Updated: 6/30/2021

Extremity Flap Reconstruction

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  • Introduction
    • Definition of flap
      • unit of tissue transferred from a donor site to a recipient site while maintaining its own vascular supply
    • Definition of pedicle
      • vascular portion of the transferred tissue
      • usually contains one artery and one or more veins
    • Indications for flap coverage
      • soft tissue injury with exposed
        • bone
        • tendons
        • cartilage
        • orthopaedic implants
  • Classification
    • Blood supply classification
      • axial pattern local flaps
        • contain single arteriovenous pedicle (a "named vessel")
        • indications
          • primary/secondary closure not advisable and
          • area cannot support STSG or FTSG and
          • length-width ratio needed > 2:1
      • random pattern flaps
        • supported by numerous microcirculation with no single arteriovenous pedicle
        • indications
          • primary/secondary closure not advisable andarea cannot support STSG or FTSG and
          • length-width ratio needed < 2:1
      • venous flap
        • uses veins as inflow and outflow of arterial blood
    • Tissue type classification
      • cutaneous
        • include skin and subcutaneous tissue
      • fascial flap
        • include fascia with no overlying skin
        • example
          • temporoparietal flap
      • muscle flaps
        • usually requires additional transfer of a skin graft to cover muscle
        • alternatively, muscle can be transposed as part of a musculocutaneous flap (composite flap)
        • if motor nerve is not preserved the flap will atrophy to 50% of its original size
      • bone flaps
        • free fibula
          • based on peroneal artery pedicle
          • useful for diaphyseal reconstruction
        • free iliac crest
          • based on deep circumflex iliac vessels
          • useful for metaphyseal reconstuction
      • composite flaps
        • consists of multiple tissue types
          • examples
            • radial forearm flap (fasciocutaneous)
    • Mobilization type classification
      • local flap
        • tissue transferred from an area adjacent to defect
      • distal random pattern flap
        • transfer of tissue to a noncontiguous anatomic site
        • indications
          • surrounding tissue will not support a local flap
          • length-width ratio needed < 2:1
      • distal axial pattern flap
        • indications
          • surrounding tissue will not support a local flap
          • length-width ratio needed > 2:1
      • free tissue transfer
        • indicatoins
          • local or distant tissue not sufficient for distal axial and random pattern flaps
  • Techniques
      • Flap Techniques
      • Fingertips & Hand
      • See Finger amputation and Flaps
      • Arm Flaps
      • Lateral arm flap
      • Lateral arm defects
      • Blood supply by posterior radial collateral artery (branch of profunda brachii)
      • Latissimus Dorsi myocutaneous flap
      • For large defects around the elbow
      • Blood supply provided by perforators off of the thoracodorsal artery
      • Leg Muscle Flaps
      • Medial Gastroc flap
      • Used for medial and midline defects over proximal third of tibia
      • Pedicle supplied by medial sural artery
      • Lateral Gastroc flap 
      • Used for lateral defects over the proximal third of tibia
      • Pedicle supplied by lateral sural artery
      • Soleus
      • Used for wounds over the middle third of tibia
      • Supplied by branches of the popliteal artery trunk, the posterior tibial artery (medial), and the peroneal artery (proximal)
      • Gracilis
      • Most common donor for free muscle transfer
      • Nerve is anterior division of obturator nerve
      • Artery is branch of medial femoral circumflex artery
      • Free flap
      • Used for wound coverage over distal third of tibia, or in the middle and proximal leg when soleus and gastrocnemius are damaged
      • Groin flap
      • Axial flap that has been a mainstay of providing soft-tissue coverage of the upper extremity
      • Based on the superficial circumflex iliac artery
      • Risk of injury to lateral femoral cutaneous nerve
      • Bone Flaps
      • Free iliac crest
      • Based on deep circumflex iliac vessels
      • Useful for metaphyseal reconstruction
      • Useful for diaphyseal reconstruction
      • Based on peroneal artery pedicle
      • Vascular bone graft from radius
      • Gaining popularity for osteonecrosis of scaphoid fractures
      • Harvested from dorsal aspect of distal radius
      • Based on 1-2 intercompartmental superretinacular artery (branch of radial artery)
      • Index metacarpal transposition
      • Indicated to reduce the space left between the index and ring finger following middle ray amputation.
      •  An alternative technique is deep transverse intermetacarpal ligament reconstruction.
      • Little metacarpal transposition
      • Indicated to reduce the space left between the middle and little finger following ring ray amputation.
  • Technique
    • Ladder of reconstruction
      • in order of increasing complexity
        • primary closure
        • secondary closure
          • healing by secondary intention
        • skin graft
        • local flap
        • regional flap
        • free tissue transfer
  • Complications
    • Flap Failure
      • inadequate arterial flow
        • treatment
          • immediate return to operating room
      • inadequate venous outflow
        • treatment
          • loosen dressings, removal of selected sutures
          • return to operating room if not relieved by above measure
    • Donor site morbidity
      • may be cosmetically unacceptable
      • pain related to grafting
      • seroma
        • treatment
          • aspiration
          • excision if encapsulated
    • Nonunion for vascularized bone transfer
      • incidence
        • may be as high as 32% if no additional bone graft is used
  • Prognosis
    • Free tissue transfer within 7 days for severe trauma in the upper extremity has been shown to decrease complication rates

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(OBQ18.45) A 32-year-old man sustains a traumatic amputation of his right thumb (Figure A). He undergoes the soft-tissue coverage procedure shown in Figure B. What artery does this flap rely on, and which nerve is at risk during this procedure?

QID: 212941
FIGURES:
1

Medial femoral circumflex artery; femoral branches of genitofemoral nerve

2%

(29/1708)

2

Medial femoral circumflex artery; lateral femoral cutaneous nerve

5%

(88/1708)

3

Superficial circumflex iliac artery; femoral branches of genitofemoral nerve

12%

(209/1708)

4

Superficial circumflex iliac artery; lateral femoral cutaneous nerve

63%

(1082/1708)

5

Superficial circumflex iliac artery; ilioinguinal nerve

17%

(282/1708)

L 3 A

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(SBQ16HK.3) A 67-year-old man presents with aseptic loosening of a primary total knee arthroplasty (TKA). He has a history of a prior tibial plateau fracture which was treated with open reduction and internal fixation via an anterolateral approach and subsequently was converted to a primary posterior-stabilized TKA utilizing a standard midline, medial parapatellar approach. He is scheduled for revision TKA and the more medial incision is used, leaving a small lateral skin bridge. He presents a few weeks later with wound necrosis and after multiple rounds of debridement and negative pressure wound therapy, he is left with the lateral defect seen in Figure A. Which of the following surgical options would best address his defect?

QID: 211141
FIGURES:
1

Gastrocnemius flap

83%

(1157/1391)

2

Latissimus dorsi free flap

10%

(141/1391)

3

Gracilis free flap

4%

(50/1391)

4

Split-thickness skin graft

0%

(3/1391)

5

Full-thickness skin graft

2%

(27/1391)

L 2 A

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(OBQ13.240) A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness?

QID: 4875
FIGURES:
1

Moberg volar advancement flap

75%

(3453/4591)

2

Foucher first dorsal metacarpal artery flap

7%

(341/4591)

3

Littler neurovascular island flap

7%

(330/4591)

4

Free great toe pulp transfer

5%

(238/4591)

5

Holevich first dorsal metacarpal artery flap

4%

(192/4591)

L 2 B

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(OBQ12.158) A 58-year-old man presents with right middle finger swelling. Radiographs and an MRI of his hand are shown in Figure A and B. Tissue biopsy and staging investigations are performed. The tumor is then resected en bloc with the middle metacarpal, which is amputated 1.5cm from the carpometacarpal joint. The attached deep transverse intermetacarpal ligaments are sacrificed. To prevent scissoring of the remaining digits and small objects falling through the gap between index and ring fingers, which of the following procedures should be performed?

QID: 4518
FIGURES:
1

iliac crest bone grafting

4%

(201/5485)

2

ring metacarpal transposition

17%

(934/5485)

3

second toe transfer

3%

(175/5485)

4

index metacarpal transposition

52%

(2859/5485)

5

suture of deep transverse intermetacarpal ligaments

23%

(1259/5485)

L 4 B

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(OBQ06.1) A 32-year-old male sustains a type IIIb open proximal third tibia fracture. Four days after intramedullary nailing of the tibia, the wound is clean and ready for coverage with a medial gastrocnemius rotational flap. What is the dominant arterial blood supply to this flap?

QID: 12
1

Superior and inferior genicular arteries

4%

(106/2468)

2

Anterior tibial artery

2%

(38/2468)

3

Posterior tibal artery

27%

(657/2468)

4

Sural artery

57%

(1407/2468)

5

Saphenous artery

10%

(245/2468)

L 4 A

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(OBQ05.3) The sural artery provides the vascular supply to which musculocutaneous flap?

QID: 40
1

soleus

16%

(295/1845)

2

gastrocnemius

68%

(1257/1845)

3

latissimus dorsi

0%

(7/1845)

4

tibialis anterior

0%

(8/1845)

5

peroneus longus

15%

(268/1845)

L 3 A

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