Flap course Day1 -The lateral arm flap

Flap course Day1

Omdurman teaching hospital

Upper limb & anterior trunk

 The lateral arm flap

Skin, fat and fascia. A portion of the humerus can be used to make this an osteocutaneous flap.
Innervation: posterior cutaneous nerve of the forearm.
Blood supply: posterior radial collateral artery.
Artery: Small caliber, often less than 1.5 mm.
Vein(s): The venae are typically paired and the dominant is similar in size to the artery..
Pedicle length: Short. It does not reach proximal to the proximal edge of the flap unless the flap is designed very distally.

Marking the flap outline. The axis of the flap lies over the lateral intermuscular septum. The more distal the flap is made, the thinner the skin. It can be based very distally, as a lateral forearm flap.

 The axis of the humerus is marked from the deltoid insertion to the lateral epicondyle. The lateral arm flap is designed with its longitudinal axis on this marking. The skin of the arm is pinched to judge the maximum with of the flap is a large paddle is needed. Usually, four to five centimeters are the widest a flap can be. The flap can be quite long however, from the deltoid insertion to distal to the lateral epicondyle. Alternatively, a lateral forearm flap can be marked using the distal think skin around the lateral epicondyle, as shown in the diagram.

 

The flap is supplied by the radial collateral artery. It originates from the brachial artery and wraps posteriorly around the humerus, descending on the lateral aspect of the humerus and then branching into an anterior and posterior segments. The posterior branch supplies the lateral arm and lateral forearm flaps.

Anatomy of the lateral arm flap. The radial nerve travels across the proximal base of the flap. It sends a sensory branch with the pedicle of the flap that supplies the distal lateral arm.

 

Posterior flap elevation is performed first. The flap is elevated deep to the muscular fascia. The fascial is peeled anteriorly until the septum is encountered.

The anterior aspect of the flap is then elevated until the septum, and then the flap can be raised from distal to proximal. The septal attachment to the humerus is released as the flap is elevated.

The lateral arm flap has long been the workhorse of microvascular surgeons in the cover of small and moderate-sized defects, especially in the head, neck, and the extremities. Its versatility, however, has always been restricted by its small skin paddle

The lateral Arm Osteocutaneous Flap The lateral arm flap can also be harvested as an osteocutaneous flap. The wedge of bone with periosteal cuff is harvested under the septum and septal pedicle. A narrow portion of bone approximately 1 to 1.5 centimeters wide can be harvested.

Flap course Day1 - Deltopectoral flap

Flap course Day1

Omdurman teaching hospital

Upper limb & anterior trunk

Deltopectoral flap

Deltopectoral Flap, was developed by Bakamjian as an axial-pattern skin flap, and its blood supply depends on perforating branches from the internal mammary artery. The main blood supply of the deltopectoral flap is provided by the second and third intercostal arteries. Deltoid portion is random.

 Indications

1. Carotid coverage after pharyngocutaneous fistula formation
2. for cervical and neck reconstructions
3. Hypopharyngeal reconstruction
4. Sternum reconstructions
5. Oral cavity & floor of the mouth
6. Paired Deltopectoral Flap was prescribed for lower lip reconstruction. 

Contraindications

1. For most cases, other flaps are a better choice.
2. Prior chest wall surgery or injury (eg, radical mastectomy, pacemaker)
3. Prior cardiac surgery with use of internal mammary artery for bypass

Consent Inclusions

1. Chest wall and neck scar
2. Possible need for skin grafting to shoulder
3. Bleeding, infection
4. Flap failure (distal necrosis possible)

 

To prevent injury to the perforators, flap elevation should remain lateral to a vertical line approximately 2 cm from the sternal border. The vessels provide an axial blood supply to the proximal two thirds of the flap; the remaining third is random in distribution. The elevation of this flap below the pectoralis fascia protects the subdermal network of vasculature for the random distribution. A delay technique may be valuable.

Interesting  Classification of sternal wounds: Pairolero and Arnold have based their classification of sternal wounds on timing of presentation of infection; this classification divides wounds into 3 categories.This classification system does not indicate the type of reconstruction necessary for management of each type of sternal wound. Type II and III wounds are typically referred to plastic surgeons for reconstruction.

• Type I: Type I wounds occur in the first few days postoperatively, contain early wound separation with or without sternal instability, and are characterized by serosanguineous drainage without cellulitis, osteomyelitis, or costochondritis.
• Type II: Type II wounds occur within the first few weeks and are characterized by drainage, cellulitis, mediastinal suppuration, and positive cultures. Type II wounds are characterized by fulminant mediastinitis.
• Type III: Type III wounds occur months to years after surgery and are characterized by the presence of chronic draining sinus tracts, localized cellulites, osteomyelitis, or retained foreign bodies. Mediastinitis is a rare complication of type III wounds.

Flap course Day1 Omdurman teaching hospital Upper limb & anterior trunk - revision

Flap course Day1

Omdurman teaching hospital

Upper limb & anterior trunk - revision

((Don't tell me the moon is shining; show me the glint of light on broken glass))

(Sense is the measure of the possible; it is composed of experience and prevision; it is calculation applied to life)

Thank to Mr. Osama Murtada & Mr. Ali

Axial Flap
Based upon a named artery. It is survival depends upon the artery not the width of the flap.

Random Flap
Has random unnamed vessels supplying it. Survival is directly proportional to the width of the flap.

Cormack & Lamberty classification:

They classified fasciocutaneous
flaps into three major types, differentiated by the

origin of the circulation to their “fascial plexus. ”  Type A

flap had multiple “fascial feeders ”  or perforators that did
not require specific identification, ( random
skin flap). Type B flaps contained a large, solitary septocutaneous
perforator. Type C flap relied on multiple and usually
Very small segmental septocutaneous branches, so that
elevation of these flaps almost always necessitated inclusion
of the source vessel with the flap in order to maintain their
complete integrity.

Survival length of the flap maybe increased by delaying the flap.

To delay a flap, elevate as a bipedical flap and return it to the flap’s bed. Two weeks later, elevate as a unipedical flap.

Flap course day 1 Omdurman teaching hospital Radial artery forearm flap

Flap course day 1
Omdurman teaching hospital
Radial artery forearm flap

It can be used as an island-skin flap, a free flap or as a compound forearm flap including vascularised nerve, bone or tendons.

The Radial Forearm Flap

Skin and fascia: optional tendon and bone

Innervation: No.

Blood supply: Radial artery and perforators from the radial artery.

Artery: Large caliber artery.

Vein(s): The venae of the radial artery can be small. The subcutaneous venous system or cephalic vein can be used for drainage, making for a larger caliber vessel.

Pedicle length: Can be dissected up to the takeoff from the brachial artery just distal to the antecubital fossa.

The course of the radial pulse is determine and the flap is outlined over the radial artery. The position of the flap can be pushed radially, ulnarly, or more proximally depending on the needs of the recipient area. Consideration should be given to the location of the cephalic vein if that is to be used for venous drainage.

The success of the RRFF flap depends on cutaneous perforators and the septocutaneous perforators.

Radial Forearm Osteocutaneous Flap: a segment of the radius can be harvested with the flap, in congruity with a portion of FPL muscle. It must be a unicortical block of volar radius, and no wider than 1.5 centimeters. The radius is prone to fracture is a segment of radius is harvested.

The reverse radial forearm fascial (RRFF) flap is widely used in the hand coverage in distal soft-tissue reconstruction . The traditional RRFF flap incorporates the radial artery from the forearm and is perfused by retrograde flow through the palmar arch.

 However, to produce this flap, a major artery to the hand must be sacrificed, which compromises the viability of the hand and may lead to ischemia. Some authors have recommended reconstructing the radial artery with a vein graft in a RRFF flap

Author: Terance (Terry) Ted Tsue, MD; Chief Editor: Arlen D Meyers, MD, MBA

Flap course day 1 Omdurman teaching hospital Foucher's First Dorsal Metacarpal Artery Flap

Flap course day 1

Omdurman teaching hospital

 Foucher's First Dorsal Metacarpal Artery Flap for Thumb Reconstruction