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Inservice Exam - 2005
Flaps
(A) Buccinator
(B) Depressor anguli oris
(C) Levator labii superioris
(D) Orbicularis oris
(E) Zygomaticus major
The correct response is Option A.
Because the buccinator muscle is sandwiched between the facial artery and the oral mucosa, it must be included in a facial artery musculomucosal flap. The buccinator muscle originates from the pterygomandibular raphe and inserts into the orbicularis oris muscle and mucosa of the lateral lip elements.
The other muscles listed are supplied by the facial nerve but are not included in a facial artery musculomucosal flap because of their location. The depressor anguli oris and zygomaticus major muscles lie superficial to the plane of dissection for this flap. The levator labii superioris muscle inserts into the lateral half of the lip, but its origin is from the infraorbital margin of the maxilla. The orbicularis oris muscle is anterior to the plane of dissection for the facial artery musculomucosal flap.
References:
1. Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg. 1992;90:421-429.
2. Wexler A. Anatomy of the head and neck. In: Ferraro JW, ed. Fundamentals of Maxillofacial Surgery. New York: Springer-Verlag; 1997:53-114.
A 65-year-old man undergoes operative removal of a basal cell carcinoma at the junction of the upper cheek and temporal region, followed by coverage of the resultant 10 _ 5-cm defect with a submental myocutaneous flap. This flap derives its blood supply from a branch of which of the following arteries?
(A) Facial
(B) Inferior thyroid
(C) Lingual
(D) Superior thyroid
(E) Transverse cervical
The correct response is Option A.
The submental flap is a myocutaneous flap that is useful in head and neck reconstruction. This flap provides a contour, color, and tissue texture that is suitably matched to the face. The flap is elevated below the level of the platysma muscle and includes the submental artery and vein, which are direct branches of the facial artery and vein. The flap can be transposed to cover defects in the lower and central thirds of the face and into the inferior aspect of the upper third of the face.
The submental artery is a consistent branch of the facial artery and gives off one or two cutaneous perforators to the submental skin. The submental artery runs in relation to the anterior belly of the diagastric muscle. Of the choices listed, the facial artery is the most superior branch of the external carotid artery. The lingual artery provides the blood supply to the tongue, the superior thyroid and inferior thyroid arteries provide the blood supply to the thyroid gland, and the transverse cervical artery gives off a descending branch, which provides the blood supply to the trapezius muscle.
References:
1. Faltaous AA, Yetman RJ. The submental artery flap: an anatomic study. Plast Reconstr Surg. 1996;97:56-60.
2. Pistre V, Pelissier P, Martin D, et al. Ten years of experience with the submental flap. Plast Reconstr Surg. 2001;108:1576-1581.
Which of the following arteries is the basis of the major blood supply to the pectoralis major myocutaneous flap for head and neck reconstruction?
(A) Internal mammary
(B) Lateral thoracic
(C) Superior thoracic
(D) Thoracoacromial
(E) Transverse cervical
The correct response is Option D.
The major blood supply to the pectoralis major myocutaneous flap is the thoracoacromial artery. This flap has been the workhorse for head and neck reconstruction. It remains a lifeboat flap for microvascular flap failures in the area. It arises from the second part of the axillary artery (continuation of the subclavian artery) and divides into four branches with the pectoral branch supplying the pectoral muscles and the flap. The superior thoracic artery arises from the first part of the axillary artery and also supplies some part of the pectoral muscles. The lateral thoracic artery also arises from the axillary artery but does not supply the flap. The internal mammary artery does supply the pectoralis major muscle and its accompanying skin; however, it cannot be pedicled on this axis for head and neck reconstruction. The transverse cervical artery originates from the subclavian artery and supplies the muscles of the neck and scapula.
References:
1. Gabella G. Cardiovascular. In: Bannister LH, Berry MM, Collins P, et al, eds. Gray’s Anatomy. 38th ed. New York: Churchill Livingstone, 1995:1504-1574.
2. Ariyan S. Pectoralis major muscle and musculocutaneous flaps. In: Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb’s Encyclopedia of Flaps. Vol 1. Philadelphia: Lippincott Williams & Wilkins; 1998:470-473.
Which of the following interventions is most appropriate to improve the viability of an ischemic skin flap?
(A) Apply medicinal leeches to the flap
(B) Apply nitroglycerin paste to the flap
(C) Elevate the affected area
(D) Ensure adequate fluid resuscitation
(E) Perform hyperbaric oxygen therapy
The correct response is Option D.
The initial 24-hour period is critical to flap viability. In cases of compromised arterial inflow, steps that can be taken to improve arterial inflow are of primary concern. Ensuring adequate postoperative fluid resuscitation is paramount. This ensures adequate cardiac output and optimizes tissue perfusion.
Medicinal leeches are indicated for venous congestion and would have questionable value in an ischemic setting. Although hyperbaric oxygen therapy and elevation may both have beneficial effects in this setting, they are less appropriate than fluid resuscitation. Some clinicians will use 2% nitroglycerin ointment to ischemic areas every four to six hours or silver sulfadiazine cream twice daily. Either of these techniques is believed to be useful in reducing the risk and extent of full-thickness skin loss but would probably not be as important as ensuring adequate hydration.
References:
1. Lockwood T. Body contouring with excisions. In: Goldwyn RM, Cohen MN, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001:1148-1149.
2. Zamboni WA, Roth AC, Russel RC, et al: The effect of hyperbaric oxygen on reperfusion of ischemic axial skin flaps: a laser Doppler analysis. Ann Plast Surg. 1992;28:339.
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