This document provides an overview of flaps in surgery. It discusses that flaps transfer tissue with its own blood supply to reconstruct defects. Flaps can be classified based on composition, proximity to defect, and blood supply pattern. Common classifications include cutaneous, musculocutaneous, and free flaps. Postoperative monitoring involves assessing color, capillary refill time, temperature, and blanching to check flap viability. Complications include seroma, hematoma, necrosis, and infection. Careful anatomical dissection and tension-free inset are important to prevent flap failure.
3. Introduction
• A flap is a unit of tissue that is harvested
from its donor site and transferred to
another location for reconstructive
purposes.
• A flap is brought to the wound with its own
blood supply.
4. Introduction cont..
• There are a tremendous variety of surgical
flaps that canbe created depending on the
individual patient’s reconstructive needs and
available tissues.
• The main aim is to design an appropriate flap
and to restore the defect with a minimal
amount of morbidity related to the flap donor
site
5. Introductioncont..
• The different kinds of flaps can be broadly
classified by three distinct characteristics:
• (a) the types of tissue contained(composition)
• (b) the proximity to the defect(method of
movement)
• (c) the pattern of blood supply.
6. .
Classification of flap
• BASED ON COMPOSITION:
• Cutaneous flap- which contains skin and
subcutaneous tissue.
• Muscle flap-which contains only muscle.
• Musculocutaneous flaps -contain a portion of
muscle along with the overlying skin and all
the intervening tissues.
7. Classification of flap
• BASED ON COMPOSITION:
• An osseous flap- contains a segment of bone.
• An osteocutaneous flap- includes skin as well as
the bone.
• Flaps can also be designed to include fascia and
peripheral nerves.
• Visceral flaps contain segments of jejunum,
stomach, colon, or the greater omentum.
• The choice of flap depends upon the
reconstructive needs and availability of tissue.
8. Classification of flap
• BASED ON PROXIMITY TO THE DEFECT:
• The location and distance between the flap
donor site and the defect tells the method
required to transfer the tissue with
preservation of the blood supply.
9. Classification of flap
• BASED ON PROXIMITY TO THE DEFECT:
• Local flaps have a donor site located
immediately adjacent to the defect.
• Regional flaps are harvested from the same
anatomic region as the defect.
• Distant flaps are harvested and transferred
from outside the anatomic region of the
defect.
10. Classification of flap
• The tissue transmitting the blood supply is
called the flap pedicle.
• When the blood supply is not divided during
the transfer, it is referred to as a pedicled flap.
11. Free tissue transfer
• When the distance between the donor site & the
defect exceeds the length of the pedicle
• The vessels can be divided and reattached to
uninjured vessels within or adjacent to the defect
• after the placement of tissue .
• Flaps transferred in this fashion are called free
flaps
12. Classification of flap
• Based on the pattern of blood supply:
• Random pattern flaps
• Axial pattern flaps
• Musculocutaneous flaps
• Fasciocutaneous flaps
• Direct cutaneous flaps
• Perforator flaps
• Free flaps.
13. Random Pattern Flaps
• Blood supply is based on unnamed vessels
that is attached in the base of the flap that
perfuse through the subdermal plexus.
• Used to reconstruct relatively small & full-
thickness defects.
• length-to-width ratio of 3:1.
• Random pattern flaps can be further
subdivided based on the geometry of the
transfer.
15. Random Pattern Flaps
• Transposition flaps
• flap is placed adjacent to an area needing
reconstruction and rotated into the defect.
• 1.Z-plasty
• 2.Rhomboid (Limberg) flap .
• 3. Modified Limberg flap
• 4. Dufourmental modification
• 5. Rotational flaps
16. Transposition flaps
• 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.
17. Transposition flaps
• Rhomboid (Limberg) flap
• flap is designed with opposing 60° and 120°
angles at the corners of a rhomboid designed
immediately adjacent to the defect.
18. Transposition flaps
• It can be modified to allow the flap to rotate
into the defect with primary closure of the
donor site with minimal distortion of the
surrounding tissues.
• Closure of gluteal defect by complex closure.
21. Transposition flaps
• Rotation flaps are semicircular flaps of skin
and subcutaneous tissue that revolve in an arc
around a pivot point to shift tissue in a circle.
22. ADVANCEMENT FLAP
• The tissue is moved forward from the donor
site along the flap’s long axis.
• Depend on skin elasticity to stretch and to fill
a defect
• Rectangular advancement flap
• V-Y advancement flap
24. 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.
26. INTERPOLATED FLAPS
• Flap is taken from a near by but not
immediately adjacent donor site and
transposed either above or below the
intervening skin to recipient defect.
27. Axial Pattern Flaps
• An axial pattern flap contains atleast one direct
cutaneous branch blood supply along its
longitudinal axsis.
• Eg:deltopectoral flap-based on cutaneous vessels
perforating from inside the chest from the
internal mammary artery and vein.
• Long flaps can be designed based on these
vessels, which can reach into the head and neck
to provide thin tissue from the upper chest to
restore defects.
29. Musculocutaneous Flaps
• These flaps are potential flap 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.
• classified according to their principal means of
blood supply and the patterns of vascular
anatomy and according to mode of innervation.
32. Common muscleflaps:
Tensor Fascia Lata:
• Applications- Coverage of lower abdominal
wall, perineum, ischium and sacrum
• Vascular Anatomy: Ascending branch
lateral circumflex femoral (off Profunda
femoris)
33. Common muscleflaps:
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.
34. Common muscleflaps:
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.
35. Common muscleflaps:
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.
36. Common muscleflaps:
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.
37. Common muscleflaps:
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.
38. 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 skin graft or random skin flap is
insufficient for coverage (eg, in coverage over
tendon or bones).
39. Fasciocutaneous Flaps
• Fasciocutaneous flaps
are usually thinner
compared to
musculocutaneous
flaps.
• They also do not create
a functional loss of
muscle in the donor
site.
40. Fasciocutaneous Flaps
• Sural perforator fasciocutaneous flaps are a
example of reconstructing lower extremity
defects.
41. Direct Cutaneous Flaps.
• Some surgical flaps have a vascular pedicle
that reaches directly to the superficial tissues
and subdermal plexus without passing
through a muscle or fascia plexus.
• These are called direct cutaneous flaps.
42. Perforator Flaps
• A perforator is a blood vessel passing through
the deep fascia and contributing blood supply
to the fascial plexus.
• Perforators arise from a source or mother
vessel to a given angiosome.
• Blood supply to all portions of the skin was
organized into discret units, which they called
angiosomes
43. Perforator Flaps
• Advantages of perforator flaps include preservation of
functional muscle and fascia at the donor site .
• Disadvantages :
• Difficult dissection needed to isolate the perforator
vessels
• Longer operating time associated with this dissection
• Anatomic variability of position
• Size of perforator vessels- short pedicle length
available, and fragile nature of small blood vessels.
44. Perforator Flaps
• Doppler ultrasound is used routinely to locate
the perforators before flap elevation.
• color flow duplex scanning and thermography,
may also be used.
46. Principlesofflapsurgery
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
47. Principlesofflapsurgery 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.
48. Principlesofflapsurgery 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:
49. Postoperativeflapmonitoring:
• 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
51. Causesofflapfailure:
• 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.
