Local, Regional, and Free Flap Reconstruction
Core concepts
Understand flap vascular anatomy: random vs axial, pedicled vs free, and the angiosome concept. Know local facial flaps and regional flaps (nasolabial, paramedian forehead, pectoralis major, submental, supraclavicular, deltopectoral). For free tissue transfer, know workhorse flaps-radial forearm, anterolateral thigh, fibula, scapular/parascapular, latissimus-and their pedicle, skin paddle, and bone options. Understand perforator concepts, flap monitoring (clinical, Doppler, implantable), and the difference between arterial vs venous thrombosis presentations. Know indications for vein grafts and the role of flap thinning and secondary procedures.
Traps
Questions test flap selection by defect composition and pedicle length/reach. Another trap is confusing venous congestion (blue, brisk bleeding) with arterial insufficiency (pale, cool, sluggish). Know that the radial forearm is thin and pliable but sacrifices a major artery and may need a graft; the ALT is versatile with a long pedicle. Also know that flap monitoring salvage depends on early recognition.
Worked example / rule of thumb
A large through-and-through cheek defect needing lining, cover, and volume: consider a folded fasciocutaneous free flap (ALT or radial forearm) or a composite approach. Rule of thumb: match tissue type and pedicle reach; blue and congested = venous, pale and quiet = arterial-re-explore early.