Flaps general Flashcards
ALT flap:
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons
1) Type B/C
2) Dominant (Descending branch of lateral femoral circumflex)
3) VC and Lateral femoral cutaneous nerve (anterior and posterior branches)
4) ASIS Superolateral patella Midpoint along line with 3cm radius (perforators, Skin paddle 10cm distal to ASIS and 7cm proximal to patella, Width of 9-10cm = primary closure)
5) Pros: Minimal donor site morbidity, sensate flap possible
Cons: Intramuscular dissection (85%)
DCIA flap:
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant?
1) Type 1
2) Dominant: Deep circumflex iliac
3) Single vein accompanies the artery and Sensory: T12
4) ASIS
Ellipse centered from ASIS along curvature of the iliac crest (Cutaneous perforators clustered in area measuring 4x6cm, above midpoint of the iliac crest, 5cm posterior to ASIS)
5) Pros: Large bone segment, bulk, ideal for hemimandible reconstruction
Cons: Can be too bulky for H+N recon, risk of hernias, damage to LFCN
Variants: Myocutaneous (Rubens flap), Perforator DCIA, Osteomyocutaneous
Deltopectoral flap:
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant?
1) Type C
2) Dominant: 1st, 2nd, 3rd IMA perforators
Source: Internal mammary artery
3) VCs and Sensory T2-T4 intercostals
4) Superior border: Infraclavicular line
Inferior: Parallel and superior to nipple
Lateral: Deltopectoral groove
Delay: Extend onto deltoid, lateral to deltopectoral groove
5) Pros: Easy dissection, reliable for H+N recon.
Cons: Morbidity and chest wall distortion.
Variants: IMAP, delay
VRAM/TRAM/DIEP flap:
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant?
1) Type 3
2) Dominants:
Superior epigastric (2-3cm, 1-2mm, internal mammary)
Inferior epigastric (6-10cm, 1-2.5mm, external iliac
Minor:
Segmental intercostal perforators (7th-12th)
3) Veins: Superiorly, one vein predominates
Inferiorly, veins combine to form a large single vein before entering external iliac
Nerve: 7th-12th intercostals
4) Midline
Costal margin
ASIS
Pubis
5) None written
DUA (Dorsal Ulnar Artery) Flap:
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant?
1) Typa A
2) Dominant:
Ulnar artery (dorsal branch)
Source: Ulnar artery
3) Veins: 2 VCs
Diameter 0.8-1mm
1 vein connects to superficial system
Nerve: Sensory Dorsal ulnar branch
4) Ulnar artery axis: Medial epicondyle to pisiform
DUA perforator 2-4cm proximal to pisiform
Boundaries:
- Anterior : PL
- Posterior: EDC D4
Artery located within septum between FCU and ECU.
5) Pros: Does not sacrifice main artery,
Cons: Retrograde venous drainage, used for small deficits
Facial Artery Myomucosal (FAMM) flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant?
1) No type
2) Dominant:
Facial artery, angular branch
Source: External carotid artery
3) Venous plexus, but no VCs with the facial artery
4) Doppler identification of the facial artery/angular branch
Artery lies between buccinator muscle and overlying muscles of facial expression
Flap consists of mucosa, submucosa, buccinator muscle 5-8mm thick
Based superiorly (retrograde blood flow typically used for for palatal fistula recon), or inferiorly (more robust blood supply)
**If inferiorly based for palatal reconstruction, bite block required post-op until flap division 2-3 weeks later
5) Pros: Reliable anatomy, local tissues, robust, minimal morbidity if flap kept narrow
Cons: Small size, risk of cheek contracture if very wide flap harvested
Variants: Superior or inferior based design
FDMA/Quaba/DMA flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant?
1) Type A
2) Dominant:
Dorsal metacarpal artery
Source: Dorsal carpal arch
3) Veins: VCs
Nerve: Radial or ulnar dorsal sensory
4) The FDMA (kite) flap design runs from the metacarpophalangeal (MCP) joint of the index finger proximally to the proximal interphalangeal (PIP) joint of the index finger distally, the radial and ulnar borders being the midlateral lines on either side of the digits.
The DMA/Quaba flaps have similar elliptical skin designs, with the longitudinal axis centered on the intermetacarpal space, spanning the level of the metacarpal heads to the distal wrist. The ulnar and radial borders of the skin paddle are determined by a pinch test and by the ability to close the donor site primarily
A handheld pencil Doppler probe can be used to identify the dorsal metacarpal artery, as well as the cutaneous perforator emanating from the DMA in between the metacarpal heads, which corresponds to the pivot point for both the DMA and Quaba flaps. The pivotal point of the flap is approximately 1.5 cm proximal to the leading edge of the web space.
5) Pros: Reliable anatomy, versatile, local option, thin tissue, sensate PRN
Cons: At risk for venous congestion, less reliable for ulnar sided defects
Variants: Composite flap (with tendon graft), sensate
Fibula flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant?
1) Type B/C
2) Dominant:
Peroneal artery perforators
Source: Peroneal artery/tibioperoneal trunk
3) Vein: VCs
Nerve: Sensory Superficial peroneal nerve
4) Peroneal head
Lateral malleolus remain ~6cm proximal to avoid destabilizing mortise
Axis = posterior crural septum between lateral and superficial posterior compartments
Skin paddle centered over septum in middle/distal third where majority of perforators located
5) Pros: Large segment of vascularized cortical bone, versatile, multiple osteotomies as needed (periosteal + endosteal blood supply)
Cons: Contraindicated in Peronea Magna (~1%), Risk of nerve damage
Variants: Osseous, Osteofasciocutaneous, Osteomusculocutaneous, Epiphyseal (based off of Anterior Tibial artery).
GASTROCNEMIUS flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 1
2) Dominant:
Medial or Lateral sural arteries
Source: Popliteal artery
3) Vein: VCs
Nerve: Branches of the tibial nerve
4) 1) Midline stocking seam incision
2) 2cm posterior to fibula/tibia (overlying muscle belly)
Origin: Femoral condyles
Insertion: Calcaneus (Achilles tendon)
5) Pros: Medial head is larger, less risk of damage to peroneal nerve
Cons: Contraindicated if DVT
Variants: Musculocutaneous, functional muscle transfer
GLUTEUS flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 3
2) Dominant:
Superior Gluteal
Inferior Gluteal
Minor:
1st perforator of profunda femoris
3) Vein: Superior and inferior gluteal veins
Nerve: Inferior gluteal nerve (L5-S2)
4) Origin:
- PSIS
- Coccyx
- Lateral sacrum
- Ischial tuberosity
Insertion:
- Greater trochanter
- IT tract
5) Pros: 50% of muscle can be used without deficit, can be re-advanced
Cons: Donor site
Variants: Semi-circular, functional muscle transfer, SGAP, IGAP, free flap
Gracilis flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 2
2) Dominant:
Medial circumflex femoral
Source: Femoris profunda
Minors: Branches of deep femoral or superficial femoral (in the distal half of the muscle)
3) Vein: VCs
*Can include greater saphenous vein as secondary outflow
Nerve: Sensory: Anterior femoral cutaneous / Motor: Obturator
4) Pubic tubercle to medial femoral condyle adductor longus tendon
Gracilis lies 2cm posterior
- Skin paddle taken from proximal 2/3 as distal 1/3 is unreliable
5) Pros: Reliable pedicle, good arc of rotation, distal tendon available
Cons: Risk of lymphedema, limited/unreliable skin paddle, weak muscle, difficult in obese patients
Variants: Myocutaneous, TUG/TMG flap, Functional muscle transfer
Groin Flap/SCIA/SCIP
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) type A
2) Dominant:
Superficial Circumflex Iliac Artery (SCIA)
Source: Superficial femoral artery
3) Vein: Single vein draining to the saphenous, Superficial to the SCIA
Nerve: Sensory T12: lateral cutaneous nerve
4) Femoral vessels
Pubic symphysis
ASIS
Inguinal ligament
Skin paddle centered over 1/3 super to ligament +
2/3 inferior to ligament
Vascular pedicle lies 3cm below and parallel to inguinal ligament
Random blood supply distal to ASIS
5) Pros: Good salvage option when micro not possible, hidden donor site, thin in low BMI patients
Cons: Short pedicle if free flap, thick for high BMI patients
Variants: SCIP perforator flap, Delay if needing to extend far beyond ASIS (q2weeks for delay)
IGAP flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type C
2) Dominant:
Perforator of inferior gluteal artery
3) Vein: VC
Nerve: Clunial nerves (superior, medial, inferior)
4) PSIS
Ischial tuberosity
Inferior gluteal crease
- Pedicle 2/3 distance from PSIS to ischion
- Paddle oriented along inferior gluteal crease
- Inferior incision 2-3cm caudal to inferior gluteal crease
5) Pros: Longer pedicle than SGAP, hidden scar in inferior gluteal crease
Cons: Increased risk of dehiscence, nerve injury, difficult
Lateral Arm flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type B
2) Dominant:
Posterior branch of radial collateral (PRCA)
Source: Profunda brachii
3) Vein: Deep VCs
Superficial to Cephalic
Nerve: Sensory Lower lateral cutaneous nerve
Branch of radial nerve
Perforates lateral head of triceps near deltoid
4) Deltoid insertion
Lateral epicondyle
Lateral intermuscular septum
**Anterior branch of radial collateral artery runs with radial nerve
5) Pros: Thin flap, reliable anatomy, easy dissection, sensate
Cons: Smaller width, short pedicle
Variants: Extended lateral arm, reverse (anastomoses of radial collateral artery with radial recurrent artery), fascial, osteocutaneous, vascularized nerve graft
LATISSIMUS DORSI flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 5
2) Dominant: Thoracodorsal
Minor: Para-spinal and lumbar perforators
Source: Subscapular
3) Vein: VC
Nerve: Thoracodorsal (C6-8)
4) Midline
Posterior iliac crest
Anterior border of the muscle (posterior mid-axillary)
Scapular tip
Skin paddle must be 8cm superior to iliac crest
Superior muscle fibers located below scapula
5) Pros: Robust, large surface, reliable
Cons: Seroma, loss of function paralysis
Variants: Chimeric (LD+serratus), TDAP, Reverse, Fonctional, Hemi-LD
Masseter flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 1
2) Dominant: Masseteric artery
Source: IMAX
3) Vein: Massteric vein
Nerve: Masseteric nerve (V3)
1-4 branches: multiple in 75% of patients
4) Zygomatic arch
Mandibular body
Mandibular notch
**Stensen’s duct runs superficial to the masseter, and deep to facial musculature
5) Pros: Local option, +/- expendable muscle of mastication, nerve used for facial reanimation
Cons: Minimal excursion, sacrificing functional muscle
Variants: Inferiorly based
MEDIAL PLANTAR flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type B
2) Dominant: Medial plantar artery
Minor: Myocutaneous perforating vessels from the abductor hallucis brevis and flexor digitorum brevis
Source: Posterior tibial artery
3) Vein: VC
Nerve: Medial plantar nerve (L4-5)
4) Non-weight-bearing instep skin
Head of first metatarsal (distal)
Cubicle of the navicular bone (proximal)
5) Pros: Good padding, minimal donor site morbidity
Cons: Primary closure impossible, must skin graft
Variants: reverse V-Y advancement (1-2cm), myofasciocutaneous (abductor hallucis)
MFC/MFT flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) None
2) Dominant: Descending geniculate artery
Or Medial geniculate artery
Source: Superficial femoral
** Deep to vastus medialis
3) Vein: VCs / Greater saphenous vein for superficial
Nerve: Sensory Saphenous nerve / pierces fascia proximal to sartorius insertion
4) Medial femoral condyle
Femur axis
5) Pros: Straight-forward dissection, vascularized corticocancellous bone
Cons: Not suitable for large defects, cannot segment
Variants: MFT / cartilaginous articular surface, osteofasciocutaneous
MSAP flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type C
2) Dominant: Medial sural artery perforator
Source: Medial sural/popliteal
3) Vein: VCs
Nerve: None
4) Axis from middle of popliteal fossa crease to medial malleolus
Perforators start ~ 6cm distal to crease on axis line (up to 16cm distal)
1-4 perforators
5) Pros: Relatively thin flap, long pedicle length,
Cons: STSG if flap too large, tedious dissection, small calibre of vessel if taken at medial sural
Variants: Chimeric flap with 2nd perforator going to muscle
PAPF flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type B/C
2) Dominant: Profunda femoris artery perforator
Source: Medial branch of Profunda Femoris
3) Vein: VCs
Nerve: None
4) Gluteal fold : 1cm below
Groin crease
Posterior limit of IT band postero-lateral
Gracilis medially
Flap harvested from upper 1/3 of posterior thigh
Pinch test
5) Pros: Alternative flap for breast recon, donor site well hidden
Cons: Small size limited by pinch test, inconsistent dominant perforator location
Paraspinal flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 4
2) Dominant: Segmental perforators from posterior intercostal vessels
Minor: Lateral perforator row
3) Vein: Closely parallels arteries
Nerve: Motor + Sensory Segmental intercostals
4) Group of muscles consisting of semispinalis, longissimus, iliocostalis
Muscle bulk is thickest in upper lumbar and thoracic areas
Superiorly covered by trapezius from the occiput to T12 and by latissimus from T6-L2
Midline
6-8cm lateral
5) None
PECTORALIS MAJOR flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 5
2) Dominant: Pectoral branch of thoracoacromial
Minor: Pectoral branch of lateral thoracic
Minor segmental:Internal mammary perforators (5-6cm from midline)
Source: Axillary
3) Vein: Single veins accompanying the artery
Nerve: Motor Medial and lateral pectoral
Sensory 2nd-7th intercostal nerves
4) Clavicle, Acromion
Xiphoid
Midline
Anterior axillary line
6th intercostal space
- Pedicle at junction of medial 2/3 and lateral 1/3 of clavicle
- Bisection of mid-clavicle to acromio-xiphoid line
5) Pros: Reliable, local
Cons: Decreased cutaneous vascularity if based on internal mammary perforators, deformity if myocutaneous, loss of anterior axillary line
Variants: Myocutaneous, muscle advancement, turnover flap, functional muscle, osteomyocutaneous
Posterior Interosseous Artery (PIA) flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type B
2) Dominant: Posterior interosseous artery
Source: Common interosseous or ulnar artery
Minor: Anterior interosseous
3) Veins: VCs (1 or 2)
Nerve: Sensory Lower branch of the dorsal antebrachial nerve (C5-8)
4) Line drawn from lateral epicondyle to DRUJ
Intermuscular septum between EDM and ECU. Runs with PIN in the proximal 1/3. Gives off 4-7 septocutaneous perforators
Dominant perforator identified at junction of proximal 1/3 and distal 2/3, just distal to supinator. Approximately 7-10cm distal to lateral epicondyle.
In the middle third, gives off a middle cutaneous perforator with a VC communicating between superficial/deep veins of the flap
*Anastomotic branch from AIA 3cm proximal to DRUJ
5) Pros: Does not sacrifice main artery, sensate
Cons: Tedious dissection, narrow skin paddle, short pedicle, unreliable vascular supply, PIN injury
Variants: Harvest EIP
Radial Forearm flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type B
2) Dominant: Radial artery
Source: Brachial artery
3) Veins: Deep VCs
Superficial Cephalic
Nerves: Sensory Medial (C8-T1) and lateral (C5-C6) antebrachial cutaneous
Motor Superior gluteal
4) Antecubital fossa
Scaphoid tubercle
Doppler radial artery
**Pre-op Allen’s test
Distal edge of skin paddle should not pass wrist crease
5) Pros: Reliable anatomy, easy dissection, long pedicle, sensate
Cons: STSG for donor site, minimal flap bulk
Variants: Reverse, adipofascial, fascial, osteofasciocutaneous, myocutaneous, vascularized tendon graft, flow-through
Rectus Femoris flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 2
2) Dominant: Lateral circumflex femoral
Source: Femoris profunda
Minors: Muscular branches of superficial femoral
3) Vein: VCs
Nerves: SensoryAnterior femoral cutaneous
Motor Femoral (6 – 13 cm inferior to ASIS)
4) ASIS
Central patella
*Pinch test to determine width
- Reliably carries skin paddle over muscle
- A transverse line marked from the level of the pubis shows the approximate path of the lateral circumflex femoral artery
5) Pros: Volume, large skin paddle, easy dissection
Cons: Short pedicle, important for knee extension/hip flexion
Variants: Myocutaneous, Functional muscle transfer
Sartorius flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 4
2) Dominant: Segmental perforators (6-7) from superficial femoral artery
Source: Superficial femoral artery
*Segmental perforators enter muscle on its deep + medial surface
Branches of SCIA, LCF, DGA
3) Veins: VCs (drain to superficial femoral vein)
Nerve: Motor Femoral nerve
4) ASIS
Medial tibial tuberosity (Pes anserus)
Unreliable skin paddle
Preserve minimum of 3 perforators in raised flap
Most proximal perforator 6.5cm distal to ASIS
5) Pros: Readily available flap for groin vessel coverage
Cons: Unreliable skin paddle
Variant: None
SCAPULAR/PARASCAPULAR flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) FC type B
2) Dominant: Circumflex Scapular
Minor: 2nd/3rd intercostals
Source: Subscapular
3) Vien: VCs
Nerve: None
4) Standing/sitting position
Palpate triangular space (teres major, teres minor, long head triceps)
Lateral scapular border
Lateral extension: mid-ax
Medial extension: midline
Superiorly: scapular spine
Inferiorly: > angle of scapula
- Pedicle is 2/5 length from the scapular spine to tip
- Scapular axis: Horizontal
- Parascap axis: Lateral border of scapula
5) Pros: Reliable, large skin paddle, compound (osteocutaneous), minimal morbidity, good color match H&N, 2 team approach
Cons: STSG sometimes needed, insensate, positioning
Variants: Adipofascial, osteocutaneous (2-3cm wide, 10-14cm long)
Serratus flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 3
2) Dominant: Lateral thoracic artery +
Serratus branches of thoracodorsal artery
Source: Axillary artery
3) Vein: Single vein accompanying artery
Nerve: Sensory T2-T4 intercostals
Motor Long thoracic (C5-6-7)joins thoracodorsal pedicle at level of 6th rib and continues distally
4) Harvest 3-4 lowermost slips, leaving upper fibers for scapula stability
Between anterior border of lat dorsi = posterior axillary line, and lateral border of pec major = anterior axillary line
5) Pros: Versatile, based off thoracodorsal system
Cons: Risk of winging scapula
Variants: Myocutaneous, Fascial, Chimeric, Myoosseous (either 5th/6th rib attached to muscle, or chimeric inferolateral scapula based off angular branch
SGAP flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type C
2) Dominant: Perforator of superior gluteal artery
3) Vein: VC
Nerve: Clunial nerves (superior, medial, inferior)
4) PSIS
Coccyx
Greater trochanter prominence
IT tract
- Identify vessels 1/3 distance between PSIS and greater trochanter
- Pedicle 5cm lateral and 6cm inferior to PSIS
5) Pros: Less dehiscence
Cons: Less pliable skin paddle, frequent revision required, visible scar, short pedicle, difficult dissection
Variants: Semi-circular, functional muscle transfer, SGAP, IGAP, free flap
SIEA flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type A
2) Dominant: Superficial inferior epigastric artery
Source: Femoral artery
3) Vein: SIEV + VCs
SIEV located medial to the SIEA
Nerve: Sensory T10-T12
4) Inferior: 7cm superior to vulvar commissure
Superior: Pinch test/level of umbilicus
Laterally: ASIS
Hemi-abdomen max if perfused on one pedicle
The anterior superior iliac spine and the pubic tubercle are marked, and a line is drawn between them. The midpoint of the line represents the deep origin of the vessel from the femoral artery. When the line is divided in thirds, one should look for the SIEA and vena comitans between the lateral and central third, and the medial SIEV between the central and medial third.
5) Pros: Good donor site, easy dissection
Cons: Limited to hemi-abdomen, small pedicle, increased risk of thrombosis, not always present
Variants: Pedicled
Pudendal (Singapore) flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type A
2) Dominant: Posterior labial artery
Source: Internal pudendal artery
3) Vein: Posterior labial vein
Nerve: Sensory Pudendal nerve S2-4 / Posterior cutaneous nerves of the thigh S1-3
4) Doppler identification of posterior labial vessels
Flap based posteriorly
Oblique orientation
Medial border: scrotum/labia majora
Lateral border: medial thigh skin
5) Pros: Versatile, thin, pliable, sensate, favorable donor site
Cons: Limited dimensions for total vaginal reconstruction, not available if radical vulvectomy performed, risk of injury to groin lymphatics
Soleus flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 1
2) Dominant: Muscular branches of popliteal artery
Source: Popliteal
3) Vein: VCs
Nerve: Motor Posterior tibial nerve
4) 2cm posterior to fibula or tibia
5) Pros: Medial flap has greater bulk and arc of rotation, proximal/middle third coverage
Cons: Less reliable for distal third, if based off distal perforators, requires pre-op Angio, Risk of distal necrosis
Variants: Turnover flap
Submental flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type C
2) Dominant: Submental artery
Source: Facial artery
*Branches from facial 5cm away from its origin. Origin of submental = 3-5cm anterior to the mandibular angle, and 7mm inferior to border. 70%, artery runs under the digastric
3) Vein: VCs
Submental vein
- Separate from artery
- Must be included if reverse flow flap design due to valves in the VCs
* Drains into facial vein
Nerve: Sensory Transverse cervical (not routinely included) / Motor Cervical branch to platysma
4) Minimum 1cm inferior to mandibular border
Can span between both angles
Width of the flap determined by pinch test (up to 8cm)
Bilateral skin paddle can be carried on one artery
* Mark patient in upright position ensuring incision place minimum 1cm posterior from mandibular border
5) Pros: Reliable anatomy, easy dissection, long pedicle, sensate
Cons: STSG for donor site, minimal flap bulk
Variants: Island flap (can reach level of upper cheek/nose), perforator flap (no functional consequence to including digastric however), free flap (facial artery used as main artery)
Supraclavicular flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type A
2) Dominant: Supraclavicular artery
Source: Transverse cervical artery
3) Vein: VCs
*Drains into transverse cervical vein
Nerve: Supraclavicular nerves (C3, C4)
- Medial branch / sternoclavicular joint
- Middle branch / supraclavicular fossa
- Lateral branch / acromioclavicular joint
4) Artery found in triangle composed of:
- Anterior = SCM
- Posterior = Trapezius
- Inferior = Clavicle
8 cm lateral to sternoclavicular joint
3 cm superior to clavicle
2 cm posterior to SCM
5) Pros: Thin, pliable, reliable, regional, axially based, innervated, good color match, minimal morbidity
Cons: Small vessel diameter and length, can be damaged during neck dissection,
Variants: Pedicled, Island, Tissue expansion
Tensor Fascia Lata flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 1
2) Dominant: Lateral circumflex femoral (Ascending/transverse branch)
Source: Femoris profunda
* The vascular pedicle should be anticipated 7 to 12 cm distal to the ASIS and can be confirmed with Doppler ultrasound
3) Vein: VCs : join lateral side of femoral vein
Nerve: Sensory Lateral cutaneous branch of T12 / Lateral femoral cutaneous nerve of the thigh
Motor Superior gluteal
4) ASIS to lateral femoral condyle demarcates anterior muscle border
3cm posterior/parallel represents tensor muscle
*The distal third of the skin territory is unreliable and requires a delay procedure to ensure its vascularity
5) Pros: Large amount of fascia, minimal morbidity
Cons: Unsightly donor site from rotational bulge or STSG
Variants: Myofascial (abdo recon), osteomyocutaneous (6cm of iliac crest), perforator
Tongue flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 1
2) Dominant: Sublingual artery
Source: Lingual artery bilaterally
3) Vein: VCs of the lingual artery / Lingual vein
*Combines with facial vein to drain into the internal jugular vein
Nerve: Sensory
1) Lingual branch of trigeminal sensation anterior 2/3
2)Chorda tympani branch of facial taste + sensation to anterior 2/3
3)Lingual branch of glossopharyngeal taste + sensation to posterior 1/3
Motor Hypoglossal nerve
4) 5 paired extrinsic muscles: genioglossus, hyoglossus, styloglossus, chondroglossus, glossopalatini
4 intrinsic muscles
Flap can be based dorsally, ventrally, or laterally which can then be based anterior or posterior
*Avoid dorsally based flaps to spare critical areas of taste + tactile sensation
5) 1. Supine, bite block or fixed mouth retractor
2. Traction suture placed at tip of tongue
3. Determine flap design (dorsal, ventral or lateral) and pedicle base (anterior/antegrade or posterior/retrograde)
4. Identify midline
5. Base should measure at least 1.5-2cm and a depth of 5mm (mucosa, submucosa, muscle) no easily identifiable plane of dissection
6. Flap design should extend to within 1cm of the apex of the tongue for posteriorly based flaps, while anterior based flaps extend to the level of the papillae vallata
TPFF flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type A
2) Dominant: Superficial temporal artery
Source: External carotid artery
*Located anterior and deep to superficial temporal vein
Superior to zygomatic arch, gives off deep branch, middle temporal artery, to temporalis muscle
3) Vein: STV runs with artery but can be found up to 3cm away
Immediately below the subdermal fat
Drains into retromandibular vein
Nerve: Auriculotemporal nerve (V3)
4) Doppler identification of the STA beginning in the pre-auricular region
Skin incision: zig-zag, “Y”
5) Pros: Reliable anatomy, robust vascular supply, thin tissue
Cons: Risk of alopecia
Variants: Fasciocutaneous (hair-bearing), free flap
TRAPEZIUS flap
1) Type ?
2) Pedicule?
3) Vein and Nerve?
4) Markings?
5) Pro and cons and variant
1) Type 2
2) Dominant: Transverse Cervical
Minor: Dorsal scapular artery
Posterior occipital
Posterior intercostals
Source: Thyrocervical trunk (80%), subclavicular (20%)
3) Vein: Transverse cervical
Nerve: Spinal Accessory (Motor) C3-C4 (Sensory)
4) Occiput
Clavicle
Tip/Spine of scapula
Acromion
T12
Midline
- A line drawn from T12 to the
acromion outlines the muscle
*DSA 2cm medial to scapula, exits between rhomboid major and minor - If skin paddle exceeds T12 inferiorly, must include DSA
** Preserve CN XI, superior fibers, rhomboids
5) Pros: Robust, local recon
Cons: Short pedicle, loss of shoulder function, color mismatch
Variants: Extended lateral, Dorsal Scapular Artery Perforator
Classification Mathes & Nahai Type 1
1) Pedicule?
2) Examples (6) ?
1) 1 DOMINANT
2)
Gastrocnemius
Tensor fascia lata
APB
ABDM (hand)
Vastus lateralis
1st dorsal interosseus
Classification Mathes & Nahai Type 2
1) Pedicule?
2) Examples (8) ?
1) 1 DOMINANT + MINEURS
2) Brachioradialis
Coracobrachialis
Triceps
Trapezius
Gracilis
Biceps femoris
Rectus femoris
Soleus
Classification Mathes & Nahai Type 3
1) Pedicule?
2) Examples (6) ?
1) 2 DOMINANTS
2) Pectoralis minor
Rectus abdominis
Orbicularis oris
Temporalis
Serratus
Gluteus maximus
Classification Mathes & Nahai Type 4
1) Pedicule?
2) Examples (6) ?
1) SEGMENATAIRES
2) FDL
FHL
EHL
External oblique
Tibialis anterior
Sartorius
Classification Mathes & Nahai Type 5
1) Pedicule?
2) Examples (4) ?
1) 1 DOMINANT + SEGMENATAIRES
2) Pectoralis MAJOR
Internal oblique
Latissimus dorsi
