Plastics/Flaps Flashcards

1
Q

What is the arterial supply, nerve for the Radial forearm flap?

What M&N type?

A

radial artery

sensation LABC or MABC

Can be a M&N type 1 (May include BR, FCR, or PL)

But is generally a Fasciocutaneous flap (Type B FC flap)

ASIDE:

Mathes and Nahai Classification of fasciocutaneous (AKAPerforator flaps):

Type A- perforator is direct from artery to skin.

Type B- Septocutaneous perforators (ALT)

Type C- Musculocutaneous Perforators.

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2
Q

what can you cover with the radial forearm flap?

list sites for both as free flap and pedicled flap

A

Pedicled: hand, wrist, forearm, elbow

free: head/neck, UE, LE, plantar foot (sensate)

esophagus, penis

2.5mm x 20cm pedicle

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3
Q

What is the arterial supply and nerve supply to lateral arm flap?

M&N type?

A

artery: posterior br of radial collateral a

posterior cutaneous n of arm or lower lateral cutaneous nerve of arm (branch of radial n)

7.5cm x 2.5mm pedicle

M&N type B

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4
Q

what can you cover with the lateral arm flap?

both pedicled and free

A

pedicled: shoulder, axilla, elbow
free: head/neck

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5
Q

What is the artery and nerve supply for the medial gastroc flap?

M&N type?

A

M&N type 1

2mm x 6 cm

•Pedicles

–Major - Medial and Lateral sural arteries

–Minor – paired anastomotic sural vessels

•Innervation

–Tibial nerve

–Saphenous (medial), Sural (lateral)

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6
Q

what can you cover with medial gastroc flap?

A

proximal 1/3 tibia

anterior knee

distal 1/3 posterior thigh

popliteal fossa

Contralateral leg flap

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7
Q

What is the artery and nerve supply for the rectus femoris flap?

M&N type?

A

M&N type 2

artery:

  • *dominant pedicle**- descending branch of lateral circumflex femoral artery (5cm, 2mm pedicle)
  • *minor pedicle**- ascending branch of lateral circumflex femoral artery
  • *minor pedicle** - muscular branch of superficial femoral artery

nerve:

femoral n (motor)

anterior fem cutaneous n (sensory)

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8
Q

what can you cover with rectus femoris flap?

A

inferior abdomen, groin, pubic/perineal region

This flap based on the descending branch of the lateral circumflex femoral artery provides a reliable muscle with or without skin paddle primarily for local coverage and reconstruction, at the expense of terminal thigh extension
m Coverage: inferior abdomen, groin, perineum, ischium

Reconstruction: abdominal wall

Microvascular transplantation: functional muscle for facial reanimation and upper extremity reconsruction

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9
Q

What is the major arterial supply and nerve supply of the gracillis flap?

M&N type?

A

M&N type 2

1.6mm x 6cm

Artery: Dominant: medial femoral circumflex aa (ascending branch)

Minor pedicle: Branch of SFA 2cm x 0.5mm

Motor: anterior branch of obturator nn

Sensory: medial femoral cutaneous nerve (L2-3).

•Dominant

– Ascending branch of medial circumflex femoral.

–Length – 6 cm, Diameter – 1.6 mm.

•Minor

–one or two branches of superficial femoral

–Length – 2 cm, Diameter – 0.5 mm

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10
Q

What are the uses of the gracillis flap?

A

pedicled: perineal region (vagina, anus perineum), complex pelvic injuries

free flap: extremities and head/neck

per Halifax flap manual:

Perineal, abdominal, ischial and upper/lower extremity reconstruction (free flap).

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11
Q

What flap can you use to cover a midshaft tibia defect?

A

soleus flap

M&N type 2

Popliteal AA muscle branches 1.5mm x 1cm

posterior Tibial branches 2mm x 2 cm

Peroneal AA branches 2mm x 2 cm

•Dominant

–Proximal two branches of popliteal artery (Length 0.5-1 cm, diameter 1-1.5mm)

–Proximal two branches of posterior tibial artery (Length 1-2 cm, diameter 1-2 mm) medial belly

–Proximal two branches of peroneal artery (Length 1-2 cm, diameter 1-2 mm) lateral belly

•Minor

–3-4 segmental branches of posterior tibial (L 1-1.5 cm, D 0.5 1mm)

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12
Q

Name & Describe the vascular classification for muscle flaps.

A

Mathes & Nahai

5 Types:

Type 1 - One vascular pedicle

Ex: Gastrocs flap, TFL Vastus lateralis, genioglossus Styloglossus

Type 2 - dominant pedicle and minor pedicle(s)

Ex: Gracilis, Trapezius, Soleus, rectus femoris, bicpes femoris, triceps

Type 3 - Two dominant pedicles

Ex: Glut Max, Rectus Abdominus, Pec minor, serratus, tempporais

Type 4 - Segmental vascular pedicles

Ex: Sartorius, Tib ant, Ext Oblique, EHL, FDL, FHL

Type 5 - one dominant pedicle and secondary segmental pedicles

Ex: Lat Dorsi, Pec Major, fibula, internal oblique

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13
Q

What is a Mathes and Nahai Type 1 Flap?

A

Type 1 - One vascular pedicle

–Tensor fascia Lata

–Gastrocnemius

–Vastus Lateralis

–Genioglossus

–Styloglossus

–Anconeus

–Abductor Digiti minimi

–Abductor Pollicis Brevis

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14
Q

What is a Mathes and Nahai Type 2 Flap?

A

Type 2 - dominant pedicle and minor pedicle(s)

–Gracilis

–Trapezius

–Soleus

–Rectus femoris

–Coracobrachialis

–Biceps Femoris

–Triceps

–SCM

–Platysma

–Brachioradialis

–Abductor digiti minimi (foot)

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15
Q

What is a Mathes and Nahai Type 3 Flap?

A

Type 3 - Two dominant pedicles

–Gluteus Maximus

–Rectus abdominus

–Serratus

–Pectoralis Minor

–Temporalis

–Intercostal

–Orbicularis oris

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16
Q

What is a Mathes and Nahai Type 4 Flap?

A

Segmental Pedicles

–Sartorius

–Tibialis Anterior

–External Oblique

–Extensor Hallucis Longus

–Flexor digitorum longus

–Flexor hallucis longus

17
Q

What is a Mathes and Nahai Type 5 Flap?

A

Single Dominant and secondary segmental pedicles.

–Latissimus Dorsi

–Pectoralis Major

–Fibula

–Internal oblique

18
Q

What is the most reliable M&N flap for transfer?

A

Types I, III and V often recognized as most reliable flaps for transfer (the ones with a reliable dominant pedicle)

Note that dominant pedicle in type II muscles may not actually capture all the territory of the minor pedicles.

19
Q

What flaps use the following arteries?
Lateral femoral circumflex?

Medial femoral circumflex?

A

Lateral femoral circumflex:

  • TFL (ascending branch)
  • Rectus femoris (decending branch)
  • ALT flap

Medial femoral circumflex?

  • Gracilis (ascending branch)
20
Q

Why is a lateral gastroc flap better than medial?

M&N type?

A

less soft tissue defect, medial gastroc gives diamond appearance to calf.

M&N type 1

21
Q

What are the 8 principles of tendon transfer?

A
  1. expendable donor
  2. one tendon transfer performs one function
  3. adequate strength
  4. same excursion
  5. same direction
  6. synergistic
  7. supple joint
  8. soft tissue equilibrium (The principle of soft tissue equilibrium refers to the idea that a tendon transfer should pass through a healthy bed of tissue that is free from inflammation, edema, and scar )

OR:

Rule of 13 S’s

In a Sensible patient, I will transfer a

  • Strong, Sacrificeable, Synergistic tendon with Sufficient excursion
  • Straight through a Scarless, Stable bed, Subcutaneously
  • across a Supple, Sensate joint
  • to achieve a Single function by Securing distally
22
Q

What is the reconstructive ladder?

A

Rung 1: Healing by secondary intention
Rung 2: Primary closure
Rung 3: Delayed primary closure
Rung 4: Split thickness graft
Rung 5: Full thickness skin graft
Rung 6: Tissue expansion
Rung 7: Random flap
Rung 8: Axial flap
Rung 9: Free flap

23
Q

What are the 4 stages of graft take?

A

•IMBIBITION (0-48 hours)

–Imbibe= drinking. Drinking the nutrients up from ECF.

•INOSCULATON (48-72h)

–Adjacent graft and recipient blood vessels join.

•NEOVASCULARIZATION (72h-7 days)

–Ideally, complete vascularization within 4-7 days

•MATURATION (12-18 months)

–Like any scar…

24
Q

What is the maximum defect for a moberg advancement flap? Why?

A

you can only advance 1.5-2cm or else you get IP joint stiffness. Moberg flaps are used for thumb defects.

The Moberg flap is suited for medium (1.8-3 cm) defects. For defects >1.5 cm, there is increased risk of wound dehiscence, parrot beak nail deformity, and decreased soft tissue padding. Modifications such as V-Y flaps, bilateral Z-plasties, Burrow triangles, 2 lateral triangular flaps at the proximal edge of the flap, or advancement of an island flap with skin grafting of the secondary defect (O’Brien modification), are recommended.

25
Q

What are 3 extra-plexus nerves that can be used for nerve transfer in brachial plexus injuries?

A
  1. median
  2. ain
  3. ulnar
26
Q

What types of M&N flaps are:

  • gracilis
  • TFL
  • Gluteus maximus
  • Pectoralis major
  • Rectus femoris
  • soleus
  • Gastrocs
  • Lat dorsi
  • Forearm
  • ALT
A
  • gracilis 2
  • TFL 1
  • Gluteus maximus 3
  • Pectoralis major 5
  • Rectus femoris 2
  • Soleus 2
  • Gastrocs 1
  • Lat dorsi 5
  • Forearm FC Type B
  • ALT FC Type B
27
Q

What is the Mathes and Nahai Classification of fasciocutaneous (AKA Perforator flaps)?

A

Type A- perforator is direct from artery to skin (example medial circumflex FC flap (gracilis)

Type B- Septocutaneous perforators (ALT, radial forearm)

Type C- Musculocutaneous Perforators (Paramedian forehead flap, post tib artery perforator)

28
Q

What type of flap is the Anterolateral thigh flap?

What is the arterial and nerve supply?

A
  • A type B and C (septocutaneous and musculocutaneous perforators) fasciocutaneous flap
  • Useful for local or distant defect reconstruction
  • Flap size up to 8cm X 25cm with primary closure

•Indications:

–Free: anywhere

–Local: Thin flap, large surface area wounds –> Groin, knee, abdomen, trochanteric region

AA supply is from the Lateral femoral circumflex artery.

Nerve supply is the LFCN