Flaps and grafts Flashcards
What does interpolated mean in a flap?
A two stage procedure.
What are two ways to locate the supratrochlear artery?
2cm from the midline or the medial border of the eyebrow.
At what time interval do you take down a paramedian flap?
3wks
Ipsilateral paramedian pedicle flaps do what.
Increase rotational torsion and longer pedicle to reach the defect.
What is a paramedian interpolated flap best for.
Large defects on the nose usually 2 cm or greater
T or F vascularity of the nasal ala as a recipient bed tends to be poor so the risk of composite graft necrosis is high?
False
If a composite graft becomes necrotic it should be debrided.
False
How much larger should a composite graft be over the size of the defect.
5 to 10 %
what are the four stages of graft healing?
- imbibition 24-48 hrs passive diffusion 2.inosculation day 2-5 attachment of vessels 3.neovascularization 7-10 days new capillary growth 4. Vasomotor normalization. 12-18 months
What is a mercedes flap?
advance from three directions looks like a mercedes logo.
What is the maximum size of a composite graft?
1 cm or less
How much larger should a composite graft be than the defect size?
5 to 10%
What is an interpolation flap?
a two stage procedure with a pedicle.
List four interpolation flaps.
- Paramedian forehead flap 2. a postauricular mastoid flap to ear 3.Melolabial from cheek to nose 4.cheek to ear
only one of the interpolation flaps has an axial blood supply which one is it?
the paramedian forehead flap using the supratrochlear artery.
How do you locate the supratrochlear artery.
2 cm from the midline of the glabella or the medial edge of the eyebrow. There is a supratrochlear notch in the orbit which is palpable and pedicle should be centered.
What are the sizes of a split thickness skin grafts.
Thin .15 - .3mm Intermediate .3mm to .45mm Thick .4mm to . 6mm
What do all rotation flaps have?
a pivot point
What type of flap is a mustarde flap.
a rotation flap for the eyelid upper cheek.
What is the standard pivotal restraint in a rotation flap?
Length of flap is 4x the width of the defect.
what is a dorsal nasal flap?
a rotational flap from the glabella to the nasal tip. an upside down V is cut in the glabella and the flap is rotated on the nasal tip.
What is the largest defect that should be repaired on the nasal tip with a dorsal nasal flap?
2cm
Where is the pivot point in a mustarde flap.
at the tip of the triangle of good skin removed below the defect.
a bilobe flap can be used up to what size.
1.5 cm
What makes up a bilobed flap?
two 45 degree rotations that make a 90 degree total rotation.
what type of flap is a bilobed flap.
a transposition flap
what type of flap is a rhomboid flap
transposition flap
The Rieger flap is also known as what.
The dorsal nasal flap.
Name three transposition flaps
bilobed, rhombic and banner
What is a banner flap
like a bilobed but only one lobe.
What is the definition of a transposition flap?
pick up flap and transpose over intervening tissue.
How much angle of rotation is in a rhomboid flap.
60 degrees
What is the name of the blade to harvest split thickness skin grafts.
Weck blade
What type of flap is this?
advancement flap
What type of flap is this?
o to z
What type of flap is an O to Z flap
A double rotation flap
With each of these z plasty angle how much % length gain do you get.
- 30 degree angle
- 45 degree angle
- 60 degree angle
- 25% gain
- 50% gain
- 75% gain
What type of flap is this?
Rieger Flap
In a bilobe flap what are the angles of rotation.
two 45 degree angles of rotation in an arc for a total of 90 degrees
Draw the diagram for a Rhomboid flap
What type of flap is this?
Tenzel flap
Tenzel flaps can be used to repair how much of the eyelid?
up to 60%
What type of flap is a tenzel flap considered?
A rotation flap like a mustarde flap.
In a rotation flap the length of flap to width of defect is what ratio.
4 to 1
What limits rotation flaps mobility?
Pivotal restraint
How can you improve flap mobility in a rotation flap.
Longer arc length and backcut
What is the name of this planned flap?
Spiral flap
What are spiral flaps best used for?
small defects on the nose to recreate the alar groove
what is the typical defect size on the nose for a spiral graft.
.5cm to 1.5 cm
What are two advantages split thickness skin grafts have over Full thickness grafts.
Able to cover large areas.
May work better on poorly vascularized wound beds.
What is a tertiary intention?
A delayed closure after a wound has been left open for a period of time.
what is primary intention?
Any wound closure immediately.
What is a dufourmentel flap
a modified rhombic flap
How much does a z plasty increae the scar length at each angle 30 degree 45 degree and 60 degree
25% 50% 75%
What angle to you need in a z - plasty to increse the length by 75 %
60 degree
what angle do you need to increase scar lenght by 50% in a z plasty
45 degree
if you want to increase scar length by 25% in a zplasty what angle do you use
30 degree
what type of flap is a z plasty
transposition
how do you make a z plasty
three equal incisions to make 2 eqilateral triangles which are then transposed
The increase in the length of a scar in a z plasty is in what arm?
The middle arm
small angle flaps in a z plasty carry what risk
increase in tip necrosis
large angle flaps increase risk of what in a z plasty
tissue cones and tension
after a full thickness skin graft after how many weeks post surgery can it be evaluated for dermabrasion
6 weeks
What is the name of this flap
nasolabial rotation flap
at what level do you undermine on the cutaneous lip?
at the level of the muscle below the sub Q fat
At what level do you undermine in the cheek?
subQ fat
at what level do you undermine on the nose?
submuscular just above the periosteum or cartilage.
where do you undermine on the forhead.
just above the frontalis muscle.
where do you undermine on the scalp
Subgaleal space.
what are the first cells to migrate into a wound?
Neutrophils.
what white blood cells stimulate angiogenesis and collagen production.
Macrophages
What cells arrive late in the wound healing process and aid in maturation of the scar.
lymphocytes
in the maturation phase (remodeling) of wound healing Collagen III is replaced by what?
Collagen I which is more crosslinked
What are the three phases of wound healing
inflammatory(6hrs to 10 days)
Proliferative 1day to 14
Maturation 10 days to one year
what monofilament polyglyconate (Glycolic acid) suture has the best tensil strength at one month
maxon
an interpolation flap is also known as a what
tissue importation flap
what is the most common Defect reconfiguration flap
island advanment flap
what are examples of tissue reorientation flaps
Rombic
Bilobed
Melolabial fold flap
Spears flap
What type of flap is this?
a banner flap
what is an abbe flap
a cross lip interpolation flap from one lip to the other with blood supply from the labial artery
If absorbable braided sutures such as vicryl are used as epidermal sutures they may last up to 4 weeks before dissolving if you don’t do what?
hydrate them with ointment
Tie over bolsters does what for post op pain increase, decrease, no change
increase
what type of grafts have the highest failure rate.
composite
what can you do to a split thickness skin graft to increase survival
do meshing
what type of graft has the worst textural and color mismatch
Split thickness skin graft
Why is there more scaling and crusting over a split thickness skin graft
loss of adenexal structures lead to xerosis
how much should you oversize a eyelid graft
100 to 200%
one week post graft placement what color should it not be?
white
What closure is best over a convex surface.
S-plasty
a single tangent flap is known as what
burrow’s flap
a bilateral single tangent flap is also know as what?
AT to T or O to T
A Bilateral double Tangent flap is known as what?
H flap
A Double Tangent Flap is known as what
U flap
What is the eponym for this flap
Rieger Flap
of the two absorbable mono filament sutures with long 6 mo absorbtion time Polydioxanone (PDS) and Maxon (Glycolic acid) which has the strongest tensile strenth at one month
Maxon
What is the best monofilament subQ non absorbant suture for a running stich?
Prolene
what two nonabsorbable sutures have poor knot security?
nylon and prolene
both horzontial and vertical mattress sutures can be used in areas of what?
High tension
in a suborbital defect which is more likely to show pincushing a graft or island flap
Island flap
what has the highest cure rate for chondrodermatitis
surgery
what % of the lower eyelid margin can be closed with a direct closure?
30%
Which causes the least tissue injury when sutureing but most difficult to pierce the skin.
conventional cutting
reverse cutting
Tapered (rounded)
tapered (rounded)
Between conventional cutting and reverse cutting needles which one is least likely to cause the suture to cut through the wound edge.
reverse cutting the cutting edge is on the reverse side facing away from the wound edge.
what split thickness skin graft is most commonly used in derm surgery
medium
in a flap the primary tension vector is what?
the direction of the force that counteracts the movement of the flap
What two features of a suture are directly porportional to the knot security
coefficient of friction and
configuration (monofilament or multifiliment)
what does capillarity mean with sutures.
the ablility to absorb.
multifilament absorb better than monofilament
what is the USP size of a suture
the diameter required to give a certain tensile strength
name a suture with low memory
silk
Name a suture with good elasticity
Novafil
which type of sutures have good pilability
braided
What type of rhoboid flap is this?
limberg
What type of rhoboid flap is this?
dufourmental
What type of rhoboid flap is this?
Webster 30 degree angle
how much of the upper and lower lip can be removed safely for a wedge excision
up to 33% of upper and 50% of lower.
when would you consider a wedge excison closure over a locoregional flap on the eyelid?
when the defect is deep and involving the tarsal plate.
what types of flaps are tissue reconfiguration flaps
Rombic flaps, bilobed,
What is the maximum width to length ratio of this flap
and according to Bolognia which letter should be sewn up first?
4 to 1
Letter A
what are some things that can be done to help with hypergranulation tissue.
steroids
Betablockers such as timolol
no occlusive dressings
remove foreign bodies
pulse dye laser
silver, iodine,aluminum chloride, gentian violet/methylene blue
at what level of the skin will you get scar formation if the defect reaches that level
In the superficial dermis.
what type of defect do you get wound contration
full thickness defects not partial thickness
besides wound edge where else can you get reepitheliazation from?
adenexal structures if they are present.
Hydrolysis breaks down all absorbable sutures except for what?
Gut
What type of process breaks down gut sutures
proteolysis
where do you get the most wound contraction concave or convex surfaces
concave
what is a good superficial suture technique for areas of high tenison that are cosmetically sensitive?
running subcuticular
in a full thickness skin graft when does sensory innervation begain
2 to 4 week but it may be months or 2 years for full innervation
In a full thickness skin graft when do you get full vascularzation
4 to 7 days
Spiral flaps are good for small nasal defects that straddle the what?
alar groove
what is the wound strength at these intervals
1 wk
2 wks
one month
one year
<5%
10%
30-40%
80% max
a tip stitch is also known as what
half buried horozontial stitch
in a bilobed flap what should the angle be between each lobe of the flap
45 degrees both together create a 90 degree rotation
identify each of the dressings
A. Tegaderm film permeable to gas and water vapor not wound fluids - see through
B. DuoDerm Hydrocolloid draws water makes gel (oder plus yellow/brown)
C. Gelfoam
D: Alginate (Maxorb) oder plus yellow brown
E. Hydrogel (Skintegrity) mostly water prone to infections use antibiotics before exudates
F.Vaseline Gause (Xeroform)
what artery does the Abbe flap use as it’s blood supply?
the labial artery
What are the first cells in the inflammatory phase in a wound.
Platelets
They attract other lymphocytes
at what level do you undermine in the forehead area?
below the deep SMAS and the periosteum, but not in the superficial SMAS where sensory nerves tend to run.
wound contraction peaks at what day from fibroblasts turning into myofibroblasts
14 days
