Which of the following muscles comprise the borders of the triangular space?

(A) Anterior border of the scapula, serratus anterior, and long head of the triceps muscles
(B) Latissimus dorsi, teres major, and teres minor muscles
(C) Medial border of the scapula, rhomboideus major, and rhomboideus minor muscles
(D) Triceps, teres major, and teres minor muscles

The correct response is Option D.

The triceps, teres major, and teres minor muscles comprise the borders of the triangular space. A knowledge of this region is essential to harvest the scapular and parascapular flaps, which receive their blood supply from the circumflex scapular artery. The pedicle of the parascapular flap arises from the triangular space and enters the deep surface of the flap.

The other muscles listed above can be identified in the region of the shoulder and trunk but do not define the triangular space.

References
1. Mathes SJ, Nahai F, eds. Reconstructive Surgery: Principles, Anatomy, and Technique. New York, NY: Churchill Livingstone, Inc; 1997.
2. Strauch B, Yu HL, eds. Atlas of Microvascular Surgery: Anatomy and Operative Approaches. New York, NY: Thieme Medical Publishers, Inc; 1993.

In a patient who is undergoing dissection of a gracilis musculocutaneous flap, the gracilis muscle can be identified immediately posterior to which of the following muscles in the thigh?

(A) Adductor longus muscle
(B) Adductor magnus muscle
(C) Pectineus muscle
(D) Sartorius muscle

Reproduced with permission of Rosse C, ed. Hollinshead's Textbook of Anatomy. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:359.

The correct response is Option A.

In order to effectively identify the gracilis muscle prior to flap harvest, the patient should be placed in the supine position with the knee in abduction. With the patient in this position, the adductor longus muscle can be palpated before surgery. Following incision, the gracilis muscle is easily identified posterior to the adductor longus.

The adductor magnus muscle lies posterior to the gracilis, and the pectineus muscle is found anterior to the adductor longus at the floor of the femoral triangle. The sartorius muscle overlies the gracilis muscle distally.

References
1. Mathes SJ, Nahai F, eds. Reconstructive Surgery: Principles, Anatomy, and Technique. New York, NY: Churchill Livingstone, Inc; 1997.
2. Rosse C, ed. The free lower limb: thigh, leg, and foot. In: Hollinshead's Textbook of Anatomy. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:359.

A 25-year-old woman who sustained the forearm avulsion shown in the photograph above subsequently underwent reconstruction using a free groin flap based on the superficial circumflex iliac artery. Which of the following best describes the vascular anatomy of this flap?

(A) The superficial circumflex iliac artery arises directly from the external iliac artery in approximately 85% of patients
(B) The superficial circumflex iliac artery arises from a common trunk, terminally splitting with the superficial inferior epigastric artery in approximately 70% of patients
(C) The superficial circumflex iliac and superficial inferior epigastric arteries have separate origins in approximately 40% of patients
(D) The superficial circumflex iliac artery is generally found approximately 1 cm below the inguinal ligament in approximately 70% of patients

The correct response is Option C.

The free groin flap is typically an axially patterned flap that receives its vascularity by the superficial circumflex iliac artery, which arises from the common or superficial femoral artery and then traverses laterally, parallel to the inguinal ligament, typically 2 to 3 cm inferior to the ligament. Although it provides excellent thin soft-tissue coverage of cutaneous defects and is associated with minimal donor site morbidity, especially in women, its use is limited by potential variations in vascular anatomy, as shown in the illustration below.

In 45% to 50% of persons the superficial circumflex iliac artery and superficial inferior epigastric artery arise from a common trunk, as shown in the figure on the left. In contrast, 40% to 45% of persons have a superficial circumflex iliac artery and superficial inferior epigastric artery that arise from separate origins, as shown in the figure on the right. The middle figure demonstrates a large superficial circumflex iliac artery without a superficial inferior epigastric artery, which is present in 10% to 15% of persons. In patients being considered for reconstructive procedures using the free groin flap, vascular anatomy can be determined preoperatively using Doppler ultrasonography.

In addition to its usefulness in coverage of cutaneous defects, as shown in the postoperative photograph below, the free groin flap can also be deepithelialized and transferred as soft-tissue fill in patients with Romberg's disease or hemifacial microsomia.

References
1. Acland RD. The free iliac flap: a lateral modification of the free groin flap. Plast Reconstr Surg. 1979;64:30.
2. Mathes SJ, Nahai F, eds. Reconstructive Surgery: Principles, Anatomy, and Technique. New York, NY: Churchill Livingstone, Inc; 1997;2:1005.

A Z-plasty revision procedure is to be performed for lengthening of a scar contracture. In order to achieve a theoretical 100% gain in the length, the angle of the Z-plasty should be how many degrees?

(A) 30
(B) 45
(C) 60
(D) 75
(E) 90

Reproduced with permission of Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:20.

The correct response is Option D.

The Z-plasty is a technique in which pairs of triangular transposition flaps are created adjacent to a scar and then transposed across the scar, resulting in an increase in the length of the central limb and a change in the orientation of the scar. This technique can be used in patients undergoing burn reconstruction to lengthen linear scar contractures, disperse linear scars, and realign the scars within the lines of minimal tension. The actual amount of scar lengthening correlates directly with the angle and length of the flap limbs, as demonstrated in the table above.

References
1. McCarthy JG. Introduction to plastic surgery. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;1:68.
2. Place MJ, Herber SC, Hardesty RA. Basic techniques and principles in plastic surgery. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:13-26.
3. Rohrich RJ, Zbar RI. A simplified algorithm for the use of Z-plasty. Plast Reconstr Surg. 1999;103:1513-1517.

After undergoing radical mastectomy of the left breast for management of breast carcinoma, a 40-year-old woman with obesity is scheduled for delayed reconstruction using a transverse rectus abdominis myocutaneous (TRAM) flap. Which of the following is the most likely sequela of a delayed TRAM flap procedure?

(A) Increased blood flow to the deep inferior epigastric artery
(B) Increased diameter of the superior epigastric artery
(C) Increased pressure within the superior epigastric vein
(D) Increased quantity of choke vessels
(E) Increased quantity of myocutaneous perforators

The correct response is Option B.

A delay procedure is appropriate for any patient considering TRAM flap reconstruction who has risk factors for flap loss, including obesity, a smoking history, a previous history of radiation therapy, or large volume requirements. A delayed procedure is typically performed in the outpatient setting and involves ligation of the deep and superficial inferior epigastric vessels, eliminating blood flow through the deep inferior epigastric artery. Studies of patients who have undergone this procedure demonstrated increased diameter and flow volume of the superior epigastric artery. The vascular structures within the flap are also dilated during the delay procedure. The choke vessels connect adjacent vascular regions and have been shown in animal studies to achieve maximum dilation 48 to 72 hours after surgery. Cell hypertrophy has been demonstrated within the walls of the choke vessels.

References
1. Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast Reconstr Surg. 1999;104:2079-2091.
2. Restifo RJ, Ward BA, Scoutt LM, et al. Timing, magnitude, and utility of surgical delay in the TRAM flap: II: clinical studies. Plast Reconstr Surg. 1997;99:1217-1223.

A 53-year-old man has a chronic draining sinus of the perineal region one year after undergoing abdominoperineal resection of a low-lying rectal carcinoma followed by localized radiation therapy. Following debridement of the affected area, which of the following is the most appropriate management?

(A) Healing by secondary intention
(B) Primary closure
(C) Skin grafting
(D) Coverage with a fasciocutaneous flap
(E) Coverage with a muscle flap

The correct response is Option E.

In a patient who has a chronic, irradiated wound, the most appropriate management is coverage with a muscle or musculocutaneous flap with a vascular pedicle that lies outside the field of radiation, such as the gracilis flap. Secondary intention healing is unlikely to be successful in a radiated wound bed, and primary closure of a previously radiated, nonhealing wound will also not result in appropriate healing. Skin grafting will be ineffective due to the poor vascularity of the wound bed. A fasciocutaneous flap is less appropriate than a muscle flap to fill the dead space within the wound.

References
1. Ariyan S, Krizek TJ. Radiation effects: biologic and surgical considerations. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;1:831.
2. Ramasastry SS. Chronic problem wounds. Clin Plast Surg. 1998;25:367.

A 53-year-old man has a chronic draining sinus of the perineal region one year after undergoing abdominoperineal resection of a low-lying rectal carcinoma followed by localized radiation therapy. Following debridement of the affected area, which of the following is the most appropriate management?

(A) Healing by secondary intention
(B) Primary closure
(C) Skin grafting
(D) Coverage with a fasciocutaneous flap
(E) Coverage with a muscle flap

The correct response is Option E.

In a patient who has a chronic, irradiated wound, the most appropriate management is coverage with a muscle or musculocutaneous flap with a vascular pedicle that lies outside the field of radiation, such as the gracilis flap. Secondary intention healing is unlikely to be successful in a radiated wound bed, and primary closure of a previously radiated, nonhealing wound will also not result in appropriate healing. Skin grafting will be ineffective due to the poor vascularity of the wound bed. A fasciocutaneous flap is less appropriate than a muscle flap to fill the dead space within the wound.

References
1. Ariyan S, Krizek TJ. Radiation effects: biologic and surgical considerations. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;1:831.
2. Ramasastry SS. Chronic problem wounds. Clin Plast Surg. 1998;25:367.

Which of the following is NOT an indication for Z-plasty?

(A) Adjusting soft-tissue contour
(B) Dispersing linear scars
(C) Lengthening linear scar contractures
(D) Preventing burn scar contractures

The correct response is Option D.

The Z-plasty is a fundamental plastic surgery technique that involves the elevation and interposition of two equal, interposed triangular skin flaps. This procedure can be used to improve soft-tissue contour via reorientation of skin, realign scars within the lines of minimal tension, and lengthen linear scar contractures. However, it is not performed for prevention of burn scar contractures.

References
1. Hudson DA. Some thoughts on choosing a Z-plasty: the Z made simple. Plast Reconstr Surg. 2000;106:665-671.
2. Place MJ, Herber SC, Hardesty RA. Basic techniques and principles in plastic surgery. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:19-20.
3. Rohrich RJ, Zbar RI. A simplified algorithm for the use of Z-plasty. Plast Reconstr Surg. 1999;103:1513.

A 60-year-old man has a patent but widely exposed Gore-Tex dialysis access graft in the antecubital fossa. A photograph is shown above. Appropriate coverage of this defect is best accomplished using a flap that is vascularized by which of the following structures?

(A) Deep inferior epigastric artery
(B) Radial recurrent artery
(C) Septal branches of the profunda brachii artery
(D) Superficial circumflex iliac artery
(E) Ulnar artery

The correct response is Option B.

This defect is best reconstructed using a brachioradialis flap, which derives its vascularity from the radial recurrent artery pedicle. The brachioradialis muscle lies in a superficial position on the forearm and, therefore, is best suited for reconstruction of defects involving the anterior elbow; it is less reliable for coverage of posterior elbow defects. Because it is an accessory flexor, the patient will not experience weakness or loss of motion following flap transfer. Transposition of the muscle alone followed by skin grafting of the recipient site will prevent skin deficits at the donor site.

The deep inferior epigastric artery provides the primary blood supply for both the free rectus abdominis flap and the free transverse rectus abdominis (TRAM) flap. Free flap reconstruction could be performed in this patient but is unnecessary when a local flap is available. In addition, venous hypertension resulting from the arteriovenous fistula would increase this patient's risk for free flap failure.

The septal perforating branches of the profunda brachii artery provide the primary vascularity for the lateral arm flap, which is especially reliable when transferred as a free flap. The distally based lateral arm flap is dependent on the tenuous anastomoses between the recurrent radial vessels and the profunda brachii artery and, thus, would not be directly vascularized by the profunda brachii artery.

The superficial circumflex iliac artery supples blood to the groin flap, which is used to cover defects of the hand, wrist, and distal forearm but often lacks adequate length to reliably cover elbow defects.

Although the ulnar forearm flap, supplied by the ulnar artery, can be used for reconstruction of forearm, elbow, and arm defects, its harvest would involve sacrifice of the dominant blood supply to the hand and fingers. In addition, transfer of this flap would intensify steal phenomenon, which is typically seen in patients who have large arteriovenous fistulas created for dialysis access.

References
1. Strauch B, ed. Atlas of Microvascular Surgery. New York, NY: Thieme Medical Publishers, Inc; 1993.
2. Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb's Encyclopedia of Flaps. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998.

Which of the following structures provides the vascular supply to the osteocutaneous radial forearm flap?

(A) Fascioperiosteal perforators between the flexor carpi radialis and palmaris longus muscles
(B) Fascioperiosteal perforators between the brachioradialis and flexor carpi radialis muscles
(C) Musculoperiosteal perforators from the recurrent radial artery
(D) Musculoperiosteal perforators through the flexor digitorum profundus muscle
(E) Musculoperiosteal perforators through the pronator teres muscle

The correct response is Option B.

During harvest of the osteocutaneous radial forearm flap, a segment of radius as long as 10 cm with as much as 40% of the cross-section of the radius can be harvested. This flap can be found between the insertion of the pronator teres and brachioradialis muscles and is raised from the radial and ulnar sides. Vascularity is primarily supplied by fascioperiosteal perforators that lie within the intermuscular septum between the brachioradialis and flexor carpi radialis muscles. Musculoperiosteal branches of the flexor pollicis longus and perforators in the pronator quadratus muscle arising from the radial artery also supply blood to the flap. Dissection is performed laterally to the anterolateral intermuscular septum between the flexor carpi radialis and brachioradialis muscles and medially to the medial side of the intermuscular septum between the brachioradialis and flexor carpi radialis muscles. The brachioradialis is retracted radially and the flexor carpi radialis is retracted medially. The bellies of the flexor pollicis longus and pronator quadratus muscles are divided longitudinally to the radial periosteum, and the periosteum is incised beyond the attachments of the septum to the radius. Bone instruments are used to remove a segment of radius attached to the intermuscular septum and to the remnants of the pronator quadratus and flexor pollicis longus.

The recurrent radial artery is part of the anastomotic vasculature that surrounds the elbow. The fascioperiosteal perforators lie within the intermuscular septum between the brachioradialis and flexor carpi radialis muscles, not the flexor carpi radialis and palmaris longus muscles. There are no functional perforators arising from the flexor digitorum profundus or pronator teres muscles to supply blood to the radius.

References
1. Serafin D. Radial forearm flap. In: Atlas of Microsurgical Composite Tissue Transplantation. Philadelphia, Pa: WB Saunders Co; 1996:389.
2. Strauch B, Yu HL. Radial forearm osteocutaneous flap. In: Atlas of Microvascular Surgery. New York, NY: Thieme Medical Publishers, Inc; 1993:63.