Fundamentals

Terminology, procedure cards, and the landmark papers, on one shelf. Education only, not a substitute for operative texts or clinical judgment.

Terminology

Every term you’ll hear on a plastics rotation, defined in plain language. Search it or filter by topic.

78 terms

Axial flap: A flap based on a named, direct cutaneous artery running along its long axis. Has a more reliable and longer arc of rotation than a random-pattern flap. Example: groin flap based on the superficial circumflex iliac artery.
Anastomosis: Surgical connection between two vessels (artery-to-artery, vein-to-vein). In microvascular surgery, performed under an operating microscope with 9-0 or 10-0 nylon sutures on vessels 1–3 mm in diameter. Can be end-to-end (ETE) or end-to-side (ETS).
Angiosome: A three-dimensional block of tissue (skin, fat, muscle, bone) supplied by a single source artery. Concept described by Taylor & Palmer (1987); underpins rational flap design and explains patterns of tissue ischemia.
Arterial insufficiency: Inadequate arterial inflow to a flap or replanted part. Signs: pale color, absent capillary refill, cool temperature, absent Doppler signal. Less common than venous congestion but equally time-critical.
ADM (Acellular Dermal Matrix): Processed human or animal dermis with cells removed, leaving a collagen scaffold. Used in breast reconstruction to provide lower pole support for implants/expanders and reduce capsular contracture.
ALT flap: Anterolateral thigh flap, based on perforators from the descending branch of the lateral circumflex femoral artery. Enormously versatile, with a large skin paddle, long pedicle, minimal donor morbidity, and the go-to for head/neck and extremity reconstruction.
Animation deformity: Visible distortion of a subpectoral implant when the pectoralis contracts. A key reason to consider prepectoral placement.

BIA-ALCL: Breast Implant-Associated Anaplastic Large Cell Lymphoma, a rare T-cell lymphoma of the periprosthetic capsule linked to textured implants, not a breast cancer. Classically presents as a late seroma; aspirate and send for CD30. Generally excellent prognosis with complete capsulectomy.

Contracture: Permanent shortening of skin, scar, or muscle limiting range of motion. Burn contractures and capsular contractures (around breast implants) are common clinical problems in plastic surgery.
Capsular contracture: Pathological thickening and contraction of the fibrous capsule that naturally forms around a breast implant. Classified by Baker grade (I–IV). Leading cause of implant-based reconstruction failure. Associated with radiation, biofilm, and hematoma.
Chimeric flap: Multiple independent tissue components (e.g. skin, muscle, bone) fed by a single source vessel, allowing complex three-dimensional reconstruction with one anastomosis.
Cleft lip: Congenital failure of fusion of the medial nasal and maxillary processes, producing a gap in the upper lip that may be unilateral or bilateral, complete or incomplete. Commonly repaired around 3–6 months of age.
Cleft palate: Congenital failure of fusion of the palatal shelves, leaving a communication between the oral and nasal cavities. Repaired around 9–18 months to give the best chance at normal speech.
Craniosynostosis: Premature fusion of one or more cranial sutures, restricting skull growth perpendicular to the fused suture and producing a characteristic head shape (e.g. sagittal fusion → scaphocephaly).
Compartment syndrome: Pressure inside a fascial compartment exceeding perfusion pressure, causing ischemia. Pain out of proportion and pain on passive stretch are the early signs; pulselessness is late. Treat with emergent fasciotomy; do not wait for imaging.

Delay phenomenon: A staged procedure that partially disrupts a flap's blood supply before the final transfer, allowing the flap to physiologically adapt: increasing blood flow through remaining vessels and extending the zone of reliable perfusion.
Debridement: Removal of nonviable, necrotic, or contaminated tissue to promote healing. Methods: sharp (scalpel/scissors), enzymatic (collagenase), autolytic (occlusive dressings), mechanical (wet-to-dry, now largely abandoned), or biological (maggot therapy).
Donor site: The anatomic region from which a flap or graft is harvested. Donor site morbidity (scarring, functional deficit, hernia) is a key factor in choosing the reconstruction.
Dominant pedicle: The primary blood supply to a muscle or flap: the named vessel that, if divided, would result in muscle/flap necrosis. Muscle flaps are designed around their dominant pedicle (Mathes & Nahai classification).
DIEP flap: Deep Inferior Epigastric Perforator flap: lower abdominal skin and fat transferred on perforators dissected free of the rectus abdominis, so the muscle and fascia stay intact. The workhorse of autologous breast reconstruction and the main alternative to a TRAM.
Distraction osteogenesis: Gradually separating two bone segments after an osteotomy so new bone forms in the widening gap. Used to lengthen the mandible or advance the midface without a bone graft.
Dupuytren contracture: Progressive fibroproliferative disease of the palmar fascia producing cords and fixed flexion, most often of the ring and small fingers. Treated by needle aponeurotomy, collagenase, or fasciectomy.
Deep partial-thickness burn: Burn into the reticular dermis: mottled pink-white, less blanching, less sensate. Heals slowly with scarring and often needs excision and grafting.

End-to-end anastomosis (ETE): Both vessel stumps are joined directly. Preferred when vessels are similar in diameter and sacrificing the donor vessel is acceptable.
End-to-side anastomosis (ETS): The flap pedicle vessel is sewn into the side of the recipient vessel. Used when vessels are size-mismatched or when the recipient vessel must remain in continuity (e.g., internal mammary artery).
Epithelialization: Migration and proliferation of keratinocytes from wound edges or adnexal structures (hair follicles, sweat glands) to re-surface a wound. Rate ~1–2 mm/day from each edge under ideal conditions.
Escharotomy: Full-thickness incision through the eschar (burned skin) to release compartment pressure in circumferential burns. Required when burns restrict chest excursion or cause limb ischemia. Does not require anesthesia if burn is full-thickness.

Flap: A unit of tissue (skin, fat, muscle, fascia, or combinations) that is transferred with its own blood supply intact. Classified by blood supply (random vs. axial), composition (cutaneous, fasciocutaneous, myocutaneous), and movement (local, regional, or free).
Free flap: A flap completely detached from its donor site (pedicle divided) and re-attached to recipient vessels via microvascular anastomosis. Allows transfer of tissue anywhere on the body.
Fasciocutaneous flap: A flap containing skin, subcutaneous fat, and the deep fascia, with blood supply running within or above the fascia. Provides durable, pliable coverage without sacrificing muscle.
Full-thickness skin graft (FTSG): Graft containing epidermis and full dermis. Better cosmetic outcome and less secondary contraction than SSG; requires direct closure of donor site. Needs an ideal wound bed. Common donor sites: pre-auricular, groin, antecubital fossa.
Fat necrosis: Death of adipose tissue due to ischemia, most commonly in the distal zones of autologous breast reconstruction flaps. Presents as a firm, palpable mass; can mimic recurrent tumor on imaging.
Fibula free flap: Vascularized bone flap on the peroneal artery, the standard for mandibular reconstruction. Supplies up to ~25 cm of bone that can be osteotomized to shape and accept dental implants.
Flow-through flap: A flap whose pedicle is anastomosed in-line with a recipient artery so distal perfusion is preserved. Useful in an extremity with only one remaining vessel.
Full-thickness burn: Burn through the entire dermis: leathery, dry, white or charred, and insensate because the nerve endings are destroyed. Requires excision and grafting.

Graft take: Successful engraftment of a skin graft. Phases: (1) plasmatic imbibition, where the graft absorbs wound fluid; (2) inosculation, alignment of donor and recipient vessels; (3) neovascularization, new capillary ingrowth. Requires immobile, well-vascularized bed.
Granulation tissue: New connective tissue and capillaries formed on the surface of a healing wound. Beefy-red, moist, and fragile; supports epithelialization. Target of wound bed preparation.

Hypertrophic scar: An elevated, erythematous scar that stays within the boundaries of the original wound. Develops within weeks; may regress over months. More common after burns. Treated with compression, silicone, steroid injection, or laser.
Hematoma: Collection of blood in a surgical wound. Can compromise flap perfusion and increase infection risk. May require operative evacuation.

Keloid: A scar that grows beyond the original wound boundaries (unlike hypertrophic scar). More common in darker skin phototypes and in certain body locations (earlobes, chest, shoulders). Tends to recur after excision alone; requires adjuvant therapy.
Kleinert protocol: Post-flexor-tendon-repair rehab using elastic traction: the patient actively extends while the band passively flexes, keeping the repair gliding without loading it to rupture.

Latissimus dorsi flap: Pedicled or free flap based on the thoracodorsal artery. Reliable and large; used for breast reconstruction (often with an implant), chest wall coverage, and extremity salvage.
Le Fort fracture: A classification of midface fractures: I (transverse, palate-separating), II (pyramidal, through the nose/orbital floor), III (craniofacial disjunction). Defined by where the midface separates from the skull base.
Lymphedema: Chronic limb swelling from an overloaded or obstructed lymphatic system, classically after axillary node dissection and radiation. Managed with compression, and increasingly with physiologic surgery (LVA, vascularized lymph node transfer).
LVA: Lymphaticovenular anastomosis: a supermicrosurgical connection of an obstructed lymphatic channel to a nearby venule, diverting lymph into the venous system to treat lymphedema.

Myocutaneous (musculocutaneous) flap: A flap composed of muscle plus the overlying skin, supplied by musculocutaneous perforators from the dominant pedicle to the muscle. Example: pedicled TRAM, latissimus dorsi myocutaneous flap.

NPWT (Negative-Pressure Wound Therapy): Application of subatmospheric pressure (~125 mmHg) to a wound via a foam dressing and sealed drape. Promotes granulation, reduces edema and bacterial load, and manages exudate. Trade name VAC (Vacuum-Assisted Closure).

Pedicle: The stalk connecting a flap to its origin, containing the feeding artery and draining vein. In a pedicled flap the pedicle remains attached throughout; in a free flap the pedicle is divided and re-anastomosed at the recipient site.
Pedicled flap: A flap whose pedicle remains intact throughout transfer. The tissue "rotates," "advances," or is "transposed" while still connected to its blood supply. Examples: pedicled TRAM, latissimus dorsi, rotational flap.
Perforator: A small blood vessel that arises from a deeper source vessel and pierces (perforates) the deep fascia or muscle to reach the overlying skin and fat. Perforator flaps (e.g., DIEP) harvest skin/fat based solely on these vessels, sparing underlying muscle.
Primary intention: Wound closure by direct approximation of edges (e.g., suture, staples, adhesive). Requires clean wound edges with minimal tissue loss.
Propeller flap: A local perforator flap islanded on a single perforator and rotated up to 180° like a propeller to cover an adjacent defect: reconstruction without microsurgery.
Parkland formula: Burn resuscitation estimate: 4 mL × body weight (kg) × %TBSA of lactated Ringer’s over the first 24 hours, half in the first 8 hours from the time of injury. A starting point; titrate to urine output, not to the formula.
Prepectoral vs subpectoral: Where a breast implant sits: on top of the pectoralis major (prepectoral) or beneath it (subpectoral). Prepectoral avoids animation deformity and pectoral pain but depends on good mastectomy flap perfusion, usually with ADM support.

Random-pattern flap: A flap without a named axial vessel; relies on the subdermal plexus. Length-to-width ratio traditionally limited to ~1.5–2:1 to avoid distal ischemia. Examples: local rotation, transposition, and advancement flaps.
Replantation: Reattachment of a completely amputated body part using microvascular techniques. Distinguished from revascularization (where some tissue bridge remains).
Revascularization: Restoration of blood flow to an incompletely amputated (devascularized) part where a tissue bridge (skin, nerve) still connects it to the body.
Recipient site: The defect or wound being reconstructed; where the flap or graft is ultimately placed.
Radial forearm free flap: Thin, pliable fasciocutaneous flap on the radial artery, the classic choice for intraoral and pharyngeal lining. Requires a patent palmar arch (check with an Allen test) because the radial artery is sacrificed.
Rule of 10s: A classic readiness guide for cleft lip repair: roughly 10 weeks old, 10 pounds, hemoglobin 10 g/dL. A rule of thumb for safe timing, not an absolute law.
Replantation indications: Highest priority: thumb, multiple digits, hand/wrist through palm, almost any pediatric amputation, and sharp clean amputations. Single digits distal to the FDS insertion and severely crushed or avulsed parts are relative contraindications.
Rule of nines: Rapid bedside estimate of burn surface area in adults: head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%. Children have proportionally larger heads, so pediatric charts differ.

Skin graft: Epidermis (and variable dermis) harvested from a donor site and transferred without its blood supply; relies on the recipient wound bed for take (plasmatic imbibition → inosculation → neovascularization). Classified as split-thickness (SSG) or full-thickness (FTSG).
Split-thickness skin graft (SSG / STSG): Graft containing epidermis and partial dermis. More reliable take than FTSG (thinner = easier revascularization); donor site heals by re-epithelialization. Can be meshed to expand coverage. Higher contraction than FTSG.
Secondary intention: Wound left open to heal by granulation tissue formation, contraction, and epithelialization. Used when infection is present, tissue is missing, or primary closure would create unacceptable tension.
Seroma: Accumulation of serous fluid in a dead space created by surgery. Common after mastectomy, lymph node dissection, and abdominoplasty. Managed with aspiration or prolonged drain.
Supermicrosurgery: Microsurgery on vessels smaller than roughly 0.8 mm, requiring specialized instruments and high magnification. Enables lymphaticovenular anastomosis and perforator-to-perforator repair.
Superficial partial-thickness burn: Burn into the papillary dermis: blistered, moist, pink, blanching, and very painful. Heals in about 2–3 weeks without grafting and usually without scarring.
SMAS: Superficial Musculoaponeurotic System: the fibrous layer investing the muscles of facial expression and continuous with the platysma. Repositioning the SMAS (rather than just pulling skin) is what makes a facelift durable and natural.

Tertiary intention (delayed primary closure): Wound initially left open (e.g., contaminated wound), then closed surgically after 3–5 days once the bacterial load falls and healing begins.
Tissue expander: A silicone balloon placed subcutaneously and inflated serially with saline over weeks to stretch overlying skin, generating extra tissue for reconstruction (breast, scalp, extremity). Exploits the principle of mechanical creep.
TRAM flap: Transverse Rectus Abdominis Myocutaneous flap: the same abdominal tissue as a DIEP but carried on rectus muscle. Simpler to raise than a DIEP, at the cost of abdominal wall strength (bulge/hernia risk).

Venous coupler: A mechanical ring-pin device that everts and joins two vein ends without hand-sewn sutures. Faster and reliable for veins; not used for arteries.
Venous congestion: Outflow obstruction in a flap or replanted part. Most common cause of free flap failure. Signs: dusky/purple color, brisk capillary refill (<1 sec), tense turgor. Requires urgent re-exploration.
Velopharyngeal insufficiency (VPI): Incomplete closure between the soft palate and pharyngeal walls, letting air escape nasally and producing hypernasal speech. A common issue after cleft palate repair.

Zone of injury: The area of tissue damaged by trauma, radiation, or prior surgery. Recipient vessels within the zone of injury are unsuitable for anastomosis due to intimal damage and poor healing; healthy vessels outside this zone must be used.
Z-plasty: A technique using two opposing triangular flaps to lengthen a scar, reorient a contracted scar, or break up a linear scar. The classic 60° Z-plasty increases length by ~75%. Used for contracture release and scar revision.
Zone II ("no man's land"): The region of the flexor tendon sheath between the distal palmar crease and the FDS insertion, where FDP and FDS run together inside a tight sheath. Notorious for adhesions after repair.