Reconstruction Flashcards
Vascular supply for each regional flap:
- Pectoralis Major
- Deltopectoral
- Superior based SCM
- Inferior based platysma
- PM - Thoracoacromial
- DP - Inferior mammary perforators
- Sup SCM - Occipital
- Inf Platysma - Occipital
Amount in cc of each cancellous harvest site
- Calvarium
- Posterior illeum
- Anterior illieum
- Tibial plateu
- Calvarium - trick question. No cancellous bone
- Post illeum - 100cc
- Ant illeum - 40cc
- Tib plateu - 15cc
Sequence of wound/bone healing: Inflammatory
- Cell types, what is released and why
- If stem cells are transplanted, do they release growth factors?
- Platelets
- TGF-b (transforming) - CT cell differentiation
- PDGF (platelet derived) - cellular proliferation
- VEGF (vascular endothelial) - angiogenesis
- EGF (epidermal)
- FGF (fibroblast)
- Stem cells do not release growth factors. Only there to be acted upon
Sequence of wound/bone healing: Proliferative
- Cell type, what is released and why?
- What slows down angiogenesis and why?
- Proliferation: Fibroblasts
- EGF/VEGF - angiogenesis
- FGF - type III collagen (unorganized) for provisional matrix
- Flattening of O2 tension curve, aka graft is no longer hypoxic. Minimized granulation tissue
Sequence of wound/bone healing: Remodeling
- What process increases wound strength?
- Organization of and conversion of type III collagen to type I
Collagen formation by fibroblasts requires O2 tension of at least
40mm hg
- Infection affects healing by:
- Edema affects healing by:
- Infection
- Increased collagenase
- Decreased O2, <30mm Hg
- Prolongs inflammatory phase beyond 4-6 days
- Edema
* Compromised perfussion
- Diabetes
- Steroids
- Tobacco
- Cutis Laxa
- Ehlers-Danlos
- Nutrition
- Diabetes: vessel injury, decreased O2 and nutrients
- Steroids: Inhibit neutrophils (clean up wound, bacteria) and macrophages (growth factor factor)
- Tobacco: CO decrease O2 tension, perfussion (vasoconstriction)
- Cutis Laxa: Aquired or genetic, elastin defective
- Ehlers-Danlos: Defective collagen metabolism
- Nutrition: Low protein prolongs inflammation
Hypertrophic scar vs keloid
Tissue consistency
Location
Histology
long term prognosis
Hypertrophic scar (HS) vs keloid
Tissue consistency
- Keloid is rubbery.
- HS red, pruritic, firm
Location
- Keloid: sternum, mandible, deltoid
- HS anywhere
Histology
- Keloid: thick collagen fibers, hyanlinized collagen bundles
- HS: thin collagen fibers, no hyanlinization
long term prognosis
- Keloid: grows for years
- HS: Regresses over time
Keloid / Hypertrophic Scar tx
3 steps
Keloid / Hypertrophic Scar tx
3 steps
- Excision
- Intralesional steroid injection (40mg kenalog) 2x month for 6 months
- Pressure dressing with silicone 12-24hrs/day for 2 months
Random pattern flap length to width ratio
3:1 length to width
Rotation flap
- Ideal arc angle
- Arch length relative to diameter defect
30 degrees arch
4:1
- Rhomboid flap angles
- Z plasty angles effect on length increase
- 30, 45, 60 degrees
- Rhomboid flap angles = 60 and 120 degrees
- Z plasty angles effect on length increase
- 30 degrees increases length 25%
- 45 degrees increasing length 50%
- 60 degrees increasing legth 75%
Scar revision excision design
- <2cm
- 2-5cm
- >5cm
Scar revision excision design
- <2cm = Z-plasty or single ellipse
- 2-5cm = geometric W-plasty
- >5cm = serial excision/local flap
Temporoparietal flap
- Pedicle
- Areas of reconstruction
- Other advantages
- Disadvantages
Temporoparietal flap
Pedicle
- STA
Areas of reconstruction
- Orbit, maxilla, auricle
Other advantages
- Pliable
- Hair bearing skin paddle
- Minimal donor site morbidity
Disadvantages
- Superficial plane dissection difficult
Temporalis Flap
- Pedicle
- Areas of reconstruction
- Other advantages
- Disadvantages
Pedicle
- Deep and middle temporal arteries
Areas of reconstruction
- Oral defect obliteration
- Cranial base
- TMJ gap arthroplasty
- Facial reanimation
Other advantages
- Good bulk for intraoral
- Easy dissection
Disadvantages
- Temporal hollowing. Can minimize with facial implant or repositioning posterior flap into anterior location
Paramedian flap
- Pedicle
- Areas of reconstruction
- Other advantages
- Disadvantages
Pedicle
- Supratrochlear a. 1.7-2.2 cm from midline
Areas of reconstruction
- large nasal defect
Other advantages
- good tissue match
- min donor site morbidity
Disadvantages
- pedicle division at week 3
Nasialabial flap
- Pedicle
- Areas of reconstruction
- Other advantages
- Disadvantages
Pedicle
- Angular a. or random pattern, inferior or superior based
Areas of reconstruction
- lower 2/3 nose, upper lip, small/medium palate defects
Other advantages
- None
Disadvantages
- nasofacial sulcus blunted, ectroption, scleral show
Facial Artery MyoMucosal flap (FAMM)
- Pedicle
- Areas of reconstruction
- Other advantages
- Disadvantages
Pedicle
- branch of facial a.
Areas of reconstruction
- Lower alveolus
- FOM
- Lip vermillion
- Palate/upper alveolus
Other advantages
- Good tissue match
Disadvantages
- Trismus
Tongue Flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantages
Pedicle
- Random or dorsolingual branch of lingual
Areas of reconstruction
- Retromolar trigone
- Palate
- Buccal
Other advantages
- 3-10mm thickness
Disadvantages
- pedicle division 3 weeks
Palatal island flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantages
Pedicle
- Greater Palatine
Areas of reconstruction
- Palate, retromolar
Other advantages
- Minimal donor site morbidity
- Can harvest entire palate with single pedicle
- Can rotate 180deg
Disadvantages
- not mentioned
Submental Island Flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantages
Pedicle
- Submental artery
Areas of reconstruction
- FOM, retromolar, tongue, soft palate
Other advantages
- Good tissue match
- Min morbidity
Disadvantages
- Can’t use if neck dissection indicated
Cervicofascial flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantages
Pedicle
- Random
Areas of reconstruction
- Resurface neck/face
Other advantages
- Easy, reliable
Disadvantages
- limited volume
- May not work s/p radiation and/or neck dissection
Platsyma flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantages
Pedicle
- Has muscle perforators, basically random pattern
Areas of reconstruction
- FOM, buccal, lower face
Other advantages
- Thin, pliable
- Min morbidity
Disadvantages
- Limited arch
- Difficult to harvest
- May not work s/p radiation and/or neck dissection
SCM flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantage
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
Trapezius Flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantage
Pedicle
- Dorsal scapular artery
Areas of reconstruction
- Lateral neck
- Skull cutaneous
Other advantages
- Long pliable pedicle
- Hairless skin
Disadvantage
- Shoulder weaker
- Patient repositioning
Supraclavicular flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantage
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
Pectoralis Major Myocutaneous Flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantage
Pedicle
- Thoracoacromial
- Long thoracic
Areas of reconstruction
- Large head and neck
Other advantages
- Easy harvest
- No patient repositioning
- One stage, protect neck vessels
Disadvantage
Deltopectoral flap
Pedicle
Areas of reconstruction
Other advantages
Disadvantage
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[
Which vessel diameter ratio discrepancy requires end to side anastamosis
3:1
Ratio of venous to arterial thrombosis
4:1
Important factors of flap failure (8)
- Smoking
- Obesity
- PVD
- Long surgery
- Loose anastamosis
- Presence of infection
- Kinked pedicle
- Vein graft used
Non-important factors for free flap failure (4)
- Hypotension and/or vasopressor
- Type of magnification
- Running vs coupler vs interrupted
- Anastamosis type: end to end vs side to end
Tissue Expander effect on:
- Epidermis
- Dermis
- Fat
- Epidermis thickened
- Dermis thinned
- Fat atrophy
Z-plasty
- 30’
- 45’
- 60’
- 30’ lengthens 25%
- 45’ lengthens 50%
- 60’ lengthens 75%
Midface Defect Classification
- Name of classification system
- Describes what 2 aspects of defect
- Prosthesis alone acceptable for which defects?
- James Brown 2010
- Vertical + Horizontal
- Prosthesis alone for vertical Type I, II. Any Horizontal Types a-d
Nasal tip subunits
Which subunits have no cartilage?
Name at least 6 subunits of tip
Nasal sill lies sandwiched between colummela and ?
- Nasal sill, Ala have no cartilage
- Tip (lobule), columella, sill, ala, alar-facial groove, domes
- Nasal sill between columella and Ala
Defect >50% nasal subunit
- Management
- Excise and reconstruct entire subunit
- Reconstruct all involved layers (skin, cartilage, lining)
Which part of nose doesn’t always require lining replacement?
Proximal nose
Nasal cartilage recon
- Best source
- Other sources
- Timing of cartilage recon
- 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
Nasal Lining Recon
- Best
- Other options
- Disadvantages of each
- 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)
Ear Cartilage Recon
- Cartilage in which parts of ear?
- Sources for cartilage
- Upper 2/3 of ear
- Nasal septum, contralateral ear, rib 6-9
Superficial ear defects
- Cartilage intact, not composite
- Excludes helical rim and lobule
- Fortunately can heal by which method? Why?
- Heal by secondary intention
- Because underlying cartilage prevents scar contracture
Ear peripheral defects
- Primary closure possible with what size defect?
- < 15% or 15-20mm
Eyelid defect
- What defect size can be closed primarily?
- Medium defect upper/lower eyelid?
- Large defect upper eyelid?
- Large defect lower eyelid?
- <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
Upper lip divided into central (philtrum segment) and lateral segments
- Central subunit
- Lateral subunit
- 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
Lower lip recon
- <1/3 lower lip defect options
- 1/3 - 2/3 lip defect options
- >2/3 defect options
- Total defect options
- <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
Mandible Recon
- Indications for free flap
- Indications for non-vascularized flap
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
Estimate autogenous bone graft needed
- 1cm linear defect on panorex = ??cc uncompressed bone
- 1cm = 10cc uncompressed bone
Autogeneous bone harvest sites
- 3 primary sites
- Volume of uncompressed bone
- Available cortical bone
- Disadvantages
- 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
Anterior Illeum Graft
- Contraindications
- Tubercle relative to ASIS
- Most commonly affect nerve and its course
- Most common reason for gait disturbance
- Incision placement
- Layers of dissection
- Medial muscles
- Lateral muscles
- Attached directly to ASIS
- Complications and management
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
*
AICBG
- Nerves
- Nerves
- Illiohypogastric L1,L2 Posterolateral gluteal skin
- Subcostal T12,L1 Hip skin
- Lateral femoral cutaneous, branch of illiohypogastric, Lateral thigh skin
Injury to lateral femoral cutaneous nerve
- Causes condition known as..?
- Can occur during which procedure?
- How is it prevented?
Causes Meralgia paraesthetica
AICBG
Incision too far anterior, 2.5% population have nerve that crosses over ASIS, aggressive medial retraction
PIBG
- Contraindications
- Nerves
- Incision placement
- Layers of dissection
- Medial muscles
- Lateral muscles
- Complications and management
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
*
PIBG vs AICBG
- Which has higher rates of gait disturbance, hematoma, infection, pain, hyperesthesia, hernia, illeus?
- Which has higher rate of seroma?
- Which has longer delay to abulation? 3 days vs 1 day
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
Tibial Bone Graft
- Anatomy
- Location of growth plate in skeletally immature
- Nerve
- Blood Vessel
- Tourniquet usage
- Lateral Incision approach
- Medial Incision approach
- Which approach is more difficult in obese patients?
- Complications and management
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
Costochondral Graft
- Contraindications
- Anatomy
- Neurovascular bundle
- Rib selection based on reconstruction need
- Incision placement
- Layers
- Retractors
- Harvest keys to maintain costochondral junction
- Complications and Management
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
