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Questions and Answers
Which flap is commonly used for eyelid reconstruction?
Which flap is commonly used for eyelid reconstruction?
The Pectoralis Major Myocutaneous Flap is based on the pectoral branch of the lateral thoracic artery.
The Pectoralis Major Myocutaneous Flap is based on the pectoral branch of the lateral thoracic artery.
False
What is an example of a Type V axial flap?
What is an example of a Type V axial flap?
Pectoralis major flap
The Abbe-Estlander Flap is based on the __________ vessels to reconstruct the floor and angle of the mouth.
The Abbe-Estlander Flap is based on the __________ vessels to reconstruct the floor and angle of the mouth.
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Match the following flaps with their primary uses:
Match the following flaps with their primary uses:
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Which of the following is NOT a predisposing factor for wound healing issues?
Which of the following is NOT a predisposing factor for wound healing issues?
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The inflammatory phase of wound healing lasts up to 4 days.
The inflammatory phase of wound healing lasts up to 4 days.
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What is the primary principle behind Vacuum Assisted Closure (VAC) dressing?
What is the primary principle behind Vacuum Assisted Closure (VAC) dressing?
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The phases of wound healing are Hemostasis, Inflammatory, Proliferative, and __________.
The phases of wound healing are Hemostasis, Inflammatory, Proliferative, and __________.
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Match the following indications with their corresponding descriptions:
Match the following indications with their corresponding descriptions:
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Which stage of pressure sore involves non-blanchable erythema of intact skin?
Which stage of pressure sore involves non-blanchable erythema of intact skin?
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The greater trochanter is the most common site affected by pressure sores.
The greater trochanter is the most common site affected by pressure sores.
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What type of dressing is used in the treatment of a Stage 2 pressure sore?
What type of dressing is used in the treatment of a Stage 2 pressure sore?
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In Stage 4 pressure sores, there is full thickness skin and __________ loss.
In Stage 4 pressure sores, there is full thickness skin and __________ loss.
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What is the primary purpose of meshing in skin grafts?
What is the primary purpose of meshing in skin grafts?
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Match the following stages of pressure sores to their treatments:
Match the following stages of pressure sores to their treatments:
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Infection by β-hemolytic streptococci can lead to graft failure.
Infection by β-hemolytic streptococci can lead to graft failure.
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What is the process called that occurs after 4 days, where new blood vessels form at both ends of the graft?
What is the process called that occurs after 4 days, where new blood vessels form at both ends of the graft?
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The physiological transfer of nutrients to a graft during the first 24-48 hours is known as __________.
The physiological transfer of nutrients to a graft during the first 24-48 hours is known as __________.
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Match the following terms with their correct descriptions:
Match the following terms with their correct descriptions:
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What is the ideal length to breadth ratio for a random flap?
What is the ideal length to breadth ratio for a random flap?
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A Z-plasty can be used to decrease the length of a wound.
A Z-plasty can be used to decrease the length of a wound.
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Name one use of a rhomboid flap.
Name one use of a rhomboid flap.
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A random flap is based on _____ blood supply.
A random flap is based on _____ blood supply.
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Match the following types of flaps with their uses:
Match the following types of flaps with their uses:
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Which of the following characteristics is true for keloids?
Which of the following characteristics is true for keloids?
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Hypertrophic scars generally grow beyond the boundary of the scar.
Hypertrophic scars generally grow beyond the boundary of the scar.
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What is the most common defect associated with cleft lip and palate?
What is the most common defect associated with cleft lip and palate?
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Keloids are predominantly found in individuals with ________ skin.
Keloids are predominantly found in individuals with ________ skin.
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Match the following risk factors with their related conditions:
Match the following risk factors with their related conditions:
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What is the major advantage of using the DIEP flap for breast reconstruction compared to the TRAM flap?
What is the major advantage of using the DIEP flap for breast reconstruction compared to the TRAM flap?
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The TRAM flap includes skin, subcutaneous fat, and muscle.
The TRAM flap includes skin, subcutaneous fat, and muscle.
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Which blood vessels supply the DIEP flap?
Which blood vessels supply the DIEP flap?
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The TRAM flap is associated with an increased risk of __________ due to muscle removal.
The TRAM flap is associated with an increased risk of __________ due to muscle removal.
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Match the flap type to its key feature:
Match the flap type to its key feature:
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What is the ratio of Type 1 collagen to Type 3 collagen during the remodeling phase?
What is the ratio of Type 1 collagen to Type 3 collagen during the remodeling phase?
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Wound strength after one week is approximately 30% of normal.
Wound strength after one week is approximately 30% of normal.
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What is the primary intention in wound healing?
What is the primary intention in wound healing?
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Vitamin C deficiency can lead to __________ collagen and matrix.
Vitamin C deficiency can lead to __________ collagen and matrix.
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Match the following factors affecting wound healing with their categories:
Match the following factors affecting wound healing with their categories:
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Study Notes
Axial Flaps
- Axial flaps are rotated on a named blood vessel, remaining attached to the donor site
- Classified by pedicles (the blood vessels supplying the flap)
- Type V: Dominant pedicle (1) + minor pedicles (multiple)
- Examples:
- Pectoralis major flap
- Latissimus dorsi flap
- Used in head and neck reconstruction
Specific Axial Flaps
- Deltopectoral Flap (DP): Based on perforators of the internal mammary artery
- Pectoralis Major Myocutaneous Flap (PMMC): Commonly used by head and neck surgeons, Based on the pectoral branch of the thoracoacrominal artery
- Other Axial Flaps (for head and neck): Bilateral deltopectoral flaps
- Abbe-Estlander Flap (oral cavity): Based on labial vessels (vessels on the inside of the lip) to reconstruct the floor and angle of the mouth
- Karapandzic Flap (Lip Switch): Used in oral cancer reconstruction
Prevention of Pressure Sores
- Predisposing factors:
- Wheelchair bound patient
- Poor nutritional status (↓ S.albumin)
- Wet/macerated area
- Modes of prevention:
- Adequate nutrition: monitor and correct S.albumin
- Bedsheet: Dry + no wrinkles
- Frequent change of position
- Air/water mattress (If unable to change position): Lift the patient for 10 seconds every 10 minutes for repositioning
Vacuum Assisted Closure (VAC) Dressing
- Principle: Negative pressure occlusive dressing (-125 mmHg) hastens wound healing
- Sucks out dead tissue
- ↑ vascularity (may cause complications like bleeding)
- Indications:
- Chronic non-healing wounds
- Venous ulcer (without slough)
- Burn wounds (without eschar)
- Bed sores (after debridement)
- Diabetic ulcer (without osteomyelitis)
Wound Healing Phases
- Hemostasis → Inflammatory → Proliferative → Remodeling
Inflammatory Phase
- Lasts up to 4 days
- Neutrophils (Acute phase) are later replaced by macrophages
Graft Survival
- Imbibition (24-48 hours): Plasmatic transfer of nutrients
- Inosculation (2-4 days): Buds from donor extract nutrition
- Neovascularisation (After 4 days): Both ends form new vessels
Meshing
- Cuts made to STSG: Increases the surface area (x1.5)
- Prevents seroma formation
Graft Failure: Causes
- Seroma/hematoma: Beneath the graft, lifts it up, hampers imbibition
- Infection: β-hemolytic streptococci, staphylococcus
- Movement (Shearing force)
- Poor recipient bed: Fibrotic/granulation tissue (must be debrided), Lacks periosteum/perichondrium/perineurium
Bed Sores/Pressure Sores
- Formation: Formed when constant pressure >30 mmHg (Same pressure for compartment syndrome).
- Affected Sites: Ischium (most common) > Greater trochanter > Sacrum > Heel
Pressure Sore Grading and Management
-
Stage 1: Non-blanchable erythema of intact skin. Treatment: Keep area dry, Offloading (Air/water mattress), Opsite spray (Prevents ↑ staging), Debridement
-
Stage 2: Partial thickness skin loss with exposed dermis. Treatment: VAC dressing (-ve pressure), Debridement
-
Stage 3: Full thickness skin loss. Treatment: VAC dressing (-ve pressure), Debridement, Flap closure (e.g., Tensor fascia lata flap)
-
Stage 4: Full thickness skin and tissue loss. Treatment: Debridement, Flap mobilisation, Flap closure
-
Recent Updates: Unstageable full-thickness pressure injury, Deep tissue pressure injury
Types of Flaps
-
Random Flap: Rotated on dermal plexus (Based on dermal blood supply), Ideal length: breadth ratio = 3:1 (As long flaps with a narrower base do not survive), Uses: Post burn contractures, cleft palate repair
- Examples:
- Z-plasty: 30°, 45°, 60° angles can be made, used to increase the length of the wound
- V-Y plasty: used for elongation of the wound (75% length gain (max elongation))
- Rhomboid flap: used for reconstruction of tissue
- Rhomboid Flap for basal cell carcinoma and pilonidal sinus
- Examples:
Altered Wound Healing (Altered remodeling phase)
- Keloids (Type III collagen): Site: Sternum (m/c), ear lobe, shoulders, Predisposition: Dark skin, Growth: Grow beyond the boundary of scar, Relieving factors: Does not subside with time/pressure, c/f: Raised, red, itchy lesion, Rx: Intralesional Triamcinolone, Recurrent → Sx excision, Laser/radiotherapy
- Hypertrophic scars: Site: Extensor Surfaces, Predisposition: Children, Growth: Grows within the boundary of scar, Relieving factors: Subsides with time/pressure, c/f: -, Rx: Silicon gel pads
Cleft Lip and Palate
- Incidence: 1 in 600 live births
- Males > Females
- M/C defect → Combined lip + palate
Risk Factors
- Phenytoin
- Anti-epileptics, maternal intake
- Steroids
- Genetic: Pierre Robin syndrome
Additional Notes
- Retrognathia with posteriorly displaced tongue
- Isolated cleft palate
Flaps for Breast Reconstruction
i) Latissimus dorsi flap
ii) TRAM v/s iii) DIEP
| Feature | TRAM Flap | DIEP Flap |
|---|---|---|
| Tissue Included | Skin + subcutaneous fat + muscle | Skin + subcutaneous fat |
| Blood Supply | Superior epigastric vessels - Axial Inferior epigastric vessels - Free If both - "Supercharged TRAM" | Deep inferior epigastric artery perforator - Free flap |
| Abdominal Wall Morbidity | ↑ (D/t muscle removal) ↑ risk of incisional hernia Abdominal incision - Elliptical (Same for both TRAM/DIEP) Best flap for breast reconstruction: DIEP flap | ↓ (muscle not removed) ↓ risk of incisional hernia |
iv.Superficial inferior epigastric artery (SIA) flap
Proliferative Phase
- After 4 days, macrophages and fibroblasts predominate
- Fibroblasts lay down Type 3 collagen (disorganized)
Remodeling Phase
- Type 1 collagen replaces type 3 in a ratio 4:1
Important Points
Wound strength
- After 1 week: ~10% of normal
- After 3 months: ~70-80% of normal (maximum)
- Wound never regains original strength
Factors Affecting Wound Healing
Local
- Foreign body
- Radiation
- Infection
- Trauma
Systemic
- Anemia
- Malnutrition (S.albumin < 3.4 g/dL)
- Immunocompromised
- Vitamin C deficiency → Abnormal collagen/matrix
- Steroids → Inhibit inflammatory phase (Should only be restarted 3-4 days post injury)
Types of Wound Healing (Physiological process)
- Primary intention: Sutured wound, Good scar, Clean incision, Minimal granulation, Minimal wound contracture
- Secondary intention: Wound left open, Granulation, contracture, Increased time to heal, Bad scar (keloid/hypertrophic)
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Description
This quiz covers the concept of axial flaps, including their classification, types, and specific examples used in head and neck reconstruction. It will also address the prevention of pressure sores associated with certain patient conditions. Test your knowledge on crucial surgical techniques and their applications.
