Flaps techniques

Question 1

ALT surgical technique?

Answer 1

1. Positioning: supine with circumferential prep of the leg
2. Medial skin incision down to rectus femoris fascia
3. Identify perforators
4. Dissection in the subfascial plane laterally towards intermuscular septum
5. Medial retraction of the rectus femoris for increased exposure of septum and identify descending branch of lateral circumflex femoral
6. If intramuscular perforator, proceed with intramuscular dissection vs. removing segment of vastus lateralis
7. Proceed with proximal dissection
8. Complete lateral skin incision and elevate flap
9. Avoid TFL (backup if flap fails)

Question 2

DCIA surgical technique?

Answer 2

(Osseous +/- internal oblique)
1. Supine, beanbag placed under ipsilateral buttock
2. Skin design incorporates extension of the incision into the inguinal crease (from femoral pulse to ASIS) allowing exposure of the proximal pedicle
3. Dissection through subcutaneous tissues identifying the external oblique aponeurosis with its muscle located laterally. TFL identified below iliac crest.
4. EO aponeurosis incised parallel to the inguinal ligament to expose the IO muscle.
5. Medial to the ASIS, LFCN identified and protected
6. IO muscle incision superiorly, laterally, and medially (to desired size). Identify ascending branch on deep surface of IO muscle, and trace it proximally until joining the DCIA.
7. DCIA is then dissected as it courses laterally along the curvature of the iliac crest on deep surface of iliacus muscle
8. Below the vessel, the iliacus muscle/fascia are divided, exposing the inner surface of the ilium
9. Dissection continues until desired bone length is reach (can extend to posterior axillary line)
10. If full thickness iliac crest is required, TFL and gluteus medius are dissected off the lateral border of the iliac crest in the subperiosteal plane.
11. Osteotomies done with uni or bicortical with saw/osteotomes  ASIS should be spared and not included in the osteotomies to avoid disrupting inguinal ligament attachment
12. Closure should be done in layers to avoid herniation: re-anchor internal oblique to remaining iliac bone, and close external oblique fascia.
13. Drains x2

Variants:

Osteomyocutaneous:
1. Skin island design along the iliac crest extending from ASIS posteriorly as per desired length
2. Identification of the vascular pedicle proximally
3. Skin paddle is incised superiorly. Approximately 3-4cm above the crest, three layers of the abdominal musculature are divided, leaving a 2-3cm cuff of muscle with the skin flap attached to the underlying muscle and bone.
4. Along the inferior border, similar dissection with keeping a portion of the TFL and gluteus medius included.
5. Rest of dissection is identical as osseous flap.

Myocutaneous (Rubens):
1. Similar dissection as previously described with larger skin paddle and muscle cuff included
2. Muscle cuff 5-6cm superior to crest included
3. Perforating osseous branches of DCIA are divided

Question 3

Deltopectoral surgical technique?

Answer 3

1. Supine, arm adducted to avoid distortion of anatomic landmarks
2. Incisions down to underlying pectoralis (or deltoid) muscle including the fascia with flap dissection.
3. Flap is raised from lateral to medial.
4. Cutaneous branches from thoracoacromial vessels ligated as needed.
5. Dissection continues until perforators identified, which can be as much as 6cm lateral to midline.
6. Flap transposed
7. Close over drains

Question 4

VRAM/TRAM/DIEP surgical technique?

Answer 4

VRAM
1. Supine, skin paddle vertically over half of the rectus muscle
2. Width of skin paddle  pinch test, medial incision in midline to preserve flow to umbilicus
3. Incise skin down to anterior rectus sheath
4. Dissect anterior rectus sheath off muscle from costal margin as far inferiorly as required
5. Dissection laterally to linea semilunaris and medially to linea alba
6. Cauterize intercostal neurovascular pedicles laterally
7. Divide the muscle and ligate either SEA or DEA depeding on superior/inferior based pedicle

TRAM
1. Upper abdominal incision carried down to rectus sheath
2. Upper skin flap elevated, patient placed in semi-flexed position, and inferior incision planned
3. Suprafascial dissection from lateral to medial until lateral row of perforators visualized
4. Incise sheath and isolate muscle
5. Complete contralateral suprafascial dissection
6. Ligate pedicle (superiorly or inferiorly)

Question 5

Dorsal Ulnar Artery Flap surgical technique?

Answer 5

1. Supine, tourniquet, pre-op markings and doppler identification (+ ALLENS TEST PRN)
2. Radial/anterior incision down onto FCU
3. Retract FCU radially, and continue subfascial dissection to identify pedicle within interval between FCU and ECU
4. Ulnar/posterior incision with subfascial dissection on ECU (ulnar retraction on ECU to facilitate dissection)
5. Complete proximal and distal incisions
6. Flap is raised and isolated on the DUA
7. Rotation into deficit and closure

Question 6

Facial Artery Myomucosal (FAMM) flap surgical technique?

Answer 6

1. Doppler identification of the facial artery  FAMM flap = mirror image of nasolabial flap
2. Flap is designed centered over course of facial artery with oblique orientation extending from retromolar trigone to the labial sulcus near alar margin
3. Remain anterior to Stensen’s duct
4. Incise mucosa, submucosa, and buccinator on either side of the facial artery.
5. Identify facial artery (either superiorly or inferiorly depending on design + pedicle location). Ligate facial artery in order to raise flap.
6. Maintain facial artery within the flap since connections between artery and mucosa are loose.
7. Do not skeletonize flap on facial artery alone, increased risk of venous congestion and flap failure
8. Donor site closure should be done loosely at base of flap to avoid compression of vascular pedicle

Question 7

FDMA/Quaba/DMA flap surgical technique?

Answer 7

FDMA
1. Proximal incision over MCP, including large vein to improve outflow
2. Pedicle NOT identified, can be visualized through the thin layer of epimysium, and one can take the entire width of the visible surface of the epimysium to secure the pedicle.
3. Dissection deep to the epimysium starts at the second metacarpal and is carried radially from there.
4. After the pedicle is secured, the distal part of the skin island is incised and the flap is raised in the tissue plane above the paratenon, which has to be kept intact for perfect take of the full-thickness graft.

Quaba/DMA
Difference = epimysium not included in Quaba flap as compared to DMA  based off perforator located distal to junctura tendinum
1. Dissection starts from proximal to distal.
2. markings. Dissection is carried down through skin and subcutaneous tissue just above the paratenon of the extensor apparatus.
3. The axis of the flap is in the midline between adjacent metacarpals, and the dissection plane of the skin paddle is located underneath the epimysium of the interosseous muscle (for DMA only).
4. The DMA in the intermetacarpal space is ligated proximally and kept attached to the overlying skin paddle. The epimysium overlying the interosseous muscles is elevated with the flap to ensure protection of the DMA. The DMA itself often lies within or below the interosseous fascia
5. Dissection is continued from proximal to distal until the junctura tendinum is reached. The point proximal to the junctura tendinum can determine the pivot point if the arc of rotation is insufficient, and the junctura tendinum can be transected
6. The pedicle should be surrounded by the portion of subcutaneous tissue and a superficial vein that can be included within the flap to preserve and potentially improve venous drainage, if required, with the addition of a venous anastomosis, as needed.

Question 8

Fibula surgical technique?

Answer 8

1. Supine, bump placed under ipsilateral hip, saline or sandbag placed under foot to keep knee in flexion
2. Sterile tourniquet, prep and drape up to proximal thigh for STSG harvest
3. Anterior skin incision, stay suprafascial over Peroneus tendons to improve graft take. Once posterior to tendons, subfascial dissection (use Alices to retract skin and fascia) and identification of perforators.
4. Anterior retraction on lateral compartment with Senn/rakes and, muscles separated from fibula while keeping a 2-3mm muscle cuff. Push upwards with thumb to aid in muscle division. Proximally, caution to avoid damaging common peroneal nerve as it wraps around peroneal neck + superficial branch descending in lateral compartment.
5. Continue with anterior dissection until reaching anterior compartment. Muscles dissected off interosseous membrane. Avoid deep peroneal nerve and anterior tibial artery.
6. Incise IO membrane in the middle (as Tibial nerve and posterior tibial artery are more protected by deep compartment muscles). Then complete division of IO with Stevens from distal to proximal. Avoid damaging mortise = distal extent of dissection.
7. Posterior skin incision and subfascial dissection to join septeum. Protect Sural nerve and lesser saphenous vein.
8. Elevate soleus off of deep compartment using Alices for lateral traction. Divide muscle with ligasure, continuing proximally up until fibular branch to soleus identified. Preserve branch until completing dissection (muscular cuff of soleus maintained PRN). Muscular branches are very large.
9. Incise fascia of FHL to facilitate dissection from anterior approach following osteotomies.
10. Osteotomies with oscillating saw. Proximally, osteotomy should be done as proximal as possible to facilitate pedicle dissection. Distally, osteotomy up to level of the mortise. Subperiosteal dissection, protect pedicle medially with right angle retractor. Remove only small segment of periosteum to preserve blood supply to bone.
11. Lateral retraction on bone and identify Tibialis Posterior as the most anterior structure. Muscle is bipennate. Divide muscle with ligasure, remaining superficial to pedicle.
12. Last structure to divide is FHL in similar fashion to Tib Post.
13. Pedicle dissection as proximal as required.
14. Prior to closure, suture FHL to soleus with 1st MTP in extension using Vicryl 2.0.
15. Two layer closure, imbricate muscles to cover tendons if needed.
16. STSG.

Question 9

GASTROCNEMIUS surgical technique?

Answer 9

1. Supine with leg rotated (internally or externally). Can be prone. Tourniquet.
2. Incision placed over muscle or midline
3. Elevate skin flaps and dissection down to gastroc fascia
4. Dissection within areolar plane between gastroc and soleus starting medially
5. Plantaris identified
6. Distal dissection to tendinous insertion, take at least 1cm of tendon
7. Distal to proximal dissection
8. Identify raphe between medial and lateral muscles
9. Lesser saphenous vein and sural nerve are visualized and preserved, then retracted laterally to allow division of the medial and lateral gastrocnemius.
10. Arc of rotation tested. Can be increased by: further proximal dissection up to sural vessels, divide muscle at origin (+5cm), fascial scoring, interpositional vein graft
11. Fix muscle using tendinous insertion
12. Close over drains
13. STSG over muscle

Question 10

GLUTEUS flap surgical technique?

Answer 10

1. Positioning: Ventral
2. Incise skin down to muscle fascia
3. Divide the muscle laterally and continue dissection medially
4. Identify submuscular space (where the underlying piriformis is)
5. For advancement towards the midline, the origin of the muscle is divided along the sacrum (taking care not to injure gluteal vessels)
6. Do not undermine perforators
7. Once the muscle has been fully divided around the skin island, advance and inset flap

Question 11

Gracilis flap surgical technique?

Answer 11

1. Supine/frog leg or lithotomy positioning
2. Incision overlying gracilis muscle, and identification of greater saphenous vein
3. Counter incision over the insertion of the gracilis distally and apply traction to aid definitive identification
4. More proximally, the muscle is readily identified immediately posterior to the adductor longus muscle
5. Identify NV pedicle near lateral aspect
6. Dissection may then quickly proceed on the medial surface of the muscle from origin to insertion.
7. Distalmost portions of the muscle are dissected, dividing the minor pedicles as they are encountered.
8. When dissecting the medial circumflex femoral vessels to take the fascia investing the adductor longus muscle. This allows an easy dissection that both exposes and protects these vessels
9. Ligate minor pedicle branches PRN
10. Proximal dissection between adductor brevis/longus provides 2cm more length
11. **If TUG, identify perforator over gracilis with Doppler. Anterior incision subQ over femoral triangle. Subfascial once adductor fascia reached. Dissection posterior until perforator identified. Intra-muscular perforator dissection to medial femoral circumflex. Complete posterior incision in subfascial plane.

Question 12

Groin Flap/SCIA/SCIP surgical technique?

Answer 12

1. Supine position, bump placed under ipsilateral hip
2. Doppler identification of femoral vessels and trajectory of SCIA
3. Skin incision along lateral, superior and inferior margins
4. Flap is raised from lateral to medial in the suprafascial plane
5. Once the sartorius muscle is identified, dissection is deepened in the subfascial plane up to the medial border of the sartorius
6. If greater pedicle length is required, a perforator flap based on deep branch can be utilized (intramuscular dissection)

Question 13

IGAP surgical technique ?

Answer 13

1. Positioning: Ventral, decubitus lateral
2. Identify perforators using Doppler
3. Skin incision down to muscular fascia
4. Subfascial dissection from lateral to medial
5. Identify perforators
6. Intramuscular dissection parallel to muscle bundle in a retrograde manner
7. Ligate all side branches to minimize intrapelvic bleeding
8. Avoid injury to posterior femoral cutaneous nerve, sciatic nerve, and inferior gluteal nerve
9. A patch of muscle can be taken that includes the perforators, however it will severely shorten the pedicle length
10. Divide perforator at inferior gluteal artery and harvest flap

Question 14

Lateral Arm surgical technique?

Answer 14

1. Supine or lateral decubitus, arm free draped
2. Posterior incision down to triceps fascia.
3. Subfascial dissection with 15 blade towards lateral intermuscular septum, identifying PRCA and Posterior cutaneous nerve of forearm.
4. Anterior incision and subfascial dissection overlying brachialis and brachioradialis joining posterior dissection. Subfascial dissection similar to SGAP (multiple septal planes)
5. Flap/septum raised distal to proximal up to the bifurcation of anterior and posterior branches of radial collateral. Distally, pedicle is more adherent to humerus. Raise pedicle with small periosteal cuff.
6. Careful with retraction anteriorly as radial nerve runs anteriorly in the brachialis after wrapping around humerus
7. **If extended lateral arm, skin paddle extends 6-7cm distal to lateral epicondyle. Small perforator with anterior takeoff that supplies the distal skin.

Question 15

LATISSIMUS DORSI flap surgical technique?

Answer 15

1. Positioning: Decubitus lat/ventral, beanbag, mayo stand for free draped arm
2. Incise skin paddle (bevel out)
3. Expose muscle (remain suprafascial)
4. Incise muscle inferior and medial
5. Avoid incising lumbar fascia (risk of hernias)
6. Raise flap inferiorly to superiorly
7. Avoid the posterior/anterior serratus
8. Ligate intercostal and lumbar perforators and branches to serratus PRN
9. Identify pedicle superiorly
   - Enters the deep surface of the muscle in the posterior axilla 10 cm inferior to the muscle insertion into the humerus.
   - The vessel then bifurcates into a transverse (upper) and a descending (lateral) branch that can be the basis for muscle splitting.
10. Transfer flap, drains, tension free closure

Question 16

Masseter flap surgical technique?

Answer 16

1. Access via curvilinear incision below mandibular angle or facelift approach
2. Muscle can be palpated with mastication pre-operatively
3. Dissection through subcutaneous tissues and deep to SMAS
4. Identification of facial artery/vein inferiorly helps identify and protect marginal mandibular branch
5. Muscle needed for recon is then harvested based off proximal blood supply
6. If utilized for facial reanimation/smile, can resect buccal fat pad to decrease bulk

Nerve identification:
1. Facelift incision
2. Skin flap raised in subcutaneous plane
3. SMAS exposed and a triangular flap is elevated exposing the masseter deep to it
4. Dissection through superficial and middle muscle bellies to identify nerve
5. Course of the nerve is oblique in line with mandibular notch to oral commissure

Question 17

MEDIAL PLANTAR flap surgical technique?

Answer 17

1. Positioning: Decubitus dorsal or lateral
2. Tourniquet
3. Incise skin circumferentially down through the plantar fascia
4. Expose the flexor digitorum brevis laterally and abductor hallucis medially
5. Separate the two muscles distally (just proximal to the MTP joint) to expose the vessels and nerve
6. The vascular pedicle is divided and the dissection is continued proximally
7. Dissection is deep to the plantar fascia at all times
8. Medial plantar nerve can be dissected intra-fascicularly in order to preserve sensation to both the flap and the distal medial foot
9. Continue dissection proximally to the tuberosity of the calcaneus
10. Transfer flap
11. Skin graft donor site

Question 18

MFC/MFT flap surgical technique ?

Answer 18

1. Supine, frog leg, sterile tourniquet on proximal thigh.
2. Medial skin incision (~8cm) centered over medial femoral condyle.
3. Dissection down to vastus medialis, protecting saphenous vein and nerve.
4. Once the muscle is identified, fascial incision and anterior retraction. Retract gracilis posteriorly.
5. Identify descending genicular artery, and trace it distally to the level of the medial femoral condyle. Adductor magnus lies on the floor.
6. Area for bone flap is marked centered over rich arterial network.
7. Periosteum is incised medially, laterally, and distally. Proximally, the pedicle needs to be dissected circumferentially in order to separate from the proximal aspect of the periosteum. Once dissected, proximal periosteum is incised.
8. Pilot holes with K-wires at 4 corners.
9. Osteotomies with oscillating saw and completed with straight/curved osteotomes.
10. Remove small rectangle of bone distally in order to facilitate full thickness bone flap harvest. Easier to place curved osteotome at desired thickness/depth.
11. Flap is isolated on its pedicle, vessels clipped proximally, and transferred.
12. Pack bone defect with bone wax
13. Three-layer closure (fascia, subQ, skin) over a drain. Avoid excessive tension on muscular fascia closure, limits knee ROM in post-op.

Question 19

MSAP flap surgical technique ?

Answer 19

1. Supine position, frog leg
2. Doppler perforators along axis
3. Anteromedial skin incision
4. Subfascial dissection and identification of perforators dissecting from anterior to posterior
5. Intramuscular perforator dissection through the medial gastroc
6. Dissection continued proximally until bifurcation of medial and lateral sural arteries, can decide to ligate lateral sural and harvest flap on common trunk.
7. Complete posterior skin incision and subfascial dissection, joining anterior dissection.
8. Transfer flap, close over drains

Question 20

PAPF flap surgical technique?

Answer 20

1. Supine, lithotomy position
2. Doppler identification of perforator 2-4cm posterior to gracilis
3. Superior, anterior, inferior skin incision
4. Dissection proceeds deep to muscular fascia anteriorly
5. Flap raised from anterior to posterior in order to identify perforator
6. Perforator dissection (intramuscular through adductor magnus vs septal) until sufficient length obtained
7. Posterior dissection completed in Scarpa fascial plane later/posterior to Adductor Magnus
8. Transfer, close over drains

Question 21

PAPF flap surgical technique?

Answer 21

1. Positioning: Prone
2. Midline incision
3. Skin flaps undermined laterally for 6-8cm superficial to the deep fascia overlying paraspinal muscles
4. In cervical/thoracic areas, trapezius and latissimus can be elevated with the skin as a composite myocutaneous flap
5. Once deep fascia exposed, it is incised 5-6cm from the midline
6. Blunt dissection medially and laterally to mobilize the muscle
7. Pedicles do not need to be visualized, as the blood supply is segmental
8. Mobilize muscles medially and suture with figure-of-eight sutures
9. Submuscular drain placement with careful placement if presence of CSF leak
10. Increase flap reach by releasing medial and deep muscle attachments +/- ligation of medial row perforators

Question 22

PECTORALIS MAJOR flap surgical technique?

Answer 22

1. Positioning: Supine
2. Incise skin down to muscle fascia (+/- skin paddle if myocutaneous)
3. Identify inferolateral border of pectoralis major and expose underlying pectoralis minor
4. Dissect in the submuscular plane until the thoracoacromial pedicle is visualized on the deep surface of the muscle at the junction of the medial 2/3 and lateral 1/3 of the clavicle
5. Release the muscle medially (lateral to the internal mammary perforators) and laterally from its humeral insertion
6. Taper the flap towards the pedicle in order to improve rotation

Question 23

Posterior Interosseous Artery flap surgical technique ?

Answer 23

1. Arm in pronation, axis marked, doppler identification of perforators
2. Radial incision down through antebrachial fascia over the EDM
3. Subfascial dissection towards intermuscular septum between EDM/ECU, muscles retracted radially and ulnarly, respectively
4. Identify PIN within septum and preserve branches to extensors. Nerve is more radial than artery. Last muscle innervated is EIP.
5. As dissection proceeds from proximal to distal, protect dorsal cutaneous branch of ulnar nerve ~ 6cm proximal to ulnar carpal joint
6. Standard: identify communicating branch with AIA, and ligate, raising flap from distal to proximal. Reverse: Identify and protect anastomotic branch with AIA (beneath EIP), and all branches joining the dorsal carpal arch. Clamp proximal PIA to assess perfusion of the flap through retrograde supply.

Question 24

Radial Forearm flap surgical technique?

Answer 24

1. Supine, hand table, tourniquet
2. Confirm radial artery trajectory with doppler
3. Distal incision, identify radial artery/veins. Circumferential dissection.
4. Ulnar incision, subfascial dissection towards septum from ulnar to radial. Preserve cutaneous perforators, bipolar muscular ones.
5. Radial incision, complete subfascial dissection.
6. Protect dorsal branch of radial sensory nerve and cephalic vein (to include in flap PRN)
7. Flap raised distally to proximally preserving paratenon on flexor tendons for STSG
8. Temporary vascular clamp on artery, verify vascular status of hand, before clipping pedicle
9. Proximal incision along flap edge, preserve MABC/LABC if sensate flap
10. Continue dissection proximally to obtain desired pedicle length up to bifurcation of brachial artery
11. Transfer flap, closure of proximal incision, STSG distally

Question 25

Rectus Femoris flap surgical technique ?

Answer 25

1. Supine position
2. Incision of the skin paddle down to the muscular fascia.
3. The superficial surface of the rectus femoris muscle is exposed from its origin to its insertion.
4. Retraction of the sartorius muscle superiorly in the medial direction will expose the origin of the muscle.
5. Inferiorly, the insertion of the muscle is exposed by freeing the vastus medialis and the vastus lateralis muscles.
6. The tendinous insertion of the muscle is then divided, and the muscle is dissected from distal to proximal.
7. Suture vastus lateralis to medialis to preserve approximately 15 degrees of knee extension

Question 26

Sartorius flap surgical technique?

Answer 26

1. Supine or frog leg
2. Cutaneous incision down to superficial fascia
3. Raise skin flaps laterally and medially to expose sartorius
4. Dissection of muscle begins lateral to medial in order to identify perforators (entering from medial and deep surface)
5. Preserve maximum number of perforators
6. Incise muscle superiorly (superior to most proximal perforator), and inferiorly PRN
7. Flap is turned over medially to cover femoral vessels
8. Close in layers over a drain (keep minimum 2-4 weeks depending on drainage)
9. Consider incisional vac

Question 27

SCAPULAR/PARASCAPULAR flap surgical technique ?

Answer 27

Positioning: lateral decubitus or ventral
2. Doppler to identify pedicle in triangular space
3. Incise inferiorly and medially
4. Dissect suprafascially from medial to lateral
5. Once the teres major is encountered, change plane to subfasical
6. Continue dissection into triangular space and identify pedicle
7. Ligate branches to teres major/minor
8. Continue dissection towards subscapular artery to maximize pedicle length up to 10cm

Question 28

Serratus flap surgical technique?

Answer 28

1. Lateral decubitus, arm free draped, beanbag support with axillary roll
2. Skin incision between latissimus dorsi and pectoralis major
3. Dissection onto anterior surface of serratus
4. Protect long thoracic nerve during dissection
5. Identify two main arterial supplies on the anterior surface of the muscle
6. Upper slips raised on lateral thoracic, lower slips raised on thoracodorsal pedicle
7. Harvest only the lower 3-4 slips to avoid functional limitations/winging of the scapula
8. Muscular slips are dissected from the ribs anteriorly using cautery in a supraperiosteal plane (poorly defined plane)
9. Flap is raised from anterior to posterior towards the scapula
10. If used for intra-thoracic recon, 1-2 ribs often need to be resected

Question 29

SGAP flap surgical technique?

Answer 29

1. Positioning: Ventral
2. Skin incision
3. Dissection from lateral to medial in the subfascial plane (of gluteus maximus)
4. Identify perforator between piriformis and gluteus medius
5. Intramuscular dissection to the superior gluteal artery
6. Ligate side branches in order to maximize pedicle length
7. Meticulous hemostasis to prevent bleeding into pelvis from retracted vessels
8. Flap can then be used as rotational flap for sacral or gluteal wounds or harvested as a free tissue transfer

Question 30

SIEA flap surgical technique?

Answer 30

1. Supine positioning with pre-op markings done with patient standing upright
2. 4-5 cm exploratory incision made in the groin crease centered on projected location of pedicle
3. Dissection down to Scarpa’s fascia to identify SIEV located superficially, and then deep to Scarpa’s to identify SIEA, located more laterally
4. Once pedicle is isolated and dissected back to its source vessels, flap is raised similar to DIEP, from lateral to medial
5. Preserve DIEP perforators and clamp to assess perfusion on SIEA pedicle before sacrificing

Question 31

Pudendal (Singapore) flap surgical technique?

Answer 31

1. Lithotomy or frog-leg position
2. Incision around periphery of flap
3. Dissection down to deep fascia
4. Fascial incision and subfascial dissection from anterior to posterior
5. Elevate fascia and epimysium off the adductor muscle, include in flap elevation
6. Judicious subcutaneous undermining towards the base of the pedicle to facilitate rotation
7. Flaps can be turned into a true island flap PRN

Question 32

Soleus flap surgical technique?

Answer 32

1. Supine, tourniquet
2. Medial skin incision, dissection until muscle is identified
3. Plane between the gastroc and soleus is developed. Plantaris tendon identified on anterior surface of soleus confirming the correct plane.
4. Medial origins of the muscle from the tibia are divided, exposing the FDL, PT, FHL and posterior tibial artery and nerve.
5. Superficially, soleus is separated from the gastroc
6. Distal division of the muscle, sparring the Achilles insertion . Segment of tendon can be harvested with the flap to facilitate muscle insetting but often not required.
7. Muscle raised from distal to proximal, dividing muscle along the intermuscular raphe. Muscular branches from minor pedicles ligated as needed to allow for flap rotation/transposition.
8. Proximally, muscle division must be performed at its midpoint to avoid risk of not carrying the nutrient vessels  some lateral muscle can be included to increase safety
9. Close over drains
10. STSG
11. Splint (foot, ankle, up to knee)

Question 33

Submental flap surgical technique?

Answer 33

1. Supine, head in extension
2. Lateral dissection beginning on contralateral side
3. Flap is elevated in the subplatysmal plane, plastysma included with the flap
4. When crossing midline, care is taken when digastrics encountered
5. Digastric is divided on either side of the flap incisions and dissection proceeds with identification of the submental artery
6. Flap can be lengthened by dividing facial artery proximal to the takeoff of the submental artery : flap perfusion is then retrograde through the distal facial artery, in this case, submental vein must be maintained due to poor reverse flow through the VCs (Adds 1-2 cm to the arc of rotation)

Question 34

Supraclavicular flap surgical technique?

Answer 34

1. Supine, shoulder roll, neck and arm draped
2. Doppler identification of supraclavicular artery
3. Incision and flap dissection in subfascial plane from lateral to medial
4. Complete proximal/medial skin incision once pedicle identified
5. Deepithelialize skin paddle for insetting, +/- tunneling of flap
6. Wide undermining anteriorly/posteriorly to allow for primary closure
7. Drain

Question 35

Tensor Fascia Lata flap surgical technique?

Answer 35

1. Supine or lateral decubitus
2. Cutaneous incision down to fascia lata (can be incised)
3. Tack fascia to skin paddle to avoid shearing
4. Proceed with subfascial dissection distal to proximal
5. Vascular pedicle should be anticipated, starting 12 cm distal to the ASIS
6. At this level identify lateral femoral cutaneous nerve at the anterior margin of the flap if a sensate flap is desired
7. The lateral circumflex femoral vascular pedicle is then identified on the deep surface of the muscle and is dissected medially in the plane between the rectus femoris and the vastus lateralis muscles
8. Ligate branches to the gluteus minimus and vastus lateralis PRN.

Question 36

Tongue flap surgical technique?

Answer 36

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

Question 37

TPFF flap surgical technique?

Answer 37

1. Doppler identification of the STA
2. Dissection begins pre-auricular to identify artery, vein and nerve
3. Skin flaps raised just deep to hair follicles to avoid damaging hair follicles
4. Superficial fascia identified, marked, and incised superiorly
5. Flap is raised from superior to inferior in areolar plane between superficial and deep fascia
6. Middle temporal artery should be ligated if only superficial fascia required
7. Flap tapered over vessels inferiorly for improved arc of rotation
8. Caution to avoid frontal branch of facial nerve when approaching zygomatic arch

Question 38

TRAPEZIUS flap surgical technique?

Answer 38

Positioning: Ventral
2. Incise skin paddle directly down to muscle
3. Wide elevation of skin and subcutaneous tissue off the muscle
4. Undermine muscle laterally
5. Release origin of muscle from the spinous processes
6. Raise flap inferiorly to superiorly
7. Ligate branches of intercostal arteries
8. Identify the pedicle superiorly (posterior surface of muscle)
9. Divide muscle lateral to the pedicle (preserve superior fibers to maintain shoulder function)

Question 39

c) Nommer la structure qui constitue le repère pour appuyer votre plaque/mèche de reconstruction

Answer 39

i) Posterior ledge = process orbital of palatine

Question 40

b. What 4 structures prevent reduction in dorsal dislocation

What structure do you need to release ?

Answer 40

Noose = Superficial tranverse metacarpal ligament, lumbrical, FDP and volar plate, natatory ligament, ADQ

A 1 pulley