flaps in surgery slideshare plastic surgery cosmetic surgery African experience NIGERIAN SURGERY HISTORY OF FLAPS medicine medical school burrows triangle rotational flaps transpositional flaps

1. FLAPS IN SURGERY
DR ADESIYAKAN ADEDOTUN

2. OUTLINE
• Introduction
• Historical perspective
• Physiology
• Principle
• Classification
• Uses
• Care
• Complications
• Future trends
• Conclusion

3. INTRODUCTION
• DEFINITION - A FLAP is a block of tissue mobilized from
its donor site along with its blood supply and transferred
to another location for reconstructive purposes
• It is the last step of the reconstruction ladder vs the
reconstruction tool box
• Knowledge of the regional anatomy is essential for a
successful procedure

5. HISTORICAL
PERSPECTIV
E
Flappe - dutch
Sushruta samita 600BC
described operations for
nasal reconstruction using a
cheek flap following nasal
amputation for Indian
criminals

6. HISTORICAL
PERSPECTIVE
TIME RESEARCHER FLAP
ANCIENT
ROMAN
CELSIUS ADVANCEMENT
1965 BAKAMIJAN PHARYNGEAL
1983 HAESEKER ARTERIAL
1975 OPERATING MICROSCOPE MICROSURGERY
1975 DAN AND TAILOR FIRST FREE FLAP

7. PHYSIOLOGY
• Flap survival depends on the following physiologic factors
• I) blood supply of the flap through its base
• ii) formation of new vascular channels between flap and
recipient bed
• iii) perfusion pressure of the supplying blood vessel

8. PHYSIOLOGY
• Chronologic changes of a flap and recipient site after elevation and transfer
• I )10 - 24 hours - ischemia, congestion and edema, vasodilation then
occurs ( mediated by sympathetic vascular nerve supply disruption and
release of vasodilator mediators including bradykinin
• ii ) 1-3 days - angiogenesis and increased number and quality of
anastomosis between flap and recipient bed
• iii) 4-7 days - reorientation of the vessels along the long axis of the flap,
created neovessels now functionally significant
• iv). 1 week - circulation well established between the flap and recipient
bed
• v) 3 weeks - flap achieves 90% of its final circulation

9. PRINCIPLES
•
s/n DESCRIPTION
1 ALWAYS REPLACE LIKE FOR LIKE (RALPH MILLARD)
2 RECONSTRUCTION IN TERMS OF UNITS
3 HAVE A PATTERN AND BACK UP PLAN
4 STEAL FROM PETER TO PAY PAUL
5 DONOR AREA

10. TECHNICAL
CONSIDERATION
• RECONSIDER THE RECONSTRUCTION LADDER
• L:B RATIO
• RADIUS
• PIVOT
• PRIMARY AND SECONDARY DEFECT
• DELAY - vascular dilatation, choke vessels ,angiosomes ,
law of vascular equilibrium

11. CLASSIFICATION
• This can be based on the following
• -CIRCULATION
• -COMPONENT
• CONGRUITY
• - CONFIGURATION
• - CONDITIONING

12. CIRCULATION
• RANDOM PATTERN - Based on indistinct vascular supply
but rather on subdermal and dermal plexus
• AXIAL PATTERN - based on distinct artery or group of
arteries

14. CONGRUITY
• A- LOCAL FLAP
• The donor site is adjacent the recipient site
• B - REGIONAL FLAP
• The donor site though not adjacent the recipient site it is within the same region
• C - DISTANT FLAP-
• DIRECT - transferred to a distant site directly
• Donor and recipient sites are approximated
• Flap later divided after 3/52 and inset
• E.G groin flap, thenar flap

17. • Tubed Flap
• Transfered with the lateral flap edges sewn together
• Flap then moved to another location
• Microvascular / free flap
• Flap with vascular pedicle divided completely from
donor vessels
• Anastomosed to the recipient vessels

19. CONFIGURATION
• ROTATIONAL
• TRANSPOSITION
• ADVANCEMENT
• INTERPOSITION

20. ROTATIONAL
• Rotational flap is a semicircular skin and subcutaneous
tissue flap that is rotated into the defect on a PIVOT
• It provides the ability to mobilize large areas of tissue with
a wide vascular base
• Secondary defect can be closed primarily or with a graft
• Back cut and burrows triangle
• Various adaptations

23. TRANSPOSITION
• A rectangular or square block of skin and subcutaneous
tissue transferred laterally about a pivot
• Takes advantage of regional laxity to mobilize tissue
• They accomplish redistribution and redirection of tension
• Usually smaller in size than advancement and rotation
flaps
• Resultant scars are geometric broken lines that may be
less conspicuous

28. ADVANCEMENT
FLAPS
• Single pedicle advancement flaps
• Bipedicle advancement flaps
• V-Y advancement flaps
• Z plasty
• W pasty

30. BIPEDICLE FLAP

35. INTERPOSITION FLAP
• From a nearby but not
immediately adjacent
• Transposed either above
or below the intervening
skin and to recipient
• Used when the
surrounding tissue are of
different units and lack
laxity

36. ANATOMIC COMPONENTS
• SKIN
• FASCIA
• MUSCLE
• BONE
• VISCERAL
• COMPOSITE -
• Contains more than one structural tissue

37. • COMPOSITE -
• Fascio- cutaneous e.g radial forearm flap
• myo- cutaneous e.g TRAM flap
• Osseo - cutaneous e.g fibular flap
• Tendo- cutaneous e.g dorsalis pedis flap
• Sensory/innervated flaps e.g dorsalis pedis flap
with peroneal nerve

38. MYOCUTANEOUS
FLAPS
• Muscles have independent intrinsic supply
• Compared to skin flaps, they are less stiff and more
malleable
• to comform to wounds with irregular three dimensional
contour
• They can be further classified based on principal means of
blood supply and the pattern of vascular anatomy

39. MATHES AND NAHIA
CLASSIFICATION
TYPE DESCRIPTION
I ONE VASCULAR PEDICLE
II DOMINANT AND MINOR PEDICLE
III TWO DOMINANT PEDICLES
IV SEGMENTAL VASCULAR PEDICLES
V ONE DOMINANT PEDICLE AND SECONDARY SEGMENTAL PEDICLES

41. FLAP VASCULAR ANATOMY APPLICATION
TENSOR FASCIA LATA
ASCENDING BRANCH OF
LATERAL CIRCUMFLEX
ARTERY
LOWER ABDOMINAL,
ISCHIUM, SACRUM
PERINEUM
TRAPEZIUS
TRANSVERSE CERVICAL
OCCIPITAL ARTERY,
DORSAL SCAPULAR
SKULL, HEAD AND NECK,
SHOULDER
GLUTEUS MAXIMUS
INFERIOR AND SUPERIOR
GLUTEAL
FIRST PERFORATOR OF
PROFUNDA
SACRUM, ISCHIUM ,
TROCHANTER
TRANSVERSE RECTUS
ABDOMINIS
SUPERIOR AND INFERIOR
EPIGASTRIC
BREAST

42. FASCIOCUTANEOUS
FLAP
• Characteristically less bulky and useful when thinner flaps
are required
• however, not as resistant to infection as muscle flaps and
monitoring can be difficult
• Can be classified based on vascular anatomy

43. CLASSIFICATION
TYPE DESCRIPTION
A DIRECT CUTANEOUS PEDICLE TO THE FASCIA
B SEPTOCUTANEOUS PERFORATOR
C PERFORATORS FROM MUSCULO-CUTANEOUS SOURCE

44. FLAP MODIFICATIONS
• SENSORY FLAPS
• VASCULARIZED BONE
• TISSUE EXPANSION
• FUNCTIONAL MUSCLE FLAP

45. PREOPERATIVELY
• INFORMED CONSENT - pain scar, compromise or loss of
function, failure . DOUBLE CONSENT !!!!
• Factors that may impact healing - nutritional status , anaemia,
infection , tobacco use ,comobidities , radiation , peripheral
vascular disease, obesity
• Avoid nicotine , caffeine , vasoconstrictive agents
• INVESTIGATIONS - FBC, E/U/Cr protein and albumin,
angiogram, ECG,
• Pre-op marking and planning- color texture, thickness and size

46. INTRA-OPERATIVE
CARE
• ANAESTHESIA
• POSITIONING AND ACCESSIBILITY
• PREPARE donor and recipient site
• REASSESS VASCULARITY
• AVOID TENSION
• METICULOUS ANASTOMOSIS
• DONOR SITE CARE

47. POST-OPERATIVELY
• ICU - oxygenation
• MONITOR viability , identification and prompt intervention
• Color, Capillary refill, temperature
• Small needle stab
• Ph monitoring
• Trans- cutaneous Po2
• Doppler ultrasound
• VISIBLE LIGHT SPECTROSCOPY

49. COMPLICATIONS
•
• FLAP NECROSIS - venous thrombosis
• Causes - poor design ,poor bed, tension, injured blood
supply, twisting/kinking , hematoma , infection
• DONOR SITE MORBIDITY
• Scarring , wound dehiscence ,poor graft take

50. CONCLUSION
• FLAPS represent the most advanced step-in the
reconstruction ladder
• An indepth understanding of the neuromuscular anatomy
is paramount
• Various adaptions exist for diverse purposes
• Adequate peri-operative care is essential for favorable
outcome

51. THANK YOU