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Flashcards in Reconstruction Deck (57)
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1

Vascular supply for each regional flap:

  1. Pectoralis Major
  2. Deltopectoral
  3. Superior based SCM
  4. Inferior based platysma

  1. PM - Thoracoacromial
  2. DP - Inferior mammary perforators
  3. Sup SCM - Occipital
  4. Inf Platysma - Occipital

2

Amount in cc of each cancellous harvest site

  1. Calvarium
  2. Posterior illeum
  3. Anterior illieum
  4. Tibial plateu

  1. Calvarium - trick question. No cancellous bone
  2. Post illeum - 100cc
  3. Ant illeum - 40cc
  4. Tib plateu - 15cc

3

Sequence of wound/bone healing: Inflammatory

  1. Cell types, what is released and why
  2. If stem cells are transplanted, do they release growth factors?

 

1. Platelets

  • TGF-b (transforming) - CT cell differentiation
  • PDGF (platelet derived) - cellular proliferation
  • VEGF (vascular endothelial) - angiogenesis
  • EGF (epidermal)
  • FGF (fibroblast)

 

2. Stem cells do not release growth factors. Only there to be acted upon

4

Sequence of wound/bone healing: Proliferative

  1. Cell type, what is released and why?
  2. What slows down angiogenesis and why?

1. Proliferation: Fibroblasts

  • EGF/VEGF - angiogenesis
  • FGF - type III collagen (unorganized) for provisional matrix

2. Flattening of O2 tension curve, aka graft is no longer hypoxic. Minimized granulation tissue

5

Sequence of wound/bone healing: Remodeling

1. What process increases wound strength?

1. Organization of and conversion of type III collagen to type I

6

Collagen formation by fibroblasts requires O2 tension of at least

40mm hg

7

  1. Infection affects healing by:
  2. Edema affects healing by:

1. Infection

  • Increased collagenase
  • Decreased O2, <30mm Hg
  • Prolongs inflammatory phase beyond 4-6 days

2. Edema

  • Compromised perfussion

8

  1. Diabetes
  2. Steroids
  3. Tobacco
  4. Cutis Laxa
  5. Ehlers-Danlos
  6. Nutrition

  1. Diabetes: vessel injury, decreased O2 and nutrients
  2. Steroids: Inhibit neutrophils (clean up wound, bacteria) and macrophages (growth factor factor)
  3. Tobacco: CO decrease O2 tension, perfussion (vasoconstriction)
  4. Cutis Laxa: Aquired or genetic, elastin defective
  5. Ehlers-Danlos: Defective collagen metabolism
  6. Nutrition: Low protein prolongs inflammation

9

Hypertrophic scar vs keloid

Tissue consistency

Location

Histology

long term prognosis

Hypertrophic scar (HS) vs keloid

Tissue consistency

  • Keloid is rubbery.
  • HS red, pruritic, firm

Location

  • Keloid: sternum, mandible, deltoid
  • HS anywhere

Histology

  • Keloid: thick collagen fibers, hyanlinized collagen bundles
  • HS: thin collagen fibers, no hyanlinization

long term prognosis

  • Keloid: grows for years
  • HS: Regresses over time

10

Keloid / Hypertrophic Scar tx

3 steps

Keloid / Hypertrophic Scar tx

3 steps

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

11

Random pattern flap length to width ratio

3:1 length to width

12

Rotation flap

  • Ideal arc angle
  • Arch length relative to diameter defect

30 degrees arch

4:1

13

  • Rhomboid flap angles
  • Z plasty angles effect on length increase
    • 30, 45, 60 degrees

  • Rhomboid flap angles = 60 and 120 degrees
  • Z plasty angles effect on length increase
    • 30 degrees increases length 25%
    • 45 degrees increasing length 50%
    • 60 degrees increasing legth 75%

14

Scar revision excision design

  • <2cm
  • 2-5cm
  • >5cm

Scar revision excision design

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

15

Temporoparietal flap

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages

Temporoparietal flap

Pedicle

  • STA

Areas of reconstruction

  • Orbit, maxilla, auricle

Other advantages

  • Pliable
  • Hair bearing skin paddle
  • Minimal donor site morbidity

Disadvantages

  • Superficial plane dissection difficult

16

Temporalis Flap

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages

Pedicle

  • Deep and middle temporal arteries

Areas of reconstruction

  • Oral defect obliteration
  • Cranial base
  • TMJ gap arthroplasty
  • Facial reanimation

Other advantages

  • Good bulk for intraoral
  • Easy dissection

Disadvantages

  • Temporal hollowing. Can minimize with facial implant or repositioning posterior flap into anterior location

17

Paramedian flap

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages

Pedicle

  • Supratrochlear a. 1.7-2.2 cm from midline

Areas of reconstruction

  • large nasal defect

Other advantages

  • good tissue match
  • min donor site morbidity

Disadvantages

  • pedicle division at week 3

18

Nasialabial flap

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages

Pedicle

  • Angular a. or random pattern, inferior or superior based

Areas of reconstruction

  • lower 2/3 nose, upper lip, small/medium palate defects

Other advantages

  • None

Disadvantages

  • nasofacial sulcus blunted, ectroption, scleral show

19

Facial Artery MyoMucosal flap (FAMM)

  • Pedicle
  • Areas of reconstruction
  • Other advantages
  • Disadvantages

Pedicle

  • branch of facial a.

Areas of reconstruction

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

Other advantages

  • Good tissue match

Disadvantages

  • Trismus

20

Tongue Flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

Pedicle

  • Random or dorsolingual branch of lingual

Areas of reconstruction

  • Retromolar trigone
  • Palate
  • Buccal

Other advantages

  • 3-10mm thickness

Disadvantages

  • pedicle division 3 weeks

21

Palatal island flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

Pedicle

  • Greater Palatine

Areas of reconstruction

  • Palate, retromolar

Other advantages

  • Minimal donor site morbidity
  • Can harvest entire palate with single pedicle
  • Can rotate 180deg

Disadvantages

  • not mentioned

22

Submental Island Flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

Pedicle

  • Submental artery

Areas of reconstruction

  • FOM, retromolar, tongue, soft palate

Other advantages

  • Good tissue match
  • Min morbidity

Disadvantages

  • Can't use if neck dissection indicated

23

Cervicofascial flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

Pedicle

  • Random

Areas of reconstruction

  • Resurface neck/face

Other advantages

  • Easy, reliable

Disadvantages

  • limited volume
  • May not work s/p radiation and/or neck dissection

24

Platsyma flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantages

Pedicle

  • Has muscle perforators, basically random pattern

Areas of reconstruction

  • FOM, buccal, lower face

Other advantages

  • Thin, pliable
  • Min morbidity

Disadvantages

  • Limited arch
  • Difficult to harvest
  • May not work s/p radiation and/or neck dissection

25

SCM flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

SCM flap

Pedicle

  • Occipital a.

Areas of reconstruction

  • Superior based most useful: Lateral/lower face, oral defects, rebulk s/p parotidectomy

Other advantages

  • Leaving one of the heads maintains great vessel coverage

Disadvantages

  • Limited arch
  • May not be suitable in oncology patient

26

Trapezius Flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

Pedicle

  • Dorsal scapular artery

Areas of reconstruction

  • Lateral neck
  • Skull cutaneous

Other advantages

  • Long pliable pedicle
  • Hairless skin

Disadvantage

  • Shoulder weaker
  • Patient repositioning

27

Supraclavicular flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

Pedicle

  • Supraclavicular a.

Areas of reconstruction

  • Lower face cutaneous
  • Pharyngopharynx
  • Oral, lip

Other advantages

  • Easy harvest, thin pedicle, min morbidity

Disadvantage

  • Distal flap necrosis
  • 7% supraclavicular a. have anatomic variation

28

Pectoralis Major Myocutaneous Flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

Pedicle

  • Thoracoacromial
  • Long thoracic

Areas of reconstruction

  • Large head and neck

Other advantages

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

Disadvantage

29

Deltopectoral flap

Pedicle

Areas of reconstruction

Other advantages

Disadvantage

Pedicle

  • Internal mammary a. perforators

Areas of reconstruction

  • Last option for H&N recon

Other advantages

  • Reliable and easy harvest
  • Lots of bulk

Disadvantage

  • Requires 2nd surgery 3-6 weeks
  • May not work if previous Pectoralis major fla[

30

Which vessel diameter ratio discrepancy requires end to side anastamosis

3:1