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Flaps and Grafts > Fasciocutaneous flaps > Flashcards

Fasciocutaneous flaps Flashcards

1
Q

Describe the deltopectoral flap

A

Anatomic landmarks

  • At border of sternum, overlying ribs 2-4, to the deltopectoral groove, inferior and parallel to the clavicle
  • A modification can be the extended DP flap, whereby the lateral border extends to lateral shoulder, can be done with a delay (raise the superior and inferior margins, divide all thoracoacromial perforators, stick silicone sheet in between

Blood supply

  • IMA perforators 1-3 (2,3 are largest); can be transferred on 1 or all 3
  • Enter flap ~ 4cm lateral to sternal border
  • Length ~ 1-2cm; width ~ 1-2mm
  • corresponding VCs

Innervation:

  • 2-4 IC nerves

Uses:

  • Regional: Lower 1/3 of face, intra-oral cavity and neck
    • commone use is to cover parastomal defects
    • special use is as a secondary cervical trachea option, tubed, 2-stage
    • with delay can cover middle face
  • Distant: possible to take as IMAP free flap (divide rib, take some IMA) but would be uncommon choice.

Steps:

  • incise upper, lower and lateral border
  • raise in subfacial plane (fascia of delt and pec major)
  • divide thoracoacromial perforators
  • IMA perforators are usually ~ 4cm lateral to sterum, slow down at 6cm lateral to sternum
  • transpose or rotate or tube into defect

Advantages: proximity to neck, thin, pliable, fast

Disadvantages: (so many this flap is a very low option on any list): donor site morbidity (unsightly, requires graft, can elevate NAC), multi-stage approach (with delay or tube or both)

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2
Q

Describe the lateral intercostal artery perforator flap (LICAP)

A

Regional uses: thorax (LICAP, DICAP), breast, sterum (AICAP), axilla

  • Common use is partial breast reconstruction of lateral quadrant +/- inferior pole defects

Distant uses: (uncommon) H&N, extremity (bc thin, pliable)

Artery:

  • ICAP - lateral (LICAP), dorsal (DICAP), anterior (AICAP) perforators of posterior intercostal vessels; lateral is longest at ~ 10-15cm & 1.5mm diameter

Landmarks: Standing, ellipse designed ~ 12 x 24cm overlying 9-11th ribs centred on mid-axillary line w/ ~ 5cm posterior to posterior axillary line. Use doppler to identify perforators

Steps: raise posterior border first overlying the LD in sub-fascial plane. Retract the anterior border of LD to follow the LICAP perforator through SA and external oblique to gain access to IC space. Release muscle from lower border of rib to see perforator branch from main posterior IC and incise periosteum

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3
Q

Describe the scapular and parascapular flaps

A

Blood supply

  • Circumflex scapular artery (L = 4cm D = 2.5-4mm); 2VCs
    • transverse branch = scapular; descending branch = parascapular
    • found exiting the triangular space (teres minor (sup) teres major (inf) long head triceps (lat))
    • find also 1 finger breadth below mid-point of lateral scapular border; use doppler

Markings

  • Scapular - ensure lateral aspect of paddle overlies the triangular space; 2cm inferior to spine, 2cm superior to apex, 2cm medial to vertebral column
  • Parascapular - ensure superior tip overlies the triangular space and paddle is over lateral border; inferiorly “a few” cm distal to apex

Technique

  • Prone or lateral decub
  • Markings
  • 2 schools of thought for raising
  • 1) Raise medial to lateral, suprafascial, when see pedicle from triangular space then enter fascia, retract muscles and ligate pedicle as far proximally as possible (question to keep or not the TDA pedicle)
  • 2) Raise lateral to medial and ID vessels right away
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4
Q

List all the flaps that can be raised off the subscapular system

A
  • Scapular
  • Parascapular
  • Scapular or parascapular osteocutaneous
  • Lateral scapula (periosteal branch of CSA)
  • Scapular tip (angular arter off TDA)
  • Latissimus dorsi
  • Latissimus dorsi osteomyocutaneous (scapula apex from angular branch of TDA)
  • TDAP
  • Serratus muscle
  • Serratus w/ rib
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5
Q

Define the border of the triangular space - why is it relevant for flap dissection?

A

long head of triceps (lateral)

Teres minor/subscapularis (superior)

Teres Major (inferior)

Key as the exit point of the circumflex scapular artery for the parascapular and scapular flaps -origin is subscapular artery

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6
Q

are muscle flaps better than fasciocutaneous flaps for lower extremity complex trauma wound coverage? What helps you decide?

A
  • animal model data suggest lower infection and faster union and perhaps stronger (at least early) union in muscle flaps compared to FC flaps
  • clinical studies - usually retrospective, suggest no difference
    • ex: Fu Chan Wei, PRS, 2006 - 177 free flaps in 174 pts, 98 musc, 79 FC for open distal 1/3 leg and ankle fractures
    • no statistically significant difference in infection, chronic OM, primary union, overall union, walking without crutches at 2 years
  • factors to help decide btwn M vs FC - if significant 3D defects - muscle flaps better for conformation; FC flaps can better tolerate secondary procedures, don’t require skin graft
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7
Q

what is the role of the deep fascia in FC flaps?

A
  • primary blood supply in FC flaps is in the suprafascial plexus
  • subfascial plexus does not contribute much to overall blood supply
  • tend to take deep fascia in order to optimially protect the suprafascial blood supply
  • can leave the deep fascia (ex: suprafascial radial forearm) when careful to preserve the suprafascial plexus
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8
Q

list a way to describe or classify fasciocutaneous flaps

A
  • a fasciocutaneous flap consists of skin, subcutaneous adipose tissue, and deep investing fascia
  • it can be sub-classified on the basis of the vascular pedicle to the skin, as described by MATHES AND NEHAI:
    • type A = direct cutaneous - pedicle enters fascia in deep cutaneous tissue and travels in this plane for a while ex: TPF, reverse sural, SIEA, DMCA, gluteal thigh
    • type B = septocutaneous - the perforator runs between 2 muscle bellies (ie in an IM septum) - some ALT, lateral arm, radial forearm, PIA flap, scapular
    • type C = musculocutaneous perforator - a vessel that directly supplies the muscle sends a perforator through the muscle to the overlying skin - ie some ALT, DIEP, TDAP
  • there is an alternate system by cormac and lamberty, and by nakajima, but they make less sense to me
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9
Q

Define and compare prelamination and prefabrication. Give an example of each.

A
  • Pre-fabrication is the transfer of a vascular pedicle (artery, VCs and surrounding adventitia, or muscle or fascia) to a desired donor tissue. The transferred pedicle is allowed to neovascularize to the overlying donor tissue, and then that donor tissue can be transferred (either local or FTT) to the defect
    • example: combine with tissue expansion, to transfer hair bearing scalp to cheek/beard in man
      • microvascular transfer of radial artery with radial forearm fascia flap under pareital hair-bearing scalp, with a tissue expander underneith both
      • expansion during pedicle neovascularization
      • transposition of expanded hair-bearing skin to burned face
  • Prelamination is the process of transferring additional tissues (ex: skin graft, cartilage) or other devices (silicone) under a donor tissue with its own pedicle, to create a three-dimensional framework in a remote site. the framework is allowed to neovascularize and is transferred as a composite flap on its original donor pedicle to the desired recipient site
    • example: template and elevate of radial forearm flap into shape of a nose, underlay cartilage 3D nasal framework and re-inset the skin flap in its original location
    • transfer as a composite free tissue transfer for total nasal reconstruction after the framework has revascularized
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10
Q

Describe the cutaneous blood supply

A

FASCIA

  • Sub-fascial - minor
  • Intra-fascial - minor
  • Supra-fascial - dominant for FC flap survival

SUBCUTANEOUS FAT

  • Superficial fascia separates superficial (dense) from deep (loose) fat. Supplied by FC and MC perforators

SKIN

  • Subdermal - distribution fx
  • Dermal - thermoregulatory fx
  • Subepidermal - nutritive fx
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11
Q

Describe 3 types of perforators

A
  • Direct
    • supply axial patttern skin flaps
  • Musculocutaneous
    • arise form muscle vessels, not axial
  • Septocutaneous
    • pass between septa of muscle
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12
Q

How do you classify Fasciocutaneous flaps?

A
  • Blood supply
    • Cormack and lamberty
    • Mathes and nahai
  • Composition
    • fascia, + skin, +muscle, + bone
  • Geometry
    • Adv. Rotate, Transpose
  • Destination
    • local/regional pedicled, distant free
  • Vascular directionality
    • Proximally based (Anterograde)
    • Distally-based (retrograde)
    • Flow-through
    • Venous flap: inflow in through direct AV anstomosis
    • Supercharging/Turbocharging
  • Flap preparation
    • Tissue expansion
    • Flap prelamination: (Pribaz) insertion of other tissues into flap before trasnfer (nasal recon)
    • Flap prefabrication: (Khouri) trasnfer pedicle w adventitia +/- fascia to new region to develop a whole new blood supply to recipient tissue before final transfer (RF fascia to supraclav w TE to get color match flap)
    • Microdissection of flap - to harvest only subdermal plexus w pedicle to achieve thin cutaneous perforator flap (ALT ,TdAP, DIEP, TFL)
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13
Q

Describe the cormack and lamberty and the mathes and nahai classifications

A

1- Cormack & Lamberty

A: Multiple

many FC vessels entering flap

long axis of flap lies parallel to predominant fascial plexus

Eg. transposition, rotation

B: Single

consistent presence and location, may be used as local pedicled or micro flap

Eg. Scapular, medial arm

C: Segmental

mulitple perforators from one source

preservation of br. to bone allows OC flap

eg. radial forearm, lateral arm, peroneal

Mathes & Nahai

Direct

pedicle arises form one soruce deep to fascia and continues superficial to fascia

eg. TPF, Groin (SCIA)

Septocutaneous

perforators course between muscles

eg. RF, scapular, lateral arm

Musculocutaneous

perforators course through muscle

eg. deltopectoral, DIEP, TdAP, median forehead

Comparing two classifications

CLA = MNC - multiple perforators come through muscle

CLB = -single perforator either direct (MNA) or indirect (MNB)

CLC = MNB segmental perforators usualy eminate of septocutaneous perforator

2- Mathes & Nahai

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14
Q

How does venous outflow occur in retrograde/reverse flow flaps

A

2 theories

  • Bypass theory - interconnectiosn between VC
  • Incompetenet valves - pressure gradient/dilatation causes intrinsic valve dysfunction
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15
Q

List the perforator FLAPS of the trunk - listed by direct/septo/musculocutnaeous perforator

A

FASCIOCUTANEOUS

  • Scapular/Parascapular
    • Circumflex scapular artery H and V branch

DIRECT CUTANEOUS

  • SIEA
  • Lateral thoracic/Axillary
  • Groin
    • superficial circumflex iliac artery
  • Pudendal

MUSCULOCUTANEOUS

  • Deltoid
  • Pectoralis Major
  • Pectoralis Minor
  • Serrtus Ant
  • Lat dorsi
  • Rectus abdominis
  • Internal oblique
  • Gluteus Maximus
  • Deltopectoral flap
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16
Q

what are 4 ideal components in order to raise a perforator flap?

A
  1. predictable and consistent blood supply
  2. perforator size > 5mm
  3. suficiently long vascular pedicle
  4. primary tension free donor site closure
17
Q

List 10 principles of free tissue transfer

A
  1. Any tissue with a viable blood supply can be transferred
  2. Choose the simplest flap wiht the least donor site morbidity that achieves your reconstructive goals
  3. Anastomosis is outside zone of injury / radiation field
  4. Tension free anastomosis (with vein graft better than tension + no vein graft)
  5. Fasciocutaneous flaps are ideal for resurfacing, and minimize donor site morbidity
  6. Muscle flaps are ideal for bulk, obliteration of dead space, and 3D contour
  7. Osseous flaps revascularize more quickly, over larger defects, than bone grafts
  8. Muscle flap + skin graft is less donor site morbidity than myocutaneous flap
  9. Most flaps fail 2’ venous thrombosis
  10. Early flap failure typically tehcnical failure or no reflow phenomenon; late flap failure typically infection or ischemia-reperfusion
18
Q

List advantages and disadvantages of fasciocutaneous flaps

A
  • advantages include:
    • closer to replacing like with like for superficial or soft tissue defects
    • large surface area can be covered
    • no muscle morbidity
    • minimal bulk
    • improved post-op recovery
    • greater pliability w/ 2’ surgery
  • disadvantages
    • donor defect can cosmeticlaly appear poor if large scar or skin graft rquired
    • if a MC perforator flap, dissection through muscle can sometimes be tedious and variable
    • long oR time
    • variability in perforator size and position
    • pedicle can kink or twist
    • does not contour well
19
Q

list factors or indications that help you decide between fasciocutaneous and muscle flap

A
  • FC is ideal for:
    • resurfacing
    • requirement to reconstruct skin - like with like
    • anticipated need for reoperation (easier secondary access to site)
    • large surface area required
    • typically less bulk (not always)
    • wish to minimize donor size morbidity by avoiding sacrifice of muscle
    • cutaneous sensation
  • Muscle is ideal for:
    • need to obliterate dead space
    • need bulk
    • need to contour over a 3D defect
    • functional restoration (sensorimotor flaps)
    • controversial whether preferred in context of possible colonization/contamination/previous infection/to prevent infection
20
Q

Name the 7 plexuses of cutaneous blood supply, describe their function or role in cutaneous surgery:

A
  1. subepidermal - in papillary dermis; nutritive function
  2. intradermal - thermoregulatory function
  3. subdermal - @ jxn of reticular dermis & superficial SC fat; distributive fxn & dermal bleeding
  4. subcutaneous - superficial and deep layers; supplied by either direct cutaneous, septocutaneous or musculocutaneous perforators
  5. suprafascial - primary blood supply to fasciocutaneous flap
  6. intrafascial - very minor contribution to blood supply to fasciocutaneous flap
  7. subfascial - minor contribution to vascularity, but cannot sustain a flap on its own
21
Q

list the advantages and disadvantages of muscle flaps (myocutaneous)

A
  • advantages
    • bulk
    • obliteration of dead space
    • can be contoured
    • functional restoration
    • reliable pedicle
    • different sized muscles
    • can have skin flap
    • resistant to infection (controversial)
  • disadvantages
    • functional morbidity
    • contour and cosmetic deformity
    • excess bulk
    • unpredictable atrophy
    • muscle fibrosis makes 2’ surgery difficult - not much mobility
22
Q

List factors that you consider when planning for reconstruction of a defect using a flap

A
  • Donor site
    • expendability
    • cosmetic deformity
    • functional morbidity (weakness, loss ROM, hernia, bulge etc)
  • Flap
    • pedicle length/diameter
    • bulk and size of flap
    • option as functional transfer
    • option as sensate transfer
    • ability to split the flap, or take multiple flaps off same pedicle (chimeric)
    • ability to harvest composite flap
    • proximity to defect, zone of injury, radiation field
  • Recipient site
    • Quality of wound bed: infected, irradiated, poorly vascularized
    • Size and components of defect
  • Surgical
    • reliability of anatomy
    • reliability of survival
    • difficulty and time of flap dissection, inset
    • patient positioning
    • ability to use 2 teams
23
Q

what factors do you consider pre-op when planning for a free flap?

A
  • patient positioning
  • antibiotic prophylaxis
  • vte prophylaxis: mechanical/chemical
  • hair removal, if indicated
24
Q

what intraoperative factors do you consider during a free flap

A
  • pedicle dissection, muscle relaxation
  • sutures required
  • vessel irrigation
  • trouble shooting
    • revisiion anastomosis
    • chemical vasodilators: paparavine, lidocaine
    • systemic heparization
  • tension free anastomosis
  • avoid pedicle compression, twisting, kinking
  • consider the degree of muscle atrophy
  • use drains
25
Q

what post op factors do you consider after free tissue transfer

A
  • vte prophylaxis: initial bed rest to early ambulation, mechanical (TEDS, SCDs), chemical (daily enox or bid heparin)
  • extremity elevation
  • hydration, nutrition
  • splinting of recipient or donor as required
  • flap monitoring
    • allow window for monitoring
    • CCTT doppler
    • adjuncts: scratch, vioptix, ___
26
Q

describe the temporoparietal flap

A
  • the TPF flap is typically a fascial only flap, occassionally a hair-bearing FC flap
  • it is indication for regional coverage or obliteration of deadspace or separation of functional structures in the upper face, mid-face, anterior cranial base (ex: obliteration of orbital exentoration), for special regional uses to cushion to TMJ or dynamic oral commisure restoration and for distant uses like providing a gliding surface for tendons
  • it is supplied by a direct cutaneous perforator (MN-A), the superficial temporal artery and vein (D ~ 1mm L ~ 3cm) and can be harvested sensate w auriculotemporal nerve
  • the TPF originates from the temporal fossa and “inserts” into SMAS
  • the STA is dopplered from pre-auricular, to bifurcation with anterior and parietal branches ~ 4cm superior to ZA, and follow the parietal branch over TPF
  • the incision is then marked pre-auricular heading to vertex (~ 12cm), branching into a “T” or “Y” over temporal fossa
  • make the incision in pre-auricular area, identify the vessels to ensure they are viable, continue to dissect in deep subcutaneous plane (just deep to hair follicles) from here because plane is easier to find
  • once superficial surface of fascia is preserved, incise superiorly, elevate from cranial to caudal using periosteal elevator, and ensure keeping STA w fascia as proceed caudally to pre-aurciular area
  • rotate from here or ligate and use as free tissue transfer
27
Q

WHAT ARE THE CONTENTS OF TRIANGULAR SPACE, QUADRILATERAL SPACE, TRIANGULAR INTERVAL?

A
  • TS: sup - t. minor (& subscap); inf - t. major; lateral - long head tricpes; contents - circumflex scapular artery
  • QS: sup - t. minor (& subscap); inf - t. major; medial - long head tricpes; lateral - lateral head triceps; contents - posterior circumflex humeral artery & axillary n to deltoid
  • TI: sup - t. major; medial - long head tricpes; lateral - lateral head triceps; contents - profunda brachii and radial nerve
28
Q

describe skin paddle for scapular FC flap and parascapular FC flap

A
  • can be ellipse / island / free or as transposition flap
  • for scapular, general land marks are: 2cm “in” from each of these landmarks are borders of flap ellipse
    • posterior axillary fold, midline/vertebra, spine of scapula, inferior tip of scapula
  • for parascapular flap, apex is located at the triangular fossa, laterally can be at or 2cm wihtin posteiror axillary fold, medially so that it can close, and distally not farther than 1/2 between inferior tip and PSIS, following along the axis from TS to PSIS
29
Q

describe a parascapular flap

A
  • parascapular flap is commonly a fasciocutaneous flap, but special variant for osseocutaneous
  • common regional indications include upper back, lateral back, intrathoracic, shoulder, axilla; distant indications include anything for a relatively thin, hairless FC flap (extremity, H&N, etc); special indications include maxillary reconstruction or mandible reconstruction with vascularized bone
  • MN type B flap, with vascular pedicle from circumflex scapular artery (D 2-2.5, L 5-6cm) - the parascapular flap is harvested off vertical branch of CSA
  • skin paddle as previously described, along axis of pedicle/lat scap border to PSIS, apex at pedicle and inferiorly not longer than 1/2 from tip to PSIS
  • incise skin superolaterally, dissect down to and through deep investing fascia
  • aim to identify muscles of TS, and see pedicel emerging
  • once pedicel identified, can safely elevate rest of flap in subfascial plane, and ligate the transverse branch
  • may need to retract teres minor to take CSA from take-off on subscapular a
30
Q
A
31
Q

List direct cutaneous flaps

A

· H&N:

o Superficial temporal artery – TPF flap

o Supra-orbital, supratrochlear arteries – paramedian forehead flap

o Occipital artery, Post-Auricular artery (hair-bearing)

o 2nd and 3rd perforating branches of IMA – deltopectoral

· Trunk

o Lateral thoracic – external mammary flap

o Superficial inferior epigastric artery – “SIEA” – abdominal flap

o Superficial circumflex iliac artery – groin flap

o Superficial external pudendal artery – sepa and penile flaps (? Singapore flap?)

· Leg

o Dorsalis pedis artery – dorsalis pedis flap

32
Q
A

Flaps and Grafts (4 decks)

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