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Flaps > Flaps general > Flashcards

Flaps general Flashcards

1
Q

ALT flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons

A

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%)

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1
Q

DCIA flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

A

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

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2
Q

Deltopectoral flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

A

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

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3
Q

VRAM/TRAM/DIEP flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

A

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

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4
Q

DUA (Dorsal Ulnar Artery) Flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

A

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

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5
Q

Facial Artery Myomucosal (FAMM) flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

A

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

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6
Q

FDMA/Quaba/DMA flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

A

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

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7
Q

Fibula flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

A

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).

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8
Q

GASTROCNEMIUS flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

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9
Q

GLUTEUS flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

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10
Q

Gracilis flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

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11
Q

Groin Flap/SCIA/SCIP

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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)

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12
Q

IGAP flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

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13
Q

Lateral Arm flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

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14
Q

LATISSIMUS DORSI flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

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15
Q

Masseter flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

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16
Q

MEDIAL PLANTAR flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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)

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17
Q

MFC/MFT flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

18
Q

MSAP flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

19
Q

PAPF flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

20
Q

Paraspinal flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

21
Q

PECTORALIS MAJOR flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

22
Q

Posterior Interosseous Artery (PIA) flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

23
Q

Radial Forearm flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

24
Q

Rectus Femoris flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

25
Q

Sartorius flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

26
Q

SCAPULAR/PARASCAPULAR flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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)

27
Q

Serratus flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

28
Q

SGAP flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

29
Q

SIEA flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

30
Q

Pudendal (Singapore) flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

31
Q

Soleus flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

32
Q

Submental flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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)

33
Q

Supraclavicular flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

34
Q

Tensor Fascia Lata flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

35
Q

Tongue flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

36
Q

TPFF flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

37
Q

TRAPEZIUS flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

A

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

38
Q

Classification Mathes & Nahai Type 1

1) Pedicule?

2) Examples (6) ?

A

1) 1 DOMINANT

2)
Gastrocnemius

Tensor fascia lata

APB

ABDM (hand)

Vastus lateralis

1st dorsal interosseus

39
Q

Classification Mathes & Nahai Type 2

1) Pedicule?

2) Examples (8) ?

A

1) 1 DOMINANT + MINEURS

2) Brachioradialis

Coracobrachialis

Triceps

Trapezius

Gracilis

Biceps femoris

Rectus femoris

Soleus

40
Q

Classification Mathes & Nahai Type 3

1) Pedicule?

2) Examples (6) ?

A

1) 2 DOMINANTS

2) Pectoralis minor

Rectus abdominis

Orbicularis oris

Temporalis

Serratus

Gluteus maximus

41
Q

Classification Mathes & Nahai Type 4

1) Pedicule?

2) Examples (6) ?

A

1) SEGMENATAIRES

2) FDL

FHL

EHL

External oblique

Tibialis anterior

Sartorius

42
Q

Classification Mathes & Nahai Type 5

1) Pedicule?

2) Examples (4) ?

A

1) 1 DOMINANT + SEGMENATAIRES

2) Pectoralis MAJOR

Internal oblique

Latissimus dorsi

Flaps (5 decks)

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