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ABOMS (Johnston) > Reconstruction > Flashcards

Reconstruction Flashcards

1
Q

Vascular supply for each regional flap:

  1. Pectoralis Major
  2. Deltopectoral
  3. Superior based SCM
  4. Inferior based platysma
A
  1. PM - Thoracoacromial
  2. DP - Inferior mammary perforators
  3. Sup SCM - Occipital
  4. Inf Platysma - Occipital
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2
Q

Amount in cc of each cancellous harvest site

  1. Calvarium
  2. Posterior illeum
  3. Anterior illieum
  4. Tibial plateu
A
  1. Calvarium - trick question. No cancellous bone
  2. Post illeum - 100cc
  3. Ant illeum - 40cc
  4. Tib plateu - 15cc
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3
Q

Sequence of wound/bone healing: Inflammatory

  1. Cell types, what is released and why
  2. If stem cells are transplanted, do they release growth factors?
A
  1. Platelets
  • TGF-b (transforming) - CT cell differentiation
  • PDGF (platelet derived) - cellular proliferation
  • VEGF (vascular endothelial) - angiogenesis
  • EGF (epidermal)
  • FGF (fibroblast)
  1. Stem cells do not release growth factors. Only there to be acted upon
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4
Q

Sequence of wound/bone healing: Proliferative

  1. Cell type, what is released and why?
  2. What slows down angiogenesis and why?
A
  1. Proliferation: Fibroblasts
  • EGF/VEGF - angiogenesis
  • FGF - type III collagen (unorganized) for provisional matrix
  1. Flattening of O2 tension curve, aka graft is no longer hypoxic. Minimized granulation tissue
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5
Q

Sequence of wound/bone healing: Remodeling

  1. What process increases wound strength?
A
  1. Organization of and conversion of type III collagen to type I
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6
Q

Collagen formation by fibroblasts requires O2 tension of at least

A

40mm hg

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7
Q
  1. Infection affects healing by:
  2. Edema affects healing by:
A
  1. Infection
  • Increased collagenase
  • Decreased O2, <30mm Hg
  • Prolongs inflammatory phase beyond 4-6 days
  1. Edema
    * Compromised perfussion
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8
Q
  1. Diabetes
  2. Steroids
  3. Tobacco
  4. Cutis Laxa
  5. Ehlers-Danlos
  6. Nutrition
A
  1. Diabetes: vessel injury, decreased O2 and nutrients
  2. Steroids: Inhibit neutrophils (clean up wound, bacteria) and macrophages (growth factor factor)
  3. Tobacco: CO decrease O2 tension, perfussion (vasoconstriction)
  4. Cutis Laxa: Aquired or genetic, elastin defective
  5. Ehlers-Danlos: Defective collagen metabolism
  6. Nutrition: Low protein prolongs inflammation
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9
Q

Hypertrophic scar vs keloid

Tissue consistency

Location

Histology

long term prognosis

A

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
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10
Q

Keloid / Hypertrophic Scar tx

3 steps

A

Keloid / Hypertrophic Scar tx

3 steps

  1. Excision
  2. Intralesional steroid injection (40mg kenalog) 2x month for 6 months
  3. Pressure dressing with silicone 12-24hrs/day for 2 months
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11
Q

Random pattern flap length to width ratio

A

3:1 length to width

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12
Q

Rotation flap

  • Ideal arc angle
  • Arch length relative to diameter defect
A

30 degrees arch

4:1

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13
Q
  • Rhomboid flap angles
  • Z plasty angles effect on length increase
    • 30, 45, 60 degrees
A
  • 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%
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14
Q

Scar revision excision design

  • <2cm
  • 2-5cm
  • >5cm
A

Scar revision excision design

  • <2cm = Z-plasty or single ellipse
  • 2-5cm = geometric W-plasty
  • >5cm = serial excision/local flap
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15
Q

Temporoparietal flap

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages
A

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
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16
Q

Temporalis Flap

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages
A

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
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17
Q

Paramedian flap

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages
A

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
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18
Q

Nasialabial flap

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages
A

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
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19
Q

Facial Artery MyoMucosal flap (FAMM)

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages
A

Pedicle

  • branch of facial a.

Areas of reconstruction

  • Lower alveolus
  • FOM
  • Lip vermillion
  • Palate/upper alveolus

Other advantages

  • Good tissue match

Disadvantages

  • Trismus
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20
Q

Tongue Flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

A

Pedicle

  • Random or dorsolingual branch of lingual

Areas of reconstruction

  • Retromolar trigone
  • Palate
  • Buccal

Other advantages

  • 3-10mm thickness

Disadvantages

  • pedicle division 3 weeks
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21
Q

Palatal island flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

A

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
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22
Q

Submental Island Flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

A

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
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23
Q

Cervicofascial flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

A

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
24
Q

Platsyma flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

A

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
25
Q

SCM flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

A

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
26
Q

Trapezius Flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

A

Pedicle

  • Dorsal scapular artery

Areas of reconstruction

  • Lateral neck
  • Skull cutaneous

Other advantages

  • Long pliable pedicle
  • Hairless skin

Disadvantage

  • Shoulder weaker
  • Patient repositioning
27
Q

Supraclavicular flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

A

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
28
Q

Pectoralis Major Myocutaneous Flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

A

Pedicle

  • Thoracoacromial
  • Long thoracic

Areas of reconstruction

  • Large head and neck

Other advantages

  • Easy harvest
  • No patient repositioning
  • One stage, protect neck vessels

Disadvantage

29
Q

Deltopectoral flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

A

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[
30
Q

Which vessel diameter ratio discrepancy requires end to side anastamosis

A

3:1

31
Q

Ratio of venous to arterial thrombosis

A

4:1

32
Q

Important factors of flap failure (8)

A
  1. Smoking
  2. Obesity
  3. PVD
  4. Long surgery
  5. Loose anastamosis
  6. Presence of infection
  7. Kinked pedicle
  8. Vein graft used
33
Q

Non-important factors for free flap failure (4)

A
  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
34
Q

Tissue Expander effect on:

  • Epidermis
  • Dermis
  • Fat
A
  • Epidermis thickened
  • Dermis thinned
  • Fat atrophy
35
Q

Z-plasty

  • 30’
  • 45’
  • 60’
A
  • 30’ lengthens 25%
  • 45’ lengthens 50%
  • 60’ lengthens 75%
36
Q

Midface Defect Classification

  • Name of classification system
  • Describes what 2 aspects of defect
  • Prosthesis alone acceptable for which defects?
A
  • James Brown 2010
  • Vertical + Horizontal
  • Prosthesis alone for vertical Type I, II. Any Horizontal Types a-d
37
Q

Nasal tip subunits

Which subunits have no cartilage?

Name at least 6 subunits of tip

Nasal sill lies sandwiched between colummela and ?

A
  • Nasal sill, Ala have no cartilage
  • Tip (lobule), columella, sill, ala, alar-facial groove, domes
  • Nasal sill between columella and Ala
38
Q

Defect >50% nasal subunit

  • Management
A
  • Excise and reconstruct entire subunit
  • Reconstruct all involved layers (skin, cartilage, lining)
39
Q

Which part of nose doesn’t always require lining replacement?

A

Proximal nose

40
Q

Nasal cartilage recon

  • Best source
  • Other sources
  • Timing of cartilage recon
A
  • 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
41
Q

Nasal Lining Recon

  • Best
  • Other options
  • Disadvantages of each
A
  • 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)
42
Q

Ear Cartilage Recon

  • Cartilage in which parts of ear?
  • Sources for cartilage
A
  • Upper 2/3 of ear
    • Nasal septum, contralateral ear, rib 6-9
43
Q

Superficial ear defects

  • Cartilage intact, not composite
  • Excludes helical rim and lobule
  • Fortunately can heal by which method? Why?
A
  • Heal by secondary intention
  • Because underlying cartilage prevents scar contracture
44
Q

Ear peripheral defects

  • Primary closure possible with what size defect?
A
  • < 15% or 15-20mm
45
Q

Eyelid defect

  • What defect size can be closed primarily?
  • Medium defect upper/lower eyelid?
  • Large defect upper eyelid?
  • Large defect lower eyelid?
A
  • <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
46
Q

Upper lip divided into central (philtrum segment) and lateral segments

  • Central subunit
  • Lateral subunit
A
  • 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
47
Q

Lower lip recon

  • <1/3 lower lip defect options
  • 1/3 - 2/3 lip defect options
  • >2/3 defect options
  • Total defect options
A
  • <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
48
Q

Mandible Recon

  • Indications for free flap
  • Indications for non-vascularized flap
A

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
49
Q

Estimate autogenous bone graft needed

  • 1cm linear defect on panorex = ??cc uncompressed bone
A
  • 1cm = 10cc uncompressed bone
50
Q

Autogeneous bone harvest sites

  • 3 primary sites
  • Volume of uncompressed bone
  • Available cortical bone
  • Disadvantages
A
  • 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
51
Q

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
A

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
    *
52
Q

AICBG

  • Nerves
A
  • Nerves
    • Illiohypogastric L1,L2 Posterolateral gluteal skin
    • Subcostal T12,L1 Hip skin
    • Lateral femoral cutaneous, branch of illiohypogastric, Lateral thigh skin
53
Q

Injury to lateral femoral cutaneous nerve

  • Causes condition known as..?
  • Can occur during which procedure?
  • How is it prevented?
A

Causes Meralgia paraesthetica

AICBG

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

54
Q

PIBG

  • Contraindications
  • Nerves
  • Incision placement
  • Layers of dissection
  • Medial muscles
  • Lateral muscles
  • Complications and management
A

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
      *
55
Q

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
A

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
56
Q

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
A

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
57
Q

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
A

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

ABOMS (Johnston) (8 decks)

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