Introduction
Local pedicled flaps
Free microvascular flaps
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
-Length: 12 cm (4-30 cm) -Width: 5 cm (4-15 cm) -Thickness: 1 cm -Bone: Length: 10 cm (6-14 cm), Width: 1 cm (0,7-1,5 cm) | -18 cm (15-22 cm) | -3 mm (2,5-3,5 mm) | -Cosmetic impairment -Diminishing blood supply of hand -Injury of superficial sensory branch of the radial nerve (neuroma) | -Back, arm on hand table, extended to 90 degrees | -Constant anatomy -Allen test |
Flap raising
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Skin incision preserving fascia at the ulnar border of skin paddle
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Radial to flexor carpi radialis tendon: radial artery taken with fascia
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Dissection of artery and veins proximally; including subcutaneous veins
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Ligating distal artery and veins
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Primary skin closure or split thickness skin graft (in combination with collagen matrix)
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
-Length: 12 cm (5-20 cm) -Width: 6 cm (3-12 cm) -Thickness: 1 cm (5-35 mm) | -6 cm (4-8 cm) | -1,5 mm (1-3 mm) | -Sensory deficit posterolateral arm -Lateral epicondylar pain -Scarring | -Back, arm on hand table, extended to 90 degrees | -Constant anatomy -If necessary skin closure by z-plasty or split thickness skin graft |
Flap raising
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Skin incision at the posterior circumference of the flap, taken with the underlaid fascia
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Dissection to the lateral intermuscular septum and including into the flap: posterior radial collateral artery
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Flap raising at the anterior margin of the flap sacrificing the posterior cutaneous nerve of the forearm and the radial nerve (loop)
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Dividing the intermuscular septum directly at the humerus
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Primary skin closure or split thickness skin graft
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
-Length: 16 cm (4-35 cm) -Width: 8 cm (4-25 cm) -Thickness: 2,5 mm (3-9 mm) -Muscle dimension: 2-25 cm | -12 cm (8-16 cm) | -2,1 mm (2-2,5 mm) | -Cosmetic impairment when closed by split thickness skin graft -functional loss due to fascia elevation | -Supine or lateral decubitus | -Inconstant perforator anatomy, meticulous preparation -when bulkiness is required-harvesting with vastus lateralis (or rectus femoris) |
Flap raising
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Preoperative hand held doppler examination half way between the ASIS and the lateral patella border to evaluate the perforating vessels
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Incision over the rectus femoris muscle 3 cm from the lateral intermuscular septum taken with fascia to include the intermuscular septum
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Identification of the pedicle, if necessary: muscular perforators (including vastus lateralis muscle), circumcision of the skin island
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Dissection of the vascular pedicle to the lateral circumflex femoral artery
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
-Length: 18-20 cm (6-30 cm) -Width: 7-8 cm (4-16 cm) -Thickness: 2 cm (1,5-3 cm) -Bone: Length: 10-14 cm, Width: 2-3 cm, Thickness: 1,5-3 cm | -5-7 cm, extended up to 20 cm | -1,2 mm (0,8-1,4 mm) | -Cosmetic deformity if skin graft is necessary for closure | -Lateral decubitus position | -May provide non-hair-bearing skin |
Flap raising
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Medial incision with fascia overlying the infraspinatus muscle, blunt dissection of the flap from teres minor and infraspinatus muscle to the posterior muscle triangle: circumflex scapular artery
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Vessel loop around circumflex scapular artery and dissecting the pedicle preserving the bone perforators, if bone has to be harvested
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If necessary osteotomy of the scapula bone segment
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
-Length: 26 cm (6-32 cm) -Width: 12 cm (8-16 cm) -Thickness: 2 cm (1,5-3 cm) -Bone: Length: 12-14 cm, Width: 2-3 cm, Thickness: 1-2 cm | -5-7 cm, extended up to 20 cm | -1,2 mm (0,8-1,4 mm) | -Cosmetic deformity if skin graft is necessary for closure | -Lateral decubitus position | -May provide non-hair-bearing skin -Tissue pre-expansion by expander implantation is possible -Combination with the scapular flap |
Flap raising
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Flap elevation from distal to proximal preserving fascia
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Vascular pedicle appears immediately superior to the superior border of teres maior muscle, superior skin incision after exposure of the vessels, dissection proceeds from superior to inferior (vessels are observed at the inferior border of the teres minor muscle
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Continue dissection in the quadrangular space, ligature of branches to the lateral border of the scapula, teres minor muscle, dissection to the thoracodorsal artery
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
-Muscle: Length:35 cm (21-42 cm) -Width: 20 cm (14-26 cm) -Thickness: 1,5 cm (0,5-4,5 cm) -Skin: Length: 18-35 cm, Width: 7-20 cm, Thickness: 2,5 cm (1-5 cm) | -8,5 cm (6,5-12 cm) | -3 mm (2-4 mm) | -Cosmetic deformity if skin graft is necessary for closure -Weakness of shoulder possible -High rate of seroma | -Lateral decubitus position -Prone or supine with 45° lateral tilt | -Skin alone can be harvested as perforator flap (TAP flap) |
Flap raising
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Incision along the mid axillary line
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Identification of the anterior border of the latissimus muscle
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Branch of thoracodorsal artery to the serratus anterior muscle leads to the vascular pedicle of the latissimus muscle
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Circumcision of the skin paddle (fixation of skin paddle to the muscle with stay sutures), elevation of the muscle creating a muscle strip between the cranial pole of the skin paddle and the vascular pedicle
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Dividing side branches of the thoracodorsal vessels (use for the TAP flap without any muscle)
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
Muscle: -Length: 25 cm (23-29 cm) -Width: 6 cm (4-8 cm) -Thickness: 1,5 cm (0,7-2 cm) Skin: -Length: 13 cm (10-20 cm) -Width: 25 cm (20-20 cm) -Thickness: 2,5 cm (1-6 cm) | -7 cm (6-8 cm) | -3,5 mm (3-5 mm) | -Herniation | -Supine position | -Supercharging with superficial epigastric artery or vein -Mesh implantation to restore abdominal strength at donor site |
Flap raising
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Skin incision in the lower abdominal wall, dissection of the subcutaneous fat preserving superficial inferior epigastric artery and vein (in case of performing a SIEA flap), cranial skin incision
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Dissection from the lateral to the medial aspect taken care of the perforators in the lateral and medial line on both sides
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Pick the best perforator, temporarily clip out the other perforators and watch the flap's circulation
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Selection of the best perforator (sometimes 2-4 perforators are necessary), incision of the fascia longitudinally in direction of the pubis, intramuscular dissection of the perforator, save segmental intercostals nerves, rectus muscle can be taken with the perforators (TRAM)
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Deep inferior epigastric artery is taken as long as necessary for the pedicle length
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After flap transplantation repair of the anterior sheath of the rectus with a braided resorbable suture (mesh at big fascia defects which cannot be closed without tension), adherence zone undermining up to the xiphoid process, closure of abdomen in layers after exteriorizing the umbilicus
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
Skin: -Length: 12 cm (10-32 cm) -Width: 6 cm (4-14 cm) Muscle: (lateral hemi-soleus): -Length: 16 cm (18-30 cm) -Width: 8 cm (6-15 cm) Bone: -Length: 16 cm (6-26 cm) -Thickness: 2 cm (1-3 cm) | - Up to 10 cm, depending on bone length and location of donor site (proximal or distal) | -1,5 mm (1-2,5 mm) | -Cosmetic deformity -Limitations and discomfort in ankle function -Peroneal nerve palsy | -Supine position, knee flexed 90°, pelvic girdle internally rotated -Prone position | -Preoperative vascular study could be useful (angiogram) |
Flap raising
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Skin incision over peroneus muscle keeping 2 cm to the posterior intermuscular septum
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Visualizing of the perforators
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Dissection of the posterior intermuscular septum, soleus muscle and flexor hallucis longus muscle proximal to the skin paddle, identification of peroneal vessels (vessel loop)
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Circumcision of the skin paddle, elevation bone, skin paddle and posterior intermuscular septum
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Distal osteotomy of fibula (6-8 cm distance to the ankle), proximal osteotomy of fibula (5 cm distance to fibula head)
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Anterior septum incised between the osteotomies, periosteum remains untouched; harvesting of bone and distal ligation of fibular artery and vein after dislocation of fibula and incising interosseous membrane
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
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-Length: 7-25 cm -Bowel lumen diameter: 3-5 cm | -5 cm (4-6 cm) | -2 mm (1,5-2,5 mm) | -Intestinal leak or stricture -Peritonitis -Ileus -Adhesive bowel obstruction | -Supine position | -Decrease ischemia time -Mal odeur and secretion |
Flap raising
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Midline laparotomy, ligament of Treitz is identified in the left upper quadrant, small bowel is followed 40-60 cm below ligament of Treitz
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Vascular arcades identified by transillumination, jejunal segment longer than the defect has to be selected, marking the segment's proximal portion
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Complete division of mesentery, vasa recta are clamped
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Bowel clamping with atraumatic clamps, isolation of the jejunal segment, harvesting of the bowel using intestinal stapling
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Free dissection of the jejunal artery and vein
Flap size | Pedicle length | Pedicle diameter | Donor site morbidity | Patient's position | Special considerations |
---|---|---|---|---|---|
Skin: -Length: 15 cm (10-20)cm -Width: 10 cm (5-15 cm) Bone: -Lenght: 4 cm (3-8 cm) -Width: 2 cm (1-3 cm) | -2 cm (1,5-3 cm) | -1,5 mm (0,8-2 mm) | -Subcutaneous seroma -Sensory loss lateral thigh region -Lymphedema of the lower extremity -Abdominal wall hernia | -Supine position |
Flap raising
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Incision 2 cm superior to the connection of pubic tubercle and anterior superior iliac spine, starting lateral from femoral artery
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Ligature of the superficial epigastric vessels
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Incision of the inguinal ligament parallel to its fibers, transsection of the internal oblique muscle, deep circumflex iliac artery is palpated in the groove formed by transverses and iliacus muscle, blunt dissection (vessel loop)
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Transsection of the muscles from the iliac crest
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Distal osteotomy of the iliac crest, ligation of the vascular pedicle at the distal osteotomy, proximal osteotomy, flap harvesting
Discussion
1. Soft tissue defects
2. Bony defects
3. Flap choice
Soft tissue defect
| |
---|---|
Floor of mouth | - Radial forearm flap |
- Lateral arm flap | |
- TAP | |
- Alt | |
Tongue | - ALT |
- Radial forearm flap | |
- Lateral arm flap | |
- TAP | |
Palate | - Radial forearm flap |
- Lateral arm flap | |
- TAP | |
- ALT | |
Bone Defect
| |
Mandible/Palate | - Fibula osteocutaneous flap (up to 25 cm bone) |
- Iliac crest flap (14-16 cm bone) | |
- Radial forearm osteocutaneous flap (30% radius circumference) | |
- Scapular osteocutaneous flap (up to 10 cm bone) | |
Hypopharynx
| |
Partial defect | - Radial forearm flap |
- Lateral arm Flap | |
- TAP | |
- ALT (strongly recommended when external skin coverage is necessary- wrap flap) | |
- Latissimus dorsi muscle | |
Circumferential defect | - ALT (wrap to build a tube) |
- Jejunum | |
- Latissimus dorsi muscle | |
- TRAM/DIEP | |
Defects creating dead space | - Rectus abdominis muscle |
- ALT with vastus lateralis |