Anterolateral Thigh Free Flap Reconstruction of Parotidectomy Defect

CHAPTER 1

Hi, I am Neerav Goyal. I'm one of the head and neck and reconstructive surgeons here at Penn State Health and a division chief of the head and neck surgery division. Hi, I am Emily Funk. I am also one of the head and neck microvascular reconstruction surgeons here at Penn State. So today we're gonna be showing a video of a parotid reconstruction. We used an anterolateral thigh free flap. There's a lot of good options for doing parotid reconstruction. As you heard from our partner, Dr. Slonimsky, there was a pretty big tumor that he removed that left a pretty big concavity in that space. And how do you think things went in terms of using the ALT free flap? Yeah, I think things went really well. You know, of course whenever we're looking at any type of mass or malignancy that we're removing, I think it's great that we always think about what are the different options of what can we be using here? What could be used to reconstruct based on the size, based on the region, based on the skin involvement. And I think that in this case today, using the anterolateral thigh free flap worked out really well for the symmetry of her face, for getting things kind of put back together after they were all done removing that malignancy. And I think that overall we'll have a pretty good outcome with her long term. I think one of the big things that we realize is a lot of this is also dependent on the body habitus. So, you know, one of the things that you'll see us kind of going through during the dissection is, you know, we identify our pedicle, we identify, you know, everything going to the perforators of the flap, and then we identified that we're probably gonna have too much bulk. And so we went back and we dissected out the perforators from the muscle and we kind of showed that meticulous technique for both the larger perforator, as well as the smaller one that you had identified. And then even when we brought it up to the head and neck and after doing the anastomosis, we serially removed portions of the reconstruction to ensure that we achieved an optimal contour. Yeah, and I think that's one of the things that's pretty interesting about doing free flap reconstructions is that there is a lot of that variability. You know, you can get into the OR and there might be a difference in the types of perforators or the locations of the perforators that may not be where you were expecting. There might be a little bit more subcutaneous fat or less laxity in the tissues. And I think that it kind of is one of the more creative parts of our job is figuring out how to best utilize what we have to reconstruct the defect that, you know, we're given. Yeah, exactly. And you know, I think one of the nice things is, you know, we recognize that there was probably a little bit too much fat that was placed at the very end, but we know that these patients often get radiation afterwards. And so we have to actually overfill to allow for, that good contouring after radiation. So, you know, hopefully the video will kind of highlight the key techniques that we use to identify the flap, raise the flap and create a good result for our patient. Yeah. Yeah, absolutely and I think that one of the other things is, you know, it's gonna be interesting to see once, you know, when patients get radiated, it's all a little bit different. But in this particular case, I think that this was a really beneficial way to kind of provide her with a better long-term outcome than doing something like a static free fat, you know, transfer without microvascular anastomosis. I think that that ultimately, you know, this kind of, this case highlights, you know, ways that we can, now that we're using flaps more and more commonly, ways that we can really integrate them into areas where we might've in the past done something that ultimately was a little more... Variable. Variable. Yeah. And, but you know, now we might have better outcomes with doing this type of a surgery. Great.

CHAPTER 2

We're starting our procedure here for a patient who has a big parotid tumor. You can see here that our resident, Dr. Bavier, is marking out what's typically called a modified Blair incision that's going in a pretragal crease and then coming below the lobule of the ear extending posteriorly to the mastoid and it'll come into a crease in the neck. We can also see that there's some distension of the skin secondary to the tumor and so Dr. Slonimsky our surgical oncologist will be resecting some of that skin with with his procedure. We also have wire, leads in to monitor different branches of the facial nerve, so that we can use that to help with assessing the health of the nerve after identification and dissection of the nerve off of the tumor. Given the size of this tumor, we're likely gonna be talking about doing reconstruction here. And so we prepared with my partner Dr. Funk for reconstruction using the leg and we'll be marking that out once we have the prep done. But generally we use what's called the anterolateral thigh flap. That's based on some perforators off the deep femoral artery and we'll power the skin, fat, fascia, and even some muscle from the vastus lateralis. As we take a look at the reconstructive component, we always prepare for several options for reconstruction at the leg. So we, you know, we're prepping for both an anterolateral thigh flap as well as the possibility of doing what's called an MSAP or a medial sural artery perforator flap that's based off the calf. Ultimately our goal is to restore volume after the parotidectomy, after removal of the tumor and also restore any skin loss that occurs with resection of the tumor and it's involvement with the skin on the face. We marked our ASIS, our anterior superior iliac spine and made a line down to our lateral aspect of our patella. Generally we'll make a mark that's kind of at the midpoint here. It looks like we've done about a two-centimeter semicircle around this and we've identified a couple perforators here that go to the skin as well as a perforator down here that Dr. Funk's marked with a Prolene. Oh, I've got one up here as well. That's gonna be your transverse pedicle. Yeah. So, yeah, you know, I think it's really important to recognize that there's also the perforators that come off the profunda as well as the transverse branch. And we can see that there's a good distance between these two in terms of their perforators. But you can design a flap that's based off your TFL and the transverse pedicle as well. So Emily, what'd you think about just using, just using fat and fascia? Do you wanna take some skin with, or do you take skin usually? I usually always take the skin. Yeah. And then just take it off afterwards. Take it off afterwards. Uh huh. And if we do need a leave the little corner on it, she's gonna use that skin there, I thought it'd be helpful. Yeah. That should be pretty good, right. She's got a good amount of laxity here, so I think that that will close primarily. So usually I like to make an incision that's about this big and I try to find, make sure that we didn't end up being too lateral. Okay. 'Cause I've had a couple situations, especially usually in the skinnier folks where you end up being, you know, the vastus ends up being draped over the rectus. So I'll look for my pocket first and then once I can confirm pedicle, then we'll go from there.

CHAPTER 3

Yep, you're right. Can we go 25, please? So I think if you use that corner it'll concentrate the current a little bit more. Knife, please. Yeah, I usually just open the whole thing, then I usually do a really wide. You do a really wide skin paddle. Yeah. That's the other thing, that I've done before is I'll mark out from the ASIS to the middle of the patella. So roughly kind of along the line of where the rectus is gonna run. And so then that usually marks my anterior cut. So then we're kind of, you know, we're far enough forward no matter what. I just don't think that we need as big of a skin paddle for her and I'm, you know, I wanna make sure that we're, lemme see. Do you have Weities by any chance? All right, yeah, try to stay in the center, don't bevel towards me, yep. And if anything you can bevel medially to just make sure you end up on that rectus. So ultimately the pedicle is gonna sit between, in a septum that sits between our vastus lateralis and rectus femoris. You should be getting close to the muscle. So if you take a feel with your finger, you'll feel it faster the muscle there? Yeah, we're here. So you wanna try to get through and just see muscle fibers. You can also open this up more superiorly. I think that'll give you better access. And cut, yeah. And then we went up to 25? Yes. Okay, thank you. So do you start here? No. Or like the inferior pedicle, yeah. It's still too deep or, yeah, you should be right there. I see the thing, it's just cutting. Do we have a bigger Weity. Mm. That probably won't be big enough. Lemme see an appendiceal then. Yeah, I think this is gonna be a great case for kind of a fat only or fat and fat fascia flap. So, yeah. So it'd be good to get onto muscle. I mean I sure see the muscle just deep to this, right? Yep. There you go. Okay. I started to say a, so yeah for me at, we stay a little bit higher here since we're working in the superior aspect. Yeah. So then do you try to identify your perforator before you open the rest of the incision? Yeah, not the perforators, but I'll just identify the pedicle and then once we have the pedicle then I'll open the rest of it, 'cause I'll know exactly where... Oh, okay. Rectus is gonna lie. Okay, so we should be able to slide our finger into the septum. That's it there. Yeah, so just make a little cut right here on the fascia. On the muscle itself. Yep. Yeah, that's okay. Good, good. Good, since you can see here how I can get my finger into this pocket and that pocket's gonna be deep to the rectus. And then if you take a look here and now we're looking at that. Yep, pedicle is right there. Yep, vastus is over here. Exactly. So we've got our vastus, we have our pedicle. And so now I can say, hey, we're safe to make our skin paddle incision on along this trajectory, 'cause we're gonna end up on our rectus. Alright. Okay. So you can make your whole incision now.

CHAPTER 4

Let's open this up here. Mark. So yeah, no it's okay. So you know, I think we've talked about it a little bit, but sometimes when you have these bleeders in the hole, it's better to get more exposure than to try to dig in that hole because you're gonna just, you're not gonna see the vessel end. DeBakey please. Now if we have the Harmonic, sometimes I'll use the Harmonic just to make these cuts all the way through. Is it tested? You're probably, yeah, you're probably gonna wanna come up here. You know, I'd be really interested, in seeing your technique a little bit more, Emily, as you talked about the skin only flop, obviously less relevant here. So, but you would identify the perforators as we're coming through the fascia. So the interface between the fascia and the fat, is that what you meant? No, at the skin. Oh, at the skin. Okay. It's not... So you dissect through the fat? You like kind of go through gently with like a tenotomy. Yeah, yeah. And just cut whatever you see that doesn't look like it has a vessel in it. Uh huh. And you see, hopefully, your big vessel. Uh huh, uh huh. You want to Doppler them out really well. Yeah. And then you try to, once you identify them... Then you go proximally. Then you go proximally. Interesting. So it's not you identify the fascia can use perforators and then try to take it distally to the fat. Not paper. Yeah. Oh, okay. Okay. So he really just loves doing ALT for the minimal morbidity and so he... Yeah, for everything. Instead of MPAP, instead of forearms, you know, just to try to kind of make it his workhorse. Yeah. And so I think that, I asked Kolli he said we have a... Can I have a Ray-Tec down? He said that he's the one that actually wrote the paper on the technique. Uh huh. I thought it was a guy out of Korea. I thought, you know, actually I thought it was, I figured it was probably Taiwan, 'cause they do a ton of ALTs and they have, you know, their patient population's a lot thinner. You know, so the nice thing about the ALT flap is that for... Yeah, so the nice thing about the ALT flap is you have a lot of components that you can use for reconstruction. We can use the fat, the adipose tissue, we can use the fascia that lines the vastus lateralis. We can even use some of the vastus lateralis muscle. And there are, you know, described cases of using the femur, in some practices we'll use the femur as a bony component. The other component that's nice with the ALT is when it comes to using the muscle is, you can also take the nerve to the vastus laterals and potentially use it as a motor component. You know, that can be used for things like facial reanimation. For the purposes of our reconstruction today, the main component as mentioned before, is really volume, volume restoration. And so we're gonna be focusing on making sure we have a good amount of fat and adipose tissue that can allow us to reconstruct. You know, even looking at our skin paddle design right now, we can see that it's a relatively narrow and long skin paddle. I do think that we'll have plenty of volume once we bring this up to the face. Usually we don't need too much fat in terms of, you know, square inches or square, sorry, cubic centimeters to restore volume in this space. So Dr. Polanik here is, is getting down onto the rectus muscle in a broader plane. So I would start, come up here where you have muscle visualized. Uh huh, right there. And so you can kind of stay right underneath the fascia there and kind of aim a little bit more medially. So you're entering up on the center of the muscle. Yep. Yeah. Both of them? Yeah. Can I have a wet lap pad please? And so, you know, if there's not as much fat, the Bovie may be a little bit faster Mark. It just kind depends, you know, earlier you're cutting through all that extra tissue so it, you know, it seemed like it would make sense to use the Harmonic. Yeah, it does. I feel like the Harmonic is helping it spread. Yep, try not to pull too far back here 'cause we want get subfascial and then kind of end up back in that plane here. So you don't want to end up shearing the fat off of your perforators, Before you come to the fascia, I'd kind of get everything to that same plane all the way across. Mm hmm, aim a little bit... So if you take a look here, this is kind of the midpoint patella here. So that's roughly gonna match where the midline of the rectus is. So you're gonna be a little bit more over towards me. So she said, here you would've started by making your incision here, that's what you're saying, right? And then you would've elevated to see your rectus. I would have made the whole incision though. You would, oh you would still have made the whole incision but you would've started your dissection here? I would make my incision on the skin and then I kind of bevel out towards the fascia. Yeah, yeah. To identify, the rectus. Yeah. And then start my... Yeah, okay. I'm also wildly not patient enough with the Harmonic. Yeah, well that's, well I mean before it was just really thick and didn't seem like the Bovie was doing much. But this is again, I agree with you. I see like now that what I was just saying to Mark, like now it's reasonable to kind of go back to the Bovie. Also hate getting burnt with the Harmonic. Yeah. Fortunately that has not happened to me. And that's actually why, I always have a wet lap to cool it down. I'm pretty particular about making sure that that's used after every cut. You can put the Harmonic down. Yeah, I'll take the Harmonic there. I burnt myself with a bipolar one time. So I'll usually use the Bovie here and the key here is what I always recommend, Mark, is you wanna stay on the rectus. Okay. So we've already identified where our septum is, right? Yeah. So try not to come right on the septum, but you're actually gonna come on the rectus. So if you take a look at where my finger is, exactly. So go ahead. You can make that cut. Yeah and even further onto the muscle, like if the muscle's not twitching then you're not far enough on the muscle. Alright. And then so... Oh yeah, yeah, I think that's a great, no, it's not there, on the muscle. Nope, to, even further. Yep, so coming right on my finger, yep. And finish that cut proximally. Yeah, superiorly, good. All right. You wanna try using the blade? Sure. Okay, so now you can see this is vastus intermedius. And then where did our pedicle go? You can see our pedicle right there. Now it might be a good time for a light, huh? Okay, let's open this up a little bit more. You want another wet lap? I think we're okay right now. What was that? Another wet lap? Oh no we're good. So one thing you gotta be careful of is your cutaneous nerve that can be in this space, right? I don't think we need to take it with us. This doesn't need to be sensate necessarily. So end up on the rectus. So aim a little bit. Yep. Nope, it's right on my finger now. So I've dissected underneath the fascia. I'm kind of pulling it up towards you. Yep. Good. Can I get an appendiceal, please? So we should see the pedicle right here now. Okay, so you see her pedicle right there. Yeah. And I think like Dr. Funk was alluding to, there should be a second pedicle and it's just underneath my finger hidden a little bit underneath the fat. But that's gonna do transverse when that's gonna come right there. You wanna try using the knife? Sure. Do we have a 10, awesome, great. So Mark's gonna take it. Yep. Mark, so you wanna have good tension here and then Dr. Funk will kind of go over... And then you see how you're just gonna cut through this fascia. So like right on the muscle right here, just cut down. Should I come on that side so I can cut towards me? Or does it not matter? Yes, cut towards you. Start like at my finger. Yeah. Yep. That's it. That's the fascia. You might need a little bit more right here. Okay, good. This is the biggest blade I've ever seen. They're great. They're fantastic. A little bit more on here. Yeah. Okay, so you have an Allis? Alright, now you can give that back. And that was it. Well, I mean I usually do the whole thing but, Yeah, keep going. Now we need to look for the... Oh, I see what you're saying. I was gonna say, so I would use, okay, we're good. Usually if there's like little branches in there, I won't cut through those. Yeah, yeah. Those are, but otherwise I just keep one. Do you like using Gelpis or? I do actually use it again once I... Oh the knife? Yeah, to cut the fascia here. Come up here, I like identify my perforators first. Let me see the, oh, I see. So you'll find the perforators on the fascia now? Yeah. Okay. But if you wanna go up on that tendon, I just get on the vastus tendon and cut down. Yeah, exactly. And I have the bipolar in my other hand for those little branches. So I guess maybe, usually I just go like this. There's a bleeder. You made one. I know. That was the perforator to the rectus. Here you go. Lemme me get an appendiceal again please. I have it here. Yep. Oh, no, it's gonna go to Dr. Polanik, please. Be careful, be careful. So this is almost gonna be where your perforator, almost always your perforators are gonna follow directly opposite where a perforator goes into the rectus. So you can see that there's a little perforator here that's coming across the fascia. That's pretty thin. I don't actually see anything large in terms of a fasciocutaneous perforator here. There's a perforator right there. Do you see that hint right there? Yeah. So once we, once... He's using bipolar, all right. Can we turn the Doppler on? And that actually may line up with this guy right here. You see it right here? Yep. There. Okay, nice. Can I get our marking pen please? Do you wanna look for another one? We can look for the second one, right here. So, sometimes you can just kind of see a shadow. Yeah, nice. That was the second one or the same one? This is the first one. Okay. Latus, Latus. Yeah. Come on. There's a little portion. Okay. And then I think there might be one right there. It may come off the same branch. That may be the only one. Okay. Okay, good? Yep. Yeah, thanks. All right Dr. Funk. I've never done that in my life. Huh? I've never seen that. You've never looked for the perforators? No. Oh, I thought we were gonna do it for dissecting 'em out. So how do you guys usually look for in them? Just with visualization? Yeah, we just find 'em on the bottom of the fascia here. You see 'em anywhere here? Here, so like... Oh, you'll spread to find 'em? Yeah, I'll spread find them. Yeah, yeah, yeah, I got you. Yeah, so usually I'll just look for the shadow of 'em and then I'll spread to find 'em. But you know, here we Doppler 'em out and usually at this stage I'll just start making my medial cut in the fascia medial to the pedicle. Yeah. And then, you know, we can start tracing out some of these perforators if we want, or we can... I usually do it with a blade, but she's very vascular. So let's get a Schnidt. A Bovie or what do you want? Yeah, yeah, that's fine. Mark, you got a free hand? Yeah. Okay, go ahead. Okay. Slide down with him. Yep, move up with a retractor. Yep. Great. Yep, alright, move up. Good. So you do some dissection of them just like proximally or you just identify them? Of what? The pedicle? Of the perforators that you just marked. Oh yeah, we will. So I mean I've done it a bunch of different ways. We can either, I'll either dissect them out here and then trace 'em towards the pedicle or I'll trace the pedicle laterally, distally towards the perforators. So again, now that we have this open, you can see your pedicle pretty nicely right there. Yeah. And so we can start dissecting 'em. Let's see where our marks are. Do you dissect them from proximal... To distal? Distal to proximal? Yeah. Do you still identify them through the muscle belly or do you take all around them? Yeah, so I think that's a good question. So I think for this particular, so you don't dissect it through the muscle. I only have ever done that. I've never done it where you don't dissect them. Oh, interesting, yeah. You know, people just take like... Yeah, so it depends, like what I'm reconstructing. So if I'm just trying to fill in a hole, like for laryngectomy, I'll usually take the muscle with, because it doesn't really matter, like that extra bulk, I think in her case, I probably don't wanna take any muscle with, and it's gonna be mostly fat, 'cause then we can kind of contour that better. So I will dissect out the pedicle muscles. I'd like to see you do it sometime when you don't, because I don't, I know I hear it's faster, but I've never seen it done. Yeah, it's faster just because you just, you literally, you know, you'll take, I'll just take a square of muscle around it. So I'll just go with a Harmonic. I'll come below my posterior cut. You'll make your back cut. And make your back cut. And I go below my back cut and then I just come back around. It is kind of a blind move though, because you're not seeing your perforators. Let me see a Schnidt, and I have had one situation where we lost one perforator in just coming across the muscle because, you know, they had the vessel kind of bent. Bent, yeah, exactly. Meant posteriorly. So here, where would you go? You know, where would you start with your perforator dissection? Would you start here or would you start kind of where, you know, over there? No, I would start. Oh, you would start all the way up here. I would start all the way up here. Yeah, yeah, yeah. All right, go for it. Couple here. So where's her? Can I get a Burlisher please? Where's her fascia at here? Right there. There? Mm hmm. So usually I haven't released the septum so I do have a little bit more tension. So you haven't released which? I haven't released the muscle. Oh, I gotcha, okay. So you'll identify the perforators, when it's still here. When I open it. Oh, okay. Okay. I don't know if I can do it like this. We'll see, because I don't wanna grab anything here. So then like I would grab here. Can I get a DeBakey? Yeah, I'll take a DeBakey as well. So you're gonna kind of tent up the fascia? Yeah, usually it would be kind of self tented. Uh huh. Because it's still attached to the rectus. It's still attached. Uh huh. And then I kind of just come through anything I know is not a perforator. Uh huh. And then this is kind of how I find them. I can't tell if that's... Ink or perforator. Huh, sorry about that. Once you get into this good plane, it's usually - I can't tell if this is the right... So I'll start down low. So there's a perforator right there. Yeah, I'm gonna see if I can turn around to kind of see that. See that? Yep. And then... Just open this safely so we can see. I don't see a perforator in there do you? No. And there's one right there, yeah. So you'll have this super thin. Interesting, yeah, I usually will have the fascia kind of, you know, acting as kind of a layer of protection over the pedicle. So I just do see-through. Mm hmm. That's here, there's a bigger one there. Mm hmm. The MAP. And Kolli does like just huge spreads. And then if the perforator pops he's like "Oh." We got another one. Yeah. So there's one there. So this is actually gonna end up looking pretty similar to the MSAP dissection then, because you're taking all this fat down. So do you wanna keep, continue doing your way? 'Cause I don't wanna... No, it's okay. If we need that... Yeah. Okay, let's take this fascia down and then we can switch back. Good. All right so we can see our perforator. Where'd it go? Is he in there? You can see something right here. There's a big one there. See him under there? Yep. Yeah, so you can see him really nicely. Mm hmm, yeah, coming into the fascia there. Nice. Mark, if you wanna take a look. So you see this vessel right here? And you can see a branching over here into our flap. Yeah. Okay. That's great. So, and then I would do that the whole way down until I have all my perforators and then that's where I start dissecting. And then you start dissecting proximally essentially. You would be going from here towards, yeah, yeah, yeah, yeah. Towards the... Yeah, yeah. The bigger pipes. Yeah, if we're gonna continue my way, I would find all of them right now because I didn't see those other ones super well. I think it's hiding right here. I think this is it down here. See him? I think this stuff is all fool's fascia. Sure. Fooling us. Not the true fool's fascia. Not the true fool's fascia. Yes. The head and neck fool's fascia. The ALT fool's fascia. Yeah. Yeah, so it's interesting. You know when we dissected 'em out, I would just go straight over where we heard the Dopplers and just leave the rest of the fascia intact and then just trace those guys out preferentially. I see. So... It's definitely not as clean. I think when we open this, when we've already opened this, once I open the first layer I can just kind of bluntly finger dissect and find them all. I don't have to do quite as much dissection as I'm currently doing. See how like as I go forward that's just opening that down and you see there's a little guy way down there. Yeah. And then kind of go, it is very gentle finger dissection but it still, still see it open to there. It opens to this one but obviously I don't wanna trace four. Yeah, so then, but from here we would start tracing. Correct. Medially. This one looks like it may end up going in the muscle. So then like that one I would trace towards... I have the angle if you want me to... Yeah, go for it. It's kind of going... Superficially. Superficially here. Take this down. Do you have the Harmonic? If it's all right, I'm gonna prefer the bipolar here. We didn't have nice bipolars so. I think you had your Silverglides. Only had UCSD. Oh interesting. That was a UCSD thing, so... But I do usually start inferiorly to superiorly just to make sure I'm not coming across anything. Mm hmm and then we have backups. Yeah. Chad, I'll get two more packs of Ray-Tecs. So Mark, you can take a look here and you can see that this guy's turning into a bigger pipe now and it looks like it's probably gonna be musculocutaneous. So it's diving in between that. That's the superficial, the superficial aspect of the vastus lateralis. Yeah, so this is pretty similar to what I do here after we've kind of dissected out the perforator without kind of opening up the rest of the fascia. I usually put a lone star on the rectus if we need to. Yep. Do we have any lone stars up here? I don't. Okay, could we get two or three? All right, let's get Mark back in. So what we're looking at here is a perforator that's going to our, sorry this is a perforator that's gonna go to our skin paddle. We've had several of these perforators marked here and so that's gonna directly correlate. This guy will likely correlate to this perforator that we've identified. Do you have a lone star, please? We're gonna get some lone stars in position just to help retract, two should be good. Yeah, we'll see. Yep, the same thing as with the nerve. Yeah. Just really making sure you see the entirety of the pedicle and being, you know, being pretty careful with... I'm gonna probably stop there. Yeah, exactly. Do you want maybe switch spots if it's going? Yeah, I think that's a great point. DeBakey please. They're probably hiding. Yep, there're over there. Let's move that Bovie back into the container before it slips somewhere. Yeah, so we're getting some stim here going through the muscle. Okay. You're right on top of it. No, I think there's one more layer. Yeah, so always be careful about that. There may be some branches that are going to the muscle, so you wanna be a little bit cautious about that, but if you're not right on top of it, there's a chance that you know, you may miss a turn later on, essentially. How are you doing Dr. Slonimsky. It's good. Yeah. There you go. It's right there, see that? You chasing the femur? Yep. It kind of keeps just diving, like. It's gonna, it's gonna, so when we take, can I get the appendiceal again? So you see this move here and you're gonna see... Right here? No, so if you take a look at the pedicle. Over here, right? Yeah, right up. Yep. And then this is gonna be nerve, so this is our nerve to our vastus right here. And then actually wait, that might be nerve right there. Just working. Okay, we can open up some of that fascia a little bit more. But what will happen is this pedicle will come in along the side of the muscle here. So you have to get through all this muscle still to get to that spot. See this? So this is not, you know if you tent it like this and you can see it a little bit better. All right, be careful about flicking the muscle like that. That's how you're gonna get through one of the branches. Yep. Big spread there or yeah, that's good. Good. Okay. You able to see? Yep. Okay. I'm gonna just go like halfway up my tines. Okay, great. That's probably good. Okay. Can I have smooth Geralds? So you see that? Whole branch going up here. Yep, so you can see a little peripheral going up to the muscle there. So see if you can kind of... Should I stay more perineal to that? Yeah, you're gonna Like right there, here is where maybe I was like right there. Yep. So come in that pocket there. Mm hmm. And I would probably stop about that distance. Yeah. Okay, I'm just kind of opening up more superficially here. Okay, good. See it. I see it. Stop right here. Yeah. There's that perforator there, which we don't need to follow that, right? Because we're gonna be following... Lemme take a look here. I'm gonna borrow this guy. So just keeping it kind of tented. Ilm gonna switch with you if that's all right. And so Mark, I'll have you hold this. You get that one out? Yeah, almost. Switching back to a little bit more of what I usually do. Kind of coming from the main pipe going more distally. Okay. And we'll kind of meet in the middle. Too thick. All right. So we're seeing our pedicle right here. We're seeing the portion that Mark dissected out right there. All right. So we can see our perforator going in this direction. I think I see another one going towards it on the side there. Right here. This guy? No, I'm looking at the... It might just be a shadow of the muscle but it might be striation here. Oh, I see what you're seeing, this little red. I was saying I saw something there. Yeah, I see that. Yeah. That one may have been cut though. I wasn't sure if that was just going into the side of it. A little more counter tension, sorry. Thank you for reading my mind. All right. Nope. Nothing? Not that I see. That looks okay. So let's see when it's gonna make the main pipe. That's the question. Looks like we're almost there. So I'm gonna have you grab here, Mark. That's your main pipe running along there, right? Yep. We got one little guy here, and I can't imagine as much of anything, but this will give us some sense of where I need to be here. Okay. Something is bleeding. Yeah. I'm still a bipolar guy, for this. Harmonic please. Why is that? Is it faster or? No, mostly if, it'll let me, lemme go a little layer by layer. Yeah, exactly. Gives me a little bit more peace of mind. You know for most of my recons, I will take a little cuff of muscle. Yeah. So just, you know, doing a little bit more of this dissection. I usually, what I'll do is if I trace out the top, I'll leave a little cuff on the bottom. That's what I do. Yeah. So you'll have little, you know, semicircle is of muscle. Some padding for it. Yeah, exactly. Yeah. And yeah, that's actually my biggest concern with doing too much of this dissection. The question is, where is this going? Hey Laura. Yeah. Would you be able to clean the bipolar? Yes. Looks like there's a little pipe down there. Okay, go ahead Mark, you have a free hand, ready? Yep. Okay. On. I don't think your right hand doing too much right now. Yeah, thank you. If you wanna get rid of that. Thank you. All right, so now we're actually seeing that this pipe's getting bigger here. You see that? Yeah. We're getting a couple adjacent perforators. So it looks like it may be even traveling higher. Yeah, I think it is. Were you seeing something there Mark? I thought it saw something. Yeah, so did I. I think it was a shadow, here you can open that. There it is. You see it right there. Mm hmm. Yeah. But at least that kind - at least that, in my mind that makes me a little more comfortable 'cause it gives me kind of an end goal and general trajectory of where I'm gonna be doing my dissection. So you know, the fact that it's curving up is now known to me as opposed to, you know, me trying to be like, hey, why did it just take that turn? And so I feel a little bit safer about these moves. You know, now the challenge is here we're, you know, we are actually denervating a reasonable amount of muscle. You can kind of appreciate that Mark. You know, every time I'm taking a grab the muscle kind of twitches away. So usually that means we're getting closer and closer to kind of a larger branch of the nerve to the vastus. Yeah. But I think it's important to know that most literature suggests that even if you were to take the whole vastus or just denervate it completely, there's usually not a significant gait disturbance. So you know, you can see here, it looks like there's a vessel up here. We'll save a little bit of muscle there. We'll see. You want scissors, probably, you can try one more time. Oh that is my fault. One second. Don't use a Bovie, don't use a bipolar. Are you still stimulating? 'Cause I had the bipolar on. Does the bipolar cause the same artifact for you Emily? Not the same as Bovie, but significant. It's still pretty significant? Okay. And so now we're out here. All right. So layer by layer here, right? So starting with the superficial spot. Yep. Another Allis, please. Yep. Please take the DeBakey. Gerald with teeth. So you guys will trace that all your perforators then, Emily? Yeah. Okay. All right, so we did one with bipolar. You wanna do the next one? Use a Harmonic, show how it's done. And be careful with how much you're pulling. Open this up here. Yeah, I think you're kind of coming through the tendon. Yeah, I think that's why it's so sticky. Yep. Is it ready to be? Go ahead. Just make sure we're not seeing, okay, go ahead. Am I good there? Yeah. We'll find out if it starts bleeding. Okay, nice. So we can see it going all the way into here. Right here. All right. So I'll switch with you or you and Dr. Polanik take over in terms of, and I wanna learn your approach as well. Can I see a tenotomy? You want me to hold these for you? Yeah. Okay. So you're using the tenotomies to get to the fascia and just kinda identify visually. There's one right there. Yep. Little guy. Yep. There's a little guy over here. Just trying to decide which one we should go with next. I was just gonna go inferiorly down to this guy. Yeah, yeah, do it. That one's really nice and open. This might go a little bit too far back. Yeah, he's going. So to answer your question Mark, it should be on the transcutaneous. Yeah. I only know it is the top right. I couldn't remember what it was called there. But yeah, that's the transcutaneous mode. So generally what that does is that it has a higher gain and greater penetration. Oh there was something there I think. Right? Yeah. Okay, you wanna check our skin paddle quickly? Check with this? Yeah, sure. I know this guy should be... Okay, great. Is that the one you think that one is? That's the one that I think is coming from that one, yeah, okay. Move the Doppler goo outta the way. You've identified something in this space or not yet? No I've not. Okay. I don't think so. I think I'm actually a little bit out of my plane here. This is my plane right here. And you find that the perforators all generally are kind of in the same plane deep to that this fascial opening? Yeah, now. Okay. You have the wet lap still? We're good. I just wanna make sure it's in the spot where Mark has access to it. So is the nerve under or on top of the tumor? We don't know yet. Ah. I think it's under, because we started opening, and we could not see it yet. Yeah. Yeah. Did you end up taking some skin? I will have to eventually. I marked where... It's really stuck? Yeah. It's gotta be somewhere in here, I think. Mark, can you pick this up right here for me? There it is. There's something big here. Unless I'm just looking at muscle. Oh, that's muscle. We're a little bit out of our plane right here. Are you seeing another perforator? No. Hmm. You're getting something bleeding. There's something there. Yeah, something's bleeding right there. I don't know if that was it, but... Yeah, it might have been. You think this guy's something we can trace or? Yeah. I mean he's really tiny. I don't know that I can keep him. Can I get half by three pledgets? I think we're just in the wrong plane here, but. What do you mean by that? So like, I went too deep here, like this smooth. See how this is a little bit more packing tape-ish. Yeah. And this one is a little bit more smooth here. So this one is one you can like open up really easily. And so like this area where we were at the top, like we didn't start at that plane so we could have been a little confused there, but... Because I don't see anything else on there. But we could look more carefully through this stuff. I don't know. Yeah, so right now this is gonna be our main guy. That's our main one right now. Yeah. That's the only thing I'm, unless we look up, unless we, didn't we see something up here too? I don't know whether or not it's been separated from this fascia. I don't think we, had identified anything there. Okay. All right, well we can just try to keep this one then. This guy down here? Yeah. So... Or we'll take more muscle with us. Can I see the McCabe please? Or Jake is fine. I need to go in there. I mean for an ALT, I wouldn't typically follow this one. So tiny. So you see where he's going? It looks to me that it's turning up. It actually looks like it almost branched there, but... Yeah. Oh yeah, there I see one. Did you guys ever use the SPY at all? No, uh-uh. Yeah, I think it's... The plastic surgeons did at UCSC. Yeah, for the breast recon? No, like when they would come help us with stuff sometimes. Oh, okay, yeah. SPY is a technology that uses indocyanine dye and a filter on a video camera that allows that to kind of fluoresce. So it can be helpful for tracking profusion, cross vessels. And some places we will use it pretty regularly for their reconstruction. I find it most helpful in situations where you have a good anastomosis, but there's question about distal perfusion and it can kind of give you a good understanding of what portion of your skin paddle or your flap is vascularized to potentially help you kind of make sure that you have a fully perfused flap. So as I was describing, you know, I've had a situation where one of these perforators was ligated using a cautery. And so we were able to identify that using the SPY and then essentially cut out the portion that was traumatized and re-anastomosis around it, to have a successful reconstruction. Yeah. Do you want any retraction medially there, Emily? I think I'm okay. Okay. That's nice. That's actually a nice thing. So Mark, you can see again how as when we're getting closer, you know we're dissecting the muscle the whole time, but as we get closer to the nerve or to a larger branch of the nerve, you get much more motor units that are activating get much stronger muscle response. I do find that sometimes I will end up shearing like, a branch going into the muscle. Yeah, yeah. No we saw one of those perforators gonna the muscle earlier. I mean in the end everything's superficial. The pedicle has to go anywhere, right? If we're trying to minimize how much muscle we're taking with us. You know, but for example, a pedicle this small, that's really where I'd worry about leaving it bare, you know, dissecting on the underside of it as well. I've never really dissected on the underside. Yeah or I'd worry about leaving it hanging on the leg for a little bit too long and it just, you know, it thrombosis, on that pressure point, that weak point. So I think after dissecting out this perforator, the next step should be dissecting out the pedicle. So Mark, you're gonna dissect out the artery and the vein. We'll get some of that dissection going more proximally towards where it branches off the profunda. So I think as long as you drop your hand enough when you do this, usually it's okay. Grab right here. So we're continuing to follow this perforator up to where it branches off of our main pedicle. Oh, it's diving down here. So again, I don't think this is a worthwhile endeavor in terms of the size. The caliber is not increasing rapidly. We still have it right here. Oh it looks like it's a little bit bigger right there, right? Like right here? No, just supi right there. It may actually join the other guy or you think it's gonna end up going deeper? I can't tell. It's starting to, it looks like it's trying to dive down here. Yeah. I usually take this stuff. Yep. So you're just taking some of that fascia on top of the vastus with a little cuff of vastus It looks like. I might be getting a lot of glare here but I can't see it. Lemme see this pickup. Can you see it now? I can see it here, but I don't see, where it's going in there. Oh you're right, it's pretty thin. Is it going up right here? It's going right here. I think it's right here. Yep. Yep. Sorry, I guess I inadvertently gave you the much tougher dissection here. Yeah, there it's, you got it. There we go. Does the Harmonic cause any interference? It should not, right? I don't think so. Yeah. Gonna become another perforator. Right under here. So you're using a Jake right now or a Burlisher? Jake. Yeah, I like to use a McCabe. Oh, interesting. Yeah, someone else is saying that too. It was you know, I only use the McCabe for facial nerve dissection and maybe some recurrent dissection. But I've heard of a lot of people liking the McCabe for... Yeah, Dr. Coketti teaches you use the McCabe for everything in head and neck. Using the McCabe for everything? Everything. He hates tonsils. Yeah. And then if you're not using tonsils, you have to use a mosquito. Yeah, well that's all right. We have the McCabe on all over our head and neck sets now. So before it used to be a separate pull and so it wouldn't always get pulled. McCabe, like I don't feel as worried like I'm really dropping my hand here, with the McCabe like the... Yeah, because the curve. The curve is just a little bit more. Yeah and it's not as bad as the right angle. It's not as significant as the right angle. Correct. I think you're at perforator there. So you're, or we're at the pedicle. We're seeing some branches there. Yeah, we're seeing a branch here. I mean I don't know that that thing is worth it's weight in anything. All right, let's go back here. Am I just trying to clear this stuff on top? Yep. Or get free from this lateral thing? No, just clear. So first I clear the stuff on top, then I'll start dissecting at 360. So I feel like I have a good spot to enter right here, and then I can kind of work my way forward and back. Or should I start further? So I would start where you see right here? Yeah. So get in that spot. Huh, bigger spread. Yep. You have a Jake in your hand? Let me see the bipolar. My biggest concern with the Jake is I think you have to be comfortable with how much you're spreading and where you're dissecting, 'cause if you're not in the right plane it's very easy to create your own plane. And that could be like, like Dr. Funk said, that could be in a vessel. Are you done with stim Rich? Yeah. So we're using bipolar so just let us know so we're not interfering with you. So much like a nerve dissection, you may want to use like a Kittner or something to give you counter traction. Okay. To help, kind of push the vessel towards you. Can I have a Kittner please? I'll take that, Gerald then for now. It's so funny, it never occurred to me that somebody would do an ALT differently. Yeah, well that's, you know, I think it, you know, actually my technique has changed, 'cause when we were doing it in fellowship, we always took a cuff of muscle so we never did any pedicle dissection. So, you know, that's why I'm kind of interested because you know, most of my pedicle dissection technique is, or you know, the perforated dissection technique is just based on, oh, be careful that may not be fascia. Okay, that's fascia. So just remember it's gonna be vein, artery, vein. So I'm just trying to see if we see this. So there's artery right there. Yeah. Okay. So yep, so kind of make a spread right there. On top or... Alongside. Yeah. Mm hmm. This may be nerve. Nerve should be kind of just adjacent to this bundle. Mm hmm. Good. And so generally speaking, like, you know, this is usually where I'm using, I personally am using a blunter instrument mostly because you're gonna see these little veins that kind of come into and around. Yeah. And so to avoid accidentally perforating them, you know, use something a little bit bigger as I'm making kind of bigger spreads here. Sure. So and then, I mean you can even just... Can I have a Schnidt, please, and then the Kittner? The wet Kittner, yeah. Yeah, I think I like to use like the Schnidt when you have someone that, where you have good tension. Yeah, agreed. It's not gonna make any moves. It's not gonna make any progress. Yeah, everything will just bounce off of it. So you're gonna take your Kittner here. Mark has two attendings to assist. All right. So now you see this space here, right? Yeah. So you see how this is tented? Yeah. So you can see what's kinda holding you up here. I would make, you know, one big spread, no, sorry. Just again easy to dissect. So that's why I kind of just tore. I was just gonna kind of go right up the middle, right here. Yep, yep. I think that's a great idea. Yeah, big spread. Good. Come out and then we can see... So see how this fascia is kind of in the way now, so we can take it down. At what stage in the skin cancer do you recommend, like on derm path like for them to do a sentinel or... For skin cancer? Yeah, for the tumor board today. Oh, interesting. Yeah, I don't know. I think you do for... We don't have like great literature on what... There isn't, so, there is a nice paper that was, or like a nice little viewpoint that was published in, on the H&S website. And so it's pretty much for those patients that have high risk features and are node positive, there's value because like those are the same patients that you probably would've said, "Hey, you know, it might be worth doing a neck dissection on even if they're node, sorry, did I say node positive? Node negative. Node negative. Thank you, yeah. Yeah, so you know, like patients who had P&I, patients who had, you know, any evidence of, or immunosuppression. I think those are the ones that it's worthwhile. Do you mean even like after excision in Mohs that you would still consider offering them? Yeah, or a sentinal. Sentinel after Mohs? I think, you know, we talked about like scarring and things like that, right? But like I think with Mohs, that's probably your best chance in the sense that you don't have as much distortion of your anatomy. You know? So I'll have to take a look at that little article again where, you know, I forgot who wrote it. Do you feel like you need a chair, I mean I... No, for you. Oh no, I'm okay. I'm okay. Yeah. Thank you for asking. So we're just extending the incision to provide better visualization. What branches? All branches. So... So right here? Yep, it's like kind of where it's inserting on the TFL, so it's just a little... Are you guys still stemming? No, they're good. Actually we can see our transverse pedicle a lot better now. Thanks. You can just make a quick spread there just to show for... Can I have that Kittner and Schnidt back? Sure, you wanna put the Gelpis in? We can get those in too. Lemme see a smooth Geralds please. Yep. So you have a couple layers of fascia with you. So I'd come out for a sec and I would go up here. So you see this? This space? Yeah. So open that first. Yep, big spread. Yep. Good. So again, thin fascia, right? But you see what this does for you is it allows you to see the entire length of your direction, right? So let's say that pedicle was coming straight up towards you. You wouldn't have recognized that in the prior move. Yeah. And then that's where you could have risked injury. So nerve. Yep. Vein, artery, vein, right? And this is gonna come and join the rest of your system up here. And you'll see a perforator that'll come off that goes towards your rectus. You can take that down if you need increased pedicle length. Yeah. But that's usually where you want to kind of pause and say, "Hey, you know, we might be at our limit." So if we take a look now we can see, our transverse branch right here. Yeah. This looks like our circumflex system up here. Yeah. So we're getting very close to the kind of the most proximal portion of our pedicle. I'm gonna let Dr. Funk take a look and see if she agrees and see if she would, you know, do anything more. Oh I'm going farther than right there. Yeah. So at this point we have a pedicle out. You can start to 360 the pedicle a little bit. And you wanna separate the nerve to see what I'm kind of doing right here. Separating the nerve from our pedicle and just bringing that over and you can see how much that's stimulating the vastus down here. Yeah. And then we can kind of get around there and so we're ready for us to take it down. We can continue dissecting a little bit more here. Yep. So get all this medial stuff down. You see this? Yep. And then I think we're gonna be pretty close to a pause point where we're gonna wait to see how much we need to harvest to fill the space. I'm gonna get the nerve ready first. Yep. A little branch. You have it up? Here let me retract for you Emily. You're fine. Yeah, there's a little branch there. Right there, yeah. Do you like to clip those little branches? Yeah, I will. Yeah, so you know, usually I've already done my posterior dissection at this point and I have the flap kind of in my hand. But you're just waiting, right? Yeah. Because we're not sure on size. Yeah, yeah, yeah, exactly. So you know, we're at a point where we could unscrubb now or you know, and then come back or keep working on this and you know, little bit less ideal position 'cause the nice thing is when you have the flap in your hand, you're lifting up, you can see the backside, right. And so you can put that on some better stretch. That can tear. Yep. I think I'm a little bit outside my depth of field. Yep, so just go on the medial aspect. Mm hmm. That can tear. Mm hmm. So where are you going now? So this is going like this? Yep, lemme see a Ray-Tec. So I don't, yeah, I would go medially. Can we have a new bipolar? All right, so, come, see here, Mark. It like right here? Yep. Yep. Do we want this guy kind of cleared away from it? I dunno if I can break through that. No I wouldn't. The Harmonic. These ones are orange and a green. Blue micros or? I do have the blue ones. Yeah, we just need a cord then. So generally I like to avoid putting the hot tine towards the vessels. So this is where I was saying like I don't really care about this fascia. The key is separating the pedicle from the underlying structures in 360-ing it, right? So it's making sure that we have a nice spot. Did we get something there? And there's gonna be branches that are gonna go to your deeper muscles as well to either your intermedius or your medialis. So you have to be kind of cognizant to that as well. Yeah, I feel like it's hard to do this without lifting up the flap. Yeah. Mark looks like he's gonna persevere. Good. Yeah, that's awesome. So that's good. So I think we're in a position where we can stop there. We're gonna back up here. We have our pedicle dissection right here, right? Yeah. And it's going in nicely. And then we have this guy, which which I'm gonna try to save. You are? I don't think we're gonna dissect it out further, but we're gonna try to save it. Let's open that up so you can Bovie that. Whatever. It doesn't matter. Bovie will just sometimes be a little bit faster, max. I'll just adjust the retractor things. Good, again. Okay, I think that should be good because now we can see right here. So we're on the underside of our lateralis. Good. All right. So now we can kind of see here our perforator going into our pedicle. We have our pedicle elevated medially. We have our lateralis there, intermedius there. And we have our other branch coming down here and that's probably our inferior most branch in terms of your perforator. We can try to do a couple broad dissection here. And see is we got anything else. Okay. Come across here. Good. And where's our... you're good. I have faith in my Schnidt. All right. Actually, we'll come a little bit more superficial. I'm gonna borrow your pickup Emily. Thank you. Normally 'cause I have to change my practice, 'cause normally I'd just be taking a cuff of muscle there. Oh, okay. And so since, it doesn't really matter as much, but let's try to preserve more muscle. All right. So we're gonna see our perforator here. That's, sorry, not a perforator or pedicle. Looks like we have a nice little perforator here too, huh. A very tiny perforator. That I just made bleed. All right. Where is our pedicle? Looks like it might be diving further. Usually I'll clip this. Let's see if I can get the pedicle out a little bit better. I'm gonna take this perforator, sacrifice it. Hold on one sec. And let's get some clips. Yeah, they are, they're very loose. You can probably do it with a little... With a Freer? Yep. We got a Ray-Tec down. is that what that was? Okay, so now we can see our pedicle coming. And that was our pedicle right here. See that? That we just cut through? Or that we clipped? Yeah, that we just clipped, yeah. It's okay, it was the side that we wanted to clip. Yeah, yeah, yeah. All right. Just looks small down there. Yeah, well I, you know, I've always noticed that it peters out pretty quickly after it gives off like the couple perforators. Yeah. So let's see. May need something sharper here. There we go. Okay on the lower side. Max. Yep. And just pay attention to see if you're seeing any stim when you grab before you, yep. There you go. That looks like your pedicle there. Yeah, there was our bigger guy. Let's got a small clip on this, just below me. Mm hmm. Good. Okay. Get the whole thing? You have a medium up? Yeah. Hold this. Good. Okay. Okay, and here we can see our pedicle diving away. Thanks. All right, great. So, we're gonna have some nerve component in here also. Mark, why don't you grab like a mosquito. Can I have a mosquito, please. We're gonna try and separate out the components. So just kind of, yep. Mm hmm. Good. Nice. Nicely done. Okay. Good. Medium clip to him. Yeah. We can put a second one on the part that's staying in the body if you'd like. Stimming. Flip it. Where do you want the second one? Inferiorly. You may wanna flip it. Flip the, in your hand. Yep. So it's kind of aimed inferiorly. Yep. Good, good. Okay. Good. You want two left in the body? Yeah. Okay, clips again. Okay, go ahead. Inferiorly. Inferiorly. Yep. This one. Did you say one sec? Yeah, you're good, no, I said that's fine. Sorry. All right. Okay bipolar. Stay towards the medial side. Medial tine. Yeah. Give me a Ray-Tec, please. All right. Anything else that you wanna do Emily, before we make our posterior cut? You can dissect the vessels 360, but I guess we can't really lift them off anyways. I think actually Mark did a pretty good job. We have one branch up here, right there. And that might be our transverse, something that is going transversely Are the vessels are like cleared up to where we can clip 'em though individually? No, well, yeah, Mark can do that. All right, go for it Mark. Right here, this is where you want them? Where we're gonna be clipping? Yeah, just so we can like... No, higher. So you wanna go see where it's trying to branch right there. See that there's a guy going up there? Yep and the one going in there. Yep. Did the veins run up into one? Maybe, maybe not. Other side. A little bit, yeah, yes, good, stop here. Yeah, back up. You mean because you're not seeing the second one? Yeah. Yeah. It may just be one. I thought there we had a second one over here, but I'm not seeing this clearly. You know, it's really interesting. I never really cared about the second vein. Yeah, maybe I do need a chair. It's like I'm just slightly outside my focal distance from my loops. So you see this little bit of fascia that's right there. So you gotta open that up. Might have to move your left hand. Yeah, sorry. You want the McCabe? I do want something sharper though. Lemme me see that for a sec? I think it's an arterial branch. No, you're good. Okay. Go ahead. Oh, you're a little too deep. Yeah. Good. That's better. Perfect. Okay, so yeah, so I think going back to what Dr. Funk was saying, you know, in terms of separating the vessels. I will keep, here you have it almost blue line, so it's already starting to separate. I'll keep this little bit of fascia on up until I get to the point where I wanna separate it. And so now that you have it, let's say we're going right here. You can see that there's a little branch right there. Yeah. So you're probably gonna end up going right there. Maybe a little bit higher. So, you know, here I use blunter tools just to reduce the risk of perforating something. And just, you're gonna kind of separate the vessels like that. And every, I would say every once in a while, Mark, I would lift up my peanut to give him a little bit of blood flow. Blood flow. Yeah. Pseudo-ischemic time or micro-ischemic time. Good. Yeah. So you see you getting deep to it. Yeah. Okay. So now you can go from the medial aspect and come through that hole just like you would with like a hypoglossal, you know, but you gotta make sure you're kind of teasing it out to make sure you're not coming through a vein. I think there might be a little fascial layer on this because like, it's kind of like... It's puckering. Yeah. Yeah. That's okay. So I think you're in a couple different planes, yep. Yeah, I'm trying to just connect this, or check, get into the closest point. Mm hmm, mm hmm. I like that you guys sit during parotids here. Oh yeah, for the nervous dissection. Yeah. Yeah. Everyone made fun of me at Jefferson. Good, that's it, done. Good. Yep. And now get around the artery. So I would go yeah, exactly. You can go on the outside of the artery. So you can come from the lateral aspect and come medially. All right. Mm hmm. Good. And so since you're yeah, the natural tendency in my hand would be to go that way. Exactly. Yeah and I think based on where you're standing, that's probably easier for you than to come. I like your tiny spreads. You're not gonna shear anything with that smaller spread. Be careful what you're grabbing though. Yeah. All right, so right angle or a McCabe. So here I think your hand, you're limited in terms of where your hand needs to be. Yeah. So this is where I think having a more angled instrument may help. And then you're gonna come in here... Just hook around it. And just hook around it, exactly. If you take a look at the instruments, so you compare the McCabe right to the right angle. It's much sharper. All right, just remember what we're storing up top. Hmm. Good. A little bit lower. A little bit, yeah. Gentle, gentle. It's a tiny vessel, huh? Mm hmm. There you go. That's it. All right. Nothing's bleeding. So we finished our dissection. Just to kind of review the anatomy, we're seeing our rectus right here. And, you can identify the rectus based on kind the chevron pattern where we're seeing fibers coming up towards the midline and both directions. And then we follow the septum between our rectus and our vastus to identify our pedicle. We have our perforator out right here that's gonna go to our skin paddle. And we have marked out Dopplers there. We have a second tinier perforator that's here that we're gonna try to preserve, but we may have to sacrifice. So what's left now is to make our posterior cut and identify how much tissue we need to reconstruct. All right, we're good here.

CHAPTER 5

All right, so Dr. Slonimsky has removed the cancer or he has removed the tumor. And so now we're at a stage where we're gonna start taking a look at harvesting the rest of the flap and also kind of determining the total volume that we want to take. As I mentioned before, you know, given that there wasn't much skin taken, this is a situation where we don't necessarily need to take a skin paddle with us. And we can do this as kind of a fat, fascia, fat, I'm sorry, fat, fascia, muscle, or fat, and fascia only flap to kind of minimize to bulk and also allow us to contour the bulk a little bit better. Sure. Sometimes I will still take our skin paddle with us and then I'll just de-epithelialize the skin paddle. And having the dermis there can be beneficial because it will help minimize how much fat atrophy impacts the volume. All right. So we're gonna work towards dissecting some more of the nerve out, you know, again, if we can save the nerve, that's ideal, though it's not essential. Yeah, that's like a vein up here. Great. So again, we got our pedicle here. Mark, this is the perforator going towards the skin. Here's our main guy. Here's nerve. We're gonna make our, can I see our marking pen please? Just gonna kind of remark our posterior border here. All right. Yeah, that was kind of what I was saying, like we're kind of tear dropping it a little bit so it just kind of narrows the ellipse. Yeah. So when we make this cut, we're gonna bevel slightly backwards, right? Because when we take a look at where our perforator is, our perforator may travel like this and then come up. Yeah. So I usually will bevel towards the TFL in a posterior plane. Lemme see an Allis, please. Just sometimes having a little bit of stretch on the skin paddle can be helpful just to give you some counter tension. Yep. Try not to dive. A lot weaker there. Yeah, exactly. Okay, good. So you're gonna go on this side. You know what, stop for a second. Just I know made a couple marks here just to recognize, okay good. So a lot of this design is actually to assist with closure. It's not necessarily that we're gonna - so go a little bit, just make a straight line from here to there. It's not necessarily to, because we need all this skin, 'cause as we mentioned before, it doesn't look like there's much if any of the skin defect on top. But this will allow us to have a linear closure at the end of our flap elevation. And the other benefit is that it gives us flexibility in terms of how much fat we need to fit the space. And just watch your depth. You're getting into the fat there. Yep, so really this, you know, on the cut you just wanna get the dermis. So you see here we still have dermis there? Yeah. So try our best just to go through the dermis, so until you see the fat pooching out but not into the fat. Yeah. You wanna be on this side? No it's okay. Yeah, just the coag for those vessels. Okay, good. I think you can switch to coag. We gotta open this up still. Try to bevel outto be out even a little bit further it right there. Same thing as before. If you're finding that the Bovie's having a hard time controlling the vessels, you can just use the Harmonic as well. Let me get a Senn. Mm hmm. Okay. Tore some vessels there. Bevel a little bit more posterior. Yeah because you have a narrow skin paddle so that's where you're at risk. And don't pull the paddle forward as much 'cause you're at risk of of bringing it over your septum, there see it. Yeah. Don't open the fascia yet. You know, just kinda like, I usually do, I like to see the layer, expose the layer, then we go below the layers. That way you're minimizing how many depths you're, you know the different depths you're at. The fascia is over here. Lemme see the Bovie for a second. You get used to us. Yeah, I'm used to having the table on the opposite side. Super deep, there it is. Yeah. Wow. So sorry, I was recognizing that there's a good amount of adiposity, you know, so to which is again to our benefit. Okay so then a dab there. Now we can, again we can take a Harmonic from here. This is our... Frozen report. Yes. Going back to what Dr. Funk was talking about, you know, Harmonic versus Bovie. I prefer the Harmonic where we're taking tissue bulk, so we're going through a lot of tissue. So there I think it has benefit because it's gonna be faster than kind of going back and forth with Bovie again and again. Whereas, you know, when you get thinner then the Bovie I think definitely wins out. So just kind of coming through and this will kind of, you know, do a better job of getting some of those smaller vessels that are kind of nuisance vessels that are in the way. Ray-Tec, please, lemme hold this for you. Okay. Good. Okay. Okay. This one I don't have much faith for. Hey, something there, very faint. So I'll probably go in a few minutes as we finish this discussion. Yeah. Okay. Go ahead. So the other thing that this does for us by beveling out like this is you've also kind of undermined for your closure, right? Yeah. You want to be going a little bit more. You don't want it curving yet. You want to curve, you wanna go this way. So if you end up with a rectangle of fat, that's okay. You can always take more, we can always take more fat away, right? Okay. Just 'cause we're starting to like escape where this fascial plane is. Yeah, I think you just need to be a little bit deeper. So here's the fascial plane right here, but yeah, why don't you just open this up. Yep and then just kind of bevel. Yeah, exactly. Just be aiming slightly towards the outside and what's gonna happen as soon as you finish this cut here, it's gonna release and then you're just gonna have to kind of be, again, cognizant of not undercutting your pedicle. If you go to min, sorry max, it will act like a Bovie on cut. Let's see, there might have been a pedicle here. So let's take one, sorry, one second. Let's take a look again, here's our pedicle here. That's gonna be these guys, right? So it's gonna be roughly at this point. So everything here is gonna be safe. So you can use a Bovie or whatever and you can kind of angle in a little bit more. We don't have to be, as insistent on, you know, kind of going wide there. Yep. Good. Lemme switch to the dull ones, please. I would just use the Bovie here. I think it's gonna give you a little bit better kind of fine control over your direction. Uh huh, same towards the back part of the cut. Yep, right there. And then bevel slightly towards me. Yep, there you go. Good and then remember the TFL is, you know, is a muscle, so you know it looks large like fascia but it's gonna become muscle as you go higher up. And stop. Good and actually that looks like a really good angle 'cause you're ending up on the medial aspect of the TFL. So you can see here TFL. This is actually a nice view here. So you can see the TFL here. Yeah. And you see your vastus, that we kind of partially dissected through there. So... Okay, so let's get everything else to that fascia layer or the TFL layer, technically. Okay. Okay. So I almost always take a cuff of fascia of the TFL, sorry. So I'll put it on cut and just kind of make an incision that goes like this. Just the back end. Once you go through TFL, you're gonna be on your vastus, and you're gonna be on your vastus fascia. So it's gonna release very suddenly. Yeah. And then it's largely gonna be on the pedicle because we've dissected all the muscle off the pedicle. Alright. On the superficial surface. So basically just cut and connect it with this. Mm hmm, watch your depth though. You just wanna go just through the fascia on cut. Good, that's it. And sometimes if you get a little cautious you can also go like this and then cut on your finger. Or just take a pair of scissors and just cut all the way out. You're going back a little bit so you can get a little bit closer. Yep. Okay. Watch your depth, don't end up in the fat. And so when we come up here, you'll see that my finger should come up, see through this fascia here? So this is the fascia that vastus. There's a perforator. Yeah. So you know, as long as you actually stay this way, you'll be safe. Mm hmm and then I'll usually, you can use the Bovie, but usually use a Bovie on cut through muscle will lead a lot of bleeding. So I'll usually use the Harmonic for the muscle component. We have all these toys. All these toys, right. Might as well use them all. Yep. Can you still see my finger in the right spot? Yep, I see your finger right there. Yep. Go a little bit further back. So try to get your Harmonic in that same pocket. Too far, too far, come here and go lateral. Yeah and then taking a second break. Is it still connected or you cut it down? Oh, okay. The vein is cut. The vein is cut, okay. Sorry. Okay, good. So now we're seeing this fascia here. And so when I lift up, you should see the pedicle, see it right there? Yep. Same thing here. So this is probably air, but the pedicle is gonna be... It's gonna be right here. You can see one line there. It's gonna be right through this fat. So we can, now I'll take a knife and you can just kind of score the fascia here. And that will allow it to elevate off the vastus. Are we going all the way up to there? Yeah, so take a take a look here first. Okay, so and you see where my finger is, right? Yeah. So my finger is supporting the pedicle. Yeah. And pushing it forward. You know, I wanna, I'm sorry. Let's turn the Doppler on one more time. Yeah, we should be good. There's plenty of moisture here that it's not gonna make a difference. Okay. Okay. So you're gonna gently hold this up and I'm gonna see if we can kind of listen to it on this side. Okay. I see it pulsating too. So this gives you a sense the pedicle is actually going here. So aiming towards kinda the mid belly is gonna be safer and you can kind of see that there's gonna be some vessels you're gonna encounter here. A 15 blade. So you see there's a kind of a set of vessels right here. Sorry, aim? We can, let's start here and we'll open this and then you'll probably need the Harmonic to get through that fat. Mm hmm. Yep, light touch. You've done a bleph. It's just kind of like the bleph. You just kind of run it across. Yep. Good, good. And so you see how that fascia is elevating there, right? Yeah. Okay. Open up all the way down there. Okay. All right, looks like you have a little bit more to open up here, so you can take the Bovie. Have you ever done a fascioadiopo, like the free tissue from the abdomen? What do you mean, without a vessel? Yeah. Just a fat graft, yeah. I usually take dermis with. Yeah. Because I find the dermis kind of helps maintain the integrity of the fat. For parotid defects? Yeah. Yeah, we did it all the time or we, you know, we started to do it but you know, again it was just kind of a capacity thing. So like that's an easy thing for us to do. Is that what like Crine was doing a lot? For big ones, for bigger ones, he would like use the dermis essentially, he would just... So you're saying for bigger ones he would not do a free flap? Correct, well no, I mean it was huge, he would do a free flap. Yeah. But for some of the ones that were kind of in between. Yeah. Would do like the dermis with fat, which I'd never, I've seen fat, I'd never seen... Yeah, yeah, yeah. So I like the dermis because it just kind of keeps the integrity of it doesn't flop around as much. So I'd probably use your Harmonic here just to kinda get through this stuff. See this? Yeah. Got all these vessels sitting there. It'd just be kind of nuisance bleeding, a little bit more. Yeah. Towards the back, yep, good. Is this one that you think you would've been okay doing a dermis back wrap for, and so in terms of... It looks huge, but the hole isn't as big as I thought it might be. Oh yeah, we're gonna have plenty extra here. Yeah, you know, with her not knowing if we were gonna need to take some skin and all that kind of stuff, I think this is the right call her. Yeah. Yeah, I think it's interesting. You know, so I did a lot of 'em when I first started. You know, the nice thing is you can always come back and put more in, right? Yeah. But I didn't like the variability of it. And then I had one that had some... We had one that had that... Yeah, that's what I was about to say and then so you then I then you know like that and that you get to kind of nurse her. Yeah. I had to nurse her along for like a couple weeks and in the end, you know, it all looked okay 'cause there was just so much scar that would form. Yeah. You know, that it's still the defect ended up filling in nicely, but it was not the way that I wanted to fill it, you know, in terms of the overall progress of her care. So, yeah, so I'd be interested in seeing how you do this part at this, you know, at this juncture. So we've kind of elevated the fascia off. I have the pedicle right here, right? And then, so this is really usually a part where I'll start making some cut. I'll make some cuts here and start to take the thin layer of muscle with us. But you know, we had talked a little bit about how just taking, you know, just taking a little cuff around the fat, around the pedicle. So would you come through, you know, would you come through the fascia here and just kind of remove all this? I would... You got, this guy is nice. I essentially just trace launch into the vessels that we branched out. Yeah. Yeah. Oh, and since you already have all the fascia open, it's not as much of a... It's not as much of a... I mean, still wherever they're in the muscle. Yeah. And then just doing a little blunt dissection, and handling it like, you know... Yeah. Sometimes I do that with... Tenotomies, yeah. With the Harmonic. Oh, interesting, okay. Yeah, go ahead. Let's do it Funk style. One time I called Dr. Kolli and raised that part in like five minutes, by just cutting it all... Yeah, to dry it up, yeah. To dry it up. But yeah, I can come in and... Yeah, sure. Good, so now we have this guy up and so you can see this space right here. Some of this, you can kind of stay on the fascia and we can also do this with a knife. Take that down. We got the little guy, right there. Let's see, you wanna get a pickup or something, just to kind of move this outta the way? We're gonna move the pad outta the way here. This, yeah that's great. So I'm just kind of opening up. Oh. Oh, it's very strong movement. It's this little piece of fat. Mm hmm, go ahead. Believe me, I'm gonna save this little guy of yours. Huh? I'm saving this little guy. Oh yeah. You have faith in him? I think so, yeah, I think so. So this is not how you typically do it? No, it is. Okay. But I just, I go all the way around. Oh, I see. So I don't, you know, I'll go here then I'll kind of bump up a little bit. But there will just be like a thin layer of muscle kind of all the way around. I see. And so this is what you mean, like gimme these spreads you just do with a Harmonic and then take it down kind of a thing. Or like if I'm feeling wildly lazy and it's a pretty robust perforator. Yeah. Like I'll just take the Harmonic right here. Yeah. And I'll turn it on and then... Yep, and that's kinda what I mean. So I'll usually I'll just take the Harmonic here and then just ride all the way up. Yeah. And so, you know, I wouldn't necessarily dissect here, you know what I mean? Yeah. To get that out. You think on these small perforators, like it's bit of a risk? Yeah. I dunno where that perforator went. That one that was there. It must have been the thing I tore at the beginning. There you go. It sounded bigger than what I tore. Yeah, I agree. Let's see what happens when we take this fascia down if something just reveals itself. Nothing, oh, there. I thought I saw a hint of a branch there. Do you wanna give him a little counter tension on that muscle right there? Yeah, let's, why don't you regrab over here. Thanks. This is kind of, this is nice. Yeah, so I, you know, so this is all a little new but I like this approach and I don't feel, you know, before I felt like I'd be kind of leaving it naked in terms of the vessel. But there's actually a good cuff that you can kind of leave here. Yeah, there's usually like, I usually feel like I take more than I... Need to. Even intend to. Yeah. And then it still is enough to swell up and make everything huge, you know. In terms of the muscle? Yeah. Interesting. Now now that's free. So that's probably that other branch we were hearing right here. And this is this, yeah. And that looks like it's going in the muscle even deeper. Yeah. So, but I mean I think we're gonna say that we've lost it. And we were actually, we were still getting all three perforators. All three tagged skin perforators. You mean when we Dopplered it? With the Doppler. Is that it right there, look. Right here? Yeah. That's going the wrong way now. Yeah. It might be this guy. And that might've been what we were hearing. It might be this guy. Yeah. It's not still connected, right? Yeah, to something. Yeah, I... Looks like he's joining this guy. The main guy. See? Yeah, he's joining there for sure. Do you want me to hold him? Oh yeah, thanks. Lemme see a smooth Geralds So I think that where we got confused there is a muscle branch going off towards the midline and then the other little guy's connecting into him. I think, so had I continued carrying it through. Why don't you regrab for him a little lower there, yep. Yeah, that's where you are. Is it meeting? Yeah. Oh nice. This is kind of cool 'cause it looks like both perforators are coming to the same guy, the same branch off of our pedicle. That's great. See him. You see our guy coming right here? Coming through here. And then right here. I wanna release this while we have tension on it. Yeah, great. It's always when it tents at that little angle, like based off that little braider or that little branch that it's always like, where I'm like, okay, I don't wanna, I don't wanna make too big of spreads, otherwise I'm gonna shear it, yeah. Let's get some clips here. This is where I can see the, you know, you take the Harmonic. And it cooks back a little bit. Yes. Hmm, there's definitely a little nerve there. You want Metz or you gonna...? If you have a Metz, that'd be nice. Do you wanna try to clip one farther away or so they're not so slippage prone or? No, it'll be good. You'll be all right. That'll be good. Our Metz back. So when we come here, there's gonna be more stim, I'm sure, so far. Yep, yep, there you go. I feel like, I don't know what they quote, but I've noticed it's about two to three millimeters of spread. With the Harmonic. There's definitely a nerve here. I mean this thing is firing like crazy. Do you have the Harmonic accessible? You're left handed, aren't you? No, I'm ambidextrous. That's why I'm trying to figure out which side the buttons are on. So I would go here. Otherwise if you keep on digging deeper, you're just gonna take a bigger and bigger cuff of muscle. So we kind of like roll it off the top. That's big one man. Got some nerve there. No? No. Open a little bit wider. Yep. Thank you. All right, here. There might be some sort of nerve in here 'cause it's just twitching a lot again. So see that white? Can we get a Valsalva, please? Does Valsalva work as well for the leg as it does for the neck? That's a great question, I mean... Because I don't think it does. I always do it. So I'm assuming in my mind the answer is yes. 'Cause I think you're still... But when you think about it, like when you're Valsalva-ing, like I don't feel like you're expanding the blood vessels in your calves the way you are in your neck. But you're still squeezing on the distal drainage. The backflow. Yeah. Yeah. The primary drainage into the heart. And so then actually that's what should cause your backflow. But you're right. You know how much of that is IVC obstruction versus SVC obstruction? And so maybe that makes a difference. You're good to kind of take this stuff down right here. So lemme see your Schnidt, so we'll switch back. So we're seeing our guy here. So this is kind of what Dr. Funk was talking about in terms of rolling around. So you're gonna make this cut and then we should have the pedicle essentially free. So I like doing this pretty early just because. The back ones? Yeah, 'cause then you're not tenting it on the side like as we're moving up. Yeah. 'Cause then you're not like tethered there. Just by the pedicle. Just that tiny little perforator, you know? Well, so yeah, so I think, you know, it's interestingly that this is where, what I would've done first is I do just come all the way across. Across there. And just cut all the muscle. Yeah, I usually do... You know? Release the fascia when I come through my back cut. Yeah, yeah, we did. We got most of it, I guess we have a little bit left here. Which I think we did. Yeah. So we can do some of that, that might help. Here we go. Let's take this down. And then if you wanna take the 15 again, you can kind of score the remaining fascia up here. And I sometimes even just made all these cuts with a knife and leave Mark to help with hemostasis afterwards. So just cut right across there. You see where the fascia's still, so there, you're probably through fascia. Yeah. But here you're not. Yeah, see that? Yep, yep. Again, just like a bleph. Just drag it, drag it. Like a bleph? Yeah, in terms of how much pressure you put, what's something that you use as an analogy? The IJ, but I hear you don't... I don't. Yeah. I don't like to use the knife. I prefer to use a Bovie or a bipolar on it. I heard. Yeah. But Dr. Troy was a big fan of the knife as well. Knife back. Careful there, yeah. Usually what I say is you can use whatever you want, but if they're not sure then they're stuck using my way. I haven't done bleph more than once. Really? I only did eyelid weights. We didn't do any cosmetics in residency. Is that right? Yeah, we didn't have it like much essentially approval to do any cosmetics in our program. Well, what does that mean? Like they didn't, the hospital didn't have the structure in place where you could do anything cosmetic. Oh, interesting, interesting. So you couldn't have a cosmetic practice at the hospital. Correct and then all of the, like... The private guys were not interested. The ones that required blephs, like the ones that were like, you know, through Medicare, whatever, everything went through up ophtho. And then rotate your wrist down, so the taught tine is down. Yeah, there you go. Now you're safe. We can see your perforator here. And we can see the three inches of muscle that we're taking. See you still take a ton of muscle. I know. It's not like you're taking that much less muscle. I almost think it's a little bit more in this focal area. Like I wouldn't... Yeah, when you're lifting it off the back corner, it's a lot. All right, so... And it shreds up the muscle away more. Yeah, yeah. I don't know if there's a right answer. As opposed to taking just the top all the way. But like, that's why I think that when you just take the bottom, you can easily catch your perforator. Yeah, I hear you. 'Cause you're just skimming off the top. Hey, can you hold the flap, Emily? Oh yeah. It's nice to be able to once your fellow is capable of doing this part to say like later. Yeah. Yeah. This is gonna take you an hour. Take your time, yeah. This is now where we're gonna get a little bit... Do you want a Weity in there or anything? Does that help you? For here? Just to get, pull this outta your way. To me this is all good. It's all good, okay. Yeah, it's just, I'm just kind of looking at how narrowly this is pedicled now and whether I want to try to get a little bit more muscle on it. Don't you have that muscle on the superior side? Or is that not attached? This is mostly detached here now. So there's gonna be a nerve right here. You can see some more branches right here. So here's nerve. No, maybe not. Thought that was gonna be our nerve. Okay. And this is where you can kind of kill the flow just by pulling. Yeah. All right, let's find our clipped end. Where is it? Relax here. There is right there. See it there? Yep. Okay, so lift up. So the nice thing is we can even use this as a vein graft or an artery graft. And I've had to do that once where we use the distal end as graft material, if the pedicle was too short. And you know, some people talk about doing reverse flow, which is an option also. I'm generally not a fan of a reverse flow just 'cause the lumen usually ends up being much smaller. Yeah. But you know, I've used the vein, you know, 'cause essentially if we look here, we have about four centimeters of vein maybe give or take from here to here. Yeah. That we could use as a vein graft. Angle in my angle. Oh, I see. Yep, yeah, there you go. We might cut it this time. We've already done the neck this time. Is it bleeding or...? No, I'm just already grabbing it. Okay. Good thing that wasn't the LigaSure. Yeah. Go ahead. That a nerve in there? Now the cancer's out. Should we switch out the table? Well what we usually do. I have them build a Mayo for closing the leg and everything else comes up. So you're okay with continuing with... Yeah, for sure. So almost always there's gonna be a point where this nerve crosses and that's, you know, that's usually where I'm like, all right, well you know, we did all this work to try to preserve the vastus nerve. Yeah. But inevitably it has to be sacrificed. So we may see here that this nerve is gonna go on in between the artery and the perforator, in which case we're not gonna be able to separate it. Right, so then we end up cutting it. We might get lucky where we can tuck. Lindsay, can I borrow a couple Ray-Tecs? Tuck the nerve underneath. I don't want to open a whole pack. Or sorry, tuck the pedicle underneath. Can you see that? Yeah. So here's our nerve sitting directly on top. And so we might be able to tuck this pedicle underneath in this direction. And then we'll have everything on this side here. So if you wanna grab a dissecting, like a mosquito or something, and you can kind of... A mosquito, please. You're gonna come in between. A mosquito, or Jake actually. Yep and so you want, you see the space here between the nerve and the pedicle? Right here? Nope. Nope. Grab what you're, yeah. Do you want us to just cut the digastric? It doesn't matter. If you wanna try to fold it underneath, we can see. And then if it looks like it's caught up then we'll cut it. Flip your ties. No, so you wanna flip your ties, you wanna ride right here? So you wanna, our goal is to separate the pedicle from the nerve, right? Yeah, I was gonna just cut this first and then ride right through it. Oh okay, sure. Or just go through it. No, there's a little vessel there. Right on top of the nerve. Yep, that's a much better plane, spread, spread more. You're good, you can cut it, you can tear it. All right. Metz, because the reason I was saying that is you see that little branch, right there? Metz please, or tenotomies, what'd you call 'em, Jamie's. The land of mosquitoes drove me crazy. Oh I see, in terms of calling, okay, okay. In terms of if you're gonna use a blunt detector, just because. Yeah. - [Dr. Emily] Because. That's really funny. A mosquito is just child's play. That's really funny. I use a mosquito quite a bit. I bounce back and forth between a mosquito, Jake, and a tonsil. Okay, yeah, so you see one more layer of fascia. You see that when you lift, pull it? Yeah. You see it there, it's not there. Yeah, yeah. There might be a little guy in there. Yeah, I think there is. Now you need to dissect on the under side of it. So lift the nerve up. Lift this fascia, you have fascia right there. Lift straight up. Grab on there? Yeah. Lemme see a Jake also, are you finding in the pocket or it's not really? No, I'm just trying to hold some counter tension. Okay. Do the second branch there? Here hold the flap for a second. I'm gonna see if I can kind of help you out on this part. I'm gonna gonna have you hold right there with the other hand. So when I take a look here, see this little bit of pink stuff? Yeah. That's kind of what I'm grabbing. And the pink stuff you can see here there's other branches, see that? Yeah. There's another branch right here. Our pedicle just right below that. Yep, exactly. So that's the part that gives pause. Right, but there's not gonna be branches that go up to the nerve. Yeah. And there's not gonna be branches of significance that go up to the nerve. But again, when I get here, this is where I'm gonna be a lot more cautious because there may be a branch that goes from the perforator to the top of the pedicle. Okay. And it may be that this nerve ranch right here is not actually going to anything, that might be actually pedicle now. So again, you see our perforator here. Yeah. And it looks like there might be a little branch directly opposite it. Right, so you got your bipolar, the blues and I just take that down. Watch the nerve, kind of almost directly in the center. Yep, right there, good. Good. So now that we have that elevated, lemme see where our pedicle is. See that? Yeah. So now we know all that's safe. Yeah. Right. But now we got some branches on this side we gotta take down. Okay, go ahead. Bipolar. Don't burn. Squeeze first. Okay, go ahead. Okay, good. And I think there still is one more branch right here, right? Yeah. So this of course is like the annoying one 'cause it's right in between everything. Yeah. But same approach. Expose it, get underneath it, right? Yeah. And this is one where sometimes I will cut it on purpose and then reanastomosis after we've evaluated the flap out gotten the flap out. Yeah. And so I may actually just do that here because I'm a little. Yeah, it's like riding right under. Exactly. Okay, so take a tenotomies and just cut it, should be sharp. Flip it or anything? Nope, no, no, 'cause we're gonna, oh, to identify it? Yeah. Not really. Just cut it and we'll identify right after. This is it right here? You see the other end right here. Or just another guy. Yeah, cut it. Cut this guy too. Can I have a tenotomy? Grab this. Can I have a medium clip, please. Can I have a tenotomy? They don't have 12 monitored, but obviously you'll see something move. Yeah. All the little branches. Okay. Medium. Medium clip. Much more lower. So much further away from the pedicle. Yep. Yep. Make sure there's another small in here. I have four left. Can I have a... Ray-Tec first. Okay, go ahead and cut. It's down here somewhere? I think it's the one in the middle, maybe. Just come across everything. Can I have a medium clip? No, I got it. Just get rid of that one. So... Is that artery still pretty puny down there? Yeah, probably. You might want to beef it up. I think I have always gone back and forth. Go ahead. Right there. Mm hm, right there. Okay, medium clips. Or you wanna, oh the Harmonic should be okay. It's like reminding myself that I have three and a half X loops on. So it's not really that big. And then seeing the, seeing your medium clip going, I'm like, man that's a humongous clip. So this is going back to that 360 component, right? So now that we have the flap elevated, I can lift the flap like this. And use that to help show the other branches that are showing up here. Go ahead. Sorry, so you're gonna take this guy. You wanna come here. Okay, so now we see the nerve here, right? Yeah. So we kept the main branch of the nerve intact. Take these, you see these little guys, you can take those down with like a scissor or even just tearing it. So now we have that. Let's make sure I haven't killed the pedicle by pulling on it too much. And then... There's our pedicle there. Good. There you go. So do you strip the adventitia all the way to the carotid? No. So every move is a back and forth, you know, you're kind of seeing where your pedicle is, kind of thinking about the three dimensionality of the space. Now we see our perforator there and it's gonna be kind of coming up like that. No, it's the only way. It's the only way you get better in either direction, right? Because there's, once you're in practice, there's kind of a limitation of exchange of ideas except from your fellow or other faculty. So you know, we're kind of already at the level of our main pedicle, but we're still kind of creating a cuff of muscle, right? And that's on me. So what we gotta do is we gotta get back to where we were before with the 360 plane. What were we saying about dissecting until it bleeds? Yeah. No, I just made something bleed, that's what I was saying. Oh. Okay. So yeah, it's easy enough. We just put a little bit pressure there. Looks like a little branch, does not look like our main perforator. So already trying to slow down a little bit. We're seeing that it's pumping beyond it, right? So, I'm not occluding it. You okay if I clip the artery and let it start... Yeah, yeah, that's fine. Do you wanna look at the length here? No, you're good. I trust you. And we got four centimeters of vein graft if you need it. Yeah, just the distal pedicle. Are you taking it now? No. Oh, okay. For me, when I do the neck, I like to stay above the ansa when I take out the nodes. Contrary to what I was saying about trying to get right underneath the pedicle, I'm gonna take a little bit more muscle here. Yep. Mm hmm. She also took off. There's like a ton of people at... For what? Yeah, it's like everybody and their mom. Is playing? Yeah. You guys good if we harvest? Yep. Okay, appendiceal. All right, so let's go back to see what was there. All right, so again, kind of taking a look here. I want to kind of lift up. There was that one other branch that I remember we had kind of run across here. Oh, that's the problem. I thought we already traced out the artery and vein, didn't we? We did, but there, see this guy? Gonna clip that. Yeah, remember you had come underneath it and then there was a spot, where we got caught up. See, where it grabbed further. Yeah. So just go to some small clip. Can I have a small clip? Okay, cut. Can I have a tenotomy? Oh nice. Okay. Nice here. You got that? Okay, lemme see a smooth Geralds. And bipolars. Watch how much you're grabbing there. Not cooking as much. We got a bunch of veins here. Okay. There's something here. That's a vein. So come on this side. Can we borrow it? I think your angle is a little bit tough. You have the pedal? That's your left foot. That one? Yeah. Okay. Lift up. Let me see the smooth Geralds. Yeah. Clip. So you see this is the branch that was bleeding. What do you think, small or medium, I can't tell. Can I have a medium clip? Scissors. So let's come back up here. You're gonna take your right angle. Do you have a preference? Artery first. Vein first. Emily? You always clamp the artery first. Yeah. Thank you.

CHAPTER 6

Let the blood come out. Yeah. There you go. Higher. Yep. So come across the artery. Clamp. You're gonna come across and clamp the artery. All right. Yep. As high as possible. Trying to stay where my, there it is. Large clamp. Large micro clamp. Okay, we're starting ischemia time. Let me see, I'm gonna take this from you. Let's get another right angle, to try to come right below this vein. The valve, you see the bulge there? Remember you were saying it kind of narrowed. So come right at the bulge. Higher, yep. Okay. Large clamp please. Do you need a large clamp? Yep. Thank you. Okay, 15 blade to me. If you can go higher on your clamp, that'd be good. Not really, it's kind of like escaped. It's running away from me. Okay. May I see this? We probably won't need too much pedicle length. Two millimeters, that should be enough, right? How many millimeters? Two millimeters. Did one of the clips fall off? Something's bleeding. Though it's hard to say what. Lemme see a DeBakey. Oh, there we go. See that? Something holding this down there? Yeah, there may be one more branch here. Lemme see a mosquito. This is where you find that other branch that's going to the intermedius. No. Oh. Okay, tenotomies. Hey. It was, you found it and traced it out. You gotta do it right? Can't just throw away all that work. There we go. Exactly. All right, we're gonna take these guys off for a second. The downside with this is you could potentially confuse which one's your artery and which one's your vein. Yeah. Yeah. But there's something right here that was snagging us. Rich, do you wanna do a nerve anastomosis? Sure. All right, I see this here. Take the Harmonic. You see that little band? Yep.

CHAPTER 7

So really what I'm assessing right now is just kind of getting a sense of how much volume we're gonna need. We have our flap here. This includes skin fat, fascia, and our vessels. And as we take a look here, it looks like probably the amount that we're gonna have to reconstruct, it's probably close to kind of a little bit more than a golf-ball size. We definitely have more than that available right now. Once we do the anastomosis and have it revascularized, then we're gonna start to trim it down to get it to fit the space. So I did put, oh, here, let me get this clip back up. Can I reach under you for a second? Yeah. Gonna take this digastric tag back up. Yep. Can I get another, can I get a medium loaded? Yeah, that's helpful I think. Yeah, that's great. Man, it's like you're gonna hit me with those long things. Tube of hep saline? Yeah, the medium. It looks so dark. What's our - this is the vein I think. And this is the artery. Now I kind of wish I left the clips on. That's the vein right here. That's the vein. Okay. The vein I remember being so much bigger but it just collapsed down. So let's, I'll put the medium on that and put that outta the way. What do you put those on for? Oh, I don't like, I don't know. I never like to leave them open. Lemme see a Jake. So you usually just leave the vessels open the whole time? Yeah. Interesting. Can I get a Jake, please? This is straight. Thank you. That's, I mean that's the same thing. No, I want a curved mosquito, a fine tip - those are the Jakes. They're fine-tipped, curved instruments, like a short Burlisher. I'm okay with the straight ones otherwise, but I just haven't used one before, so it just kind of feels weird in my hand. All right, lemme see the medium. Medium clip? Clamp, yep. Yep, lemme see a micro-scissor? All right, so we got our vein over on your side. Let's bring the vein over to me. We're gonna bring it back afterwards because we're gonna end up flipping everything. Yeah. So I'll, let me see the Ray-Tec. Lemme see a curved mosquito. A curved scissor. You want me to hold it towards facing you? No, just like that, perfect. What's that? Joel never let's me put my fists down. What do you mean? Oh, with your scissors? Yeah. I mean, honestly this is good enough for me. Let me see a frame clamp please. All right, fine. Okay. One of our guys would, one of my mentors would do like a circumcision. You would just grab the adventitia, pull it. Yep, just like that. Pull it forward. Yeah. And then I'll retract back. Lemme see a dilator. Yeah, she's got it. Oh, that's the frame. She'll take a dilator. This is too big, there should be one down. And then you gotta load on the Rizutti. Let me get a pair of straight micros. Or if you have the black, do you have black tenotomies by any chance? Oh, this will be good. I have black tenotomies. It's okay, there we go. Okay, we're good. I'll take the clamp loaded again. You clipped it? Yeah. Okay. Let me get a medium clamp. Okay, lemme get a Jake. So like here, this, I would just kind of take a Jake and just literally just make big spreads. And usually the reason for this is to kind of get rid of some of the kink. You know, how it's all kind of twisted. Were you guys able to find both ends? Yeah. Okay. So I left one long on the proximal component and short on the distal component. And then left the other guy reverse. Let me see the clamp scissors. I'm just gonna cut it there. Dilator please. Maybe cut right there. Let me get the Rizutti. What'd you call it? Let's let it bleed out, right? Yes. Dilator please. I'll take a Ray-Tec again. Oh, I know where it is. Thank you. I think we can cut it off there. All right, you okay doing this without a background? Yeah. Lemme see a Rizutti. You wanna clean it up more? Lemme see the dilator again. Hep saline, please. Hep saline? Yep. Okay. Lemme get a 9-0 please, on a 130. Lemme see a Rizutti please. I wanna zoom in if that's okay? Yes, please. Okay.

CHAPTER 8

Gimme another pickup. My super long suture. Longest suture ever. Scissors. I guess I just handed you the straight. I'm sorry. You see the end? Huh? Do you see the end? Not yet, pickups. Not yet. Not yet. It's definitely not there yet. No. There it is. I think it's good. I just left this tail a little bit long. I need a little trim. Yeah, just above me. Just cut this one. Too short? A little short. Yeah. Good there? You want me to trim it? No, I usually don't trim it. Okay. Yeah, I like the needle better, but I guess I don't remember appreciating the suture being so long. It's so long. But it may, you know, again, it may just be that we're zoomed in a lot more than I'm typically used to zooming in. You are really zoomed in. So try to get three sutures. Do we have Tisseel guys? The four mLs. Yeah, did you guys put a drain in already? No. So we can do some other stuff while waiting for that to warm up. Just cut this one instead? Yeah. It's just the, yeah. It's just, yeah, just empty suture. I think I'm trying to get the suture length to be close to a 100 size, so I'm just wasting suture here and there. There we go. This is probably one that I'll just do two on this side. Oh, I see what you're saying. Sorry. I misjudged it. I thought I thought I saw you kind of flicking the end of it. Scissor, do you have another 9-0? Yeah, so I usually like to open 'em in pairs. The flap cart's outside Rich, if it's not in the room, thanks. It'll say BB100 or BB130. You said on 130? Yeah, please. Got it? I'm sticking up. Yeah, that one's too short. Is this the scissor that I'm picking up? I think it is. Yeah. Yeah. And then, we can get the fat out or...? You got it? I need to go under. Yeah, I'll take the scissor, thanks, you have the hep saline? Pickup. Pick up. I have some weird bend in my suture. I was trying to tuck it under that muscle. I don't know if it made it or not. There's a... I gotta do one more. Do you need me to get another one? Yeah, have another one in the room. It doesn't need to open, it just needs to be in the room, because we're done with our anastomosis. But we would need it in case there's a leak. Pickup please. Gotta get that guy out. It's so long. I don't know what it is. There must be a shadow somewhere that... It's definitely out of our field. You can't tell. And then like when you start to pull, it's really hard to see when the end is coming. When it's ending, yeah, exactly. Until it comes down into our view. So I'm sorry, I didn't realize you had it up, but you, what I do is I take a glove, I cut a finger off of it and then like a background, I'll put it underneath the nerve and then I roll it like a taco. You do what now with the glove? You leave a glove in the human body? No, no, no, no, no. It's just a... Scaffold. Scaffold, thank you. 30 seconds. So you went like this and you just rolled a glove like this, right? And you have it in a U and you just put it in between. Let it sit for a little bit. It starts to turn white and then you're done. Lemme see a Jeweler's. Did I do that backwards? I don't know. All right, no, let's bring it over this way. Okay, let's bring the vein over on this side. This vein. No 'cause that veins like right here. Okay. Lemme see a 2-0 silk please. So right now we're gonna size our vein here. We just did our arterial anastomosis, which we can see on the underside of that drainage. Here's our arterial anastomosis right there. And here's our vein here. We're gonna size. Yeah, can I get a 3-0 coupler. Great, 3-0 coupler, please. You wanna do... We can definitely get a 4-0 on this. You wanna do a 4-0? Yeah we got the, you had the other side. Hold on, it might be a different side. You want 3-0 or 4-0? Hold on, lemme see other side. It was actually this side that I was, that I... This side is the one that's more. Yeah, exactly. We're sticking with 3-0. Lemme see the stamper. That thing? The hockey stick. Yeah, this is not it. This is the angle dilator. It's a longer instrument that's in the coupler set, mm hmm. Oh, we're doing the wrong side first. That'll be fine. Oh yeah, we are. That'll be okay. There's a good amount of length. We'll be alright. Yeah, we go two attendings just, doing whatever. Okay. This is a little. Yeah, here, does it help? No. No. Okay. It's a little tighter than I thought. I dunno if I have the edge on this side. The edge is here. So yeah, I mean, endocrine, there was, you know, routinely only four people applying or three people applying. Oh really? Total. Like in the entire country. And there was, you know, there was like, there was the Stanford program, there's a Harvard program, and there's only four programs. Did you have people in your residency who were like, oh, I wanna do endocrine and do a fellowship for it? Because I feel like in general you get so much endocrine as a resident. Yeah. And it may be our bias, 'cause you know, Goldenberg does a ton of it. Hep saline, please. That most people are like, "Hey, I don't need a fellowship to do a thyroid." And you know - there's a little what? A little clot. Weck-Cel. Say again. Wecks. Wecks. Yeah, so, you know, it was interesting. So, you know, we did it for a little bit and then I think David was pretty quickly saying, "Hey, like, I don't think it makes sense." And I was like, "Yeah, I agree. I think we should do a head and neck fellowship." And then I think the biggest challenge has been is that, that I've been the only person doing micro. Yeah. And generally what people want is flaps. You know, so like, you know, saying, Hey, you know, I'm doing maybe, you know, 40 or 60 flaps plus the other stuff. They're like, well that's kind of a low volume relative to most other programs today. Hold on, we're caught on something. There we go So, you know, we've tried to say like, you know, one of our added benefits is the, this is the extra pedicle, is the endocrine experience. Yeah. Do you take artery off first? Yeah, I did that wrong, not this side though. Huh? Yeah, I do. It doesn't matter. You wanna do the vein first? Let's do the vein first. The clamps are in the way. This drainage, outflow, inflow. Look at that fill up, a lot of backflow. So Mark, just super important, you know, whenever we take the clamps off, you always take the outflow off first, so you're not backing up fluid. So for the vein, you take off the neck side first, then the flap side. And then for the artery, you take the flap side first and then the neck side. Okay, end ischemia time. This right here looks like it's a little twisted, huh? Yeah. Lemme see a wet Ray-Tec please. Yeah, I just, I don't even put a pad. I just do that. All right. So now we're taking a look at our anastomosis here. We had a small little, sorry, hep saline. We had a small little leak that was coming off the artery. So what we were just talking about is, is putting a little bit of - putting a Ray-Tec on it and just giving some time to kind of form a clot across the little leak. It looks like I see a little airknot in one of my sutures here, so I'm just gonna tighten that up. Or cause a leak again. Hep saline. That might be why it's leaking. There's just a little bit of a airknot there. I need a pickup. That's not a pickup. Whoa. You are correct. Oh, there we go. Got it tighter. And we got a little leak there. All right, let me get the, you have that 9-0? We'll just throw a suture, saying probably that knot was not fully down. Yeah. Yeah. And it probably would just, you know, if we put pressure on again, it probably would just calm down again. So we did these things called, you know, sweetheart stitches here or that's what my fellowship director would call em. It's actually more of an adventitial stitch. It's pretty much doing the same thing that the Weck-Cel did or Ray-Tec does and provides a little bit external pressure just to, of course this is that super long suture again. Did a break? It already stopped on its own even without the suture. Can you leave the microwipe closer? I usually use it to get rid of all that extra suture. Thank you. And we already said end ischemia time, right? Yep. Okay, thank you. Are you done with it? Yes. Yeah, so I would typically like do... A ton of irrigation. A ton of irrigation. Just to warm it up. Just to summarize here, I'm gonna zoom out. All right. So we're looking at our field here. This is our vein right there. And I think our scope video might be inverted. And here's our artery. Just for a frame of reference. This is superior here. This is posterior. This is posterior here. This is inferior down here. So this is superior, inferior, anterior, posterior. So we we're turned about 90 degrees, it looks like. Digastric. And this is the digastric up top. Yeah. That superior is right here. So we put a little suture here to help secure the flap to try to, you know, avoid too much tension on our pedicle. So I just cut that suture. That's clipped off, right? Yeah. So that's the other side. So this should sit like this. Yeah, do you wanna put anything underneath that little at the vein? Right here? No, at the actual. Oh, at the actual... Where it comes out. You think it's so problematic. All right, so we have our flap in place. We have our pedicle in place. Can we turn the Doppler on please? Interesting that where it comes off right there is a little kink. Yeah, do we have any Gelfoam? There's a little bit of leakage there as well. We'll work on it as we're taking a look at the flap and letting it profuse and, oh yeah, let's get some irrigation for Dr. Funk. Can we get some warm irrigation. And then I'll take the metal Yank. Can I have a bucket of it? All right, so we're just irrigating right now. This is to try to help warm up the flap a little bit and kind of open up some of the microcirculation at the dermal epidermal plexus, we're seeing healthy bleeding at the edges of the flap, which shows good distal perfusion of the flap. And we're gonna see if we can get a cutaneous Doppler and to kind of confirm that we have a good signal that we can use to help monitor the flap after surgery. How do you want this Gelfoam cut? Just take off a little half by half. That's good. Let's just finish with this one, 'cause I am failing at preventing this from leaking everywhere. But the nice thing is we're seeing really nice bleeding from the edges of the fat here. I do think it helps the microcirculation. Oh, I'm sure it does, yeah. There is a paper about it. Is there? Yeah. Yeah, can we turn this on? Can you turn the Doppler on, guys? Okay, sounds good. Let's see if you got the other guy. Amazing. Let's see this last guy. This is the maybe, this is that little guy, but we got healthy bleeding right there. Hey. I heard something. Hear it?

CHAPTER 9

Yeah, it's pretty subtle, but it's there. All right, great. So all of our stitches are showing good signal. That's great. And it's kind of now the contouring component, right? First things first, and then we're gonna end up de-eping all of this. So I think, I think in the end it was about this big is how much fat I take. So maybe we can even just kind of core out around here. So... Not twisting it, so... Let me see... I think we could leave a little bit up here for the skin. And this is gonna be tough to close, you know, I think... Oh yeah, well I was gonna just chop this off. You're gonna chop off my perforator? No, it's gonna be too much. She's gonna be living with a bigger tumor. Do you wanna Harmonic this all off or bipolar? Yeah, let's - lemme get a knife. I usually just end up cutting it. Are you done with the microscope? And the nice thing is, yes. Yes. Just, no, no, just leave it on the leave it on the Mayo please. Okay. Yep. And then, or you put it somewhere where it's accessible. That's fine. Yeah. Thanks. And the nice thing is kind of confirms for us good, you know, good perfusion at the end. Can I shut this off? Yes, thank you. All right. Can always harvest a little. Lemme see that Allis. No, I just said it bleeds so much. Oh, I see the flap, yeah. You know, but it's interesting, when I took a look at him, I feel like we have a lot of bulk there and that's why I said to him, I was like, yeah, I don't worry about it. You know, if you get radiated, this thing will trim down really fast. If you're not gonna get radiated then we'll cut it out in a little bit. But you're probably gonna get radiated. He's gonna get radiated. Because we can also kind of thin out the fat and we can use it to kind of fill the neck dissection defects. Yeah, we can just tuck this fascia in. Yeah. And do we have a Penrose up? I'm gonna make a cut up here. Knife please, 'cause all the, I mean this was normally here so I think that's all extra skin also. Oh, thank you. Allis please, be careful the hot tines facing you. We always used Harmonics in neck dissections. Yeah, I tend to use the bipolar a lot. I don't use the blade that much. I use the blue bipolars. We didn't have cutting bipolars where I was, so... Yeah, we got a lot more to take out here. So I think this is gonna sit just like that. I'm gonna de-ep the whole thing, I think, 'cause I would like it to close primarily. I should get a drain also. You wanna just do it just Penrose or you- I guess we should actually put a JP in. Huh, 'cause they did a neck. This is twisted right here. Can we get a medium clip? It is twisted. So it looks like this is the way it needs to sit. Okay. Scissors. Keep this in saline also. Cut it right here. Did you, oh, do we have the Gelfoam? Let's put that Gelfoam in now. So we're putting a little piece of Gelfoam in just in between the artery and the vein. And what that's gonna do is it's gonna kind of round out this area by the coupler. You can kind of see the coupler is a little bit rounder here. So, you know, I think this will be a nice contour. And even if there's a little bit of fat showing, Allis please, we can use, you know, even some Xeroform and allow that to kind of come in. We have a bipolar up here? You see each of the perforators now? Oh, we should have tried to dissect this off and find them. We'll have to watch it afterwards. You wanna do, well now we're done. No, it's too late. Much too late for this. As we see both perforators bleeding. But like that's what we're looking for right. You know, it's like you're looking in that... That's actually really interesting. Yeah, I got you. Yeah, yeah, makes sense. That thickness is what you're looking for. And so pretty much you just find that, yeah. Okay, cool. And so it's it's very similar to... Yeah, to how we were finding the... I would small clip these. Really, over bipolar, okay. Small clip. Do you have GEMs? I don't care, tbh. But I just want us to see if I can get it isolated. It's hard. It's like I'm not, I can't control how far I'm pushing this because I'm used to using the GEMs with a microscope. So I'm trying to make the same movement and obviously it's nowhere. This is maybe a loaded a little bit too far. - [Speaker] You want new one? No, it's okay, it worked. Yeah. Okay. That's okay. What is this, oh, thank you. No, you don't want it. I didn't know what it was. So that's what we're looking for is just these little... Yeah and then you, so you find that and you start tracing it back the same way. But you wear your three x loops or whatever. Yeah. Yeah. And then you trace it down, you cut the fascia, and then you just take it, you do the trace just like you would, you're just doing the whole thing. What is this, this is our EJ, that's the other end of our pedicle. So let's see if we can kind of tuck this in here. Do you wanna put the Penrose under it under visualization? Yeah, that sounds great. And so now I think we can actually still trim a lot of this stuff on the back. The nice thing about having the clips is we know exactly where our perforator is. So I like that idea. Oh yeah, so what do you like, I feel like I need to know what your preferences are. You don't always use a round drain. You'll use round or flat. The only thing I use round for is the legs. The only thing that you do use rounds for. Is legs and the scapula. And the scapula, why? That's just what I, I don't have a reason. Okay. And then you use flats for everything else. Yeah. And you use like a 10 flat. I don't care though. Like I honestly. Yeah. That's not something I feel strongly about. Yeah. One thing I do typically do is allow enough space in knees for them to probe it. And this one that doesn't matter, but when you're just putting it like right under for it to clot, like our practice was to be able to irrigate through it or to put like a cotton back of a cotton tip through it to flush out any plugs. Oh, interesting. So do we think that it was truly the penrose not working or that was kind of, the way you guys rationalized it? Probably both. Okay. Yeah. I'm gonna... I mean there's definitely cases of both where... Yeah, I'm gonna have you let go for sec. Where you'd like open something up and there would be a massive amount of stuff in there, but... Just right adjacent to it. I mean, drains what I'm taught is drains do not prevent hematomas. Yeah, exactly. So essentially what we're doing here is we're serially cutting this down to size. You know, we were debating a little bit about keeping it vascularized, you know, doing this before vascularizing versus now. I personally prefer to have it vascularized because then you know exactly where your pedicle is. The counterpoint is by having to vascularize you have it attached at a narrow spot. And so if that pulls in a weird way or there's too much tension on it and lemme see a small clip, please, then you could end up shearing it off of your anastomosis. And so Dr. Funk is doing an excellent job of keeping me safe there in preventing us from losing it. It still looks pretty big, huh? Let's bring her neck towards me. Let me get a silk. I think this needs to be trimmed more. So we got our one clip here somewhere. You're okay. Oh, hold off on the silk. I'm sorry. So I can take, I'm holding the clip. This guy. I'm hitting you. Sorry, that was my fault. I think I grabbed the other side of your blade or your scissor. Okay, so let's see where the skin's gonna sit now. And lemme see it, lemme see the... You have the flap. Yep, so a lot of extra here still. But when she's sitting upright it'll be more. It's gonna, it, oh yeah, I agree. Let me see the scissors again. Clip is right there. Mm hmm. Okay. Does any of this tuck in further? Okay, let go of this hand. That's looking pretty good. Okay, lemme see a 3-0 Vicryl. We can elevate more. A little more flat here. We still can, this is looking pretty good now. So I think we just need to continue to trim in a vertical layer, I figured worst case scenario it ends up being a fat graft, so... I just mean like that, it's right over the external where are our anastomosis is.

CHAPTER 10

So I don't think we're gonna get, if we have, we'll have to get some of those perforator Dopplers. Yeah. I mean you're still gonna monitor it? Yeah. But you know, this is one where I was thinking we could even get her out a little bit earlier. Oh, yeah, for sure. It's almost like a gracilis flap, right? I've also been cautious on mine. I typically, for skins, if they're looking as good as mine have been. Yeah, three days. We would let them leave after three days or so, but it's early days. Yeah, yeah. Man, this other guy's got his VAC issue regardless. Right. Well we can also take it off, I mean. Yeah. Okay, so let's see where that sits. Or we could do a regular VAC. Okay, lemme see a scissor. This will need to be a little bit higher. Let go for a sec. Scissor to cut the suture? Yeah. Whoo, it's going out. Can I get a stitch? Can I stitch some down here maybe? Yeah, sure. You want a 3-0... Yeah, Vicryl. It doesn't matter, yeah. You are a righty, correct? I am a righty. Like a normal human. Lemme see a 3-0 Vicryl. Do you wanna hold it? I'm just gonna do one to anchor it in here. Yeah. Yeah. Though I think, you know, we'll probably end up cutting it a little bit. So sometimes with these sutures, I'll also throw a stitch in the flap itself to try to help secure it in a certain position. Are you talking to me or your internal ear? I'm narrating. Okay. It's really hard for me to tell. All right. So we're throwing this buried stretch to anchor the lobule back in position. Reduce the chance of a pixie ear. And then once Dr. Funk has that secured, we'll bring this back into position and we'll able to better contour. So what I did there was I threw in an anchoring stitch to connect to the fat. Fits in well here. Yeah, exactly. There we go. Okay, let's take a look now. So let's relax there. Okay. So as I take a look, we still have a lot of extra bulk here, that you put this one in? Yes. Nice. All right. So we can shave all this. Lemme see a pair of scissors. So do we have the contour we need up here is my question? It's hard when we don't have her on the face out. That's something. That's literally what I said. I was like, "We should have definitely done like a light haul drape here to get the other part of the face out." There we go. Stitch right here, clip right there. I mean, you're above the fascia so if you cut the perforators, it's not like the end of the world. We're just gonna clip 'em again. Needle. Just gotta make sure we don't pack it in. So what do I do though at the meeting? The tumor board meeting is from five to six and... You know, you're just, we we'll we'll hop on and we'll say "Hey, you know, we have our faculty meeting today too." I don't think it usually overlaps, but... Okay, I was gonna say, is that how it is every month? I don't think so. But we can double check that too. Relax there. Yeah, that's looking pretty good. I was gonna say. I'm gonna put one more stitch here just to see where this is gonna end up lying. I think that we could still take a little bit from here. Yeah, I agree. Suture. Or we could anchor more of it forward somehow, you know, because when I push forward on it, it looks nice. Yeah, yeah, yeah. Okay, let's see if we can... So maybe when we tuck it in... Let's get a... Can we have a malleable, please? Yeah, thank you. What size? Medium size. Half inch or one inch. I'm gonna try to pull it forward on the skin flap. Oh you are, oh, I just thought you wanted me to hold it forward and you do it. Okay, let's relax there. Okay, great. You can let go, lemme see a 3-0 Vicryl. Ray-Tec please. You want me to... Try again. If you can. I don't wanna compress the pedicle though, you know? I see, that's true, I like that. That makes sense. We do this, and it's gonna be pretty tight. Yeah it is. And you know, with the vascularized flap, I don't think we're gonna lose as much. We won't. Yeah. But I think, you know, maybe what we do is let's close the rest of this. Okay. And then we'll see whatever's kind of pooching out and we can kind of trim. Lemme get the heavy Mayos. I'll take a stitch. Mark, did everything go okay? Might need a step. Huh? On the leg? Yeah. Yeah. It looks like we may beat you at closing the face here. That's the motivation. Mm. We're slowly removing 50% to 80% of our flap now. Good coverage for the blood vessels is all... Oh, okay, good, all right. I mean, even then like, you know, you can see it's kind of bulgy. Here's our pedicle right here. We have little clips on it. So we're just taking off. Oh, look at that pulsation there. Lemme get a GEMs again. She doesn't have platysma here that I'm getting. Lemme see a 3-0 Vicryl. Oh, 'cause we efaced all of the, all of the empty space in this person's... Yeah, everything is full... Everything is plugged. I'm actually for it. We used, in Israel, we used to do Penrose. What was the rationale behind using a Penrose, over a closed suction drain in Israel? Not to cause any suction over the pedicle. Yeah. I feel like you, like every time I tell you something new, there's like, you're like, well why do you do that? It's something that I try to tell the residents is that I don't really care how you wanna approach something as long as you have a reason for it. Right. I took the skin off because it looked like it was gonna be too much. So you know, you're thinking hey, well maybe we should let the skin on for this spot. Right, but the skin we took off with about that much fat on it. Well, it's ALT right? Let's aim for extubation as well, please. Yes, sir. It was just a fat or muscle filler. The only time that I will irrigate is if I notice that I'm not getting a good Doppler signal on the ALT or I'm not getting good bleeding. It's minimally invasive to irrigate. It just makes a mess. To me it was maximally invasive. So now since my socks, my sneakers, my feet, everything's just soaked. Wow, okay, I quit. You're gonna have to probably thin this a little bit more. Oh, is that your alarm? That's my alarm that's been going off. I mean I can almost see through some of these parts. So I think it'll still need to be thinned a little. Oh yeah. We need a quarter of that if anything. Oh, a quarter of the size or a quarter of the thickness? Quarter of the size. So what we're working on here is we're just doing our closure. I usually like to use absorbable suture, Vicryl or Monocryl, and then we're running a Monocryl for our skin. You know, usually that gives you some good longevity of your suture with good tensile strength. Another 3-0 Vicrylm please. Needle down, it's not guarded. Okay, let's get the Doppler on one more time. So you're Dopplering over the skin graft, but you're not... We're gonna see, we're gonna see right now. That's all I wanna see. You hear it? Just hold that, don't move the strings. Okay, just take a look. It's right at the intersection there. Okay. We can turn that off.

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CHAPTER 12

So I think there were a couple things that we highlighted during the case, during the elevation. One was just identifying the pedicle and taking your time to identify each of those perforators as it goes to the pedicle. You saw when we were dissecting out the muscle, the posterior aspect of the pedicle, that we were taking care to almost flip back and forth and make sure that none of our dissection was involving the pedicle could risk injuring the pedicle when we come across the cautery. The other thing was that nerve to the vastus lateralis. So I think we might've had a camera that showed the neurorrhaphy, the repair at the end. But really important to know that that nerve almost always intertwines at your pedicle. Sometimes you get lucky and you're able to dissect it out completely without having to cut it. But sometimes the right thing to do is to cut that nerve and then repair it after your flaps been harvested. Anything else that you saw? Yeah, I think that, you know, there's a lot of variability in the perforators and I think that's something that the case really highlighted. Yeah. Because we had a really large perforator and then a very small perforator. It's really amazing kind of looking at the angiosomes of what these little perforators, how much skin they can supply. Sure. And so I think it is a good point to not rule out or write off any of your perforators, especially early on until you know you have a really robust perforator that's supplying your flap and then even then it's usually really helpful just to be able to try to include all the blood supply that you can because you might need it. I think the other thing that we talked a little bit about was the possibility of using vein grafts. So, you know, I think, think both of us as reconstructive surgeons, you always have a plan A, B, C, D. You know, what happens if the pedicle is too short? Do I have an ability to get something else to get the pedicle to reach? When we were doing the arterial anastomosis, we saw a little leak. And so, you know, one of the things that I say, to our trainees is you have a leak, you pack it, you give yourself 30 seconds, you give yourself a little micro break, it takes some of the stress and the adrenaline off of potentially having to throw another suture. And as we noted, you know, it actually repaired itself. There was no leak. And then it turned out, as I manipulated it, I did need to throw one more suture there. But because I had taken that break, because both of us were kind of just kind of level set and even keeled, it allowed us to kind of approach that very rapidly in a very, you know, precise and calm manner. So I really do think once you do the arterial anastomosis, you have it off of ischemia. You know, some surgeons will even leave the room and just go for a quick walk. Just do something to just kind of take your mind off of it, so you don't try to over manipulate your anastomosis. I think one of the other points I'd make is, especially for people in their training, you know, further on towards fellowship and things like that, is that, you know, there's a lot, of flexibility in your case in terms of how you're gonna end up reconstructing what you think you're gonna reconstruct. And so like for example, today, even when we debulked the flap, we still saved the skin. We still saved any of the vessels that we trimmed in case we needed them. And we did end up using a full-thickness skin graft. And so that's preventing you from having to harvest another piece of tissue or do more rotational flaps. You can kind of utilize what you have and kind of minimize the patient morbidity overall by kind of utilizing and being creative of what you've already harvested and done. This case, I think things pretty much went as planned. But when we prepared the patient, we had prepped two different sites. We prepped actually three, four different sites. We prepped the upper leg, which is where we harvested from. We prepped the lower leg, which would've been for a medial sural artery perforator flap. We prepped the shoulder and we prepped underneath the chin, which would've been for what we call local or pedicle flaps. So we have all those options available. Let's say during the surgery we identified that there was no perforator that went to the skin and we couldn't use the anterolateral thigh flap. Then instead of taking out an ellipsis skin, we would've had just one incision there, which we would've closed up and would've healed nicely. And we would've moved on to our planned B or C. I'd say probably the biggest thing where we kind of changed our plan was initially we said, "Hey, we might keep a little bit of skin," but as soon as we brought the tissue up there, we noticed how big the flap really was relative to the defect. And so we said, "All right, let's adjust. We're gonna de-ep this, we're gonna take off all the skin, and we're gonna, you know, contour this down to where it needs to be." Again, this was kind of a pretty straightforward case, but there are days where you see the patient in clinic and you see them in the OR three weeks later, two weeks later. And the tumor has dramatically changed since their last set of imaging or their last exam. And so it's always good to have those patients prepped that, you know, here are the different options that I might have that I might use or utilize in terms of different locations or flaps, or ways that you could reconstruct, you know, the ultimate cancer resection site. Yeah.