A power point on the various types of flaps and their respective indications. This presentation briefly describes the various flaps and how to care for flaps.

1. FLAPS

2. Background
• Flap is a blocks of tissue mobilized from its donor site and transferred
to another location (adjacent or remote) for reconstructive purposes.
• Unlike graft flaps have their own blood supply.
• The block of tissue may be composed of skin, subcutaneous tissue, fascia,
muscle, bone or viscera e.g. (omentum)

3. Reconstructive Ladder

4. FLAPS Vs GRAFTS
FLAPS
• Can carry other tissues
• Has its own blood supply
• Better colour take less likely to
contract
• Can bridge defects
• Requires no pressure dressing
GRAFTS
• Limited to transplantation of skin.
• Depends on recipient site for
nourishment.
• May discolour or contract
• Cannot bridge defects
• Requires pressure dressing

5. Classification of Flaps
• The six Cs” of flap characteristics
• Circulation (blood supply)
• Constituents (composition)
• Contiguity (destination)
• Construction (flow)
• Conditioning
• Conformation

6. Flap Blood Supply and Physiology

7. Classification of Flaps - Circulation
• Axial vs Random Flaps
1. Axial pattern flaps
• Has a known or named artery coursing along its longitudinal axis.
2. Random pattern flap
• Has no known vessel at its core and relies on the random subdermal plexus for
perfusion.
• Limited to a 3:1 length to width ratio to maintain viability at the tip.

8. Classification of Flaps - Circulation
• Pedicle vs Free Flaps
1. Pedicled Flaps
• The flaps remain attached to a known native vascular pedicle and are
limited to the arc of rotation or advancement that these vessels afford.
2. Free Flaps
• Flap is raised on a known vascular pedicle that is transected and
anastomosed to a new blood supply at the recipient site.
• Requires microsurgical techniques

9. Classification of Flaps - Circulation
• Flaps containing muscle or fascia can also be classified further by the
type of blood flow that supplies them.
• Cormack and Lamberty classification for fascial flaps
• Mathes and Nahai Classification for muscles
• Mathes and Nahai Classification

10. The Mathes and Nahai classification of muscle flaps
Type 2
• muscles are supplied by both a dominant and minor
vascular pedicle.
• Type 3
• These muscles possess two large vascular pedicles from
separate vascular sources
• These pedicles have either a separate regional source of
circulation or are located on opposite sides of the muscle

11. The Mathes and Nahai classification of muscle flaps
• Type 4
• muscles are supplied by segmental vascular pedicles entering
along the course of the muscle belly.
• Each pedicle provides circulation to a segment of the muscle.
• Type 5
• One dominant vascular pedicle near the insertion of the
muscle and secondary segmental vascular pedicles near the
origin.
• The internal vasculature can be supplied by either pedicles

12. Classification of Flaps - Constituents
• Cutaneous flaps/Fasciocutaneous/fascial
• Muscle/musculocutaneous
• Visceral
• Nerve
• Bone and/Cartilage
• Lymph node (with subcutaneous fat)

13. Classification of Flaps - Constituents
1. Cutaneous flaps
• Simplest of the flaps and made of skin (with subcutaneous fat).
• The blood supply is random in nature and located within the subdermal
plexus.
2. Fasciocutaneous/fascia
• Fasciocutaneous flaps - skin, subcutaneous tissue, and fascia.
• Fascial flaps – deep fascia with overlying skin.

14. Fasciocutaneous Flap

15. Classification of Flaps - Constituents
3. Muscle/musculocutaneous
• Muscles flaps can be used in stand-alone fashion, or with an overlying skin graft
• Musculocutaneous flaps – muscles can be harvested with overlying skin and soft
tissue for added bulk.
• The muscle provides bulk for deep, extensive defects and protective padding for
exposed vital structures (e.g., tendons, nerves, vessels, bones, and prostheses).

16. Muscle Flap

17. Classification of Flaps - Constituents
• Bone Flaps
• Osteomyocutaneous and Osteocutaneous
• Commonly transferred bones
• Fibula based on the peroneal artery,
• Iliac crest based on the deep circumflex iliac artery
• The scapula based on the circumflex scapula or
thoracodorsal arteries
• The calvarial osseous flap based on the superficial
temporal artery or occipital artery

18. Fibula – Osteocutaneous flaps
• mandibular reconstruction
• pelvis reconstruction
• Patients who need further
growth of the long bone e.g.
humerus

19. Classification of Flaps - Constituents
• Visceral Flaps
• Reconstruction the esophagus with a long segment of jejunum.
• colon or jejunum as flaps have been for vaginal reconstruction.
• Appendix - reconstructing the urethra
• Lymph node (with subcutaneous fat)
• Management of lymphoedema

20. Classification of Flaps - Contiguity(Destination)
• Local –immediately adjacent to the defect
• Flaps are moved via advancement, transposition, rotation, or interpolation etc
• Regional – moved from the adjacent region
• Require larger movements than those seen in local flaps.
• These often still include rotations, advancements and transpositions.
• Distant – moved from a remote anatomic area.
• Tubed flaps and free flaps

21. Classification of Flaps - Contiguity(Destination)
• Rotational Flaps

22. Classification of Flaps - Contiguity(Destination)
• Advancement
• V-Y advancement Key stone
•

23. V-Y Advancement Flap

24. Classification of Flaps - Contiguity(Destination)
• Advancement Flap
• Unipedicle H-Plasty Bilateral Unipedicle H-plasty

25. Classification of Flaps - Contiguity(Destination)
• Transposition Flaps
• Z-plasty Rhomboid

26. Classification of Flaps - Contiguity(Destination)
• Islandization
• Propeller

27. Classification of Flaps –Contiguity (Destination)
Regional Flaps
• Pectoralis Major Myocutaneous Flaps • Transverse Rectus Abdominis Muscle
Flap

28. Classification of Flaps –Contiguity (Destination)
Regional Flaps
• Latissimus dorsi flap
• Trapezius flap
• Delto-pectoral flaps
• Used for covering rather than soft tissue displacement

29. Classification of Flaps - Contiguity(Destination)
• Distant Flaps
• E.g Groin flaps

30. Flap Classification Based – Construction (Flow)
• Retrograde-flow flaps
• Turbocharged and supercharged flap
• Venous flaps (arterialized venous flap)

31. • retrograde flow digital artery flap raised on the ulnolateral border of
the proximal phalanx could be used for coverage of a dorsal proximal
interphalangeal joint (PIPJ) defect.

33. Flaps Classification Based on conditioning
1. Delay Flaps
• The goal of a delayed flap is to enhance flap circulation, ensuring flap survival
after advancement, transposition, or transplantation to a defect site.
• Surgical flap delay is accomplished in two ways:
• Standard delay - incision at the periphery of the cutaneous territory or partial flap
elevation
• Strategic delay - division of selected pedicles to the flap to enhance perfusion through
the remaining pedicle or pedicles.

34. Flaps Classification Based on conditioning
2. Tissue Expansion
• The tissue expander is inserted under the skin to increase skin dimensions to
provide sufficient skin circumference for designing an advancement or
transposition flap.
• Immediate skin expansion & delayed expansion.
• Delayed- Tissue expander is injected with saline weekly for 6weeks to 3months

35. Flaps Classification Based on conditioning
• Failure of tissue expanders
• Failure of tissue expansion is usually attributable to inadequate stability of skin and
associated soft tissue during the expansion process.
• Failure of the expander is signaled by wound dehiscence followed by expander
exposure and infection.

36. Flaps Classification Based on conditioning
• Flap prelamination
• Partial to complete flap elevation and suturing of the flap to form
structures at the site of and when these structures have healed they are
used for reconstruction (transposition or transplantation).
• Prefabrication
• A suitable artery and vein are selected and buried in fascia or
subcutaneous tissue in the planned flap territory
• In 6 weeks, the flap based on the new vascular pedicle is elevated and
either transposed or transplanted by microsurgery.

37. Flaps Classification Based on conditioning
• Sensory flaps
• All flaps using the skin component may be designed to incorporate the
sensory nerve in the flap base or coapt the severed nerve to a suitable
sensory nerve at the recipient site.
• Muscle flap
• For function to be preserved,
• the motor nerve must be preserved along with dominant vascular supply,
• the muscle must be reattached to a new bone or tendon across a joint, and
• the muscle must exert a direct force on its new point of attachment

38. Flap Classification Based – Conformation
• A compound flap typically consists of multiple tissue components linked
together in a manner that allows their simultaneous transfer
• Two major classes of compound flaps
• Solitary Vascularization
• Composite flaps e.g. osteomuscular flaps
• Combined Vascularization
• Conjoined flaps
• Chimeric flaps

39. Flap Classification Based – Conformation

40. Causes of flap failure
• Poor anatomical knowledge when raising the flap
• Too much tension flap inset
• Infection
• Poorly applied dressing (too tight)

41. Postoperative flap management
• Avoid pressure at the base of the flap
• Nurse the flap in a non-dependent part o the body
• Avoid constricting bandages
• Avoid excessive motion at flap insert site
• Padding of areas adjacent
• Use of plaster splint to immobilize the proximal and distal joint to the flap site
• Avoid prolong bed rest
• Encourage rage of motion exercise at donor site to avoid joint stiffness and
muscle weakness (Usually POD 7 - 10 )
• Physiotherapy

42. Postoperative flap management
• Antibiotic therapy
• Peri-operative antibiotic –reconstruction of contaminated defects or implants
with history of prior infection
• Postoperative antibiotic therapy should be based on wound cultures
• Adequate pain management

43. Monitoring of the Flap
• Create a flap nursing
• Flap details – type, location, dressing and
• Type of flap dressing
• Special instructions
• Flap Clinical signs
• Temperature – flap should be warm
• Colour – pink is ideal
• Capillary refill – (2 – 3)sec
• Texture – flap should be soft
• Skin changes – similar to surrounding tissue
• Oedema/swelling – may be due to collection in or under the flap
• Pulse – should be palpable or use a doppler

44. Monitoring of the Flap
• Patients General Clinical Signs
• Pulse – 60 – 00bpm
• BP > 90/60 but < 140/90
• Resp – 16 – 20cpm
• SPO - >94%
• Pain score

45. Complications of Flap
• Haemtoma
• Seroma
• Superficial skin necrosis
• Fat necrosis
• Infection