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 Free fibula • 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
QUESTIONS 1 of 13 1 2 3 4 5 6 7 8 9 10 11 12 13 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A Type & Select Correct Answer 1 Moberg volar advancement flap 75% (3427/4553) 2 Foucher first dorsal metacarpal artery flap 7% (336/4553) 3 Littler neurovascular island flap 7% (327/4553) 4 Free great toe pulp transfer 5% (236/4553) 5 Holevich first dorsal metacarpal artery flap 4% (190/4553) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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: A B Type & Select Correct Answer 1 iliac crest bone grafting 4% (200/5439) 2 ring metacarpal transposition 17% (917/5439) 3 second toe transfer 3% (175/5439) 4 index metacarpal transposition 52% (2838/5439) 5 suture of deep transverse intermetacarpal ligaments 23% (1252/5439) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Type & Select Correct Answer 1 Superior and inferior genicular arteries 4% (101/2364) 2 Anterior tibial artery 2% (38/2364) 3 Posterior tibal artery 27% (643/2364) 4 Sural artery 56% (1327/2364) 5 Saphenous artery 10% (240/2364) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ05.3) The sural artery provides the vascular supply to which musculocutaneous flap? QID: 40 Type & Select Correct Answer 1 soleus 16% (295/1836) 2 gastrocnemius 68% (1248/1836) 3 latissimus dorsi 0% (7/1836) 4 tibialis anterior 0% (8/1836) 5 peroneus longus 15% (268/1836) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (0) Podcasts (1) Hand | Extremity Flap Reconstruction Hand - Extremity Flap Reconstruction Listen Now 13:11 min 10/16/2019 200 plays 5.0 (1)