FLAPS

1. Flap techniques of DCIA,
FREE FIBULA AND RADIAL FOREARM
FREE FLAPS
Professor Dr Jameel Kifayatullah
Oral and Maxillofacial Surgeon
Khyber college of dentistry Peshawar

2. Iliac crest flap
• Step 1) Skin incision ,exposure of inguinal
ligament
• Step 2) identification of internal oblique
muscle
• Step 3) Exposure of vascular pedicle
• Step 4) Dissection of DCIA Towards the
anterior superior iliac spine
• Step 5)Skin incision along iliac crest

3. Iliac crest flap
• Step 6) Transection of Muscles at Lateral Rim
of iliac crest
• Step 7) Detachment of muscles from gluteal
surface of pelvis
• Step 8) Transection of oblique abdominal
muscles ,Exposure of iliacus muscle by
retracting the peritonium
• Step 9) Incision of iliacus muscle below DCIA
• Step 10) Transection of sartorius muscle at
ASIS

4. Iliac crest flap
• Step 11) Distal osteotomy at iliac crest
• Step 12) Completion of osteotomy below the
course of DCIA
• Step 13) Transection and trimming of residual
muscle fibres
• Step 14) Myo-osseous iliac crest bone flap
ready for microvascular transplantation

5. INGUINAL LIGAMAENT
Tuberculum pubicum Common femoral artery Profunda femoral
artery
ANTERIOR SUPERIOR
ILIAC SPINE
FEMORAL ARTERY
EXTERNAL ILIAC
ARTERY
DEEP CIRCUMFLEX
ILIAC ARTERY
ASCENDING
BRANCH

6. Orientation of skin incision for raising of
myo-osseous iliac crest bone flaps

7. Step 1 Skin incision, exposure of
inguinal ligament

8. Step 2 Identification of internal oblique muscle

9. Step 3 Exposure of vascular pedicle

10. Step 4 Dissection of DCIA towards the
anterior superior iliac spine (ASIS)

11. DEEP CIRCUMFL
ARTERY
LATERAL FEMORAL CUTANE
NERVE
ASCENDING BRANCH
ILIACUS MUSCLE
INTERNAL OBLIQUE
ABDOMINUS MUSCLE
EXTERNAL OBLIQUE
ABDOMINUS MUSCLE
ANSVERSE
DOMINUS
MUSCLE
MUSCLE
PSOAS
MUSCLE
INGUINAL
LIGAMENT
TRANSVERSUS
ABDOMINUS EXTERNAL OB
ABDOMINUS M
INTERNAL OBL
ABDOMINUS M

12. Deep circumflex iliac artery
LATERAL FEMORAL CUTANEOUS
NERVE CROSSING OVER DCIA

13. Step 5 Skin incision along iliac crest

14. Step 6 Transection of muscles at lateral
rim of iliac crest

15. Step 7 Detachment of muscles from
gluteal surface of pelvis

16. Step 8 Transection of oblique abdominal muscles,
exposure of iliacus muscle by retracting the peritoneum

17. Transverse abdominus muscle
Internal oblique
abdominis muscle
External oblique abdominus
muscle
Iliacus muscle
Deep circumflex iliac artery

18. Step 9 Incision of iliacus muscle below
DCIA

19. Step 10 Transection of sartorius
muscle at ASIS

20. Step 11 Distal osteotomy at iliac crest

21. Step 12 Completion of osteotomy
below the course of DCIA

22. Step 13 Transection and trimming of
residual muscle fibres

23. TRANSVERSE ABDOMINUS
MUSCLE
INTERNAL OBLIQUE
ABDOMINUS MUSCLE
EXTERNAL OBLIQUE
ABDOMINUS MUSCLE
DEEP CIRCUMFLEX ILIAC
ARTERY
ILIACUS MUSCLE
PERIPERITONIAL
FATTY TISSUE

24. Step 14 Myo-osseous iliac crest bone flap
ready for microvascular transplantation

25. ILIAC MUSCLE (CUT)
ILIAC BONE
MYO OSSEOUS FLAP
WITH PEDICLE
Flap perfusion is maintained until the recipient vessels are ready
for anastomoses

26. Fibular Flap raising technique
• Step 1) incision of skin and fascia
• Step 2) identification of perforator
• Step 3) Exposure of lateral margin of fibula
• Step 4) Detachment of soleus and Flexor
hallucis Longus Muscle
• Step 5) Opening of Deep Flexor
Space,Identification of Peroneal Branches
• Step 6) Exposure of Peroneal vessels
• Step 7) Dissection of vascula pedicle

27. Fibular Flap Raising technique
• Step 8) Distal Osteotomy
• Step 9) Proximal Osteotomy,Protection of Pedicle
• Step 10) Incision of Anterior Intermuscular
Septum
• Step 11) Exposure of interosseous membrane
• Step 12) Transection of interosseous membrane
• Step 13) Distal ligation of peroneal vessels
• Step 14) Division of Tibialis Posterior Muscle

28. Fibular Flap Raising technique
• Step 15) Incision of skin and fascia at Dorsal
periphery of Skin paddle
• Step 16) Complete elevation of skin paddle
including muscle cuff around perforator
• Step 17) Distal Transection of flexor hallucis
longus muscle
• Step 18) Proximal Transection of remaining
Flexor Hallucis muscle Fibers
• Step 19) Flap Raising Completed
• Doi: 10.1007./978-3-319-53670-5_9

29. Patient positioning and flap design
b

30. Patient positioning and flap design
a

31. Step 1 Incision of skin and fascia

32. Step 2 Identification of perforator

33. PERONEUS MUSCLE
SOLEUS MUSCLE PERONEAL
ARTERY Posterior intermuscu
with septo(myo)cuta
Step 3 Exposure of lateral margin of
fibula

34. Step 4 Detachment of soleus and
flexor hallucis longus muscle

35. Step 5 Opening of deep flexor space,
identification of peroneal branches

36. Step 6 Exposure of peroneal vessels

37. Step 7 Dissection of vascular pedicle

38. STEP 8 DISTAL OSTEOTOMY

39. Step 9 Proximal osteotomy, protection
of pedicle

40. Step 10 Incision of anterior
intermuscular septum

41. Step 11 Exposure of interosseous
membrane

42. Step 12 Transection of interosseous
membrane

43. Step 13 Distal ligation of peroneal
vessels

44. Step 14 Division of tibialis posterior
muscle

45. Step 15 Incision of skin and fascia at
dorsal periphery of skin paddle

46. Step 16 Complete elevation of skin paddle
including muscle cuff around perforator

47. Step 17 Distal transection of flexor
hallucis longus muscle

48. FLEXOR HALLUCIS LONGUS
MUSCLE(CUT)
Tibialis posterior muscle
covered by interosseous
membrane (cut)
PERONEUS
MUSCLE
EXTENSOR
MUSCLE
Posterior intermuscula
septum
PERONEAL ARTERY AND VENA
COMMITANTES

49. Step 18 Proximal transection of
remaining flexor hallucis muscle fibers

50. Step 19 Flap raising completed

51. Radial forearm Flap
• Step 1) ulnar skin incision and undermining of
forearm fascia
• Step 2) Incision of Fascia and exposure of
Flexor carpi ulnaris
• Step 3) distal skin incision ,Subfascial
dissection
• Step 4) Exposure of the flexor carpi radialis
tendon
• Step 5) identification of Radial vessels and
superficial radial nerve at distal flap margin

52. Radial forearm Flap
• Step 6) Ligation of radial vessels at distal flap
border
• Step 7) Radial skin incision
• Step 8) Dissecting the pedicle alonng
brachioradialis muscle
• Step 9)complete subfascial flap elevation
• Step 10) skin incision at proximal flap margin
and wavy incision fro exposure of pedicle

53. Radial forearm Flap
• Step 11 Exposure of additional superficial vein
(optional)
• Step 12 Exposure of vascular pedicle
• Step 13 Complete dissection of pedicle
• Step 14 Separation of residual attachments at
flap hilum
• Step 15 Flap raising completed with additional
superficial vein and nerve

54. Standard design of the radial forearm
flap

55. Step 1 Ulnar skin incision and
undermining of forearm fascia

56. Step 2 Incision of fascia and exposure
of flexor carpi ulnaris

57. Step 3 Distal skin incision and
subfascial dissection

58. Step 4 Exposure of the flexor carpi
radialis tendon

59. Step 5 Identification of radial vessels and
superficial radial nerve at distal flap margin

60. Step 6 Ligation of radial vessels at
distal flap border

61. Step 7 Radial skin incision

62. Step 8 Dissecting the pedicle along
brachioradialis muscle

63. Step 9 Complete subfascial flap
elevation

64. Step 10 Skin incision at proximal flap
margin and wavy incision for exposure
of pedicle

65. Step 11 Exposure of additional
superficial vein (optional)

66. Step 12 Exposure of vascular pedicle

67. Step 13 Complete dissection of pedicle

68. Step 14 Separation of residual
attachments at flap hilum

69. Step 15 Flap raising completed with
additional superficial vein and nerve