Chapter 66 - Regional, Free Flaps Flashcards
during what time period is flap most prone to thrombosis
first 48 hours
how delayed graft harvest helps graft
elevate distal portion from underlying vasculature, then replace into defect…wait a few wk
improved pressure gradient, improved viability of distal angiosomes
Angiosome
tissue supplied by single artery
choke vessels connect neighboring angiosomes
more angiosomes in a flap connected in series –> decreased pressure gradient –> increased chance of distal necrosis
Fasciocutaneous vs myocutaneous
myo contains muscle, branch of vascular pedicle perforated muscle to supply skin, so skin perfusion is less robust than with fasciocutaneous, can get skin flap necrosis easier
Allen test
clench fist –> occlude ulnar/radial aa –> 10 deg flexion –> release ulnar a –> assess thumb/index finger capillary refill
Tests ulnar collateral circulation
If inadequate, may be due to incomplete superficial palmar arch and lack of communicating vessels between deep and superficial arch
how to evaluate foot circulation prior to fibular free flap
MRA, ABI, doppler
this flap removes peroneal artery, so they must have collaterals from anterior tibial and posterior tibial
How location determines abdominal closure with rectus flap
Above arcuate line, posterior sheath made of transversus and internal, so just need to close posterior
Below arcuate line, posterior sheath comprised only of transversalis fascia, so must close Ant & Post sheaths to prevent hernia
Pinprick flap interpretation
Rapid dark blood: venous congestion
Slow/No: arterial insufficiency
Signs of venous congestion
Bluish, warm/swollen, bounding doppler, rapid dark blood
Signs of arterial insufficiency
Pale, cool, weak/no Doppler, slow/no bleeding on pinprick
When flap thrombus typically occurs, salvage rate
80% within 2 days
If managed in <6 hours, 75% salvage success
How leeches helps flaps
If venous congestion and cannot surgically salvage
Saliva has hirudin (Xa inhibitor)
Which antibiotic do you give to patients who are on leech therapy
Cipro
For aeromonas hydrophilia
How long can flap survive ischemia
4 hrs
After this you get AV shunting, PMN/radical release with reperfusion
Pec flap: type, Pedicle, uses, disadvantages
MyoQ
Thoracoacromial
Single stage, easy, cover carotid
Bulky, perforators may get damaged
Deltopectoral flap: type, Pedicle, uses, disadvantages
FascioQ
Internal mammary, perforating br (2/3)
Cutaneous defects neck
Need skin graft at donor site, distal portions unreliable when extended over deltoid
Latissimus flap: type, Pedicle, uses, disadvantages
MyoQ
Thoracodorsal
Cutaneous neck/scalp
Semidecubitus position
Trap flap: type, Pedicle, uses, disadvantages
MyoQ
Transverse cervical
Cutaneous posterolateral
Short arc, variable pedicle anatomy, lateral decubitus
Supraclavicular flap: type, Pedicle, uses, disadvantages
FascioQ
Supraclavicular a
Color match, for neck, temporal, face
Dehiscence
Temporoparietal fascia flap: type, Pedicle, uses, disadvantages
Fascia
STA
Thin, durable, vascular, facial/SB defects
Frontal br CN VII, alopecia
SCM flap: type, Pedicle, uses, disadvantages
MyoQ
Occipetal/Sup Thyroid/Transverse Cervical (need 2/3)
May pedicle Sup/Inf, oral/pharyngeal defects, neck/face
Poor viability, donor site contour abnl
RFFF: type, Pedicle, uses, disadvantages
FascioQ or OsteoQ
Radial a
Thin/pliable, long pedicle, versatile
Skin graft, hand vascular compromise
ALT flap: type, Pedicle, uses, disadvantages
MyoQ or SeptoQ
Lat Circumflex Fem Descending br
Pliable, long pedicle, large SA
Volume unpredictable (variable pedicle)
Rectus Abd flap: type, Pedicle, uses, disadvantages
MyoQ or mm
Deep Inf Epigastric
Large volume (glossectomy, SB)
Hernia risk
Fíbula flap: type, Pedicle, uses, disadvantages
OsteoQ
Perineal
Mandible
Ankle pain/instability, foot vascular compromise
Scapular flap
FascioQ or OsteoQ Circumflex scapular Muscle/Skin/Bone good, for complex midface/oromandibular Lat Decub (poss brach plex injury) Shoulder weakness if mm not approximated
Lateral arm flap: type, Pedicle, uses, disadvantages
FascioQ
Profunda Bracho
Thickness based on BMI, oropharynx/low volume facial
Small pedicle, may have radial nerve palsy if tight closure
Jejunum flap
Enteral
Superior mesenteric a
Circumferential pharyngoesophageal
Peristalsis affects swallowing, production of succus entericus…dysguesia, difficult voice rehab
