Thread by @PlasticsFella

This is gonna be great in 15 mins with Stoke Mandeville and @pcneligan

Live tweeting in this thread, followed by summary of key points

Link: us02web.zoom.us/webinar/regist…

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@PLASTAUK @AcademicBucks @JPRASurg @BAPRASvoice @ICOPLASTsurgery @plasticstrainee

https://twitter.com/DrJamesKKChan/status/1258704461796687872

1/ What's involved in creating a textbook (5th Edition)?

- Zoom meetings
- Co-editors
- Long process (> 1 year)
- Finish editing by 2022
- Prior to publication: scatterproofs etc etc
- Publication: 2023

He would love suggestions for improving book (via email)

2/ Advantage of perforator flaps (PF)
- precision of donor tissue selection
- increase versatility
- longer pedicle length

3/

Disadv of PF

-understand anatomy
- can damage pedicle
- demand a particular technique of dissection

4/

3 types of PF
- direct
- muscle perforator
- septal perforator

these 3 types supply all 400 perforator flaps in the body

5/

What do you need?

- Doppler (Essential - everything else is bonus)
- CT Angio (position, course, caliber, NO info about perfusion capacity)
- ICG accurate for perfusion capacity
- Thermography (cheap, accurate)

6/

Perforator Patterns

1. Short IM course
2. Long IM course
3. Subfascial segment (easy to damage)
4. Paramuscular (?septal) -
5. Perforator at tendinous inscription (in abdomen)

7/ Facial Artery Perforator Flap (FAP)

- Based on perforators of facial artery
- Exploratory incision assess perforator (pulsating)
- Take 2 perforators (>2 is random flap, less reliable)
- Dissect perforator to source vessel (common mistake) to increase length

8/ Submental Artery Flap

- take artery and vein together (next to each other)
- can take ant belly of digastric and platysma (no morbidity)

9/ Parascapular Flap

- good for shoulder/suprascapular
- circumflex scapular artery
- can take as osteocutaneous flap (lateral border of scapula)
- increase length by dividing branches to lat. border of scapula (allows more rotation)

10/ Ant Neck flap coverage

- pec major: bulky, impinge on tracheostome
- deltopectoral: donor site morbidity, dog-ear on tracheostome
- IMAP flap: better option (PRS, 2007)

11/ Dorsal Scapular Artery Perforator Flap

- Angrigiani C, 2003
- a trapezius flap without muscle
- adv: no muscle, longer pedicle, reduced bulk means easier to tunnel.

12/ Intercostal Artery Perf. Flap

- Hamdi 2006 JPRAS
- Post, Lat, Ant. ICA modifications
- Lat: lateral chest wall or lateral breast defect, good cosmesis

13/ Thoracodorsal Flap (TDAP)

useful in:
- partial breast recon
- upper arm recon

14/ SCIP Flap

- donor site: minimal morbidity
- nice think skin
- many uses: diabetic foot ulcers, vulval recon, thorax
- "neligans favourite flap"

15/ SCAP Flap

- thick
- good pedicle length
- keeps muscle
- great for covering buttock, lower back

16/ ALT

- 15% septo
- 85% musculo
- subfascial: start medial, anterograde
- suprafascial: don't need to take fascia, goes retrograde, can take it thinner (can just take scarpas)

17/ Keystone Flap

- described by Felix Behan
- Width of flap is 1-1.5 x width of the defect
- incise skin, fat, fascia
- undermining at the leading edge
- then close secondary defect with V-Y

18/ Q&A - Mindset of Microsurgery

- doesn't distinguish between surgery and micro
- dissect flap with loupes, sometimes microscope
- don't have mindset that it is really difficult, just a lot of focus

19/ Q&A - Maximum amount of rotation

- 180 degrees
- should not strangulate then

20/ Perf. Flaps in Radiated Area

- Perforator for the flap is usually fine, its the healing of the flap to the radiated bed.
- sometimes can get pre-op CT angio to assess perforator is any concerns

21/ Q&A: Perforators in a Trauma Zone

- Tread carefully!
- Easily for the flap to die
- For example, would consider free flap instead of perf flap in a crush flap

22/ Q&A: Lower limb algorithm

Strongly dependent on mechanism - crush injury would prefer a free flap

23/ Q&A: Venous Congestion

- Common in pedicle flaps
- If pink, not worried
- If blue, worried
- Happy to use leeches early.