Chapter 66 - Regional, Free Flaps

Question 1

during what time period is flap most prone to thrombosis

Answer 1

first 48 hours

Question 2

how delayed graft harvest helps graft

Answer 2

elevate distal portion from underlying vasculature, then replace into defect…wait a few wk
improved pressure gradient, improved viability of distal angiosomes

Question 3

Angiosome

Answer 3

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

Question 4

Fasciocutaneous vs myocutaneous

Answer 4

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

Question 5

Allen test

Answer 5

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

Question 6

how to evaluate foot circulation prior to fibular free flap

Answer 6

MRA, ABI, doppler

this flap removes peroneal artery, so they must have collaterals from anterior tibial and posterior tibial

Question 7

How location determines abdominal closure with rectus flap

Answer 7

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

Question 8

Pinprick flap interpretation

Answer 8

Rapid dark blood: venous congestion

Slow/No: arterial insufficiency

Question 9

Signs of venous congestion

Answer 9

Bluish, warm/swollen, bounding doppler, rapid dark blood

Question 10

Signs of arterial insufficiency

Answer 10

Pale, cool, weak/no Doppler, slow/no bleeding on pinprick

Question 11

When flap thrombus typically occurs, salvage rate

Answer 11

80% within 2 days

If managed in <6 hours, 75% salvage success

Question 12

How leeches helps flaps

Answer 12

If venous congestion and cannot surgically salvage

Saliva has hirudin (Xa inhibitor)

Question 13

Which antibiotic do you give to patients who are on leech therapy

Answer 13

Cipro

For aeromonas hydrophilia

Question 14

How long can flap survive ischemia

Answer 14

4 hrs

After this you get AV shunting, PMN/radical release with reperfusion

Question 15

Pec flap: type, Pedicle, uses, disadvantages

Answer 15

MyoQ
Thoracoacromial
Single stage, easy, cover carotid
Bulky, perforators may get damaged

Question 16

Deltopectoral flap: type, Pedicle, uses, disadvantages

Answer 16

FascioQ
Internal mammary, perforating br (2/3)

Cutaneous defects neck

Need skin graft at donor site, distal portions unreliable when extended over deltoid

Question 17

Latissimus flap: type, Pedicle, uses, disadvantages

Answer 17

MyoQ
Thoracodorsal
Cutaneous neck/scalp
Semidecubitus position

Question 18

Trap flap: type, Pedicle, uses, disadvantages

Answer 18

MyoQ
Transverse cervical
Cutaneous posterolateral
Short arc, variable pedicle anatomy, lateral decubitus

Question 19

Supraclavicular flap: type, Pedicle, uses, disadvantages

Answer 19

FascioQ
Supraclavicular a
Color match, for neck, temporal, face
Dehiscence

Question 20

Temporoparietal fascia flap: type, Pedicle, uses, disadvantages

Answer 20

Fascia
STA
Thin, durable, vascular, facial/SB defects
Frontal br CN VII, alopecia

Question 21

SCM flap: type, Pedicle, uses, disadvantages

Answer 21

MyoQ
Occipetal/Sup Thyroid/Transverse Cervical (need 2/3)
May pedicle Sup/Inf, oral/pharyngeal defects, neck/face
Poor viability, donor site contour abnl

Question 22

RFFF: type, Pedicle, uses, disadvantages

Answer 22

FascioQ or OsteoQ
Radial a
Thin/pliable, long pedicle, versatile
Skin graft, hand vascular compromise

Question 23

ALT flap: type, Pedicle, uses, disadvantages

Answer 23

MyoQ or SeptoQ
Lat Circumflex Fem Descending br
Pliable, long pedicle, large SA
Volume unpredictable (variable pedicle)

Question 24

Rectus Abd flap: type, Pedicle, uses, disadvantages

Answer 24

MyoQ or mm
Deep Inf Epigastric
Large volume (glossectomy, SB)
Hernia risk

Question 25

Fíbula flap: type, Pedicle, uses, disadvantages

Answer 25

OsteoQ
Perineal
Mandible
Ankle pain/instability, foot vascular compromise

Question 26

Scapular flap

Answer 26

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

Question 27

Lateral arm flap: type, Pedicle, uses, disadvantages

Answer 27

FascioQ
Profunda Bracho
Thickness based on BMI, oropharynx/low volume facial
Small pedicle, may have radial nerve palsy if tight closure

Question 28

Jejunum flap

Answer 28

Enteral
Superior mesenteric a
Circumferential pharyngoesophageal
Peristalsis affects swallowing, production of succus entericus…dysguesia, difficult voice rehab