Flaps and different types, differentiations from graft principle of flap surgery

1. FLAPSAND
CLASSIFICATION
Dr.KiranPandey
MS-GSResident,NAMS

2. Contents
1. Introduction
2. History
3. pathophysiology
4. Graft vs flap
5. Classifications of flaps
6. Principles of flap surgery
7. Post operative assessment of flap
8. complications

3. Introduction
 A flap is a vascularized block of tissue
 Mobilized from its donor site
 Transferred to another location, adjacent or remote,
 For reconstructive purposes.

4. Introduction
Flap is used :
• Toreconstruct a large primary defect
• Replace tissue loss during trauma or surgical excision.
• Provide padding over bony prominences.
• Bring in better blood supply to poorly vascularizedbed.
• Improve sensation to an area{sensate flap}

5. History
 Origin Indian Subcontinent: 600 BC
 Sushruta Samita described :
 Nasal reconstruction using Cheek flap for reconstruction of nose.
 since amputation of the nose (an organ of "respect and reputation") was
common as criminal punishment.

6. Historycont..
 First muscle flap of recorded history in 1906.
 Louis Ombredanne:
Breast reconstruction following mastectomy.

7. Historycont..
• Sir Harold Delf Gillies:
• Father of plastic surgery.
• Pioneer in facial injury repairs.

8. Differencesbetweenflapand graft:
graft flap
Limited to transplantation of skin Can carry other tissues
Depends on recipient site on nutrion Has its own blood supply
Cosmetic –may discolor or contract Better color take and less likely
to contract
Less adaptable to weight bearing Most adaptable to weight bearing
Less able to survive on a bed with
questionable nutrition
Can be used on a bed with
questionable
nutrition
Requires pressure dressing Does not requires pressure dressing
Cannot bridge defects Can bridge defects

9. Physiologicfactorsaffectingflap survival:
 Blood supply to the flap through its base.
 Formation of new vascular channels between flap and recipient bed.
 Perfusion pressure of the supplying blood vessel.

10. Pathophysiology
Changes of a flap and the recipient site after elevation and transfer:
 After 10-24 hours –
Decreased arterial supply;
Congestion and edema;
Dilation of arterioles and capillaries
 After 1-3 days –
Increased number and quality of Anastomoses between flap and
recipient bed;
Increased number of small vessels in pedicle

11.  After 3-7 days - Reorientation of vessels along the long axis of the flap;
anastomoses created at 1-3 days now functionally significant
 After 1 week - Circulation well established between flap and recipient bed
 After 2 weeks - Continuous maturation of anastomoses
 After 3 weeks - Flap achieves 90% of its final circulation

12. Classificationofflaps
Classification of Flaps Can be based on:
 Congruity
 Circulation
 Anatomical Components

13. Based on congruity:
A. Local flap:
 Tissue is adjacent to the open
wound in need of coverage.
 Eg. Wound on lip may be repaired
by a flap on adjacent cheek

14. Classification:Basedon congruity:cont..
B. Regional flap:
 Skin flap is not from the adjacent area but from the same region
 Eg.wound on the tip of the nose might be repaired with a flap from
forehead.
C. Distant flap:
 Tissue transferred from an non contiguous anatomic site (ie, from a
different part of the body) is referred to as a distant flap.

15. Classification:Basedon congruity:cont..
Distant flap Is of two types:
Pedicled flap:
 Transferred while flap is still attached to their original blood supply.
Free flap:
 Physically detached from their native blood supply and then reattached to
vessels at the recipient site.
This anastomosis typically is performed using a microscope, thus is
known as a microsurgical anastomosis.

16. Classification:Basedon congruity:cont..
D. Island flap
Flap consisting of skin and subcutaneous tissue, with a pedicle
made up of only the nutrient vessels.

17. Classification:Basedoncirculation
A. Axial pattern flap:
• Contains atleast one direct cutaneous
branch blood supply along its
longitudinal axsis.

18. Classification:Basedoncirculation
B.random pattern flap:
• Myocutaneous flap with a random
pattern of arteries, as opposed to an axial
pattern flap.

19. Classification:On thebasisof
anatomicalcontent:
1. Skin flap
2. Muscle and myocutaneous flap
3. Fascia and fascio cutaneous flap

20. Skinflap:
Uses:
1. Recipent bed with poor vascularity
2. Coverage of vital structures
3. Reconstructing full thickness structures
e.g. Eyelid ,cheek, nose, lip, ear etc.
4. Padding of bony prominences

21. Skinflaps:cont..
Types :
Those rotating around a pivot point:
A) Rotation flap
B) Transposition flap
C) Interpolation flap
Advancement flaps
A) single pedicled advancement flap
B) V-Y advancement flap
C) bipedicled advancement flap

22. Skinflaps:cont..
A.Rotation flaps :
 Are semicircular flaps of skin and subcutaneous tissue
 That revolve in an arc around a pivot point to shift tissue in a circle.
 Provide the ability to mobilize large areas of tissue with a wide
vascular base for reconstruction

24. Skinflaps:cont..
B.Transposition flaps :
• Are rectangular or square and turn
laterally to reach the defect.
• Donor site can be closed primarily.

25. Skinflaps:cont..
C. Interpolation flap:
 From a near by but not immediately adjacent
donor site
 Transposed either above or below the
intervening skin to recipient defect.

26. Skinflaps:cont..
Advancement flap:
 Advancement flaps move directly forward and rely on skin elasticity
to stretch and to fill a defect.
 No rotational or lateral movement is applied
It is of 3 types:
A. Single pedicle advancement flap.
B. Bipedicle advancement flap.
C. V-Y flap advancement flap.

27. Skinflaps:advancementflapcont..
• Single pedicle advancement flap:
Rectangular skin flap is moved forward by virtue of its elastic
properties.
• Bipedicle flap:
Insicion is made parallel to the defect and the flap is undermined and
advanced

28. Skinflaps:advancementflapcont..
V-Y advancement flap:
 Advance skin on each side of a V-shaped incision to close the wound
with a Y- shaped closure.
 V-Y pedicle plasty technique allows most patients to regain sensation
and two-point discrimination in the fingertip

30. Skinflap:typescont..
Rhomboid flaps:( limberg flap.)
 Rely on the looseness of adjacent skin to transfer
 rhomboid-shaped flap into a defect that has been converted into a
similar rhomboid shape

31. Skinflap:typescont..
• Z-plasty:
• Z-plasty transposes two interdigitating triangular flaps without tension
to use lateral skin to produce a gain in length along the direction of the
common limb of the Z.

32. Skinflap:typescont..
Common indications of z plasty:
 Lengthening of a contracted linear scar across a flexor crease.
 Changing the direction of a cosmetically unfavorable scars.

33. Muscle and myocutaneousflap:
• Consideration of a muscle as a potential flap is possible because
muscles have independent, intrinsic blood supply.
• Compared with skin flaps, muscle flaps are less stiff,and more
malleable to conform to wounds with irregular three dimensional
contours.
• Muscle flaps are classified according to their principal means of blood
supply and the patterns of vascular anatomy and according to mode of
innervation.

35. Common muscleflaps:
Tensor Fascia Lata:
• Applications- Coverage of lower abdominal wall, perineum,
ischium and sacrum
• Vascular Anatomy: Ascending branch lateral circumflex
femoral (off Profunda femoris)

36. Common muscleflaps:
Trapezius:
 Applications – Skull, head and neck, Oral cavity,
posterior trunk and shoulder. Mandible facial
reanimation
Blood supply:
 Dominant: Transverse cervical artery.
 Minor: Branch of Occipital artery. Dorsal
Scapular artery.

37. Common muscleflaps:
Gluteus Maximus:
• Applications – Sacrum , Ischium, Trochanter,
breast reconstruction
Vascular Anatomy
 Dominant:
Superior gluteal artery Inferior Gluteal artery
 Minor:
First perforator of Profunda femoris , Intermuscular
branches of lateral circumflex femoral artery.

38. Common muscleflaps:
Pectoralis Major myocutaneous flap:
Applications:
Coverage, Reconstruction, Functional transfer, Free
flap.
Vascular Anatomy:
 Dominant:
Pectoral branch of Thoracoacromial artery.
 Minor :
Pectoral branch of lateral thoracic , Minor Segmental
Internal mammary perforators.

39. Common muscleflaps:
Transverse rectus abdominis muscle flap
(TRAM flap):
• It is either superior pedicle based on the superior
epigastric vessels or inferior pedicle based on the
inferior epigastric.
• Superior pedicle based flap is used to cover
postmastectomy area or chest wall defect.
• Inferior pedicle flap is used to cover the defects in
groin and thigh.

40. Common muscleflaps:
Serratus Anterior :
Applications – head and neck, Thorax, axilla, posterior trunk, breast
reconstruction and free tissue transfer.
Vascular anatomy:
Dominant Lateral thoracic Branches of Thoracodorsal artery.

41. Myocutaneousflap:
Musculocutaneous flap
 Also called a myocutaneous flap,
 Muscle flap designed with an attached skin paddle.

42. FasciaandFasciocutaneousFlaps:
 Fasciocutaneous flaps are tissue flaps that include skin, subcutaneous
tissue and the underlying fascia.
 If raised without skin referred to as fascial flaps.
 Fasciocutaneous flaps to provide coverage when a skin graft is
insufficient for coverage . eg, in coverage over tendon or bones.
 Less bulky, fasciocutaneous flaps are indicated when thinner flaps are
required
 Fasciocutaneous flaps are not as resistant to infection as muscle
flaps. Monitoring flap failure occasionally can be difficult

43. Classification of fasciocutaneous

44. Principlesofflapsurgery
Principle I:
 Replace Like With Like
 when a part of one's person is lost, it should be replaced in kind,
bone for bone, muscle for muscle, hairless skin for hairless skin, an
eye for an eye, a tooth for a tooth

45. Principlesofflapsurgerycont..
 Principle II: Think of Reconstruction in Terms of Units
 Human beings may be divided into 7 main parts: the head, neck,
body, and extremities. Each of these body parts can be further
subdivided into units.
 The head, for example, is composed of several regional units:
scalp, face, and ears. All of these different units and subunits must
be considered and reproduced during reconstruction.

46. Principlesofflapsurgerycont..
 Principle III: always have a pattern and a back-up plan
 The surgeon should ask him or herself "what do I do next if this fails?"
Proceed to the operating room only after answering this question
definitively
 Principle iv: never forget the donor area:

47. Postoperativeflapmonitoring:
The gold standard of postoperative flap monitoring is clinical observation.
1. Flap color
2. Capillary refilling time
3. Surface temperature monitoring
4. Blanching assessment

48. Complications:
1. Seroma formation
2. Hematoma formation
3. Flap necrosis
4. Fat necrosis
5. Donor site infection

49. Causesofflapfailure:
• Poor anatomical knowledge when raising the flap(such that the
blood supply is deficient from the start)
• Flap inset with too much tension.
• Local sepsis or a septicaemic patient.
• The dressing applied too tightly around the pedicle.