Keywords
microsurgery - learning - education - free flaps - flap - surgery
Microsurgical education predominantly focuses on skill acquisition with numerous courses,[1] simulators, and nonbiological and biological models[2]
[3]
[4]
[5] described. There is little emphasis on the microsurgical literature regarding study
techniques to better understand how to raise and inset flaps safely. There are several
Web sites that help provide useful summaries,[6] seminal papers,[7] and excellent textbooks.[8]
[9] Many of these references can be overwhelming and do not provide a succinct and structured
way to organize this large volume of information. In addition, there is a lack of
structure to learn this information, specifically, a lack of flap study mnemonics.
Study mnemonics are a useful way to organize large amounts of data. “P6LAND” divides information into three parts: preoperative, intraoperative, and postoperative
considerations. This organization helps highlight the important aspects of raising
flaps in a succinct way. The aim of this paper is to highlight the specifics of the
mnemonic and provide an appendix for the most common fasciocutaneous, muscle, perforator,
and bone flaps. The mnemonic has been referred to as P6LAND: Preoperative, Position, Pedicle, LANDmarks, Plane, Protection, Postoperative.
The order of the mnemonic refers to the steps of the procedure. For example, preoperative
workup must come first and includes any physical examination maneuvers or special
investigations that needs to be completed before a surgical intervention may commence.
The next five focus on important steps intraoperatively including the position of
the patient, the main pedicle (and corresponding venous supply and nerve supply),
landmarks of the flap (markings, and proximal and distal landmarks), the dissection
plane, and anatomic structures to protect when operating. Finally, the postoperative
phase refers to important tests, monitoring, or investigations to monitor the viability
of the flap. Below, will be a more thorough discussion of each factor.
Preoperative Considerations
Preoperative Considerations
The preoperative workup includes any physical examination tools or special investigations
that need to be completed before a surgical intervention may commence. Special tests
(such as an Allen's test), use of Dopplers to mark out any perforators, and imaging
(i.e., computed tomography) are some examples of preoperative considerations.
Intraoperative Considerations
Intraoperative Considerations
Position
Position information describes the position of the patient intraoperatively. Most
flaps can be procured with the patient in supine position. Variants include lateral
decubitus (such as for scapular/parascapular, latissimus dorsi [LD] flaps), prone,
or modifications of supine (e.g., “frog-legged” for the gracilis flap).
Pedicle
Pedicle information relates to the artery, veins, and possible innervation of the
flap. Pedicle information, first and foremost, describes the main arterial blood inflow
and the main venous outflow.
Landmarks
“Land” stands for landmarks of the flap, which include general markings, proximal,
distal, and possible medial and lateral landmarks. This provides information related
to the general anatomic boundaries of the flaps. For example, the proximal landmark
of an anterolateral thigh flap (ALT) is the anterior superior iliac spine while the
distal landmark is the lateral border of the patella.
Plane
The plane describes the dissection plane such as suprafascial, subfascial, intramuscular,
submuscular and can refer to compartments.
Protection
Protection refers to structures that must be protected which may be encountered during
the dissection. These structures include the pedicle itself as well as other neurovascular
structures or areas that may result in complications. For example, in the LD flap
procurement, the thoracolumbar fascia must be carefully preserved to prevent painful
postoperative lumbar hernias.
Postoperative Considerations
Postoperative Considerations
Finally postoperative describes the care including flap checks (timing, assessment),
need for a stepdown bed, and any other monitoring (i.e., donor site). It also refers
to the position of the patient to prevent pressure at the pedicle or donor. For example,
for the supraclavicular flap, the recommendation is to decrease pedicle strain by
ensuring the neck is in a semiflexed position. Alternatively, after a deep inferior
epigastric perforator (DIEP) harvest, the patient sits in a flexed position to prevent
undue tension or pressure on the abdominal donor and incision.
Please see [Table 1]: P6LAND mnemonic details for a concise summary. Also, see Appendix A: Flap mnemonic examples, for use of this mnemonic in common free flaps.
Table 1
P6LAND mnemonic details
Considerations
|
Preoperative
|
Special tests (Allen's test, Doppler), imaging (i.e., computed tomography angiogram)
|
Intraoperative
|
Position
|
Patient position
|
Pedicle
|
Involving arteries/veins (and number) ± nerves
|
Landmarks
|
Markings
|
Proximal
|
Distal
|
Other
|
Plane
|
Dissection plane
|
Protection
|
Of neurovascular and anatomic structures during dissection
|
Postoperative
|
|
Flap checks, stepdown, monitoring devices, drains, positioning of patient
|
Prevalidation of P6LAND
We have attempted validation of this mnemonic with trainees. Residents from levels
2 to 5 and fellows were included in the validation process. We randomized 40 learners
into “control” and “experimental” groups with training levels considered during randomization.
Both groups were asked to provide information on five most common free flaps: (1)
DIEP, (2) LD, (3) ALT, (4) fibula, (5) radial free forearm flap. The “experimental”
group was shown the P6LAND mnemonic. Trainees were asked to then provide information that they would typically
give to examiners when asked about each flap. They were timed during the process.
The trainees in the control group scored 33.8 ± 10.2% when describing key information
regarding the flaps including but not limited to pedicle, preoperative assessment,
and protection of key structures, whereas the trainees in the experimental group scored
72.9 ± 10.2%. The control group took approximately 10 minutes to discuss five free
flaps, whereas the experimental group took approximately 14 minutes.
Conclusion
In conclusion, this mnemonic, P6LAND, represents a good educational tool for trainees and residents to help in remembering
keys points when discussing flaps. The aim of this work was to create a mnemonic that
makes logical sense and follows the natural sequence of flap procurement. This would
prove to be helpful not only when learning these flaps but also when discussed in
formal exams. It provides an organized way that ultimately will allow them to remember
the key points when assessing patients and performing these procedures both efficiently
and safely. We believe that this manuscript is additive to the plastic surgery education
literature. Much of our tools rely on memorization with the amount of information
available for flaps being quite daunting. This mnemonic is helpful to distill this
information therefore making it a useful adjunct.
Appendix A: Flap mnemonic examples
Table of contents
Flap type
|
Anatomic location
|
Flap
|
Fasciocutaneous
|
Scalp
|
Temporoparietal fascia
|
Trunk
|
Scapular
|
Parascapular
|
Groin
|
Upper extremity
|
Deltopectoral
|
Supraclavicular
|
Lateral arm
|
Muscle
|
Trunk
|
Latissimus dorsi
|
Pectoralis major
|
Rectus abdominis
|
Lower extremity
|
Gluteus maximus
|
Gracilis
|
Gastrocnemius
|
Bone
|
Trunk
|
Iliac crest
|
Lower extremity
|
Fibula
|
Perforator
|
Trunk
|
Superficial inferior epigastric artery
|
Thoracodorsal artery perforator
|
Deep inferior epigastric perforator
|
Upper extremity
|
Free radial forearm
|
Lower extremity
|
Superior gluteal artery perforator
|
Inferior gluteal artery perforator
|
Tensor fascia lata
|
Anterolateral thigh flap
|
Anteromedial thigh flap
|
Fasciocutaneous
Scalp
Temporoparietal fascia flap
Preoperative (preop)
|
Doppler superficial temporal artery (STA)
|
Position
|
Supine, gel donut, head turned away
|
Pedicle
|
STA and vein
N: auriculotemporal nerve
|
Landmarks
|
Markings
|
• Pitanguy's line
• Preauricular incision extending cephalad toward vertex for 12 cm with Y-extension
• Boundaries between zygomatic arch and temporal fusion line (within temporal fossa)
|
Proximal
|
Zygomatic arch
|
Distal
|
Temporal fusion line
|
Plane
|
Subsuperficial temporal fascia, supra/subdeep temporal fascia
|
Protection
|
Frontal branch, auriculotemporal n, middle temporal branch; alopecia (minimal cautery
use); bony prominences—padding
|
Postoperative (postop)
|
No direct pressure
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[10]
[11]
Trunk
Scapular
Preop
|
Doppler pedicle
|
Position
|
Lateral decubitus (with sandbag)/prone
|
Pedicle
|
Circumflex scapular artery (and vein)—transverse branch
N: none
|
Landmarks
|
Markings
|
• Triangular space:
- 1st line: midpoint of scapular spine to tip of scapula
- 2nd line: at upper 2/5th of line 1, to lateral border of scapula
• Center axis on axis (transverse flap): laterally between axilla and lateral scapular
border, medially midway between medial border of scapula and midline
• Pinch test for primary closure
|
Proximal
|
Midline/scapular spine (midway between medial border of scapula and midline)
|
Distal
|
Posterior axillary line/midback (laterally between axilla and lateral scapular border)
|
Plane
|
Subfascial plane toward triangular space (medial to lateral)
|
Protection
|
• Bony prominences—padding
• Prone—globe protection, gel rolls, pillow under ankles, foam around face, arms abducted < 90 degrees
and externally rotated on arm boards above head
|
Postop
|
No direct pressure on flap
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[12]
[13]
[14]
Parascapular
Preop
|
Doppler pedicle
|
Position
|
Lateral decubitus (with sandbag)/prone
|
Pedicle
|
Circumflex scapular artery (and vein)—vertical branch
N: none
|
Landmarks
|
Markings
|
• Triangular space localization landmarks
- 1st line: midpoint of scapular spine to tip of scapula
- 2nd line: at upper 2/5th of line 1, to lateral border of scapula
• Center skin on axis; superiorly just inferior to triangular space, inferiorly midway
between tip of scapula and posterior superior iliac spine (PSIS) (oblique line)
• Pinch test for primary closure
|
Proximal
|
Superiorly just inferior to triangular space
|
Distal
|
Inferiorly midway between tip of scapula and PSIS (oblique line)
|
Plane
|
Subfascial plane distal to proximal
|
Protection
|
• Bony prominences—padding
• Prone—globe protection, gel rolls, pillow under ankles, foam around face, arms abducted < 90 degrees
and externally rotated on arm boards above head
|
Postop
|
No direct pressure
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[12]
[13]
[14]:
Groin
Preop
|
Femoral artery pulse, Doppler
|
Position
|
Supine with sandbag under hip
|
Pedicle
|
Superficial circumflex iliac artery (and vein)
N: none
|
Landmarks
|
Markings
|
• Line: 2.5 cm inferior and parallel to line from pubic tubercle to anterior superior
iliac spine (ASIS)
• Flap: centered over line, 2.5 cm above and 5 cm below inguinal ligament (1/3rd above
and 2/3rd below)
|
Proximal
|
Lateral (ASIS)
|
Distal
|
Medial border of sartorius
|
Plane
|
Suprafascial plane to lateral border of sartorius then subfascial plane to medial
border of sartorius
|
Protection
|
Femoral vessels, lateral femoral cutaneous nerve
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[15]
[16]
[17]
[18]
Upper extremity
Deltopectoral
Preop
|
Not applicable (N/A)
|
Position
|
Supine
|
Pedicle
|
1st to 3rd (2nd most dominant) perforating branches of the internal mammary artery
(and veins)
N: 2nd–4th intercostal nerves
|
Landmarks
|
Markings
|
• Mark: sternum, infraclavicular line, deltopectoral groove, anterior axillary line,
and nipple
• Boundaries between sternum to anterior axillary line
- Superiorly from infraclavicular line to 4th intercostal space (above nipple)
• Narrower the pedicle = more arc of rotation
|
Proximal
|
Deltopectoral groove/anterior axillary line
|
Distal
|
Sternum/infraclavicular line (to 4th intercostal space above nipple) supraclavicular
|
Plane
|
Subfascial (lateral to medial)
|
Protection
|
Cephalic vein
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
No direct pressure
|
Sources: Adapted from.[19]
[20]
[21]
[22]
[23]
Supraclavicular
Preop
|
Doppler, computed tomography angiogram (CTA)
|
Position
|
Supine with bolster under shoulders, head to contralateral side
|
Pedicle
|
Supraclavicular artery (with venae comitantes)
N: supraclavicular nerve branches
|
Landmarks
|
Markings
|
• Triangle: inferiorly by clavicle, medially by posterior border of SCM, laterally
by external jugular vein (origin of supraclavicular artery)
• Skin island: elliptical/fusiform design over supraclavicular and shoulder/upper
arm
• Pinch test for primary closure
|
Proximal
|
Infraclavicular/base of neck
|
Distal
|
Mid-deltoid
|
Plane
|
Subfascial
|
Protection
|
Spinal accessory nerve and supraclavicular nerves
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
± drain/s
Position to decrease pedicle strain (i.e., semiflexed neck position)
|
Sources: Adapted from.[24]
[25]
[26]
Abbreviation: SCM, sternocleidomatoid.
Lateral arm
Preop
|
Doppler, tourniquet
|
Position
|
Supine or lateral decubitus
|
Pedicle
|
Posterior radial collateral artery (venous system: superficial—cephalic vein; deep—venae
comitantes)
N: posterior brachial cutaneous and posterior antebrachial cutaneous
|
Landmarks
|
Markings
|
• Line between deltoid insertion and lateral epicondyle
• Skin pedicle: centered over the axis ± cephalic vein if possible
• Pinch test for primary closure
|
Proximal
|
Deltoid insertion
|
Distal
|
Lateral epicondyle of humerus
|
Plane
|
Subfascial dissection
|
Protection
|
Radial nerve, cephalic vein
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
Posterior elbow splint
|
Sources: Adapted from.[27]
[28]
[29]
Muscle
Trunk
Latissimus dorsi
Preop
|
N/A
|
Position
|
Lateral decubitus (sterile mayo stand with pillow and free arm draped)
|
Pedicle
|
Thoracodorsal artery and vein; n: thoracodorsal nerve
|
Landmarks
|
Markings
|
• Mark posterior axillary line, posterior iliac crest, dorsal midline, scapula tip,
T7 (uppermost medial origin), superior and lateral borders of muscle
• Skin paddle design: transverse, vertical or oblique
• Most inferior limit is 8 cm from PSIS
|
Proximal
|
Axillae
|
Distal
|
PSIS/dorsal midline
|
|
Medial
|
Posterior midline
|
|
Lateral
|
Posterior axillary line
|
Plane
|
Supramuscular and submuscular
|
Protection
|
Thoracolumbar fascia (thoracolumbar hernia)
Bony prominences (gel pads), axillary roll, pillow between knees
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
Drain/s in back donor
|
Sources: Adapted from.[30]
[31]
[32]
[33]
[34]
[35]
Pectoralis major
Preop
|
N/A
|
Position
|
Supine with shoulder bump, arms at sides
|
Pedicle
|
Thoracoacromial artery and vein
N: lateral + medial pectoral n
|
Landmarks
|
Markings
|
• Mark axis, sternal border, clavicle, anterior axillary line, 6th intercostal space
(lower border of pectoralis major), template of deltopectoral flap (to preserve as
salvage)
• Mark skin paddle:
-Females: horizontal line in IMF
- Males: designed medial to NAC in males
• Boundaries of skin > any skin overlying muscle
|
Proximal
|
Clavicle/lateral border of sternum
|
Distal
|
Sternocostal head
|
Plane
|
Supramuscular plane, submuscular plane
|
Protection
|
Internal mammary artery perforators
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
Drains
|
Sources: Adapted from.[36]
Abbreviations: IMF, Inframmary Fold; NAC, nipple areolar complex.
Rectus abdominis
Preop
|
Doppler
|
Position
|
Supine
|
Pedicle
|
Superior and deep inferior epigastric arteries, corresponding veins
Innervation: intercostal nerves (7–12th)
|
Landmarks
|
Markings
|
• Mark midline, xyphoid, costal margin, umbilicus, pubis, ASIS
• Mark skin paddle:
- TRAM: superior incision above umbilicus to include perforators
1. Pinch test: inferior incision marked
- VRAM: median straight line (leaving umbilicus in situ), curvilinear laterally,
directly over muscle
2. Pinch test: for primary closure
3. Center paddle over muscle (or laterally if diastasis)
|
Proximal
|
Inframammary fold/costal margin
|
Distal
|
Pubis crease
|
Plane
|
• Above arcuate line: only anterior sheath
• Below arcuate line: only muscle harvested
|
Protection
|
Note any diastasis rectus, hernias, abdominal incisions
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
Drains
|
Sources: Adapted from.[37]
[38]
[39]
[40]
Abbreviations: TRAM, transverse rectus abdominus myocutaneous; VRAM, vertical rectus
abdominus myocutaneous.
Lower extremity
Gluteus maximus
Preop
|
CTA, magnetic resonance angiography, Doppler
|
Position
|
Prone, lateral decubitus, or jackknife
|
Pedicle
|
Superior and inferior gluteal arteries and veins, first perforator of profunda femoris
artery and venae comitantes
N: inferior gluteal nerve
|
Landmarks
|
Markings
|
• Mark gluteal crease
• Four lines:
- Line 1: PSIS—coccyx
- Line 2: PSIS—ischial tuberosity
- Line 3: PSIS—greater trochanter
- Line 4: greater trochanter to midpoint Line 1 (PSIS—coccyx)
• SGA = junction of medial and middle 1/3rd of Line 3 (PSIS—troch)
• IGA = intersection Line 2 (PSIS—ischial tub) and Line 4 (greater troch to mid Line
1)
• Line 4: piriformis muscle
• SGA perforators above piriformis and lateral to SGA >> major perforator in triangle
lateral to SGA and between Lines 3 and 4
• IGA perforators below piriformis and above gluteal crease
• Skin paddle: designed as large V-Y design (if future readvancement needed) centered
over perforators if possible/over muscle
• Rotation: inferior-based rotation with pivot point at medial base of muscle
|
Proximal
|
Third from PSIS to trochanter
|
Distal
|
Midline (gluteal cleft)
|
Plane
|
Supramuscular, submuscular
|
Protection
|
Sciatic nerve, posterior femoral cutaneous nerve
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
Drain
|
Sources: Adapted from.[41]
[42]
Abbreviations: SGA, superior gluteal artery; IGA, inferior gluteal artery.
Gracilis
Preop
|
N/A
|
Position
|
Supine frog-leg, lithotomy
|
Pedicle
|
Medial circumflex femoral artery (with venae comitantes)
N: obturator nerve, anterior femoral cutaneous nerve
|
Landmarks
|
Markings
|
• ID adductor longus tendon
• Mark axis, perforators, estimated pedicle entry, obturator nerve (2–3 cm proximal
to pedicle and enters at 45 degrees angle), and skin paddle
• Skin paddle boundaries: proximal 2/3rd of thigh, 2–3 cm on each side of muscle
• Pinch for primary closure
• TUG: skin paddle located transversely over perforators ∼ 10 cm distal to pubic tubercle
- Placed slightly posterior to gracilis to capture the bulky tissue in gluteal region
- o Anterior limit is femoral triangle
|
Proximal
|
Medial tibial condyle
|
Distal
|
Pubis
|
Plane
|
Subfascial
|
Protection
|
Greater saphenous vein
|
Postop
|
Drain
|
Sources: Adapted from.[43]
[44]
[45]
Abbreviation: TUG, transverse upper gracilis
Gastrocnemius
Preop
|
Tourniquet
|
Position
|
Supine with leg internally/externally rotated, lateral decubitus
|
Pedicle
|
Medial and lateral sural arteries (w/venae comitantes)
N: branches of the tibial nerve
|
Landmarks
|
Markings
|
• Direct access thru vertical incision 2 cm posterior to tibial border for medial,
2 cm posterior to fibula for lateral incision is in upper 1/3rd
• Access thru existing wound
|
Proximal
|
• Medial head: medial condyle of femur
• Lateral head: lateral condyle of femur
|
Distal
|
Achilles tendon
|
Plane
|
Areolar plane, submuscular plane
|
Protection
|
Lesser saphenous vein, sural nerve
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
Elevation of lower extremity ± gentle compression dressings
|
Sources: Adapted from.[46]
[47]
[48]
[49]
Bone
Trunk
Iliac crest (deep circumflex iliac artery flap)
Preop
|
Doppler
|
Position
|
Supine with bump below hip, hip slightly flexed
|
Pedicle
|
Deep circumflex iliac artery and venae comitantes
|
Landmarks
|
Markings
|
• Markings of ASIS, inguinal ligament, femoral vessels, iliac crest, flap axis
• Medial incision from lateral to femoral pulse to ASIS
• Lateral incision over crest (or skin paddle)
• Skin paddle boundaries 2/3rd above and 1/3rd below crest, from ASIS to posterior
axillary line
|
Proximal
|
Medial incision over inguinal ligament—lateral to femoral pulse to ASIS
|
Distal
|
Iliac crest/gluteus medius/tensor fascia lata
|
Plane
|
Suprafascial over external oblique
|
Protection
|
Lateral femoral cutaneous, genitofemoral, ilioinguinal, and iliohypogastric nerves;
external iliac vessels
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
Activity modifications
|
Sources: Adapted from.[50]
[51]
Lower extremity
Fibula
Preop
|
Tourniquet, CTA (especially in traumatic injuries)
|
Position
|
Supine or lateral decubitus
|
Pedicle
|
Peroneal artery, lateral inferior genicular artery, anterior tibial perforator, and
venae comitantes
N: superficial peroneal nerve
|
Landmarks
|
Markings
|
|
Proximal
|
Head of fibula
|
Distal
|
Lateral malleolus
|
Plane
|
Supraperiosteal, subperiosteal, intramuscular
|
Protection
|
Compartments: lateral (common peroneal nerve, around neck of fibula), anterior compartment
(anterior tibial artery), posterior (deep; peroneal artery); ankle stability (leave > 6 cm
of bone proximal to lateral malleolus for ankle stability)
|
Postop
|
Leg in splint, activity modifications, no direct pressure
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[52]
[53]
[54]
Scapula—please see above
Sources: Adapted from.[3]
[4]
[5]
Perforator
Trunk
Superficial inferior epigastric artery
Preop
|
CTA, Doppler
|
Position
|
Supine
|
Pedicle
|
Superficial inferior epigastric artery and venae comitantes
N: segmental intercostals T10–T12
|
Landmarks
|
Markings
|
|
Proximal
|
ASIS/pubic tubercle
|
Distal
|
Umbilicus
|
Plane
|
Suprafascial to external oblique + internal oblique, deep to Scarpa's fascia
|
Protection
|
Femoral vessels
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
No full hip extension
|
Sources: Adapted from.[55]
[56]
[57]
Thoracodorsal artery perforator
Preop
|
Doppler, color Doppler ultrasonography, or CTA
|
Position
|
Lateral decubitus with shoulder abduction and 90 degree of elbow flexion (axillary
roll, pillow between knees, sterile mayo stand with pillow, and arm free draped)
|
Pedicle
|
Thoracodorsal artery (descending/vertical branch)
N: posterior rami of lateral cutaneous branches of intercostal nerves
|
Landmarks
|
Markings
|
• Standard latissimus dorsi landmarks
• Line: starting 8 cm below axilla (vascular hilum of latissimus dorsi) to PSIS
• Skin island: centered at ant border of latissimus dorsi
• Pinch test: identify widest portion of skin paddle to close by primary closure
|
Proximal
|
Lateral border of inframammary fold
|
Distal
|
Latissimus dorsi muscle
|
Plane
|
Suprafascial, subfascial
|
Protection
|
Thoracodorsal nerve
|
Postop
|
Flap checks (Doppler, color, cap refill, temp, turgor)
No full abduction of shoulder
|
Sources: Adapted from.[58]
Deep inferior epigastric perforator
Preop
|
CTA of the abdomen, Doppler
|
Position
|
Supine
|
Pedicle
|
Deep inferior epigastric artery, two veins
N: 10th–12th intercostal n cutaneous branch/s
|
Landmarks
|
Markings
|
• Mark superior incision above umbilicus to include perforators
• Pinch test: inferior incision marked tentatively
|
Proximal
|
Superior portion of the umbilicus
|
Distal
|
6–8 cm superior to the vaginal cleft
|
Plane
|
Subfascial/submuscular
|
Protection
|
Superficial inferior epigastric artery/venae
|
Postop
|
Position: flexion of trunk
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[59]
[60]
[61]
[62]
[63]
[64]
[65]
Upper extremity
Free radial forearm
Preop
|
Allen's test, tourniquet
|
Position
|
Supine
|
Pedicle
|
Radial artery + vein (venae comitantes ×2, cephalic vein)
± lateral/medial antebrachial ± lateral/medial cutaneous nerves
|
Landmarks
|
Markings
|
• 1 cm distal to antecubital fossa to scaphoid tubercle
• Skin boundaries between antecubital fossa and wrist crease
• Width up to 2/3rd of forearm circumference with 1/3rd lateral to radial artery to
include cephalic vein
|
Proximal
|
Midforearm
|
Distal
|
Wrist crease
|
Ulnar
|
Flexor carpi radialis tendon
|
Radial
|
Brachioradialis tendon
|
Plane
|
Suprafacial and subfascial
|
Protection
|
Flexor carpi radialis and brachioradialis tendons and paratenon; dorsal branch of
the radial nerve
|
Postop
|
Splint (if osseocutaneous), split-thickness graft for donor coverage
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[66]
[67]
Lower extremity
Superior gluteal artery perforator
Preop
|
Doppler
|
Position
|
Prone/lateral decubitus
|
Pedicle
|
Superior gluteal artery (and vein)
N: inferior gluteal nerve
|
Landmarks
|
Markings
|
• Mark gluteal crease
• Mark three lines:
- Line 1: PSIS—coccyx
- Line 2: PSIS—greater trochanter
- Line 3: greater trochanter to midpoint Line 1
• SGA = junction of medial and middle 1/3rd of Line 2
• Piriformis muscle = Line 3
• SGA perforators above piriformis and lateral to SGA, major perforator in triangle
lateral to SGA and between Lines 3 and 4
• Skin paddle: oriented obliquely in superolateral direction
• Skin pinch for primary closure
|
Proximal
|
Trochanter
|
Distal
|
Midline (gluteal cleft)
|
Plane
|
Subfascial
|
Protection
|
Sciatic nerve, inferior gluteal vessels
|
Postop
|
Drain
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[68]
Inferior gluteal artery perforator
Preop
|
Doppler
|
Position
|
Prone/lateral decubitus
|
Pedicle
|
Inferior gluteal artery (and vein)
N: inferior gluteal nerve
|
Landmarks
|
Markings
|
• Mark gluteal crease
• Mark four lines:
- Line 1: PSIS—coccyx
- Line 2: PSIS—ischial tuberosity
- Line 3: PSIS—greater trochanter
- Line 4: greater trochanter to midpoint Line 1 (PSIS—coccyx)
• IGA = intersection Line 2 (PSIS—ischial tuberosity) and Line 4 (greater trochanter
to mid Line 1)
• Piriformis muscle = Line 4
• IGA perforators below piriformis and above gluteal crease.
• Skin paddle: transverse paddle, 2 cm below gluteal crease; superior incision determined
by pinch test and include perforators (1ry closure <= 10 cm)
|
Proximal
|
Trochanter
|
Distal
|
Midline (gluteal cleft)
|
Plane
|
Subfascial
|
Protection
|
Sciatic nerve, superior gluteal vessels
|
Postop
|
Drain
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[69]
Tensor fascia lata
Preop
|
Doppler
|
Position
|
Supine
|
Pedicle
|
Ascending or transverse branch lateral circumflex femoral artery and venae comitantes
N: superior gluteal n, lateral cutaneous branch of T12 and lateral femoral cutaneous
nerve of the thigh
|
Landmarks
|
Markings
|
• Mark: ASIS, lateral femoral condyle, axis, perforators
• Skin paddle: ASIS to 10 cm proximal to knee; greater trochanter posteriorly to lateral
edge of rectus femoris border medially
-Leave distal 10 cm of Iliotibial tract to maintain knee stability.
• Pinch (< 9 cm can close by primary intention)
|
Proximal
|
Greater trochanter
|
Distal
|
Lateral condyle of tibia
|
Plane
|
Subfascial plane, submuscular plane
|
Protection
|
Lateral femoral cutaneous nerve
|
Postop
|
Hip flexion (if pedicled), drains
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[70]
[71]
[72]
Anterolateral thigh flap
Preop
|
Doppler
|
Position
|
Supine
|
Pedicle
|
Descending branch of lateral circumflex femoral artery and vena comitantes
N: lateral femoral cutaneous nerve
|
Landmarks
|
Markings
|
• Lines:
-ASIS to superolateral patella
-At midpoint, draw circle with 3 cm radius.
• Skin island: medial edge of rectus femoris to lateral edge of vastus lateralis
- Proximally 10 cm inferior to ASIS and distally 7 cm superior to patella
• Pinch test: width of 10 cm can be taken for primary closure
|
Proximal
|
ASIS
|
Distal
|
Superolateral border of the patella
|
Plane
|
Supra- or subfascial
|
Protection
|
Intermuscular septum (between rectus femoris and vastus lateralis muscles) to protect
vessels
|
Postop
|
Skin graft for donor, drain/s
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[73]
[74]
Anteromedial thigh flap
Preop
|
Doppler
|
Position
|
Supine
|
Pedicle
|
Lateral circumflex femoral descending artery—septocutaneous branch
|
Landmarks
|
Markings
|
• Lines:
-ASIS to superolateral patella
• Skin island: medial edge of rectus femoris to lateral edge of vastus lateralis
- Proximally 10 cm inferior to ASIS and distally 7 cm superior to patella
• Pinch test: width of 10 cm can be taken for primary closure
|
Proximal
|
ASIS
|
Distal
|
Superolateral border of the patella
|
Plane
|
Subfascial
|
Protection
|
Great saphenous vein
Saphenous nerve
|
Postop
|
Drain/s
Flap checks (Doppler, color, cap refill, temp, turgor)
|
Sources: Adapted from.[75]
[76]
[77]
[78]