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Flap techniques
The document describes the step-by-step techniques for raising three types of flaps in microvascular reconstruction: the iliac crest flap, fibular flap, and radial forearm flap. For each flap, the key steps are outlined, including skin and fascial incisions, identification and dissection of vascular pedicles, osteotomies if applicable, and completion of flap elevation. Diagrams accompany the text to illustrate the relevant anatomy and surgical steps. The overall aim is to provide an educational guide to raising these flaps for microvascular transplantation.
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Flap techniques
- 1. Flap techniques ofDCIA, 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 pubicumCommon femoral artery Profunda femoral artery ANTERIOR SUPERIOR ILIAC SPINE FEMORAL ARTERY EXTERNAL ILIAC ARTERY DEEP CIRCUMFLEX ILIAC ARTERY ASCENDING BRANCH
- 6. Orientation of skinincision for raising of myo-osseous iliac crest bone flaps
- 7. Step 1 Skinincision, exposure of inguinal ligament
- 8. Step 2 Identificationof internal oblique muscle
- 9. Step 3 Exposureof vascular pedicle
- 10. Step 4 Dissectionof DCIA towards the anterior superior iliac spine (ASIS)
- 11. DEEP CIRCUMFL ARTERY LATERAL FEMORALCUTANE 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 iliacartery LATERAL FEMORAL CUTANEOUS NERVE CROSSING OVER DCIA
- 13. Step 5 Skinincision along iliac crest
- 14. Step 6 Transectionof muscles at lateral rim of iliac crest
- 15. Step 7 Detachmentof muscles from gluteal surface of pelvis
- 16. Step 8 Transectionof oblique abdominal muscles, exposure of iliacus muscle by retracting the peritoneum
- 17. Transverse abdominus muscle Internaloblique abdominis muscle External oblique abdominus muscle Iliacus muscle Deep circumflex iliac artery
- 18. Step 9 Incisionof iliacus muscle below DCIA
- 19. Step 10 Transectionof sartorius muscle at ASIS
- 20. Step 11 Distalosteotomy at iliac crest
- 21. Step 12 Completionof osteotomy below the course of DCIA
- 22. Step 13 Transectionand trimming of residual muscle fibres
- 23. TRANSVERSE ABDOMINUS MUSCLE INTERNAL OBLIQUE ABDOMINUSMUSCLE EXTERNAL OBLIQUE ABDOMINUS MUSCLE DEEP CIRCUMFLEX ILIAC ARTERY ILIACUS MUSCLE PERIPERITONIAL FATTY TISSUE
- 24. Step 14 Myo-osseousiliac crest bone flap ready for microvascular transplantation
- 25. ILIAC MUSCLE (CUT) ILIACBONE MYO OSSEOUS FLAP WITH PEDICLE Flap perfusion is maintained until the recipient vessels are ready for anastomoses
- 26. Fibular Flap raisingtechnique • 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 Raisingtechnique • 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 Raisingtechnique • 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 andflap design b
- 30. Patient positioning andflap design a
- 31. Step 1 Incisionof skin and fascia
- 32. Step 2 Identificationof perforator
- 33. PERONEUS MUSCLE SOLEUS MUSCLEPERONEAL ARTERY Posterior intermuscu with septo(myo)cuta Step 3 Exposure of lateral margin of fibula
- 34. Step 4 Detachmentof soleus and flexor hallucis longus muscle
- 35. Step 5 Openingof deep flexor space, identification of peroneal branches
- 36. Step 6 Exposureof peroneal vessels
- 37. Step 7 Dissectionof vascular pedicle
- 38. STEP 8 DISTALOSTEOTOMY
- 39. Step 9 Proximalosteotomy, protection of pedicle
- 40. Step 10 Incisionof anterior intermuscular septum
- 41. Step 11 Exposureof interosseous membrane
- 42. Step 12 Transectionof interosseous membrane
- 43. Step 13 Distalligation of peroneal vessels
- 44. Step 14 Divisionof tibialis posterior muscle
- 45. Step 15 Incisionof skin and fascia at dorsal periphery of skin paddle
- 46. Step 16 Completeelevation of skin paddle including muscle cuff around perforator
- 47. Step 17 Distaltransection of flexor hallucis longus muscle
- 48. FLEXOR HALLUCIS LONGUS MUSCLE(CUT) Tibialisposterior muscle covered by interosseous membrane (cut) PERONEUS MUSCLE EXTENSOR MUSCLE Posterior intermuscula septum PERONEAL ARTERY AND VENA COMMITANTES
- 49. Step 18 Proximaltransection of remaining flexor hallucis muscle fibers
- 50. Step 19 Flapraising 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 ofthe radial forearm flap
- 55. Step 1 Ulnarskin incision and undermining of forearm fascia
- 56. Step 2 Incisionof fascia and exposure of flexor carpi ulnaris
- 57. Step 3 Distalskin incision and subfascial dissection
- 58. Step 4 Exposureof the flexor carpi radialis tendon
- 59. Step 5 Identificationof radial vessels and superficial radial nerve at distal flap margin
- 60. Step 6 Ligationof radial vessels at distal flap border
- 61. Step 7 Radialskin incision
- 62. Step 8 Dissectingthe pedicle along brachioradialis muscle
- 63. Step 9 Completesubfascial flap elevation
- 64. Step 10 Skinincision at proximal flap margin and wavy incision for exposure of pedicle
- 65. Step 11 Exposureof additional superficial vein (optional)
- 66. Step 12 Exposureof vascular pedicle
- 67. Step 13 Completedissection of pedicle
- 68. Step 14 Separationof residual attachments at flap hilum
- 69. Step 15 Flapraising completed with additional superficial vein and nerve