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Flashcards in Flaps Deck (294):
1

A 28-year-old man is brought to the emergency department after sustaining a dog bite to the face. Physical examination shows subtotal loss of the nose and glabella. Staged reconstruction with a forearm flapis performed, with initial elevation of the flap, placement of cartilage grafts, and creation of nostrils. Thinning and refinement are performed during a second procedure with additional cartilage grafting. The flap is microsurgically transferred to reconstruct the nose in a third procedure. Which of the following is the most appropriate description of this flap?
A) Delayed
B) Freestyle
C) Prefabricated
D) Prelaminated
E) Tubularized

D) Prelaminated

The flap described in this scenario is a prelaminated flap. A prelaminated flap is an axial flap that is modified with the addition of various grafts (e.g., skin, mucosa, cartilage, bone), re-creating the missing tissues at the donor site prior to flap transfer.

2

Prelaminated flap

A prelaminated flap is an axial flap that is modified with the addition of various grafts (e.g., skin, mucosa, cartilage, bone), re-creating the missing tissues at the donor site prior to flap transfer.

3

Delayed flap

A delayed flap is one thatundergoes one or more vascular insults prior to final flap elevation to induce increased circulation and maximize flap perfusion.

4

Freestyle flap

A freestyle flap is a nonaxial flap harvested by locating a cutaneous Doppler signal in a chosen donor site, identifying the vessels supplying that tissue, and dissecting them down to a pedicle of sufficient length and/or diameter. The anatomy is not known ahead of time, and thus harvest is performed "freestyle."

5

Prefabricated flap

A prefabricated flap is created by transferring a vascular pedicleinto an area of tissue that is ideal for transfer to induce angiogenesis from the pedicle into that tissue, which can then be harvested for transfer.

6

Tubularized flap

A tubularized flap is one that is sewn to itself to create a tube or passive conduit, such as an anterolateral thigh flap used for pharyngoesophageal reconstruction.

7

A 52-year-old man is brought to the emergency department after sustaining injuries in a motor vehicle collision. Physical examination shows a traumatic degloving injury to the dorsum of the right hand with exposed, intact extensor tendons. Reconstruction with a fascial free flap and full-thickness skin grafting are planned. Which of the following arteries supplies blood to the most appropriate choice of flap?
A) Posterior auricular
B) Superficial temporal
C) Superior thyroid
D) Supratrochlear
E) Transverse facial

B) Superficial temporal

The temporoparietal fascial flap is supplied by the superficial temporal artery. This thin fascial free flap is useful in reconstruction of traumatic injuries that are not amenable to reconstruction with a skin graft alone. This flap is particularly useful in reconstruction of gliding surfaces with denuded tendons or exposed joints

8

Temporoparietal fascial flap blood supply

The temporoparietal fascial flap is supplied by the superficial temporal artery.

9

Temporoparietal fascial flap

This thin fascial free flap is useful in reconstruction of traumatic injuries that are not amenable to reconstruction with a skin graft alone. This flap is particularly useful in reconstruction of gliding surfaces with denuded tendons or exposed joints

10

A 48-year-old man has infected hardware 4 weeks after undergoing spinal fusion. The neurosurgeon washes out the wound and requests consultation for coverage of the defect. In the operating room, the plastic surgeon notes that coverage with a paraspinous muscle flap is not possible, as the muscle has been heavily debrided by the neurosurgeon. Use of a reverse latissimus dorsi flap is planned. These two flaps share an arterial blood supply from which of the following arteries?
A) Circumflex scapular
B) Posterior intercostal
C) Superior gluteal
D) Thoracodorsal
E) Transverse cervical

B) Posterior intercostal

The paraspinous muscle is supplied by the posterior intercostal artery; this is the same vessel that supplies the reverse latissimus dorsi flap. For a midline spinal defect, it is unlikely that these vessels are damaged; however, this is possible in large oncologic resections or traumatic injuries

11

The paraspinous muscle is supplied by:

The posterior intercostal artery

12

The reverse latissimus dorsi flap is supplied by:

The posterior intercostal artery

13

The circumflex scapular artery supplies what flaps?

The scapular and parascapular flap

14

The parascapular flap is supplied by:

The circumflex scapular artery

15

The scapular flap is supplied by:

The circumflex scapular flap

16

The transverse cervical artery supplies:

The trapezius muscle flap

17

The trapezius muscle flap is supplied by

The transverse cervical artery

18

The superior gluteal artery supplies:

The gluteus maximus flap

19

The gluteus maximus flap is supplied by:

The superior gluteal artery

20

The thoracodorsal artery is the main arterial supply to:

The latissimus muscle

21

The main supply to the latissimus muscle:

The thoracodorsal artery

22

A 55-year-old woman is for soft-tissue coverage of an open joint elbow wound. The vascular pedicle of the flap in the photograph shown passes between which of the following tendons?
A) Brachioradialis and abductor pollicis longus
B) Brachioradialis and flexor carpi radialis
C) Brachioradialis and flexor pollicis longus
D) Brachioradialis and pronator teres
E) Flexor carpi radialis and pronator teres

B) Brachioradialis and flexor carpi radialis

Proximally, the radial artery runs deep to the brachioradialis muscle and it passes distally between the bellies of the brachioradialis and flexor carpi radialis. The radial forearm flap cutaneous paddle is perfused by septocutaneous perforators from the radial artery.

23

Anatomical course of the radial artery vs muscles

Proximally, the radial artery runs deep to the brachioradialis muscle and it passes distally between the bellies of the brachioradialis and flexor carpi radialis.

24

The radial forearm flap cutaneous paddle is perfused by:

The radial forearm flap cutaneous paddle is perfused by septocutaneous perforators from the radial artery.

25

A 45-year-old woman is brought to the emergency department after sustaining a shotgun injury to the nondominant left forearm. A preoperative x-ray study is shown (heavily comminuted ulna fracture). Bone stabilization is performed. The ulnar nerve, multiple flexor tendons, and the ulnar artery are repaired during surgery and are left exposed. A photograph taken following the repair is shown. The wound was covered with allograft skin while viability of the hand was confirmed for 2 days. Which of the following is the most appropriate definitive coverage for the wound?
A) Free anterolateral thigh flap
B) Full-thickness skin grafting from the groin
C) Pedicled groin flap
D) Reverse lateral arm flap
E) Split-thickness skin grafting from the thigh

A) Free anterolateral thigh flap

Shotgun blasts at close range can create a devastating pattern of injury. X-ray study shows a heavily comminuted ulna fracture. The scenario also involves tendon, vascular, and nerve injury. In choosing the appropriate coverage for the wound described, the surgeon will need to consider the protection of exposed structures, the ability to rehabilitate the extremity, and the possible need for future surgery on the arm. A free tissue transfer will provide viable, full-thickness tissue from a nontraumatized area to cover the wound.

Skin grafting, whether split-thickness or full-thickness, carries several liabilities. Both types of grafts provide skin but no subcutaneous tissue. In addition, both heal by adhering to the wound bed. Because the patient described has exposed tendon in the wound bed, skin grafting would likely cause significant tendon adhesions and thus impaired mobility. In addition, adhesion of the skin graft to a nerve, particularly a repaired nerve, carries a risk of chronic pain and nerve dysfunction.

26

Proposed benefit of fasciocutaneous flaps over muscle flaps

- fat on the deep surface may allow better glide of tendons and nerves
- the fasciocutaneous flap, once healed, can be incised like normal skin for any future surgery

27

What would be downsides for using a skin graft to cover an upper extremity wound?

- No subcutaneous tissue
- Adheres to wound bed - if tendons are exposed, adhesions may impair mobility; adherence to a nerve may cause chronic pain and nerve dysfunction

28

The lateral arm flap donor site can be closed primarily for flaps up to _______

The lateral arm flap donor site can be closed primarily for flaps up to 12 × 6 cm

29

A 55-year-old man is scheduled to undergo a large oncologic extirpation in the groin. Closure of the resulting defect with a rectus femoris musculocutaneous flap is planned. Which of the following is the most likely functional outcome?
A) 15-Degree extensor lag of the knee
B) 20-Degree flexion contracture of the hip
C) Compromised ability to stand for extended periods
D) Inability to adduct the leg
E) No loss of function

A) 15-Degree extensor lag of the knee

Flexion contracture of the hip, difficulty standing for extended periods, and difficulty adducting the leg have not been described with thisflap harvest.

30

Morbidity of a rectus femoris flap?

It is generally recommended to perform patellar tendon repair following harvest of the rectus femoris; despite this repair, there can still be about 15 degrees of extensor lag at the knee.

31

Expanded rectus femoris flap

The expanded flap can reach the he xiphoid, and it has impressive width. The donor site can be closed primarily with an acceptable scar. The muscle remains innervated and functional, which may help prevent bulging. Large or complicated abdominal wall defects.

32

A 70-year-old woman has a circular defect 18 cm in diameter on the parietal aspect of the scalp after excision of squamous cell carcinoma. The pericranium has been removed with the scalp tissue. Adjuvant radiation therapy is planned beginning 4 to 6 weeks after surgery. Which of the following is most appropriate for coverage of the defect?
A)Latissimus dorsi muscle free flap with split-thickness skin graft
B) Primary closure after galeal scoring
C) Split-thickness skin grafting
D) Temporary reconstruction with a split-thickness skin graft followed by a rotation-advancement flap after scalp tissue expansion

A)Latissimus dorsi muscle free flap with split-thickness skin graft

The latissimus dorsi muscle free flap with split-thickness skin grafting can be used to reconstruct large scalp defects in a single stage, allowing the patient to proceed with radiation therapy after recovery from surgery.

Skin grafts usually have poor take on bare calvarium devoid of pericranium.

33

When will skin grafts not take on the cranium?

When it is on the skull and devoid of pericranium

34

Primary closure of a scalp defect is limited to?

About 3 cm in diameter, even with galeal scoring

35

A 79-year-old woman comes to the office because of a large scalp defect following Mohs micrographic surgery for basal cell carcinoma. A photograph of the defect (left) and a rotation flap designed to cover thedefect (right) are shown. At the completion of the procedure, a large “dog ear” is noted at the pivot point of the flap. Which of the following is the most appropriate next step in management?
A) Burrow triangle
B) Compression
C) Direct excision
D) Staged advancement
E) Observation

E) Observation

The temptation to excise should be resisted, as most of these dog earsresolve over time. Photographs immediately after the procedure and 5 months later are shown

36

Treatment of doggier of the scalp

The temptation to excise should be resisted, as most of these dog earsresolve over time. Photographs immediately after the procedure and 5 months later are shown

37

A 50-year-old man is scheduled to undergo resection of a squamous cell cancer of the right floor of the mouth with invasion into the mandibular body. Composite resection of the right hemimandible and a 2-cm resection of the floor of the mouth followed by immediate reconstruction with a fibula flap are planned, necessitating the use of an osteocutaneous flap. Which of the following best describes the course of the blood supply for the skin paddle of this flap?
A) Musculocutaneus and septocutaneous perforators from the peroneus longus and brevis muscles
B) Musculocutaneus perforators from the flexor hallucis brevis muscle
C) Septocutaneous and musculocutaneus perforators from the anterior tibialis muscle
D) Septocutaneous perforators from the posterior inter muscular septum
E) Septocutaneous perforators from the posterior tibialis muscle

D) Septocutaneous perforators from the posterior inter muscular septum

The blood supply for the fibula flap skin paddle used for reconstruction arises from septocutaneous perforators from the peroneal artery that traverse the posterior intermuscular septum.

38

Blood supply to the fibula flap skin paddle

Septocutaneous perforators from the peroneal artery that traverse the posterior intermuscular septum.

39

Which of the following is the most appropriate Mathes and Nahai classification of the rectus abdominis muscle?
A ) Type I
B ) Type II
C ) Type III
D ) Type IV
E ) Type V

C ) Type III

Type III-two dominant pedicles gluteus maximus, rectus abdominis, serratus anterior, and semimembranosus.

40

Definition of Mathes and Nahai Type I

One vascular pedicle

41

Definition of Mathes and Nahai Type II

Dominant and minor pedicle

42

Definition of Mathes and Nahai Type III

Two dominant pedicles

43

Definition of Mathes and Nahai Type IV

Multiple segmental pedicles

44

Definition of Mathes and Nahai Type V

One dominant and secondary segmental pedicles

45

List of Mathes and Nahai Flaps: Type I

gastrocnemius, rectus femoris, and tensor fascia lata.

46

List of Mathes and Nahai Flaps: Type II

abductor digiti minimi, abductor hallucis, biceps femoris, flexor digitorum brevis, gracilis, peroneus longus, peroneus brevis, platysma, semitendinosus, soleus, sternocleidomastoid, temporalis, trapezius, and vastus lateralis.

47

List of Mathes and Nahai Flaps: Type III

gluteus maximus, rectus abdominis, serratus anterior, and semimembranosus.

48

List of Mathes and Nahai Flaps: Type IV

extensor digitorum longus, extensor hallucis longus, flexor digitorum longus, flexor hallucis longus, sartorius, and tibialis anterior.

49

List of Mathes and Nahai Flaps: Type V

pectoralis major and latissimus dorsi.

50

A 54-year-old man is scheduled for correction of a defect on the back 1 week after undergoing resection of a 3 x3-cm recurrent sarcoma. The skin was closed primarily during the procedure, but skin necrosis and wound breakdown occurred. History includes radiation therapy to the spine for soft-tissue sarcoma 2 years ago. Physical examination shows a 5 x5-cm defect in the mid back at the level of T10 with exposed spinous processes. Which of the following is most appropriate to achieve complete wound closure?
A ) Latissimus dorsi flap
B ) Rectus abdominis free tissue transfer
C ) Split-thickness skin graft
D ) Trapezius muscle flap
E ) Wide undermining with primary reclosure

A ) Latissimus dorsi flap

The latissimus dorsi flap would allow for the mobilization of sufficient skin and muscle to close the defect in the patient described. The latissimus dorsi muscle is a Mathes-Nahai Type V flap, with the main blood supply from the thoracodorsal artery and vein, and secondary segmental pedicles from the posterior intercostal and lumbar perforators. The latissimus dorsi insertion onto the humerus can be divided to provide further mobilization of the flap.

A free rectus abdominis muscle flap could be performed, but recipient vessels in this area are not readily available.

Split-thickness skin grafting over a previously irradiated wound bed with exposed bone is not likely to heal. A trapezius muscle flap will not reach the level of T10. Wide undermining is a poor choice because this would lead to further devascularization of previously irradiated skin

51

The latissimus dorsi muscle is a Mathes-Nahai Type ___ flap,

The latissimus dorsi muscle is a Mathes-Nahai Type V flap,

52

How can the latissimus be further mobilized?

The latissimus dorsi insertion onto the humerus can be divided to provide further mobilization of the flap.

53

Detailed blood supply of the latissimus

The main blood supply is from the thoracodorsal artery and vein, and secondary segmental pedicles from the posterior intercostal and lumbar perforators.

54

How can the pedicle of a latissimus be extended?

If needed, interposition vein grafts can be used to extend the vascular pedicle.

55

Wide undermining to close previously irradiated skin

Wide undermining is a poor choice because this would lead to further devascularization of previously irradiated skin

56

A 35-year-old man undergoes coverage of a soft-tissue defect on the posterior right elbow with a reverse lateral arm flap. He does not have a history of serious illness and has never smoked cigarettes. Vascular examination shows no abnormalities. Arterial blood to the flap is provided primarily by which of the following arteries?
A ) Artery to the biceps muscle
B ) Inferior cubital
C ) Musculocutaneous perforating branches from the brachioradialis muscle
D ) Posterior radial collateral
E ) Radial recurrent

E ) Radial recurrent

57

The most likely dominant arterial supply to the reverse lateral arm flap is the:

The most likely dominant arterial supply to the reverse lateral arm flap is the radial recurrent artery. It

58

Anatomy of the radial recurrent artery

It is a branch of the radial artery and arises in the cubital fossa. It anastomoses with the posterior radial collateral artery just above the lateral epicondyle and medial to the brachioradialis within the lateral intermuscular septum.

59

The reverse lateral forearm flap can be used to:

This pedicled flap can be used to cover defects of the elbow and requires retrograde flow through the posterior radial collateral artery via the radial recurrent artery. P

60

Start to be concerned about the reverse lateral forearm flap when:

After rotating this flap more than 180 degrees, venous insufficiency may result and require microanastomosis of a superficial vein in the flap to a receptor vein in the defect to augment outflow.

61

Lateral arm flap blood supply

The posterior radial collateral artery is the dominant inflow for the standard lateral arm flap.

62

Antecubital flap blood supply

The inferior cubital artery is the dominant inflow and the musculocutaneous perforating branches from the brachioradialis muscle are the minor pedicles for the antecubital flap.

63

Medial arm flap blood supply

The artery to the biceps muscle supplies the medial arm flap.

64

A 60-year-old man undergoes debridement and coverage with a gracilis muscle free flap to correct exposed hardware 6 weeks after undergoing fracture fixation of the right ankle. During the hospital stay after the fracture fixation procedure, heparin was administered subcutaneously for deep venous thrombosis prophylaxis. The flap coverage procedure is complicated by thrombosisof the arterial anastomosis that requires thrombectomy and reanastomosis. Systemic heparin is administered because of the complication and continued postoperatively. Three days after this surgery, his right lower extremity, including the flap, is swollen and congested. Pulses in the leg are weak. Which of the following is the most appropriate test for this patient?
A ) Activated partial thromboplastin time (aPTT)
B ) D-dimer
C ) Factor V Leiden
D ) Platelet count
E ) Prothrombin time (PT)

D ) Platelet count

The most appropriate test is a platelet count to determine the possibility of heparin-induced thrombocytopenia (HIT) with thrombosis. This immune-mediated complication can occur in up to 3 to 5% of patients on heparin therapy, especiallythose previously exposed to heparin within the last 3 months of the second exposure. Approximately 20% of patients with HIT will have thrombotic events with potentially devastating consequences: 30% mortality and 30% limb loss.

65

Heparin-induced thrombocytopenia can occur in ______% of patients on heparin therapy

This immune-mediated complication can occur in up to 3 to 5% of patients on heparin therapy

66

Setup for increased likelihood of heparin-induced thrombocytopenia

Patients previously exposed to heparin within the last 3 months of the second exposure.

67

Approximately ____% of patients with HIT will have thrombotic events with potentially devastating consequences:

Approximately 20% of patients with HIT will have thrombotic events with potentially devastating consequences: 30% mortality and 30% limb loss.

68

Pathogenesis of heparin induced thrombocytopenia

The pathogenesis of HIT involves the formation of multimolecular complexes between heparin and platelet factor 4.

In some patients, immunoglobulin G-class antibodies are generated against the heparin: platelet factor 4 complexes. This results in potent platelet activation, platelet aggregation, and a marked increase in thrombin generation. T

69

HIT involves multi molecular complexes between what and what?

The pathogenesis of HIT involves the formation of multimolecular complexes between heparin and platelet factor 4.

70

Diagnosis of heparin induced thrombocytopenia

The key to successful treatment is early recognition, and clinical diagnosis remains the gold standard.

71

Laboratory criteria of heparin induced thrombocytopeia

A 30% decrease in baseline platelet count combined with any form of thrombosis in a patient receiving heparin should be considered heparin-induced thrombocytopenia and thrombosis until proven otherwise.

72

Treatment of heparin induced thrombocytopenia

The most essential element in the treatment of heparin-induced thrombocytopenia and heparin-induced thrombocytopenia and thrombosis remains discontinuation of ALL heparin.
Starting alternative anticoagulant therapy (eg, danaparoid sodium, lepirudin, or argatroban) as soon as there is a strong clinical suspicion of HIT is advocated. This should be continued until platelet levels have returned to baseline.

73

What is D-dimer?

D-dimer is a fibrin degradation product that is elevated in the presence of thrombosis.

74

PT measures:

PT is a measure of the extrinsic pathway of coagulation, and

75

aPTT measures:

aPTT is a measure of both the intrinsic and common pathways of coagulation.

76

A 7-year-old boy with sickle cell disease is brought to the emergency department after sustaining a Gustilo Type IIIB fracture of the lower extremity during an all-terrain vehicle collision. Soft-tissue coverage of exposed hardware and bone is planned. Which of the following factors is most likely to adversely affect perfusion to microsurgical reconstruction in this patient?
A ) High sympathetic tone
B ) Prostacyclines
C ) Sludging
D ) Young age of patient

C ) Sludging

Abnormally elevated rheologic factors associated with hematologic disorders such as sickle cell disease can seriously compromise perfusion. This usually happens in the form of sludging within the vessel lumen, causing flap compromise.

77

Microsurgery safety and children

Microvascular surgery in young patients was once considered high risk because of misconceptions of higher sympathetic tone and higher propensity for spasm. This has been proven false. Many studies have proven microvascular surgery to be safe for children.

78

A 54-year-old man is scheduled for soft-tissue reconstruction of an esophageal defect caused by cancer. A free anterolateral thigh flap will be used. Harvest of the flap will most likely involve taking a cuff of which of the following muscles?
A ) Gracilis
B ) Rectus femoris
C ) Sartorius
D ) Tensor fascia lata
E ) Vastus lateralis

E ) Vastus lateralis

The anterolateral thigh flap is based on the descending branch of the lateral femoral circumflex vessels. Although classically thought of as providing septocutaneous perforators between the rectus femoris and the vastus lateralis muscle, increased familiarity with this flap and critical anatomical evaluation have shown that its perforators are primarily musculocutaneous through the vastus lateralis in themajority of cases.

79

The ALT flap is based on what blood supply?

Descending branch of the lateral femoral cutaneous vessels

80

Perforators of the ALT are primarily through:

The vests lateralis

81

ALT flap: Once musculocutaneous perforators are found, it may be safer to ________________________________

ALT flap: Once musculocutaneous perforators are found, it may be safer to harvest a cuff of vastus lateralis muscle with the perforators to maximize perfusion, as an intramuscular dissection can be tedious and risks damage to the perforators

82

A 45-year-old woman is scheduled to undergo delayed breast reconstruction using a transverse gracilis myocutaneous flap. Which of the following arteries provides the dominant blood supply of this flap?
A ) Deep femoral circumflex
B ) Lateral femoral circumflex
C ) Medial femoral circumflex
D ) Superficial femoral circumflex

C ) Medial femoral circumflex

83

Anatomy of the gracilis

Its innervation comes from a branch of the anterior division of the obturator nerve, which has 2 to 4 fascicles entering the muscle 6 to 10 cm from the origin.

84

Innervation of the gracilis

The gracilis muscle arises from the anterior body and the inferior ramus of the pubis and the ischium. It passes distally in the medial thigh posterior to the long adductor and sartorius muscles and inserts on the medial aspect of the proximal tibia posterior, deep to the sartorius tendon and anterior to the semitendinous muscle insertion.

85

Vascular pedicle for the gracilis flap: length/logistics

A vascular pedicle can be obtained that is 4 to 6 cm long with a vessel diameter of 1 to 2 mm. Two minor vascular pedicles, which are branches of the superficial femoral artery, are located distally and may be sacrificed.

86

Functional loss after gracilis muscle harvest

No significant functional loss can be seen after removal of the gracilis muscle.

87

Skin paddle of the myocutaneous graciliss free flap

The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region allows taking a moderate amount of tissue
(suitable for autologous breast recon in selected patients)

88

Where does the proximal pedicle enter the gracilis muscle?

The proximal pedicle enters the gracilis muscle 8 to 12 cm below the pubic tubercle

89

A 52-year-old woman undergoes reconstruction of the left breast using an ipsilateral extended latissimus dorsi myocutaneous pedicled flap. Postoperatively she develops venous congestion along the distal end of the skin paddle. Leeches are used in an attempt to relieve venous congestion. Which of the following is the most effective prophylactic antibiotic therapy?
A ) Cephalexin
B ) Ciprofloxacin
C ) Clindamycin
D ) Metronidazole
E ) Penicillin

B ) Ciprofloxacin

Medicinal leeches (Hirudo medicinalis) have been used as an aid to salvage congested free flaps. The incidence of infection associated with leech therapy reported in the literature ranges from 2.4% to 20%.

Susceptibility to fluoroquinolones such as ciprofloxacin continues to be observed. Prophylactic antibiotics with a fluoroquinolone and aminoglycoside are recommended, and therapy should be continued until any open wound or necrotic tissue has completely healed.

90

Hirudo medicinalis

Medicinal leeches

91

Incidence of infection associated with leach therapy ranges from:

The incidence of infection associated with leech therapy reported in the literature ranges from 2.4% to 20%.

92

Organism responsible for infection w/ leech therapy

The organism most often responsible is Aeromonas hydrophila, a gram-negative anaerobe that is part of the intestinal resident flora of the leech.

93

Antibiotic resistance to Aeromonas hydrophila

Resistance to penicillins and first-generation cephalosporins is not uncommon because of their production of beta-lactamase enzymes. Resistance to trimethoprim and sulfamethoxazole, tetracycline, imipenem,and even gentamicin has also been reported.

94

Prophylactic antibiotics during leech therapy

Susceptibility to fluoroquinolones such as ciprofloxacin continues to be observed. Prophylactic antibiotics with a fluoroquinolone and aminoglycoside are recommended, and therapy should be continued until any open wound or necrotic tissue has completely healed.

95

A 67-year-old man undergoes three-vessel coronary artery bypass grafting using the left and right internal mammary vessels and a saphenous vein graft. He develops mediastinitis postoperatively and requires wide operative debridement with a resultant chest defect. Reconstruction with which of the following flaps is most likely to result in flap necrosis?
A ) Latissimus dorsi
B ) Omentum
C ) Pectoralis major
D ) Rectus abdominis
E ) Serratus anterior

D ) Rectus abdominis

The rectus abdominis muscle has several sources of blood supply, including the superior and inferior epigastrics and intercostal vessels. For the purpose of chest wall reconstruction, the rectus muscle is pedicled upon its superior blood supply, the superior epigastric vessels, which itself is a continuation of the internal mammary vessels. Since the internal mammaries have been used on both sides for the purpose of coronary artery bypass grafting, the blood supply to the rectus has been compromised.

96

Rectus flap after compromise of the internal mammary

Although it is possible to raise the rectus muscle on only the eighth intercostal blood vessel, this method is less reliable and less likely to be sufficient to sustain the entire rectusmuscle, making it prone to flap necrosis.

97

A 35-year-old man is undergoing repair of a pressure sore on the left ischium using the musculocutaneous flap shown in the photograph. Which of the following is the Mathes and Nahai classification of this flap (gluteal musculocutaneous flap)?
A ) Type I
B ) Type II
C ) Type III
D ) Type IV
E ) Type V

C ) Type III

The gluteal musculocutaneous flap is a Type III flap, meaning it has two dominant pedicles (the superior and inferior gluteal arteries). These arteries are separated by the piriformis muscle and are sourced to the internal iliac system.

98

The gluteal musculocutaneous flap is a Type ___ flap

The gluteal musculocutaneous flap is a Type III flap

99

Relevance of the performs to gluteal musculocutaneous flaps

Its two dominant perforator arteries are separated by the piriformis muscle

100

Blood supply to the gluteal musculocutaneous flap

The superior and inferior gluteal arteries, which are separated by the piriformis muscle and are sourced to the internal iliac system.

101

When used for breast reconstruction, both the superior and the inferior gluteal artery perforator flaps utilize a vascular bundle that is a terminal branch of which of the following arteries?
A ) Deep circumflex iliac
B ) External iliac
C ) Femoral
D ) Internal iliac
E ) Pudendal

D ) Internal iliac

Both the superior and inferior gluteal arteries are terminal branches of the internal iliac artery.

102

The superior and inferior gluteal arteries are terminal branches of:

Both the superior and inferior gluteal arteries are terminal branches of the internal iliac artery.

103

Evolution of the superior gluteal artery

As the superior gluteal artery passes the greater sciatic foramen, it divides into superficial and deep branches.

104

Anatomy of the deep branch of the superior gluteal artery

The deep branch travels between the gluteus medius muscle and the iliac bone.

105

Anatomy of the superficial branch of the superior gluteal artery

The superficial branch goes onto supply the gluteus muscle and the overlying skin territory.

106

The superficial branch of the superior gluteal artery supplies:

The superficial branch goes onto supply the gluteus muscle and the overlying skin territory.

107

Anatomical basis for the S-GAP flap

The superficial branch of the superior gluteal artery nourishes the fat and skin in the musculocutaneous flaps in this region. These perforating vessels can be separated from the underlying muscle and fascia and form the basis for the S-GAP flap, which allows maximal preservation of the donor site muscle and other underlying structures while creating a reliable skin–soft-tissue flap.

108

Number of perforators associated with an S-GAP

2-3 perforators

109

Pedicle length of an S-GAP

3-8 cm

110

A 35-year-old man sustains a traumatic injury to the lower leg and undergoes closure of the wound using an anterolateral thigh free flap (shown). A cuff of muscle is harvested with the flap to fill a bone defect. Which of the following muscles can be safely harvested while using the same vascular pedicle as the flap?
A ) Adductor longus
B ) Rectus abdominis
C ) Vastus intermedius
D ) Vastus lateralis
E ) Vastus medialis

D ) Vastus lateralis

The anterolateral thigh flap is located over the lateral third of the thigh, between the borders of the rectus femoris and vastus lateralis muscle. Its blood supply comes from perforating branches of the lateral circumflex femoral artery and its venae comitantes. These vessels arise from the profunda femoris artery and vein. By utilizing the transverse branch of the lateral femoral circumflex artery and venae comitantes and their musculocutaneous perforators, the vastus lateralis muscle can be harvested with the anterolateral thigh flap.

111

The ____________ can be included with the ALT flap for added bulk

The vests lateralis

112

A 27-year-old man has a large segmental defect of the humerus. Reconstruction using an osteocutaneous free flap from the lower leg is planned. A portion of which of the following muscles is most appropriately included with the bone to protect the pedicle and improve reliability of the skin island?
A ) Extensor digitorum longus
B ) Flexor hallucis longus
C ) Gastrocnemius
D ) Peroneus longus
E ) Tibialis posterior

B ) Flexor hallucis longus

The fibular free flap is a workhorse flap for reconstruction of large segmental bone defects. The vascular supply of this flap comes from the peroneal artery. Alarge segment of bone can be harvested, consisting of the majority of the fibula with the exception of the proximal 6 cm at the fibular head and the distal 6 cm near the ankle joint. The fibular flap can be harvested with a skin paddle on the lateral aspect of the leg, based on perforators through the lateral intermuscular septum or via the muscle. The pedicle is located adjacent to the flexor hallucis longus muscle in the deep posterior compartment of the leg. Inclusion of a cuff of the flexor hallucis longus muscle can be performed to protect the pedicle and add bulk to the reconstruction if necessary.

113

Vascular supply of the free fibula

Peroneal artery

114

What parts of the fibula can / cannot be harvested?

Can harvest the majority of the fibula with the exception of the proximal 6 cm at the fibular head and the distal 6 cm near the ankle joint.

115

Skin paddle for the fibular flap

The fibular flap can be harvested with a skin paddle on the lateral aspect of the leg, adjacent to the flexor hallucis longus muscle, based on perforators through the lateral intermuscular septum or via the muscle.

116

What can be done to protect the pedicle of the free fibular flap?

Including a cuff of the flexor hallucis longus muscle

117

A 55-year-old man has complete excision of squamous cell carcinoma of the scalp resulting in a 6 x 8-cm occipital defect with exposed calvaria. Reconstruction with a lower third trapezius island flap is performed. Which of the following arteries is the major blood supply for the flap?
(A)Dorsal scapular
(B)Occipital
(C)Superficial cervical
(D)Thoracoacromial
(E)Thoracodorsal

(A)Dorsal scapular

The predominant blood supply of the inferior portion of the trapezius myocutaneous flap is the dorsal scapular artery.

118

The predominant blood supply of the inferior portion of the trapezius myocutaneous flap is:

The predominant blood supply of the inferior portion of the trapezius myocutaneous flap is the dorsal scapular artery.

119

The dorsal scapular artery is a separate branch of:
Or forms a common trunk with:

The dorsal scapular artery is a separate branch of the subclavian artery or forms a common trunk with the superficial cervical artery.

120

Supply of the superior or descending part of the trapezius:

The superior or descending part of the trapezius is supplied by branches of the occipital artery.

121

The middle or transverse trapezius is supplied by:

The middle or transverse trapezius is supplied by the superficial cervical artery.

122

Supply of the pectoralis major muscle flap:

The thoracoacromial artery supplies the pectoralis major muscle flap

123

Supply of the latissimus dorsi muscle flap:

The thoracodorsal artery supplies the latissimus dorsi muscle flap.

124

A patient with a complex defect that requires replacement of skin, muscle, and bone is scheduled to have reconstruction with a single free flap from the subscapular system. Which of the following would NOT be used as part of this reconstruction?
(A)Parascapular fasciocutaneous tissue
(B)Serratus anterior muscle
(C)Trapezius muscle
(D)Vascularized rib
(E)Vascularized scapular bone

(C)Trapezius muscle

Unlike the other tissues, the trapezius muscle is based on the transverse cervical artery (based on the thyrocervical trunk in 80% of cases or the subclavian artery in 20% of cases). The subscapular system allows for the creation of chimeric flaps that can include bone, muscle, fascia, fat, and skin.

125

The trapezius is based on the:

The trapezius muscle is based on the transverse cervical artery

126

Origin of the transverse cervical artery in ____% cases

Based on the thyrocervical trunk in 80% of cases or the subclavian artery in 20% of cases

127

Flaps that have been based on the sub scapular system

Serratus anterior muscle / fascia
Latissimus dorsi muscle / fascia
Scapular and parascapular fascia and overlying skin
Scapular bone
Rib bone

128

Which of the following arteries is the major blood supply to the flap most often used in the reconstruction of open-knee defects?
(A)Anterior tibial
(B)Medial circumflex femoral
(C)Peroneal
(D)Posterior tibial
(E)Sural

(E)Sural

The medial and lateral sural arteries supply circulation to the gastrocnemius muscle, which, when released and rotated proximally, provides the best coverage for complex knee wounds. The gastrocnemius muscle may be harvested with overlying skin or may be skin-grafted.

129

What flap provides the best coverage for complex knee wounds?

The gastrocnemius muscle

130

Use of the gastrocnemius muscle for complex knee wounds:

Released and rotated proximally, provides the best coverage for complex knee wounds; may be harvested with overlying skin or may be skin-grafted.

131

Blood supply to the gastrocnemius muscle

Medial and lateral sural arteries

132

Blood supply for the gracilis muscle

The medial circumflex femoral artery and profunda femoris vessels

133

An 84-year-old man comes to the office because he has had pain and purulent drainage from the left groin incision site since undergoing a left common iliac artery to common femoral bypass procedure performed for critical stenosis of the iliac artery three weeks ago. Temperature is 38.8°C (101.8°F), blood pressure is 140/90 mmHg, and pulse rate is 100/min. Physical examination shows an exposed vein graft at the groin incision site. A magnetic resonance angiogram shows a patent bypass graft; the superficial femoral artery is patent, but a profundus branch is occluded. Following debridement, wound coverage with which of the following flaps is the most appropriate next step?
(A)Anterior lateral thigh
(B)Gracilis muscle
(C)Rectus femoris muscle
(D)Sartorius muscle
(E)Vastus lateralis muscle

(D)Sartorius muscle

The sartorius muscle would provide the most reliable option for wound coverage for the patient discussed. The sartorius muscle flap originates from the anterior iliac spine and inserts into the medial tibia. Eight to eleven perforators off the superficial femoral artery segmentally supply the sartorius, a type V muscle flap. The proximal pedicle is located approximately 6 cm from the anterior superior iliac spine. The sartorius muscle is adjacent to the femoral vessels.

134

Preferred muscle coverage for the middle one third of the lower extremity

Soleus muscle

135

Anatomy of the sartorius muscle

The sartorius muscle flap originates from the anterior iliac spine and inserts into the medial tibia

136

Blood supply of the sartorius muscle

Eight to eleven perforators off the superficial femoral artery segmentally supply the sartorius, a type V muscle flap.

137

Where is the pedicle of the sartorius muscle located?

The proximal pedicle is located approximately 6 cm from the anterior superior iliac spine. The sartorius muscle is adjacent to the femoral vessels

138

Origin of the medial circumflex femoral artery

Proximal portion of the profound femoris artery

139

Origin of the lateral circumflex femoral artery

Proximal portion of the profound femoris artery

140

Blood supply of the rectus femoris muscle

The rectus femoris muscle is a type I muscle flap with a single dominant blood supply from the lateral femoral circumflex artery

141

A 59-year-old man comes to the office for follow-up examination three weeks after undergoing left total knee replacement. Physical examination shows a draining sinus on the distal aspect of the knee. Surgical removal of the hardware and flap reconstruction are planned. Which of the following is the dominant pedicle to the muscle flap that is most appropriate for reconstruction?
(A)Anterior tibial artery
(B)Ascending branch of the medial circumflex femoral artery
(C)Medial sural artery
(D)Perforating branch of the distal superficial femoral artery
(E)Proximal branches of the posterior tibial artery

(C)Medial sural artery

The muscle flap best suited to reconstruct this defect is a medial head of gastrocnemius muscle rotation flap. Its dominant pedicle is the medial sural artery, which is a branch of the popliteal artery.

142

The lateral sural artery is the dominant blood supply to the ___________________

The lateral sural artery is the dominant blood supply to the lateral head of the gastrocnemius

143

The soleus is based off of:

The soleus is based off the proximal two branches of the posterior tibial artery, branches of the proximal popliteal, and branches of the peroneal artery.

144

The dominant pedicle of the gracilis muscle flap is located between the adductor longus and which of the following muscles?
(A)Adductor brevis
(B)Adductor magnus
(C)Pectineus
(D)Sartorius
(E)Semitendinosus

(A)Adductor brevis

The dominant pedicle of the gracilis muscle flap is located between the adductor longus and adductor brevis muscles.

145

The dominant pedicle of the gracilis muscle flap is located between which muscles?

The dominant pedicle of the gracilis muscle flap is located between the adductor longus and adductor brevis muscles.

146

The origin of the dominant vascular pedicle to the gracilis muscle flap may originate from:

The origin of the dominant vascular pedicle to the gracilis muscle flap may originate from either the profundus femoris or medial circumflex femoral vessels

147

Dominant vascular pedicle of the gracilis vs what can be transferred?

Although the dominant vascular pedicle easily nourishes the entire muscle, the distal third of the skin overlying the gracilis muscle does not receive sufficient blood supply for reliable transfer.

148

During dissection for a microsurgical free parascapular flap, the circumflex scapular artery is located in the triangular space bordered by the teres minor, the long head of the triceps, and which of the following muscles?
(A)Infraspinatus
(B)Latissimus dorsi
(C)Subscapularis
(D)Teres major
(E)Trapezius

(D)Teres major

The circumflex scapular artery arises from scapular artery approximately 3 to 4 cm from its origin at the axillary artery. It then passes through the triangular space, which is bordered above by the teres minor, the teres major below, and the long head of triceps laterally.

149

The circumflex scapular artery arises from _______ @ where?

The circumflex scapular artery arises from scapular artery approximately 3 to 4 cm from its origin at the axillary artery.

150

Borders of the triangular space

Triangular space, which is bordered above by the teres minor, the teres major below, and the long head of triceps laterally.

151

A 28-year-old man is brought to the emergency department 30 minutes after he sustained avulsion injuries to the nondominant left hand when it became caught in a motor vehicle fanbelt. Physical examination shows amputation of the index finger at the level of the proximal interphalangeal joint as well as a 2 x 1-cm area of soft-tissue loss. Replantation of the amputated digit is performed, and the resulting 2 x 1-cm soft-tissue avulsion volar defect is covered with an arterialized venous flow-through flap with overlying skin interposed as a vein graft in the arterial repair. Which of the following is the most likely early complication of this flap procedure?
(A)Arterial thrombosis
(B)Congestion of the flap
(C)Failure of the replantation
(D)Hematoma from vessel leak
(E)Loss of flap due to infection

(B)Congestion of the flap

Venous flow-through flaps (VFTFs) are unusual but are gaining acceptance for certain kinds of hand and finger wounds. The ideal site for coverage with a VFTF is a long and narrow defect needing thin soft tissue. VFTFs typically become congested in the first week and then decongest over the following two weeks as they revascularize from the wound bed.

A small defect such as the 2-cm defect needing coverage during the replantation of the finger in the scenario described is the ideal candidate for this flap.

Although VFTFs are more susceptible to infection than typical flaps, congestion of the flap with superior epidermolysis is a much more likely complication.

152

Ideal site for coverage with a venous flow through flap

The ideal site for coverage with a VFTF is a long and narrow defect needing thin soft tissue.

153

Natural course of a venous flow through flap

VFTFs typically become congested in the first week and then decongest over the following two weeks as they revascularize from the wound bed.

154

What can't venous flow through flaps be use to transfer?

VFTFs cannot reliably transfer composite tissue such as bone and tendon or cover a wide defect such as an entire palm.

155

Contraindications for venous flow through flap

Because VFTFs do not bring in vascularization to the wound bed as well as classic flaps, they are not indicated in radiated or potentially infected wound beds.

156

A 22-year-old man has undergone multiple debridements of a wound of the right hand since he sustained a gunshot wound six days ago. Physical examination shows a significant soft-tissue defect and a 4-cm segment of bone loss from the third metacarpal. A radial forearm osteofasciocutaneous flap procedure for simultaneous reconstruction of the soft-tissue and skeletal defects is planned. Which of the following portions of the radius is the most appropriate site for harvesting the cortical bone graft?
(A)Radial aspect, between the brachioradialis and pronator teres insertions
(B)Radial aspect, between the brachioradialis insertion and flexor pollicis longus origin
(C)Radial aspect, between the pronator teres insertion and flexor pollicis longus origin
(D)Ulnar aspect, between the brachioradialis and pronator teres insertions
(E)Ulnar aspect, between the pronator teres insertion and flexor pollicis longus origin

(A)Radial aspect, between the brachioradialis and pronator teres insertions

When raising a radial forearm osteofasciocutaneous flap, cortical bone should be harvested from the radial aspect of the radius between the brachioradialis and pronator teres muscle insertions. A cuff of the flexor pollicis longus to the radius is maintained to preserve the periosteal vessels. A small cuff of periosteum is maintained on both sides of the radial vessels

157

When raising a radial forearm osteofasciocutaneous flap, cortical bone should be harvested from:

When raising a radial forearm osteofasciocutaneous flap, cortical bone should be harvested from the radial aspect of the radius between the brachioradialis and pronator teres muscle insertions.

158

What is done in a radial forearm osteofasciocutaneous flap to preserve the periosteal vessels?

A small cuff of periosteum is maintained on both sides of the radial vessels

159

How much of the radius can be harvested?

A segment up to 10 cm in length and up to 40% of the cross-sectional area of the radius may be harvested.

160

Which of the following commonly used muscle flaps provides the versatility of two dominant vascular supplies?
(A) Gastrocnemius
(B) Latissimus dorsi
(C) Pectoralis major
(D) Rectus abdominis
(E) Sartorius

(D) Rectus abdominis

The rectus abdominis muscle is supplied by both the superior and inferior deep epigastric vessels.

161

Which Mathes and Nahai classification has two dominant pedicles?

Type III

162

Origin of the superior epigastric pedicle of the rectus abdominis muscle

The superior epigastric pedicle is an extension of the internal mammary circulation

163

Pedicle flaps based on the inferior epigastric vessels are useful for:

Pelvic and abdominal reconstruction with the rectus muscle

164

The rectus abdominis flap is a Type _____

Type III

165

The gastrocnemius muscle is a Type ______

Type I

166

Injury where precludes the gastrocnemius as a safe flap?

Injury to the upper posterior calf

167

The pectoralis major is a Type _____

Type V

168

The gracilis is a Type ____

Type II

169

The biceps femoris is a Type _____

Type II

170

The sartorius is a Type ____

Type IV

171

Useful muscle for coverage of the femoral sheath after a vascular surgical wound dehiscence with exposed prosthetic graft

Sartorius muscle

172

A 54-year-old man has a nonhealing wound of the lateral aspect of the right ankle three months after he underwent open reduction and internal fixation of a fracture. Physical examination shows exposed bone at the base of the wound but no evidence of deep infection. Which of the following flap procedures is most appropriate for closure of this patient's defect?
(A) Bilateral V-to-Y advancement flaps
(B) Dorsalis pedis fasciocutaneous flap
(C) Extensor digitorum brevis muscle flap
(D) Flexor digiti minimi muscle flap
(E) Lateral calcaneal flap

(E) Lateral calcaneal flap

The most appropriate procedure to close this defect is a lateral calcaneal flap, which has an axial pattern based on the lateral calcaneal artery, a terminal branch of the peroneal artery. This flap is very reliable, even in older patients, and lateral calcaneal artery patency and flow can be determined by preoperative Doppler examination.

The dorsalis pedis fasciocutaneous flap would reach this defect but has significant donor site morbidity and should be reserved for situations in which other options are not available. The flexor digiti minimi muscle flap is lateral on the foot but is not able to reach the lateral ankle.The extensor digitorum brevis muscle flap has a large arc of rotation but requires sacrifice of the dorsalis pedis artery.

173

The lateral calcaneal flap is based on?

Lateral calcaneal artery

174

The lateral calcaneal artery is a terminal branch of:

The peroneal artery

175

Management of donor site for lateral calcaneal flap:

Skin grafting

176

The extensor digitorum brevis muscle flap requires sacrifice of:

The dorsalis pedis artery

177

When should the dorsalis pedis fasciocutaneous flap

The dorsalis pedis fasciocutaneous flap has significant donor site morbidity and should be reserved for situations in which other options are not available.

178

A 39-year-old woman with exposed hardwareafter spinal fusion undergoes an external oblique turnover muscle flap procedure. The blood supply to this flap is primarily from which of the following vessels?
(A) Deep circumflex iliac
(B) Deep inferior epigastric
(C) Iliolumbar
(D) Intercostal
(E) Subscapular

(D) Intercostal

The external oblique turnover muscle flap is not commonly used but has the potential to provide adequate coverage of large defects of the back that extend to the midline at the level of T10 to L4. The upper half of the flap is supplied by the 4th through 11th intercostal arteries, whereas the lower half is supplied by one or two vessels from the deep circumflex iliac artery (95%) or the iliolumbar artery (5%). The upper half has a strictly segmental blood and nerve supply, whereas the lower half has segmental innervation but derives its blood supply from one artery.

179

What can the external oblique turnover muscle flap be used for?

The external oblique turnover muscle flap is not commonly used but has the potential to provide adequate coverage of large defects of the back that extend to the midline at the level of T10 to L4.

180

Blood supply to the external oblique turnover muscle flap

Upper half of the flap: 4th through 11th intercostal arteries
Lower half: one or two vessels from the deep circumflex iliac artery (95%) or the iliolumbar artery (5%).

181

The direct vascular supply to the arm flap shown (lateral arm flap) is which of the following arteries?
(A) Posterior interosseous
(B) Posterior radial collateral
(C) Profunda brachial
(D) Recurrent radial
(E) Superior ulnar collateral

(B) Posterior radial collateral

The lateral arm flap was initially described by Song and popularized by Matloub, et al. and Katsaros, et al. The lateral arm free flap is based on the posterior radial collateral artery, which is a branch of the profunda brachial artery.

182

The lateral arm free flap is based on the _____________, which is a branch of the _______________

The lateral arm free flap is based on the posterior radial collateral artery, which is a branch of the profunda brachial artery.

183

This reverse pedicled lateral arm flap is based on the:

This reverse pedicled lateral arm flap is based on the radial recurrent artery.

184

This medial arm flap is based on the:

The superior ulnar collateral artery is the dominant pedicle of the medial arm flap.

185

Why is the medial arm flap less than optimal?

The medial arm flap is useful for upper extremity coverage, but there are significant variations in the superior ulnar collateral artery which makes this flap a less-than-optimal choice for microvascular surgical reconstruction.

186

Potential morbidity of the posterior interosseous flap

Use of the posterior interosseous flap can compromise motor nerves to the extensor carpi ulnaris or extensor digiti quinti.

187

The pedicle posterior interosseous flap can cover:

The wrist, and extend to the first web space.

188

Which of the following muscles is included in a facial artery musculomucosal flap?
(A) Buccinator
(B) Depressor anguli oris
(C) Levator labii superioris
(D) Orbicularis oris
(E) Zygomaticus major

(A) Buccinator

Because the buccinator muscle is sandwiched between the facial artery and the oralmucosa, it must be included in a facial artery musculomucosal flap.

189

Anatomy of the buccinator

The buccinator muscle originates from the pterygomandibular raphe and inserts into the orbicularis oris muscle and mucosa of the lateral lip elements.

190

What muscle is included in a facial artery musculomucosal flap?

Because the buccinator muscle is sandwiched between the facial artery and the oralmucosa, it must be included in a facial artery musculomucosal flap.

191

A 65-year-old man undergoes operative removal of a basal cell carcinoma at the junction of the upper cheek and temporal region, followed by coverage of the resultant 10 x 5-cm defect with a submental myocutaneous flap. This flap derives its blood supply from a branch of which of the following arteries?
(A) Facial
(B) Inferior thyroid
(C) Lingual
(D) Superior thyroid
(E) Transverse cervical

(A) Facial

The submental flap is elevated below the level of the platysma muscle and includes the submental artery and vein, which are direct branches of the facial artery and vein. The flap can be transposed to cover defects in the lower and central thirds of the face and into the inferior aspect of the upper third of the face.

192

Elevation of the submental flap

The flap is elevated below the level of the platysma muscle and includes the submental artery and vein, which are direct branches of the facial artery and vein. The flap can be transposed to cover defects in the lower and central thirds of the face and into the inferior aspect of the upper third of the face.

193

Which of the following arteries is the basis of the major blood supply to the pectoralis major myocutaneous flap for head and neck reconstruction?
(A) Internal mammary
(B) Lateral thoracic
(C) Superior thoracic
(D) Thoracoacromial
(E) Transverse cervical

(D) Thoracoacromial

The major blood supply to the pectoralis major myocutaneous flap is the thoracoacromial artery.

The internal mammary artery does supply the pectoralis major muscle and its accompanying skin; however, it cannot be pedicled on this axis for head and neck reconstruction. The transverse cervical artery originates from the subclavian artery and supplies the muscles of the neck and scapula.

194

What is the major blood supply to the pectoralis major myocutaneous flap?

The major blood supply to the pectoralis major myocutaneous flap is the thoracoacromial artery.

195

Which of the following interventions is most appropriate to improve the viability of an ischemic skin flap?
(A) Apply medicinal leeches to the flap
(B) Apply nitroglycerin paste to the flap
(C) Elevate the affected area
(D) Ensure adequate fluid resuscitation
(E) Perform hyperbaric oxygen therapy

(D) Ensure adequate fluid resuscitation

The initial 24-hour period is critical to flap viability. In cases of compromised arterial inflow, steps that can be taken to improve arterial inflow are of primary concern. Ensuring adequate postoperative fluid resuscitation is paramount. This ensures adequate cardiac output and optimizes tissue perfusion.

Not as important as adequate volume resuscitation:
Although hyperbaric oxygen therapy and elevation may both have beneficial effects in this setting, they are less appropriate than fluid resuscitation. Some clinicians will use 2% nitroglycerin ointment to ischemic areas every four to six hours or silver sulfadiazine cream twice daily.

196

What is the theoretic gain in length achieved by performing a Z-plasty with angles of 75 degrees?
(A) 25%
(B) 50%
(C) 75%
(D) 100%

(D) 100%

The theoretic gain in length correlates directly with the angle and length of the flap limbs. The actual gain in the length of the central axis will be decreased by 30% to 50% because of the contractile properties of skin

197

Which angle of Z-plasty is performed and why?

A 60-degree Z-plasty is performed most commonly because it produces a significant gain in length while minimizing the tension of closure.

198

Z-plasty: Theoretic gain with 30 degrees

25%

199

Z-plasty: Theoretic gain with 45 degrees

50%

200

Z-plasty: Theoretic gain with 60 degrees

75%

201

Z-plasty: Theoretic gain with 75 degrees

100%

202

Z-plasty: Theoretic gain with 90 degrees

120%

203

Z-plasty: Real gain vs theoretic gain

The theoretic gain in length correlates directly with the angle and length of the flap limbs. The actual gain in the length of the central axis will be decreased by 30% to 50% because of the contractile properties of skin.

204

Theoretic gain of different Z-plasty angles

30 degrees - 25%
45 degrees - 50%
60 degrees - 75%
75 degrees - 100%
90 degrees - 120%

205

According to the Mathes/Nahai classification of muscle and musculocutaneous flaps, which of the following is a type III flap?
(A) Gastrocnemius
(B) Gluteus maximus
(C) Latissimus dorsi
(D) Pectoralis major
(E) Vastus lateralis

(B) Gluteus maximus

The gluteus maximus and rectus abdominis muscle flaps have a type III vascular pattern consisting of dual dominant pedicles.

206

Immediately after undergoing reconstruction of a wound of the dorsal aspect of the hand using a reverse radial forearm flap, a patient has marked venous congestion of the flap. There is no hematoma visible under the flap. Which of the following is the most appropriate management?
(A) Increasing the temperature of the hand
(B) Elevation of the hand
(C) Intravenous infusion of heparin
(D) Application of leeches to the flap
(E) Anastomosis of an outflow vein

(E) Anastomosis of an outflow vein

When harvesting a reverse island flap such as the reverse radial forearm flap, the surgeon should always attempt to preserve an outflow vein, which will be necessary for drainage of the flap if the reverse flow venous system does not function adequately. Most patients exhibit only mild venous congestion, and leeches can be applied to drain the flap sufficiently and thus preserve it. However, any patient who has immediate onset of marked venous congestion in which the cause is not obvious (ie, kinking of the pedicle or hematoma under the flap) should undergo immediate anastomosis of an outflow vein to decompress the flap.

Conservative measures such as increasing the temperature of the hand, elevating the extremity, or infusing heparin intravenously will ultimately fail in a patient with marked venous congestion requiring immediate operative treatment.

207

The deep inferior epigastric artery arises from which of the following arteries?
(A) External iliac
(B) Femoral
(C) Internal iliac
(D) Internal mammary
(E) Superficial inferior epigastric

(A) External iliac

The deep inferior epigastric artery and vein arise from the external iliac artery at a point just proximal to where the artery passes beneath the inguinal ligament.

208

The deep inferior epigastric artery and vein arise from the _____________

The deep inferior epigastric artery and vein arise from the external iliac artery at a point just proximal to where the artery passes beneath the inguinal ligament.

209

The third perforating branch of the profunda femoris artery, which is the blood supply for the lateral thigh flap, originates at a level that is immediately caudad to which of the following muscles?
(A) Adductor brevis
(B) Adductor longus
(C) Adductor magnus
(D) Gracilis
(E) Pectineus

(A) Adductor brevis

The third perforating branch of the profunda femoris artery provides the predominant blood supply for the lateral thigh flap. The third perforating branch originates immediately caudad to the adductor brevis muscle, pierces the insertion of the adductor magnus, courses superficially, and then traverses between the biceps femoris and the vastus lateralis.

210

Supply to the lateral thigh flap

The third perforating branch of the profunda femoris artery provides the predominant blood supply for the lateral thigh flap

211

The lateral thigh flap is innervated by:

The lateral thigh flap is innervated by the lateral cutaneous nerve of the thigh.

212

According to the Mathes-Nahai classification of muscle and musculocutaneous flaps, which of the following is a type I flap?
(A) Gluteus maximus
(B) Gracilis
(C) Latissimus dorsi
(D) Sartorius
(E) Tensor fascia lata

(E) Tensor fascia lata

The tensor fascia lata, gastrocnemius, and vastus lateralis muscle flaps have a type I vascular pattern consisting of one dominant pedicle. These muscles can be used as rotation flaps for regional reconstruction or as free tissue for transfer

213

Transfer options for Type I flaps

The tensor fascia lata, gastrocnemius, and vastus lateralis muscle flaps have a type I vascular pattern consisting of one dominant pedicle. These muscles can be used as rotation flaps for regional reconstruction or as free tissue for transfer

214

Which of the following muscles comprise the boundaries of the triangular space in which the circumflex scapular artery is located?
(A) Infraspinatus, latissimus, and teres minor
(B) Latissimus, long head of thetriceps, and teres major
(C) Latissimus, teres minor, and teres major
(D) Long head of the triceps, supraspinatus, and teres major
(E) Long head of the triceps, teres major, and teres minor

(E) Long head of the triceps, teres major, and teres minor

The boundaries of the triangular (or omotricipetal) space, in which the circumflex scapular artery is located, are comprised of the long head of the triceps muscle laterally, the teres major muscle inferiorly, and the teres minor muscle superiorly.

215

Omotricipetal slace

The triangular space

216

Borders of the triangular space

The long head of the triceps muscle laterally, the teres major muscle inferiorly, and the teres minor muscle superiorly.

217

The quadrangular space can be found:

The quadrangular space can be found immediately lateral to the triangular space.

218

The quadrangular space is defined by:

This space is defined by the surgical neck of the humerus, lateral head of the triceps muscle, teres major muscle, and teres minor muscle.

219

What passes through the triangular space?

The circumflex scapular artery

220

What passes through the quadrangular space?

The axillary nerve and posterior humeral circumflex artery

221

In a patient who is undergoing dissection of a gracilis musculocutaneous flap, the gracilis muscle can be identified immediately posterior to which of the following muscles in the thigh?
(A) Adductor longus muscle
(B) Adductor magnus muscle
(C) Pectineus muscle
(D) Sartorius muscle

(A) Adductor longus muscle

In order to effectively identify the gracilis muscle prior to flap harvest, the patient should be placed in the supine position with the knee in abduction. With the patient in this position, the adductor longus muscle can be palpated before surgery. Following incision, the gracilis muscle is easily identified posterior to the adductor longus.

222

How to identify the gracilis for flap harvest?

In order to effectively identify the gracilis muscle prior to flap harvest, the patient should be placed in the supine position with the knee in abduction. With the patient in this position, the adductor longus muscle can be palpated before surgery. Following incision, the gracilis muscle is easily identified posterior to the adductor longus.

223

A 25-year-old woman who sustained the forearm avulsion shown in the photograph above subsequently underwent reconstruction using a free groin flap based on the superficial circumflex iliac artery. Which of the following best describes the vascular anatomy of this flap?
(A) The superficial circumflex iliac artery arises directly from the external iliac artery in approximately 85% of patients
(B) The superficial circumflex iliac artery arises from a common trunk, terminally splitting with the superficial inferior epigastric artery in approximately 70% of patients
(C) The superficial circumflex iliac and superficial inferior epigastric arteries have separate origins in approximately 40% of patients
(D)The superficial circumflex iliac artery is generally found approximately 1 cm below the inguinal ligament in approximately 70% of patients

(C) The superficial circumflex iliac and superficial inferior epigastric arteries have separate origins in approximately 40% of patients

The free groin flap is typically an axially patterned flap that receives its vascularity by the superficial circumflex iliac artery, which arises from the common or superficial femoral artery and then traverses laterally, parallel to the inguinal ligament, typically 2 to 3 cm inferior to the ligament. Although it provides excellent thinsoft-tissue coverage of cutaneous defects and is associated with minimal donor site morbidity, especially in women, its use is limited by potential variations in vascular anatomy.

224

What limits the groin flap?

Although it provides excellent thinsoft-tissue coverage of cutaneous defects and is associated with minimal donor site morbidity, especially in women, its use is limited by potential variations in vascular anatomy, as shown in the illustration below.

225

A Z-plasty revision procedure is to be performed for lengthening of a scar contracture. Inorder to achieve a theoretical 100% gain in the length, the angle of the Z-plasty should be how many degrees?
(A) 30
(B) 45
(C) 60
(D) 75
(E) 90

(D) 75

226

Vascular supply of the free groin flap

The free groin flap is typically an axially patterned flap that receives its vascularity by the superficial circumflex iliac artery.

227

After undergoing radical mastectomy of the left breast for management of breast carcinoma, a 40-year-old woman with obesity is scheduled for delayed reconstruction using a transverse rectus abdominis myocutaneous (TRAM) flap. Which of the following is the most likely sequela of a delayed TRAM flap procedure?
(A) Increased blood flow to the deep inferior epigastric artery
(B) Increased diameter of the superior epigastric artery
(C) Increased pressure within the superior epigastric vein
(D) Increased quantity of choke vessels
(E) Increased quantity of myocutaneous perforators

(B) Increased diameter of the superior epigastric artery

A delay procedure is appropriate for any patient considering TRAM flap reconstruction who has risk factors for flap loss, including obesity, a smoking history, a previous history of radiation therapy, or large volume requirements. A delayed procedure is typically performed in the outpatient setting and involves ligation of the deep and superficial inferior epigastric vessels, eliminating blood flow through the deep inferior epigastric artery. Studies of patients who have undergone this procedure demonstrated increased diameter and flow volume of the superior epigastric artery.

228

Delay procedure description for a pedicle TRAM

A delayed procedure is typically performed in the outpatient setting and involves ligation of the deep and superficial inferior epigastric vessels, eliminating blood flow through the deep inferior epigastric artery.

229

Delay of a pedicle TRAM: What happens to the vessels?

The blood flow through the deep inferior epigastric artery is eliminated. Studies of patients who have undergone this procedure demonstrated increased diameter and flow volume of the superior epigastric artery.

230

A 53-year-old man has a chronic draining sinus of the perineal region one year after undergoing abdominoperineal resection of a low-lying rectal carcinoma followed by localized radiation therapy. Following debridement of the affected area, which of the following is the most appropriate management?
(A) Healing by secondary intention
(B) Primary closure
(C) Skin grafting
(D) Coverage with a fasciocutaneous flap
(E) Coverage with a muscle flap

(E) Coverage with a muscle flap

In a patient who has a chronic, irradiated wound, the most appropriate management is coverage with a muscle or musculocutaneous flap with a vascular pedicle that lies outside the field of radiation, such as the gracilis flap. Secondary intention healing is unlikely to be successful in a radiated wound bed, and primary closure of a previously radiated, nonhealing wound will also not result in appropriate healing. Skin grafting will be ineffective due to the poor vascularity of the wound bed. A fasciocutaneous flap is less appropriate than a muscle flap to fill the dead space within the wound.

231

Which of the following is NOT an indication for Z-plasty?
(A) Adjusting soft-tissue contour
(B) Dispersing linear scars
(C) Lengthening linear scar contractures
(D) Preventing burn scar contractures

(D) Preventing burn scar contractures

Z-plasty is not performed for prevention of burn scar contractures.

232

A 60-year-old man has a patent but widely exposed Gore-Tex dialysis access graft in the antecubital fossa. A photograph is shown above. Appropriate coverage of this defect is best accomplished using a flap that is vascularized by which of the following structures?
(A) Deep inferior epigastric artery
(B) Radial recurrent artery
(C) Septal branches of the profunda brachii artery
(D) Superficial circumflex iliac artery
(E) Ulnar artery

(B) Radial recurrent artery

This defect is best reconstructed using a brachioradialis flap, which derives its vascularity from the radial recurrent artery pedicle. The brachioradialis muscle lies in a superficial position on the forearm and, therefore, is best suited for reconstruction of defects involving the anterior elbow; it is less reliable for coverage of posterior elbow defects. Because it is an accessory flexor, the patient will not experience weakness or loss of motion following flap transfer. Transposition of the muscle alone followed by skin grafting of the recipient site will prevent skin deficits at the donor site.

Free flap reconstruction could be performed in this patient but is unnecessary when a local flap is available. I

233

Deficits following brachioradialis flap

Because it is an accessory flexor, the patient will not experience weakness or loss of motion following flap transfer.

234

Vascular supply of the brachioradialis flap

Radial recurrent artery

235

Most utility for the brachioradialis flap:

The brachioradialis muscle lies in a superficial position on the forearm and, therefore, is best suited for reconstruction of defects involving the anterior elbow; it is less reliable for coverage of posterior elbow defects.

236

Which of the following structures provides the vascular supply to the osteocutaneous radial forearm flap?
(A) Fascioperiosteal perforators between the flexor carpi radialis and palmaris longus muscles
(B) Fascioperiosteal perforators between the brachioradialis and flexor carpi radials muscles
(C) Musculoperiosteal perforators from the recurrent radial artery
(D) Musculoperiosteal perforators through the flexor digitorum profundus muscle
(E) Musculoperiosteal perforators through the pronator teres muscle

(B) Fascioperiosteal perforators between the brachioradialis and flexor carpi radials muscles

During harvest of the osteocutaneous radial forearm flap, a segment of radius as long as 10 cm with as much as 40% of the cross-section of the radius can be harvested. This flap can be found between the insertion of the pronator teres and brachioradialis muscles and is raised from the radial and ulnar sides. Vascularity is primarily supplied by fascioperiosteal perforators that lie within the intermuscular septum between the brachioradialis and flexor carpi radialis muscles. Musculoperiosteal branches of the flexor pollicis longus and perforators in the pronator quadratus muscle arising from the radial artery also supply blood to the flap.

237

A 56-year-old man has a deep soft-tissue defect of the posterior neck with exposure of the vertebral bone after undergoing excision of a malignant tumor. Which of the following would preclude the use of a trapezius flap for coverage of the defect?
(A) Atherosclerotic occlusion of the occipital arteries
(B) Atherosclerotic occlusion of the vertebral arteries
(C) Prior ipsilateral carotid endarterectomy
(D) Prior ipsilateral radical neck dissection
(E) Prior ligation of the ipsilateral circumflex scapular vessels

(D) Prior ipsilateral radical neck dissection

The transverse cervical artery, which provides the primary vascular supply to the trapezius flap, is typically divided during an ipsilateral radical neck dissection. Therefore, the trapezius flap cannot be used for coverage of a defect in a patient who has undergone an ipsilateral radical neck dissection.

238

The ________ artery is a secondary source of vascularity for the trapezius muscle flap.

The occipital artery is a secondary source of vascularity for the trapezius muscle flap.

239

In a patient who has undergone resection of a squamous cell carcinoma of the floor of the mouth, which of the following free flaps will provide vascularized bone and a sensate skin paddle?
(A) Iliac crest flap
(B) Lateral arm flap
(C) Parascapular flap
(D) Serratus anterior flap

(B) Lateral arm flap

Because the lateral arm flap provides both vascularized bone and a sensate skin paddle, it is best used for reconstruction of this patient's defect involving the floor of the mouth.

The iliac crest osteocutaneous flap, parascapular flap: bulky and insensate

Serratus anterior flap: Very little/ poor quality bone

240

How much skin can be elevated with the lateral arm flap?

As much as 7 cm x 12 cm

241

Which bone can be harvested with the lateral arm flap, and why?

Because of its periosteal attachments, as much as one-third of the posterior lateral humerus (or 10 cm to 15 cm in length and 1 cm to 1.5 cm in diameter) can be harvested.

242

The iliac crest osteocutaneous flap is based on:

Deep circumflex iliac artery

243

The iliac crest osteocutaneous flap can support a skin paddle as large as:
A bone segment as large as:

Can provide a skin paddle as large as 12 cm * 6 cm and a bone segment as large as 8 cm

244

The iliac crest osteocutaneous flap : downsides

The skin component is bulky and insensate. Meticulous closure of the donor site defect is required to prevent hernia formation.

245

The parascapular flap is based on:

The circumflex scapular artery

246

Advantages of the parascapular flap

Advantages of this flap include multiple skin paddles, a large segment of bone, and a high degree of independent motion between the skin and bone segments. The serratus anterior and/or latissimus dorsi muscles can be included with the flap to reconstruct complex defects.

247

Disadvantages of the parascapular flap

Skin paddles are bully and insensate

248

Serratus anterior: Preventing postoperative winging of the scapula

Must retain upper 4-5 muscle slips

249

Primary disadvantage of the serratus anterior flap

This primary disadvantage of this flap is that any bone incorporated with it will be less substantial and have poor vascularization when compared with other osteocutaneous flaps.

250

A 21-year-old man sustains an avulsion injury involving the skin of the dorsal aspect of the right hand. On examination, there is a loss of paratenon; the extensor tendons are exposed. A reverse radial forearm flap is to be used for coverage of the defect.The venous outflow of this flap depends primarily on which of the following vessels?
(A) Accessory cephalic vein
(B) Basilic vein
(C) Cephalic vein
(D) Radial venae comitantes
(E) Ulnar venae comitantes

(D) Radial venae comitantes

The reverse radial forearm flap has small, intercommunicating veins that lie between the paired venae comitantes and act as shunts, bypassing the valves and allowing blood flow directly between the venae comitantes. Thus, retrograde flow is established, and a useful, viable vascularized flap is created.

251

A 57-year-old man undergoes composite resection of an advanced squamous cell carcinoma of the retromolar trigone. An osteocutaneous free flap that provides a 6-cm bone segment, intraoral lining, and external skin will be used for reconstruction of the defect. Which of the following osteocutaneous free flaps will allow for maximum independence in repositioning the skin paddle in relation to the bone segment?
(A) Fibular
(B) Iliac crest
(C) Lateral arm
(D) Radial forearm
(E) Scapula

(E) Scapula

Reconstruction in this patient should be performed using the scapular flap, which will provide the greatest degree of leeway in positioning the skin paddle in relation to the bone segment.

A 3-cm vascular pedicle extends from the border of the scapula to the overlying skin and allows for an additional three degrees of spatial freedom when insetting the skin paddle. In addition, the angular branch of the thoracodorsal artery has been shown to consistently provide an independent source of perfusion to the inferior pole of the scapula. This allowsfor a greater arc of rotation between the bone and skin paddle because each portion derives its vascularity from separate sources.

252

Scapular free flap: Positioning bone vs muscle

A 3-cm vascular pedicle extends from the border of the scapula to the overlying skin and allows for an additional three degrees of spatial freedom when insetting the skin paddle. In addition, the angular branch of the thoracodorsal artery has been shown to consistently provide an independent source of perfusion to the inferior pole of the scapula. This allowsfor a greater arc of rotation between the bone and skin paddle because each portion derives its vascularity from separate sources.

253

A 25-year-old woman sustains a contact injury to the posterior aspect of the scalp. Following debridement, she has a 6 * 4-cm defect of the posterior scalp with exposed bone. Which of the following is the most appropriate next step in management?
(A) Excision and primary closure
(B) Full-thickness skin grafting
(C) Coverage with a rotation flap
(D) Hair transplantation
(E) Tissue expansion

(C) Coverage with a rotation flap

Rotation flap. This flap provides local hair-bearing tissue and can be used to cover defectsas large as 6 cm. In order to advance an adequate length of flap, multiple relaxing incisions must be performed within the galea. If the galea is not carefully divided, injury to the subcutaneous vessels or hair follicles may result, leading to the onset of alopecia or delayed wound healing.

254

Rotation flaps for the scalp can cover up to _____

6 cm

255

Tissue expansion is appropriate for scalp reconstruction of defects from ___% to ___%

15%-50%

Don't want <15% because of the multiple procedures / frequent office visits

256

Excision and primary closure combined with extensive undermining are only appropriate for patients who have defects measuring _________

Excision and primary closure combined with extensive undermining are only appropriate for patients who have defects measuring less than 5 cm.

257

Which of the following structures provides motor innervation to the gracilis free muscle flap?
(A) Anterior branch of the obturator nerve
(B) Femoral nerve
(C) Inferior branch of the superior gluteal nerve
(D) Medial femoral cutaneous nerve
(E) Median sural nerve

(A) Anterior branch of the obturator nerve

The anterior branch of the obturator nerve provides motor innervation to the gracilis free muscle flap. This nerve branch courses between the adductor longus and adductor brevis tendons to innervate the gracilis muscle.

258

Each of the following is an effective technique for continuous postoperative free flap monitoring EXCEPT
(A) differential surface temperature monitoring
(B) external Doppler ultrasonography
(C) intravenous injection of fluorescein
(D) laser Doppler ultrasonography
(E) photoplethysmography

(C) intravenous injection of fluorescein

259

A 25-year-old man sustains an extravasation injury of the dorsal aspect of the wrist. Following debridement, the extensor tendons are exposed; a photograph is shown above. Findings on Allen's test demonstrate radial dominance. Which of the following is the most appropriate next step in management?
(A) Dressing changes and healing by second intention
(B) Split-thickness skin grafting
(C) Coverage with a free lateral arm flap
(D) Coverage with a free rectus abdominis muscle flap and split
thickness skin graft
(E) Coverage with a reverse radial forearm flap

(C) Coverage with a free lateral arm flap

In this patient who has exposure of the tendons and loss of paratenon after sustaining a wrist injury, the most appropriate management is coverage of the defect using a free lateral arm flap. This is a pliable fasciocutaneous flap that will provide durable coverage of this patient's defect with optimal cosmetic results and minimal donor site morbidity.Its good gliding surface will permit tendon gliding without tethering. If tethering were to occur subsequently, a secondary tenolysis could be easily performed underneath this thin fla

260

A vastus lateralis muscle flap elevated on its dominant pedicle provides reliable coverage for each of the following anatomic sites EXCEPT the
(A) acetabulum
(B) groin
(C) knee
(D) perineum
(E) trochanter

(C) knee

When the vastus lateralis flap is based on its dominant pedicle, the descending branch of the lateral femoral circumflex artery, it has an area of rotation that will provide vascularized coverage of the lower abdomen, groin, perineum, ischium, trochanter, and acetabular fossa. However, the flap must be reversed in order to rotate and provide coverage of knee defects. When used in this manner, the flap is then based on a branch of the lateral genicular artery, which is a minor distal pedicle. Because the risk for partial flap loss is greater, this flap is not often advocated for coverage of knee defects.

261

Pedicle for the vastus lateralis flap

The dominant pedicle is the descending branch of the lateral femoral circumflex artery

262

The vastus lateralis flap may be rotated to cover:

The vastus lateralis flap may be rotated to provide vascularized coverage of the lower abdomen, groin, perineum, ischium, trochanter, and acetabular fossa.

263

What would have to be done to allow the vastus lateralis flap to cover knee defects?

The vastus lateralis flap must be reversed in order to rotate and provide coverage of knee defects. When used in this manner, the flap is then based on a branch of the lateral genicular artery, which is a minor distal pedicle. Because the risk for partial flap loss is greater, this flap is not often advocated for coverage of knee defects.

264

Each of the following is an effective technique for continuous postoperative free flap monitoring EXCEPT
(A) differential surface temperature monitoring
(B) external Doppler ultrasonography
(C) intravenous injection of fluorescein
(D) laser Doppler ultrasonography
(E) photoplethysmography

(C) intravenous injection of fluorescein

Although fluorescein 15 mg/kg is often administered intravenously to determine the viability of a flap's skin paddles, this cannot be used for continuous free flap monitoring because fluorescein often takes several hours to clear from the skin. Lower doses of fluorescein can be used for sequential monitoring, but not for continuous monitoring.

265

Free flap monitoring: What temperature change is deemed significant?

Differential surface temperature monitoring compares the temperature of the transferred tissue with the normal surrounding tissue. A temperature difference of greater than 1.8C (35.3F) is believed to be significant.

266

A 25-year-old man sustains an extravasation injury of the dorsal aspect of the wrist. Following debridement, the extensor tendons are exposed; a photograph is shown above. Findings on Allen's test demonstrate radial dominance. Which of the following is the most appropriate next step in management?
(A) Dressing changes and healing by second intention
(B) Split-thickness skin grafting
(C) Coverage with a free lateral arm flap
(D) Coverage with a free rectus abdominis muscle flap and split thickness skin graft
(E) Coverage with a reverse radial forearm flap

(C) Coverage with a free lateral arm flap

In this patient who has exposure of the tendons and loss of paratenon after sustaining a wrist injury, the most appropriate management is coverage of the defect using a free lateral arm flap. This is a pliable fasciocutaneous flap that will provide durable coverage of this patient's defect with optimal cosmetic results and minimal donor site morbidity.Its good gliding surface will permit tendon gliding without tethering. If tethering were to occur subsequently, a secondary tenolysis could be easily performed underneath this thin flap.

The reverse radial forearm flap has been linked to the development of hand ischemia in patients who demonstrate radial dominance on Allen's testing.

267

Allen's testing and the reverse radial forearm flap

The reverse radial forearm flap has been linked to the development of hand ischemia in patients who demonstrate radial dominance on Allen's testing.

268

A 45-year-old man is evaluated 2 weeks after open reduction and internal fixation of an extra-articular fracture of the distal tibia because of wound dehiscence. Physical examination shows exposed hardware and a 5 × 3-cm open wound above the medial malleolus. After thorough debridement, hardware removal, and placement of an external fixator, the wound is closed with a perforator propeller flap based on a posterior tibial artery perforator. During dissection and inset, the flap becomes progressively swollen and blue, with brisk capillary refill noted for the entire length of the flap. Which of the following is the most appropriate next step in management?
A) Application of nitropaste
B) Free flap salvage
C) Postoperative leech therapy
D) Proximal perforator dissection to source vessel
E) Observation

D) Proximal perforator dissection to source vessel

This patient has an open wound in the distal third of the tibia closed with a propeller flap based on a perforator from the posterior tibial artery. The most common complications associated with this type of reconstruction are venous congestion and partial flap loss. If congestion is encountered during flap elevation, it is essential to dissect the perforator all the way back to the named source vessel to release all fascial attachments and any areas of potential constriction or tethering. This would be the first strategy to improve venous outflow during flap dissection. The venae comitantes accompanying the perforator are very thin-walled and susceptible to kinking, especially when flap inset requires a 180-degree rotation.

Propeller flaps are island fasciocutaneous flaps based on a single dissected perforator. They are termed “freestyle” because the design of the flap is determined intraoperatively based on the dissection of the perforator, which has variable anatomy. Ideal perforators are greater than 0.5 mm in diameter and pulsatile. Perforator flaps of the lower extremity should be designed longitudinally based on directional blood flow. Most published series report greater than 90% flap survival with an 8 to 10% rate of complications. If tension or kinking still exists after proximal perforator dissection, microsurgical venous supercharging would be the next course of action, if possible. De-rotating the flap and placing it back into the donor site as a delay procedure can be used as a last resort; however, vascular delay is traditionally used to augment the arterial inflow of a flap by allowing the choke vessels to open and organize the flow in an axial fashion. The flap remains susceptible to venous congestion when it is rotated for inset after the delay as well.

A small amount of decreased venous drainage is expected with most perforator flaps; however, it is generally mild, not progressive, and confined to the distal tip of the flap. This venous insufficiency can be observed and will generally resolve in the early postoperative period. In this case, the congestion was noted early during flap dissection along the full length of the flap. For severe early venous congestion, observation is not appropriate.

Leech therapy is often used to relieve venous congestion of flaps and replanted parts postoperatively if additional venous outflow cannot be established surgically. Abandoning further surgical efforts to plan for leeching would not be advised as an initial course of action.

The traditional reconstructive algorithm for reconstruction of distal one-third defects recommends free tissue transfer. The advent of perforator propeller flaps allows for reconstruction with available like tissue that does not involve microsurgery. Free flap reconstruction would generally be the plan following complete flap loss, but it would not be the next step in management of venous congestion.

Acute venous insufficiency should not be managed with nitropaste therapy.

269

A 43-year-old electrician sustains a high-voltage electrical injury and undergoes multiple debridement procedures of the right upper extremity. The hand, ulnar aspect of the forearm, and medial upper arm are spared. Two weeks following the injury, a final debridement is performed leaving a 6-cm segment of the brachial artery and median nerve exposed in the proximal forearm. Which of the following is the most appropriate method for wound coverage?
A) Above-elbow amputation
B) Dermal substitute followed by skin graft
C) Free tissue transfer
D) Local tissue flap
E) Split-thickness skin graft

D) Local tissue flap

The most appropriate method for wound coverage is a local tissue flap, which could come from the intact medial upper arm and/or ulnar aspect of the forearm. A split-thickness skin graft is not appropriate coverage for vital structures. The time it takes for a dermal substitute to vascularize and form the basis of subsequent grafting is too long to leave such vital structures exposed. Free tissue transfer is an option; however, this patient is 2 weeks out from injury and the associated hypercoagulable state is a relative contraindication if local tissues are available. Above-elbow amputation is not an appropriate option as the hand is spared and there are viable coverage options for this young manual laborer.

270

A 62-year-old man is diagnosed with osteosarcoma involving the mandible. Microsurgical reconstruction with a free osseocutaneous flap using iliac bone is planned. The vascular pedicle to this flap is which of the following?
A) Deep circumflex iliac vessels
B) Deep inferior epigastric vessels
C) Superficial circumflex iliac vessels
D) Superficial femoral vessels
E) Superficial inferior epigastric vessels

A) Deep circumflex iliac vessels

The deep circumflex iliac artery (DCIA) arises from the lateral aspect of the external iliac artery. From its takeoff point, it travels toward the anterior superior iliac spine (ASIS) between the transversalis fascia and transversus abdominis muscle. Just medial to the ASIS, it gives off an ascending branch which supplies the internal oblique muscle. Lateral to the ascending branch, the DCIA courses through the transversalis fascia along the inner lip of the iliac crest, where it lies in the line of fusion between the iliacus and transversalis fascia, and supplies the iliac crest bone.

The deep inferior epigastric vessels supply transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps. The superficial circumflex iliac vessels supply the groin flap. The superficial inferior epigastric vessels supply the superficial inferior epigastric artery (SIEA) flap, which comprises the skin and subcutaneous tissue only of the lower ipsilateral hemi-abdomen. The superficial femoral vessels supply flaps such as the sartorius muscle flap.

271

Supply to the groin flap

superficial circumflex iliac vessels

272

The superficial circumflex iliac vessels supply what?

The groin flap

273

Supply to the iliac crest osseocutaneous flap

Deep circumflex iliac vessels

274

A 32-year-old male athlete sustains a contact burn to the right foot. Serial debridement results in exposure of the medial aspect of the first metatarsophalangeal joint. A photograph is shown. Which of the following is the most appropriate option for definitive wound management?
Exposed joint/medial metatarsal
A) Amputation of the great toe
B) Bony debridement and primary closure
C) Coverage with a fasciocutaneous free flap
D) Local tissue rearrangement
E) Negative pressure wound therapy

C) Coverage with a fasciocutaneous free flap

The most appropriate option to obtain definitive wound coverage is a fasciocutaneous free flap harvested from outside the zone of injury. Amputation is not indicated when the majority of the great toe is viable. In addition, this would be highly morbid for this young athlete. Negative pressure wound therapy alone would promote healing by secondary intention, but with an exposed joint this would likely result in an unstable wound. Local tissue rearrangement in this area results in marked donor site morbidity. Bony debridement and primary closure may lead to a healed wound, but functional morbidity would be high in this athlete.

275

A 65-year-old woman has a draining sinus tract at the lower chest 2 weeks after undergoing a cardiac bypass procedure. After extensive debridement, there is a large central defect requiring an omental flap for obliteration of the dead space. Which of the following arteries supplies the omental flap?
A) Gastroduodenal
B) Gastroepiploic
C) Left gastric
D) Superior epigastric
E) Superior mesenteric

B) Gastroepiploic

The blood supply to the omental flap is through the right and left gastroepiploic arteries.

Understanding the anatomy and blood supply to the omentum is crucial for success in omental flap transfer. The greater omentum is harvested from the transverse colon, as the short gastric vessels are ligated and the gastroepiploic vessels preserved. The omentum can be transposed to the chest through either an opening in the diaphragm or a fascial defect in the abdominal wall.

The left gastric vessels arise from the celiac vessels and supply the lesser curvature of the stomach. The gastroduodenal artery arises from the celiac trunk and provides blood supply to the pylorus and proximal duodenum. One of the terminal branches of the gastroduodenal artery is the right gastroepiploic artery. The superior epigastric artery supplies the rectus abdominis muscle and is not intraperitoneal. The superior mesenteric artery arises from the aorta below the celiac trunk and supplies the lower duodenum through the transverse colon; it does not carry the blood supply necessary for design of an omental flap.

276

A 50-year-old woman has wound breakdown in the lumbosacral region after spinal instrumentation, as shown in the photograph on the left. The superior aspect is closed with local paraspinal muscle advancement. The lower aspect is closed with a musculocutaneous V-Y advancement flap, as shown in the photograph on the right. Which of the following Mathes/Nahai classifications is most appropriate for this flap?
(Gluteal V-Y advancement flap)
A) Type I
B) Type II
C) Type III
D) Type IV
E) Type V

C) Type III

The gluteal V-Y advancement flap used in the clinical scenario described is a Mathes/Nahai Type III flap. Type III muscle flaps demonstrate two large, independent vascular pedicles arising from separate regional arteries. Other Type III muscles include the rectus abdominis and serratus anterior. Angiographic studies have shown equal filling of the intramuscular vascular system with either pedicle injection. Type III muscle flaps can be based on either pedicle and can be split to preserve muscle function. In this particular ambulatory patient, only the superior half of the gluteal muscle (based on the superior gluteal artery) was used in order to preserve lower gluteal function.

277

Type I muscle flaps

Type I muscles have a single dominant pedicle. Examples include the gastrocnemius, rectus femoris, and tensor fascia lata flaps.

278

Type II muscle flaps

Type II muscle flaps demonstrate one or more large vascular pedicles near the muscle origin and several small pedicles entering the muscle belly distally. Commonly used muscle flaps in this group include the gracilis, soleus, and trapezius. The minor pedicles are typically divided to allow maximal muscle transposition. Division of the minor pedicles typically has little effect on muscle flap survival, but poorly planned musculocutaneous flaps may suffer distal skin ischemia if not planned appropriately. This vascular pattern is the most common pattern observed in anatomical studies of human cadaveric muscle.

279

Type III muscle flaps

Type III muscle flaps demonstrate two large, independent vascular pedicles arising from separate regional arteries. Type III muscles include the gluteal muscle, rectus abdominis and serratus anterior. Angiographic studies have shown equal filling of the intramuscular vascular system with either pedicle injection. Type III muscle flaps can be based on either pedicle and can be split to preserve muscle function.

280

Type IV muscle flaps

Type IV muscles demonstrate segmental vascularization along the entire length of the muscle. The sartorius and tibialis anterior muscles are the most clinically relevant muscles that display this type of pattern. The segmental nature of the blood supply severely limits the ability to transpose these muscles and therefore the utility is limited.

281

Type V muscles flaps

Type V muscles display one dominant vascular pedicle near the muscle origin and multiple segmental pedicles near the muscle insertion. The latissimus and pectoralis major muscles demonstrate this vascular pattern. Angiographic studies demonstrate that the intramuscular vasculature can be supplied by either the dominant or segmental pedicles. As a result, the flaps can be elevated on either vascular system.

282

A 27-year-old woman is evaluated for a traumatic wound to the left heel that she sustained when she was attacked by a shark 6 days ago. Physical examination shows a 5 × 5-cm soft-tissue defect with exposed bone. Reconstruction with a sensate flap taken from the instep region is planned. Which of the following nerves provides innervation to this flap?
A) Calcaneal
B) Lateral femoral
C) Medial plantar
D) Superficial peroneal
E) Sural

C) Medial plantar

The nerve supply to the medial plantar artery flap is the medial plantar nerve.

The medial plantar artery flap is a sensate flap that can be used for coverage of heel defects. The flap incorporates tissue from the medial instep of the foot in a non–weight-bearing area, and can be transposed posteriorly to allow for coverage of heel defects. This flap provides durable plantar glabrous skin that can allow for weight bearing.

The flap is based on the medial plantar artery, which arises from the posterior tibial artery. A branch of the medial plantar nerve providing sensation to the instep of the foot can be harvested with the flap, allowing for preservation of sensation in the reconstructed heel.

283

The lateral femoral cutaneous nerve provides sensation to:

the anterolateral thigh flap

284

The superficial peroneal nerve provides:

motor innervation to the lateral leg

285

The sural nerve provides:

sensation to the lateral side of the foot

286

The calcaneal nerve provides:

native sensory innervation to the heel

287

A 52-year-old man with a 10-year history of intravenous drug use is evaluated for right groin pseudoaneurysm. He has a history of right groin reconstruction with a local sartorius flap. After vascular reconstruction, he is left with an exposed vascular conduit in need of stable coverage. The local groin tissues are indurated and stiff. The rectus femoris muscle is rotated to provide coverage. Which of the following lower extremity function deficits is most likely in this patient?
A) Inability to abduct the thigh
B) Inability to extend the knee
C) Inability to flex the ipsilateral hip
D) Weakened extension of the knee
E) No functional deficit

D) Weakened extension of the knee

The rectus femoris muscle is the most superficial and central of the quadriceps extensor muscle group. It is a bipennate muscle that extends from the ilium to the patella and is surrounded by the vastus lateralis and vastus medialis muscles. The rectus femoris acts as an extensor of the knee, specifically powering the terminal 15 to 20 degrees of knee extension. It is also a powerful flexor of the hip. Recent studies have shown that the use of this muscle is effective for groin reconstruction. Mild, isolated deficits are observed although there is no clinical significance of this deficit.

288

A 25-year-old man is brought to the emergency department after he sustained a mutilating injury to the right hand and wrist that requires soft-tissue reconstruction. Examination shows exposed tendon and bone over the dorsum of the right hand and wrist. The zone of injury extends to the level of the elbow. Allen test is abnormal. Which of the following is the most appropriate method of reconstruction?
A) Coverage with a groin flap
B) Coverage with a reverse radial forearm flap
C) Full-thickness skin grafting
D) Negative pressure wound therapy
E) Split-thickness skin grafting

A) Coverage with a groin flap

The patient described has a mutilating injury to the dorsum of the hand and wrist with exposed extensor tendons and metacarpals, which would not be an appropriate bed for a skin graft. Skin grafts survive initially by plasmatic imbibition and then by inosculation from the wound bed. Wounds with extensive exposure of tendons do not provide the potential for in-growth of vascularized tissue to maintain a skin graft. The radial forearm flap cannot be used in this patient because the palmar arch has been injured and the patient does not have communication between the radial and ulnar arterial system such that arterial compromise can occur if the radial artery is transected for the flap. Negative pressure wound therapy can be considered temporarily, but will not provide definitive management of this complex wound.

289

A 9-year-old girl is evaluated for scar revision after sustaining a laceration of the left cheek that was repaired in the emergency department 2 years ago. Examination shows a 4 × 0.7-cm scar that is pale, flat, and wide in appearance. It has an oblique orientation between the oral commissure and zygomatic arch. W-plasty is considered. Which of the following is the most likely outcome of the W-plasty when compared with linear closure in this patient?
A) Decreased initial wound tension
B) Decreased procedural time
C) Increased contracture of the wound
D) Increased removal of healthy tissue

D) Increased removal of healthy tissue

The W-plasty was first described by Borges in 1953. The repair involves a regular pattern of interdigitating triangular advancement flaps. This repair allows for the scar to have an accordion-like effect secondary to the broken line configuration. The W-plasty and geometric broken line closure (GBLC) techniques are commonly used for scar revisions and are best indicated for scars that cross the relaxed skin tension lines (RSTL) to redirect portions of the scar. Because of the flexibility these scars have, they are also indicated over convex or concave surfaces.

Compared with linear closure, the W-plasty will have decreased contracture of the wound because of the interrupted orientation of the scar. Even though a portion of the final closure will go against the RSTLs, W-plasties can be designed to orient a significant portion along the RSTLs. Because of the many triangular flaps made and repaired, it takes significantly longer to perform a W-plasty repair. The main disadvantage of the W-plasty and GBLC procedures is the need to remove a significant amount of healthy tissue on either side of the scar to be revised, which can lead to increased wound tension and the need for significant undermining.

290

A 24-year-old right-hand-dominant male construction worker is evaluated because of a right dorsal thumb abscess that is treated with debridement and administration of antibiotics. A photograph of the residual defect is shown. Which of the following is the most appropriate method for reconstruction in this patient?
Exposed EPL
A ) Coverage with a muscle flap
B ) Coverage with a skin flap
C ) Full-thickness skin grafting
D ) Negative pressure wound therapy
E ) Split-thickness skin grafting

B ) Coverage with a skin flap

The residual defect includes exposed extensor tendon without paratenon. This fact, combined with the need for flexion at the interphalangeal joint and avoidance of contracture, as well as the likely need for future tenolysis, makes a skin flap the most appropriate option for reconstruction. In the scenario described, a first dorsal metacarpal artery pedicled skin flap is used to reconstruct the thumb defect with the need for back grafting of the donor site. This provides the best combination of low donor-site morbidity, the ability to provide stable soft-tissue coverage over exposed tendon without paratenon, and the competitive advantage of being relatively easy to re-elevate for subsequent procedures, if needed.
A muscle flap could be used to reconstruct the defect but would not be optimal due to the increased donor site morbidity from muscle sacrifice, as well as the increased difficulty in re-elevation versus a skin flap over tendon.

Healing by secondary intention, with or without topical negative pressure wound therapy, will certainly result in extensive contracture as well as an increased time to heal. This will impact the patient’s outcome both in terms of his ability to return to work as a construction worker as well as limitations on his functional range of motion.

Skin grafting, whether split- or full-thickness, is not a reliable option in this patient because of the exposed tendon without paratenon. It is important to note that this is a classic contraindication to skin grafting and therefore leads to a flap-based reconstruction.

Furthermore, skin grafts would lead to increased contraction versus flaps and would be difficult to re-elevate for subsequent procedures.

291

A healthy 40-year-old man comes to the office because of an injury to his finger. Examination shows a 4 × 3-cm, full-thickness defect over the proximal interphalangeal (PIP) joint of the right index finger. The joint capsule and extensor tendons are exposed. No sign of infection is noted. Coverage with an arterialized venous free flap from the forearm is planned. Which of the following is the main disadvantage of using this flap in reconstruction?
A ) Difficult flap monitoring
B ) High incidence of total flap failure
C ) Inability to transfer flap with nerve and/or tendon
D ) Limited supply of donor sites
E ) Technically demanding flap harvest

A ) Difficult flap monitoring

Arterialized venous free flaps are thin fasciocutaneous flaps that are useful in reconstructing defects of the hand. The main advantage of an arterialized venous flap is the ease of harvesting a thin flap without the need to sacrifice a major artery at the donor site. The design of venous flaps is very easy because of direct visualization of the venous plexus through the thin overlying skin. There is no limitation of the donor site because it is possible to find the venous network at any location of the body. They can be harvested as composite flaps, including nerve and tendon flaps. Despite many advantages, arterialized venous flaps are not commonly selected as the first choice for microsurgical reconstruction. Venous congestion is an expected part of the flap’s postoperative course, and this makes monitoring the flap especially difficult as compared with other conventional flaps. Signs of vascular insufficiency and characteristic edema and congestion of venous flaps are difficult to differentiate. In cases of venous congestion, flap viability can be monitored only by palpating the pulse or by laser Doppler probe analysis. Though venous congestion is common, the ultimate success rate of arterialized venous flaps is similar to that of conventional flaps, with total flap loss a rare occurrence.

292

An 18-year-old man undergoes open reduction with tension band wiring to treat a fracture of the olecranon he sustained in a bicycle collision. Postoperatively, he develops a wound infection, resulting in an open wound over the elbow. Coverage with a posterior interosseous fasciocutaneous flap is planned. Which of the following best describes the anatomical location of the dominant pedicle of this flap?
A ) Anterior to the pronator teres and deep to the brachioradialis
B ) Between the extensor carpi ulnaris and the extensor digiti minimi
C ) Between the flexor digitorum profundus and flexor pollicis longus
D ) Deep to the brachioradialis and lateral to the flexor carpi radialis
E ) Superficial to the anconeus and extensor digitorum muscle

B ) Between the extensor carpi ulnaris and the extensor digiti minimi

The posterior interosseous flap is a pedicled forearm flap based off the posterior interosseous artery (PIA) proximally. It can be rotated to cover elbow, antecubital fossa, or proximal volar forearm defects. A reversed version, based off the anterior interosseous arterial connections to the PIA, can be used for wrist and hand defects.

The PIA emerges in the proximal dorsal forearm deep to the supinator. It then courses between the extensor carpi ulnaris (ECU) and the extensor digiti minimi (EDM). During dissection of a standard posterior interosseous flap, the pedicle is found distally in the forearm between the ECU and EDM then dissected proximally.

The superficial branch of the radial nerve is located anterior to the pronator teres and deep to the brachioradialis. The anterior interosseous artery is found between the muscle bellies of flexor digitorum profundus and the flexor pollicis longus.

Distally in the forearm, the radial artery is deep to the brachioradialis and radial to the flexor carpi radialis. Proximally in the forearm, the posterior cutaneous nerve of the forearm is found superficial to both the anconeus and extensor digitorum muscle.

293

A 50-year-old woman has significant tenderness of the residual tip of the index finger 8 weeks after undergoing amputation of the fingertip. Physical examination shows significant stump tenderness. Which of the following therapy modalities is most appropriate for desensitization of the amputation stump?
A ) Functional electric stimulation
B ) Immobilization
C ) Kinesiology tape
D ) Semmes-Weinstein monofilaments
E ) Vibration

E ) Vibration

Vibration is a modality that may be used in therapy to desensitize an amputation stump neuroma. The treatment consists of vibratory stimulation applied to the periphery of the sensitive area and then gradually moving toward the center. Some additional methods used in therapy to treat neuroma pain include desensitization, massage, and transcutaneous nerve stimulation. Functional electric stimulation is similarly not a therapeutic modality. Kinesiology taping is used for edema control and comfort. It would not be used on an amputated stump. Semmes-Weinstein monofilaments are used to quantify sensation to fine touch and are not used for desensitization.

294

A 48-year-old man is brought to the emergency department after being involved in a high-speed motorcycle collision. Physical examination shows comminuted fractures of the left radius and ulna. A photograph of his wounds is shown. After debridement of the necrotic tissue, the brachial vessels and median nerve are exposed. Microsurgical techniques are not available. Which of the following is the most appropriate choice for tissue coverage in this patient?
(on forearm just distal to elbow)
A ) Groin flap
B ) Lateral arm flap
C ) Posterior interosseous artery flap
D ) Radial forearm flap
E ) Split-thickness skin graft

B ) Lateral arm flap

The vascular supply of the lateral arm flap is from the posterior radial collateral artery, a terminal branch of the deep brachial artery. This artery communicates distally with the ulnar artery, allowing the flap to be raised in a distally based fashion, as it was for the patient in this item. For most adult patients, a 12 × 6-cm flap can be harvested and still allow for primary donor site closure. The major extremity vessels are not disturbed with the harvest of this flap.