Flaps general

Question 1

ALT flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons

Answer 1

1) Type B/C

2) Dominant (Descending branch of lateral femoral circumflex)

3) VC and Lateral femoral cutaneous nerve (anterior and posterior branches)

4) ASIS Superolateral patella Midpoint along line with 3cm radius (perforators, Skin paddle 10cm distal to ASIS and 7cm proximal to patella, Width of 9-10cm = primary closure)

5) Pros: Minimal donor site morbidity, sensate flap possible
Cons: Intramuscular dissection (85%)

Question 1

DCIA flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

Answer 1

1) Type 1

2) Dominant: Deep circumflex iliac

3) Single vein accompanies the artery and Sensory: T12

4) ASIS
Ellipse centered from ASIS along curvature of the iliac crest (Cutaneous perforators clustered in area measuring 4x6cm, above midpoint of the iliac crest, 5cm posterior to ASIS)

5) Pros: Large bone segment, bulk, ideal for hemimandible reconstruction
Cons: Can be too bulky for H+N recon, risk of hernias, damage to LFCN
Variants: Myocutaneous (Rubens flap), Perforator DCIA, Osteomyocutaneous

Question 2

Deltopectoral flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

Answer 2

1) Type C

2) Dominant: 1st, 2nd, 3rd IMA perforators
Source: Internal mammary artery

3) VCs and Sensory T2-T4 intercostals

4) Superior border: Infraclavicular line
Inferior: Parallel and superior to nipple
Lateral: Deltopectoral groove

Delay: Extend onto deltoid, lateral to deltopectoral groove

5) Pros: Easy dissection, reliable for H+N recon.
Cons: Morbidity and chest wall distortion.
Variants: IMAP, delay

Question 3

VRAM/TRAM/DIEP flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

Answer 3

1) Type 3

2) Dominants:
Superior epigastric (2-3cm, 1-2mm, internal mammary)

Inferior epigastric (6-10cm, 1-2.5mm, external iliac

Minor:
Segmental intercostal perforators (7th-12th)

3) Veins: Superiorly, one vein predominates
Inferiorly, veins combine to form a large single vein before entering external iliac

Nerve: 7th-12th intercostals

4) Midline
Costal margin
ASIS
Pubis

5) None written

Question 4

DUA (Dorsal Ulnar Artery) Flap:

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

Answer 4

1) Typa A

2) Dominant:
Ulnar artery (dorsal branch)

Source: Ulnar artery

3) Veins: 2 VCs
Diameter 0.8-1mm
1 vein connects to superficial system

Nerve: Sensory Dorsal ulnar branch

4) Ulnar artery axis: Medial epicondyle to pisiform
DUA perforator 2-4cm proximal to pisiform
Boundaries:
- Anterior : PL
- Posterior: EDC D4
Artery located within septum between FCU and ECU.

5) Pros: Does not sacrifice main artery,
Cons: Retrograde venous drainage, used for small deficits

Question 5

Facial Artery Myomucosal (FAMM) flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

Answer 5

1) No type

2) Dominant:
Facial artery, angular branch
Source: External carotid artery

3) Venous plexus, but no VCs with the facial artery

4) Doppler identification of the facial artery/angular branch

Artery lies between buccinator muscle and overlying muscles of facial expression

Flap consists of mucosa, submucosa, buccinator muscle  5-8mm thick

Based superiorly (retrograde blood flow typically used for for palatal fistula recon), or inferiorly (more robust blood supply)

**If inferiorly based for palatal reconstruction, bite block required post-op until flap division 2-3 weeks later

5) Pros: Reliable anatomy, local tissues, robust, minimal morbidity if flap kept narrow
Cons: Small size, risk of cheek contracture if very wide flap harvested
Variants: Superior or inferior based design

Question 6

FDMA/Quaba/DMA flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

Answer 6

1) Type A

2) Dominant:
Dorsal metacarpal artery
Source: Dorsal carpal arch

3) Veins: VCs
Nerve: Radial or ulnar dorsal sensory

4) The FDMA (kite) flap design runs from the metacarpophalangeal (MCP) joint of the index finger proximally to the proximal interphalangeal (PIP) joint of the index finger distally, the radial and ulnar borders being the midlateral lines on either side of the digits.

The DMA/Quaba flaps have similar elliptical skin designs, with the longitudinal axis centered on the intermetacarpal space, spanning the level of the metacarpal heads to the distal wrist. The ulnar and radial borders of the skin paddle are determined by a pinch test and by the ability to close the donor site primarily

A handheld pencil Doppler probe can be used to identify the dorsal metacarpal artery, as well as the cutaneous perforator emanating from the DMA in between the metacarpal heads, which corresponds to the pivot point for both the DMA and Quaba flaps. The pivotal point of the flap is approximately 1.5 cm proximal to the leading edge of the web space.

5) Pros: Reliable anatomy, versatile, local option, thin tissue, sensate PRN

Cons: At risk for venous congestion, less reliable for ulnar sided defects

Variants: Composite flap (with tendon graft), sensate

Question 7

Fibula flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant?

Answer 7

1) Type B/C

2) Dominant:
Peroneal artery perforators
Source: Peroneal artery/tibioperoneal trunk

3) Vein: VCs
Nerve: Sensory Superficial peroneal nerve

4) Peroneal head
Lateral malleolus  remain ~6cm proximal to avoid destabilizing mortise

Axis = posterior crural septum between lateral and superficial posterior compartments

Skin paddle centered over septum in middle/distal third where majority of perforators located

5) Pros: Large segment of vascularized cortical bone, versatile, multiple osteotomies as needed (periosteal + endosteal blood supply)

Cons: Contraindicated in Peronea Magna (~1%), Risk of nerve damage

Variants: Osseous, Osteofasciocutaneous, Osteomusculocutaneous, Epiphyseal (based off of Anterior Tibial artery).

Question 8

GASTROCNEMIUS flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 8

1) Type 1

2) Dominant:
Medial or Lateral sural arteries
Source: Popliteal artery

3) Vein: VCs
Nerve: Branches of the tibial nerve

4) 1) Midline stocking seam incision
2) 2cm posterior to fibula/tibia (overlying muscle belly)

Origin: Femoral condyles
Insertion: Calcaneus (Achilles tendon)

5) Pros: Medial head is larger, less risk of damage to peroneal nerve

Cons: Contraindicated if DVT

Variants: Musculocutaneous, functional muscle transfer

Question 9

GLUTEUS flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 9

1) Type 3

2) Dominant:
Superior Gluteal
Inferior Gluteal
Minor:
1st perforator of profunda femoris

3) Vein: Superior and inferior gluteal veins
Nerve: Inferior gluteal nerve (L5-S2)

4) Origin:
- PSIS
- Coccyx
- Lateral sacrum
- Ischial tuberosity
Insertion:
- Greater trochanter
- IT tract

5) Pros: 50% of muscle can be used without deficit, can be re-advanced

Cons: Donor site

Variants: Semi-circular, functional muscle transfer, SGAP, IGAP, free flap

Question 10

Gracilis flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 10

1) Type 2

2) Dominant:
Medial circumflex femoral
Source: Femoris profunda

Minors: Branches of deep femoral or superficial femoral (in the distal half of the muscle)

3) Vein: VCs
*Can include greater saphenous vein as secondary outflow
Nerve: Sensory: Anterior femoral cutaneous / Motor: Obturator

4) Pubic tubercle to medial femoral condyle adductor longus tendon

Gracilis lies 2cm posterior

• Skin paddle taken from proximal 2/3 as distal 1/3 is unreliable

5) Pros: Reliable pedicle, good arc of rotation, distal tendon available

Cons: Risk of lymphedema, limited/unreliable skin paddle, weak muscle, difficult in obese patients

Variants: Myocutaneous, TUG/TMG flap, Functional muscle transfer

Question 11

Groin Flap/SCIA/SCIP

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 11

1) type A

2) Dominant:
Superficial Circumflex Iliac Artery (SCIA)
Source: Superficial femoral artery

3) Vein: Single vein draining to the saphenous, Superficial to the SCIA
Nerve: Sensory T12: lateral cutaneous nerve

4) Femoral vessels
Pubic symphysis
ASIS
Inguinal ligament

Skin paddle centered over 1/3 super to ligament +
2/3 inferior to ligament

Vascular pedicle lies 3cm below and parallel to inguinal ligament

Random blood supply distal to ASIS

5) Pros: Good salvage option when micro not possible, hidden donor site, thin in low BMI patients

Cons: Short pedicle if free flap, thick for high BMI patients

Variants: SCIP perforator flap, Delay if needing to extend far beyond ASIS (q2weeks for delay)

Question 12

IGAP flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 12

1) Type C

2) Dominant:
Perforator of inferior gluteal artery

3) Vein: VC
Nerve: Clunial nerves (superior, medial, inferior)

4) PSIS
Ischial tuberosity
Inferior gluteal crease

• Pedicle 2/3 distance from PSIS to ischion
• Paddle oriented along inferior gluteal crease
• Inferior incision 2-3cm caudal to inferior gluteal crease

5) Pros: Longer pedicle than SGAP, hidden scar in inferior gluteal crease

Cons: Increased risk of dehiscence, nerve injury, difficult

Question 13

Lateral Arm flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 13

1) Type B

2) Dominant:
Posterior branch of radial collateral (PRCA)
Source: Profunda brachii

3) Vein: Deep VCs
Superficial to Cephalic

Nerve: Sensory Lower lateral cutaneous nerve
Branch of radial nerve
Perforates lateral head of triceps near deltoid

4) Deltoid insertion
Lateral epicondyle
Lateral intermuscular septum

**Anterior branch of radial collateral artery runs with radial nerve

5) Pros: Thin flap, reliable anatomy, easy dissection, sensate

Cons: Smaller width, short pedicle

Variants: Extended lateral arm, reverse (anastomoses of radial collateral artery with radial recurrent artery), fascial, osteocutaneous, vascularized nerve graft

Question 14

LATISSIMUS DORSI flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 14

1) Type 5

2) Dominant: Thoracodorsal
Minor: Para-spinal and lumbar perforators
Source: Subscapular

3) Vein: VC
Nerve: Thoracodorsal (C6-8)

4) Midline
Posterior iliac crest
Anterior border of the muscle (posterior mid-axillary)
Scapular tip

Skin paddle must be 8cm superior to iliac crest

Superior muscle fibers located below scapula

5) Pros: Robust, large surface, reliable

Cons: Seroma, loss of function paralysis

Variants: Chimeric (LD+serratus), TDAP, Reverse, Fonctional, Hemi-LD

Question 15

Masseter flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 15

1) Type 1

2) Dominant: Masseteric artery
Source: IMAX

3) Vein: Massteric vein
Nerve: Masseteric nerve (V3)
1-4 branches: multiple in 75% of patients

4) Zygomatic arch
Mandibular body
Mandibular notch

**Stensen’s duct runs superficial to the masseter, and deep to facial musculature

5) Pros: Local option, +/- expendable muscle of mastication, nerve used for facial reanimation

Cons: Minimal excursion, sacrificing functional muscle

Variants: Inferiorly based

Question 16

MEDIAL PLANTAR flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 16

1) Type B

2) Dominant: Medial plantar artery
Minor: Myocutaneous perforating vessels from the abductor hallucis brevis and flexor digitorum brevis
Source: Posterior tibial artery

3) Vein: VC
Nerve: Medial plantar nerve (L4-5)

4) Non-weight-bearing instep skin
Head of first metatarsal (distal)
Cubicle of the navicular bone (proximal)

5) Pros: Good padding, minimal donor site morbidity

Cons: Primary closure impossible, must skin graft

Variants: reverse V-Y advancement (1-2cm), myofasciocutaneous (abductor hallucis)

Question 17

MFC/MFT flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 17

1) None

2) Dominant: Descending geniculate artery
Or Medial geniculate artery
Source: Superficial femoral
** Deep to vastus medialis

3) Vein: VCs / Greater saphenous vein for superficial
Nerve: Sensory Saphenous nerve / pierces fascia proximal to sartorius insertion

4) Medial femoral condyle
Femur axis

5) Pros: Straight-forward dissection, vascularized corticocancellous bone

Cons: Not suitable for large defects, cannot segment

Variants: MFT / cartilaginous articular surface, osteofasciocutaneous

Question 18

MSAP flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 18

1) Type C

2) Dominant: Medial sural artery perforator
Source: Medial sural/popliteal

3) Vein: VCs
Nerve: None

4) Axis from middle of popliteal fossa crease to medial malleolus
Perforators start ~ 6cm distal to crease on axis line (up to 16cm distal)
1-4 perforators

5) Pros: Relatively thin flap, long pedicle length,

Cons: STSG if flap too large, tedious dissection, small calibre of vessel if taken at medial sural

Variants: Chimeric flap with 2nd perforator going to muscle

Question 19

PAPF flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 19

1) Type B/C

2) Dominant: Profunda femoris artery perforator
Source: Medial branch of Profunda Femoris

3) Vein: VCs
Nerve: None

4) Gluteal fold : 1cm below
Groin crease
Posterior limit of IT band postero-lateral
Gracilis medially

Flap harvested from upper 1/3 of posterior thigh

Pinch test

5) Pros: Alternative flap for breast recon, donor site well hidden

Cons: Small size limited by pinch test, inconsistent dominant perforator location

Question 20

Paraspinal flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 20

1) Type 4

2) Dominant: Segmental perforators from posterior intercostal vessels

Minor: Lateral perforator row

3) Vein: Closely parallels arteries
Nerve: Motor + Sensory Segmental intercostals

4) Group of muscles consisting of semispinalis, longissimus, iliocostalis

Muscle bulk is thickest in upper lumbar and thoracic areas

Superiorly covered by trapezius from the occiput to T12 and by latissimus from T6-L2

Midline
6-8cm lateral

5) None

Question 21

PECTORALIS MAJOR flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 21

1) Type 5

2) Dominant: Pectoral branch of thoracoacromial

Minor: Pectoral branch of lateral thoracic

Minor segmental:Internal mammary perforators (5-6cm from midline)
Source: Axillary

3) Vein: Single veins accompanying the artery
Nerve: Motor Medial and lateral pectoral

Sensory 2nd-7th intercostal nerves

4) Clavicle, Acromion
Xiphoid
Midline
Anterior axillary line
6th intercostal space

• Pedicle at junction of medial 2/3 and lateral 1/3 of clavicle
• Bisection of mid-clavicle to acromio-xiphoid line

5) Pros: Reliable, local

Cons: Decreased cutaneous vascularity if based on internal mammary perforators, deformity if myocutaneous, loss of anterior axillary line

Variants: Myocutaneous, muscle advancement, turnover flap, functional muscle, osteomyocutaneous

Question 22

Posterior Interosseous Artery (PIA) flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 22

1) Type B

2) Dominant: Posterior interosseous artery
Source: Common interosseous or ulnar artery

Minor: Anterior interosseous

3) Veins: VCs (1 or 2)
Nerve: Sensory Lower branch of the dorsal antebrachial nerve (C5-8)

4) Line drawn from lateral epicondyle to DRUJ

Intermuscular septum between EDM and ECU. Runs with PIN in the proximal 1/3. Gives off 4-7 septocutaneous perforators

Dominant perforator identified at junction of proximal 1/3 and distal 2/3, just distal to supinator. Approximately 7-10cm distal to lateral epicondyle.

In the middle third, gives off a middle cutaneous perforator with a VC communicating between superficial/deep veins of the flap

*Anastomotic branch from AIA 3cm proximal to DRUJ

5) Pros: Does not sacrifice main artery, sensate

Cons: Tedious dissection, narrow skin paddle, short pedicle, unreliable vascular supply, PIN injury

Variants: Harvest EIP

Question 23

Radial Forearm flap

1) Type ?

2) Pedicule?

3) Vein and Nerve?

4) Markings?

5) Pro and cons and variant

Answer 23

1) Type B

2) Dominant: Radial artery
Source: Brachial artery

3) Veins: Deep VCs
Superficial Cephalic

Nerves: Sensory Medial (C8-T1) and lateral (C5-C6) antebrachial cutaneous

Motor Superior gluteal

4) Antecubital fossa
Scaphoid tubercle
Doppler radial artery

**Pre-op Allen’s test

Distal edge of skin paddle should not pass wrist crease

5) Pros: Reliable anatomy, easy dissection, long pedicle, sensate

Cons: STSG for donor site, minimal flap bulk

Variants: Reverse, adipofascial, fascial, osteofasciocutaneous, myocutaneous, vascularized tendon graft, flow-through

Question 24

Rectus Femoris flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 24

1) Type 2 2) Dominant: Lateral circumflex femoral Source: Femoris profunda Minors: Muscular branches of superficial femoral 3) Vein: VCs Nerves: SensoryAnterior femoral cutaneous Motor Femoral (6 – 13 cm inferior to ASIS) 4) ASIS Central patella *Pinch test to determine width * Reliably carries skin paddle over muscle * A transverse line marked from the level of the pubis shows the approximate path of the lateral circumflex femoral artery 5) Pros: Volume, large skin paddle, easy dissection Cons: Short pedicle, important for knee extension/hip flexion Variants: Myocutaneous, Functional muscle transfer

Question 25

Sartorius flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 25

1) Type 4 2) Dominant: Segmental perforators (6-7) from superficial femoral artery Source: Superficial femoral artery *Segmental perforators enter muscle on its deep + medial surface Branches of SCIA, LCF, DGA 3) Veins: VCs (drain to superficial femoral vein) Nerve: Motor Femoral nerve 4) ASIS Medial tibial tuberosity (Pes anserus) Unreliable skin paddle Preserve minimum of 3 perforators in raised flap Most proximal perforator 6.5cm distal to ASIS 5) Pros: Readily available flap for groin vessel coverage Cons: Unreliable skin paddle Variant: None

Question 26

SCAPULAR/PARASCAPULAR flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 26

1) FC type B 2) Dominant: Circumflex Scapular Minor: 2nd/3rd intercostals Source: Subscapular 3) Vien: VCs Nerve: None 4) Standing/sitting position Palpate triangular space (teres major, teres minor, long head triceps) Lateral scapular border Lateral extension: mid-ax Medial extension: midline Superiorly: scapular spine Inferiorly: > angle of scapula * Pedicle is 2/5 length from the scapular spine to tip * Scapular axis: Horizontal * Parascap axis: Lateral border of scapula 5) Pros: Reliable, large skin paddle, compound (osteocutaneous), minimal morbidity, good color match H&N, 2 team approach Cons: STSG sometimes needed, insensate, positioning Variants: Adipofascial, osteocutaneous (2-3cm wide, 10-14cm long)

Question 27

Serratus flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 27

1) Type 3 2) Dominant: Lateral thoracic artery + Serratus branches of thoracodorsal artery Source: Axillary artery 3) Vein: Single vein accompanying artery Nerve: Sensory T2-T4 intercostals Motor Long thoracic (C5-6-7)joins thoracodorsal pedicle at level of 6th rib and continues distally 4) Harvest 3-4 lowermost slips, leaving upper fibers for scapula stability Between anterior border of lat dorsi = posterior axillary line, and lateral border of pec major = anterior axillary line 5) Pros: Versatile, based off thoracodorsal system Cons: Risk of winging scapula Variants: Myocutaneous, Fascial, Chimeric, Myoosseous (either 5th/6th rib attached to muscle, or chimeric inferolateral scapula based off angular branch

Question 28

SGAP flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 28

1) Type C 2) Dominant: Perforator of superior gluteal artery 3) Vein: VC Nerve: Clunial nerves (superior, medial, inferior) 4) PSIS Coccyx Greater trochanter prominence IT tract * Identify vessels 1/3 distance between PSIS and greater trochanter * Pedicle 5cm lateral and 6cm inferior to PSIS 5) Pros: Less dehiscence Cons: Less pliable skin paddle, frequent revision required, visible scar, short pedicle, difficult dissection Variants: Semi-circular, functional muscle transfer, SGAP, IGAP, free flap

Question 29

SIEA flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 29

1) Type A 2) Dominant: Superficial inferior epigastric artery Source: Femoral artery 3) Vein: SIEV + VCs SIEV located medial to the SIEA Nerve: Sensory T10-T12 4) Inferior: 7cm superior to vulvar commissure Superior: Pinch test/level of umbilicus Laterally: ASIS Hemi-abdomen max if perfused on one pedicle The anterior superior iliac spine and the pubic tubercle are marked, and a line is drawn between them. The midpoint of the line represents the deep origin of the vessel from the femoral artery. When the line is divided in thirds, one should look for the SIEA and vena comitans between the lateral and central third, and the medial SIEV between the central and medial third. 5) Pros: Good donor site, easy dissection Cons: Limited to hemi-abdomen, small pedicle, increased risk of thrombosis, not always present Variants: Pedicled

Question 30

Pudendal (Singapore) flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 30

1) Type A 2) Dominant: Posterior labial artery Source: Internal pudendal artery 3) Vein: Posterior labial vein Nerve: Sensory Pudendal nerve S2-4 / Posterior cutaneous nerves of the thigh S1-3 4) Doppler identification of posterior labial vessels Flap based posteriorly Oblique orientation Medial border: scrotum/labia majora Lateral border: medial thigh skin 5) Pros: Versatile, thin, pliable, sensate, favorable donor site Cons: Limited dimensions for total vaginal reconstruction, not available if radical vulvectomy performed, risk of injury to groin lymphatics

Question 31

Soleus flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 31

1) Type 1 2) Dominant: Muscular branches of popliteal artery Source: Popliteal 3) Vein: VCs Nerve: Motor Posterior tibial nerve 4) 2cm posterior to fibula or tibia 5) Pros: Medial flap has greater bulk and arc of rotation, proximal/middle third coverage Cons: Less reliable for distal third, if based off distal perforators, requires pre-op Angio, Risk of distal necrosis Variants: Turnover flap

Question 32

Submental flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 32

1) Type C 2) Dominant: Submental artery Source: Facial artery *Branches from facial 5cm away from its origin. Origin of submental = 3-5cm anterior to the mandibular angle, and 7mm inferior to border. 70%, artery runs under the digastric 3) Vein: VCs Submental vein - Separate from artery - Must be included if reverse flow flap design due to valves in the VCs * Drains into facial vein Nerve: Sensory Transverse cervical (not routinely included) / Motor Cervical branch to platysma 4) Minimum 1cm inferior to mandibular border Can span between both angles Width of the flap determined by pinch test (up to 8cm) Bilateral skin paddle can be carried on one artery * Mark patient in upright position ensuring incision place minimum 1cm posterior from mandibular border 5) Pros: Reliable anatomy, easy dissection, long pedicle, sensate Cons: STSG for donor site, minimal flap bulk Variants: Island flap (can reach level of upper cheek/nose), perforator flap (no functional consequence to including digastric however), free flap (facial artery used as main artery)

Question 33

Supraclavicular flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 33

1) Type A 2) Dominant: Supraclavicular artery Source: Transverse cervical artery 3) Vein: VCs *Drains into transverse cervical vein Nerve: Supraclavicular nerves (C3, C4) - Medial branch / sternoclavicular joint - Middle branch / supraclavicular fossa - Lateral branch / acromioclavicular joint 4) Artery found in triangle composed of: - Anterior = SCM - Posterior = Trapezius - Inferior = Clavicle 8 cm lateral to sternoclavicular joint 3 cm superior to clavicle 2 cm posterior to SCM 5) Pros: Thin, pliable, reliable, regional, axially based, innervated, good color match, minimal morbidity Cons: Small vessel diameter and length, can be damaged during neck dissection, Variants: Pedicled, Island, Tissue expansion

Question 34

Tensor Fascia Lata flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 34

1) Type 1 2) Dominant: Lateral circumflex femoral (Ascending/transverse branch) Source: Femoris profunda * The vascular pedicle should be anticipated 7 to 12 cm distal to the ASIS and can be confirmed with Doppler ultrasound 3) Vein: VCs : join lateral side of femoral vein Nerve: Sensory Lateral cutaneous branch of T12 / Lateral femoral cutaneous nerve of the thigh Motor Superior gluteal 4) ASIS to lateral femoral condyle  demarcates anterior muscle border 3cm posterior/parallel represents tensor muscle *The distal third of the skin territory is unreliable and requires a delay procedure to ensure its vascularity 5) Pros: Large amount of fascia, minimal morbidity Cons: Unsightly donor site from rotational bulge or STSG Variants: Myofascial (abdo recon), osteomyocutaneous (6cm of iliac crest), perforator

Question 35

Tongue flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 35

1) Type 1 2) Dominant: Sublingual artery Source: Lingual artery bilaterally 3) Vein: VCs of the lingual artery / Lingual vein *Combines with facial vein to drain into the internal jugular vein Nerve: Sensory 1) Lingual branch of trigeminal  sensation anterior 2/3 2)Chorda tympani branch of facial  taste + sensation to anterior 2/3 3)Lingual branch of glossopharyngeal  taste + sensation to posterior 1/3 Motor Hypoglossal nerve 4) 5 paired extrinsic muscles: genioglossus, hyoglossus, styloglossus, chondroglossus, glossopalatini 4 intrinsic muscles Flap can be based dorsally, ventrally, or laterally which can then be based anterior or posterior *Avoid dorsally based flaps to spare critical areas of taste + tactile sensation 5) 1. Supine, bite block or fixed mouth retractor 2. Traction suture placed at tip of tongue 3. Determine flap design (dorsal, ventral or lateral) and pedicle base (anterior/antegrade or posterior/retrograde) 4. Identify midline 5. Base should measure at least 1.5-2cm and a depth of 5mm (mucosa, submucosa, muscle) no easily identifiable plane of dissection 6. Flap design should extend to within 1cm of the apex of the tongue for posteriorly based flaps, while anterior based flaps extend to the level of the papillae vallata

Question 36

TPFF flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 36

1) Type A 2) Dominant: Superficial temporal artery Source: External carotid artery *Located anterior and deep to superficial temporal vein Superior to zygomatic arch, gives off deep branch, middle temporal artery, to temporalis muscle 3) Vein: STV runs with artery but can be found up to 3cm away Immediately below the subdermal fat Drains into retromandibular vein Nerve: Auriculotemporal nerve (V3) 4) Doppler identification of the STA beginning in the pre-auricular region Skin incision: zig-zag, “Y” 5) Pros: Reliable anatomy, robust vascular supply, thin tissue Cons: Risk of alopecia Variants: Fasciocutaneous (hair-bearing), free flap

Question 37

TRAPEZIUS flap 1) Type ? 2) Pedicule? 3) Vein and Nerve? 4) Markings? 5) Pro and cons and variant

Answer 37

1) Type 2 2) Dominant: Transverse Cervical Minor: Dorsal scapular artery Posterior occipital Posterior intercostals Source: Thyrocervical trunk (80%), subclavicular (20%) 3) Vein: Transverse cervical Nerve: Spinal Accessory (Motor) C3-C4 (Sensory) 4) Occiput Clavicle Tip/Spine of scapula Acromion T12 Midline * A line drawn from T12 to the acromion outlines the muscle *DSA 2cm medial to scapula, exits between rhomboid major and minor * If skin paddle exceeds T12 inferiorly, must include DSA ** Preserve CN XI, superior fibers, rhomboids 5) Pros: Robust, local recon Cons: Short pedicle, loss of shoulder function, color mismatch Variants: Extended lateral, Dorsal Scapular Artery Perforator

Question 38

Classification Mathes & Nahai Type 1 1) Pedicule? 2) Examples (6) ?

Answer 38

1) 1 DOMINANT 2) Gastrocnemius Tensor fascia lata APB ABDM (hand) Vastus lateralis 1st dorsal interosseus

Question 39

Classification Mathes & Nahai Type 2 1) Pedicule? 2) Examples (8) ?

Answer 39

1) 1 DOMINANT + MINEURS 2) Brachioradialis Coracobrachialis Triceps Trapezius Gracilis Biceps femoris Rectus femoris Soleus

Question 40

Classification Mathes & Nahai Type 3 1) Pedicule? 2) Examples (6) ?

Answer 40

1) 2 DOMINANTS 2) Pectoralis minor Rectus abdominis Orbicularis oris Temporalis Serratus Gluteus maximus

Question 41

Classification Mathes & Nahai Type 4 1) Pedicule? 2) Examples (6) ?

Answer 41

1) SEGMENATAIRES 2) FDL FHL EHL External oblique Tibialis anterior Sartorius

Question 42

Classification Mathes & Nahai Type 5 1) Pedicule? 2) Examples (4) ?

Answer 42

1) 1 DOMINANT + SEGMENATAIRES 2) Pectoralis MAJOR Internal oblique Latissimus dorsi