Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Trunk and lower extremity > CHEST WALL, ABDO WALL, BACK, GROIN Recon > Flashcards

CHEST WALL, ABDO WALL, BACK, GROIN Recon Flashcards

1
Q

What are the etiologies of chest wall defects?

A
  • Congenital
    • Pectus excavatum
    • Pectus carinatum
    • Poland Syndrome
    • Sternal cleft
  • Acquired
    • Infection: abscess, empyema, mediastinitis / sternotomy / thoracotomy wound
    • Iatrogenic: BPF, radiation (ORN, soft tissue radionecrosis)
    • Neoplastic: benign/malignant/metastatic tumour ablation
    • Trauma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

List the general principles of chest wall reconstruction

A
  1. Multi-disciplinary care
  2. Drainage of fluid collection
  3. Debridement of all necrotic, non-viable, infected tissue and/or complete cancer extirpation and staging
  4. Re-establishment of negative intra-thoracic pressure w water-tight seal
  5. Skeletal stabilization
  6. Obliteration of dead space
  7. Coverage w durable, well vascularized soft tissue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are options to manage a bronchopleural fistula?

A
  • Cladget procedure
    • 2 stage procedure
    • 1st stage drain fluid collection/open pleural drainage; 2nd stage excise BPF, fill space w abx, and close BPF & obliterate space w/ extra thoracic muscle
  • Eloesser procedure
    • 1 stage, for more debilitated patients
    • establishes open pleural drainage and full thickness skin flap sutured to pleura to convert BPF to bronchocutaneous fistula; as lung expands to skin flap wound closes
  • Thoracoplasty
    • subperiosteal resection of ribs to allow overlying soft tissue to fall into deadspace; historical
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are soft tissue options available to obliterate dead space or close off intra-thoracic defects?

A
  • Intra-cavitarty: omentum, pericardium
  • Extra-thoracic:
    • local/locoregional pedicle muscle flaps mainstay
    • Workhorse: LD, serratus, pec major, rectus abdominus
    • Also trapezius (posterior), external oblique, intercostal muscle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are your options for econstruction of pleural defect?

A
  • local/locoregional options predominate
  • free flaps rarely if ever required
  • not specifically required for reconstruction if thoracic skeleton and soft tissue being restored, so long as lung / bronchus closed from pleural cavity
  • LD, serratus anterior, pec major are work-horses
  • also omentum, rectus abdominus, intercostal muscle
  • (also external oblique)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what is a flail chest and why is it important?

A
  • a flail chest is any thoracic cage segment where > 2 contiguous ribs are missing across a segment (or fractured in 2 places)
  • results in paradoxical chest wall motion
  • impaired ability to generate negative inspiratory pressure
  • decreased ventilatory capacity/efficiency
  • sufficient disruption to normal pulmonary mechanics such that mechanical ventilation may be required (ex: trauma)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are indications for skeletal/thoracic cage reocnstruction after tumour ablation (or traumatic defect)?

A
  • Defined by McCormick
  • > 4 contiguous ribs missing
  • defect size > 5 cm
  • typically regarding anterior/anterolateral defects; impact of flail segment of posteiror chest wall on respiratory mechanics is less; in a radiated field impact on respiratory mechanics may be less due to fibrosis of chest wall
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the options for chest wall skeletal reconstruction? What is your preferred option s/p tumour ablation?

A
  • Autologous options
    • Split rib non-vascularized bone graft
    • Free fascia (non-rigid)
  • Prosthetic
    • Biosynthetic
      • ADM
    • Temporary
      • Vicryl
    • Synthetic - semi-rigid
      • Polypropylene - inexpensive, pourous, allows vascular ingrowth
      • Polytetrofluoroethylene (PTFE): semi-rigid, water-tight
      • Mersiline / Marlex mesh - allows for water-tight seal
    • Synthetic - rigid
      • Polymethylmethacrylate (PMMA): rigid, conformable, difficult to inset alone
      • Marlex mesh PMMA sandwich: PMMA conformable graft inside 2 pieces of marlex mesh, which can be secured to periphery in water-tight seal
  • My preferred option to reconstruct a skeletal defect in context of tumour ablation is a Marlex mesh - PMMA sandwich
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

List locoregional options for soft-tissue coverage of chest wall/thoracic defects

A
  • Options can be muscle only (+ skin graft), myocutaneous or fasciocutaneous
  • Anterior
    • Pec major (M, MC), rectus abdominus (M, MC; if IMA available or potentially off 8th subcostal perforator), omentum
  • Anterolateral
    • Pec major (M, MC), rectus abdominus (M, MC), latissimus dorsi (M, MC, TDAP perforator), serratus anterior (M, MC), external oblique, LICAP, parascapula
  • Posterior
    • LD (M, MC, advancement or turn-over), Trapezius, Scapula/parascapula, serratus, rectus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are considerations surrounding free tissue transfer for chest wall (anterior, anterolateral) defects?

A
  • Lack of availability of locoregional options
    • ablation, pedicles ligated
    • within zone of injury or radiation field
    • congenitally absent
  • Large surface area for resurfacing or large volume for obliteration
  • Difficult to reach: epigastrium/central abdomen
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What recipient vessels do you consider if choosing free tissue transfer to reconstruction anterior/anterolateral chest wall defects?

A
  • Ipsilateral IMA
  • Thoracodorsal
  • Thoracoacromial branches
  • Contralateral IMA
  • Transverse cervical
  • ? Lateral thoracic
  • Axillary a end to side
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the risk factors for developing a sternal wound and/or mediastinitis?

A
  • Patient:
    • age, DM, ESRD, obesity, mammary hypertrophy, osteoporosis, steroid/immunosupp
  • Technical
    • off-midline sternotomy, transverse sternal fracture, revision surgery, IMA harvest (especially bilateral), prolonged intraoperative cardiopulmonary bypass
  • Post-operative
    • delayed extubation/prolonged mechanical ventilation, development of HAP/VAP, mechanical stress to chest wall (coughing, chest compressions, aggitation)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What do you need to know when planning surgery/reconstruction for sternal wound defect s/p CABG

A
  • location of sternotomy, sternal fracture, gap between sternal edges
  • location of fixation, # wires
  • IMA harvest, LIMA/RIMA, placement of grafts
  • pericardial closure
  • depth of sternum, costal cartilages and ribs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

discuss treatment options for sternal wound s/p sternotomy for intathoracic/cardiac surgery

A
  • Timing
    • single stage vs. 2 stage
    • single: total debridement of infection, necrotic tissue, sequestrum + reconstruction in single stage
    • 2 stage: grossly infected sternal wounds, severe mediastinitus, unstable for single-stage reconstruction - cover w/ dressing or VAC in interim, not preferred approach
  • Coverage of upper/middle sternal defects
    • bilateral pec major myogenous or myocutaneous - 1st line
      • advancement flaps, consider uni/bil release of humeral insertion (through deltopectoral groove); inset in vest-over-pants
      • turnover flaps - must have ipsilateral IMA intact; not preferred
    • VRAM - typically myocutaneous
      • consider if ipsilateral IMA still intact
      • can theoretically be taken off 8th subcostal perforator, this is a small vessel
    • omentum - good back up or salvage; needs STSG; does not have similar mechanical staiblity
  • Coverage of lower/epigastrium defects
    • Pec major will reach only lower middle 1/3; could do PMMC with adjacent soft tissue rearrangement
    • VRAM, omentum as above
    • rarely free tissue transfer
  • Internal fixation
    • controversial role for internal fixation at primary (for prophylaxis) and even secondary surgery to restore integrity of sternum
    • not a necessity, but can help achieve permanent stability
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How would you classify sternal wound defects? How does this classification influence treatment choice?

A
  • Pairolero classification
  • Type 1: acute, serosanguinous discharge, wound not suppurative infection, no osteomyelitis, cultures bland
    • consider VAC, conventional dressings, or debridement (bedside vs. OR) and readvancement of skin flaps
    • Add binder and activity modifications, optimize nutrition, smoking status, immunosuppression, ventilatory demand if possible
  • Type 2: subacute - weeks out from surgery, suppurative infection w/ osteomyelitis +/- mediastinitus, positive cultures
    • treat aggressively with operative debridement, definitive culture assessment and targeted antibiotics, soft tissue closure with muscle flaps +/- internal fixation
  • Type 3: chronic, like chronic draining sinus or fistula, contaminated w/ positive cultures +/- osteomyelitis / chrondiritis
    • still treat aggressively, debride sequestrum, antibiotics, soft tissue closure w muscle flaps vs. strongly consider multiple debridements, VAC intermediate stages, closure w/ soft tissue options
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is pectus excavatum

A
  • congenital defect of chest wall/sternum
  • whereby there is inward displacement of the sternum and adjacent costal cartilages +/- ribs, caudal to the manubrium
    • can be deep or flap inward displacement
    • can be asymmetric in up to 50%; eccentric vs unbalanced
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are treatment indications for pectus excavatum?

A
  • fucntional (cardiorespiratory compromise/deficiency/complaints) - RARE
  • cosmetic
  • psychosocial
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are treatment options for pectus excavatum?

A
  • Minimally invasive - NUSS procedure; convex retrosternal bar placed at / before puberty when cartilages can be manipulated
    • disadv: pain, recurrence, reoperation, pericarditis, ptx, other infection, need for removal of bar @ ~ 2 yrs
  • Open - Ravitch procedure; open procedure that includes sternal wedge osteotomy, manipualtion of costal cartilages, placement of internal fixation
    • disadv: large open procedure, large scar, recurrence, removal of hardware, pericardiitis, ptx, other infection
  • Camoflage w custom implant - computer generated template for custom implant to camoflage defect; placed subcut or sub-muscle; typically in adult / skeletally mature
    • disadv: migration/malposition/malrotation, chronic seroma, infection/extrusion, does not meet aesthetic expectations, palpable/visible edges
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What syndromes are associated w pectus excavatum?

A
  • scoliosis
  • marfan’s
  • poland
  • < 2% w/ congenital cardiac abn
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is pectus carinatum?

A
  • Congenital defect of sternum/thoracic rib cage
  • characterized by protrusion of sternum +/- adjacent costal cartilages +/- ribs
  • 2 forms
    • chondrogladiator: most common is “keel” deformity whereby inferior 1/2-1/3 of sternum and adjacent costal cartilages + ribs & xiphisterum are protruberant
    • chrondomanubrial < 5% is “pouter pigeon” deformity which is like a “Z” with prominence of manubrium & sternal angle & adjacent costal cartilages/ribs are prominent, but with inward displacement of body and again outer/anterior displacement of distal/xiphisternum
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are common associations w pectus carinatum

A
  • scoliosis
  • cardiac defects
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the most common upper extremity finding in poland syndrome

A

normal upper extremity

(most common abnormal finding is brachysyndactyly)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is poland syndrome?

A
  • congenital absence of sternal head of pec major muscle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are associated findings w/ poland syndrome

A
  • Muscle
    • absence of pec major sternal head
    • absence or hypoplasia of shoulder girdle / scapulothoracic muscles like pec minor, serratus anterior, latissimus dorsi, subscapularis, supra/infraspinatus
  • Dermoglandular
    • absence / hypoplasia of breast, NAC, both
    • absence / abrnomal axillary, chest wall adnexal hair growth
  • Skeletal
    • abnormal / ___ sternum, abrnomal/missing costal cartilage, abrnomal/missing ribs
  • Upper extrmeity
    • brachysyndactyly
  • Visceral
    • dextrocardia
    • renal abnormalities
    • hematologic malignancies
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

what are associated syndromes w poland syndrome

A
  • Klippel-Feil - congenital cervical spine fusion , short neck, cleft palate, spina bifida
  • Sprengel - winging of scapula
  • Moebius - congenital abscence of CN VII +/- CNVI +/- other cranial n +/- club feet/strabismus, absent digits
  • Hematologic malignancies
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

what is your treatment approach for a male w poland syndrome

A
  • major issues for male are absence of anterior axillary fold, visibility and palpability of ribs, lack of definition and contour to chest wall, asymmetry
  • Consider imaging to confirm normal arterial supply to ipsilateral shoulder girdle muscles (ie LD)
  • To reconstruct anterior axillary fold, consider ipsilateral pedicle LD transfer, inset at ~ IMF to aim to recreate IMF/pec origin contour, and cover obvious ribs
    • disadv: doesn’t always achieve the idealized appearance bc insertion not the same, morbidity of harvest large muscle in context of abrnomal shoulder girdle
  • To reconstruct CW asymmetry and cover obvious ribs, can consider custom subcut silicone implant; can be combined w ipsi LD and placed submuscular
    • disadv: migration/malposition/rotation, persistent seroma, infection, palpable / visible implant edges, extrusion, not achieving aesthetic goals
  • Could consider sandwich ADM to provide subcut thickness and aim to decrease visibility of ribs on CW and cover w fat grafting; could fat graft alone (addresses ribs, may to some extent address contour abn w deficient PM, does not address anteiror axillary fold)
27
Q

what is your treatment appraoch to female w poland syndrome

A
  • major issue for female w poland syndrome is abrnomal breast development
  • goal is to restore a breast mound rather than appearance of pec major
  • options
    • ipsi LD (ant axillary fold, coverage of prosthesis) + TE –> implant
    • Subcut TE (while adolescent) –> implant
    • Becker implant
    • TE to develop a subcut pocket then pedicled (or free) , completely de-epithelialized TRAM (vs. DIEP)
    • augments
      • ADM, fat grafting
28
Q

what are syndromes associated w sternal cleft?

A
  • craniofacial hemangioma
  • omphalocele
  • PHACES
    • P - posterior fossa malformation
    • H - facial hemangioma
    • A - arterial abn (coarctation, subclavian)
    • C - cardiac abn
    • E - eye/endocrine
    • S - midline sternal cleft abn
29
Q

what is the etiology of abdominal wall defects?

A
  • Congenital
    • omphalocele
    • gastroschisis
    • bladder extrophy
    • diaphragmatic or umbilical hernia
    • prune belly
  • Acquired
    • Trauma
    • Tumour
    • Infection
    • Iatrogenic: radiation, abdominal compartment sydrome, enterocutaneous fistula, incisional hernia, inability to close after laparotomy
    • Idiopathic hernia
30
Q

what is the difference between omphalocele and gastroschisis

A
  • Gastroschisis
    • no membrane; gut is herniated through umbilical ring
    • umbilical stalk/vessels to LEFT of defect
    • GI malabsorption common
    • associated congenital anomalies less common
  • Omphalocele
    • gut herniated through umbilical stalk and covered by membrane
    • stalk vessels at centre of membrane covering defect
    • no gut malabsoprtion
    • common associated congenital anomalies - heart, renal, chromosomal trisomies
31
Q

What are the reconstructive goals and principles of surgery for abdominal wall defects?

A
  1. Multidisciplinary care: general surgery, ICU, ID, nutrition, resp, medicine, plastics etc
  2. Reduction of bioburden and/or complete tumour resection
  3. Restoration of abdominal domain
  4. Restoration of musculofascial integrity
  5. Provision of durable, well vascularized coverage for vital abdominal structures
  6. Reinforcement of attenuated areas
  7. Minimize foreign body
  8. Control the dead space
  9. Prevent recurrence
  10. Fewest procedures as possible
32
Q

what functions are restored w abdominal wall reconstruction (or, what functions are influenced when there is a large abdominal wall defect or distortion to normal anatomy?)

A
  1. Aesthetic contour
  2. Assistance w micturition and defecation
  3. Assistance w respiration (accessory muscle of respiration)
  4. Postural and truncal stability
  5. Imply signals of satiety
  6. Prevent strangulation and incarceration of hernia
33
Q

Describe the motor innervation to abdominal wall muscles

A
  • RA: 5 lower IC, subcostal
  • EO: lower IC, subcostal and iliohypogastric
  • IO and TA: subcostal, iliohypogastric & ilioinguinal
34
Q

What are the vascular zones of the abdomen?

A
  • Described by Nahai for angiosomes and Huger in context of abdoplasty
  • Zone 1 is superior and deep inferior epigastric zone: from xiphoid, along costal cartilages, along lateral edge of RA down to line between asis
  • Zone 2: SCIA, DCIA, SIEA and external pudental, inferior to line between ASIS to inguinal crease and pubis
  • Zone 3: intercostal and subcostal(lowest 6) and lumbar vessels (4), lateral to costal cartilages/ASIS to anterior axillary line
35
Q

How would you classify defects of abdominal wall?

A
  • By location
    • Both Mathes and Rorhich outlined zones of abdomen
    • Generally there is a central/umbilical zone, and bilateral upper and lower quadrant zones
    • Following this Mathes indicated 3 zones (1 central, 1 upper (per hemi-abdo), 1 lower (per hemiabdo)) and Rohrich outlined 3 central single zones (upper, mid, lower) and 3 paired lateral zones (upper, mid, lower)
  • By etiology
  • By defect analysis: partial/full thickness, location, size, depth, tissues involved, structures at base, absolute vs relative deficiency of tissue
  • incisional hernia location
    *
36
Q

how do you classify abdominal wall hernias?

A
  • Butler described a classification of abdominal wall hernias that informs his decision regardin which type of mesh to utilize in closure
  • Low risk
    • few RFs & no h/o abdominal infection
    • use synthetic mesh
  • comorbid
    • patient risk factors for hernia
    • synthetic mesh not contra-indicated; there may be reasons why biologic mesh is preferred
  • Potentially contaminated
    • previous wound infection/hostile abdomen, XRT, stoma, intra-operative violation of GIT, enterocutaneous fistula
    • synthetic mesh essentially contra-indicated (can use carefully in previous infxn, XRT); use biologic mesh
  • Contaminated - abdiminal infection/sepsis, septic mesh
    • synthetic absolutely contra-indicated; may consider delayed hernia repair/lap closure
37
Q

What are risk factors for development of abdominal hernia?

A
  • patient: obesity, DM, COPD, immunosuppression, smoker, non-compliance w post-op instructions
  • local hernia factors: recurrence, previous / active abdominal infection, obstruction, strangulation or incarceration, loss of abdominal domain, enterocutaneous fistula, radiation
38
Q

What investigation do you order and what do you look for when considering reconstruction of large abdominal wall defect / hernia?

A
  • extent of relative / absolute myofascial loss
  • extent of loss of abdominal domain
  • location of rectus abdominus muscle
  • intra-abdominal process
39
Q

List options for soft tissue coverage for abdominal wall defects

A
  • Primary closure
  • secondary closure
  • skin graft
  • VAC assisted closure using one of above options
  • locoregional random or axial fasciocutaneous or myocutaneous flaps
  • tissue expansion and use of above
  • free flap
40
Q

List options for myofascial closure/reconstruction in abdominal wall defects

A
  • Primary closure
  • Skin graft
  • VAC + one of above
  • components separation
  • autologous fascial graft
  • mesh: synthetic vs biologic
  • fascial component of flap
41
Q

What is the treatment approach when abdomen there is intra-abdominal catastrophe?

A
  • debridement of bioburden, enterocutaneous fistula
  • if edema or pressure or pt stability prevents closure, then temporize w bagota bag
  • rarely in this context is primary closure indicated or required
  • plan for second look, +/- delayed primary closure vs. vac, eventual skin grafting over granulation over bowel, and reconstruction after 1 year
42
Q

which abdominal wall defects will permit primary closure?

A
  • typically <=5cm wide (recurrence 60% w 6cm width defect)
  • recurrence reduced by 1/2 when closure reinforced w mesh underlay
43
Q

define components separation

A
  • local release of external oblique fascia to permit mobilization of bipedicle rectus abdominus neurotized musculofascia flaps
44
Q

what is the indication for components separation?

A
  • clean stable abdominal wounds (typically midline abdominal hernias) that will not permit primary closure
  • alternatively in wounds where mesh is contra-indicated
45
Q

what advancement do you expect w components separation

A
  • PER SIDE:
    • epigastrium: 4cm
    • umbilicus: 8cm
    • pelvis: 3cm
    • if add posterior rectus sheath release: 2cm
  • thereover overall
    • without post rectus sheath release: 8/16/6
    • with post rectus sheath release: 12/20/10
46
Q

what is a contra-indication to components separation

A
  • any contra-indication to closure
    • unstable patient, elevated intra-abdominal pressure / risk for abdo compartment syndrome, abdominal catastrophe or sepsis
    • also specifically presence of an enterostomy, unless the plan is to close and re-site the stoma or reverse the stoma
47
Q

Describe the critical steps for abdominal components separation

A
  • Removal of skin graft
  • adhesionolysis of intra-abdominal contents
  • restoration of abdominal domain
  • elevation of skin flap to mid-axillary line, preserving the musculocutaneous perforators
  • identification of linea semilunaris
  • longitudinal fasciotomy over EO ~ 1-2cm lateral to linea semi-lunaris
  • elevate plane between EO (above) and IO (below), dissect/separate to the posterior axillary line
  • mobilize bilaterally to midline
  • parachute synthetic or biologic mesh underlay (retrorectus placement), as indicated, to reinforce the repair and reduce the risk of recurrence
  • use of progression tension sutures and closed suction drains to manage the dead space
48
Q

what are the complications of abdominal components separation

A
  • early:
    • abdominal compartment syndrome
    • hematoma/seroma
    • infection
    • dehiscence / evisceration
    • umbilical necrosis
  • late
    • recurrence of hernia (5-30%)
    • mid-lateral / flank hernia
    • scar
49
Q

Discuss the use of mesh for abdominal wound repair

A
  • for reconstruction of myofascial integrity
  • indicated to bridge a myofascial defect (bridge mesh) or reinforce a myofascial repair (underlay better than onlay)
  • temporary mesh - vicryl mesh - can be utilized w/ infection
  • prosthetic mesh
    • synthetic
      • cannot be used w active infection, entrance into GIT, enterocutaneous fistula, stoma / stoma reversal, peritonitis, open abdominal wound
      • use caution w previous infection, XRT, placement adjacent to bowel
      • typically synthetic meshes are now coated w biologic surface that can be placed adjacent to bowel
      • advantages: less costly, readily available, maintains strength, no donor site
      • disadvantages: no ingrowth or incorporation, capsule formation +/- capsule scar, limited indications (above); must be removed in contaminated field or w/ infection
    • biologic
      • no specific contra-indications (except for pt refusal, allergy etc)
      • adv: broader indications, ingrowth and incoportation, once revascularized/incorporated - does not need to be removed in context of infxn
      • disadv: maybe weakens or stretches over time
50
Q

List locoregional options for soft tissue coverage of abdominal wound, by zone (central, upper quadrant, lower quadrant)

A
  • mathes zone
  • zone 1: central
    • components separation (brings overling skin, rectus advancement) - choice flap
    • upper: superiorly based rectus abdominus, thoracoepigastric
    • lower: TFL, rectus femoris, pedicle groin flap (SCIA), ALT
  • Zone 2: upper
    • LD, SA or LD+SA - upper lateral - or choice flap
    • TDAP, thoracoepigastric
    • superiorly based rectus abdominus - choice flap
  • zone 3: lower
    • groin, ALT, siea
    • RA, VL, TFL (choice flap), gracilis
    • inferiorly based rectus abdominus
51
Q

what are ptoential free flap options for abdo wall coverage

A
  • depends on size of defect, need for fascia
  • common choices for free tissue transfer would be: ALT, latissimus myocutaneous +/- TFL
52
Q

List options for recipient vessels for abdo wall free tissue transfer

A
  • DIEA
  • SIEA
  • SCIA
  • DCIA
  • IMA
  • SEA
53
Q

WHAT ARE SOME POTENTIAL ETIOLOGIES FOR BACK DEFECTS

A
  • Congenital
    • spina bifida, myelomeningocele
    • (giant) congenital melanocytic nevus
  • Acquired
    • Trauma
    • Tumour
    • Infection
    • Iatrogenic: radiation, dishiscence post op/post instrumentation, pressure sore
54
Q

What are principles of reconstruction of back defects?

A
  • reconstruction choice based on size, location, depth, compoistion of defect and exposed structures
  • avoid skin grafts
  • use excellent surgical technique including precise 2 layer closure, as little tension as possible
  • control dead space using closed suction drains +/- progressive tension sutures
  • consider tissue expansion
  • aim for as aethetically pleasing as possible
55
Q

how do you classify defects of the back?

A
  • location
    • upper, middle, lower third
  • structures involved and/or exposed
    • skin, fat, muscle, bone, hardware, CNS
  • simple vs complex
    • large, radiation, infection, exposed hardware, spinal instability, recurrence/failed previous attempts
56
Q

List options for locoregional coverage of back defects, by location

A
  • Upper third
    • trapezius
    • LD - on TDA (advancement/island/pedicle) vs. turnover (on paraspinal)
      • consider w/ SA
    • paraspinous muscle advanceent or turnover
    • parascapular
  • middle third
    • LD - on TDA (advancement/island/pedicle) vs. turnover (on paraspinal)
      • consider w/ SA
    • paraspinous muscle advancement or turnover
  • Lower third
    • glut max (rotation, advancement, perforator, island)
    • LD - turnover vs. advanceent (would need to be advanced w SA to reach inferiorly)
    • paraspinous muscle
    • lumbar perforator flaps
  • All
    • can consider random pattern flap design, ensuring following L:W or 1:1 to 2:1
      • good options for the back are rotation flaps, transposition flaps
57
Q

what are the different types of spina bifida?

A
  • spina bifida cystica
    • meningocele - herniation of meninges; often no neurologic deficits +/- atrophic skin cover
    • myelomeningocele - herniation of meninges and spinal cord; often neurologic deficits
    • syringomyelocele - herniation of meninges and spinal cord w/ dilated central canal
    • myelocele - no bone, meningeal or soft tissue cover over spinal cord
  • spina bifida occulta
    • abnormal bone fusion but intact skin; harbinger’s are dimple, hair, lipoma, atrophy, nevus
58
Q

what is spina bifida?

A
  • incomplete fusion of dorsal spine
59
Q

what are treatment principles for spina bifida cystica?

A
  • multidisciplinary
  • early clsore
  • layered repair
60
Q

treatment options

A
  • local random flaps: FC vs. MC
    • advancement, rotation, V-Y, ying yang, +/- bilateral relaxing incisions
    • can mobilize thoracolumbar fascia w LD, glut max
  • tissue expansion
  • reverse LD
  • glut max/sgap
61
Q

List flaps used to cover groin wounds

A
  • FC: groin flap (SCIA), ALT (desc br LCFA)
  • M/MC:
    • SFA: sartorius
    • PFA: TFL, rectus femoris, VL, gracilis,
    • from ext iliac (DIEA) VRAM
62
Q

what recipient vessel would you use for free tissue transfer to back?

A
  • ideally a vessel of subscapular system; ideally TDA or serratus branch; also consider lateral thoracic
  • for lower +/- middle third defects, may require vein graft
  • for lower third, using SGA/IGA as recipient is generally not thought to be feasible
63
Q

Where is Cloquet’s node? Why is it important?

A
  • most cephelad deep inguinal node, under inguinal ligament
  • positivity often indicates need for deep pelvic adenectomy; perhaps not a sensitive indicator
64
Q

what is the blood supply ot the skin in the region of the groin?

A
  • SCIA
  • DCIA
  • external pudendal, from common femoral

Trunk and lower extremity (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions