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CC BY-NC-ND 4.0 · J Reconstr Microsurg Open 2023; 08(02): e97-e113
DOI: 10.1055/s-0043-1777098
Original Article

“P6LAND”: An Educational Tool for Free Flaps

Natalia Ziolkowski
1   Division of Plastic, Reconstructive, and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
,
Siba Haykal
1   Division of Plastic, Reconstructive, and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
2   Toronto General Hospital Research Institute, University of Toronto, Toronto, Ontario Canada
3   Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
› Author Affiliations Funding None.
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Abstract

Background Microsurgical education requires both technical skill and didactic knowledge. Learners are frequently asked to describe free flaps and their knowledge tested in clinical work and during exams.

Methods We have created an educational tool that will aid learners in remembering important information related to flaps.

Results “P6LAND” which divides and organizes information into three parts: Preoperative considerations, Pedicle, Position, LANDmarks, Plane of dissection, Protection and Postoperative considerations.

Conclusion The aim of this paper is to further describe this educational tool and to provide a compendium for the most common fasciocutaneous, muscle, perforator, and bone flaps based on the literature. This tool was also prevalidated among a group of learners.

Keywords

microsurgery - learning - education - free flaps - flap - surgery


Publication History

Received: 19 November 2022

Accepted: 31 July 2023

Article published online:
28 November 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Singh M, Ziolkowski N, Ramachandran S, Myers SR, Ghanem AM. Development of a five-day basic microsurgery simulation training course: a cost analysis. Arch Plast Surg 2014; 41 (03) 213-217
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Loh CYY, Wang AYL, Tiong VTY. et al. Animal models in plastic and reconstructive surgery simulation-a review. J Surg Res 2018; 221: 232-245
    CrossrefPubMedGoogle Scholar
  • 3 Pafitanis G, Ghanem AM, Myers S. Experimental pork belly : a simulation training model for intramuscular perforator dissection. Plast Reconstr Surg Glob Open 2018; 6 (01) 1-6
    PubMedGoogle Scholar
  • 4 Pafitanis G, Cooper L, Hadjiandreou M, Ghanem A, Myers S. Microvascular anastomotic coupler application learning curve: a curriculum supporting further deliberate practice in ex-vivo simulation models. J Plast Reconstr Aesthet Surg 2019; 72 (02) 203-210
    CrossrefPubMedGoogle Scholar
  • 5 Pafitanis G, Hadjiandreou M, Miller R. et al. The use of mobile computing devices in microsurgery. Arch Plast Surg 2019; 46 (02) 102-107
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Buntic R, Buntic R. Atlas of Microsurgery Techniques and Principles. Accessed September 5, 2021 at: https://www.microsurgeon.org/
    PubMed
  • 7 Joyce CW, Carroll SM. Microsurgery: the top 50 classic papers in plastic surgery: a citation analysis. Arch Plast Surg 2014; 41 (02) 153-157
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Shokrollahi K, Whitaker IS, Nahai F. Flaps. 1st ed.. New York, NY: Thieme Medical Publishers, Inc.; 2017
    Google Scholar
  • 9 Zenn M, Jones G. Reconstructive Surgery: Anatomy, Technique, and Clinical Applications. St. Louis, Missouri: Quality Medical Publishing; 2012
    Google Scholar
  • 10 Horen SR, Jahromi AH, Konofaos P. Temporoparietal fascial free flap: a systematic review. 2021; 87 (06) e189-e200
    PubMedGoogle Scholar
  • 11 Collar RM, Zopf D, Brown D, Fung K, Kim J. The versatility of the temporoparietal fascia flap in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2012; 65 (02) 141-148
    CrossrefPubMedGoogle Scholar
  • 12 Tang AL, Bearelly S, Mannion K. The expanding role of scapular free-flaps. Curr Opin Otolaryngol Head Neck Surg 2017; 25 (05) 411-415
    CrossrefPubMedGoogle Scholar
  • 13 Ferrari S, Ferri A, Bianchi B. Scapular tip free flap in head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2015; 23 (02) 115-120
    CrossrefPubMedGoogle Scholar
  • 14 Powell DK, Nwoke F, Urken ML. et al. Scapular free flap harvest site: recognising the spectrum of radiographic post-operative appearance. Br J Radiol 2013; 86 (1023): 20120574
    CrossrefPubMedGoogle Scholar
  • 15 Cobb ARM, Koudstaal MJ, Bulstrode NW, Lloyd TW, Dunaway DJ. Free groin flap in hemifacial volume reconstruction. Br J Oral Maxillofac Surg 2013; 51 (04) 301-306
    CrossrefPubMedGoogle Scholar
  • 16 Amouzou KS, Berny N, El Harti A, Diouri M, Chlihi A, Ezzoubi M. The pedicled groin flap in resurfacing hand burn scar release and other injuries: a five-case series report and review of the literature. Ann Burns Fire Disasters 2017; 30 (01) 57-61
    PubMedGoogle Scholar
  • 17 Al Bayati MJ, Samaha MJ, Samaha G, Habal MB, Thaller SR, Panthaki ZJ. The groin flap revisited: remembering the contributions of Dr Ian Jackson to plastic surgery. J Craniofac Surg 2021; 32 (3, Suppl 3): 1207-1209
    CrossrefPubMedGoogle Scholar
  • 18 Al-Qattan MM, Al-Qattan AM. Defining the indications of pedicled groin and abdominal flaps in hand reconstruction in the current microsurgery era. J Hand Surg Am 2016; 41 (09) 917-927
    CrossrefPubMedGoogle Scholar
  • 19 Hwang K. The origins of deltopectoral flaps and the pectoralis major myocutaneous flap. J Craniofac Surg 2016; 27 (07) 1845-1848
    CrossrefPubMedGoogle Scholar
  • 20 Chan RCL, Chan JYW. Deltopectoral flap in the era of microsurgery. Surg Res Pract 2014; 420892
    PubMedGoogle Scholar
  • 21 Andrews BT, McCulloch TM, Funk GF, Graham SM, Hoffman HT. Deltopectoral flap revisited in the microvascular era: a single-institution 10-year experience. Ann Otol Rhinol Laryngol 2006; 115 (01) 35-40
    CrossrefPubMedGoogle Scholar
  • 22 Mikami T, Kagimoto S, Yabuki Y. et al. Deltopectoral flap revisited for reconstruction surgery in patients with advanced thyroid cancer: a case report. BMC Surg 2017; 17 (01) 101
    CrossrefPubMedGoogle Scholar
  • 23 Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 1965; 36: 173-184
    CrossrefPubMedGoogle Scholar
  • 24 Wirtz NE, Khariwala SS. Update on the supraclavicular flap. Curr Opin Otolaryngol Head Neck Surg 2017; 25 (05) 439-444
    CrossrefPubMedGoogle Scholar
  • 25 Trautman J, Gore S, Potter M. et al. Supraclavicular flap repair in the free flap era. ANZ J Surg 2018; 88 (06) 540-546
    CrossrefPubMedGoogle Scholar
  • 26 Hamidian Jahormi A, Horen SR, Miller EJ, Konofaos P. A comprehensive review on the supraclavicular flap for head and neck reconstruction. Ann Plast Surg 2022; 88 (06) e20-e32
    CrossrefPubMedGoogle Scholar
  • 27 Ullah S, Asif M, Ubaid M, Khalid A, Khan M, Rahman MF. Lateral arm flap: its usage as pedicle and free flap. Cureus 2020; 12 (12) e12136
    PubMedGoogle Scholar
  • 28 Kokkalis ZT, Papanikos E, Mazis GA, Panagopoulos A, Konofaos P. Lateral arm flap: indications and techniques. Eur J Orthop Surg Traumatol 2019; 29 (02) 279-284
    CrossrefPubMedGoogle Scholar
  • 29 Amin JD, Amin N, Hatten KM. The lateral arm free flap for head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2020; 28 (05) 365-369
    CrossrefPubMedGoogle Scholar
  • 30 Tan O, Aydin OE, Cinal H. et al. Latissimus dorsi flap harvest with a short incision. Microsurgery 2013; 33 (03) 203-206
    CrossrefPubMedGoogle Scholar
  • 31 Abdelmofeed AM, Fadey MA, Seif O, Abdelhalim MH, Younes MT. Usefulness of nerve-sparing pedicled segmental latissimus dorsi muscle flap combined with lateral thoracic skin flap for partial volume reconstruction in laterally located breast cancer. Eur J Plast Surg 2023; 46: 541-550
    CrossrefPubMedGoogle Scholar
  • 32 Lin CH, Wei FC, Levin LS, Chen MC. Donor-site morbidity comparison between endoscopically assisted and traditional harvest of free latissimus dorsi muscle flap. Plast Reconstr Surg 1999; 104 (04) 1070-1077 , quiz 1078
    CrossrefPubMedGoogle Scholar
  • 33 Chung J-H, You H-J, Kim H-S, Lee BI, Park SH, Yoon ES. A novel technique for robot assisted latissimus dorsi flap harvest. J Plast Reconstr Aesthet Surg 2015; 68 (07) 966-972
    CrossrefPubMedGoogle Scholar
  • 34 Djordjevic ML, Bumbasirevic MZ, Vukovic PM, Sansalone S, Perovic SV. Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children. J Pediatr Urol 2006; 2 (04) 333-339
    CrossrefPubMedGoogle Scholar
  • 35 Chiang I-H, Wang C-H, Tzeng Y-S. et al. Breast reconstruction using pedicled latissimus dorsi myocutaneous flaps in Asian patients with small breasts. Ann Plast Surg 2017; 78 (3, Suppl 2): S95-S101
    CrossrefPubMedGoogle Scholar
  • 36 Patel K, Lyu DJ, Kademani D. Pectoralis major myocutaneous flap. Oral Maxillofac Surg Clin North Am 2014; 26 (03) 421-426
    CrossrefPubMedGoogle Scholar
  • 37 Grinsell D, Lonie S, Wilson KC, Choong PFM. The innervated rectus abdominis flap for quadriceps reconstruction. J Plast Reconstr Aesthet Surg 2019; 72 (06) 941-945
    CrossrefPubMedGoogle Scholar
  • 38 Radwan RW, Tang AM, Harries RL, Davies EG, Drew P, Evans MD. Vertical rectus abdominis flap (VRAM) for perineal reconstruction following pelvic surgery: a systematic review. J Plast Reconstr Aesthet Surg 2021; 74 (03) 523-529
    CrossrefPubMedGoogle Scholar
  • 39 Van Vliet A, Girardot A, Bouchez J. et al. How big is too big? The effect of defect size on postoperative complications of vertical rectus abdominis flap reconstruction. Ann Plast Surg 2021; 86 (6S, Suppl 5): S571-S574
    CrossrefPubMedGoogle Scholar
  • 40 Buchel EW, Finical S, Johnson C. Pelvic reconstruction using vertical rectus abdominis. Ann Plast Surg 2003; 52 (01) 22-26
    CrossrefPubMedGoogle Scholar
  • 41 Sinnott CJ, Stavrides S, Boutros C, Kuruvilla A, Glickman LT. Dual-plane gluteal myocutaneous flap for reconstruction of ischial tuberosity pressure wounds. Ann Plast Surg 2020; 85 (S1, Suppl 1): S23-S27
    CrossrefPubMedGoogle Scholar
  • 42 Han HH, Choi EJ, Moon SH, Lee YJ, Oh DY. Combined V-Y fasciocutaneous advancement and gluteus maximus muscle rotational flaps for treating sacral sores. BioMed Res Int 2016; 8714713
    PubMedGoogle Scholar
  • 43 Doi K, Hattori Y, Soo-Heong T, Hiura Y, Kawakami F. Endoscopic harvesting of the gracilis muscle for reinnervated free-muscle transfer. Plast Reconstr Surg 1997; 100 (07) 1817-1823
    CrossrefPubMedGoogle Scholar
  • 44 Zukowski M, Lord J, Ash K, Shouse B, Getz S, Robb G. The gracilis free flap revisited: a review of 25 cases of transfer to traumatic extremity wounds. Ann Plast Surg 1998; 40 (02) 141-144
    CrossrefPubMedGoogle Scholar
  • 45 Dornseifer U, Kleeberger C, Kargl L. et al. Perfusion controlled mobilization after lower extremity free flaps-pushing the limits of time and intensity. J Reconstr Microsurg 2017; 33 (03) 179-185
    PubMedGoogle Scholar
  • 46 Walton Z, Armstrong M, Traven S, Leddy L. Pedicled rotational medial and lateral gastrocnemius flaps: surgical technique. J Am Acad Orthop Surg 2017; 25 (11) 744-751
    CrossrefPubMedGoogle Scholar
  • 47 Houdek MT, Wagner ER, Wyles CC. et al. Long-term outcomes of pedicled gastrocnemius flaps in total knee arthroplasty. J Bone Joint Surg Am 2018; 100 (10) 850-856
    CrossrefPubMedGoogle Scholar
  • 48 Gkiatas I, Korompilia M, Kostas-Agnantis I, Tsirigkakis SE, Stavraki M, Korompilias A. Gastrocnemius pedicled muscle flap for knee and upper tibia soft tissue reconstruction. A useful tool for the orthopaedic surgeon. Injury 2021; 52 (12) 3679-3684
    CrossrefPubMedGoogle Scholar
  • 49 Padberg FT, Johnston MV, Sisto SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg 2004; 39 (01) 79-87
    CrossrefPubMedGoogle Scholar
  • 50 Reece EM, Raghuram AC, Bartlett EL. et al. Vascularized iliac bone graft for complex closure during spinal deformity surgery. Plast Reconstr Surg Glob Open 2019; 7 (07) e2345
    CrossrefPubMedGoogle Scholar
  • 51 Zhao D, Wang B, Liu B. Vascularized iliac bone flap transfer for early and middle stages of osteonecrosis of the femoral head. JBJS Essential Surg Tech 2019; 9 (01) e5
    CrossrefPubMedGoogle Scholar
  • 52 Al Deek NF, Kao HK, Wei FC. The fibula osteoseptocutaneous flap: concise review, goal-oriented surgical technique, and tips and tricks. Plast Reconstr Surg 2018; 142 (06) 913e-923e
    CrossrefPubMedGoogle Scholar
  • 53 Awad ME, Altman A, Elrefai R, Shipman P, Looney S, Elsalanty M. The use of vascularized fibula flap in mandibular reconstruction; a comprehensive systematic review and meta-analysis of the observational studies. J Craniomaxillofac Surg 2019; 47 (04) 629-641
    CrossrefPubMedGoogle Scholar
  • 54 Guo L, Ferraro NF, Padwa BL, Kaban LB, Upton J. Vascularized fibular graft for pediatric mandibular reconstruction. Plast Reconstr Surg 2008; 121 (06) 2095-2105
    CrossrefPubMedGoogle Scholar
  • 55 Sarik JR, Bank J, Wu LC, Serletti JM. Superficial inferior epigastric artery: learning curve versus reality. Plast Reconstr Surg 2016; 137 (01) 1e-6e
    CrossrefPubMedGoogle Scholar
  • 56 Grünherz L, Wolter A, Andree C. et al. Autologous breast reconstruction with SIEA flaps: an alternative in selected cases. Aesthetic Plast Surg 2020; 44 (02) 299-306
    CrossrefPubMedGoogle Scholar
  • 57 Chevray PM. Update on breast reconstruction using free TRAM, DIEP, and SIEA flaps. Semin Plast Surg 2004; 18 (02) 97-104
    Article in Thieme ConnectPubMedGoogle Scholar
  • 58 Mangialardi ML, Baldelli I, Salgarello M, Raposio E. Thoracodorsal artery perforator flap in partial breast reconstruction: a systematic review. Plast Reconstr Surg Glob Open 2020; 8 (10) e3104
    CrossrefPubMedGoogle Scholar
  • 59 Beugels J, Cornelissen AJM, van Kuijk SMJ. et al. Sensory recovery of the breast following innervated and noninnervated DIEP flap breast reconstruction. Plast Reconstr Surg 2019; 144 (02) 178e-188e
    CrossrefPubMedGoogle Scholar
  • 60 Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?. Plast Reconstr Surg 2005; 115 (02) 436-444 , discussion 445–446
    CrossrefPubMedGoogle Scholar
  • 61 Tan BKH, Newman MI, Swartz KA, Samson MC. Subfascial perforator dissection for DIEP flap harvest. Plast Reconstr Surg 2009; 124 (03) 1001-1002
    CrossrefPubMedGoogle Scholar
  • 62 Tregaskiss A, Perez-Temprano A, Morris RJ. The subfascial perforator dissection for DIEP flap harvest. Plast Reconstr Surg 2008; 122 (05) 145e-146e
    CrossrefPubMedGoogle Scholar
  • 63 Feingold RS. Improving surgeon confidence in the DIEP flap: a strategy for reducing operative time with minimally invasive donor site. Ann Plast Surg 2009; 62 (05) 533-537
    CrossrefPubMedGoogle Scholar
  • 64 Gravvanis A, Niranjan NS. Retrograde dissection of the vascular pedicle of deep inferior epigastric artery perforator (DIEAP) flap. Ann Plast Surg 2008; 60 (04) 395-397
    CrossrefPubMedGoogle Scholar
  • 65 Xue EY, Cen N, Reece E, Chu CK, Winocour S. A standardized approach to deep inferior epigastric perforator flap marking. Plast Reconstr Surg Glob Open 2019; 7 (10) e2479
    CrossrefPubMedGoogle Scholar
  • 66 Médard de Chardon V, Balaguer T, Chignon-Sicard B. et al. The radial forearm free flap: a review of microsurgical options. J Plast Reconstr Aesthet Surg 2009; 62 (01) 5-10
    CrossrefPubMedGoogle Scholar
  • 67 Avery CME. Review of the radial free flap: is it still evolving, or is it facing extinction? Part one: soft-tissue radial flap. Br J Oral Maxillofac Surg 2010; 48 (04) 245-252
    CrossrefPubMedGoogle Scholar
  • 68 Hunter C, Moody L, Luan A, Nazerali R, Lee GK. Superior gluteal artery perforator flap: the beauty of the buttock. Ann Plast Surg 2016; 76 (May, Suppl 3): S191-S195
    CrossrefPubMedGoogle Scholar
  • 69 Mirzabeigi MN, Au A, Jandali S, Natoli N, Sbitany H, Serletti JM. Trials and tribulations with the inferior gluteal artery perforator flap in autologous breast reconstruction. Plast Reconstr Surg Glob Open 2011; 128 (06) 614-624
    CrossrefPubMedGoogle Scholar
  • 70 Tsuihiji K, Daniel BW, Kageyama T. et al. Free tensor fascia lata true-perforator flap transfer for reconstruction of the calcaneal soft tissue defect complicated with osteomyelitis in a patient with alcohol-induced Charcot foot: a case report and literature review. Microsurgery 2021; 41 (05) 473-479
    CrossrefPubMedGoogle Scholar
  • 71 Singh R, Wadhwani J, Rohilla RK, Kaur K. Proximal femoral resection and tensor fascia lata flap for recalcitrant trochanteric pressure ulcers. Spinal Cord Ser Cases 2019; 5: 15
    CrossrefPubMedGoogle Scholar
  • 72 Zeidler KR, Son JH, Carey JN, Watt AJ, Ho OH, Lee GK. Transverse tensor fascia lata myocutaneous flap for microvascular breast reconstruction: case report and review of the literature. Ann Plast Surg 2013; 70 (04) 438-441
    CrossrefPubMedGoogle Scholar
  • 73 Graboyes EM, Hornig JD. Evolution of the anterolateral thigh free flap. Curr Opin Otolaryngol Head Neck Surg 2017; 25 (05) 416-421
    CrossrefPubMedGoogle Scholar
  • 74 Wong C-H, Wei F-C. Anterolateral thigh flap. Head Neck 2010; 32 (04) 529-540
    CrossrefPubMedGoogle Scholar
  • 75 Schoeller T, Huemer GM, Shafighi M, Gurunluoglu R, Wechselberger G, Piza-Katzer H. Free anteromedial thigh flap: clinical application and review of literature. Microsurgery 2003; 24 (01) 43-48
    CrossrefPubMedGoogle Scholar
  • 76 Hoshal SG, Bewley AF. The anteromedial thigh free flap: a primary reconstructive option or second best?. Curr Opin Otolaryngol Head Neck Surg 2018; 26 (05) 312-318
    CrossrefPubMedGoogle Scholar
  • 77 Zhou X, Wang J, Qiang L, Rui Y, Xue M. Outcomes of using a modified anteromedial thigh perforator flap for repairing the anterolateral thigh free flap donor site: a retrospective clinical review. Medicine (Baltimore) 2018; 97 (16) e0491
    CrossrefPubMedGoogle Scholar
  • 78 Gong ZJ, Zhang S, Ren ZH, Zhu ZF, Liu JB, Wu HJ. Application of anteromedial thigh flap for the reconstruction of oral and maxillofacial defects. J Oral Maxillofac Surg 2014; 72 (06) 1212-1225
    CrossrefPubMedGoogle Scholar