Flaps Flashcards
A 28-year-old man is brought to the emergency department after sustaining a dog bite to the face. Physical examination shows subtotal loss of the nose and glabella. Staged reconstruction with a forearm flapis performed, with initial elevation of the flap, placement of cartilage grafts, and creation of nostrils. Thinning and refinement are performed during a second procedure with additional cartilage grafting. The flap is microsurgically transferred to reconstruct the nose in a third procedure. Which of the following is the most appropriate description of this flap? A) Delayed B) Freestyle C) Prefabricated D) Prelaminated E) Tubularized
D) Prelaminated
The flap described in this scenario is a prelaminated flap. A prelaminated flap is an axial flap that is modified with the addition of various grafts (e.g., skin, mucosa, cartilage, bone), re-creating the missing tissues at the donor site prior to flap transfer.
Prelaminated flap
A prelaminated flap is an axial flap that is modified with the addition of various grafts (e.g., skin, mucosa, cartilage, bone), re-creating the missing tissues at the donor site prior to flap transfer.
Delayed flap
A delayed flap is one thatundergoes one or more vascular insults prior to final flap elevation to induce increased circulation and maximize flap perfusion.
Freestyle flap
A freestyle flap is a nonaxial flap harvested by locating a cutaneous Doppler signal in a chosen donor site, identifying the vessels supplying that tissue, and dissecting them down to a pedicle of sufficient length and/or diameter. The anatomy is not known ahead of time, and thus harvest is performed “freestyle.”
Prefabricated flap
A prefabricated flap is created by transferring a vascular pedicleinto an area of tissue that is ideal for transfer to induce angiogenesis from the pedicle into that tissue, which can then be harvested for transfer.
Tubularized flap
A tubularized flap is one that is sewn to itself to create a tube or passive conduit, such as an anterolateral thigh flap used for pharyngoesophageal reconstruction.
A 52-year-old man is brought to the emergency department after sustaining injuries in a motor vehicle collision. Physical examination shows a traumatic degloving injury to the dorsum of the right hand with exposed, intact extensor tendons. Reconstruction with a fascial free flap and full-thickness skin grafting are planned. Which of the following arteries supplies blood to the most appropriate choice of flap? A) Posterior auricular B) Superficial temporal C) Superior thyroid D) Supratrochlear E) Transverse facial
B) Superficial temporal
The temporoparietal fascial flap is supplied by the superficial temporal artery. This thin fascial free flap is useful in reconstruction of traumatic injuries that are not amenable to reconstruction with a skin graft alone. This flap is particularly useful in reconstruction of gliding surfaces with denuded tendons or exposed joints
Temporoparietal fascial flap blood supply
The temporoparietal fascial flap is supplied by the superficial temporal artery.
Temporoparietal fascial flap
This thin fascial free flap is useful in reconstruction of traumatic injuries that are not amenable to reconstruction with a skin graft alone. This flap is particularly useful in reconstruction of gliding surfaces with denuded tendons or exposed joints
A 48-year-old man has infected hardware 4 weeks after undergoing spinal fusion. The neurosurgeon washes out the wound and requests consultation for coverage of the defect. In the operating room, the plastic surgeon notes that coverage with a paraspinous muscle flap is not possible, as the muscle has been heavily debrided by the neurosurgeon. Use of a reverse latissimus dorsi flap is planned. These two flaps share an arterial blood supply from which of the following arteries? A) Circumflex scapular B) Posterior intercostal C) Superior gluteal D) Thoracodorsal E) Transverse cervical
B) Posterior intercostal
The paraspinous muscle is supplied by the posterior intercostal artery; this is the same vessel that supplies the reverse latissimus dorsi flap. For a midline spinal defect, it is unlikely that these vessels are damaged; however, this is possible in large oncologic resections or traumatic injuries
The paraspinous muscle is supplied by:
The posterior intercostal artery
The reverse latissimus dorsi flap is supplied by:
The posterior intercostal artery
The circumflex scapular artery supplies what flaps?
The scapular and parascapular flap
The parascapular flap is supplied by:
The circumflex scapular artery
The scapular flap is supplied by:
The circumflex scapular flap
The transverse cervical artery supplies:
The trapezius muscle flap
The trapezius muscle flap is supplied by
The transverse cervical artery
The superior gluteal artery supplies:
The gluteus maximus flap
The gluteus maximus flap is supplied by:
The superior gluteal artery
The thoracodorsal artery is the main arterial supply to:
The latissimus muscle
The main supply to the latissimus muscle:
The thoracodorsal artery
A 55-year-old woman is for soft-tissue coverage of an open joint elbow wound. The vascular pedicle of the flap in the photograph shown passes between which of the following tendons?
A) Brachioradialis and abductor pollicis longus
B) Brachioradialis and flexor carpi radialis
C) Brachioradialis and flexor pollicis longus
D) Brachioradialis and pronator teres
E) Flexor carpi radialis and pronator teres
B) Brachioradialis and flexor carpi radialis
Proximally, the radial artery runs deep to the brachioradialis muscle and it passes distally between the bellies of the brachioradialis and flexor carpi radialis. The radial forearm flap cutaneous paddle is perfused by septocutaneous perforators from the radial artery.
Anatomical course of the radial artery vs muscles
Proximally, the radial artery runs deep to the brachioradialis muscle and it passes distally between the bellies of the brachioradialis and flexor carpi radialis.
The radial forearm flap cutaneous paddle is perfused by:
The radial forearm flap cutaneous paddle is perfused by septocutaneous perforators from the radial artery.
A 45-year-old woman is brought to the emergency department after sustaining a shotgun injury to the nondominant left forearm. A preoperative x-ray study is shown (heavily comminuted ulna fracture). Bone stabilization is performed. The ulnar nerve, multiple flexor tendons, and the ulnar artery are repaired during surgery and are left exposed. A photograph taken following the repair is shown. The wound was covered with allograft skin while viability of the hand was confirmed for 2 days. Which of the following is the most appropriate definitive coverage for the wound?
A) Free anterolateral thigh flap
B) Full-thickness skin grafting from the groin
C) Pedicled groin flap
D) Reverse lateral arm flap
E) Split-thickness skin grafting from the thigh
A) Free anterolateral thigh flap
Shotgun blasts at close range can create a devastating pattern of injury. X-ray study shows a heavily comminuted ulna fracture. The scenario also involves tendon, vascular, and nerve injury. In choosing the appropriate coverage for the wound described, the surgeon will need to consider the protection of exposed structures, the ability to rehabilitate the extremity, and the possible need for future surgery on the arm. A free tissue transfer will provide viable, full-thickness tissue from a nontraumatized area to cover the wound.
Skin grafting, whether split-thickness or full-thickness, carries several liabilities. Both types of grafts provide skin but no subcutaneous tissue. In addition, both heal by adhering to the wound bed. Because the patient described has exposed tendon in the wound bed, skin grafting would likely cause significant tendon adhesions and thus impaired mobility. In addition, adhesion of the skin graft to a nerve, particularly a repaired nerve, carries a risk of chronic pain and nerve dysfunction.
Proposed benefit of fasciocutaneous flaps over muscle flaps
- fat on the deep surface may allow better glide of tendons and nerves
- the fasciocutaneous flap, once healed, can be incised like normal skin for any future surgery
What would be downsides for using a skin graft to cover an upper extremity wound?
- No subcutaneous tissue
- Adheres to wound bed - if tendons are exposed, adhesions may impair mobility; adherence to a nerve may cause chronic pain and nerve dysfunction
The lateral arm flap donor site can be closed primarily for flaps up to _______
The lateral arm flap donor site can be closed primarily for flaps up to 12 × 6 cm
A 55-year-old man is scheduled to undergo a large oncologic extirpation in the groin. Closure of the resulting defect with a rectus femoris musculocutaneous flap is planned. Which of the following is the most likely functional outcome?
A) 15-Degree extensor lag of the knee
B) 20-Degree flexion contracture of the hip
C) Compromised ability to stand for extended periods
D) Inability to adduct the leg
E) No loss of function
A) 15-Degree extensor lag of the knee
Flexion contracture of the hip, difficulty standing for extended periods, and difficulty adducting the leg have not been described with thisflap harvest.
Morbidity of a rectus femoris flap?
It is generally recommended to perform patellar tendon repair following harvest of the rectus femoris; despite this repair, there can still be about 15 degrees of extensor lag at the knee.
Expanded rectus femoris flap
The expanded flap can reach the he xiphoid, and it has impressive width. The donor site can be closed primarily with an acceptable scar. The muscle remains innervated and functional, which may help prevent bulging. Large or complicated abdominal wall defects.
A 70-year-old woman has a circular defect 18 cm in diameter on the parietal aspect of the scalp after excision of squamous cell carcinoma. The pericranium has been removed with the scalp tissue. Adjuvant radiation therapy is planned beginning 4 to 6 weeks after surgery. Which of the following is most appropriate for coverage of the defect?
A)Latissimus dorsi muscle free flap with split-thickness skin graft
B) Primary closure after galeal scoring
C) Split-thickness skin grafting
D) Temporary reconstruction with a split-thickness skin graft followed by a rotation-advancement flap after scalp tissue expansion
A)Latissimus dorsi muscle free flap with split-thickness skin graft
The latissimus dorsi muscle free flap with split-thickness skin grafting can be used to reconstruct large scalp defects in a single stage, allowing the patient to proceed with radiation therapy after recovery from surgery.
Skin grafts usually have poor take on bare calvarium devoid of pericranium.
When will skin grafts not take on the cranium?
When it is on the skull and devoid of pericranium
Primary closure of a scalp defect is limited to?
About 3 cm in diameter, even with galeal scoring
A 79-year-old woman comes to the office because of a large scalp defect following Mohs micrographic surgery for basal cell carcinoma. A photograph of the defect (left) and a rotation flap designed to cover thedefect (right) are shown. At the completion of the procedure, a large “dog ear” is noted at the pivot point of the flap. Which of the following is the most appropriate next step in management? A) Burrow triangle B) Compression C) Direct excision D) Staged advancement E) Observation
E) Observation
The temptation to excise should be resisted, as most of these dog earsresolve over time. Photographs immediately after the procedure and 5 months later are shown
Treatment of doggier of the scalp
The temptation to excise should be resisted, as most of these dog earsresolve over time. Photographs immediately after the procedure and 5 months later are shown
A 50-year-old man is scheduled to undergo resection of a squamous cell cancer of the right floor of the mouth with invasion into the mandibular body. Composite resection of the right hemimandible and a 2-cm resection of the floor of the mouth followed by immediate reconstruction with a fibula flap are planned, necessitating the use of an osteocutaneous flap. Which of the following best describes the course of the blood supply for the skin paddle of this flap?
A) Musculocutaneus and septocutaneous perforators from the peroneus longus and brevis muscles
B) Musculocutaneus perforators from the flexor hallucis brevis muscle
C) Septocutaneous and musculocutaneus perforators from the anterior tibialis muscle
D) Septocutaneous perforators from the posterior inter muscular septum
E) Septocutaneous perforators from the posterior tibialis muscle
D) Septocutaneous perforators from the posterior inter muscular septum
The blood supply for the fibula flap skin paddle used for reconstruction arises from septocutaneous perforators from the peroneal artery that traverse the posterior intermuscular septum.
Blood supply to the fibula flap skin paddle
Septocutaneous perforators from the peroneal artery that traverse the posterior intermuscular septum.
Which of the following is the most appropriate Mathes and Nahai classification of the rectus abdominis muscle? A ) Type I B ) Type II C ) Type III D ) Type IV E ) Type V
C ) Type III
Type III-two dominant pedicles gluteus maximus, rectus abdominis, serratus anterior, and semimembranosus.
Definition of Mathes and Nahai Type I
One vascular pedicle
Definition of Mathes and Nahai Type II
Dominant and minor pedicle
Definition of Mathes and Nahai Type III
Two dominant pedicles
Definition of Mathes and Nahai Type IV
Multiple segmental pedicles
Definition of Mathes and Nahai Type V
One dominant and secondary segmental pedicles
List of Mathes and Nahai Flaps: Type I
gastrocnemius, rectus femoris, and tensor fascia lata.
List of Mathes and Nahai Flaps: Type II
abductor digiti minimi, abductor hallucis, biceps femoris, flexor digitorum brevis, gracilis, peroneus longus, peroneus brevis, platysma, semitendinosus, soleus, sternocleidomastoid, temporalis, trapezius, and vastus lateralis.
List of Mathes and Nahai Flaps: Type III
gluteus maximus, rectus abdominis, serratus anterior, and semimembranosus.
List of Mathes and Nahai Flaps: Type IV
extensor digitorum longus, extensor hallucis longus, flexor digitorum longus, flexor hallucis longus, sartorius, and tibialis anterior.
List of Mathes and Nahai Flaps: Type V
pectoralis major and latissimus dorsi.
A 54-year-old man is scheduled for correction of a defect on the back 1 week after undergoing resection of a 3 x3-cm recurrent sarcoma. The skin was closed primarily during the procedure, but skin necrosis and wound breakdown occurred. History includes radiation therapy to the spine for soft-tissue sarcoma 2 years ago. Physical examination shows a 5 x5-cm defect in the mid back at the level of T10 with exposed spinous processes. Which of the following is most appropriate to achieve complete wound closure?
A ) Latissimus dorsi flap
B ) Rectus abdominis free tissue transfer
C ) Split-thickness skin graft
D ) Trapezius muscle flap
E ) Wide undermining with primary reclosure
A ) Latissimus dorsi flap
The latissimus dorsi flap would allow for the mobilization of sufficient skin and muscle to close the defect in the patient described. The latissimus dorsi muscle is a Mathes-Nahai Type V flap, with the main blood supply from the thoracodorsal artery and vein, and secondary segmental pedicles from the posterior intercostal and lumbar perforators. The latissimus dorsi insertion onto the humerus can be divided to provide further mobilization of the flap.
A free rectus abdominis muscle flap could be performed, but recipient vessels in this area are not readily available.
Split-thickness skin grafting over a previously irradiated wound bed with exposed bone is not likely to heal. A trapezius muscle flap will not reach the level of T10. Wide undermining is a poor choice because this would lead to further devascularization of previously irradiated skin
The latissimus dorsi muscle is a Mathes-Nahai Type ___ flap,
The latissimus dorsi muscle is a Mathes-Nahai Type V flap,
How can the latissimus be further mobilized?
The latissimus dorsi insertion onto the humerus can be divided to provide further mobilization of the flap.
Detailed blood supply of the latissimus
The main blood supply is from the thoracodorsal artery and vein, and secondary segmental pedicles from the posterior intercostal and lumbar perforators.
How can the pedicle of a latissimus be extended?
If needed, interposition vein grafts can be used to extend the vascular pedicle.
Wide undermining to close previously irradiated skin
Wide undermining is a poor choice because this would lead to further devascularization of previously irradiated skin
A 35-year-old man undergoes coverage of a soft-tissue defect on the posterior right elbow with a reverse lateral arm flap. He does not have a history of serious illness and has never smoked cigarettes. Vascular examination shows no abnormalities. Arterial blood to the flap is provided primarily by which of the following arteries?
A ) Artery to the biceps muscle
B ) Inferior cubital
C ) Musculocutaneous perforating branches from the brachioradialis muscle
D ) Posterior radial collateral
E ) Radial recurrent
E ) Radial recurrent
The most likely dominant arterial supply to the reverse lateral arm flap is the:
The most likely dominant arterial supply to the reverse lateral arm flap is the radial recurrent artery. It
Anatomy of the radial recurrent artery
It is a branch of the radial artery and arises in the cubital fossa. It anastomoses with the posterior radial collateral artery just above the lateral epicondyle and medial to the brachioradialis within the lateral intermuscular septum.
The reverse lateral forearm flap can be used to:
This pedicled flap can be used to cover defects of the elbow and requires retrograde flow through the posterior radial collateral artery via the radial recurrent artery. P
Start to be concerned about the reverse lateral forearm flap when:
After rotating this flap more than 180 degrees, venous insufficiency may result and require microanastomosis of a superficial vein in the flap to a receptor vein in the defect to augment outflow.
Lateral arm flap blood supply
The posterior radial collateral artery is the dominant inflow for the standard lateral arm flap.
Antecubital flap blood supply
The inferior cubital artery is the dominant inflow and the musculocutaneous perforating branches from the brachioradialis muscle are the minor pedicles for the antecubital flap.
Medial arm flap blood supply
The artery to the biceps muscle supplies the medial arm flap.
A 60-year-old man undergoes debridement and coverage with a gracilis muscle free flap to correct exposed hardware 6 weeks after undergoing fracture fixation of the right ankle. During the hospital stay after the fracture fixation procedure, heparin was administered subcutaneously for deep venous thrombosis prophylaxis. The flap coverage procedure is complicated by thrombosisof the arterial anastomosis that requires thrombectomy and reanastomosis. Systemic heparin is administered because of the complication and continued postoperatively. Three days after this surgery, his right lower extremity, including the flap, is swollen and congested. Pulses in the leg are weak. Which of the following is the most appropriate test for this patient?
A ) Activated partial thromboplastin time (aPTT)
B ) D-dimer
C ) Factor V Leiden
D ) Platelet count
E ) Prothrombin time (PT)
D ) Platelet count
The most appropriate test is a platelet count to determine the possibility of heparin-induced thrombocytopenia (HIT) with thrombosis. This immune-mediated complication can occur in up to 3 to 5% of patients on heparin therapy, especiallythose previously exposed to heparin within the last 3 months of the second exposure. Approximately 20% of patients with HIT will have thrombotic events with potentially devastating consequences: 30% mortality and 30% limb loss.
Heparin-induced thrombocytopenia can occur in ______% of patients on heparin therapy
This immune-mediated complication can occur in up to 3 to 5% of patients on heparin therapy
Setup for increased likelihood of heparin-induced thrombocytopenia
Patients previously exposed to heparin within the last 3 months of the second exposure.
Approximately ____% of patients with HIT will have thrombotic events with potentially devastating consequences:
Approximately 20% of patients with HIT will have thrombotic events with potentially devastating consequences: 30% mortality and 30% limb loss.
Pathogenesis of heparin induced thrombocytopenia
The pathogenesis of HIT involves the formation of multimolecular complexes between heparin and platelet factor 4.
In some patients, immunoglobulin G-class antibodies are generated against the heparin: platelet factor 4 complexes. This results in potent platelet activation, platelet aggregation, and a marked increase in thrombin generation. T
HIT involves multi molecular complexes between what and what?
The pathogenesis of HIT involves the formation of multimolecular complexes between heparin and platelet factor 4.
Diagnosis of heparin induced thrombocytopenia
The key to successful treatment is early recognition, and clinical diagnosis remains the gold standard.
Laboratory criteria of heparin induced thrombocytopeia
A 30% decrease in baseline platelet count combined with any form of thrombosis in a patient receiving heparin should be considered heparin-induced thrombocytopenia and thrombosis until proven otherwise.
Treatment of heparin induced thrombocytopenia
The most essential element in the treatment of heparin-induced thrombocytopenia and heparin-induced thrombocytopenia and thrombosis remains discontinuation of ALL heparin.
Starting alternative anticoagulant therapy (eg, danaparoid sodium, lepirudin, or argatroban) as soon as there is a strong clinical suspicion of HIT is advocated. This should be continued until platelet levels have returned to baseline.
What is D-dimer?
D-dimer is a fibrin degradation product that is elevated in the presence of thrombosis.
PT measures:
PT is a measure of the extrinsic pathway of coagulation, and
aPTT measures:
aPTT is a measure of both the intrinsic and common pathways of coagulation.
A 7-year-old boy with sickle cell disease is brought to the emergency department after sustaining a Gustilo Type IIIB fracture of the lower extremity during an all-terrain vehicle collision. Soft-tissue coverage of exposed hardware and bone is planned. Which of the following factors is most likely to adversely affect perfusion to microsurgical reconstruction in this patient? A ) High sympathetic tone B ) Prostacyclines C ) Sludging D ) Young age of patient
C ) Sludging
Abnormally elevated rheologic factors associated with hematologic disorders such as sickle cell disease can seriously compromise perfusion. This usually happens in the form of sludging within the vessel lumen, causing flap compromise.
Microsurgery safety and children
Microvascular surgery in young patients was once considered high risk because of misconceptions of higher sympathetic tone and higher propensity for spasm. This has been proven false. Many studies have proven microvascular surgery to be safe for children.
A 54-year-old man is scheduled for soft-tissue reconstruction of an esophageal defect caused by cancer. A free anterolateral thigh flap will be used. Harvest of the flap will most likely involve taking a cuff of which of the following muscles? A ) Gracilis B ) Rectus femoris C ) Sartorius D ) Tensor fascia lata E ) Vastus lateralis
E ) Vastus lateralis
The anterolateral thigh flap is based on the descending branch of the lateral femoral circumflex vessels. Although classically thought of as providing septocutaneous perforators between the rectus femoris and the vastus lateralis muscle, increased familiarity with this flap and critical anatomical evaluation have shown that its perforators are primarily musculocutaneous through the vastus lateralis in themajority of cases.
The ALT flap is based on what blood supply?
Descending branch of the lateral femoral cutaneous vessels
Perforators of the ALT are primarily through:
The vests lateralis
ALT flap: Once musculocutaneous perforators are found, it may be safer to ________________________________
ALT flap: Once musculocutaneous perforators are found, it may be safer to harvest a cuff of vastus lateralis muscle with the perforators to maximize perfusion, as an intramuscular dissection can be tedious and risks damage to the perforators
A 45-year-old woman is scheduled to undergo delayed breast reconstruction using a transverse gracilis myocutaneous flap. Which of the following arteries provides the dominant blood supply of this flap? A ) Deep femoral circumflex B ) Lateral femoral circumflex C ) Medial femoral circumflex D ) Superficial femoral circumflex
C ) Medial femoral circumflex
Anatomy of the gracilis
Its innervation comes from a branch of the anterior division of the obturator nerve, which has 2 to 4 fascicles entering the muscle 6 to 10 cm from the origin.
Innervation of the gracilis
The gracilis muscle arises from the anterior body and the inferior ramus of the pubis and the ischium. It passes distally in the medial thigh posterior to the long adductor and sartorius muscles and inserts on the medial aspect of the proximal tibia posterior, deep to the sartorius tendon and anterior to the semitendinous muscle insertion.
Vascular pedicle for the gracilis flap: length/logistics
A vascular pedicle can be obtained that is 4 to 6 cm long with a vessel diameter of 1 to 2 mm. Two minor vascular pedicles, which are branches of the superficial femoral artery, are located distally and may be sacrificed.
Functional loss after gracilis muscle harvest
No significant functional loss can be seen after removal of the gracilis muscle.
Skin paddle of the myocutaneous graciliss free flap
The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region allows taking a moderate amount of tissue
(suitable for autologous breast recon in selected patients)
Where does the proximal pedicle enter the gracilis muscle?
The proximal pedicle enters the gracilis muscle 8 to 12 cm below the pubic tubercle
A 52-year-old woman undergoes reconstruction of the left breast using an ipsilateral extended latissimus dorsi myocutaneous pedicled flap. Postoperatively she develops venous congestion along the distal end of the skin paddle. Leeches are used in an attempt to relieve venous congestion. Which of the following is the most effective prophylactic antibiotic therapy? A ) Cephalexin B ) Ciprofloxacin C ) Clindamycin D ) Metronidazole E ) Penicillin
B ) Ciprofloxacin
Medicinal leeches (Hirudo medicinalis) have been used as an aid to salvage congested free flaps. The incidence of infection associated with leech therapy reported in the literature ranges from 2.4% to 20%.
Susceptibility to fluoroquinolones such as ciprofloxacin continues to be observed. Prophylactic antibiotics with a fluoroquinolone and aminoglycoside are recommended, and therapy should be continued until any open wound or necrotic tissue has completely healed.
Hirudo medicinalis
Medicinal leeches
Incidence of infection associated with leach therapy ranges from:
The incidence of infection associated with leech therapy reported in the literature ranges from 2.4% to 20%.
Organism responsible for infection w/ leech therapy
The organism most often responsible is Aeromonas hydrophila, a gram-negative anaerobe that is part of the intestinal resident flora of the leech.
Antibiotic resistance to Aeromonas hydrophila
Resistance to penicillins and first-generation cephalosporins is not uncommon because of their production of beta-lactamase enzymes. Resistance to trimethoprim and sulfamethoxazole, tetracycline, imipenem,and even gentamicin has also been reported.
Prophylactic antibiotics during leech therapy
Susceptibility to fluoroquinolones such as ciprofloxacin continues to be observed. Prophylactic antibiotics with a fluoroquinolone and aminoglycoside are recommended, and therapy should be continued until any open wound or necrotic tissue has completely healed.
A 67-year-old man undergoes three-vessel coronary artery bypass grafting using the left and right internal mammary vessels and a saphenous vein graft. He develops mediastinitis postoperatively and requires wide operative debridement with a resultant chest defect. Reconstruction with which of the following flaps is most likely to result in flap necrosis? A ) Latissimus dorsi B ) Omentum C ) Pectoralis major D ) Rectus abdominis E ) Serratus anterior
D ) Rectus abdominis
The rectus abdominis muscle has several sources of blood supply, including the superior and inferior epigastrics and intercostal vessels. For the purpose of chest wall reconstruction, the rectus muscle is pedicled upon its superior blood supply, the superior epigastric vessels, which itself is a continuation of the internal mammary vessels. Since the internal mammaries have been used on both sides for the purpose of coronary artery bypass grafting, the blood supply to the rectus has been compromised.
Rectus flap after compromise of the internal mammary
Although it is possible to raise the rectus muscle on only the eighth intercostal blood vessel, this method is less reliable and less likely to be sufficient to sustain the entire rectusmuscle, making it prone to flap necrosis.
A 35-year-old man is undergoing repair of a pressure sore on the left ischium using the musculocutaneous flap shown in the photograph. Which of the following is the Mathes and Nahai classification of this flap (gluteal musculocutaneous flap)? A ) Type I B ) Type II C ) Type III D ) Type IV E ) Type V
C ) Type III
The gluteal musculocutaneous flap is a Type III flap, meaning it has two dominant pedicles (the superior and inferior gluteal arteries). These arteries are separated by the piriformis muscle and are sourced to the internal iliac system.
The gluteal musculocutaneous flap is a Type ___ flap
The gluteal musculocutaneous flap is a Type III flap
Relevance of the performs to gluteal musculocutaneous flaps
Its two dominant perforator arteries are separated by the piriformis muscle
Blood supply to the gluteal musculocutaneous flap
The superior and inferior gluteal arteries, which are separated by the piriformis muscle and are sourced to the internal iliac system.
When used for breast reconstruction, both the superior and the inferior gluteal artery perforator flaps utilize a vascular bundle that is a terminal branch of which of the following arteries? A ) Deep circumflex iliac B ) External iliac C ) Femoral D ) Internal iliac E ) Pudendal
D ) Internal iliac
Both the superior and inferior gluteal arteries are terminal branches of the internal iliac artery.
The superior and inferior gluteal arteries are terminal branches of:
Both the superior and inferior gluteal arteries are terminal branches of the internal iliac artery.
Evolution of the superior gluteal artery
As the superior gluteal artery passes the greater sciatic foramen, it divides into superficial and deep branches.
Anatomy of the deep branch of the superior gluteal artery
The deep branch travels between the gluteus medius muscle and the iliac bone.
Anatomy of the superficial branch of the superior gluteal artery
The superficial branch goes onto supply the gluteus muscle and the overlying skin territory.
The superficial branch of the superior gluteal artery supplies:
The superficial branch goes onto supply the gluteus muscle and the overlying skin territory.
Anatomical basis for the S-GAP flap
The superficial branch of the superior gluteal artery nourishes the fat and skin in the musculocutaneous flaps in this region. These perforating vessels can be separated from the underlying muscle and fascia and form the basis for the S-GAP flap, which allows maximal preservation of the donor site muscle and other underlying structures while creating a reliable skin–soft-tissue flap.
Number of perforators associated with an S-GAP
2-3 perforators
Pedicle length of an S-GAP
3-8 cm
A 35-year-old man sustains a traumatic injury to the lower leg and undergoes closure of the wound using an anterolateral thigh free flap (shown). A cuff of muscle is harvested with the flap to fill a bone defect. Which of the following muscles can be safely harvested while using the same vascular pedicle as the flap? A ) Adductor longus B ) Rectus abdominis C ) Vastus intermedius D ) Vastus lateralis E ) Vastus medialis
D ) Vastus lateralis
The anterolateral thigh flap is located over the lateral third of the thigh, between the borders of the rectus femoris and vastus lateralis muscle. Its blood supply comes from perforating branches of the lateral circumflex femoral artery and its venae comitantes. These vessels arise from the profunda femoris artery and vein. By utilizing the transverse branch of the lateral femoral circumflex artery and venae comitantes and their musculocutaneous perforators, the vastus lateralis muscle can be harvested with the anterolateral thigh flap.
The ____________ can be included with the ALT flap for added bulk
The vests lateralis
A 27-year-old man has a large segmental defect of the humerus. Reconstruction using an osteocutaneous free flap from the lower leg is planned. A portion of which of the following muscles is most appropriately included with the bone to protect the pedicle and improve reliability of the skin island? A ) Extensor digitorum longus B ) Flexor hallucis longus C ) Gastrocnemius D ) Peroneus longus E ) Tibialis posterior
B ) Flexor hallucis longus
The fibular free flap is a workhorse flap for reconstruction of large segmental bone defects. The vascular supply of this flap comes from the peroneal artery. Alarge segment of bone can be harvested, consisting of the majority of the fibula with the exception of the proximal 6 cm at the fibular head and the distal 6 cm near the ankle joint. The fibular flap can be harvested with a skin paddle on the lateral aspect of the leg, based on perforators through the lateral intermuscular septum or via the muscle. The pedicle is located adjacent to the flexor hallucis longus muscle in the deep posterior compartment of the leg. Inclusion of a cuff of the flexor hallucis longus muscle can be performed to protect the pedicle and add bulk to the reconstruction if necessary.
Vascular supply of the free fibula
Peroneal artery
What parts of the fibula can / cannot be harvested?
Can harvest the majority of the fibula with the exception of the proximal 6 cm at the fibular head and the distal 6 cm near the ankle joint.
Skin paddle for the fibular flap
The fibular flap can be harvested with a skin paddle on the lateral aspect of the leg, adjacent to the flexor hallucis longus muscle, based on perforators through the lateral intermuscular septum or via the muscle.
What can be done to protect the pedicle of the free fibular flap?
Including a cuff of the flexor hallucis longus muscle
A 55-year-old man has complete excision of squamous cell carcinoma of the scalp resulting in a 6 x 8-cm occipital defect with exposed calvaria. Reconstruction with a lower third trapezius island flap is performed. Which of the following arteries is the major blood supply for the flap? (A)Dorsal scapular (B)Occipital (C)Superficial cervical (D)Thoracoacromial (E)Thoracodorsal
(A)Dorsal scapular
The predominant blood supply of the inferior portion of the trapezius myocutaneous flap is the dorsal scapular artery.
