2. Contents
• Introduction
• History
• pathophysiology
• Graft vs flap
• Classifications of flaps
• Principles of flap surgery
• Post operative assessment of flap
• complications
3. Introduction
• A flap is a vascularized block of tissue that is
mobilized from its donor site and transferred to
another location, adjacent or remote, for
reconstructive purposes.
4. Introduction cont..
• A flap is used :
• To reconstruct 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}
6. History
• Origin in india:In 600
BC, Sushruta Samita
described operations
for nasal
reconstruction—, since
amputation of the nose
(an organ of "respect
and reputation") was
common as criminal
punishment.
• He used cheek flap for
reconstruction of nose.
7. History cont..
• the first muscle flap of
recorded history
debuted in 1906.
• Louis Ombredanne of
Paris described the use
of the pectoralis minor
muscle for breast
reconstruction
following mastectomy.
8. History cont..
• Sir Harold Delf Gillies:
• considered the father
of plastic surgery.
• Pioneer in facial injury
repairs.
9. Differences between flap and
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
10. Physiologic factors affecting flap
survival:
• includes-
• 1.blood supply to the flap through its base.
• 2.formation of new vascular channels between flap
and recipient bed.
• 3.perfusion pressure of the supplying blood vessel.
11. pathophysiology
chronologic 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
• 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
13. Classification of flaps cont..
Based on congruity:
A. local flap:
• A local flap implies that
the tissue is adjacent to
the open wound in
need of coverage.
• Eg. A wound on lip may
be repaired by a flap on
adjacent cheek
14. Classification: Based on
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: Based on
congruity:cont..
• Distant flap Is of two types:
1.pedicled flap: is transferred while flap is still
attached to their original blood supply.
2.Free flap: Free flaps are 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.
17. Classification: Based on circulation
• A. Axial pattern flap:
• An axial pattern flap
contains atleast one
direct cutaneous
branch blood supply
along its longitudinal
axsis.
18. Classification: Based on circulation
B.random pattern flap:
• A myocutaneous flap w
ith a random pattern of
arteries, as opposed to
an axial pattern flap.
19. Classification: On the basis of
anatomical content:
1.Skin flap
2.Muscle and myocutaneous flap
3.Fascia and fascio cutaneous flap
20. Skin flap:
• 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. Skin flaps:cont..
Types :
1.Those rotating around a pivot point:
• a)rotation flap
• b) transposition flap
• c)interpolation flap
2.advancement flaps
• a)single pedicled advancement flap
• b) V-Y advancement flap
• c)bipedicled advancement flap
22. Skin flaps:cont..
A.Rotation flaps :
are semicircular flaps of skin and subcutaneoustissue
• that revolve in an arc around a pivot point to shift
tissue in a circle.
• Rotation flaps provide the ability to mobilize large
areas of tissue with a wide vascular base for
reconstruction
25. Skin flaps:cont..
• C. interpolation flap: is
from a near by but not
immediately adjacent
donor site and
transposed either
above or below the
intervening skin to
recipient defect.
26. Skin flaps: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. Skin flaps:advancement flap cont..
• Single pedicle advancement flap: Here the
rectangular skin flap is moved forward by virtue of
its elastic properties.
• Bipedicle flap: here an insicion is made parallel to
the defect and the flap is undermined and
advanced
28. Skin flaps:advancement flap cont..
V-Y advancement flap:
V-Y advancement flaps advance skin on each side of
a V-shaped incision to close the wound with a Y-
shaped closure.
• The V-Y pedicle plasty technique allows most
patients to regain sensation and two-point
discrimination in the fingertip
29.
30. Skin flap: types cont..
Rhomboid flaps:( limberg flap.)
• rely on the looseness of adjacent skin to transfer
• a rhomboid-shaped flap into a defect that has been
converted into a similar rhomboid shape
31. Skin flap: types cont..
• 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. Skin flap: types cont..
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 myocutaneous flap:
• 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.
34.
35. Common muscle flaps:
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 muscle flaps:
Trapezius:
• Applications – Skull, head
and neck, Oral cavity,
posterior trunk and
shoulder. Mandible facial
reanimation.
• blood supply: Dominant:
Transverse cervical artery
Length . Minor: Branch of
Occipital artery. Dorsal
Scapular artery.
37. Common muscle flaps:
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 muscle flaps:
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 muscle flaps:
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 muscle flaps:
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. Myocutaneous flap:
• A musculocutaneous flap, also called a
myocutaneous flap, is a muscle flap designed with
an attached skin paddle.
42. Fascia and Fasciocutaneous Flaps:
• Fasciocutaneous flaps are tissue flaps that include
skin, subcutaneous tissue and the underlying fascia.
• They can be raised without skin and are then
referred to as fascial flaps.
• fasciocutaneous flaps to provide coverage when a
skin graft or random skin flap is insufficient for
coverage (eg, in coverage over tendon or bones).
43. Fascia and Fasciocutaneous Flaps:
cont..
• Because they are 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
44. Fascia and Fasciocutaneous Flaps:
cont..
classification of fasciocutaneous flaps is based on
vascular anatomy:
45. Principles of flap surgery
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
46. Principles of flap surgery cont..
• 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.
47. Principles of flap surgery cont..
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:
48. Postoperative flap monitoring:
• The gold standard of postoperative flap monitoring
is clinical observation.It includes:
• 1.flap color
• 2.capillary refilling time
• 3.surface temperature monitoring
• 4.Blanching assesment
50. Causes of flap failure:
• 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.
