All right, so my goals for the session, understand the difference between graphs and flaps, which can be confusing because of the transplant surgeons that have screwed everything up with their terminology. Understand the reconstructive ladder versus elevator. Microsurgeons tend to think of it as an elevator, pick the floor you want, but when we're talking about the exam, they may want you to go step by step by step from simplest to most complex using the actual ladder. And then understand the pertinent anatomy of some workhorse or go-to flaps. And so the end of your handout, I put the pertinent anatomy and a bunch of questions about frequently tested and frequently clinically used flaps that you guys can kind of go through on your own, because I doubt we'll have time to do it here because there's so much in there. I'll also tell you in advance, there's some stuff on finger flaps that I think Jonathan Teeting is going to cover tomorrow, and so I don't want to be redundant. So you have questions and information there you can study, but we're going to blaze through some of that. And then there are a lot of questions that I put in there. I essentially put everything I could find from the old exams in there so you guys have access to it, but we may not go through all of those questions just for time. So, past self-assessment exams, 2013, 14 questions. 2014, 20, six questions. This was a sexy session back then. And Z-plasties, groin flaps, first webs, skin grafts, skin substitutes, forearm flaps, free flaps, lots of things. So, when we're talking about soft tissue reconstruction, we think about the location of the defect, if it's fingertip, joints, fingers, hand, wrist, forearm, elbow, upper arm. And we think about the structures exposed. You've just got fat there, if it's tendon with or without peritonon, bone with or without periosteum, nerve. You can get a skin graft to take on a nerve, but be kind to your patients. Put a flap over it because that's just not that fun. Blood vessels and open joints or cartilage which usually needs a flap, in my opinion. And then we can think about the types of healing with these coverage. So, you've got secondary healing or granulation which is great for fingertip injuries. Skin grafts which can be split thickness or full thickness. Adjacent tissue rearrangements. And now these are the things like Z-plasties and a random pattern of flaps like rhomboid flaps, Lindbergh flaps, banner flaps. Local flaps, these are things that have a defined blood supply, so a named blood vessel. So, a kite flap or a banner or a flag flap which is the FDMA flap, right? That's got a named blood vessel, so that qualifies as this. Regional flaps, these are our forearm flaps. That's a great example of these, like radial forearm, ulnar forearm flap. Then we've got distant pedicled flaps. These are things like groin flaps that we just heard about from Warren. And then free flaps like the ALT which is one of my go-to flaps. Then we've got these other methods out there. Skin substitutes like Integra or Alloderm. Then we've got tissue expanders that we can use. Then we've got tissue creep we can recruit with devices like rubber bands or the Dermaclose. And so, secondary healing and granulation is great for fingertips, 10 to 15 millimeters we say, but I bet all of us have gotten much bigger defects to heal on fingertips than this with granulation. And it's good for superficial injuries without exposed critical structures, but they need to be away from joints. So, flexion creases, extensor creases, those are no-nos. And the patient has to understand they may have a scar they don't like. Although on fingertips, they tend to look really good. Skin grafts, we have full thickness and split thickness. What's the difference? Well, full thickness has a lot of primary contraction, meaning as soon as you take it, it's gonna shrink up to about half the size it was when you cut it out. But it's not gonna shrink really anymore once you put it down on the wound because it's got all these elastin fibers. That's why it contracts as soon as you cut it free from the tissue you've taken it out of. Split thickness skin grafts don't have much primary contracture because you don't have all that dermis with elastin fibers, but you will get secondary contracture where this thing shrinks over time as it heals, and I'm sure you all have seen that. Skin grafts survive by adherence and then imbibition and then inosculation until they revascularize. They require a vascularized wound bed. And the things that will kill these are hematoma and hematoma and hematoma, and then some shear, friction, infection, and then hematoma. And what's the difference between a graft and a flap? You guys probably all know this, but a graft does not bring its own blood supply. A flap does. So a graft requires a wound bed to revascularize it where a flap has a vessel that feeds it. And the reason that we're confused is because transplant surgeons call their kidneys and hearts and livers grafts when in fact they are allo flaps, but they won't listen to me when I tell them that. Skin graft survival, again, we talked about this, but they hit on this in these questions. Immediate is adherence, and then first day or two is plasmatic imbibition. Two days to five days, inosculation, and after five days, they revascularize. So here's a perfect question for that. Which of the following factors is the most common cause of autologous skin graft failure? And it was the first three causes, right? Hematoma, hematoma, hematoma. Skin substitutes, Integra is the prototypical one they'll ask about, a bilaminate skin substitute, a silicone layer for the epithelium. The dermis is a matrix made of bovine collagen and glycosaminic glycans from multiple sources. And it requires skin grafting typically, although you can use small pieces of Integra on the fingers and they'll epithelialize on their own without any problem if you just leave them alone and they don't get infected. But typically we'll let these sit for three weeks. That's kind of the standard amount of time, but you can leave these for as long as you need to, as long as they don't get infected. But they do require split thickness skin graft typically for larger surface areas like you just saw for that tumor, squamous cell resected with tendons. So 70 year old man, defect on the dorsum of his hand after resection of a Merkel cell and his radial artery was previously harvested for a cabbage. So he's not a forearm flat candidate, right? He doesn't have an intact arch. So what do you want to do for that exposed tendon area? Do you want to vac it? Do you want to split thickness skin graft naked tendons? No, are you going to do wet to dries over naked tendons? Not really. We could put on a dermal substitute followed by split thickness skin graft. That's the Integra or full thickness skin graft. Again, naked tendons aren't going to take skin graft. So we're going to put the Integra down and skin graft it later. Okay, what factors associated with the highest risk of graft failure while treating a patient with extensive burns using one of these skin substitutes? Well, they're not alive. And so they're not going to die from shear or things like this, but they can get infected. And so contamination of the wound bed is what will cause the infection there. And the first step in skin graft survival that we all know now is adherence. We're going to push along here. Adjacent tissue rearrangements. These are random patterned flaps that don't have a named blood vessel. Z-plasties, W-plasties, rhomboid flaps. So here's a free flap that I did. And then a well-meaning hand therapist puts a splint over a plate where the patient can't feel it. Now there's a hole in the middle of my free flap. How do you cover a hole in your flap? You do a flap inside your flap. So here's a rhomboid flap to fix my flap. Which of the following is an example of an axial flap? Remember, an axial flap has a named blood vessel. So a V-wide advancement, no. Crossfinger, no. A flag flap, the other name for that is the FDMA, right? It's got a named vessel for storosal metacarpal artery. So that's going to be it. Z-plasties, Warren has talked a little bit about this, but these are tested a lot. And so this 60 degree Z-plasty is the most commonly tested. It gives you a 75% increase in length. And if you just remember this table, it starts at 30 and the angles go up by 15 degrees. So every increase in 15 degrees on the angle gets you a 25% increase in length. And so 60 degrees at 75, there are certain principles that you need to remember about Z-plasties for these things. The 60 degree Z-plasty gives you the best marriage of length and depth. A four flap Z-plasty is better for reconstructing length and depth than a three flap or a five flap Z-plasty. It also gives you a smoother contour in things like web spaces. And the smaller the angle, the easier they are to close. Okay, so just keep those in mind as you go through these questions. Get them all right. Here's a 60 degree two flap Z-plasty to the first web space and then I did a jumping man flap to the second web space there. And so here's a question in theory, a 60 degree four flap Z-plasty can produce what increase in length? So we know that a two flap one does 75, Warren's already done this question, but it's nearly 160 degrees. Okay, and the math again, he's already done this question. You should make sure that when you do these things that all the limbs are exactly the same length. That is key to getting a good Z-plasty result. I'm gonna skip these because we already know the answers to them and Warren's covered some of this stuff. There are other things we can do for the web space. Z-plasties, four flap Z-plasties, metacarpal artery, FDMA flaps. This flap that came out in the journal a few years ago, the tripartite index rotation and palmar rectangular flap, which was described for clasped thumbs that has been asked about. Here's an FDMA, I think Warren's already showed this in a patient of his. Local flaps for fingers, I'm gonna skip. I'll just tell you that the Venkataswamy flap, which is the oblique triangular flap, which is my favorite homo-digital island flap, I think Scott likes it too. And I think Jonathan will cover that. So let's get to the regional flaps for the hand and wrist. So the prototype of this is the reverse radial forearm flap. This is, the way most of us are taught to do this is as a fascio-cutaneous flap, but you can take it in other ways. You can do adipofascial flap, meaning you take fat in the fascia, but you leave the forearm skin behind so you don't skin graft the donor site, you skin graft the recipient site on top of that adipofascial flap. You can also do a suprafascial dissection where you take the skin and the fat, but you leave the antebrachial fascia down. This makes a little bit nicer area to skin graft at the donor site. You also don't have to imbricate muscle all over your FCR tendon and whatever else is exposed. But it requires a palmar arch that's intact, two vessel inflow to the hand, and the patient has to be able to tolerate a skin graft that can be kind of ugly sometimes. You can also neurotize this by taking a branch of not the SRN, but the LABC, right? That's the forearm skin sensation. 34-year-old male sustains a soft tissue avulsion to the dorsum of the hand. Areas spanning the first web space to the third metacarpal exposed naked extensor tendons without peritonin. What's the best choice? So certainly you could do a radioforearm flap. Some of you in here might say, you know what, I'm gonna jump straight to the free flap. I don't necessarily think that's wrong, but they want you to go through the reconstructive ladder. And so the most acceptable, lowest form of reconstruction there is gonna be the radioforearm fascial flap with a skin graft. We're gonna skip these. They will ask a lot of questions, actually. I'm gonna go back here. About ulnar artery forearm flaps. And they tend to harp on the fact that the donor sites, if you take in a small flap, can more frequently be closed primarily with an ulnar artery forearm flap than with a radioforearm flap. That's probably true, but I do think for sure that the scar is less conspicuous and better tolerated. There's also a version of the ulnar artery flap called a Becker flap, where you can leave the ulnar artery intact. And this is a dorsal perforator that branches off of the ulnar artery that's fairly reproducible. This is an example, and you can use this to cover dorsal hand and web space areas as well. This is called the Becker flap, or the dorsal ulnar artery flap. So, regional flaps from the hand and wrist. There are other flaps we can use. So, the reverse ulnar artery forearm flap, the ulnar artery perforator forearm flap, which is that Becker flap. The reverse posterior interosseous artery flap, which is kind of shown here in this crazy thumb reconstruction. This is a second metatarsal osteocutaneous flap to replace a thumb metacarpal. And I took a tiny little flap from the foot that, as Warren said, these things swell like crazy, and I had to come back and do this reverse PIA flap for it. And so, there are a lot of choices for this. The vascular septum for the radial forearm flap sits between, what, two muscles? We see this all the time in our distal radius fractures and other things, right, between the BR and the FCR. So, you have to know this anatomy if you're gonna do these forearm flaps. And a radial forearm flap is planned to cover a large bone and soft tissue defect, which of the following is a contraindication? We all know this is an incomplete arch. So, reverse PIA flap. These are popular to ask questions about, and I think they're becoming more widely used in our practices. Things you should know about it, 20% of these flaps will have typnecrosis if you try to reach the PIP joint with them, okay? So, they cover up to the PIP joint pretty reliably, but once you get around the PIP joint, 20% typnecrosis. 5% of people do not have the perforator between the anterior interosseous and the posterior interosseous systems that connects these, that makes this flap possible. So, keep that in mind. You may want to either do a CT angiogram on them first, or you may want to explore where the perforator is first before you start incising your flap. Anybody who's ever had DRUJ surgery, who's had a Galeazzi fracture, DRUJ trauma, may not have this perforator intact, so consider that as well. That's that case I was telling you about, and it was stupid of me. Reverse PIA flap, again, can be used for lots of good things. This is covering a thumb amputation site while they think about what they wanna do for their reconstruction. You can reach all the way into the palm. You can see that thing goes all the way to the palm there. You can close that primarily most of the time. The pivot point for this is proximal to the DRUJ by about two to three centimeters, and so what people will typically say is ulnar styloid, just radial to that, and proximal by two to three centimeters, and that's where you're gonna look for that perforator when you're doing this. So, 18-year-old gentleman involved in an MBC sustained a four by five centimeter soft tissue dorsal hand effect with exposed tendons, no peritonin. The surgeon decided to perform a retrograde PIA flap. What percentage of patients have an absent communicating artery between the anterior and the posterior interosseous systems? We're all pros at this now, right? Five percent. So, what joint can't be consistently covered by this? It's the PIP. So, distant pedicle flaps to the hand and wrist. The prototype of this that we all know about is the groin flap. It depends on neoangiogenesis to perfuse the flap after the pedicle's been divided, typically three weeks or so after. You have to have a cooperative patient. I've seen patients avulse their thumb reconstructions off of this in the middle of the night without knowing it. Consider doing an X-Fix or shoulder immobilizer. I've even seen people suture arms down to their sides and beware stiffness in joints in older folks. We know that the blood supply to this is the superficial circumflex iliac artery. It usually runs two finger breaths below the inguinal ligament and parallel to it. And we know that it's embedded in the fascia to the sartorius, so when you elevate this, you want to take the fascia over the sartorius. You elevate these lateral to medial as you go. And they can be pretty useful flaps for mangled hands, especially when you don't have access to microsurgery reliably, or you have a really obese patient where all their flap choices are really thick, and this is the thinnest tissue that you can find. You do have to look out when you're elevating this for the lateral femoric cutaneous nerve. You don't want to give them neuralgia parastetica. By clipping that nerve, you can give them parasthesias and pain to their lateral and anterior thigh with this. And you guys are pros at the blood supply for this, I'm sure, superficial circumflex iliac. And this is in the list of flaps at the end of the section. So free flaps for coverage of hand and wrist, things you want to consider, pedicle length, donor blood vessel availability, need for future reconstructions. You're gonna have to come back and do bone grafting, tendon grafting, hardware removal, and how bulky is their flap, and what's the cosmetic outcome they're willing to tolerate. There's a case that Cody Azari and I did together, we call them the Duke. This is a chimeric serratus latissimus. It looks like a giant piece of steak on the arm at first, but it flattens out pretty nicely, but it always is gonna look like a skin graft, but he didn't really seem to mind that much. So contralateral forearm flaps can be used for coverage of forearms, and they're thin and cosmetic, but you have to assault the other arm, and so sometimes they're not a great choice. Muscle flaps will atrophy down, but they are harder to re-elevate to do revision work. And so fascicutaneous flaps can be a good choice for this as well. Consider your donor site. You may have to skin graft your donor site if you're taking something from the other forearm. If you do more of an ulnar-based forearm flap and it's not too big, you may be able to close it primarily and hide the scar a little bit. And so here's an ulnar artery forearm flap, and this is, if you need a small amount of tissue, this is great. So you elevate this out, you get a very long pedicle, and then you'll make this back cut. And so I make this back cut that goes towards the radial side you see outlined on the top, and then I can slide that whole forearm segment up by leaving the perforators from the radial artery and the radial fascicutaneous septum intact on the other side of that. I splint the wrist flex for a couple of weeks and gradually over the course of three weeks get it out straight, and then it's closed primarily. I really like the ALT. I think it's a great workhorse flap for covering things. And so if you have a large piece of area that you need to cover that you know you're gonna have to do revision work under, I think it's easy to re-elevate. It's nice cosmetically. It's got low morbidity. But most Americans are kinda large, and so it might be thick. You can thin this on the table, or you can thin this in revision surgeries later on. And it is a perforator flap, and so you may have to do some perforator dissection to get this down. So here's a bad injury that I got involved with about a week after. Replaced the tendons, put the flap over the tendons. And you can take this as a bi-laminate flap, where you take the fascia, split it from the flap, leave it pedicled on one end, and you can tuck that fascia beneath your tendons to interpose between the bone and the tendons to protect them. And you can put the flap over the top of the tendons, and there's a little glide plane created that way. So that's the bi-laminate version of this. And then the rest of that arm can be skin grafted. Here's a thumb that didn't survive revascularization by some colleagues that sent it over. All that muscle's dead. The bone is dead. We got a bone scan on it that shows none of those bones are alive. But you can take that ALT-free flap, and you can start doing thumb reconstruction with it, and then thin it out. So this needs a thinning. But you can do a modified ORI kind of operation. Take perforators, drill holes in bones, put the perforators in the bones, wrap the bone with fascia. And you can take that dead bone, which you see on the bone scan to the left, where there's not really just nothing but metacarpal base that has any kind of blood supply, and it was fractured, has a lot of plates and screws and stuff on it. And now we've perfused the rest of the metacarpal and the proximal phalanx. So these free flaps can be very useful. Scapular, periscapular flaps, good cosmetic donor site, nice tissue, can be thick in Americans. But it's also hard to get to the patient because they're usually laying on their back while we operate, so it can be tricky to try to arrange them. Temporoparietal fascial flaps, great for dorsal hand, very thin coverage, but can give you scar alopecia, temporal hollowing. And if you've never heard of the frontal branch or the temporal branch of the frontal nerve, then you shouldn't be trying this flap because you're probably gonna hit it and they'll hate you forever. Instead of doing these, I tend to prefer the serratus fascia flap. It can be a bit of a bloody dissection and you have to irrigate it so it doesn't dry out, but it gives you the very nice thin coverage as well and it's got a great blood vessel. You can do freestyle flaps where you just sound perforators and take those perforators and follow them out. We're gonna skip through some of these questions because we're running out of time. Flaps to the forearm. You can do lots of things to the forearm. There's so much muscle there, you can skin graft it. You can leave a lot of these things to heal secondarily. But if you need a flap, you need big flaps typically. So you can take latissimus flap, chimeric latissimus serratus flap like we just showed. Erectus abdominis, which is a nice long muscle you can take without the skin paddle or with. That's what's pictured here. That has a pretty substantial morbidity to the abdominal wall, so I don't like it. Fascius lateralis, you can take with or without skin paddle. That's the skin paddle for the ALT. Gracilis for skinnier defects. This is an ALT that needs to be thinned out later on over this plate and ulnar gunshot. You can also take deep in for epigastric artery flaps. And I'm gonna keep going because I see my clock counting down here. Coverage for the elbow. This can be pretty tricky. We have lots of different local muscle turnovers. Triceps turnovers, ankineus turnover, brachioradialis turnover, FCU turnover. You can do latissimus, though it's tricky sometimes to get that distal portion to survive at the elbow, but you can do it. Antigrade rate of forearm flap where it's going antigrade, you're taking the skin paddle distally, but then you're curling it back. Do that for both the radial and ulnar arteries. You can do posterior interosseous artery flap, reverse lateral arm flap, extended antigrade lateral arm flap. Lots of options for this. This is a lateral arm flap shown. This is an antigrade ulnar artery forearm flap shown covering elbow from a gunshot wound. People like to ask questions about ankineus. It's such a small muscle and it's got so many questions about it. I don't get it. Predominant blood supply of the ankineus flap is posterior branch of the radial collateral artery, lateral collateral artery, not really a thing, recurrent posterior interosseous artery. This is the artery that perfuses it if you stuff it into the radiocapitellar space, if you do a intersectional interposition arthroplasty. That's distally based and has to come back. So if you're gonna fold that ankineus backwards to the olecranon, you have to divide that. So that's not it. Ulnar collateral artery, no. Medial collateral artery, yes. So more questions about elbow flaps. Here's ankineus. And again, you can see in pulling it back, so you know you're gonna have to divide that posterior branch of recurrent, or the recurrent posterior interosseous artery branch. So you're gonna have to divide that to get it back. You can also do random things like the groin flap equivalent to the elbow to re-elevate thoracic wall or abdominal wall tissue and just bury it in. And these used to just be old black and white photo kind of articles because this is old technology. But with the current conflicts we've had, a lot of these wounded warriors coming back don't have donor sites. And so it's seen a resurgence. And so you can bury this into the chest wall to get coverage if you need to and treat it like a groin flap. For elbow, you can use latissimus again, lateral arm flaps, scapular, periscapular flap, ALTs, gracilis, all these can be free flaps. Think about innervating a fascicutaneous flap so you can give them some sensation right there. Upper arm and shoulder, lots of muscle there. So you can integra and skin graft like this necrotizing fasciitis patient. You can also do pedicle flaps from the serratus and latissimus systems. You can also do free ALTs, periscapulars, all these other options we've talked about. So here's a diabetic on Coumadin with CHF who had a proximal biceps repair, hematoma, soft tissue necrosis of that whole surgical site with infection all the way into the axilla. So when he comes in, we debride all this out and debride even more than is pictured here. Then he can use a latissimus flap there. You can take a lot of muscle, even more muscle than you can take with ingest the skin paddle. And you can skin graft whatever part of the muscle isn't covered with skin paddle. Then you can bring this back and revise it and it does a really nice job. Motor reconstruction donors. So if you need to replace motors, you can use gracilis. That's probably the most common as a free flap. You can use latissimus either as a pedicle option for biceps or triceps, or you can do it as free. Serratus you can do for low amplitude type of contraction. TFL has been described. Erectus femoris has been described. Pectoralis and gastrocs have all been described, though I've not ever seen those. It's usually just gracilis and latissimus, the ones that I've seen. And remember, if you're doing these, a lot of people will stimulate the nerve to this in the post free flap monitoring phase. And if the muscle stimulates when you stimulate the nerve, you see the muscle contract, they'll say, oh, the flap's alive, this flap's alive, it's doing fine. But after three days, you're gonna stop seeing that. And that's not because the flap is dead. It's because of malaria degeneration, right? We know that you can't continue to stimulate motor nerves after they've been cut for more than 48 to 72 hours. So think of other things to monitor your flap with. I think I am out of time. So we've just entered the kind of encyclopedia of flaps and their questions. So I'll leave this for you guys to go through on your own. But these are just a bunch of workhorse flaps that I put in there. Shows anatomy, shows some examples of flaps from either me or friends of mine, such as Gustavo Machado, who's doing great work in Lincoln, Nebraska. And with test questions related to them, you guys can just go through this on your own, okay? Thank you very much.

flaps

reconstructive surgery

hand

wrist

graphs

reconstructive ladder