Flashcards in Random pattern cutaneous flaps Deck (104):
It is particularly true for transposition and rotation flaps that small changes in sizes or angles may result in substantial improvements in outcomes.
The plane of flap elevation is crucial.
Secondary lobe = the portion of a flap that is used to cover the secondary defect
Tension vector = the direction of force on a given motion of the flap
A flap is a moving construct of skin and subcutaneous tissue created from tissue near an existing surgical defect.
The secondary defect refers to the operative wound created by flap elevation and closure of the primary defect.
The primary defect refers to the operative wound to be repaired, often resulting from tumour removal.
The healing from flap repairs is usually slower than the healing of granulation or skin grafting.
Much more rapid.
Hypertrophic scarring is more common in situations where incision lines cross convexities with underlying bone.
Highly sebaceous skin has high compliance, and is easy to stretch and bend.
The opposite is true, it is 'brittle'
Flaps should not rely on pedicles based on previously irradiated or scarred skin.
Perfusion is suboptimal and unpredictable.
It is recommended that aspirin be discontinued 1 week prior to surgery for patients on aspirin for primary prevention, but not for patients on aspirin for secondary prevention of further CVA or MI.
Smokers have a higher incidence of flap failure, distal flap necrosis, wound dehiscence and wound infection.
Most sensory disturbances associated with flap repairs are permanent.
The geography of the flap repair is the most accurate predictor of flap survival.
Torsion and tension are the most accurate predictors.
The tissue movement associated with advancement flaps is unidirectional.
Advancement flaps have the advantage of being able to redirect wound tension to a more favourable axis.
F Tension vector remains parallel to the primary motion of the flap.
Commonly used site for advancement flap includes the supraorbital forehead lateral to the midpupillary line
A Burrows-type advancement flap displaces the inferior dog-ear redundancy that would have resulted from a linear closure to an anatomic site from which is may be much more appropriately excised
An advancement modification (first described by Webster) is often used for operative defects above the eyebrow
F Defects of the distal nasal sidewall
A H-plasty can be used in many different facial locations.
F Best limited to eyebrow defects.
An A-T flap relies on linear tissue advancement, whereas an O-T flap relies on flap rotation.
In the plastic surgery literature the traditional island pedicle flap is referred to as a V-Y advancement flap
The island pedicle flap is not suitable for deeper operative wounds.
F Particularly suitable because it carries all the tissue layers with it.
The island pedicle flap is particularly subject to developing a protuberant appearance (pin-cushioned or trapdoor deformity).
The island pedicle flap has much less mobility than a similarly designed flap
F It has much greater mobility
The island pedicle has a rich blood supply
An island pedicle flap can only be used for areas 2cm diameter or smaller
F Defect areas of 2cm diameter or larger in the perinasal area of the upper lip can be repaired
One solution to prevent pin-cushioning of the island pedicle flap is to slightly undersize the flap, which places modest wound tension on the lateral aspects of the flap.
T This theoretically diminishes postoperative contraction of the flap.
The tapering tail of the island pedicle flap should be undermined for approximately one-third of the length of the flap, whereas the leading edge usually only needs to be undermined slightly (rarely more than 1 cm).
The island pedicle flap should be sutured flush with the surrounding skin.
F Should be inset slightly, initially slightly concave.
The bipedicle flap is a variant of a linear closure technique
The mucosal advancement flap is incised and undermined between the plane of the minor salivary glands and the underlying orbicularis muscle.
Mucosal advancement flaps generally do not alter the perceived fullness of the lower lip.
Results in a slightly flattened appearance of the lower lip
The bipedicle flap has its greatest use on the chin and cheek.
F Upper forehead and temple.
The bipedicle flap is a variant of the linear closure technique that also relies upon local tissue advancement.
The bipedicle advancement flap shares the diameter of the original surgical defect equally between primary and secondary defects.
For the bipedicle advancement flap, the pedicled portion of skin between the defect and parallel incision should be undermined.
F Shouldn’t undermine - so that it maintains a rich blood supply.
The scars that result from construction of the bipedicle advancement flap consist of two fine parallel lines.
The primary purpose of a rotation flap is redirection of wound closure tension.
For optimal rotation flap motion, the pivot of the flap should not be undermined.
F Should undermine.
A backcut into the rotation flap’s body can improve flap mobility.
Rotation flaps serve to exchange primary defects for displaced secondary defects.
Rotation flaps are best suited to closure of scalp, temple and cheek defects.
The dorsal nasal rotation flap was introduced by Tenzel
The dorsal nasal rotation flap involves full-thickness rotation of the entire nasal dorsum with a glabellar backcut to improve flap mobility.
The dorsal nasal rotation flap is elevated at the level of the nasalis muscle.
Perichondrium and periosteum
The point of pivotal restraint with the dorsal nasal rotation flap is in areas of the ipsilateral medial canthal tendon and the attachment of the nasal musculature to the nasofacial sulcus.
The dorsal nasal rotation flap can be used to repair distal nasal defects up to 3cm in diameter.
F Up to 2cm.
Longer dorsal nasal rotation flaps typically produce inferior aesthetic results.
The Mustarde flap is a large cheek and temple rotation for lower eyelid reconstruction, with extension of the flap incision into the preauricular cheek
The classic Reiger semicircular flap is a rotation of skin and orbicularis oculi muscle from the temple and lateral canthal areas.
This is true for the Tenzel flap
The classic Tenzel flap incorporates a cantholysis of one crus of the lateral canthal tendon to promote easier flap rotation
inferior crus is cut (lateral cantholysis)
The classic Tenzel flap is an advancement flap
A modified Tenzel flap; from the superior aspect of the surgical defect, q curvilinear rotation is extended laterally and superiorly past the lateral canthus and onto the temple
It is important to thin the superior aspect of the flap adequately to avoid placing a thick flap adjacent to the remaining thin tissue on the lower eyelid
Transposition flaps involve moving tissue from an area of surplus to an area of need by transposition of skin across intervening islands of unaffected tissue.
The transposition flap can be used to close difficult wounds near free margins such as the ala, lip, proximal helix or eyelid
as takes tension completely away from the primary defect
Transposition flaps are not affected by pivotal restraint
It is affected in a manner analogous to rotation flaps. It causes the transposed flap to ‘fall short’ of its intended target
All of the tension on the rhombic transposition flap is directed toward closing the primary defect.
All secondary defect
when the secondary defect is closed the flap falls into place in the primary defect
For a rhombic transposition flap, ideally a line that bisects the apex of the flap should run along or parallel to a relaxed skin tension line.
but not clear what this means!
The rhomboid transposition flap is useful for defects of the medial canthus, upper nose, lower eyelid, temple and peripheral cheek.
The rhomboid transposition flap is prone to developing dog ears and pin-cushioning.
The bilobed transposition flap is particularly useful for repairing difficult wounds on the distal nose.
The bilobed transposition flap is useful for repairing nasal wounds up to 2cm diameter.
1.5cm diam (Paver and Robs agree)
The nasalis musculature should be included in the base of a bilobed transposition flap.
For a bilobed transposition flap, the first lobe should measure approximately 95% of the area of the defect.
For a bilobed transposition flap, the second lobe should measure approximately 75% of the area of the primary lobe.
Banner transposition flaps are long, narrow, transposition flaps with a high length:width ratio, usually measuring 3:1 to 5:1.
Banner transposition flaps may be transposed 90 degrees (or even more) to cover adjacent operative wounds.
Banner flaps are not prone to develop pin-cushioning.
The base of a banner transposition flap must be undermined sufficiently to allow for ideal transposition and to promote circumferential wound contraction during healing
Nasolabial transposition flaps predictably flatten the alar groove.
Nasolabial transposition flaps are not prone to develop pin-cushioning.
For scalp flaps, incision in the galea or excisions of a portion of the galea may be useful to provide an added component of tissue advancement.
Undermining is effective and animal studies have demonstrated that the force required for a one-dimensional closure of a linear repair is reduced between 18.6% and 47.4%
Results were found in in-vivo porcine operative wounds
Regarding undermining planes in flap reconstructions, the nose should be undermined at the level of the submuscular fascia/pericondrium/periosteum.
Regarding undermining planes in flap reconstructions, the lip should be undermined well above orbicularis oris.
F Just above orbicularis oris.
Regarding undermining planes in flap reconstructions, the ear should be undermined just above perichondrium.
Regarding undermining planes in flap reconstructions, the eyelid should be undermined just above orbicularis oculi.
Regarding undermining planes in flap reconstructions, the scalp should be undermined well above the galea.
F Just above or just beneath the galea.
Regarding undermining planes in flap reconstructions, the cheek should be undermined at the level of the superficial subcutaneous fat.
F mid to deep subcut fat
Regarding undermining planes in flap reconstructions, the forehead should be undermined at the level of the superficial subcutaneous fat.
F Just above frontalis.
Regarding undermining planes in flap reconstructions, the temple should be undermined deep to the superficial fascia.
F Just above superficial fascia.
Regarding undermining planes in flap reconstructions, structures to be aware of on the nose include the nasociliary nerve and the angular artery.
Regarding undermining planes in flap reconstructions, structures to be aware of on the lip include the multiple branches of the labial artery.
Regarding undermining planes in flap reconstructions, structures to be aware of on the cheek include the parotid duct and mandibular branches of the facial nerve.
Parotid duct and buccal branches of the facial nerve.
Regarding undermining planes in flap reconstructions, structures to be aware of on the forehead include the supraorbital and supratrochlear arteries and nerves.
Regarding undermining planes in flap reconstructions, structures to be aware of on the temple include the temporal branch of the facial nerve and the superficial temporal artery.
Flaps have lower rates of associated bleeding complications than skin-graft repairs.
Higher rates dt extensive undermining.
With flaps, buried sutures should be placed sparingly because they are foreign bodies capable of producing inflammatory reactions.
Sutures of facial flaps are routinely removed 4-7 days postoperatively.
Scar massage can be initiated after the first post-operative month to soften the flap and hasten the resolution of any textural irregularities due to buried sutures.
Most surgical complications that follow facial flap repairs result from poor flap design.
F From difficulties in haemostasis.
The most plausible explanation for the development of pin-cushioning is circumferential contraction of the scar surrounding the flap’s recipient site.
The most important technique involved in reducing the risk of pin-cushioning is extensive undermining of the recipient bed.
F Proper sizing of the flap – shouldn’t be too big
The ideal flap should be even with the adjacent skin’s surface (or even slightly recessed) at the completion of the reconstructive procedure.
Another technique to minimise pin-cushioning is curvature of the flap’s edges.
They should be ‘squared-off’ to reduce pin cusioning
The ideal time to dermabrade a wound for aesthetic refinement is between the fourth and eighth post-operative weeks.
but laser resurfacing more commony used for revision thses days
The cause of flap death associated with the formation of a haematoma is due to hydrostatic compression of the flaps vascular input
It is due to the accumulated blood being an abundant source of iron, which catalyzes the formation of tissue-injuring free radicals
Most surgical complications that follow reconstructive facial surgery involve difficulties in hemostasis
The most abundant blood supply to the skin lies in the dermal vessels
The most abundant blood supply to the skin lies just beneath the dermis in the smaller, dense fat lobules of the subcutaneous tissue
so flaps should be cut down to mid fat and not just into superficial fat
Applying vaseline to skin repairs results in more infections that applying antibiotic ointment
the same rate so vaseline preferred