FLAPS & GRAFTS—-DANIEL TODD, MD FLAPS (KEEPS ITS BLOOD SUPPLY INTACT)—HEAL IN BY BOTH ORIGINAL BLOOD SUPPLY AND INOSCULATION CAN DELAY ANY FLAP—DELAY PHENOM=CLOSURE OF A-V SHUNTS BY CUTTING SYMPATHETICS—USUALLY ABOUT 2-3 WEEKS FLUORESCEINE DYE TEST—-BEST TO PREDICT VIABILITY PRIMARILY FAIL BECAUSE OF VENOUS CONGESTION/INSUFFIECIENCY—-ALLOPURINOL OR NITROBID MAY HELP OTHER RHEOLOGIC AGENTS ARE QUESTIONABLE (PENTOXYPHYLLINE) DIRECT INGROWTH OF HOST BV’S INTO THE FLAP OR GRAFT IS MOST IMPORTANT FOR REVASCULARIZATION ASA OR NSAIDS WILL GIVE YOU FITS—-KEEP THEM OFF THESE FOR A COUPLE OF WEEKS TISSUE EXPANDERS THIN THE DERMIS BUT INCREASE THE VASCULARITY—ALSO RESHAPE THE UNDERLYING BONE–THICKEN THE EPIDERMIS BIGGEST REASON FOR PROBLEMS IS VENOUS INSUFEICENCY—-ENGORGEMENT—-VENOUS CONGESTION—–POKE HOLES IN IT—PUT HOLES IN THE CARTILAGE—RELEASE SOME STITCHES—GIVE SOME DECADRON PRE OR INTRAOPERATIVELY– MEDICAL GRADE LEECHES (HIRUDO MEDICINALIS) CNA BE USED—-REMOVE CONGESTED BLOOD AND GIVE AN ANTICOAGULANT—-CAN TRANSMIT AEROMONS HYDROPHILE—A BACTERIA—COVER WITH CIPRO OF TMP/SMX ALWAYS CONSIDER HBO DEFINITIONS: FLAPS CAN BE DEFINED BY THEIR BLOOD SUPPLY: RANDOM PATTERN (LOCAL) FLAPS—BLOOD SUPPLY = DERMAL-SUBDERMAL PLEXUS LIMITED IN LENGTH /WIDTH RATIO = 3/1—–LESS THAN 15 CM MOST FACIAL FLAPS COME UNDER THIS HEADING AXIAL (ARTERIAL)PATTERN—-BLOOD SUPPLY = DIRECT CUTANEOUS ARTERIES AND VEINS ALWAYS AT LEAST 2 STAGES BY THEIR CONFIGURATION: RHOMBOID, BILOBE, ECT… BY THEIR METHOD OF TRANSFER (REALLY ONLY 2 MOVEMENTS: LIFTING AND SLIDING)—THE MOST ACCEPTED MEANS OF DEFINING THEM: LOCAL FLAPS: PIVOTAL—ROTATING THE BASE AROUND A PIVOTAL POINT——THE EFFECTIVE LENGTH OF THE FLAP DECREASES AS THEY PIVOT—-RELIES BOTH ON THE ELASTICITY AND AVAILABILITY OF THE PROXIMAL TISSUE ROTATION—BORDERS THE DEFECT—-A PIVOTAL FLAP WITH A CURVILINEAR CONFIGURATION—THOUGHT OF AS A SEMICIRCULAR FLAP—-BEST SUITED FOR REPAIRING TRIANGULAR PRIMARY DEFECTS GOOD FOR LARGE CHEEK OR NECK DEFECTS AS CLOSURE IS MORE IMPORTANT THAT OBEYING THE RSTL’S DOUBLE OR TRIPLE ROTATION/PIVOTAL FLAPS ARE GOOD FOR SCALP DEFECTS (PINWHEEL FLAP) TRANSPOSITION—-BORDERS THE DEFECT—THOUGHT OF AS A RECTANGULAR FLAP—-A PIVOTAL FLAP WITH A STRAIGHT LINEAR AXIS—WORKS BETTER THAT ROTATION FLAPS IN UTILIZING THE RSTL AND LME—-YOU IN ESSENSE SELECT A PROXIMAL DONOR SITE BASED ON HOW THE SECONDARY (DONOR) DEFECT WILL CLOSE CAN BE AXIAL, COUMPOUND, OR MOST COMMONLY RANDOM THE MOST COMMONLY USED LOCAL FLAPS USED IN THE H & N——INCLUDE: BILOBED “3″ FLAPS, NOTE FLAPS, RHOMBIC FLAPS, BANNER FLAPS ECT….“3″-BILOBED FLAP—EXCELLENT FOR NASAL DORSUM DEFECTS < 1.5 CM INTERPOLATION FLAP—-A PIVOTAL FLAP WHICH DOES NOT BORDER THE DEFECT—-LIKE A TRANSPOSITION FLAP HAS A STRAIGHT LINEAR CONFIGURATION—-BY DEFINITION PASSES OVER OR UNDER A BRIDGE OF NL TISSUE TO REACH PRIMARY DEFECT—THUS USUALLY REQUIRES A SECOND STAGE INCLUDES: PARAMEDIAN FOREHEAD FLAP, SUP BASED MELOLABIAL FLAP, BIPEDICLED TUBE SKIN FLAP USED TO RECONSTRUCT HELICAL DEFECTS, POST AURICULAR TO CONCHAL BOWL ISLAND TRANSFER FLAP ADVANCEMENT FLAPS—-HAVE A LINEAR CONFIGUATION—-MOVE INTO THE DEFECT IN A SINGLE VECTOR BY STRETCHING—THUS PRIMARILY DEPEND ON THE ELASTICITY OF TISSUE SINGLE PEDICLE (CAN BE LARGE LIKE A MUSTARDE CHEEK ADVANCEMENT FLAP—SHOULD HAVE A BIT OF A SUP VECTOR TO PREVENT ECTROPION)—CAN BE SMALL LIKE ON THE LAT FOREHEAD SLIDING HELICAL ADVANCEMENT FLAP—–MAY TAKE A TRIANGLE OUT TO HELP CLOSE THE ANTIHELICAL DEFECT—-LEAVE THE SKIN AND PERICHONDRIUM ON THE FLAP AND UNDERMINE THE POST CONCHAL BOWL FOR ADVANCEMENT —-CAN ALSO ADVANCE SOME FROM THE SUP ROOT OF THE HELIX BIPEDICAL-—-CAN TAKE OUT LAT BURROWS TRIANGLES TO FACILITATE SECONDARY MOVEMENT V–Y OR Y-V A–T OR O-T—-EXCELLENT FOR DEFECTS BORDERING SUBUNITS (LIKE ALONG THE SCALP) HINGE FLAPS—–BORDERS THE DEFECT—-DONOR EPITHELIUM IS ESSENTIALLY OPENED LIKE A BOOK AND COVERS THE OPPOSITE SIDE OF A DEFECT—-REALLY ONLY FOR DEFECTS ON STRUCTURES WITH 2 SIDES(NOSE OR EAR)—–OFTEN USED TO RECONSTRUCT THE INTERNAL LINING OF A NASAL DEFECTS WITH THE REMAINING SUBUNIT THAT IS TO BE DISCARDED
SPECIFIC FLAPS FOREHEAD FLAP—-PRIMARILY BASED ON THE SUPERFICIAL TEMPORAL ARTERY (OCCIPITAL A)—-CAN ALMOST UTILIZE ENTIRE SCALP BASED ON ST ARTERY TEMPOROPARIETAL FASCIAL FLAP (TRUE SUPERFICIAL TEMPRORAL FASCIA—CONTIGUOUS WITH THE GALEA/SMAS/PLATYSMA)—-SUPERFICIAL TEMPORAL ARTERY CAN INCLUDE SKIN—-FOREHEAD FLAP CAN INCLUDE TEMPORALIS MUSCLE—MYOCUTANEOUS FLAP LIP SWITCH FLAP—ABBE (MID) OR ESTLANDER (COMMISURE) FLAPS ORIGINALLY DESCRIBE FROM BOTTOM TO TOP—USUALLY REVERSED DUE TO SUN EXPOSURE A TRUE ESTLANDER FLAP IS A SINGLE STAGE PROCEDURE—-CAN DO A LATER COMMISUROPLASTY MAKE THE HEIGHT OF THE DONOR AND RECIPIENT IDENTICLE MAKE THE DONOR ½ THE WIDTH OF THE RECIPIENT VESSELS ARE NEAR THE MUCOSA (LABIAL ARTERY OR CORONARY ARTERY OF THE LIP)—MAKE YOUR DONOR PEDICLE LATERAL FREE THE DONOR FLAP ABOUT 3 MM PAST THE VERMILLION CUT A QUARTER MOON BURROWS TRIANGLE LATERAL TO THE ALA FOR A REVERSE ABBE FLAP TO ALLOW FOR BETTER DONOR SITE CLOSURE TEACH PTS HOW TO CARE FOR THE FLAPS—-SPONGE QID WITH H2O2 OBSERVE PTS FOR AT LEAST A FEW HOURS—IF ANY CYANOSIS–CLIP SOME PROXIMAL SUTURES PARA/MEDIAN FOREHEAD FLAP—THE INDIAN METHOD AN AXIAL PATTERN FLAP BASED ON THE SUPRATROCHLEAR BUNDLE THE WORK HORSE OF NASAL RECONSTRUCTION—-NEED CLEAR MARGINS PRIOR TO RECONSTRUCTION (OFTEN MOHS) FOR REPAIRING NASAL DEFECTS THINK–INT LINING, STRUCTURE, AND COVER (THE FOREHEAD FLAP PROVIDES COVER) STRUCTURE CAN BE FROM CONCHAL OR SEPTAL CARTILAGE—CONCHA CYMBA CONTOUR APPROXIMATES THE LOWER LATERAL CARTILAGE THINK CONTOUR OVER EVERYTHING INT LINING FROM INTRANASAL MUCOSAL FLAP OR MESOLABIAL ROTATION FLAP—OR CAN PLACE STSG ON POST FOREHEAD FLAP–THINK ABOUT SEPTAL OR INF TURB MUCOSA PT SHOULD BE PREPARED FOR A MULTISTAGED PROCEDURE DOPPLE OUT BV’S—-BASED ON THE SUPRATROCHLEAR ARTERY(VERY RELIABLE)—IF INJURED ADJACENT CASCADING VESSELS MAY BE ADEQUATE-BUT DO NOT COUNT ON ‘EM—DRAW OUT–USUALLY 2 CM (1.7-2.2 CM) FROM THE MIDLINE MAY MAKE PEDICLE AS NARROW AS 1.2 CM PREOP ABX MEASURE DEFECT—CONSTRUCT TEMPLATE—-DRAW FLAP— USE SUBUNIT PRINCIPLE OF GARY BURGET—-IF > 50% OF SUBUNIT GONE— REMOVE IT ALL AND RECONSTRUCT IT AS A SINGLE UNIT GENERALLY ROTATE IPSILATERAL USE A FOLDED GUAZE TO SIMULATE TRANSFER AND DETERMINE LENGTH (OVERESTIMATE A BIT) DO NOT HESITATE TO USE HAIRBEARING SCALP—-CAN LATER DESTROY FOLLICLES RUBBER BAND TIES TO HAIR 6-0 SILK HORIZONTAL MATTRESS TARSORRAPHY STITCH OVER LACRILUBE INJECT–BUT NOT PEDICLE THROAT PACK DRAPE OUT BOTH EARS—-CONSIDER IOWA HAT PULLEY STITCH WITH 2-0 NYLON (FAR—NEAR—NEAR–FAR) MAY THIN DISTAL FLAP TO FIT CONTOUR DO NOT THIN THE PROXIMAL 1/3 AT ALL DUE BLUNT MOSQUITO DISSECTION NEAR THE PEDICLE BASE—-CAN TAKE IT BELOW THE BROW MAY NEED TO SECTION THE CORRUGATOR SUPERCILII FOR ADDED LENGTH ALLOW ANY ARE THAT WILL NOT PULL TOGETHER PRIMARILY TO HEAL IN SECONDARILY—GET GOOD RESULT HERE TAKE CARE NOT TO TORQUE/KINK THE PEDICLE WILL GET REMARKABLE RETRACTION IF YOU DO NOT HAVE AN INTERNAL LINING USUALLY WAIT 3-4 WEEKS BEFORE DIVISION AND INSET—–4-6 WEEKS IN SMOKERS/DIABETICS CAN TWIST THE FLAP EITHER WAY TO GET BEST RESULT ELEVATE DISTAL 1/3 FLAP IN SUB Q PLANE MIDDLE 1/3 IN SUB-GALEAL PLANE PROXIMAL 1/3 SUB-PERIOSTEAL REALLLY CAN JUST GO SUB GALEAL ENTIRE TIME—ESPECIALL IN THIN SKINNED INDIVIDUALS—THEN GO DEEP TO VASCULAR PEDICLES MAY DO DERMABRASION OR SCAR REVISION AS EARLY AS 8 WEEKS OFTEN MAY LEAVE MEROCEL IN A FEW DAYS TO AID IN HEALING DP FLAP = BAKAMJIAN FLAP AXIAL PATTERN SKIN FLAPOF THE UPPER CHEST–BLOOD SUPPLY=DIRECT CUTANEOUS ARTERIES AND VEINS MEDIALLY BASED AND HORIZONTALLY ORIENTED, MAY HAVE DISTAL RANDOM SEGMENT 1ST 3 OR 4 PERFORATING INTERCOSTAL BRANCHES OF THE INT. MAMMARY ARTERY—DISTAL PORTION=RANDOM(BLOOD SUPPLY=DERMAL/SUBDERMAL PLEXUS–LIMITED RATIO W/L=3:1, <15CM) KEEP WIDE MEDIALLY CAN DELAY ANY FLAP–DELAY PHENOM=TRAINING THE FLAP–CLOSURE OF A-V SHUNTS BY CUTTING SYMPATHETICS ANY DELAY OR STAGE—3-4 WKS
CUT OUT FLAP BUT LEAVE CONNECTED DISTALLY ABOUT 4-5 CM RAISE OFF THE CHEST MUSCULATURE AND TAKE IP THE FASCIA WITH THE FLAP TO PROTECT THE AXIAL PATTERN VASCULATURE WILL NEED TO LEAVE A #10 JP DRAIN CAN ADD HBO MAY DO LONGER IF DM, SMOKER, RT, ELDERLY, ARTERIOSCLEROSIS, RADIATED,OR MALNOURISHED PRIMARILY FAIL EARLY FROM SHEAR FORCES, FLUID COLLECTIONS, INFXN, POOR VASCULARIZATION, OR TECHNICAL ERROR PRIMARILY FAIL LATE BECAUSE OF VENOUS INSUFFICIENCY WATCH OUT FOR CEPHALIC VEIN AND AXILLARY CONTENTS NEVER LET FLAP REST ON TRACH OR TIES ECT… NEVER DRAPE OVER A RECONSTRUCTION PLATE NASO(MELO)LABIAL FLAP—-BASED ON THE ANGULAR ARTERY (OFF FACIAL) INF BASED NL FLAP CROSSES THE NASOLABIAL FOLD—LOOKS BAD BETTER TO BASE FLAP SUPERIORLY AND CLOSE DONOR SITE AS NEW NL FOLD TAKE DEEP TO SQ TISSUE—DO NOT TAKE UNDER MUSCLE CLOSE DONOR SITE FIRST! BEST TO USE AS AN INTERPOLATION FLAP—–LEAVING THE NL NASOFACIAL GROOVE TO DEFINE THE SUBUNIT DIVISION WHEN REPAIRING THE ALAR SUBUNIT—-REPLACE THE FIBROFATTY TISSUE WITH A CONCHAL CARTILAGE GRAFT TO HOLD THE ALA PATENT REPLACE THE MAJORITY OF THE ALA BILAT MELOLABIAL FLAPS—MAKES FOR EXCELLENT RECONSTRUCTION OF LARGE NASAL DORSAL DEFECTS—-SUP BASED FLAPS ARE THICKEST AND COLOR MATCH IS EXCELLENT MYOCUTANEOUS FLAPS—-AXIAL FLAPS WITH SEGMENTAL VASCULAR SUPPLY KARAPANZIC—CAN OFTEN DO A SECONDARY COMMISUROPLASTY FOR RESULTANT MICROSTOMIA NASALIS MYOCUTANEOUS ADVANCEMENT FLAP—-EXCELLENT FOR LATERAL TIP DEFECTS—CANNOT BE TOO CLOSE TO THE ALA OR WILL NOTCH—-VERY GENTLE MOSQUITO DISSECTION PECTORALIS MAJOR MYOCUTANEOUS FLAP= THE WORK HORSE OF THE H&N=ARIYAN’S FLAP AN AXIAL FLAP = A SEGMENTAL VASCULAR SUPPLY DEPENDABLE, SINGLE STAGE, SENSATE, ABLE TO TOLERATE RT DOWN SIDE IS THAT IT IS BULKY AND RECURRENCE CAN BE DIFFICULT TO DETECT DEEP TO IT CAN COSIDER TAKING THE 5TH RIB AS WELL!!!!! Prep: neck to umbilicus Measure defect Blood supply: pectoral branch of thoroacromial artery(2ND DIV OF THE AXILLARY ARTERY), and less important supply from the lateral thoracic artery—KEEP INTACT IF A SHORT FLAP (PHARYNGEAL CLOSURE) Nerve Supply: lateral pectoral nerve(located medially and runs with pectoral branch of the thoracoacromial artery), and medial pectoral nerve (located laterally) Origins: 1)medial one half of clavicle, 2)sternocostal from manubrium and body of the sternum and 1st or 2nd to 6th costal cartilages, 3)abdominal from the rectus fascia Insertions: crest of the greater tuberosity of the humerus. Skin and underlying rectus fascia which is used distal to the muscle and pedicle vessels is called the “random portion”, the remainder of the flap is “axial” 1. Mark out intercostal spaces 1-6.—PLACE A 4′ X 4′ AT (WITH THE SUP EDGE) THE INF BORDER OF THE CLAVICLE—THE INF EDGE OF THE 4′ X 4″ = THE SUP EDGE OF THE SKIN PADDLE 2. Draw planned flap medial to nipple (if possible), begin at intercostal space 4 and go inferiorly.—PALPATE THE MUSCLE 3. Incise through skin and subcutaneous tissues down to level of pectoralis fascia– NOT into muscle. Round corners of incision. DON’T undermine flap—ACTUALLY BEVEL OUT A BIT. 4. Tack pec fascia to dermis with 3-0 BIOSYNl OR VICRYL sutures. 5. Make incision from upper, outer corner of skin paddle to axilla–roughly parallel to clavicle–and incise down to pec fascia. 6. Use skin hook to hold upper flap and #10 scalpel to elevate at fascia level-TAKE FASCIA UP—leave no fat down but don’t cut into muscle. Continue elevating to clavicle. Enter neck and open up until can easily fit a hand through over clavicle. BEWARE OF CEPHALIC VEIN IN THE DELTOPECTORAL GROOVE! 7. Elevate lower flap in same fashion., identify clavipectoral fascia laterally, identify inferolateral border of pectoralis major muscle and elevate it off
of the pectoralis minor and chest wall. DO NOT BOVIE ON THE CHEST WALL! WATCH for perforators. PEC MINOR MORE VERTICALLY ORIENTED—FROM THE CORONOID PROCESS OF THE SCAPULA—-UNDER A DISTINCT LAYER OF FASCIA 8. Come around inferior aspect of muscle island and cut medially with Mayos to elevate muscle off chest wall–don’t undercut flap under skin. 9. Elevate muscle off chest wall continuing superiorly–identify pedicle on undersurface of pectoralis major muscle—ABOUT 2/3 OF THE CLAVICLE OUT. CAN VISUALIZE AND PALPATE THE PEDICLE—BEWARE OF THE CEPHALIC VEIN! Continue dissection to clavicle 10. Keep a finger on the pedicle and divide laterally the humeral attachments to help rotate flap over clavicle, try to preserve the lateral thoracic artery located in this area STICK FINGER UNDER AND AROUND HUMERAL ATTACHMENTS AND BOVIE TO FINGER STAYING AS LAT AS POSSIBLE.. 11. The medial one half of the clavicle can be resected if more length is needed 12. Avoid twisting the muscle to avoid occlusion of the pedicle vessels. 13. Close chest wound primarily using 2-0 vicryl and staples, Two JP drains should be used in the chest. —SEW SKIN PADDLE IN WITH 3-0 BIOSYN 14. No tight ties around the neck. TEMPORALIS FLAP BLOOD SUPPLY—ANT AND POST DEEP TEMPORAL ARTERIAL BRANCHES OF THE IMA (VESSELS LIE BETWEEN MUSCLE AND PERIOSTEUM) V3 MOTOR SUPPLY THE FLAP CAN INCLUDE CONTIGUOUS PERIOSTEUM EXTENDING TO THE SAGITTAL MIDLINE AND CAN CARRY VASCULARIZED CRANIUM MAY REQUIRE ZYGOMATIC ARCH OSTEOTOMIES AND CORONOID PROCESS RESECTION TRAPEZIUS ANT. BASED—DESC. BRANCH OF THE TRANSVERSE CERVICLE ARTERY—DOCUMENT STATUS ON NECK DISSECTION SUP. BASED SCM NOT A TRUE MYOCUTANEOUS FLAP—FASCIA/PLATYSMA—MORE OF A MUSCLE FLAP SUP BASED—OCCIPITAL A MID—SUP THYROID A INF BASED—TRANSVERSE CERVICAL LATISSIMUS DORSI LARGEST MUSCLE IN BODY THORACODORSAL ARTERY—-MUST REPOSITION PT PLATYSMA INCONSISTENT VERTICLE BLOOD SUPPLY GRAFTS TRANSPLANTED TO A NEW SITE (BLOOD SUPPLY)—HEAL IN COMPLETELY BY INOSCULATION CLASSIFICATION BY SPECIES ALLO(HOMO)—ALLODERM (IRRADIATED DERMIS) AND IRRADIATED RIB CARTILAGE ARE VERY VALUABLE SURGICAL ADJUNCTS ALLOPLASTS—NO DONOR SITE–OPPENHEIMER (1948) EFFECT–TUMORGENIC PROPERTY OF IMPLANTS HA–HYDROXY APETITE (CA10(PO4)6(OH)2 = BONE SOURCE——NOW BONE CEMENT MEDPOR—GOOD TISSUE INGROWTH, LOW REACTIVITY AND EXTRUSION RATES METHYLMETHACRYLATE—EXOTHERMIC CANOACRYLATE (DERMABOND)—PEELS OFF IN ABOUT 7-10 DAYS GORTEX—PTFE XENO(HETERO)—PIG SKIN AUTO STSG A VALUABLE (UNDERUTILIZED) TOOL 1/15,000 OF AN INCH (WIDTH OF A 15 BLADE) BETTER TAKE MORE CONTRACTION—THIS MAY BE GOOD NO NEED TO GRAFT DONOR SITE WILL ADHERE TO BONE—PREFERABLE TO LEAVE PERIOSTEUM ON BONE LEAVE BOLSTER ON ABOUT 5-7 DAYS ROUTINE 24 HOUR ABX—NOT A BAD IDEA TO LEAVE ON P.O. ABX WHILE BOLSTER ON
WILL TAKE OVER TENDON OR BONE “BRIDGING PHENOM”—–IF VIABLE BASE ON EITHER SIDE AND DEFECT < 1 CM FTSG BETTER COLOR MATCH——-POST AURICULAR TO EYELID, PRE AURICULAR TO NOSE!! LESS CONTRACTION NEED TO CLOSE OR GRAFT DONOR SITE FTSG 70% / 30% FROM POST AURICULAR REGION—OR MAY BORROW FROM PREAURICULAR REGION—–EXCELLENT COLOR MATCH TO EYELID CLOSE PRIMARILY WITH 4-0 BIOSYN AND 4-0 NYLON INFRACLAVICULAR FOSSA IS ANOTHER GOOD MATCH FOR FACIAL FTSG——CAN GET GENEROUS GRAFT AND CLOSE DEFECT PRIMARILY ALWAYS CONSIDER THE EYELID AS A DONOR SOURCE! DERMAL GRAFT RETAINS EPIDERMAL EPITHELIAL/ADNEXAL ELEMENTS—–CAPABLE OF RE-EPITHELIALIZING IF IT BECOMES EXPOSED CONSIDER ALLODERM—ESPECIALLY FOR SOFT TISSUE DEFECTS MUCOSAL GRAFTS—–FROM PALAT OR NASAL CAVITY—-GOOD FOR LOWER EYELID ECTROPION FAT GRAFTS—–ATROPHY 50% BONE OR CARTILAGE AUTOGRAFTS CARTILAGE (AND CORNEA)—LEAST ANTIGENIC (AVASCULAR)—-RETAINS ITS BULK VERY WELL ILIAC CREST IS EXCELLENT GRAFT MATERIAL FOR MANDIBLE—CAN USE INNER OR OUTER TABLE OR FULL THICKNESS–KEEP MAXIMAL CANCELLOUS BONE NEW EVIDENCE SHOWS MULT SMALL PERFS (DRILL HOLES) IN BOTH THE DONOR AND RECEIPIENT CORTEX HELPS IN TAKE RIB CARTILAGE MAKES EXCELLENT TISSUE FOR NASAL OR TRACHEAL RECONSTRUCTION—–INCISE OVER THE FLOATING RIBS—CUT DOWN TO THEM—INCISE THE PERIOSTEUM IN AN “H” FASION—DISSCT OFF THE PERIOSTEUM CIRCUMFIRENTIALLY WITH THE FREER—-LEAVING THIS DOWN PREVENTS A PNUEMOTHORAX——CLOSE IN MULTIPLE LAYERS OVER A SUCTION DRAIN COMPOSITE GRAFTS (MULT COMPONENTS) PROBABLY LIMIT TO 1 CM IN SIZE—SUTURE IN LOOSELY WITH MAX RAW SURFACE AREA CONTACT MUST NOT HAVE ANY PORTION OF THE FLAP > 1 CM FROM THE EDGE OFTEN LOOK BAD INITIALLY—GIVE IT TIME TO PINK UP—DON’T LOOK AT IT FOR A COUPLE OF WEEKS MICROVASCULAR FREE FLAPS (FREE REVASCULARIZED TISSUE TRANSFER) OSTEO/MUSCULO/CUTANEOUS ANGIOSOME = AN ANATOMIC TERRITORY WHOSE TISSUE RELIES PREMARILY ON ONE SEGMENTAL ARTERY FLAP SALVAGE UNLIKELY AFTER 6 HOURS OF ISCHEMIA—SO YOU HAVE TO MONITOR THEM PRETTY CLOSELY RADIAL FOREARM—“CHINESE FLAP” PEDICLE CAN BE THIN FOR REPAIR OF FACIAL FEATURES GOOD FOR TONGUE RECONSTRUCTION—-CAN BE MADE SENSATE WITH AFFERENT NEURORAPHY—-WITH SENSORY RE-EDUCATION CAN IMPROVE PTS QUALITY OF LIFE BASED ON THE ANTEBRANCHIAL CUTANEOUS NERVE FIBULA—PERONEAL ARTERY AND VEIN (25 CM)—-THE MOST PORTABLE BONE IN THE BODY BEST SUITED FOR MANDIBULAR RECONSTRUCTION—-CAN PREDISPOSE TO DVT/PNEUMONIA FROM POST OP IMMOBILITY MUST LOOK OUT FOR ATHEROSCLEROSIS—UP TO 20 CM OF BONE CAN BE HARVESTED–PERONEAL ARTERY MAY BE NEEDED BY THE REMAINING FOOT IN 10% PTS—CHECK PULSES AND ANGIO PREOPERATIVELY CAN LATER APPLY OSTEOINTEGRATED IMPLANTS JEJUNAL FLAP—USED FOR ESOPHAGEAL RECONSTRUCTION (FIRST FREE FLAP)