flaps

1. INTRODUCTION TOINTRODUCTION TO
FLAPSFLAPS

2. DefinitionDefinition
 A flap is a unit of tissue that isA flap is a unit of tissue that is
transferred from one site (donor site) totransferred from one site (donor site) to
another (recipient site) while maintaininganother (recipient site) while maintaining
its own blood supply.its own blood supply.

3. Flaps : skin + additional tissueFlaps : skin + additional tissue
‘flappe’ : something hanging broad and loose,
fastened only by one side
Through continuity ( it ) survives

4. History of flapsHistory of flaps
 600 BC – ‘600 BC – ‘Sushruta Samhita’Sushruta Samhita’ describeddescribed nasalnasal
reconstruction using cheek flapreconstruction using cheek flap

5.  1440 AD –1440 AD – ForeheadForehead flap rhinoplasty originated inflap rhinoplasty originated in
Poona, India.Poona, India.
 Gaspare Tagliacozzi ( 1545-1599): Extensive work onGaspare Tagliacozzi ( 1545-1599): Extensive work on
nose reconstruction, introduced ‘nose reconstruction, introduced ‘delay’delay’
 The World wars - era of pedicled flapsThe World wars - era of pedicled flaps
 1950s and 1960s - Axial pattern flaps1950s and 1960s - Axial pattern flaps
 1980s- Fasciocutaneous flaps, osseous and1980s- Fasciocutaneous flaps, osseous and
osseocutaneous flapsosseocutaneous flaps

6.  1990s – Perforator and propeller flaps1990s – Perforator and propeller flaps

7. Propeller flapPropeller flap

8. How does a flap differ fromHow does a flap differ from a graft ?a graft ?
FlapFlap
 Transferred with itsTransferred with its
blood supply intact.blood supply intact.
GraftGraft
 Transfer of tissueTransfer of tissue
without its own bloodwithout its own blood
supply.supply.
 Survival depends entirelySurvival depends entirely
on the recipient site.on the recipient site.
..

9. The Ladder of Reconstruction
Primary closure
Partial thickness skin graft
Full thickness skin graft
Local flap
Distant flap
Free flap
Simple
Complex

10. Flap terminologyFlap terminology
 Primary defectPrimary defect
 InsetInset
 Secondary defectSecondary defect
 BaseBase
 PediclePedicle
 Bridge segmentBridge segment
 Pivot pointPivot point

11. ClassificationClassification
 Based on different criteriaBased on different criteria--
1.1. Blood supplyBlood supply
2.2. Proximity to the defectProximity to the defect
3.3. Method of transferMethod of transfer
4.4. Tissue containedTissue contained

12. Classification of flapsClassification of flaps
 According to blood supplyAccording to blood supply
1.1. Random pattern flaps - no dominant blood supply.Random pattern flaps - no dominant blood supply.
2.2. Axial flapsAxial flaps -- dominant feeding vessel.dominant feeding vessel.
3.3. Reverse flow flaps - proximal blood supply divided,Reverse flow flaps - proximal blood supply divided,
leaving the flap to survive on intact distal vessels.leaving the flap to survive on intact distal vessels.

14. Axial pattern -DeltopectoralAxial pattern -Deltopectoral flapflap

15. DP flap reconstruction of cheek defectDP flap reconstruction of cheek defect

16. ClassificationClassification of flapsof flaps
 According to proximity to defectAccording to proximity to defect
Local flaps - e.g., rhomboid flap.Local flaps - e.g., rhomboid flap.
Regional flap - e.g., paramedian forehead flap.Regional flap - e.g., paramedian forehead flap.
Distant flap - e.g., groin flap.Distant flap - e.g., groin flap.
Free flap - freeFree flap - free tissue transfer.tissue transfer.

17. LocalLocal flapflap –– rhombicrhombic flapflap

18. Regional flap – forehead flapRegional flap – forehead flap

19. Distant flap – groin flapDistant flap – groin flap

20. Free flap – ALT flapFree flap – ALT flap

21. ClassificationClassification of flapsof flaps
 According to method of transferAccording to method of transfer
1.1. AdvancementAdvancement
2.2. TranspositionTransposition
3.3. RotationRotation
4.4. InterpolationInterpolation
5.5. FreeFree

22. AdvancementAdvancement flapflap
 Moved primarily in a straight line.Moved primarily in a straight line.
 No rotational or lateral movementNo rotational or lateral movement
 Burrow triangles have been removedBurrow triangles have been removed ..

23. AdvancementAdvancement flapflap for chin defectfor chin defect

24. Transposition & Rotation FlapTransposition & Rotation Flap

25. TranspositionTransposition flapflap
 Lateral movement into the primary defect.Lateral movement into the primary defect.

26. Rotation flapRotation flap
 Rotated along the arc into the primary defect.Rotated along the arc into the primary defect.

27. ClassificationClassification of flapsof flaps
 According to tissue containedAccording to tissue contained
1.1. CutaneousCutaneous
2.2. FasciocutaneousFasciocutaneous
3.3. MusculocutaneousMusculocutaneous
4.4. MuscleMuscle
5.5. OsteocutaneousOsteocutaneous
6.6. OsteomusculocutaneousOsteomusculocutaneous
7.7. Omentum/BowelOmentum/Bowel..

28. Cutaneous flapCutaneous flap

29. Fasciocutaneous sural artery flapFasciocutaneous sural artery flap

30. Pedicled Latissimus dorsi musculocut.flapPedicled Latissimus dorsi musculocut.flap

31. Muscle flapMuscle flap
Reconstruction of middle third leg defect with soleus muscle flap
Reconstruction of hindfoot defect with free latissimus dorsi muscle flap

32. Omental flapOmental flapOsteocutaneous fibula flap

33. Omental flapOmental flap

34. Jejunum free flapJejunum free flap

35. Factors in flap decision makingFactors in flap decision making
 Location of the defectLocation of the defect
 Size of the defectSize of the defect
 Underlying or exposed structuresUnderlying or exposed structures
 Potential donor sitesPotential donor sites
 Donor site defects or disabilityDonor site defects or disability
 Viability of surrounding tissue.Viability of surrounding tissue.
 Shape & contour of potential reconstruction.Shape & contour of potential reconstruction.
 Surgeons experience.Surgeons experience.
 Surgical skills.Surgical skills.
 Patients medical history.Patients medical history.

36. Delay phenomenonDelay phenomenon
 Benefits of delay-Benefits of delay-
 Angiogenesis.Angiogenesis.
 Dilatation of choked vessels.Dilatation of choked vessels.
 Increased tolerance for metabolic changes.Increased tolerance for metabolic changes.
 Changes in sympathetic tone.Changes in sympathetic tone.

37. DelayDelay

38. Pivot PointPivot Point
 Centre around which local flaps rotate orCentre around which local flaps rotate or
transposed.transposed.

39. Principles of flap surgeryPrinciples of flap surgery
 Replace like with like.Replace like with like.
 Think of reconstruction in terms of units.Think of reconstruction in terms of units.
 Always have a pattern & a back-up plan.Always have a pattern & a back-up plan.
 Apply the Robin hood principle; steal fromApply the Robin hood principle; steal from
Peter to pay Paul, but only when Peter canPeter to pay Paul, but only when Peter can
afford it.afford it.
 Never forget the donor area.Never forget the donor area.

40. Reconstruct in terms of unitsReconstruct in terms of units

41. Replace like with likeReplace like with like
Skin BoneCartilage

42. The ‘ Robin HoodThe ‘ Robin Hood
principle ’principle ’
Rob Peter to pay Paul

43. Monitoring of flapsMonitoring of flaps
 Clinical evaluation-Clinical evaluation-
 TemperatureTemperature
 ColourColour
 Capillary refill- apprx.2 sec.Capillary refill- apprx.2 sec.
 Point bleedingPoint bleeding
 Firmness.Firmness.

44. Monitoring of flaps cont…Monitoring of flaps cont…
 Signs of insufficient arterialSigns of insufficient arterial
supply-supply-
 Cool.Cool.
 Pallid(white).Pallid(white).
 Capillary refill>2 sec.Capillary refill>2 sec.
 Slow or absent point bleeding.Slow or absent point bleeding.
 Softer.Softer.

45. Monitoring of flaps cont…Monitoring of flaps cont…
 Signs of insufficient venousSigns of insufficient venous
return(venous congestion) –return(venous congestion) –
 Capillary refill- faster than 2 sec.Capillary refill- faster than 2 sec.
 Blue to purple hue.Blue to purple hue.
 Warm.Warm.
 Brisk point bleeding, with dark blood.Brisk point bleeding, with dark blood.
 Tension, swollen.Tension, swollen.

46. Factors leading to flap vascularFactors leading to flap vascular
compromise.compromise.
 Tight dressings.Tight dressings.
 Tight sutures.Tight sutures.
 Pressure from positioning.Pressure from positioning.
 Haematoma.Haematoma.
 Kinking of the flap or pedicle or both.Kinking of the flap or pedicle or both.
 Nicotine,caffine or other vesoconstrictingNicotine,caffine or other vesoconstricting
agents.agents.
 Micro vascular technical issues.Micro vascular technical issues.

47. Fasciocutaneous flapsFasciocutaneous flaps
 Vascular basis-SubdermalVascular basis-Subdermal plexus of smallplexus of small
vessels.vessels.
o e.g.-e.g.-
 Anterior lateral thigh flapAnterior lateral thigh flap
 Posterior interosseous artery flapPosterior interosseous artery flap
 Radial forearm flap.Radial forearm flap.

48. Deltopectoral flapDeltopectoral flap

49. Fasciocutaneos flapsFasciocutaneos flaps
cont…cont…
AdvantagesAdvantages
 Thin & pliable .Thin & pliable .
 Blood supply - reliable & robust.Blood supply - reliable & robust.
 Donor site morbidity - minimal .Donor site morbidity - minimal .
 Muscle sparing.Muscle sparing.
 Restoration of sensation.Restoration of sensation.
 Many potential donor sites.Many potential donor sites.

50. Fasciocutaneos flapsFasciocutaneos flaps
cont….cont….
DisadvantagesDisadvantages
 Lack bulk .Lack bulk .
 Technically more challenging.Technically more challenging.
 Rotation - limited.Rotation - limited.
 Donor site may require skin graft closure.Donor site may require skin graft closure.
 Size limitations.Size limitations.

51. Muscle & Musculocutaneous flapsMuscle & Musculocutaneous flaps
Muscle flaps-Muscle flaps-
 Latissimus dorsi flapLatissimus dorsi flap
 Gastronemius flapGastronemius flap
Musculocutaneus flaps-Musculocutaneus flaps-
 Pectoralis major flap.Pectoralis major flap.
 Latissimus dorsi flap.Latissimus dorsi flap.
 Rectus abdominis flap.Rectus abdominis flap.

52. Gastronemius flapGastronemius flap

53. PMMC FlapPMMC Flap

54. Muscle & Musculocutaneous flapsMuscle & Musculocutaneous flaps
AdvantagesAdvantages
 Provides bulk.Provides bulk.
 Provides padding- exposed vital structures.Provides padding- exposed vital structures.
 Vascular pedicles are specific & reliable.Vascular pedicles are specific & reliable.
 Muscle is malleable.Muscle is malleable.
 Reconstruction - one stage procedure.Reconstruction - one stage procedure.
 Resistant to bacterial inoculation or infection.Resistant to bacterial inoculation or infection.
 Restoration of function.Restoration of function.

55. Muscle & Musculocutaneous flapsMuscle & Musculocutaneous flaps
DisadvantagesDisadvantages
 Donor defect may lose some degree of function.Donor defect may lose some degree of function.
 Donor defect may be aesthetically undesirable.Donor defect may be aesthetically undesirable.
 Reconstruction may provide excessive bulk,Reconstruction may provide excessive bulk,
leaving an aestheticlly unacceptable result.leaving an aestheticlly unacceptable result.
 Flaps may atrophy over time e.Flaps may atrophy over time e.

56. Osteomyocutaneous flapOsteomyocutaneous flap
 Bone along with the overlying skin & soft tissueBone along with the overlying skin & soft tissue
is transferred to the wounded area, carrying itsis transferred to the wounded area, carrying its
own blood supply .own blood supply .
E.g.E.g.
 Radius- based on radial artery.Radius- based on radial artery.
 Fibula-based on peroneal aretry.Fibula-based on peroneal aretry.

57. Microvascular free flapMicrovascular free flap
 A section of tissue and skin that is completelyA section of tissue and skin that is completely
detached from its original site and reattached todetached from its original site and reattached to
its new site by hooking up all the tiny bloodits new site by hooking up all the tiny blood
vessels.vessels.
 Requires meticulus microvascular techniques.Requires meticulus microvascular techniques.
e,g.e,g.
 Radial forearm flap.Radial forearm flap.
 Latissimus dorsi flap.Latissimus dorsi flap.

58. ConclusionConclusion
 Be thoughtfulBe thoughtful.. Consider all options, simple toConsider all options, simple to
complex, prior to any flap surgery.complex, prior to any flap surgery.
 Be knowledgeableBe knowledgeable. Know and understand the. Know and understand the
anatomy, blood supply, and quality of tissueanatomy, blood supply, and quality of tissue
available.available.
 Be prepared for failureBe prepared for failure. Have a back-up plan. Have a back-up plan
available in case the first plan fails.available in case the first plan fails.

59. THANK YOUTHANK YOU