GOOD ABDOMINAL FLAP FOR FOREARM DEFECT

1. DRVIPINV NAIR
SR Plastic surgery
PGIMER Chandigarh
OPERATIVE SEMINAR
1

2. 2

3. Taylor GI, Daniel RK.The anatomy of several free flap donor sites. Plast Reconstr Surg
1975;56:243-53.

4. Taylor GI, Daniel RK.The anatomy of several free flap donor sites. Plast Reconstr Surg
1975;56:243-53.

5.  Skin island of theTU
flap supplied
Paraumbilical
perforators from the
deep inferior epigastic
vessels.
Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and deep inferior epigastric system.
Plast Reconstr Surg 1984;73:1-14. 5
 SIZE
 Sub centimetric
 Location
 Nearly constant

6.  Largest perforator is
 2 cm umbilicus
 Directs – inferior angle
of the scapula
 Anastomoses -posterior
intercostal artery
 Angulates 45° with the
midline
6
Fan QS.The anatomy and application of the thoracoumbilical flap. Chin J Microsurg 1987;10:129-32.

7. Taylor GI, Daniel RK.The anatomy of several free flap donor sites. Plast Reconstr Surg
1975;56:243-53.

8.  Pedicled flap
 Upper limb soft tissue
defects
 Groin defects
 Free flap
 Lower extremity defects
 Scalp defects
 Depressed facial
deformity
Zhang XQ,Wang SD, Fan QY, Mao BA, ZhouY, Zhang MH.Thoracoumbilical flap: experience with 33 flaps. J Reconstr Microsurg
2004;20:133-7. 8

9. 9

10.  Pinch test
 Assesses the elasticity
 Width of the flap.
 Surrounding tissues
are undermined and
the donor site is
closed primarily

13.  GA + ETT
 Supine
 Sand bag under
lower ribs SAME
side
13

14. Mishra S, Sharma RK.The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage. Indian J
Plast Surg. 2009 Jul;42(2):169-75. 14

15.  Lateral to medial
 Just superficial to
the underlying
musculature
 Include subdermal
plexus
 Vessels within the
fat and fascia
overlying the
abdominal muscles.
Indian journal of plastic surgery July-Dec 2009 voll42
15
Mishra S, Sharma RK.The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage. Indian J
Plast Surg. 2009 Jul;42(2):169-75.

16.  The dissection ceases
 At any point of time
the flap is adequate in
length
 2-3 cm medial to the
lateral border of the
rectus muscle
Mishra S, Sharma RK.The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage. Indian J Plast
Surg. 2009 Jul;42(2):169-75.

20.  If more length is
required
 Dissection continues
medially
 Rectus muscle is
divided
 Flap based on the
inferior epigastric
artery
20
Mishra S, Sharma RK.The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage. Indian J
Plast Surg. 2009 Jul;42(2):169-75.

21.  Limb immobilized with adhesives
 Pillow underneath elbow
 Immobilization splint
 Flap monitoring
 Flap division and inset-3 weeks
21
Mishra S, Sharma RK.The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage. Indian J
Plast Surg. 2009 Jul;42(2):169-75.

22. Mishra Bharat, Sharma Ramesh K, Singh Harbans Universal Splint for upper limb support during
reconstruction by pedicled abdominal flap Year : 2015 |Volume: 48 | Issue Number: 2 | Page: 223-225

24. Early
 Post op side bleeds
 Dehiscence
 Distal necrosis of flap
 Donor site necrosis
 Post op infections
Late
 Donor site scar
 Bulky medial portion
 Bulky flap
Mishra S, Sharma RK.The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage. Indian J
Plast Surg. 2009 Jul;42(2):169-75. 24

25.  ROBUST flap
 Fixed vascular anatomy
 Single stage
 Long flap extended without
delay
 Dissection quick and easy
 Entire surgery supine position
 Donor site closed primarily
(J Hand Surg 2010;35A:1105–1110. © 2010 Published by Elsevier Inc. on behalf of the
American Society for Surgery of the Hand.) 25
(J Hand Surg 2010;35A:1105–1110. © 2010 Published by Elsevier Inc. on behalf of the
American Society for Surgery of the Hand.)
(O’Shaughnessy, K.D., Rawlani,V., Hijjawi, J.B., Dumanian,G.A. Oblique pedicled paraumbilical perforator–based flap
for reconstruction of complex proximal and mid-forearm defects: a report of two cases. J HandSurg. 2010;35:1105–1110

26.  Bulky in an obese
patient
 Insensate flap
 Scar
 Long
 May stretch with time
 Arm fixed for long time
(O’Shaughnessy, K.D., Rawlani,V., Hijjawi, J.B., Dumanian,G.A. Oblique pedicled paraumbilical perforator–based flap
for reconstruction of complex proximal and mid-forearm defects: a report of two cases. J HandSurg. 2010;35:1105–111026

27. Indian journal of plastic surgery July-Dec 2009 voll42
27
Mishra S, Sharma RK.The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage. Indian J
Plast Surg. 2009 Jul;42(2):169-75.

28. Indian journal of plastic surgery July-Dec 2009 voll42
28
Mishra S, Sharma RK.The pedicled thoraco-umbilical flap: A versatile technique for upper limb coverage. Indian J
Plast Surg. 2009 Jul;42(2):169-75.

29. 29

30. 30

31.  Muscle can be added to add bulk
 De epithelialized flaps
 Wing flaps
 Free flaps
 Osteocutaneous flaps
31

32. 32

33. 33

34. 34

35. 35

36. 36

37. 37

38. 38

39. 39

41. (Ann Plast Surg 2007;59: 495–500) 41
Wing Flaps”Perforator-Based Pedicled Paraumbilical Flaps for Skin Defects in Hand and Forearm B.Jagannath Kamath, MS (Ortho),Thangam
Verghese, MS (Gen Surg),and Praveen Bhardwaj, MS, DNB (Ortho) Annals of Plastic Surgery •Volume 59, Number 5, November 2007

42. (Ann Plast Surg 2007;59: 495–500) 42
Wing Flaps”Perforator-Based Pedicled Paraumbilical Flaps for Skin Defects in Hand and Forearm B.Jagannath Kamath, MS (Ortho),Thangam
Verghese, MS (Gen Surg),and Praveen Bhardwaj, MS, DNB (Ortho) Annals of Plastic Surgery •Volume 59, Number 5, November 2007

43. Wing Flaps”Perforator-Based Pedicled Paraumbilical Flaps for Skin Defects in Hand and Forearm B. Jagannath Kamath, MS (Ortho),Thangam
Verghese, MS (Gen Surg),and Praveen Bhardwaj, MS, DNB (Ortho) Annals of Plastic Surgery •Volume 59, Number 5, November 2007 43

44. (J Hand Surg 2010;35A:1105–1110 44
(O’Shaughnessy, K.D., Rawlani,V., Hijjawi, J.B., Dumanian,G.A. Oblique pedicled paraumbilical perforator–based flap
for reconstruction of complex proximal and mid-forearm defects: a report of two cases. J HandSurg. 2010;35:1105–1110

45. Groin Flap TU Flap
Artery Superficial
circumflex iliac artery SCIA
Deep Inferior Epigastric
DIEA
Extensive forearm
Defects
Cannot cover Good cover
Hand Oedema More Less
Post operative
physiotherapy
Cumbersome Easier
Physiologic condition Inferior Better
Mobilisation of elbow Late Early
Position Difficult and uncomfortable Better

48. . Indian J Plast Surg. 2009 Jul;42(2):169-75

49. J HandSurg. 2010;35:1105–1110

50.  Very useful coverage of
upper-limb defects
 Donor site closed
primarily
 Dissection is quick and
systematic.
 Elevated position
 Minimal oedema and
congestion
 Workhorse
 Upper extremity defects
 Especially in emergency
setting, where defect size is
large and/or emergency free
flap is not feasible.

51.  Plastic Surgery Peter C. Neligan :Volume 6 , 3rd Edition
 J.Brian Boyd, G.IanTaylor and Russel Corlett-The vascular territories of superior epigastric and deep
inferior epigastric systems .PRS- vol 73 no 1 Jan-1984
 J.Brian Boyd,Susan E. Mackinnon-An Evaluation of the Pedicled Thoracoumbilical Flap in Upper
Extremity Reconstruction.nAnnals of Plastic Surgery,vol22 no3 236-242 March 1989
 THE SUPRAFASCIAL COURSE OFTHE DIRECT PARAUMBILICAL PERFORATOR VESSELS El-Mrakby,
Hamdy H. M.D.; Milner, R. H. M.D. Plastic and Reconstructive Surgery Issue:Volume 109(5), 15 April
2002, pp 1766-1768
 Xing-quan Zhang, M.D.,1 Shao-dong Wang, M.D.,1 Qing-yu Fan, M.D.,1Bao-an Mao, M.D.,1Yong
Zhou, M.D.,1 and Ming-hua Zhang, M.D. Thoracoumbilical Flap: Experience with 33 Cases. Journal of
Reconstructive Microsurgery, Volume 20, Number 2, 2004
 Wing Flaps”Perforator-Based Pedicled Paraumbilical Flaps for Skin Defects in Hand and Forearm B.
Jagannath Kamath, MS (Ortho),Thangam Verghese, MS (Gen Surg),and Praveen Bhardwaj, MS, DNB
(Ortho) Annals of Plastic Surgery • Volume 59, Number 5, November 2007
51

52.  The pedicled thoraco umbilical flap-A versatile technique for upper limb
coverage.Sharad Mishra,Ramesh Kumar Sharma. Indian journal of plastic
surgery Jul-Dec 2009 vol42 issue 2,169-175.
 Oblique Pedicled Paraumbilical Perforator–Based Flap for Reconstruction of
Complex Proximal and Mid-Forearm Defects: A Report ofTwo Cases Kristina D.
O’Shaughnessy, MD,Vinay Rawlani, MD, John B. Hijjawi, MD,Gregory A.
Dumanian, MD(J Hand Surg 2010;35A:1105–1110
 Perforasomes of the DIEP Flap:Vascular Anatomy of the Lateral versus Medial
Row Perforators and Clinical ImplicationsCorrineWong, M.R.C.S. Michel Saint-
Cyr, M.D.Ali Mojallal, M.D.Tim Schaub, M.D.Steven H. Bailey, M.D.Simon Myers,
Ph.D.,Spencer Brown, Ph.D.Rod J. Rohrich, M.D. Plast. Reconstr. Surg. 125: 772,
2010.)
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