FLAPS Flashcards
1
Q
The pectoralis muscle is a, fan-shaped
m muscle classic ed as a type V muscle ap
A
T
2
Q
blood supply of the pectoralis major muscle is
A
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
3
Q
The thoracoacromial artery divides into
pectoral, clavicular, acromial, and deltoid branches inferior to the medial third of the clavicle.
A
F The thoracoacromial artery divides into
pectoral, clavicular, acromial, and deltoid branches are inferior to the middle third of the clavicle.
4
Q
The main blood supply to most of the skin overlying the pectoralis major muscle comes from the perforating branches of the thoracocromian arteries
A
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
5
Q
The pectoral branch of the thoracoacromial artery also supplies small perforating branches to the skin overlying its course
A
T
6
Q
The origin of the pic major ?
A
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
7
Q
The lateral thoracic artery follows the lateral border of the pectoralis major
muscle and supplies the lateral part of the pectoralis major muscle
A
The lateral thoracic artery follows the lateral border of the pectoralis minor
muscle and supplies the lateral part of the pectoralis major muscle
8
Q
the thoracoacromial artery dissipates at about the level of the fourth rib
A
T
9
Q
The venous
drainage is via paired venae comitantes that accompany the arteries
A
t
10
Q
nerve supply to PIC Major
A
lateral and medial pectoral nerves are the motor nerve that supply to the
pectoralis major muscle
11
Q
The length of the pedicle is 6 cm , but can be
in creased slightly based on ap design
A
F The length of the pedicle is 4 cm , but can be
in creased slightly based on ap design
12
Q
The length of the pectoral branch of the lateral thoracic vessels is 3-4 CM
A
T
13
Q
The lateral pectoral nerve enters the pectoralis major muscle on its
deep surface about 3 cm medial to the medial pectoral nerve
A
T
14
Q
Thus the lateral pectoral nerve enters the pectoralis major muscle on its deep surface about 3 cm medial to the medial pectoral nerve
A
T They are named for their origin from the brachial
plexus rather than the anatomic location of the portion of the muscle they supply
15
Q
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
A
T
16
Q
PIC MAJOR usually harvested as a sensate flap
A
F This flap is usually not harvested as a sensate flap
17
Q
Myo-osseous or osteomyocutaneous flap by including the lateral sternal bone via thoracoacromial connections with the internal mammary artery perforators
A
T
18
Q
Myo-osseous or an osteomyocutaneous pic major flap by including the fourth rib
A
F fifth rib
19
Q
Myo-osseous flap by including clavicular head via the pectoral branch
of the thoracoacromial artery
A
F Myo-osseous flap by including clavicular head via the clavicular branch
of the thoracoacromial artery
20
Q
Two separate muscle flaps, one based on the pectoral branch of the thoracoacromial artery and one based on the lateral thoracic artery
A
T
21
Q
reliable skin paddle could also be designed directly
over the thoracoacromial artery
A
T
22
Q
In obese patients in case we want to take the PMMC what we should do ?
A
superomedially over the internal mammary perforators in the third intercostal space, wherenthere is usually less soft-tissue bulk.
23
Q
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
A
T
24
Q
The course of the thoracoacromial artery can be estimated by drawing a line from the acromion to the xiphoid
process
A
T
25
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
26
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
27
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
28
the pedicle can be completely dissected from the muscle
with appropriately delicate technique to minimize bulk
T
29
Substantial undermining is often necessary when a wide skin paddle (> 5 cm)
T
30
For the longest arc of rotation, the skin paddle of the PMMC pedicled
the flap should be centered over the fourth intercostal space
T
31
Temporoparietal Fascia Flap
32
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
33
The TPFF is one of the thinnest and
most pliable vascularized flaps in the body
T
34
TPF–cutaneous (hair-bearing) flaps have been utilized for brow restoration and
upper lip reconstruction (mustache in men)
T
35
the workhorse flap for
microtia and ear reconstruction
T
36
A composite TPFF–osseous
flap using a split outer calvarial bone has been described for craniofacial
reconstruction. In this scenario,
T
37
The TPFF has been favored in dorsal hand and foot coverage for its ability to allow thin vascular tissue coverage and tendon gliding
T
38
TPF–cutaneous (hair-bearing) flaps have been utilized for brow restoration and
upper lip reconstruction (mustache in men)
T
39
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
40
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
41
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.
42
The STA is tortuous and release of this tortuosity may add an extra 1 to 2 cm of length to the
pedicle.
T
43
The STA lies anterior to the STV
T
44
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
45
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.
46
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
47
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
48
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
49
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
50
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
51
Flap dimensions of up to 12 × 14 cm can be elevated
T
52
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
53
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
54
Scar alopecia at the T and Y incision junction has been
reported in up to 8% of patients
T
55
Flap dissection past the temporal fusion
line is more difficult as fibrous connections to the scalp exist in this area.
T
56
Staying 2 to 3 cm posterior to the anticipated course of the frontal branch of the facial nerve is important
T
57
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
58
The drain should be positioned away from the vascular pedicle when the the TPFF is used as a pedicled flap
T
59
The most common complication after elevation of TPFF is alopecia
T Avoidance of unipolar cautery is
recommended during flap elevation
60
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
61
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
62
Deltopectoral Flaps
63
Vascular Pedicle
based on the perforating branches of the
internal m amm ary artery arising through the second, third, and
fourth intercostal spaces
64
marked 3 to 4 cm lateral to the
anterior sternal midline in the second, third, and fourth intercostal
spaces
T
65
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
66
the lower incision commences inferior to the fourth intercostal space
T
67
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
68
There is a constant perforator from the thoracoacromial ial
access that arises through the clavipectoral fascia that requires
division during elevation
T
69
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
70
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
71
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
72
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
73
Paramedian forehead flap
74
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
T
75
The vasculature of the forehead includes the supraorbital, supratrochlear, infratrochlear, and dorsal nasal arteries and angular artery
T
76
As the supraorbital comes around the orbital rim, it enters a plane between the corrugator muscle
deeply and the frontalis muscle superficially.
T
77
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
78
Dissection of the middle third of the flap is performed in the submuscular/
subgaleal plane beneath the frontalis muscle
T
79
the inferior third of the flap the plane of dissection changes to the subperiosteal plane
T
80
The supratrochlear vessels exit from the supraorbital foramen
F does not exit any bony foramen in the
vicinity of the orbital rim,
81
The oblique design of the flap can be less reliable secondary to not fully capturing the axial supratrochlear vessels
T
82
Temporalis Muscle Flap
83
type 4
f type 2
84
size of the flap
10*20
85
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
86
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
87
Dynamic movement is achievable through the third division of the trigeminal
nerve (V3)
T
88
The temporalis muscle is a flexible, fan-shaped Mathes and Nahai type III flap of moderate thickness
?? Grabb type 2
89
The muscle is 12 to 16 cm in length with a thickness of
0.5 to 1.0 cm.
T
90
The temporalis muscle is innervation
The temporalis muscle is innervated by the deep temporal nerves from the
mandibular branch of the trigeminal nerve.
91
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
92
which pedicles which usually sacrificed for muscle transfer
The middle temporal art
93
The superior margin is
approximately halfway between the upper margin of the ear and the vertex
t
94
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
95
Submental Flap
96
(70%)Of the submental art run deep to the anterior belly of
the digastric muscle
T
97
the flap is needed for the reconstruction of defects
superior to the lower two-thirds of the face
T
98
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
99
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
100
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
101
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
102
The submental flap has been used for microvascular reconstruction due to its favorable pedicle diameter and length
T
103
Supraclavicular Cutaneous Pedicled Flap
104
Supraclavicular Cutaneous Pedicled Flap type B flap
T
105
The SCP flap is an axial fasciocutaneous flap based on the supraclavicular artery.
The supraclavicular artery is a branch of the transverse cervical artery
T
106
The main pedicle runs
perpendicular to the transverse cervical vessels toward the acromioclavicular joint and proceeds over the deltoid muscle
T
107
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
108
The main nerve branch originates from the
posterior aspect of the sternocleidomastoid muscle along the midpoint of the
muscle belly
T
109
Preoperative imaging and radiographic studies are typically not necessary for
flap elevation
T
110
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
T
111
The muscle fibers
of the trapezius are more adherent than those of the deltoid and may require
additional blunt dissection
T
112
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
113
Gracilis Muscle and Myocutaneous Flaps
114
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
115
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
116
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
117
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.
118
Ligation
of this proxim al m minor pedicle does not adversely affect blood supply to the flap
T
119
distal pedicles arise from the superficial femoral artery and the most distal minor pedicle can arise from the popliteal vessels
T
120
only one adjacent perforator zone can be incorporated into an ap based solely on the main pedicle to prevent distal skin necrosis
T
121
Most musculocutaneous perforators are located in the distal two-thirds
F Most musculocutaneous perforators are located in the proximal two-thirds
122
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
123
The length of the
skin paddle w hen placed vertically should not exceed two-thirds
of the m uscle length
T
124
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
125
Septocutaneous perforators may arise from the m ain gracilis vascular pedicle between the adductor longus and the gracilis muscle
T
126
More frequently the signicant septocutaneous perforator is from the rst
m inor pedicle distal to the m ain pedicle
T
127
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
128
These proxim al m usculocutaneous and septocutaneous perforators contribute to success of
the transverse orientation of the skin paddle
T
129
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.
130
Length of pedicles : 6 to 8 cm
T
131
cutaneous branch of the obturator
nerve supplies m edial thigh skin
T
132
the gracilis m uscle is located just posteriorly to the adductor longus m uscle
T
133
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
134
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
135
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
136
the w idth of the m uscle (5 to 8 cm in adults)
T
137
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
138
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
139
Care is taken
not to injure the saphenous nerve during dissection of the tendinous portion
T
140
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
141
Th e muscular fascia need to be closed
F The m muscular fascia does
not need to be closed
142
skin graft after a
gracilis myocutaneous Flap is rare
T
143
Do not damage the posterior cutaneous nerve of the thigh
during transverse skin paddle harvest
T
144
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
145
The deep fascia is always incised and the adductor longus is retracted anteriorly to expose the pedicle vessels
T
146
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
147
Dynamic movement is achievable through the third division of the trigeminal
nerve (V3)
T
148
Scapular and Parascapular Flaps
148
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
149
The circumflex scapular artery
(external diameter: 2.5–3.5 mm)
150
The circumflex scapular artery traverses
the triangular space before dividing into its terminal cutaneous scapular and parascapular branches
T
151
The triangular space, bounded by the long head of triceps laterally, the teres minor and subscapularis superiorly, and the teres major inferiorly
T
152
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
153
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
154
The thoracodorsal artery travels an average of 8.4 cm before diving into branches to serratus anterior and latissimus dorsi
T
155
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%)
156
angular branch travels just deep to the superior border of latissimus dorsi, and at around
the scapular tip
t
157
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
158
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.
159
osseointegrated dental implants can be used with scapular bon flap for mandibular reconstruction
F poor for osseointegrated dental implants due to inadequate bone thickness
160
The angular tip of the scapula is preferred for reconstruction of the maxilla
T
161
The scabular tip can reconstruct the entire palatoalveolar complex without the need for contouring osteotomies when placed horizontally
T
162
The latissimus dorsi or teres major muscle can be harvested with the angular tip and used for soft-tissue reconstruction of the palate
T
163
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
164
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
165
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
166
If additional length is required, the thoracodorsal branch can
be ligated thereby including the subscapular vessels, which originate from the axillary vessels,
T
167
The scapular tip can be accessed through a parascapular fasciocutaneous or
latissimus dorsi myocutaneous free flap incisions if a chimeric flap is required
T
168
Skin grafting on the back is best avoided due to poor graft take
T
169
The scapular flap is useful as a second-line option for mandibular and
maxillary reconstruction when the fibular flap is not available
T
170
The scapular (transverse) or parascapular (oblique) skin paddle is based on the circumflex scapular artery, which also supplies the lateral scapular bone.
T
171
The lateral border of the scapula oriented vertically is used to reconstruct an ipsilateral hemimaxillectomy
or lateral mandibulectomy defect
T
172
Trapezius flap
173
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
174
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
175
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
176
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
177
The inferior fibers
The inferior fibers originate from the spinous processes of T4 to T12 and insert
on the spine of the scapula
178
The trapezius muscle is innervated by the spinal accessory nerve (cranial nerve XI)
T
179
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
180
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
181
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
182
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
183
Turnover flap based on the posterior branches of the intercostal vessels
T
184
10 × 2 cm segment of scapular spine can be harvested with
the flap for use in mandibular reconstruction
T
185
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
186
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
187
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
188
A skin island up to 20 × 8 cm can be supported on the middle and inferior fibers of the trapezius
muscle flap
T
189
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
190
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
191
the flap can
be based on either the descending branch of the transverse cervical artery or
the dorsal scapular artery or both
T
192
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
193
Dividing the dorsal scapular artery can
reduce the blood supply to the flap, but increases its arc of rotation and reach
T
194
undermining across the midline may eliminate the possibility of a contralateral trapezius
myocutaneous flap skin island in the future
T
195
LD Flap
196
The Origen of the LD muscle
The muscle originates from the spine of the lower six thoracic vertebrae through the posterior thoracolumbar fascia,
from the spine of the lumbar and sacral vertebrae
, and the posterior crest of the ilium.
small muscle slips from the lower four ribs as well as a slip of muscle from the external oblique muscle of the abdomen
197
The upper and anterolateral muscle borders
are primarily free
T
198
The vessel enters the muscle on the deep surface approximately 10 cm from the insertion
F The vessel enters the muscle on the deep surface approximately 10 cm from the origin, essentially where the muscle forms the posterior
axillary fold.
199
LD flap type 3 muscle flap
F TYPE 5
200
Blood supply
The thoracodorsal artery
Segmental minor pedicles, perforating branches from the intercostal and lumbar arteries, enter posteriorly and form the vascular basis of a transverse as well as
medially based latissimus muscle or myocutaneous flap
201
The nerve supply is from the thoracodorsal nerve, a branch of the posterior
cord of the brachial plexus
T
202
The nerve is frequently divided in breast reconstruction to avoid
muscle animation
T
203
The flap is usually not harvested as a sensate flap
T
204
Cutaneous thoracodorsal artery perforator flap based on lateral muscle
perforators of the thoracodorsal pedicle
T
205
For patients with small- to medium-sized breasts, the extended latissimus dorsi
myocutaneous flap can include as much of the surrounding subcutaneous and
submuscular fat as well as overlying skin
T
206
little to no functional disability is seen from sacrifice of the
latissimus dorsi muscle.
T
207
The width of the skin island is often
limited to 8 to 10 cm and the length to 20 cm
T
208
If the transfer of the muscle, anteriorly, is impeded by restricted rotation of the thoracodorsal pedicle, the serratus branch can be divided for greater
length of the pedicle arc
T
209
ligation of the serratus anterior branch of the thoracodorsal artery, angular (scapular tip) branch of the thoracodorsal artery, and circumflex scapular artery. By doing so, a pedicle of 8 to 10 cm can be harvested
with the flap.
T
210
The latissimus dorsi muscle or myocutaneous flap can be split longitudinally, basing the flap on either the descending (lateral) or transverse (medial)
branch of the thoracodorsal artery
T
211
Thoracodorsal pedicles branch 10 cm before entering the muscle
F 2 CM
212
Recognition of good latissimus contraction preoperatively is important, since latissimus muscle atrophy can occur in breast cancer patients postmastectomy, possibly reflecting compromise of the vascular pedicle
of the latissimus muscle
T
213
Use of the latissimus dorsi myocutaneous flap based on retrograde flow
from the serratus anterior branch has been described in cases where
the proximal pedicle has been transected during an axillary dissection
or other prior surgery
T
214
Transverse Rectus Abdominis Myocutaneous
Free Flap
215
the arcuate line (semicircular line or arc of
Douglas), which is generally located halfway between the umbilicus and symphysis pubis. Inferior to this point the internal oblique aponeurosis ceases
T
216
The transversalis fascia is the only layer deep to the rectus
abdomini and therefore this is an area of weakness postoperatively
T
217
The DSEA arises from the internal
the mammary artery at the level of the 5TH intercostal space
F The DSEA arises from the internal
mammary artery at the level of the sixth intercostal space
218
The DIEA usually originates 1 cm above the inguinal ligament from the external iliac artery and pierces the transversalis fascia to enter the rectus sheath just below the arcuate line where it runs on the deep surface of the rectus abdominis muscle.
T
219
The DIEA has single venae comitante, which usually join to form a single vein
prior to their junction with the external iliac vein
F The DIEA has two venae comitantes, which usually join to form a single vein
prior to their junction with the external iliac vein
220
SIEV
is usually found just deep to Scarpa’s fascia, two-thirds the distance from the
midline symphysis pubis to the anterior superior iliac spine
T
221
The veins of the
superficial system travel above Scarpa’s fascia and communicate extensively
across the midline. The superficial veins drain into the deep venous system by
way of the veins accompanying the arterial perforators
T
222
Hartrampf zones
Zone I refers to the skin overlying the rectus abdominis muscle on the side ipsilateral to the vessel used.
Zone II is the skin overlying the contralateral rectus abdominis muscle.
The skin lateral to linea semilunaris on the ipsilateral side is referred to as zone III,
and the skin lateral to the contralateral linea semilunaris is zone IV
223
The motor and sensory innervation comes from the T7 to T12 intercostal nerves, which traverse the plane between the transversus abdominis and the external oblique muscles
F
which traverse the plane between the transversus abdominis and the internal oblique muscles
224
During harvesting of the flap all the motor nerve need to sacrifice
F Efforts should be made to preserve the inferior-most larger
nerve near the arcuate line as this nerve has been shown to provide motor innervation to the entire muscle
225
MS-TRAM free flap based on the deep inferior epigastric vessels, some muscle is taken, pedicle not completely skeletonized
T
226
The
intercostal spaces are palpated to find an optimal space that is wide and readily accessible for comfortable microvascular anastomoses. This is usually at
the second or third intercostal space
T
227
the pectoralis muscle is removed to expose the intercostal space
F the pectoralis muscle is split in the
direction of its fibers to expose the intercostal space
228
Vessels usually within 1
to 3 cm from the edge of the sternum
T
229
If there is a single vein, it is usually medial
to the artery. If there are two veins, then the artery is usually between the veins
T
230
Adjacent cartilage does not need to be removed routinely
T
231
Some surgeons prefer to remove
a 2 to 4 cm segment of rib cartilage routinely to access the internal mammary
vessels
T
232
The decision to perform an MS-TRAM or a DIEP flap is based on the number, caliber, and
location of perforators as well as their orientation and course within the rectus
muscle
T
233
When a flap
based off the DIEA is used, this is best done with a flap from the contralateral side of the abdomen rotated approximately 90 degrees counterclockwise,
resulting in the vascular pedicle lying medial
T
234
If the fascia integrity is poor or a
significant amount of fascia was harvested thus making a tension-free primary
closure difficult, mesh is used to reinforce the closure
T
235
Closed-suction drains are
placed above the fascia closure in the subcutaneous tissue
T
236
Fat necrosis and partial flap loss result from inadequate perfusion. In
almost all cases zone IV should be discarded. Usually, a small portion
from the corner of zone III is also discarded.
T
237
Transverse Rectus Abdominis Myocutaneous
Pedicled Flap
238
it was the first completely autologous, Tow -stage option for
breast reconstruction
F it was the first completely autologous, single-stage option for
breast reconstruction
239
The rectus muscles originate from the anterior aspect of the xyphoid process
and sixth, seventh, and eighth costal cartilages
T
240
Deep to the fifth interspace, the IMA divides into musculophrenic and superior epigastric arteries (SEAs)
F Deep to the sixth interspace, the IMA divides into musculophrenic and superior epigastric arteries (SEAs)
241
at a distance of
approximately 2.5 to 4 cm from the midline. Just above the umbilicus, the superior epigastric vessels combine with the deep inferior epigastric system in a
web of choke anastomoses
T
242
patterns of flap perfusion based on the DIEA
type I, the SEA descends to anastomose with a single DIEA. In type II, the most commonly encountered variant, the DIEA branches into two vessels at the arcuate line, communicating with the superior system in a complex network of choke
vessels.
In type III, the DIEA branches into three vessels at the arcuate line, with a greater number of anastomoses with the superficial system
243
The epigastric
vessels send perforating vessels through the muscle in two rows, medial and
lateral, to the overlying skin. These perforating vessels are of greatest density at
the level of the umbilicus, and should therefore be included in the skin island
of the pTRAM.
T
244
Zone I lies directly
over top of the ipsilateral rectus muscle.
T
245
Originally it was felt that zone II constituted the tissue directly across the midline, overlying the contralateral rectus
muscle, with zone III lateral to the ipsilateral rectus, and zone IV in the same
position contralaterally
T
246
It is now widely recognized that the tissue lateral to the
ipsilateral rectus (traditionally zone III) has superior perfusion than the tissue
directly across midline (zone II). As such, the ipsilateral hemiabdomen now is
composed of zones I and II as well as the contralateral hemiabdomen zones III
and IV
T
247
the rectus muscles receive minor segmental
blood flow from the 8th to 12th intercostal vessels. These vessels form anastomotic connections with the epigastrics on the deep surface of the muscle. The
eighth intercostal artery is the largest of these
T
248
Motor innervation to the rectus muscles is supplied segmentally by the lower
seventh intercostal nerves that travel between internal oblique and transversus
abdominis accompanied by their vascular pedicles
F Motor innervation to the rectus muscles is supplied segmentally by the lower
six intercostal nerves that travel between internal oblique and transversus
abdominis accompanied by their vascular pedicles
249
Cutaneous sensation is
provided by T7, T8, and T9 above the umbilicus; T10 at the umbilicus; and T11,
T12, and L1 below the umbilicus.
T
250
fascia
below arcuate line not violated.
T
251
Patients with significant
cardiovascular or obstructive lung disease are not good candidates for pTRAM
T
252
A transverse elliptical skin island is marked over the lower
abdomen, extending from 2 cm above the umbilicus to the suprapubic crease
in the midline and tapering to each ASIS laterally. The inferior incision should
lie above the hair-bearing region of the pubis to avoid wound healing complications
T
253
the skin island is divided and elevated on the ipsilateral side to expose the
medial row of perforators
F the skin island is divided and elevated on the contralateral side to expose the
medial row of perforators
254
The anterior rectus sheath is then incised medially and laterally along its
length preserving a 1 to 2 cm cuff of fascia on either side
T
255
If the patient did not undergo a delay procedure,the vessels from DIEA are then ligated as proximally as possible to preserve length for possible micro anastomosis (supercharge) in
case of vascular compromise
T
256
The ipsilateral design may lead
to decrease epigastric bulging
T
257
A right flap is rotated
counterclockwise approximately 180 degrees through the tunnel so that the
lateral edge of zone II lies in the lateral aspect of the defect. Similarly, a left
flap is rotated clockwise
T
258
Consider delay procedure in patients with comorbidities, or where
more than 50% of lower abdominal tissue required. Ensure division of
the DIEA as proximal to take off from iliac as possible to preserve DIEA
pedicle length for potential supercharging
T
259
In flaps that appear vascularly compromised, supercharging of the
DIEA/V to the thoracodorsal vessels can be a salvage option.
T
260
Deep Inferior Epigastric Perforator Flap
261
The deep inferior epigastric perforator (DIEP) flap was designed to spare the rectus muscle and fascia entirely, decreasing the
abdominal donor site morbidity encountered with the transverse rectus abdominus myocutaneous (TRAM)
T
262
the deep inferior epigastric
artery perforators, which are usually located within a 10-cm radius from the
umbilicus.
F the deep inferior epigastric
artery perforators, which are usually located within a 5-cm radius from the
umbilicus.
263
The deep inferior epigastric artery originates from the medial aspect of the
external iliac artery just proximal to the inguinal ligament
T
264
The deep inferior epigastric artery then most commonly divides into two branches that
give off perforating vessels to the muscle and skin via a medial and lateral row
T
265
musculocutaneous perforators may
follow a short transverse course, a long transverse course, or a directly perpendicular course.
T
266
Lateral row perforators are more frequently perpendicular
T
267
medial row perforators branching
medially to form anastomoses across the midline and lateral row perforators
rarely extending across the midline
T
268
Inguinal lymph nodes based on the superficial circumflex iliac vessels may be harvested with the DIEP flap for treatment of the upper extremity
lymphedema.
T
269
The DIEP flap may be designed in a vertical fashion and based on single
perforators to cover small soft-tissue defects.
T
270
Pure sensory nerves running with the perforators can often be dissected for
several centimeters for innervation of the skin island
T
271
The anterior rectus fascia is closed primarily with nonabsorbable sutures
T
272
Previous Pfannenstiel incisions will generally not cause injury to the
inferior epigastric vessels.
T
273
Superficial Inferior Epigastric Artery Flap
274
The superficial inferior epigastric artery flap does not
require opening the rectus sheath or dissection of the rectus abdominis muscles, thereby completely preserving the strength and integrity of the abdominal wall.
T
275
this flap is applied more frequently than the TRAM, MS-TRAM, and DIEP flaps,
F this flap is applied less frequently than the TRAM, MS-TRAM, and DIEP flaps,
mostly due to the variable presence and caliber of the SIEA
276
the SIEA is an
adipocutaneous flap vascularized by a pedicle with a subcutaneous course.
T
277
The diameter of the SIEA ranges from 0.3 to 3.1 mm
T
278
many surgeons seek a SIEA diameter of 1.5 mm or greater when considering harvesting
this flap.
T
279
The SIEA most often originates from the common femoral artery, approximately 2 to 3 cm below the inguinal ligament
T
280
It most often arises from a
common trunk with the superficial circumflex artery. Less commonly, it may arise as a side branch of the deep femoral artery or pudendal artery
T
281
the SIEA crosses the inguinal ligament
and lies deep to Scarpa’s fascia
T
282
The SIEA crosses the inguinal ligament at the midpoint between the anterior superior
iliac spine (ASIS) and pubic symphysis
T
283
The SIEV is located superficial and medial to the SIEA.
The pedicle length of this flap ranges from 4 to 8 cm
T
284
The SIEA flap may be raised with a sensory component via the 10th to 12th
intercostal nerves
T
285
Contraindications for the SIEA flap include previous abdominoplasty, a long
Pfannenstiel scar that transects the SIEA, or any other abdominal scar would cut across the course of the SIEA
T
286
Relative contraindications would
include prior abdominal liposuction and/or active smoking, which may lead to
a higher incidence of partial flap or fat necrosis
T
287
Vascular imaging (i.e., ultrasound or CTA) can be used preoperatively to assess
the size and location of the vessels, It"s routinely used
F , not routinely used
288
the suitability of the SIEA
should be evaluated intraoperatively.
T
289
The lower incision marking for the SIEA flap should be as low as possible in order
to increase the chance of finding an SIEA of adequate diameter, typically, just
above the pubic hairline, at least 5 to 7 cm above the vulvar commissure
T
290
Patients with a SIEA of approximately 1.5 mm or greater diameter should be
considered potentially suitable candidates for the SIEA flap
T
291
the
SIEA is typically located deep and lateral with respect to the SIEV and may be
above or below Scarpa’s fascia
T
292
The SIEA pedicle is overall shorter, more superficial, and
laterally located in comparison to the DIEA, which increases the difficulty of flap inset
T
293
The SIEA unreliably supplies the contralateral hemiabdomen. As such, great caution should be taken and serial intraoperative evaluation should be performed when considering inclusion of flap tissue more than 2 cm lateral to the midline on the contralateral side
T
294
Vertical Rectus Abdominis Myocutaneous
Flap Free/Pedicled Flap
295
The VRAM is most commonly used as a
free flap
F The VRAM is most commonly used as a
pedicled flap but due to its ease of pedicle dissection and reliable anatomy, it is
also used as a free flap for upper extremity, lower extremity, and head and neck
reconstruction
296
with diastasis recti the rectus muscles will have translated laterally resulting in the fusion of
the anterior and posterior rectus fascial sheaths medially
T
297
The eighth intercostal vessels are
a known contributor to the superior epigastric pedicle and provide collateral flow in the event the internal mammary system has been harvested for cardiothoracic indications.
T
298
The nerve supply of the rectus abdominis consists of the 7th through 12th intercostal motor and sensory nerves that enter the muscle bellies laterally
T
299
In male patients and women with an android pelvic configuration, the pelvic
inlet is quite narrow which may make passage of the VRAM for pelvic reconstruction difficult, requiring thinning of the flap
T
300
The cutaneous epigastric
perforator zone extends on average 6 cm above to 6 cm below the umbilicus
and 2 cm lateral to the linea alba to 6 cm lateral to the linea alba
T
301
Groin/Superficial Circumflex Iliac Artery
Perforator Flap
302
The major advantage of the groin flap represents its hairless skin and inconspicuous donor site scar
T
303
This flap used as a free flap more than as a pedicle flap
F the flap is mainly
used as a pedicle flap to cover hand and arm wounds and infrequently used as
a free flap mainly due to its bulk, anatomical variability, and its short pedicle
length
304
The SCIP flap preserves the advantages of a groin flap with its
easily concealed donor site scar but also overcomes its disadvantages of short
pedicle length and bulkiness
T
305
The SCIP flap harvest
does not require muscle or nerve dissection leading to no functional deficits
and short operative time
T
306
The groin flap is primarily a pedicled flap for coverage of dorsal hand
and distal forearm wounds
T
307
The SCIA (0.8 to 1.8 mm in diameter) and its concomitant vein arise from the
femoral vessels underneath the deep fascia of the thigh about 2.5 cm inferior to
the inguinal ligament dividing into superficial and deep branches about 1.5 cm
from the femoral artery
T
308
The superficial branch perforates the deep
fascia immediately after its origin from the femoral artery and travels superolateral to the ASIS
T
309
In 15% of cases, the superficial vessel splits into two additional
branches, one (superficial) supplying the skin and one (deep) supplying the fascia lata and muscle, although the superficial branch can be hypoplastic or even
absent. In contrast to the superficial branch, the deep branch is mostly present
and long and large
T
310
The deep branch travels superolateral underneath the deep
fascia provides multiple muscle perforators and branches and finally penetrates
the deep fascia at the lateral border of the sartorius muscle is about 6 cm lateral
to the femoral artery
T
311
The dominant perforator of SCIA is mostly located around
1.5 to 3 cm superomedial to the ASIS and measures in average 0.85 mm
T
312
The SCIP flap can be based on either the superficial or deep SCIA branches or both.
F The
SCIP flap can be based on either the superficial or deep SCIA branches or both.
313
The SCIA may arise directly from the superficial femoral artery, the external
iliac artery, or a common trunk with the deep circumflex iliac artery (DCIA)
T
314
The lateral femoral
cutaneous nerve crosses the arterial deep branch on top or below
T
315
The concomitant vein of the SCIA system drains into the femoral vein. There
are also cutaneous veins that run parallel to the SCIA in the superficial layer of
subcutaneous tissue that ultimately drain in to the greater saphenous vein
T
316
Chimeric flap with vascularized iliac crest bone flap (based on DCIA) and
SCIP flap
T
317
Sensate SCIP flap based on lateral femoral cutaneous nerve
T
318
The long axis of the flap is centered on the
course of the SCIA, which is located 2 to 3 cm inferior and parallel to inguinal
ligament
T
319
The flap can be extended up to the posterior iliac spine
laterally and to the femoral vessels medially
T
320
Flap dimensions measure up to
25 cm in length and up to 8 to 10 cm in width
T
321
The origin of the flap
pedicle is found within the triangle formed by the lateral border of the adductor
longus muscle medially, inguinal ligament superiorly and the medial border of
the sartorius muscle
T
322
The deep
fascia is incised at the lateral border of the sartorius muscle and the superficial
circumflex iliac vessels are dissected to their origin
T
323
The SCIP flap can be harvested based on either the superficial or the deep
branch of the SCIA system.
T
324
The relationship between the superficial and deep
system is complementary, when the superficial system is small, then the
deep system is large and vice versa.
T
325
The lateral
femoral cutaneous nerve may occasionally need to be transected during flap
harvest
T
326
The cutaneous vein in the medial part of the flap is included to overcome the
sometimes too small caliber (< 0.5 mm) of the concomitant vein accompanying
the flap pedicle
T
327
As a modification, the flap can also be harvested at the level of the superficial
fascia preserving the deep adipose tissue of the subcutaneous fat containing
lymphatics and lymph nodes
T
328
The pedicle is somewhat short with mean length of 4.8 ± 1.3 cm (range:
3–8 cm)
T
329
although microdissection of the perforator can yield to a pedicle with
a mean length of 7 cm
T
330
Primary donor site closure can be achieved if the flap width is less than approximately 8 to 10 cm
T
331
The SCIP flap has lower donor site morbidity, less bulkiness, and longer
pedicle length compared to the conventional groin flap
T
332
The SCIP flap can be elevated based on the superficial branch of the SCIA
system in over 90%. If the superficial branch is absent or hypoplastic, the
flap can be harvested on the deep branch of the SCIA
T
333
A major disadvantage of the SCIP flap is its limited pedicle length. If a
pedicle length of more than 7 cm is needed, a vein graft mostly becomes
necessary. This limitation applies often only to the artery, since the vein
can be dissected out often longer than 10 cm
T
334
Superior Gluteal Artery Perforator Flap
335
Typical Indications
Breast reconstruction
Sacral and low trunk defects, as a pedicled flap
336
The internal iliac
artery arises from the bifurcation of the common iliac artery at the entry of
the pelvis, just anterior to the sacroiliac join
t
337
After approximately a 4 cm posteromedial course, the internal art exits the pelvis through the greater sciatic foramen and
divides into anterior and posterior divisions
t
338
The anterior division continues
downward, anterior to the piriformis muscle, to give rise to several branches,
including the inferior gluteal artery
t
339
The posterior division
of the internal iliac artery pierces the sacral fascia and passes superior to the
piriformis muscle. It further divides into deep and superficial branches. It is
the superficial branch (superior gluteal artery) that courses into the gluteus
maximus muscle belly and supplies multiple perforating branches that go on
to supply the overlying fat and skin
t
340
The superior gluteal artery enters the deep surface of the gluteus maximus
muscle medially. Therefore, the medially located perforators are closer to the
origin of the parent vessel and have a short intramuscular course
t
341
The laterally located perforators, however, travel 3 to 5 cm in the gluteus Maximus muscle before entering the fat and skin above. As a result, the lateral perforators tend to be better choices for SGAP flap design because they provide longer pedicle
length.
T
342
While the SGAP flap does not include muscle in the flap itself,
T
343
The gluteus maximus muscle originates
originates from the outer surface of ilium, lateral
mass of sacrum, and coccyx. It inserts into the gluteal tuberosity of the femur and
iliotibial tract
344
The piriformis muscle is located deep to the gluteus
maximus muscle,
T
345
originating on the anterolateral surface of the sacrum and
inserting on the medial aspect of the greater trochanter of the femur
T
346
The superior gluteal artery tends to be on the smaller side, ranging
from 1.5 to 2.0 mm in diameter while the accompanying vein tends to larger,
about 2.5 mm in diameter on average.
T
347
Flap dimensions can be up to 30 cm in length and 12 cm in width,
T
348
The PSIS and greater trochanter are marked and a line connecting these two points is drawn. The majority of the perforators will be found
near the junction of the medial two-thirds and lateral one-third of this line
T
349
The dissection
starts in a suprafascial plane but is quickly transitioned into a subfascial plane
when the gluteus maximus muscle is encountered
T
350
Caution should be used when retracting
these muscles since excess retraction of the piriformis muscle can cause traction on the sciatic nerve, manifesting at postoperative neuropraxia
T
351
Further flap stability can be obtained by suturing the flap
to the deep surface of the medial mastectomy skin or to the chest wall
laterally
T
352
Inferior Gluteal Artery Perforator Flap
353
The gluteal artery perforator flaps are usually reserved as secondary options
for women that desire free autologous flap breast reconstruction
T
354
The gluteal artery perforator flaps are usually reserved as secondary options
for women that desire free autologous flap breast reconstruction
T
355
It is particularly advantageous for women with smaller breast
size,
T
356
IGAP flap has a longer pedicle and typically results in less distortion of the gluteal region than SGAP flap
T
357
Typical Indications
* Breast reconstruction (free flap).
* Perineal reconstruction (pedicled flap).
* Posterior thigh reconstruction (pedicled flap).
358
The inferior gluteal artery accompanies the greater sciatic nerve, the internal
pudendal vessels, and the posterior femoral cutaneous nerve
T
359
The junction of the lower and middle thirds of a line drawn between the
posterior superior iliac spine (PSIS) and outer part of the ischial tuberosity
T
360
he inferior gluteal artery descends into the thigh
accompanied by the posterior femoral cutaneous nerve
T
361
the caliber of the
inferior gluteal artery is around 2 mm and the vein around 3.5 mm. The IGAP
flap pedicle length is typically 7 to 10 cm
T
362
V–Y pedicled advancement flap for reconstruction of abdominoperineal
resection (APR) defects.
T
363
the
inferior limit of the flap is marked 1 cm inferior and parallel to the gluteal
fold
T
364
The superior limit is drawn approximately 7 cm cephalad to this
T
365
The
length of the flap parallels the gluteal fold and is typically approximately
18 cm in length
T
366
. Care is taken at the caudal aspect to
protect the posterior femoral cutaneous nerve since injury will result in paresthesia of the posterior thigh and leg
T
367
The sciatic nerve should
never be visualized
T
368
it is preferable to harvest two perforators for improved flap perfusion particularly venous drainage
T
369
Usually, the artery is smaller
than the internal mammary artery and is the limiting factor
T
370
an artery
of 2.0 to 2.5 mm and a vein of 3.0 to 4.0 mm in diameter are sufficient for anastomosis
T
371
A significant drawback of using the IGAP for free flap breast reconstruction is the long operative time due to position changes and tedious pedicle dissection
T
372
Lateral Arm Flap
373
The flap
can be harvested as a perforator flap or as a fasciocutaneous flap
T
374
The lateral
arm flap has not emerged as a workhorse flap due to concerns regarding pedicle
length and caliber but can be a useful option when a relatively thin and pliable
flap is needed
T
375
flap based on the radial collateral artery
which is a branch of the profunda brachii artery that ultimately anastomoses
with the radial recurrent artery near the elbow
T
376
The main pedicle travels in the septum between the biceps brachii muscle and the triceps
muscle
T
377
The lateral antebrachial cutaneous nerve is a branch of
the radial nerve that travels in close proximity to the main pedicle and often
needs to be divided in order to free the pedicle and flap from the arm
T
378
lateral antebrachial cutaneous nerve can also be used to create a sensate flap
T
379
In certain circumstances, the pedicle and the radial nerve are
densely adherent to the periosteum of the humerus. A periosteal elevator is
useful in performing the dissection to minimize any trauma to the pedicle or
the radial nerve
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pedicle length of
approximately 7 cm with an average arterial diameter of 1.7 mm and an average
venous diameter of 2.5 mm
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The deltoid insertion can be released in order to achieve more pedicle length and diameter if
necessary
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382
An osteocutaneous flap can be harvested to include a portion of the
humerus with the overlying skin paddle of the lateral arm flap
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383
A chimeric flap can also be harvested to include not only the overlying
skin paddle, as well as the humerus, but also a cuff of the triceps muscle
to add additional soft tissue bulk to the flap
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384
the deltoid insertion and the lateral epicondyle. A line connecting these two
points establishes the flap meridian
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up to about half
the circumference of the upper arm can be used for the flap and a skin graft can
be used to close the donor site
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Three consistent perforators, termed A, B, and C,
are located approximately 7, 10, and 12 cm from the deltoid insertion, respectively
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The divided septal
fascia between the biceps and triceps muscle should not be reapproximated as
this can lead to compression of the radial nerve
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Avoid the use of cautery
during the flap harvest as this can cause inadvertent injury to the nerve
resulting in significant donor site morbidity.
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The lateral
arm flap has not emerged as a workhorse flap due to concerns regarding pedicle
length and caliber but can be a useful option when a relatively thin and pliable
flap is needed
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the radial forearm free flap (RFFF) remains an
essential workhorse for pharyngeal, tongue, floor of mouth, and orbital reconstruction as well as for resurfacing modest-sized cutaneous defects throughout
the body.
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Radial Forearm Fasciocutaneous/
Osteocutaneous Free Flap
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Radial Forearm Fasciocutaneous/
Osteocutaneous Free Flap
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The radial artery follows a course in the fascial plane between
the brachioradialis, radial extensors, and the pronator teres
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The forearm skin extends from 2 cm distal to the elbow crease to the wrist
crease and is supplied by perforators from the radial and ulnar artery
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In the proximal third of the forearm, the radial artery
lies between the brachioradialis and the pronator teres
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in the middle third
it lies between the brachioradialis and flexor carpi radialis muscles
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in the distal third it is subcutaneous
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the radial artery runs beneath the abductor pollicis
longus and extensor pollicis brevis, which traverses the “anatomical snuff
box.”
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The radial artery
gives rise to perforating vessels every 1 to 2 cm in the distal forearm
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The venous drainage is via paired venae comitantes that accompany the
radial artery
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400
Despite having valves, numerous interconnections between the
two veins allow for retrograde elevation of the flap
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401
The deep venae comitantes
are the main venous drainage of the RFFF and should be anastomosed when
a free flap is required.
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402
Additional superficial venous drainage of the forearm
is provided by the cephalic, basilic, and median cubital veins. The superficial
venous system can be elevated with the flap and can usually be used as an alternate drainage system.
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403
The medial and lateral antebrachial cutaneous nerves are the sensory nerve
supply to the RFFF and may be elevated with the flap to provide a sensate skin
paddle
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the flap is usually not harvested as a sensate flap
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The medial
cutaneous nerve courses with the basilic vein and the lateral antebrachial cutaneous nerve is a continuation of the musculocutaneous nerve and accompanies the cephalic vein
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A small
number of patients may be radial artery dominant and in that situation, the
contralateral limb, an ulnar artery flap, or an alternative flap should alternatively be chosen
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407
For larger defects, the entire skin of the forearm from the wrist to the elbow
flexion crease can be raised as part of the flap
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408
Most commonly, a strip of forearm skin is raised from approximately 3 × 5 cm
to 6 ×12 cm
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409
Small flaps less than 2 cm in width may be closed primarily obviating the need for a skin graft
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410
Note even when the cephalic vein is large,
the venous output is secondary to the radial venae comitantes and should not
be utilized in place of the main pedicle unless a clear anastomosis between the
superficial and deep venous system can be demonstrated
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Radial Forearm Fasciocutaneous/
Osteocutaneous Free Flap
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412
A proximal adipofascial flap of the midforearm can be incorporated into the flap design, which can be used to provide additional soft-tissue
bulk to obliterate communications between the neck and oral cavity
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413
Osteocutaneous flaps are raised by incorporating a thin segment of the distal
radius bone.5 Segments up to 12 cm
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414
The radial artery supplies vascularity to the radial bone from the pronator teres
to the radial styloid
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415
The retrograde
pedicled flap for hand defects is amendable to elevation under an axillary or
subclavian nerve block
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416
The plane of dissection is superficial to the palmaris longus but may incorporate this tendon if
desired.
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417
The
cutaneous branch of the radial nerve should be identified and preserved
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418
Once the skin paddle of the flap has been raised, a “lazy S” incision is made
from the flap over the course of the radial artery to 1 cm below the antecubital
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419
For sensate flaps, either the lateral cutaneous nerve of the forearm running along with the cephalic vein or the
medial cutaneous nerve centrally located in the forearm should be identified
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420
Radial bone may
be harvested proximally from the insertion of the pronator teres to distally at
the radial styloid.
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Grafting of the radial artery with a vein graft may be considered in radially
dominant patients
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The majority of RFFF donor defects require reconstruction with either a split- or full-thickness skin graft
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423
A postoperative splint is utilized to immobilize the wrist joint for 4 to 6 days until the bolster is removed.
Following elevation of osteocutaneous flaps, protective splinting is employed
for 6 weeks
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424
Osteocutaneous flaps should incorporate no more than 25% of the radial
bone to prevent pathological fractures postoperatively.
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425
The anterolateral thigh (ALT) flap
426
The ALT is most frequently transferred as free tissue for
soft-tissue defects ranging from scalp to lower extremity
t
427
Perforating
branches of the descending branch of the lateral femoral circumflex artery
(LFCA) supply the flap. The LFCA arises from the proximal profunda femoris
artery and divides into the ascending, transverse, and descending branches
t
428
The
descending branch of the LFCA travels deep to the rectus femoris muscle in the
intermuscular septum between the rectus femoris and vastus lateralis muscle
t
429
The vastus lateralis muscle is lateral to the rectus femoris and medial to the
tensor fascia lata (TFL).
t
430
The perforators of the LFCA that perfuse the flap commonly are mostly musculocutaneous (80%) with a course through the vastuslateralis muscle
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431
If present, septocutaneous perforators are most frequently
found proximally
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432
The primary perforator (“B” perforator) is usually found at
the midpoint between the axis from the ASIS to the lateral patella
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433
An “A” perforator frequently is located 5 cm proximal to the “B” perforator, and a “C” perforator 5 cm distal
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434
Venous drainage of the flap is through venae comitantes
that accompany the LFCA
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435
The caliber of the LFCA is approximately 2 to 3 mm
and the vein is slightly larger
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436
Distally the LFCA communicates with the superior
genicular artery above the patella.
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437
The lateral femoral cutaneous nerve (L2–L3),
which emerges from the deep fascia 10 cm below the ASIS, can be included to
provide sensory innervation.
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438
Typical skin paddle width to allow for primary
closure is 8 cm, although larger flaps have been described
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439
The pedicle length is
approximately 8 cm but can vary depending on which perforator is chosen
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440
The
more distal the perforator, the longer the pedicle.
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441
Additionally, two or more
independent skin islands can be designed around separate perforators.
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442
The lateral femoral cutaneous nerve (L2–L3),
which emerges from the deep fascia 10 cm below the ASIS, can be included to
provide sensory innervation.
T
443
A flap width greater than 8 to 10 cm typically cannot be closed primarily and
requires skin grafting
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444
The skin island classically is drawn in a lenticular shape and skewed around the
axis so that one-third of the flap is anterior to the ASIS–lateral patella line (A–P
line) and two-thirds of the flap is posterior to this line
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445
One or more nerve branches to the vastus lateralis are found adjacent to the
pedicle and may need to be sacrificed to mobilize the pedicle. However, they
can be repaired primarily during the donor site closure with neurorrhaphy
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446
Radial Forearm Fasciocutaneous/
Osteocutaneous Free Flap
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447
If there are
no suitable ALT flap perforators or if they are diminutive, then the anteromedial thigh (AMT) flap should be considered
T
448
the perforators to
this medial thigh-based flap typically arise off the rectus femoris branch of the
descending branch of the lateral circumflex femoral vessels
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449
If no significant LFCA perforating vessels are found,
(1) the medial thigh can be explored for perforators or the
(2) ALT flap can be taken with the vastus lateralis muscle thereby increasing the chances of harvesting the skin paddle with extremely small vascular perforators.
450
Gastrocnemius Muscle Flap
451
. Based proximally, the muscle can be rotated to effectively resurface
defects involving the knee and superior third of the tibia
T
452
the
medial head is used most commonly due to its larger size, greater arc of rotation and reach
T
453
risk of peroneal nerve injury during its dissection of the lateral head
T
454
Both heads of the gastrocnemius muscle may be needed to cover large defects of the knee or upper leg. The
soleus muscle should be left intact in these cases to preserve plantar flexion of
the ankle joint
T
455
The flap is most often designed as a muscle-only flap
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456
The
medial head originates from the posterior surface of the femur, superior to the medial condyle. The lateral head originates along the lateral epicondyle of the
femur
T
457
The muscle bellies extend
from the popliteal fossa to the middle third of the leg
T
458
The medial head is about
15 cm long and the lateral head is about 12 cm long
T
459
The plantaris
muscle and tendon lie between the gastrocnemius and soleus and is a key landmark during dissection
T
460
The sural nerve and lesser saphenous vein travels in
the septum between the medial and lateral heads
T
461
The vascular supply is type I according to Mathes and Nahai classification,
with each head independently supplied by a single dominant vascular pedicle the medial and lateral sural arteries.
T
462
The medial sural artery is 5.1 cm in length on average and the lateral sural
artery is 4.8 cm in length on average
T
463
The medial gastrocnemius muscle is also supplied by
small perforating branches of the lateral sural artery and posterior tibial artery.
The lateral gastrocnemius muscle’s minor pedicle is the medial sural artery
T
464
The
skin over the gastrocnemius muscle is supplied by musculocutaneous perforators, which are concentrated in the proximal part of the muscle
T
465
The muscle is innervated by the medial and lateral sural motor nerves,
which are branches of the tibial nerve.
T
466
The nerves are about 5 cm in length
T
467
The nerve can
be cut when raising a pedicled flap to prevent undesirable contraction
T
468
the common peroneal nerve anatomy is of utmost importance
when elevating a lateral gastrocnemius muscle flap
T
469
The common
peroneal nerve follows the posterior and medial aspect of the biceps tendon
T
470
The common
peroneal nerve crosses over the lateral gastrocnemius muscle head distal to the muscle’s origin
T
471
The nerve restricts the arc of rotation and can become strangulated if the muscle flap is rotated and inset on slight tension.
T
472
Gastrocnemius muscle or myocutaneous free flap (rarely used due to the
availability of other options with superior pedicle length and caliber).
T
473
the skin paddle generally
should be less than 6 cm in width in order to allow primary closure of the donor
site in myocutaneous flap
T
474
A longitudinal incision is made in the middle third of the leg, 2 cm posterior
to the medial border of the tibia
T
475
If the popliteal fossa must be crossed in order to facilitate a more proximal pedicle dissection, then the cutaneous incision should be angulated at the
popliteal crease
T
476
The fascia of the deep surface of
the muscle can also be scored for additional advancement and coverage of the
defect
T
477
The lateral
gastrocnemius is separated from the underlying soleus muscle and disinserted
from the Achilles, leaving a 1 cm cuff of tendon in continuity with the muscle flap
T
478
During lateral dissection, care must be taken
to avoid injury of the common peroneal or superficial peroneal nerves
T
479
the arc of rotation can be increased by dividing the muscle
belly’s origin after visualization and protection of the vascular pedicle
T
480
Scoring the deep and superficial fascia overlying the gastrocnemius
muscle will allow for expansion of the muscle to cover a greater surface
area. This maneuver also helps improve skin graft revascularization
T
481
Radial Forearm Fasciocutaneous/
Osteocutaneous Free Flap
T
482
Radial Forearm Fasciocutaneous/
Osteocutaneous Free Flap
T
