Basic principles,classification, geometry and uses of local flaps in plastic surgery.

1. PRINCIPLES OF LOCAL
FLAPS IN PLASTIC SURGERY
PRESENTED BY : DR. DEEPAK KRISHNA
DR. SHAMENDRA ANAND SAHU
DEPARTMENT OF BURNS , PLASTIC AND MAXILLOFACIAL
SURGERY
VARDHAMAN MAHAVIR MEDICAL COLLEGE &
SAFDARJUNG HOSPITAL ,NEW DELHI

2. Definition :
A flap is a unit of tissue that is transferred from
donor site to recipient site while maintaining its own blood
supply.
Term “Flap” :
Originated from the 16th century Dutch word
“FLAPPE” which means “anything that hung broad and
loose, fastened only by one side”.

3. Timeline of the development of flap surgery
600 BC
Sushruta Samhita
Pedicle flaps in the face and forehead for
nasal reconstruction
1597
Tagliacozzi
Nasal reconstruction by tubed pedicle flap from arm; described
“delay” of pedicle flap
1896
Tansini
Latissimus dorsi musculocutaneous flap for breast
reconstruction (post- mastectomy)
1920
Gillies
Tubed pedicle flap
1946
Stark
Muscle flaps for osteomyelitis
1955
Owens
Compound neck flap
1963
McGregor
Temporalis flap
1965
Bakamjian
Deltopectoral flap
1971
Ger
Lower extremity musculocutaneous flap
1972
McGregor and Jackson
Groin flap
1972
Orticochea
Musculocutaneous flaps
1977
McCraw et al
Musculocutaneous territories
1981 Mathes and Nahai
Classification of muscle flaps based on vascular anatomy
1981Ponten
described fasciocutaneous flap
1
11
1

4. BASED ON LOCATION OF DONOR SITE
LOCAL FLAP: Flap
transferred from an area
adjacent to the defect.
DISTANT FLAP : Flap
transferred from an
noncontiguous anatomic
site.

5. CLASSIFICATION OF FLAP
LOCAL FLAP
BLOOD
SUPPLY
METHOD OF
MOVEMENT
COMPOSITION

6. LOCAL FLAPS
Local flaps can be
classified based on
their blood supply
Random flaps
Axial flaps

7. Random flaps
Axial flaps
• Based on the rich sub dermal vascular plexus of
the skin.
• Most of the local flap are
random flaps.
• Maximum length : breadth
ratio of 1 : 1 in the lower
extremity.
• length : breadth ratio of up
to 3 : 1 in the face.
• Derive their blood supply
from a direct cutaneous
artery or named blood
vessel .
• Examples :Nasolabial flap
(angular artery) , Forehead
flap(supratrochlear artery).
• The surviving length of an
axial pattern flap is entirely
related to the length of the
included artery.

8. CLASSIFIACATION OF
LOCAL FLAP BASED
ON THE METHOD OF
MOVEMENT
ADVANCEMENT FLAP
PIVOT FLAP
INTERPOLATION FLAP

9. CLASSIFICATION OF LOCAL FLAPS ON THE BASIS OF
COMPOSITION
• Local flaps can also be categorized based on
composition .
• The composition of the defect to be
reconstructed should dictate the correct
composition of the flap used for reconstruction.
• It includes :
1.Cutaneous
2.Fasciocutaneous
3.Musculocutaneous

10. HISTORY : CUTANEOUS CIRCULATION
Carl Manchot (1889 )
Performed the first examination of the vascular supply of the
human integument.
Defined about 40 cutaneous territories on the basis of
dissection of human integument.
His work “ Die Hautarterien des menschlichen Körpers “ [The
Cutaneous Arteries of the Human Body], was initially
published in German and later translated to English by
Milton.

11. Spalteholz (1893)
Published paper on the origin, course and distribution
of the cutaneous perforators in adult and neonatal
cadavers.
He performed arterial injections of gelatin and various
pigments. The soft tissues were fixed in alcohol and
subtracted in xylol and the resulting vascular
network was embedded in Canada Balsam.

12. Salmon (1930)
French anatomist and surgeon charted more than 80
cutaneous territories encompassing the entire body .
Salmon dissected 15 human cadavers and took
radiographs of integument which enabled him to
demonstrate much smaller vessel than Manchot.

13. Manchot 40 cutaneous territories
Salmon 80 cutaneous territories

14. • The blood reaching the skin originates from deep
vessels.
• DANIEL AND WILLIAMS(1973) defined that the deep
vessels supplying skin are fundamentally two type of
arteries i.e. either musculocutaneous or direct
cutaneous arteries.
• Originally described as Direct cutaneous arteries
, are now called as septocutaneous arteries.
• Both these type of vessels are present throughout
the body but there exists appreciable difference
between them which is tabulated as following :

15. Musculocutaneous arteries
Septocutaneous arteries
Origin : Major vessel supplying muscle
Origin : segmental or muscular vessel
Travel perpendicularly through
underlying muscle bellies into the
overlying cutaneous circulation of the
skin.
Arise originally from either segmental
or musculocutaneous vessels, pass
directly within intermuscular fascial
septae to supply the overlying skin.
They are most prevalent in the supply
of skin covering the broad, flat
muscles of the torso.
This arrangement is most common
between the longer, thinner muscles of
the extremities.
Example :
Example :
latissimus dorsi flap, rectus abdominis Radial forearm flap, Dorsalis pedis flap
flap

16. WHY ?
DEEP
FASCIA
TORSO
LIMBS
WELL DEVELOPED DEEP FASCIA
COVERING THE BROAD
MUSCLES WHICH IS ELASTIC
PERMITING EXPANSION OF
ABDOMINAL MUSCLES .
DEEP FASCIA IS MORE RIGID , NOT
ONLY COVERING THE MUSCLES
BUT ALSO FORMS
INTERCOMPARTMENTAL FASCIAL
SEPTA BETWEEN MUSCLES
PROVIDING ANCHORAGE TO THE
VESSELS.

17. MUSCULOCUTANEOUS
/SEPTOCUTANEOUS
ARTERIES
CUTANEOUS
CIRCULATION
DIVIDED
INTO 3
LEVELS
skin
fascia
subcutaneous
fat

18. At the above said three anatomic levels 6
recognizable vascular plexus exists as shown in
figure :

19. Fascial plexus : divided into
1) Subfascial plexus :

plexus lying on the under surface of the fascia .

relatively minor plexus .

incapable of sustaining a fascial flap .
2) Prefascial plexus : dominant distribution system .

20. Subcutaneous Plexus
• Network of vessels which divide subcutaneous fat
into deep (loose) and superficial (dense) layers.
• More developed in torso than in extremities.
• Supplied by both septocutaneous and
musculocutaneous arteries.

21. Sub dermal Plexus :
• Primary blood supply to the skin.
• Vessels have a continuous arterial muscular wall.
• Primarily distributor function.
• Located at junction between reticular dermis and
subcutaneous fat.

22. • Corresponds with “dermal bleeding” at the edge of
the flap.
• Arterioles run upwards to the overlying dermal
plexus and others run downwards to supply adipose
tissue and various glands .

23. Dermal Plexus
• Present at lower limits of dermal papillary ridge.
• The Vessel in the plexus are arterioles and wall
contains isolated muscular elements .
• Primarily thermoregulatory function.

24. Sub epidermal Plexus
• Located at dermoepidermal junction.
• Consists mostly of capillaries having no muscle in
their wall.
• Therefore they serve to have primarily nutritive
function.

25. FLAP MODIFICATION
Modifications and refinements in both technique and
design of flaps have been used for the optimal result
in reconstructive surgery. Important modifications
are :
1. Flap delay.
2. Tissue expansion.

26. 1. DELAY PHENOMENON
It can be defined as “ preliminary surgical
intervention wherein a portion of the vascular
supply to a flap is divided before definitive
elevation and transfer of the flap”.

27. Delay procedure has been used for several hundred years.
16th century : Tagliacozzi delayed his upper arm flaps by making
parallel incisions through the skin and subcutaneous tissue
overlying the biceps muscle.
It was not until the early 1900s that the concept was recognized.
1921 :Blair introduced the term “DELAYED TRANSFER “ .
1965 : Milton using the pig model, investigated the effectiveness of
four different methods of delaying a flap .

28. MECHANISM OF INCREASED BLOOD FLOW IN FLAP DELAY
1. Increased axiality of blood flow:
Removal of blood flow from periphery of a random flap
promotes development of axial flow.
2. Opening of choke vessels.
3. Tolerance to ischemia :
adaptive metabolic changes at a cellular level within the
tissue.
4.Sympathectomy vasodilation theory :
leading to vasodilation.

29. FLAP DELAY
Surgical flap delay is accomplished in two ways:
1.STANDARD DELAY :
(A) with an incision at the periphery of the cutaneous
territory.
(B) partial flap elevation.

30. 2. STRATEGIC DELAY :
involves division of selected
pedicles to the flap to enhance perfusion
through the remaining pedicle or pedicles .

31. 2. TISSUE EXPANSION
1957 : Neumann is credited with the first modern report of this
technique.
1976 : Radovan further described the use of this technique for
breast reconstruction.
Advantages :
1. Reconstruction with tissue of a similar colour and texture to
that of the donor defect.
2. Reconstruction with sensate skin containing skin appendages.
3. Limited donor-site deformity.

32. Planning and design of local flap
• Facial defects most common
– Trauma
– Skin malignancies
• Treatment
– secondary healing
– skin graft
– local flaps

33. • History
Peripheral vascular disease/Coronary artery disease
Collagen vascular disease
Diabetes mellitis
Prior radiotherapy
Social habits
cigarettes?
• Medications
ASA, anticoagulants
• Cause of defect
recurrence?

34. Physical Exam
• Defect
size, placement
• Surrounding skin
lesions, laxity, color match, scars
• Facial structures
functional concerns, lip, lid
• Incision placement
Resting skin tension lines

35. Planning
•
•
•
•
•
•
•
•
Template
Draw options/Measure
Planning in reverse
Incise
undermine
Rotate vs. advance vs. transpose
Key stitches
Close

36. Advancement Flaps
• First employed by Celsus
in ancient
Rome, popularized by
French surgeons in the
first half of 19th century
• Was called as “sliding
flaps”
• Moves directly forwards
into the defect without
any lateral movement

37. Advancement Flaps
• Execution is facilitated by presence of excess
skin
• More feasible in elderly or when skin elasticity
is more like in very young
• Usually rectangular, perpendicular to the lines
of minimal tension
• Uses – forehead , brow

38. Procedures devised to
facilitate advancement
•Excision of Burrow’s
triangle
•Counterincision at the
flap base
•Triangular design of the
flap
•Curvilinear design of the
flap
•Z-plasty at the base

39. Advancement Flaps
Burrow’s
triangle
at the
base of
the flap

40. V-Y Advancement flap
Bilateral advancement flaps

41. V-Y Advancement Flap
Design
•Advancement should be
directed over the shortest
diameter of the defect
•The size of the V base
should match the size of
the largest diameter of the
lesion
•The V must be long
enough to allow tensionfree suture of the Y

42. V-Y Advancement Flap
•Advancement flap involves movement in two planesvertical and horizontal
•Pivot point on vertical plane which actually acts as a
pivot plane
•Pivot plane is the base of the flap at which the flap is
attached to the body

43. V-Y Advancement Flap
• α angle is determined by
– Location of defect
– Elasticity of the surrounding tissues
– Recommended to range between 20°-40°
• For leg defects, small angle is recommended
as there is less elasticity
• Gluteal region- large angle is planned

44. Bipedicle Advancement Flap

45. Multiple Y-V advancement

46. W Plasty or Zigzag plasty
• Used to break
up a single
linear scar
• For scars that
do not require
lengthening
• It redistributes
tension along
the length of
the scar

47. M-Plasty
• A useful technique to preserve
healthy tissue in scar revision
• lessen the chance of standing
cone (ie, dog-ear) deformity
• The M-plasty, by creating 2
separate 30° angles instead of
one

51. Pivot Flaps
• Derives its name from the pivot point at the
base
• The arc of rotation is under maximum tension
• 2 types
– Transposition flaps
– Rotation flaps

52. Transposition Flap
• Usually rectangular or square flap
• Transferred in a direction at right angles to
that of the blood supply
• Additional length- Back Cut
• Donor site
– Skin graft
– Another flap

53. Transposition Flap- DESIGN
• Recipient defect is
triangulated
– Right angle triangle
– Hypotenuse- near
border of the flap
– The right angle
assumes a position
opposite the flap
– In scalp defects, apex
should direct towards
the periphery of the
scalp

54. • Pivot point D- across the base of the flap, parallel and equal to
AB
• From D, a line is drawn parallel to BC
• With point D as axis, an arc is drawn from A and it intersects the
line at E
• CB is extended to meet the arc at F
• CFED is the marked flap
• Flap transposed and donor area is grafted
• In lower extremity length : breadth should be 1:1

55. Rhomboid flap described by Limberg in
1963

57. Dufourmentel Flap
• Designed by a French
Surgeon, Claude
Dufourmental in 1962
• The defect is tailored in
the shape of a rhombus
(with all sides equal)
• The short diagonal (BD)
and one of the adjacent
side (CD) are extended

58. Dufourmentel Flap
•Angle HDP is
bisected
•Line DE equals the
side of the rhombus
•EF is drawn parallel
to AC and equal to
side of the rhombus

59. Dufourmentel Flap
For square
defect, both
diagonals are
equal, eight flaps
can be designed

61. Bilateral Rhombic flap

62. Triple Rhombic flap
• Circular cutaneous defect
conceptualized as hexagon.
• Sides of hexagon are equal
to radius (r) of circle.
• First side of flap created
by direct extension equal in
length to radius at alternative
corners to prevent sharing
• of common sides.
• Second side of flap designed
parallel to adjacent side of
hexagon.

63. Bilobed Flap
• Consists of two lobes of skin and subcutaneous
tissue based on a common pedicle
• Design
– Primary flap is smaller than the defect
– Secondary flap is more triangular in shape
• Optimal angle between the two flaps is 90°, can vary
between 45° and 180°; greater the angle, larger the
resultant dog-ear

64. • Zitelli's modification (1989), the primary flap is
oriented 45° from the axis of the defect, and the
secondary flap is oriented 90° from the axis of the
defect; eliminate dog ears
• Convert the defect to a "tear drop" shape by the
excision of a triangle on the side of pedicle base
• Use a caliper as a protractor, with one tip placed at
the apex of the wound, to mark out two semicircles

65. • Outer semicircle defines the necessary length
of the two lobes
• Inner semicircle bisects the center of the
original wound and continues across the
donor skin, defines the limit of the common
pedicle of the two lobes

66. • Two lines are drawn from the apex of the wound
– First line is placed 45° from the axis of the wound
– Second line is placed 90° from the axis of the wound
– These two lines mark the central axes of the two lobes
of the flap
• Draw the flap with each lobe beginning and ending at
the inner semicircle and extending to the outer
semicircle at the point where it crosses its central axis

71. Z Plasty
• Involves transposition of two interdigitating
triangular flaps
• Effects
– Gain in length along the direction of the common
limb of the Z
– Direction of the common limb is changed
• Uses
– Prevention and treatment of contracted scars
– Scar revision

72. • In 1856, Denonvilliers first described the Z-plasty
technique as a surgical treatment for lower lid
ectropion.
• The first reference to this technique in American
literature was in 1913, by McCurdy, as treatment for
contracture at the oral commissure.
• Limberg, in 1929, provided a more detailed
geometric description.
• Numerical data showing optimal angles and length
relationships of Z-plasty limbs are credited to Davis
(1946).

73. • Release of contracture
– The central limb is placed along the line of
contracture- contractural diagonal
– 60° angle taken on each side and limbs of Z drawn, all
equal in size
– Longer diagonal is the transverse diagonal

74. •The contractural diagonal is under tension and
springs up when flaps are raised
•Causes change in shape of the parallelogram
•Contractural diagonal lengthens

76. • Mechanism of lengthening by Z plasty
– Length of contractural diagonal less than transverse
diagonal before release
– Contractural diagonal lengthens at the expense of
transverse diagonal
– Thus need for transverse skin laxity for contracture
lengthening
– Variables in construction of Z Plasty
• Angle size
• Limb length

77. • Angle size
– Length increases with in angle
ANGLE (°)
INCREASE IN
LENGTH (%)
30
25
45
50
60
75

78. • Angle size
– Increasing the angle beyond 60° will increase
lengthening but also cause increased amount of
transverse shortening
– Tension produced in the surrounding tissues tend to
be so great that the flaps can not readily be brought
in to their transposed position

79. • Limb length
– With almost fixed angle, length provides the major
variable
– Amount of tissue available determines the limb
length
– More is the amount of tissue, larger the length
and vice versa

80. Multiple Z Plasty
• Way of reducing the amount of transverse
shortening without significantly reducing the
amount of lengthening
• Also distributes the lateral tension over
various limbs of multiple Zs
• In place of one large Z plasty, a series of
multiple small Z-plasties are constructed

84. Planning of Z-plasty for contracture
release
• Narrow contractures with lax surrounding skin
eg. Bowstring contracture
• Draw an equilateral triangle on each side of
the contracture and select the more suitable
of the two sets of limbs
– Better blood supply; avoid a flap with scar at base
– Resultant scar falling into a cosmetically
favourable line

86. • Flap of scarred skin should be designed a little
longer initially than its fellow of the normal
skin
• Two angles can be of unequal sizes
also, lengthening will be equal to the average
of the two angles

87. Use in scar revision
• Straight line scar
– Break the continuity of a straight line scar, thus
rendering them more conspicuous
• Bridle scar- scar crossing a hollow
• Curving scar

88. Planning
• Scar is outlined and the final postoperative
common limb (which preferably lies in a line
of election) is drawn out

89. • The length of the intended common limb, which
determines the size of the Z-plasty, is measured out
on the line of the scar, proportioned approximately
evenly on each side of the selected line and drawn
out as the post-operative common limb

90. • From each end, a line of equal length is
marked out to meet the line drawn out
• Thus Z-plasty flaps are outlined
• This ensures that transposition of the flaps will
bring the common limb into the desired line
as planned

91. • Unacceptable scar- lies >30° off the RSTLS
– Z-plasty breaks the line of scar and changes its
direction

92. Curving Scar
• Trapdoor scars
• Significant subcutaneous scarring producing
contracture beneath the entire area of
trapdoor
• Z-plasty lengthens the marginal scar and
breaks up the subcutaneous scarring

93. Four-Flap Z-plasty

94. The 5 – Flap plasty
or “Jumping Man” flap.

95. Rotation –advancement Flap
• Semicircular flap which rotates around a pivot
point
• Located along tension lines
• Flap designed quite large than the defect to
ensure primary closure of the donor site
• skin graft or another flap are alternatives for
the donor site

96. • Tissue can move into an
adjacent defect in 2 directions.
• It can advance in a straight line
(ie, advancement flap), or the
tissue can rotate into the defect
(ie, rotation flap).
• The distinction between the two
is not always clear, and one type
of motion blends into the other .
• Furthermore, a single flap can
have both straight
(advancement) movement and
rotational (rotation) movement.

97. •Triangulation of the
defect
•Isoceles triangle
•Apex towards flap
pedicle
•Apex angle <30° to
avoid buckling of the
skin
•PIVOT POINT D- on a
projection of line AC, atleast
CD>2AC
•E is located midway between
AD
•An arc is drawn from B to D
•CBD constitutes the flap

98. Local flap template
• ABC is the triangulated
defect
• P is marked; AB=CP
and AB parallel to CP
• P as center and AP as
radius, arc is drawn
• Skin triangle ABD is
excised
• CDE is the local flap
template for ABC

99. • Conventional rotation flapgeometrically pure rotation
design where the triangulated
defect is a sector of the
semicircle
• Movement is diametrically
opposite of the defect
conflicting the fact that a skin
flap rotated about a pivot point
will become shorter in effective
length the further it is rotated

100. • Hence conventional rotation flap are successful only in
places where lax skin is present or a back cut is needed
• Flap template employs tissue just adjacent to the
triangulated defect thus ensures coverage of the defect
and closure of the donor site

101. Mustarde lateral rotation flap

103. Double rotation o-to-z

105. Postoperative Care
• Pain reliever
• Wound care
• antibiotic ointment
• Sutures removed at 5-7 days
• Revision if required - 6 months

106. Complications
• Infection
• Dehiscence
• Vascular insufficiency due to
• Mechanical tension
• Kinking
• compression
• Hematoma/seroma
• Failure/necrosis

107. FLAP NECROSIS
RANDOM PATTERN FLAP
Presents clinically as : congested , cyanosed ,blanching
momentarily on pressure initially but with time
becomes less and less until there is no circulation.
This process is acute .
settled one way or the other in 1-2 day, clearly defining
area of necrosis.

108. FLAP NECROSIS
AXIAL PATTERN FLAP
The sequence is different with clinical events not fully understood .
Necrosis takes several days to develop.
Generally compromised flap is only slight cyanosed with no other gross
signs .
The process is slow during which time the margin gets revascularised
from surrounding tissues, due to which the area of final necrosis
instead of being the entire distal flap , is an island in its centre.

109. • Length:Width
increased width of base
would increase surviving
length but feeding vessels
have same perfusion
pressure
• Perfusion pressure

110. PREVENTION OF FLAP NECROSIS
Important steps to prevent necrosis :
1.Avoiding tension by prior establishing pivot point or using
planning in reverse if local flap is jumping over intact skin .
2. Planning the flap with a margin of reserve is an additional way
in which tension can be avoided.
3.Avoding kinking particularly at the base of the flap.
4.In random flap proper length: breadth ratio should be
maintained .

111. PREVENTION OF FLAP NECROSIS
5.In axial flap , length does not extend recognized safe
length.
6.Proper plane for flap elevation for raising flap.
7. No compression at pedicle
8.Using delay principal when it was considered inadequate .
9.Avoiding infection : prevention of hematoma and
avoidance of raw area .

112. PLANE FOR FLAP ELEVATION
Proper plane for flap elevation is of prime
importance for preventing necrosis :
Trunk
Between deep fascia and underlying
muscle /aponeurosis
Limbs
Immediately superficial or deep to
investing layer of fascia .
Face
At the level of fat just deep to dermis .
Scalp
Between glea and pericranium.
Forehead
Standard : superficial to pericranium.
For smaller flap :between skin and
frontalis muscle .

113. THINNING OF FLAP
Thinning of a flap is required for :
1. To match the thickness of defect.
2. To allow it to be set without tension.
The amount of thinning which flap tolerate safely varies
greatly , such as :
Face
Smaller flap can be thinned
out considerably due to well
developed sub dermal plexus
Scalp
Thinning not possible as flap is
raised at subgleal level

114. THINNING OF FLAP
Limbs
Thinning is seldom done because :
1.Fasciocutaneous flap : investing layer of
fascia forming deep surface contains
blood vessel crucial for survival.
2.Skin flaps : subcutaneous layer of fat is
too thin to warrant thinning
Trunk
Males : thinning is often not required in
chest & upper abdomen.
Female : Thinning is often required

115. What to Do if the Flap Becomes Swollen and Bluish
Within Hours after the Operation
• A swollen, bluish flap indicates a problem with
circulation into or out of the flap.
• Usually it is a venous (i.e., outflow) problem.
• Make sure that the patient is positioned properly
and that nothing is compressing or pulling on the
pedicle.
• Loosen surrounding dressings and tape.
• Sometimes it is helpful to remove a few stitches
to ensure that the flap is not under too much
tension.

116. • Be sure that no fluid has collected under the
flap.
• Any collection of fluid requires drainage.
• Ensure adequate pain control. Pain stimulates
the sympathetic nervous system, which
decreases blood flow through the pedicle.

117. What to Do If Part of the Flap Dies
•
•
•
•
If a part of the flap has become purplish
it indicates inadequate circulation
the tissue may eventually die.
If there is no evidence of infection, you may
simply leave the flap alone.
• With time, this tissue will demarcate and die and
then separate or you may have to cut off the
dead tissue.
• While this process is occurring, the underlying
tissues will heal.