Basic Principles Of Local Flap In Plastic Surgery

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

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  • You are looking for the Best Plastic Surgery Hospital India then; you can contact with Primus. For the Best Cosmetic Surgery in Delhi, visit Primus now. The most important step in your cosmetic surgery process is finding the right cosmetic surgeon whom you can trust and depend for long-term care and whose aesthetic sense aligns with your goals. Reconstructive surgery is performed on an abnormal or odd structures of the body caused by age, congenital defects, trauma, infection, tumors or disease. It is generally performed to improve functions, but may also be done to approximate a normal appearance. Primus Super Speciality Hospital 2, chandragupt Marg Chanakyapuri New Delhi- 110021, India 011 - 66206620, 9953722892 info@primushospital.com http://www.primushospital.com/primus-reconstructive-surgery.html
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  • Local flaps can be classified based on their blood supply
  • Basic Principles Of Local Flap In Plastic Surgery

    1. 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. 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. 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. 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. 5. CLASSIFICATION OF FLAP LOCAL FLAP BLOOD SUPPLY METHOD OF MOVEMENT COMPOSITION
    6. 6. LOCAL FLAPS Local flaps can be classified based on their blood supply Random flaps Axial flaps
    7. 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. 8. CLASSIFIACATION OF LOCAL FLAP BASED ON THE METHOD OF MOVEMENT ADVANCEMENT FLAP PIVOT FLAP INTERPOLATION FLAP
    9. 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. 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. 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. 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. 13. Manchot 40 cutaneous territories Salmon 80 cutaneous territories
    14. 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. 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. 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. 17. MUSCULOCUTANEOUS /SEPTOCUTANEOUS ARTERIES CUTANEOUS CIRCULATION DIVIDED INTO 3 LEVELS skin fascia subcutaneous fat
    18. 18. At the above said three anatomic levels 6 recognizable vascular plexus exists as shown in figure :
    19. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 30. 2. STRATEGIC DELAY : involves division of selected pedicles to the flap to enhance perfusion through the remaining pedicle or pedicles .
    31. 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. 32. Planning and design of local flap • Facial defects most common – Trauma – Skin malignancies • Treatment – secondary healing – skin graft – local flaps
    33. 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. 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. 35. Planning • • • • • • • • Template Draw options/Measure Planning in reverse Incise undermine Rotate vs. advance vs. transpose Key stitches Close
    36. 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. 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. 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. 39. Advancement Flaps Burrow’s triangle at the base of the flap
    40. 40. V-Y Advancement flap Bilateral advancement flaps
    41. 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. 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. 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. 44. Bipedicle Advancement Flap
    45. 45. Multiple Y-V advancement
    46. 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. 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
    48. 48. 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
    49. 49. 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
    50. 50. 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
    51. 51. • 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
    52. 52. Rhomboid flap described by Limberg in 1963
    53. 53. 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
    54. 54. 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
    55. 55. Dufourmentel Flap For square defect, both diagonals are equal, eight flaps can be designed
    56. 56. Bilateral Rhombic flap
    57. 57. 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.
    58. 58. 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
    59. 59. • 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
    60. 60. • 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
    61. 61. • 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
    62. 62. 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
    63. 63. • 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).
    64. 64. • 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
    65. 65. •The contractural diagonal is under tension and springs up when flaps are raised •Causes change in shape of the parallelogram •Contractural diagonal lengthens
    66. 66. • 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
    67. 67. • Angle size – Length increases with in angle ANGLE (°) INCREASE IN LENGTH (%) 30 25 45 50 60 75
    68. 68. • 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
    69. 69. • 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
    70. 70. 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
    71. 71. 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
    72. 72. • 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
    73. 73. 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
    74. 74. Planning • Scar is outlined and the final postoperative common limb (which preferably lies in a line of election) is drawn out
    75. 75. • 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
    76. 76. • 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
    77. 77. • Unacceptable scar- lies >30° off the RSTLS – Z-plasty breaks the line of scar and changes its direction
    78. 78. 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
    79. 79. Four-Flap Z-plasty
    80. 80. The 5 – Flap plasty or “Jumping Man” flap.
    81. 81. 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
    82. 82. • 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.
    83. 83. •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
    84. 84. 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
    85. 85. • 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
    86. 86. • 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
    87. 87. Mustarde lateral rotation flap
    88. 88. Double rotation o-to-z
    89. 89. Postoperative Care • Pain reliever • Wound care • antibiotic ointment • Sutures removed at 5-7 days • Revision if required - 6 months
    90. 90. Complications • Infection • Dehiscence • Vascular insufficiency due to • Mechanical tension • Kinking • compression • Hematoma/seroma • Failure/necrosis
    91. 91. 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.
    92. 92. 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.
    93. 93. • Length:Width increased width of base would increase surviving length but feeding vessels have same perfusion pressure • Perfusion pressure
    94. 94. 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 .
    95. 95. 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 .
    96. 96. 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 .
    97. 97. 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
    98. 98. 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
    99. 99. 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.
    100. 100. • 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.
    101. 101. 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.

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