Flaps

A 68-year-old man undergoes excision of a recurrent scalp carcinoma, leaving a 5-cm defect with exposed calvarium lacking pericranium. The adjacent scalp is mobile enough for tissue advancement, and the patient is a poor candidate for prolonged microsurgery. What is the most appropriate reconstructive option?

A 52-year-old woman undergoes reconstruction of a cheek defect with a rotation flap. Two hours later, the distal portion of the flap is pale, cool, and has delayed capillary refill. Pinprick produces little bleeding. The flap inset appears tight. What is the most appropriate immediate management?

A 45-year-old man undergoes a local transposition flap for coverage of a dorsal hand defect. Four hours later, the flap is swollen, violaceous, and warm. Capillary refill is brisk, and pinprick produces rapid dark bleeding. What is the most likely diagnosis?

A 39-year-old woman undergoes a nasolabial flap for reconstruction of an alar defect. In the recovery area, the flap becomes tense and elevated, with increasing pain and dark swelling beneath the pedicle. What is the most appropriate next step?

A 63-year-old smoker requires local flap reconstruction after excision of a lower-leg skin cancer. The planned random-pattern flap would need to be long and narrow to reach the defect. Which design modification would most improve flap reliability?

A 58-year-old man has an infected knee prosthesis removed, leaving a deep anterior knee defect with exposed bone and a substantial dead space. After adequate debridement, which reconstructive option is most appropriate?

A 34-year-old man undergoes free-flap reconstruction of a traumatic lower-leg defect. Six hours later, the skin paddle becomes pale and cool, and the implantable Doppler signal is lost. What is the most appropriate next management step?

A 49-year-old woman requires reconstruction of a moderate-sized distal leg defect. A perforator-based local flap is planned to preserve the underlying muscle. Which operative principle is most important during flap elevation?

A 56-year-old man with previous radiotherapy requires coverage of a recurrent chest-wall wound. Local tissue is scarred, fibrotic, and poorly vascularized. What is the most appropriate reconstructive principle?

A 60-year-old man requires reconstruction with a large pedicled flap, but the distal territory has questionable perfusion because of previous surgery and scarring. The operation can be staged safely. Which strategy may improve distal flap survival?

A 47-year-old woman undergoes reconstruction of a lateral nasal defect with a bilobed flap. At closure, the secondary lobe is under marked tension and the nasal ala is pulled superiorly. What is the most appropriate intraoperative correction?

A 62-year-old man undergoes a rhomboid transposition flap after excision of a cutaneous malignancy from the upper back. Which design principle is most important for reducing distal flap ischemia?

A 55-year-old woman undergoes a cervicofacial advancement flap for a large cheek defect. On postoperative day 2, the flap remains viable, but a 2-cm distal segment is dark, dry, and clearly demarcated. There is no infection or underlying collection. What is the most appropriate management?

A 36-year-old man sustains a contaminated open fracture of the distal tibia. After serial debridement and skeletal stabilization, a free flap is planned. Which factor is most important when selecting recipient vessels?

A 51-year-old woman undergoes a pedicled flap for breast reconstruction. Several hours later, the flap becomes congested after she is positioned with excessive pressure over the pedicle. What is the most appropriate initial action?

A 44-year-old man has a dorsal hand wound with exposed metacarpal bone and extensor tendons after trauma. A thin flap is required to permit tendon gliding and later hand function. Which reconstructive principle is most appropriate?

A 59-year-old man undergoes a propeller perforator flap for coverage of a distal leg defect. After rotation through 160 degrees, the flap becomes increasingly congested. What is the most likely technical cause?

A 65-year-old woman undergoes a local flap for reconstruction of a lower eyelid defect. Postoperatively, the eyelid is pulled downward, exposing the inferior sclera. The flap remains viable. Which operative factor most likely contributed to this complication?

A 48-year-old man undergoes reconstruction of an infected sternal wound with a well-vascularized muscle flap after complete debridement. What is the principal advantage of muscle in this setting?

A 57-year-old woman undergoes free-flap reconstruction after composite resection of an oral tumor. Eight hours later, the flap is swollen and blue, capillary refill is rapid, and the venous Doppler signal has disappeared while the arterial signal remains audible. What is the most appropriate next step?

A 43-year-old woman undergoes excision of a scar contracture at the oral commissure. A V-Y advancement flap is planned to lengthen the contracted tissue without transferring skin from a distant site. Which operative principle is essential for successful advancement?

A 50-year-old man undergoes reconstruction of a triangular cheek defect using an advancement flap. During closure, standing cutaneous deformities develop at the flap base. What is the most appropriate method of correction?

A 29-year-old man sustains loss of volar soft tissue from the middle phalanx of the index finger with exposed flexor tendon. A cross-finger flap from the adjacent finger is selected. What is the main disadvantage of this reconstruction?

A 61-year-old woman undergoes a large rotational scalp flap. After the flap is inset, the distal edge appears well perfused, but the closure remains tight because the arc of rotation is insufficient. What is the most appropriate intraoperative modification?

A 54-year-old man undergoes lower-limb reconstruction with a fasciocutaneous flap. The flap is viable, but the donor site cannot be closed primarily without excessive tension. What is the most appropriate donor-site management?

A 40-year-old woman undergoes a local flap for nasal reconstruction. During elevation, the surgeon aggressively removes subcutaneous tissue to make the flap thinner. The distal flap subsequently becomes ischemic. Which structure was most likely damaged?

A 66-year-old man undergoes reconstruction of a sacral defect with a gluteal fasciocutaneous flap. Postoperatively, he is repeatedly positioned directly on the flap. The flap becomes swollen and dusky despite intact Doppler signals. What is the most appropriate initial management?

A 57-year-old woman undergoes a pedicled latissimus dorsi flap for chest-wall reconstruction. The skin paddle remains pink, but the underlying muscle appears progressively dark and noncontractile when inspected during reoperation. What is the most appropriate interpretation?

A 46-year-old man undergoes local flap reconstruction over the ankle. The flap is passed through a subcutaneous tunnel to reach the defect. Immediately after transfer, it becomes congested, but its color improves when it is withdrawn from the tunnel. What is the most appropriate correction?

A 63-year-old man requires coverage of an exposed carotid artery after extensive neck debridement. The surrounding skin is irradiated and infected, and a local random-pattern flap would be thin and unreliable. What is the most appropriate reconstructive principle?

A 52-year-old man undergoes reconstruction of a heel defect with a reverse-flow fasciocutaneous flap. Preoperative vascular assessment confirms adequate arterial inflow to the foot and a patent distal communicating circulation. Which principle allows the flap to survive after the proximal vascular connection is divided?

A 46-year-old woman undergoes a forehead flap for reconstruction of a full-thickness nasal defect. Three weeks later, the flap is healthy, and division of the external pedicle is planned. What is the most important prerequisite before pedicle division?

A 58-year-old man undergoes a pedicled groin flap for coverage of a complex hand wound. Ten days later, the flap remains viable, but the hand and groin are immobilized in an uncomfortable position. What is the most important aspect of ongoing management before pedicle division?

A 64-year-old woman undergoes breast reconstruction with a buried free flap and no external skin paddle. Postoperative examination cannot directly assess flap color or capillary refill. Which monitoring strategy is most appropriate?

A 49-year-old man undergoes reconstruction of a lower-leg defect with a free anterolateral thigh flap. The flap is initially well perfused, but after final skin closure it becomes pale and the arterial Doppler signal weakens. Releasing several recipient-site sutures immediately restores the signal. What is the most appropriate definitive correction?

A 56-year-old woman undergoes a large local advancement flap after excision of a trunk tumor. The flap reaches the defect, but its distal edge is under tension and becomes pale during temporary inset. Which intraoperative action is most appropriate?

A 38-year-old man undergoes free-flap reconstruction of a traumatic foot defect. Twelve hours later, the flap is warm and pink with normal capillary refill, but the Doppler signal is intermittently lost when the ankle is plantar-flexed. The signal returns when the ankle is placed in neutral position. What is the most appropriate next step?

A 70-year-old man undergoes reconstruction of a sacral pressure wound with a rotational gluteal flap. The flap heals, but the patient develops recurrent breakdown 3 months later after prolonged sitting without pressure-relieving equipment. What is the most important principle for preventing further recurrence?

A 45-year-old woman undergoes a perforator flap for reconstruction of a lower abdominal defect. Postoperatively, the flap remains viable but is excessively bulky and creates a significant contour deformity. When is flap debulking generally safest?

A 60-year-old man undergoes a local flap to cover an exposed tibial plate. One week later, the flap is viable, but clear fluid is draining from a small opening and a deep cavity remains beneath the flap. There is no fever or purulence. What is the most appropriate management?

A 61-year-old man undergoes reconstruction of a lateral ankle defect with a distally based fasciocutaneous flap. Immediately after inset, the flap becomes swollen and violaceous, with brisk capillary refill and dark bleeding on pinprick. The arterial Doppler signal remains present. What is the most appropriate next step?

A 46-year-old woman undergoes excision of a basal cell carcinoma from the nasal tip, leaving a 1.8-cm circular defect. The surrounding skin is relatively immobile, and primary closure would elevate the alar margin. Which local flap is most appropriate?

A 52-year-old man requires coverage of a proximal tibial defect with exposed bone following debridement of an infected knee wound. The gastrocnemius muscle is intact and the defect lies within reach. What is the most appropriate reconstruction?

A 38-year-old woman undergoes a rhomboid flap for reconstruction of a temple defect. At the end of surgery, the flap tip is pale and the donor site is under marked tension. Which modification is most appropriate?

A 57-year-old man undergoes free-flap reconstruction of a lower-leg defect. Four hours later, the flap is pale, cool, and slow to refill. The arterial Doppler signal is absent, but the venous signal had previously been normal. What is the most appropriate management?

A 64-year-old woman undergoes reconstruction of a radiated chest-wall wound with a pedicled latissimus dorsi flap. On postoperative day 1, the flap becomes tense and swollen, and the drain has stopped functioning. What is the most appropriate next step?

A 43-year-old man sustains a volar thumb defect with exposed tendon and bone after industrial trauma. Sensate durable coverage is required to restore pinch function. Which reconstructive principle is most appropriate?

A 59-year-old man undergoes a propeller perforator flap for a distal-leg defect. The flap is initially well perfused before rotation, but after 150 degrees of rotation it becomes purple and swollen. Returning it toward its original position improves the color. What is the most appropriate definitive action?

A 67-year-old woman undergoes a rotation flap for coverage of a sacral pressure injury. The flap heals, but six months later the ulcer recurs at the same site. Which factor most likely explains the recurrence?

A 55-year-old man undergoes free-flap reconstruction of a mandibular defect. The flap remains viable, but severe postoperative neck swelling causes progressive compression of the pedicle beneath a tight skin closure. Which is the most appropriate management?

A 56-year-old man is scheduled for mandibular reconstruction with a radial forearm free flap. Examination shows a palpable radial pulse, but during Allen testing the hand remains pale after release of the ulnar artery. What is the most appropriate next step?

A 48-year-old woman undergoes reconstruction of a large nasal defect after tumor excision. The defect includes external skin, a segment of alar cartilage, and internal nasal lining. What is the most appropriate reconstructive principle?

A 62-year-old man with diabetes and a history of smoking requires coverage of a distal posterior ankle wound. A reverse sural flap is being considered. Pedal pulses are weak, and the foot is cool. What is the most appropriate next step?

A 45-year-old woman undergoes a local flap for fingertip reconstruction. Several hours later, the flap is congested. The dressing is removed, sutures are loosened, and operative assessment confirms that the pedicle is not twisted, compressed, or thrombosed. Arterial inflow remains adequate, but venous outflow is insufficient. What is the most appropriate temporary salvage measure?

A 39-year-old man requires a long cutaneous flap to cover an elongated defect over the forearm. The surgeon is choosing between a random-pattern flap and an axial-pattern flap. Which characteristic most strongly favors the axial-pattern flap?

A 50-year-old woman undergoes harvest of a deep inferior epigastric perforator flap for breast reconstruction. During dissection, the selected perforator is excessively skeletonized and repeatedly stretched. The flap later develops patchy perfusion despite a patent main pedicle. What is the most likely explanation?

A 54-year-old man undergoes harvest of a large anterolateral thigh flap. The donor site can only be closed by placing the thigh skin under substantial tension. After closure, the leg becomes painful and tense, and distal pulses remain present. What is the most appropriate next step?

A 60-year-old woman undergoes breast reconstruction with a pedicled latissimus dorsi musculocutaneous flap. Six months later, contraction of the transferred muscle causes visible breast movement whenever she adducts her arm. What is the most likely diagnosis?

A 57-year-old man is being evaluated for fibular osteocutaneous free-flap reconstruction of a mandibular defect. The donor foot has a normal posterior tibial pulse but no palpable dorsalis pedis pulse. What is the most appropriate next step?

A 49-year-old man has a complex lower-face defect requiring external skin, intraoral lining, and a separate segment of vascularized muscle to fill dead space. The surgeon wants all components supplied by one vascular source while allowing independent positioning. Which reconstructive design is most appropriate?

A 58-year-old man undergoes reconstruction of a midfacial defect with a free flap. Six hours after surgery, the flap is mildly swollen but remains pink, warm, and soft, with a capillary refill time of 2 seconds and a strong Doppler signal. What is the most appropriate management?

A 47-year-old woman undergoes reconstruction of a medial canthal defect with a glabellar transposition flap. After inset, the flap is viable, but the medial eyebrow is pulled inferiorly and the nasal bridge appears distorted. What is the most likely technical cause?

A 65-year-old man requires reconstruction of an ischial pressure wound after complete bursectomy and debridement. The defect contains a deep cavity, and the surrounding skin is scarred from previous surgery. Which reconstructive option is most appropriate?

A 40-year-old woman undergoes a perforator-based abdominal flap for breast reconstruction. During flap elevation, perfusion of the lateral skin territory becomes poor after several secondary perforators are divided. What is the most appropriate intraoperative response?

A 53-year-old man undergoes pedicled flap coverage of an elbow wound. On postoperative day 1, the flap becomes pale whenever the elbow is flexed beyond 70 degrees and returns to normal when the arm is extended. What is the most appropriate management?

A 59-year-old woman undergoes a free flap for reconstruction of a lower-lip and chin defect. Twelve hours later, the skin paddle is pink, but the intraoral component is becoming dusky and foul-smelling. What is the most appropriate next step?

A 44-year-old man undergoes a local rotation flap for coverage of a scalp defect. After elevation, the flap reaches the defect only after a back-cut is extended close to its base. The distal flap becomes pale. What is the most likely cause?

A 62-year-old man undergoes free-flap coverage of an open tibial fracture. On postoperative day 3, the flap remains viable, but the patient develops fever, increasing wound pain, and purulent drainage from beneath the flap. What is the most appropriate management?

A 35-year-old woman undergoes a local flap after excision of a lesion from the nasal sidewall. Six months later, the flap is healthy but elevated above the surrounding skin because of excessive subcutaneous bulk. The scar is mature and stable. What is the most appropriate management?

A 57-year-old man undergoes free-flap reconstruction of the foot. During postoperative monitoring, the flap becomes dark red and swollen, capillary refill is less than 1 second, and pinprick produces brisk dark blood. The venous Doppler signal is absent, but the arterial signal remains strong. What is the most appropriate diagnosis and management?

A 66-year-old man undergoes pedicled pectoralis major flap reconstruction after resection of an irradiated neck wound. On postoperative day 1, the skin paddle is warm and pink, but its distal edge becomes pale whenever the patient turns his head toward the reconstructed side. The color returns when the head is placed in neutral position. What is the most appropriate next management step?

A 49-year-old woman undergoes local flap reconstruction of a large cheek defect after skin-cancer excision. The flap is viable, but final closure produces marked tension at the lower eyelid and early outward rotation of the lid margin. What is the most appropriate intraoperative management?