Reconstruction Flashcards

Question

SCM flap Pedicle Areas of reconstruction Other advantages Disadvantage

Answer 1

SCM flap Pedicle * Occipital a. Areas of reconstruction * Superior based most useful: Lateral/lower face, oral defects, rebulk s/p parotidectomy Other advantages * Leaving one of the heads maintains great vessel coverage Disadvantages * Limited arch * May not be suitable in oncology patient

Answer 2

Pedicle * Dorsal scapular artery Areas of reconstruction * Lateral neck * Skull cutaneous Other advantages * Long pliable pedicle * Hairless skin Disadvantage * Shoulder weaker * Patient repositioning

Answer 3

Pedicle * Supraclavicular a. Areas of reconstruction * Lower face cutaneous * Pharyngopharynx * Oral, lip Other advantages * Easy harvest, thin pedicle, min morbidity Disadvantage * Distal flap necrosis * 7% supraclavicular a. have anatomic variation

Answer 4

Pedicle * Thoracoacromial * Long thoracic Areas of reconstruction * Large head and neck Other advantages * Easy harvest * No patient repositioning * One stage, protect neck vessels Disadvantage

Answer 5

Pedicle * Internal mammary a. perforators Areas of reconstruction * Last option for H&N recon Other advantages * Reliable and easy harvest * Lots of bulk Disadvantage * Requires 2nd surgery 3-6 weeks * May not work if previous Pectoralis major fla[

Answer 6

1. Smoking 2. Obesity 3. PVD 4. Long surgery 5. Loose anastamosis 6. Presence of infection 7. Kinked pedicle 8. Vein graft used

Answer 7

1. Hypotension and/or vasopressor 2. Type of magnification 3. Running vs coupler vs interrupted 4. Anastamosis type: end to end vs side to end

Answer 8

* Epidermis thickened * Dermis thinned * Fat atrophy

Answer 9

* 30' lengthens 25% * 45' lengthens 50% * 60' lengthens 75%

Answer 10

* James Brown 2010 * Vertical + Horizontal * Prosthesis alone for vertical Type I, II. Any Horizontal Types a-d

Answer 11

* Nasal sill, Ala have no cartilage * Tip (lobule), columella, sill, ala, alar-facial groove, domes * Nasal sill between columella and Ala

Answer 12

* Excise and reconstruct entire subunit * Reconstruct all involved layers (skin, cartilage, lining)

Answer 13

Proximal nose

Answer 14

* Best source = septal cartilage * Rib 6-9, conchal best for ala because of curve but weaker * At time of lining/skin OR 3 weeks after lining/skin

Answer 15

* Best = Septal muchoperichondrial flap (based on septal artery from superior labial from facial a.) * FAMM (based on facial a.) superior based * FTSG (requires vascular bed)

Answer 16

* Upper 2/3 of ear * * Nasal septum, contralateral ear, rib 6-9

Answer 17

* Heal by secondary intention * Because underlying cartilage prevents scar contracture

Answer 18

* \< 15% or 15-20mm

Answer 19

* \<30% closed primarily (45% lower eyelid in older patient) * Tenzel sliding flap for 30-60% defect upper/lower lid * Cutler-Beard Island flap 2 stages, \>60% defect upper lid * Hughes flap 2 stages, \>60% lower lid

Answer 20

* Abbe for total central subunit recon - 2 stages * Primary closure for subtotal central subunit recon * \>50% lateral subunit requires Abbe - 2 stages * Involving commisure requires Estlander, 1 stage

Answer 21

* \<1/3 lower lip defect options = Primary * 1/3 - 2/3 lip defect options = Reverse Abbe, step-ladder * \>2/3 defect options = Kerapandzic, Modified Webster-Bernard * Total defect options = RFF

Answer 22

Vascularized flap * Inadequate soft tissue/oral lining * \>9cm linear defect * Any anterior mandible defect Non-vascularized flap * Adequate soft tissue/oral lining either after resection or earlier regional flap (ie pec flap) * \<9cm linear defect

Answer 23

* 1cm = 10cc uncompressed bone

Answer 24

* Tibia: 25cc, min cortical bone * Anterior illeum: 50cc, 4x5cm cortical bone, immediate gate disturbance * Posterior illeum: 100cc, 5x5cm cortical bone, positional change, outpatient not possible * Volume of uncompressed bone * Available cortical bone * Disadvantages

Answer 25

Anterior Illeum Graft * Contraindications * H/o infection/trauma to hip. * H/o hernia repair (relative) * Obesity (relative) * Tubercle relative to ASIS * Anterior tubercle is 6cm posterior to ASIS. The tubercle is the widest part of the anterior illiac crest. * Most commonly affect nerve and its course * Illiohypogastric because it passes over ASIS anterior to the tubercle. * Most common reason for gait disturbance * Disruption of Tensor fascia lata on lateral surface * Incision placement * 2cm lateral to crest, 1cm proximal to ASIS, 4-6cm in length * Layers of dissection * Skin * Subq * Campers fasscia * Scarpa fascia * Periosteum between external oblique (medial) and Tensor fascia lata (lateral) * Medial muscles * External oblique * Transverse abdominal * Iliacus * Lateral muscles * Tensor fascia lata * Gluteus minimus/medius * Attached directly to ASIS * Inguinal ligament * Sartorius * Complications and management *

Answer 26

* Nerves * Illiohypogastric L1,L2 Posterolateral gluteal skin * Subcostal T12,L1 Hip skin * Lateral femoral cutaneous, branch of illiohypogastric, Lateral thigh skin

Answer 27

Causes Meralgia paraesthetica AICBG Incision too far anterior, 2.5% population have nerve that crosses over ASIS, aggressive medial retraction

Answer 28

PIBG * Contraindications * H/o fracture, infection, radiation, osteoporosis * Nerves * Superior Cluneal N L1,2,3 * Middle Cluneal n S1,2,3 * Sciatic n 6-8 cm inferior to posterior superior illiac crest lateral to sacrum * Incision placement * Over Posterior Illiac Crest, 6-8cm * Ideally between SCN/MCN * Layers of dissection * Skin, Subq, Thoracodorsal Facia (Latissimus Dorsi), Periosteum * Medial muscles * Illiacus * Psoas major (more medial) * Lateral muscles * Gluteous Maximus more superior * Gluteous Medius/Minimus * Complications and management * Seroma: most common. Lack or premature removal of drain. Tx with aspiration and pressure dressing * Gait disturbance: Reflecting gluteal muscles *

Answer 29

PIBG vs AICBG * AICBG = Which has higher rates of gait disturbance, hematoma, infection, pain, hyperesthesia, hernia, illeus? * PIBG = Which has higher rate of seroma? * AICBG = Which has longer delay to abulation? 3 days vs 1 day

Answer 30

Tibial Bone Graft * Anatomy * Tibial Plateau * Gerdy Tubercle * Tibial Midline * Location of growth plate in skeletally immature * Tibial Plateau * Nerve * Cutaneous lateral sural nerve * Blood Vessel * Tourniquet usage * \<2hours * 50mmHg \> systolic pressure * Lateral Incision approach * KEY: Gerdy's tubercle between Patellar Tendon and Fibular Head * Incise skin, SubQ, iliotibial tract, periosteum * Iliotibial tract must be sutured as distinct layer * Medial Incision approach * Not common, less likely to enter joint space * Which approach is more difficult in obese patients? * Medial * Complications and management * Entering joint space/disrupting tibial plataeu: avoid harvesting superior * Bleeding: check hemostasis after releasing tourniquet

Answer 31

Costochondral Graft * Contraindications * Same trauma, infection, osteoporosis. Severe restrictive pulm disease (ie sarcoid, CF) * Anatomy * Inframammary crease * Sternum * Midaxillary line * Neurovascular bundle * Along inferior border of each rib * Rib selection based on reconstruction need * TMJ = contralateral rib for better contour, #5-7 * Nasal = #9-11 * Ear = #5-8 * Incision placement * Inframmamary crease midaxilla to sternum * When approaching rib, straddle rib between fingers to prevent accidental pleural injury * Layers * Skin, SubQ, Pectoralis or Rectus Abdominus m, fascia, periosteum * Retractors * Doyen rib stripper * Procedure Pearls * Close periosteum for neo-rib formation * Maintain periosteum over costochondral junction * Incise through cap then elevate rip out and lateraly before osteotomy * Water in wound to verify no PTX * Complications and Management * Small PTX: Purse string closure of pleura over drain catheter. Withdraw catheter under suction and tighten sutures. * Large PTX: chest tube