FLAPS Flashcards
The pectoralis muscle is a, fan-shaped
m muscle classic ed as a type V muscle ap
T
blood supply of the pectoralis major muscle is
thoracoacromial artery and secondary blood supply includes the lateral thoracic artery and
branches of the internal mammary artery as well as perforating branches of the
anterior intercostal arteries
The thoracoacromial artery divides into
pectoral, clavicular, acromial, and deltoid branches inferior to the medial third of the clavicle.
F The thoracoacromial artery divides into
pectoral, clavicular, acromial, and deltoid branches are inferior to the middle third of the clavicle.
The main blood supply to most of the skin overlying the pectoralis major muscle comes from the perforating branches of the thoracocromian arteries
f The main
blood supply to most of the skin overlying the pectoralis major muscle comes from the perforating branches of the internal mammary artery in the second through sixth intercostal spaces medially, and the perforating branches of the third through sixth anterior intercostal arteries,laterally
The pectoral branch of the thoracoacromial artery also supplies small perforating branches to the skin overlying its course
T
The origin of the pic major ?
the anterior surface of the medial half of
the clavicle, the anterior surface of the lateral half of the sternum, costal cartilages from the second to the sixth rib, and the aponeuorosis of the external oblique muscle
The lateral thoracic artery follows the lateral border of the pectoralis major
muscle and supplies the lateral part of the pectoralis major muscle
The lateral thoracic artery follows the lateral border of the pectoralis minor
muscle and supplies the lateral part of the pectoralis major muscle
the thoracoacromial artery dissipates at about the level of the fourth rib
T
The venous
drainage is via paired venae comitantes that accompany the arteries
t
nerve supply to PIC Major
lateral and medial pectoral nerves are the motor nerve that supply to the
pectoralis major muscle
The length of the pedicle is 6 cm , but can be
in creased slightly based on ap design
F The length of the pedicle is 4 cm , but can be
in creased slightly based on ap design
The length of the pectoral branch of the lateral thoracic vessels is 3-4 CM
T
The lateral pectoral nerve enters the pectoralis major muscle on its
deep surface about 3 cm medial to the medial pectoral nerve
T
Thus the lateral pectoral nerve enters the pectoralis major muscle on its deep surface about 3 cm medial to the medial pectoral nerve
T They are named for their origin from the brachial
plexus rather than the anatomic location of the portion of the muscle they supply
The lateral pectoral branch innervates the clavicular and sternal heads of the muscle
The medial pectoral nerve supplies the pectoralis m in or muscle and then two or three branches pass into the pectoralis major to supply the posterolateral portions of the muscle
T
PIC MAJOR usually harvested as a sensate flap
F This flap is usually not harvested as a sensate flap
Myo-osseous or osteomyocutaneous flap by including the lateral sternal bone via thoracoacromial connections with the internal mammary artery perforators
T
Myo-osseous or an osteomyocutaneous pic major flap by including the fourth rib
F fifth rib
Myo-osseous flap by including clavicular head via the pectoral branch
of the thoracoacromial artery
F Myo-osseous flap by including clavicular head via the clavicular branch
of the thoracoacromial artery
Two separate muscle flaps, one based on the pectoral branch of the thoracoacromial artery and one based on the lateral thoracic artery
T
reliable skin paddle could also be designed directly
over the thoracoacromial artery
T
In obese patients in case we want to take the PMMC what we should do ?
superomedially over the internal mammary perforators in the third intercostal space, wherenthere is usually less soft-tissue bulk.
In pic major the recommended transverse incisions are preferable since they preserve the skin over
the second and third intercostal spaces, which could be used for a deltopectoral
or internal mammary artery perforator flap
T
The course of the thoracoacromial artery can be estimated by drawing a line from the acromion to the xiphoid
process
T
In order to design a myocutaneous flap with the maximal reach of the skin what you need to do?
musculocutaneous perforating branches of the anterior intercostal blood vessels
of the fourth, fifth, and sixth costal interspaces, which communicate with the
thoracoacromial artery via choke vessels
the skin paddle is usually centered over the inferior portion of the pectoralis major muscle, outside the vascular territory of the musculocutaneous perforating branches of the thoracoacromial artery
T
the lateral thoracic blood vessels lie lateral to the thoracoacromial vessels and do not need to be
included with the flap if the maximum arc of rotation is required to reach the defect
T
the pedicle can be completely dissected from the muscle
with appropriately delicate technique to minimize bulk
T
Substantial undermining is often necessary when a wide skin paddle (> 5 cm)
T
For the longest arc of rotation, the skin paddle of the PMMC pedicled
the flap should be centered over the fourth intercostal space
T
Temporoparietal Fascia Flap
Other options when thin coverage needed
include the superficial circumflex iliac artery perforator flap (SCIP), serratus fascia/muscle flap, lateral
arm fascia flap, and anterolateral thigh fascia flap
The TPFF is one of the thinnest and
most pliable vascularized flaps in the body
T
TPF–cutaneous (hair-bearing) flaps have been utilized for brow restoration and
upper lip reconstruction (mustache in men)
T
the workhorse flap for
microtia and ear reconstruction
T
A composite TPFF–osseous
flap using a split outer calvarial bone has been described for craniofacial
reconstruction. In this scenario,
T
The TPFF has been favored in dorsal hand and foot coverage for its ability to allow thin vascular tissue coverage and tendon gliding
T
TPF–cutaneous (hair-bearing) flaps have been utilized for brow restoration and
upper lip reconstruction (mustache in men)
T
The superficial temporal artery (STA) and vein (STV) run beneath the
TPF and provide the vascular pedicle to the TPFF
The superficial temporal artery (STA) and vein (STV) run on or within the TPF and provide the vascular pedicle to the TPFF
The STA, one of the terminal branches of the external carotid artery, passes through the parotid gland
posterior to the mandibular ramus prior to taking a more superficial course and piercing the TPF at the level of the tragus where it can be palpated.
T
The STA bifurcates into an
anterior (frontal) and posterior (parietal) branches 1 to 3 cm Below the zygomatic arch.
F The STA bifurcates into an
anterior (frontal) and posterior (parietal) branches 1 to 3 cm above the zygomatic arch.
The STA is tortuous and release of this tortuosity may add an extra 1 to 2 cm of length to the
pedicle.
T
The STA lies anterior to the STV
T
The STA may be hypoplastic or have an anomalous course in patients with certain craniofacial anomlaies such as hemifacial
microsomia, Treacher-Collins syndrome or Romberg’s hemifacial atrophy
T
The auriculotemporal
nerve travels anterior to the STA in the preauricular crease
F The auriculotemporal
nerve travels posterior to the STA in the preauricular crease and can be preserved or included in flap dissection if sensory innervation to the flap is needed.
Dissection should be limited to within a 2.4 cm distance from
the tragus to prevent injury to the frontal nerve branches.
T Up to three frontal nerve branches
at the level of the zygomatic arch may be present, with the most posterior branch reported at 24 mm from the tragus and the most anterior branch within 42 mm
from the tragus
Up to three frontal nerve branches
at the level of zygomatic arch may be present, with the most posterior branch reported at 24 mm from the tragus and the most anterior branch within 42 mm
from the tragus
T
The middle temporal artery arises
from the STA at the level of the zygomatic arch where it can be seen on the temporalis muscle fascia
T
How you can make bilayered facial flap ?
Proximal dissection of the STA to include the middle
temporal artery allows for elevation of bilayered fascial flap containing the TPFF
and the deep temporal fascia
prior coronal
scalp incisions in the STA territory, ablative neck surgery sacrificing the external carotid artery or STA radiation to the STA area are contraindications to
using this flap
T
Flap dimensions of up to 12 × 14 cm can be elevated
T
Temporary removal of the zygomatic arch may improve flap reach for maxillary, posterior nasal, or oral reconstruction by an extra 1 to 2 cm.
T
The TPF can be advanced into skull base defects
and dural reconstruction for cerebrospinal fluid leaks by advancing it from the
temporal to the infratemporal fossa through a transpterygoid tunnel
T
Scar alopecia at the T and Y incision junction has been
reported in up to 8% of patients
T
Flap dissection past the temporal fusion
line is more difficult as fibrous connections to the scalp exist in this area.
T
Staying 2 to 3 cm posterior to the anticipated course of the frontal branch of the facial nerve is important
T
If
further pedicle length or caliber is needed, dissection can be extended more
proximally below the tragus paying great attention to facial nerve branches in
this area as the STA may lie within the parotid gland
T
The drain should be positioned away from the vascular pedicle when the the TPFF is used as a pedicled flap
T
The most common complication after elevation of TPFF is alopecia
T Avoidance of unipolar cautery is
recommended during flap elevation
Prior radiation to the temporal scalp area may predispose it for ischemic
injury after TPFF elevation and is a relative contraindication to using this
flap
T
Anterior dissection of the TPFF should be limited to within 2.5 cm anterior to the tragus at the level of the zygomatic arch to prevent injury
to the frontal branch of the facial nerve
Deltopectoral Flaps
Vascular Pedicle
based on the perforating branches of the
internal m amm ary artery arising through the second, third, and
fourth intercostal spaces
marked 3 to 4 cm lateral to the
anterior sternal midline in the second, third, and fourth intercostal
spaces
T
The upper incision is parallel and 2 cm inferior to the Second intercostal space
F The upper incision is parallel and 2 cm inferior to the clavicle
the lower incision commences inferior to the fourth intercostal space
T
Incisions are made along the upper and lower borders of the flap,
till the fascia of the pectoralis muscle
F Incisions are made, through the fascia of the pectoralis muscle
There is a constant perforator from the thoracoacromial ial
access that arises through the clavipectoral fascia that requires
division during elevation
T
Extra length can be obtained by dissecting out the perforators and by extending th e skin in cisions tow ard th e m idlin e
T
In the elderly, w ith w ide underm ining, the defect can be closed
prim arily; otherw ise, it is closed w ith a split skin graft
T
Delay fasion
The flap can be delayed through a short incision in line with the planned superior incision. If this thoracoacromial is present, then its ligation is
sufficient for the appropriate delay. If not, the whole flap area distal to the deltopectoral groove may need elevation
the largest perforator of the intercostal pedicles is the fourth one
F the one at the second intercostal space usually being the largest. It is an important lifeboat and should be preserved when raising a pectoralis m major ap in head and neck reconstruction
Paramedian forehead flap
the paramedian forehead flap is used most commonly for nasal
reconstruction, it may be used for other soft-tissue deficits of the central face
and eyelids
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The vasculature of the forehead includes the supraorbital, supratrochlear, infratrochlear, and dorsal nasal arteries and angular artery
T
As the supraorbital comes around the orbital rim, it enters a plane between the corrugator muscle
deeply and the frontalis muscle superficially.
T
Anesthetic
with epinephrine should not be injected into the flap itself, as the blanching it
causes will make it difficult to assess the vascularity of the flap
T
Dissection of the middle third of the flap is performed in the submuscular/
subgaleal plane beneath the frontalis muscle
T
the inferior third of the flap the plane of dissection changes to the subperiosteal plane
T
The supratrochlear vessels exit from the supraorbital foramen
F does not exit any bony foramen in the
vicinity of the orbital rim,
The oblique design of the flap can be less reliable secondary to not fully capturing the axial supratrochlear vessels
T
Temporalis Muscle Flap
type 4
f type 2
size of the flap
10*20
The temporalis muscle flap is useful for reconstructing defects of the periorbital region, maxilla,
base of skull, palate, posterior oropharynx, and floor of mouth and tongue and
includes immediate and delayed reconstruction
T
All temporalis flap may be used as a sling for the lower eyelid and lip for facial paralysis
F a split temporalis flap may be used as a sling for the lower eyelid and lip for facial paralysis
Dynamic movement is achievable through the third division of the trigeminal
nerve (V3)
T
The temporalis muscle is a flexible, fan-shaped Mathes and Nahai type III flap of moderate thickness
?? Grabb type 2
The muscle is 12 to 16 cm in length with a thickness of
0.5 to 1.0 cm.
T
The temporalis muscle is innervation
The temporalis muscle is innervated by the deep temporal nerves from the
mandibular branch of the trigeminal nerve.
The blood supply to the temporalis muscle
two branches of the deep temporal artery, the anterior and posterior, arising from the pterygoid portion of the internal maxillary artery
Accessory blood supply is from the middle temporal artery, originating from the superficial temporal artery within the temporoparietal fascia
which pedicles which usually sacrificed for muscle transfer
The middle temporal art
The superior margin is
approximately halfway between the upper margin of the ear and the vertex
t
The longitudinal nature of the blood supply allows for the splitting of the muscle into segments supplied by the anterior and posterior branches for dynamic reconstruction in facial paralysis
T
Submental Flap
(70%)Of the submental art run deep to the anterior belly of
the digastric muscle
T
the flap is needed for the reconstruction of defects
superior to the lower two-thirds of the face
T
How we can increase the length of the pedicles of the submental art ?
division of the facial vessels distal to the origin of the submental artery can provide up to 1 to 2 cm
of additional length
what about the vien how we can increase it length?
. The submental or common facial vein can be divided
and anastomosed to a suitable vein in close proximity to the recipientsite if additional length is required for reconstruction
there is often a communicating branch between the
external jugular and the facial vein that tethers the pedicle. This anatomic configuration forms a Y pattern. The surgeon can ligate the trunk of the facial vein proximal to this communicating vessel. In so doing, the Y-shaped configuration is converted to a V shape. This maneuver may provide up to an additional 5 cm of the length of the pedicle
T
Reverse flow: by ligating the facial artery proximal to the origin of the submental artery the submental flap can be by retrograde arterial flow
by the distal facial artery.
T
The submental flap has been used for microvascular reconstruction due to its favorable pedicle diameter and length
T
Supraclavicular Cutaneous Pedicled Flap
Supraclavicular Cutaneous Pedicled Flap type B flap
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The SCP flap is an axial fasciocutaneous flap based on the supraclavicular artery.
The supraclavicular artery is a branch of the transverse cervical artery
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The main pedicle runs
perpendicular to the transverse cervical vessels toward the acromioclavicular joint and proceeds over the deltoid muscle
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The supraclavicular nerve is unsensate flap
F The supraclavicular nerve from the third and fourth cervical nerves allows the SCP flap to be a sensate flap
The main nerve branch originates from the
posterior aspect of the sternocleidomastoid muscle along the midpoint of the
muscle belly
T
Preoperative imaging and radiographic studies are typically not necessary for
flap elevation
T
The SCP flap generally may be harvested up to 5 cm beyond the most distal point where
a Doppler signal can be identified, if additional flap length is necessary
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The muscle fibers
of the trapezius are more adherent than those of the deltoid and may require
additional blunt dissection
T
flaps greater than 10 cm in width, skin grafting will be required
F flaps greater than 5 cm in width, skin grafting will be required
Gracilis Muscle and Myocutaneous Flaps
Mathes-Nahai—type
TYPE 2 a. Dom inant vascular pedicle: term inal bran ch of m edial
fem oral circum ex artery
b. Minor vascular pedicle(s): distal branches from super -
cial fem oral artery
dominant vascular pedicles to gracilis muscle is the medial femoral circumflex artery only
f 10% of cases the
m ain vascular pedicle is derived directly from the profunda fem -
oris vessels
The m ain pedicle is m ost easily identi ed as it passes
betw een the adductor longus anteriorly and the adductor brevis
and m agnus m uscles posteriorly
T
The dom inant vascular pedicle
enters the m uscle belly 5 cm inferior to the pubic tubercle
on its deep surface.
F The dom inant vascular pedicle
enters the m uscle belly 8 to 12 cm inferior to the pubic tubercle
on its deep surface.
Ligation
of this proxim al m minor pedicle does not adversely affect blood supply to the flap
T
distal pedicles arise from the superficial femoral artery and the most distal minor pedicle can arise from the popliteal vessels
T
only one adjacent perforator zone can be incorporated into an ap based solely on the main pedicle to prevent distal skin necrosis
T
Most musculocutaneous perforators are located in the distal two-thirds
F Most musculocutaneous perforators are located in the proximal two-thirds
the highest concentration and largest of
these perforators within the proximal third of the muscle with a tendency to travel in a transverse direction
T
The length of the
skin paddle w hen placed vertically should not exceed two-thirds
of the m uscle length
T
How many m musculocutaneous perforators exit from the muscle ?
One or two large m usculocutaneous perforators exit the m edial or lateral side of the m uscle
Septocutaneous perforators may arise from the m ain gracilis vascular pedicle between the adductor longus and the gracilis muscle
T
More frequently the signicant septocutaneous perforator is from the rst
m inor pedicle distal to the m ain pedicle
T
How many septocutenous pedicles from gracilis flap?
two septocutenaous pedicles one from the major pedicles which is the cam between the gracilis and adductor longus
and the other one form minor pedicle came directly from the superficial femoral artery
These proxim al m usculocutaneous and septocutaneous perforators contribute to success of
the transverse orientation of the skin paddle
T
small-volum the flaps can be harvested based on the
septocutaneous perforator from the major pedicle with no need
for muscle harvest.
F from the minor pedicle with no need
for muscle harvest.
Length of pedicles : 6 to 8 cm
T
cutaneous branch of the obturator
nerve supplies m edial thigh skin
T
the gracilis m uscle is located just posteriorly to the adductor longus m uscle
T
the gracilis muscle
is unique as the only m uscle in the adductor com partm ent
that passes across both the hip joint and the knee
T
it can be identi ed by palpation just proxim al
to th e knee during knee extension (palpable) because it then
becom es im palpable during knee exion
T
straight line just posterior to the tendon
of the adductor longus connecting the pubic tubercle to the
m edial fem oral condyle considrd the posterior border of the muscle
F the anterior border of the m uscle
the w idth of the m uscle (5 to 8 cm in adults)
T
A transverse upper gracilis (TUG) skin
paddle centered over the upper third of the m uscle can m easure up to 30 cm 3 10 cm
T
regardless of the orientation
of the skin island, the width is determined by skin laxity, the
amount of subcutaneous tissue, and the soft tissue requirement at the recipient site
T
Care is taken
not to injure the saphenous nerve during dissection of the tendinous portion
T
in the case of functional muscle
transfer, the entire width of the muscle may not be needed and
the muscle may be split longitudinally based on nerve fascicular
T
Th e muscular fascia need to be closed
F The m muscular fascia does
not need to be closed
skin graft after a
gracilis myocutaneous Flap is rare
T
Do not damage the posterior cutaneous nerve of the thigh
during transverse skin paddle harvest
T
Always center the skin island
over the gracilis muscle. Limit the skin island to the proximal two-thirds of the muscle belly to avoid distal necrosis
T
The deep fascia is always incised and the adductor longus is retracted anteriorly to expose the pedicle vessels
T
the main pedicle passing behind the adductor longus muscle to enter the muscle 1 to 2 cm distal to the entry of the nerve to gracilis
T
Dynamic movement is achievable through the third division of the trigeminal
nerve (V3)
T
Scapular and Parascapular Flaps
angular branch of the thoracodorsal artery was consistently the blood supply to the scapular tip, and its inclusion allowed two separate segments of scapular bone to be raised reliably
T
The circumflex scapular artery
(external diameter: 2.5–3.5 mm)
The circumflex scapular artery traverses
the triangular space before dividing into its terminal cutaneous scapular and parascapular branches
T
The triangular space, bounded by the long head of triceps laterally, the teres minor and subscapularis superiorly, and the teres major inferiorly
T
the scapular flap therefore
extends from the triangular space to the midline, with the superior boundary
being the scapular spine and the inferior boundary being the scapular tip
T
The axis of the para scapular flap extends from the triangular space along the lateral border of the scapula to the posterior superior iliac spine
T
The thoracodorsal artery travels an average of 8.4 cm before diving into branches to serratus anterior and latissimus dorsi
T
The angular branch exit sites
commonly from the latissimus dorsi branch (51%),
from the serratus anterior branch (25%),
as the third branch of a trifurcation of the thoracodorsal vessel (20%),
or as a branch of thoracodorsal proximal to its bifurcation
(4%)
angular branch travels just deep to the superior border of latissimus dorsi, and at around
the scapular tip
t
the ipsilateral scapula is used for convenience of patient positioning except in situations where one arm is involved in the use of a walking stick or cane, there has been previous axillary dissection or irradiation, or there is lymphedema of the upper limb, in which case the contralateral scapula is preferred.
T
with this flap there will be loss of the shoulder abduction permanently
Loss of shoulder abduction has been reported for up to 6 months postoperatively, after which the range of movement should return to normal.
osseointegrated dental implants can be used with scapular bon flap for mandibular reconstruction
F poor for osseointegrated dental implants due to inadequate bone thickness
The angular tip of the scapula is preferred for reconstruction of the maxilla
T
The scabular tip can reconstruct the entire palatoalveolar complex without the need for contouring osteotomies when placed horizontally
T
The latissimus dorsi or teres major muscle can be harvested with the angular tip and used for soft-tissue reconstruction of the palate
T
The scapula is well suited to reconstruct the calvaria with the latissimus dorsi muscle (and skin grafting) used for scalp reconstruction. The long thoracodorsal vessels mean that vein grafting to the superficial temporal vessels is seldom
required
T
An anastomotic network from branches of the circumflex scapular and thoracodorsal arteries is found within teres manor
F An anastomotic network from branches of the circumflex scapular and thoracodorsal arteries is found within teres major
Up to 14 cm of bone, extending 1 cm from the glenoid fossa, can be harvested based on a single osseous branch from either the circumflex scapular or the thoracodorsal artery alone.
T
If additional length is required, the thoracodorsal branch can
be ligated thereby including the subscapular vessels, which originate from the axillary vessels,
T
The scapular tip can be accessed through a parascapular fasciocutaneous or
latissimus dorsi myocutaneous free flap incisions if a chimeric flap is required
T
Skin grafting on the back is best avoided due to poor graft take
T
The scapular flap is useful as a second-line option for mandibular and
maxillary reconstruction when the fibular flap is not available
T
The scapular (transverse) or parascapular (oblique) skin paddle is based on the circumflex scapular artery, which also supplies the lateral scapular bone.
T
The lateral border of the scapula oriented vertically is used to reconstruct an ipsilateral hemimaxillectomy
or lateral mandibulectomy defect
T
Trapezius flap
can we use trapezius flap for skulk reconstruction?
arc of rotation allows for occipital skull coverage.
Further dissection of the pedicle can extend its reach to the temporal
skull
the rhomboid major lies deep to the superior portion of trapezius
F The levator scapulae muscle lies deep to the superior portion. In its midportion and inferiorly, the rhomboid major and minor muscles, and the
latissimus dorsi muscle lie deep to the trapezius
the origen and insertion of the superior part
origins at the external occipital protuberance
and medial third of the superior nuchal line of the occipital bone of the skull
The superior fibers insert on the posterior aspect of the lateral third of the clavicle
The origin and insertion of the middle fiber
The middle fibers originate from the spinous processes of C7 to T4 and insert on the spine of the scapula and acromion
The inferior fibers
The inferior fibers originate from the spinous processes of T4 to T12 and insert
on the spine of the scapula
The trapezius muscle is innervated by the spinal accessory nerve (cranial nerve XI)
T
Preservation of the middle fiber is important to prevent shoulder drop
F shoulder droop deformity results from muscle denervation. Preservation of the superior fibers during flap harvest will maintain shoulder stability and prevent drooping
Blood supply to the trapezius
transverse cervical artery. It originates from the thyrocervical trunk (Domininat )
occipital artery, which originates from the external carotid artery,
The dorsal scapular artery (also known as the deep
branch of the transverse cervical artery) runs under the rhomboid muscles and sends a branch to the trapezius between the rhomboid major and minor muscles.
posterior intercostal arteries, which originate from the descending aorta
The dorsal scapular artery is lateral and basically runs parallel to the descending branch of the transverse cervical artery and can be used to support the trapezius muscle or
myocutaneous flap alone or along with the descending branch of the transverse cervical artery
T
Standard flap based on the descending branch of the transverse cervical artery with or without the dorsal scapular artery. The flap is vertical in design
T
Turnover flap based on the posterior branches of the intercostal vessels
T
10 × 2 cm segment of scapular spine can be harvested with
the flap for use in mandibular reconstruction
T
Shoulder droop due to spinal accessory (cranial nerve XI) nerve injury or
actual loss of the superior portion of the trapezius muscle is a painful and
debilitating complication of trapezius harvest
T
The trapezius flap has the greatest reach as a horizontal design
F The trapezius flap has greatest reach as a vertical design based on the
descending branch of the transverse cervical artery
Any skin paddle that is used should be limited to a maximum of 15 cm below the tip of the scapula,
T as skin below this may not possess adequate
perfusion
A skin island up to 20 × 8 cm can be supported on the middle and inferior fibers of the trapezius
muscle flap
T
This skin island can be located and marked between the posterior trunk midline (located by palpation of the spinous processes between C7 and T12) and the medial, vertical, border of the scapula
The top of the skin island should be marked at the midpoint of the height of the scapula
T
The inferrior end of the skin flap
The bottom of the skin island should be marked either at the inferior tip of the trapezius (T12), 10 cm (ideally) to 15 cm (maximum) below the tip of the scapula,
or at a point located halfway between the tip of the scapula and the posterior superior iliac crest
the flap can
be based on either the descending branch of the transverse cervical artery or
the dorsal scapular artery or both
T
If the dorsal scapula artery blood supply is to
be included with the flap, then the distal artery that runs beneath the rhomboid
major muscle needs to be ligated and the rhomboid minor muscle needs to be
divided for maximal reach
T
