smoking would be a relative contraindication for performing any autologous flap procedure with increased risk for wound
dehiscence and delayed wound healing.

Question 9

Patients are typically counseled to quit smoking for a minimum of 4 weeks before surgery and
often preoperatively evaluated with a urine cotinine test

Answer 9

T

Question 10

Patient preferences for postreconstruction breast size is also
important for operative planning

Answer 10

T

Question 11

The need for PMRT, though not an
absolute contraindication to immediate reconstruction, tends to be
the predominant reason to consider delayed reconstruction

Answer 11

T

Question 12

Imaging is absolutely needed in patients planned for autologous reconstraction

Answer 12

F imaging is not absolutely needed in patients without a surgical history that raises concerns about pedicle compromise

Question 13

The latissimus dorsi (LD) myocutaneous flap is a well-established pedicled flap option for breast reconstruction.

Answer 13

T

Question 14

Part of LD flap can be used ?

Answer 14

Within the latissimus the thoracodorsal branches into a
medial or transverse and a lateral or descending branch, which
allow for muscle-sparing procedures with use of part of the LD for
reconstruction

Question 15

The muscle harvested with the skin paddle provides sufficient volume for breast reconstruction

Answer 15

the muscle harvested with a skin paddle
typically does not provide sufficient volume for breast reconstruction

Question 16

The LD may also
be used in setting of salvage procedures to replace compromised
mastectomy skin flaps over implants or in cases of failed free-flap
breast reconstructions.

Answer 16

T

Question 17

TRAM Flap based on the superior epigastric artery

Answer 17

T

Question 18

Always requires mesh placement for closure of the donor site in TRAM flap

Answer 18

F often requires mesh placement
for closure of the donor site

Question 19

the deep inferior epigastric
artery system is the more dominant blood supply to the abdominal skin and fat

Answer 19

T

Question 20

a delay procedure, which is often performed 2
or 3 weeks before the pedicled TRAM procedure, when the ipsilateral deep inferior epigastric artery is ligated to facilitate the
recruitment of choke vessels with perfusion from the superior epigastric vessels

Answer 20

T

Question 21

Abdomen-based breast reconstruction is the mainstay of autologous
microvascular breast reconstruction

Answer 21

T

Question 22

The benefit of Abdomen-Based Flaps

Answer 22

reliable vascular anatomy,
extensive reported clinical experience,
reduced donor site morbidity with muscle-sparing/perforator flap options, a long pedicle with similar caliber to recipient vessels, and typically, the presence of sufficient soft tissue for reconstruction.

Question 23

The free TRAM,
free ms-TRAM, flaps are based on the deep inferior epigastric vessels

Answer 23

T

Question 24

The SIEA flap is based on the superficial inferior epigastric
vessels, which are branches from the external iliac vessels

Answer 24

F The SIEA flap is based on the superficial inferior epigastric
vessels, which are branches from the femoral vessels

Question 25

violation of the anterior rectus fascia is avoided with the SIEA flap

Answer 25

T

Question 26

violation of the anterior rectus fascia is avoided with this flap why?

Answer 26

the superficial inferior epigastric vessels, which are branches from the femoral vessels, run superficial to the abdominal wall fascia

Question 27

A small percentage of flaps (less than I0%) are reported to be superficially dominant

Answer 27

T

Question 28

within 5 to IO cm lateral from the midline, is explored for the SIEA and SIEV

Answer 28

T

Question 29

SIEA/V vessels that can be used are reported to be present in 50% of patients

Answer 29

F SIEA/V vessels that can be used are reported to be present in 30% of patients

Question 30

dissection of the SIEA and SIEV are carried to the femoral vessels. 29 Once adequate perfusion based on the superficial vessels is confirmed, all other perforators from the deep inferior epigastric system are divided

Answer 30

T

Question 31

Perfusion of flaps based on the SIEA/SIEV is not reliable across the midline

Answer 31

T

Question 32

Most of the perforators required for DIEP flap elevation are located within a 10 cm radius from the umbilicus

Answer 32

T

Question 33

In the DIEAP flap The superior abdominal flap is elevated from the superior incision for closure with the inferior incision, which is not undermined

Answer 33

T

Question 34

in cases where the SIEA is absent or too small to rely upon, the SIEV if present is dissected out to a length (5-7 cm) for potential use as an alternate flap outflow option

Answer 34

T

Question 35

primary closure without mesh is often possible with DIEP flap and free ms-TRAM flap harvests.

Answer 35

T

Question 36

Free TRAM harvests tend to include wide sections of anterior rectus fascia and may require mesh placement, particularly in cases with bilateral flaps.

Answer 36

T

Question 37

the pedicle to the gracilis muscle

Answer 37

The medial circumflex femoral artery, a branch of the profunda femoris artery, serves as the pedicle to the gracilis muscle to support the overlying fat and skin

Question 38

The skin may be oriented transversely (transverse upper gracilis (TUG) flap), vertically (vertical upper gracilis (VUG) flap) or designed as a combination of both with a bipedicled skin paddle

Answer 38

T

Question 39

Although the TUG does not provide as much skin or fat as the VUG,

Answer 39

T

Question 40

skin paddle. is more reliable in VUG muscle flap

Answer 40

F In transverse upper gracilis (TUG)

Question 41

The transverse upper thigh scar is better hidden than the vertical scar

Answer 41

T

Question 42

excessive tension from closure of the transverse skin paddle donor site may cause labial spreading.

Answer 42

T

Question 43

Medial thigh flaps are ideal for patients with small- to moderate-sized breast who desire similar-sized reconstruction

Answer 43

T

Question 44

Draw back of medial thigh flap

Answer 44

labial spreading. overall availability of sufficient tissue

Question 45

One advantage of this form of reconstruction is that flap harvest and breast reconstruction can be performed in one position with the patient supine and the hip externally rotated (thigh frog legged) for flap harvest

Answer 45

t

Question 46

the length of the vascular pedicle of gracilis flap is good and matches the caliber of the recipient's vessels

Answer 46

F, the length of the vascular pedicle is relatively short, measuring approximately 7 cm and the flap artery is often smaller than recipient arteries used for breast reconstruction (e.g., internal mammary or thoracodorsal vessels).

Question 47

Posterior Thigh Flaps or the profunda artery perforator (PAP) flap pedicle length is 5 CM.

Answer 47

F 10.6 CM

Question 48

Perforators from the pedicle are located roughly 5 to 6 cm below the gluteal crease, both medial and lateral to the midline of the posterior thigh

Answer 48

T

Question 49

The flap is designed as a horizontal ellipse with a superior incision at gluteal crease always

Answer 49

F The flap is designed as a horiwntal ellipse with superior incision at or immediately below the gluteal crease

Question 50

The superior or inferior gluteal artery perforator (SGAP or !GAP) flaps are autologous alternatives to abdominal-based flaps

Answer 50

t

Question 51

The superior gluteal artery exits the pelvis superior to the piriformis muscle at approximately the point marking the junction of the upper and middle third of a line drawn from the posterior superior iliac spine (PSIS) to the greater trochanter

Answer 51

T

Question 52

The inferior gluteal artery exits the pelvis inferior to the piriformis muscle, at approximately the point marking the junction of the upper and middle third of a line drawn from the PSIS to the ischial tuberosity.

Answer 52

T

Question 53

Gluteal artery perforator flap at least need two perforator to survive

Answer 53

F One perforator is many times sufficient to support the GAP flap

Question 54

The most suitable flap for patients with lower BMI

Answer 54

One advantage provided by use of gluteal flap is the presence of a good amount of adipose tissue for reconstruction even in patients with lower BMls.

Question 55

The pedicles length of the gluteal flap

Answer 55

5.6cm

Question 56

the thoracodorsal artery and vein. are the most common utilized recipient vessels for free flap

Answer 56

The IMA and internal mammary vein (IMV) are the more commonly utilized recipient vessels for free flap breast reconstruction; alternatives are the thoracodorsal artery and vein

Question 57

The internal mammary vessels can be accessed by removal ofthe third or fourth rib cartilage;

Answer 57

T

Question 58

At the level of the third rib, the IMA generally lies lateral to the IMV.

Answer 58

T

Question 59

The right and left IMAs are of similar diameter (1.9-2.1 mm) at third and fourth intercostal spaces

Answer 59

T

Question 60

The left IMV bifurcates at a higher level than the right IMV (third rib on the left vs. fourth rib on the right)

Answer 60

T

Question 61

At the level of the third intercostal space, the left IMV is on average smaller than the right (2.5 mm vs. 3 mm)

Answer 61

T

Question 62

The identification of venous congestion without obvious mechanical obstructions within the pedicle and perforators may lead the surgeon to consider augmenting venous outflow through use of the superficial inferior epigastric vein (SIEV

Answer 62

T

Question 63

Anticoagulation with an antiplatelet agent (Aspirin) and venous thromboembolism (VTE) prophylaxis (subcutaneous heparin or enoxaparin) is typical.

Answer 63

T

Question 64

Donor site complications

Answer 64

infection, hematoma, seroma, wound dehiscence, skin flap necrosis, umbilical necrosis, abdominal wall hernias and bulges, medial thigh lymphatic leaks, and unfavorable scars

Question 65

Studies have shown that CTA may reduce operative time for abdominal-based reconstruction

Answer 65

T

Question 66

In pedicle TRAM flap we did not take the facia of the muscle

Answer 66

F Flap harvest includes fascia overlying the rectus muscle and often requires mesh placement for closure of the donor site.

Question 67

Free Flap types

Answer 67

the free transverse rectus abdominis musculocutaneous (TRAM), free muscle-sparing TRAM (ms-TRAM), deep inferior epigastric perforator (DIEP), and the superficial inferior epigastric artery (SIEA) perforator flaps

Question 68

The free TRAM, free ms-TRAM, and DIEP flaps are based on the deep inferior epigastric vessels

Answer 68

T

Question 69

superficial to the Scarpa fascia and within 5 to IO cm lateral from the midline, is explored for the SIEA and SIEV

Answer 69

T

Question 70

the intervening segment of muscle between the two rows may be harvested with the flap as a muscle-sparing TRAM flap, obviating perforator dissection through the muscle.

Answer 70

T

Question 71

TUG provide a more reliable skin paddle.

Answer 71

T

Question 72

the horizontally designed PAP flap offers mean weight of 220 g, larger flaps are possible with the PAP designed as a fleur-de-lis

Answer 72

T

Question 73

The thoracodorsal vessels are typically identified at the lateral border of a mastectomy defect on the deep surface of the latissimus muscle.

Answer 73

T

Question 74

The PAP flap can provide sufficient tissue in patients with B or C-cup breasts

Answer 74

T

Question 75

The DIEP flap is no longer an option in patients who have had an abdominoplasty

Answer 75

T

Question 76

The latissimus dorsi musculocutaneous flap is not likely to provide sufficient tissue to reconstruct B-cup breasts in this patient

Answer 76

T

Question 77

IMV on the left side can be substantially smaller at ribs 4 and 5.

Answer 77

T