a power point presentation on flap delay

1. Flap Delay
Dr Okpako Isaac Oghenero
Senior Registrar Plastic and Reconstructive Surgery
UATH
15/06/2023

2. outline
• Introduction
• Definition
• Delay
• Flap
• Epidemiology
• Historical perspective
• Goal of delay
• Types
• Theories
• Mechanism of flap delay
• Preparation
• History
• Examination
• Investigation
• Monitoring
• Complications
• Prevention of complication
• Local experience
• Current trend
• References

3. Introduction
• Definition of terms
• Delay
• This is the phenomenon where random pattern flap survival is enhanced
• Flap
• This is a unit of tissue transferred from a donor site to a recipient site while
maintaining its innate blood supply
• Random pattern flap
• These are flaps that are raised without a named vessel they survive on the bases
of its subdermal plexus

4. Historical perspective
• The delay procedure has been used for several hundred years,
• However it was not until the early 1900s that the concept was recognized.
• Blair introduced the term “delayed transfer” in 1921
• In the 16th century Tagliacozzi delayed his upper arm flaps by making parallel
incisions through the skin and subcutaneous tissue overlying the biceps muscle.
• In 1965, using the pig model, Milton investigated the effectiveness of four
different methods of delaying a flap. He found that in developing a bipedicled
flap, the best form of delay was by making two incisions and undermining the
skin between the incisions.

5. Goal of delay
• The goal of a delayed flap is to
• enhance flap circulation,
• There by ensuring flap survival after
advancement, transposition, or
transplantation to a defect
• To increase the area of a flap

6. Types
• Medical and
• surgical
• Medical delay
• The use of drugs have been tried for
delays
• Their role has been quite questionable
with variable results
• Some examples of mediations used for
medical delay includes
• The use of
• angiogenic agents such as VEGF PDGF and
FGF
• Antispasmodic
• Alpha adregenic agents
• Beta agonist direct vasodilators
• Calcium channel blockers
• Anticoagulants
• Thrombolytics
• Antispasmodics
• Leukocyte aggregation and adhesion
inhibitors such as montelucast

7. Types of delay
• Surgical delay
• Standard delay
• Strategic delay
• Standard delay
• This is partial flap elevation achieved by
incision at the margins of the cutaneous
territory
• Strategic delay
• This is achieved by making incisions at
the border of the planned flap cutaneous
territory.
• The dissection is either deep to muscle
or fascia, depending on the flap type, to
reach pedicles entering the flap territory.
• These pedicles are divided and the
incision is closed
• Radiologic vessels embolization

8. Theories of delay
• Ischaemic theory
• This theory postulates that delay causes adaptive metabolic changes at the cellular level
making the delayed tissue to survive on less nutrient blood flow than required thereby
improving its adaptability and hence its survival after flap movement
• Increased vascularity theory
• This theory believes that delay improves blood vascularity to delayed tissues by opening
preexisting blood vessels and reorganization of blood flow to ischaemic areas (choke
vessels)

9. Mechanism of flap delay
1. Sympathectomy
2. Vascular reorganization
3. Reactive hyperemia
4. Acclimatization to hypoxia
5. Nonspecific inflammatory
reaction

10. Mechanism of flap delay
• After 10-24 hours ---- Decreased arterial supply;
congestion and edema; dilation of arterioles and
capillaries
• 1-3 days ----- Increased number and quality of
anastomoses
increased number of small vessels in pedicle
• 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
• After 2 weeks ---- Continuous maturation of
anastomoses
• FLAP DEVISION CAN THEN BE DONE AT DAY 10 TO 14

11. Preparation
• History
• Examination
• Investigation
• History
• Indication for the surgery
• Hx of comobodities such as smoking
peripheral vascular diseases,
diabetes mellitus, bleeding
dyscrasias,
• Hx of previous delay and outcomes
• Hx of drug allergies

12. Preparation
• Examination
• Anatomy of the defect needing
cover
• Anatomy of the flap
• Territories of angiosomes to be
incorporated (anatomic potential
and dynamic)
• Flap design

13. Preparation
• Investigation
• To confirm flap dimension
• Doppler
• Use of dye (fluorescene dye etc)
• Angiogram
• To prepare patient for surgery
• FBC, eucr, LFT, U/A, FBS,

14. Flap Monitoring
 Subjective and Physical Criteria:
• Clinical observation remains the
most effective method of flap
monitoring
Colour-
Capillary blanching and
Warmth can be unreliable
Surface temperature and
differential thermometry
 Photoelectric Assessment
Ultrasound Doppler
Laser Doppler
 Metabolic
• Transcutaneous oxygen tension
• Photoplethysmography

15. Complications
• Preliminary operation
• Increase cost
• Increased hospital stay
• Injury to the desired pedicle
• Flap necrosis
• May impair subsequent manipulation and flap insert

16. Prevention
• Adequate preoperative planning
• Proper flap design
• Proper identification of pedicles
• Good grasp of the anatomy

17. Local experience
• We have quite a number of
surgical delay done in this
hospital
• Most recent was a delay for
cross leg flap

18. Current trend
• More modern forms of flap
transfers have been developed
such as free flap among others
making delay phenomenon less
practiced where all expertise and
equipment are available

19. Conclusion
• Flap delay is a technique
developed for random pattern
flap to enhance flap size and
survival

20. Thank you

21. References
• Iranpour M, Khodarahmi A, Khodarahmi N, Shafiee M, Malekpourafshar R, Nakhaee N.
Montelukast for Medical Delay in Flap Surgery. World J Plast Surg. 2020 Jan;9(1):48-54. doi:
10.29252/wjps.9.1.48. PMID: 32190592; PMCID: PMC7068180.
• ynn L, Chiu- Collins M.D, Surgical delay: vascular delay. Encyclopedia of Otolaryngology, head and
neck surgery.2013
• Essentials of plastic surgery, 2nd edition
• Keynotes in plastic surgery
• Neligans volume 4: flaps pathophysiology and pharmacology
• Caitlin S., Thompson-Torgerson, Lacy A. et al. Altered mechanism of thermoregulatory
vasoconstriction in aged human skin. Pubmed 2008
• Daniel N, Rajan S, David P, et al. salvage of failed free flaps used in head and neck reconstruction.
Pubmed 2009
• image003-300x121.jpg (300×121) (cellulite-endermologie-center.com)