Expeditious closure wounds – one of the goals ofplastic surgery Closure follows a reconstructive ladder
LINEAR CLOSURESKIN GRAFTSKIN FLAPSFREE FLAPSMYOCUTANEOUS/FASCIOCUTANEOUSFLAPS
Flaps – a partially or completely isolated segment oftissue perfused with its own blood supply. A vascularized block of tissue mobilized from its donorsite and transferred to another location, adjacent orremote for reconstructive purposes. May consist of skin, subcutaneous tissue, fascia,muscle, bone or viscera (e.g.. Omentum) Reconstructive option of choice when padded anddurable cover needed Vary greatly in complexity…from simple skin flap to microvascular free flap
History of Flaps Origin in India -2500-1500 BC Sushruta 800BC –forehead flap Charak Samhita Al-Zahrawi 10th century scholar Branca family of Italy Sir Harold Gillies – work on facial injuries, modernplastic surgery
Flaps Uses1. Replace tissue loss due to trauma or surgical excision2. Provide skin coverage through which surgery can becarried on latter3. Provide padding over bony prominences4. Bring in better blood supply to poorly vascularizedbed5. Improve sensation to an area (sensate flap)6. Bring in specialized tissue for reconstruction suchas bone or functioning muscle
Classification of Flaps Can be based on (five ‘C’ s)1. Congruity2. Configuration3. Components4. Circulation5. Conditioning
Congruity Local – immediately adjacent to defect Regional – moved from adjacent region Distant – moved from remote anatomic area Pedicled – moved with intact tissue bridge for support Islanded – no intact skin but moved under the skin fornon contiguous defects.
Configuration By design and method of transfer1. Advancement2. Rotation3. Transposition4. Interpolation5. Pedicled
Components Skin flaps Containing purely another component than skin e.g.muscle ,fascia ,bone ,bowel ,omentum etc. Myocutaneous Fasciocutaneous Osteocutaneous
Circulation Random pattern flaps Axial pattern flaps1. Island axial pattern flaps2. Free flaps
Conditioning Increasing flap safety – by enhancing its axiality Used in older days Invoking delay phenomenon Classically done by cutting down on either sides of flap to beraised It opens up choke vessels Flap transferred 2-3 weeks later Particularly useful in higher risk patients e.g. Pedicled TRAM flap
SKIN FLAPS Use : 1.recipent bed with poor vascularity2.coverage of vital structures ( to operate later )3.reconstructing full thickness structures e.g.eyelid ,cheek, nose, lip, ear etc.4.padding bony prominences Disadvantage : it can’t sustain over contaminated(infected ) bed. Types : 1.those rotating around a pivot pointa)rotation b) transposition c)interpolation2.advancement flapsa)single pedicled advancement b) V-Yadvancement c)bipedicled advancement
Muscle and Myocutaneous flapsMathes and Nahai classification One vascular pedicle (eg, tensor fascia lata) Dominant pedicle(s) and minor pedicle(s) (eg, gracilis) Two dominant pedicles (eg, gluteus maximus) Segmental vascular pedicles (eg, sartorius) One dominant pedicle and secondary segmental pedicles(eg, latissimus dorsi)
According to mode of innervation (Taylor)Type I – single unbranched nerve enters muscle.Type II- Single nerve, branches prior to entering.Type III – Multiple branches from same nerve trunk.Type IV – Multiple branches from different nerve trunks.Affects suitability for functioning muscle transfer
Uses of muscle and myocutaneous flaps :1. Functional muscle flap for motor reconstruction2. Sensate Myocutaneous flap for sensatereconstruction3. Coverage of complex wounds4. Chronic vascular insufficiency5. Chronic radiation wounds6. Exposed or infected prosthesis
Local flapsAdvantages Best local cosmetic tissue match Often a simple procedure Local or regional anaesthesia optionDisadvantages Possible local tissue shortage Scarring may exacerbate the condition Surgeon may compromise local resection
Rotation Flap Movement is in the direction of an arc around a fixedpoint and primarily in one plane. This is a semi-circular flap.
Transposition flap The rectangular flap is rotated on a pivot point. The more the flap is rotated, the shorter the flapbecomes. Most commnly used in head and neck
Z plasty Creation of 2 triangular transposition flaps Length of both limbs must be same Angle may vary Uses :1. Lengthning of scar2. Changing direction of scar into more favorable one3. Interrupt scar linearity
Rhombic flaps Specially designed transposition flaps for rhombicshaped defects Defect must have 60 and 120 angles
Bilobed flaps Another variation of transposition flap 2 transposition flaps sharing common pedicle First flap used to reconstruct defect ;second used fordonor site defect
Interpolation flaps Similar to transposition flap Difference is..pedicle rest over intervening tissue Pedicle divided and inset at second stage afterrevascularization E.g. median forehead flap, thenar flap
Advancement flaps Moved primarily in a straight line from the donor siteto the recipient site. No rotational or lateral movement is applied. E.g. rectangular advancement, V-Y advancement etc.
V-Y advancement flap Create a triangular-shaped flap with the base of the flap atthe cut edge of the skin where the amputation occurred. Itshould be as wide as the greatest width of the amputation Skin incisions are made through the full thickness of theskin. Advance the flap over the defected area and suture it to thenail bed. Place corner stitches to avoid interference with the bloodsupply to the corners. Convert the V-shaped defect into afinal Y-shaped wound The V-Y pedicle plasty technique allows most patients toregain sensation and two-point discrimination in thefingertip. The cosmetic results are usually excellent, with goodcontour and fingertip padding is preserved
Combined local flaps In some circumstances, such as burn contracturerelease, local flaps can usefully be combined to importsurplus tissue from a wide area adjacent to a scar ordefect that needs removal. Examples are the W-plasty and the multiple Y-to-Vplasty, which is a very versatile means of releasing anisolated band scar contracture over a flexion crease
REGIONAL FLAPS As the distance of required flap transpositionincreases, the incorporation of a defined blood supplybecomes critical. Classified as axial, however most flaps have randompattern at their distal ends Utilized to cover large defects which require bulk Examples : 1. PMMF 2. DPF 3. Trapezius flap
Pedicled flaps Distant flaps can be moved on long pedicles that contain the blood supply. The pedicle may be buried beneath the skin to create an island flap or leftabove the skin and formed into a tube. Moving flaps long distances while still attached are with a long muscularpedicle that contains a dominant blood supply (a myocutaneous flap) orwith a long fascial layer that likewise contains a major septal blood supply(a fasciocutaneous flap)
Free flaps With fine instruments and materials it has become commonplace to beable to disconnect the blood supply of the flap from its donor site andreconnect it in a distant place using the operating microscope. The free tissue transfer is now the best means of reconstructing majorcomposite loss of tissue in the face, jaws, lower limb and many other bodysites, as long as resources allow it. Free muscle transfers should be reanastomosed within 1–2 hours.
Advantages Being able to select exactly the best tissue to move Only takes what is necessary Minimises donor site morbidityDisadvantages More complex surgical technique Failure involves total loss of all transferred tissue Usually takes more time unless the surgeon isexperienced
Causes of flapfailurepoor anatomical knowledge when raising the flap(such that the blood supply is deficient from thestart)flap inset with too much tensionlocal sepsis or a septicaemic patientthe dressing applied too tightly around the pedicle;