Flaps are vascularized blocks of tissue that are mobilized from a donor site and transferred to another location for reconstructive purposes. They can carry skin, muscle, bone or other tissues. Classification is based on congruity, circulation, and anatomical components. Key principles include replacing like with like tissue and ensuring an adequate blood supply from the pedicle or microvascular anastomosis. Complications can include congestion, infection or partial/complete flap loss if the blood supply is compromised.

1. FLAPS IN SURGERY

2. Contents
• Introduction
• History
• pathophysiology
• Graft vs flap
• Classifications of flaps
• Principles of flap surgery
• Post operative assessment of
flap
• complications

3. • A flap is a vascularized block of tissue that
is mobilized from its donor site and
transferred to another location, adjacent or
remote, for reconstructive purposes.

4. • A flap is used :
• To reconstruct a large primary defect
• Replace tissue loss during trauma or
surgical excision.
• Provide padding over bony
prominences.
• Bring in better blood supply to
poorly vascularizedbed.
• Improve sensation to an area{sensate
flap}

5. • Bring in specialized tissue for reconstruction
such as bone or functioning muscle.

6. History
• Origin in india:In 600
BC, Sushruta Samita
described operations
for nasal
reconstruction—,
since amputation of
the nose (an organ
of "respect and
reputation") was
common as criminal
punishment.
• He used cheek flap
for reconstruction of
nose.

7. History cont..
• the first muscle flap
of recorded history
debuted in 1906.
• Louis Ombredanne
of Paris described
the use of the
pectoralis minor
muscle for breast
reconstruction
following
mastectomy.

8. History cont..
• Sir Harold Delf
Gillies:
• considered the
father of plastic
surgery.
• Pioneer in facial
injury repairs.

9. Differences between flap
and graft:
graft flap
Limited to transplantation of skin Can carry other tissues
Depends on recipient site on nutrion Has its own blood supply
Cosmetic –may discolor or contract Better color take and less likely
to contract
Less adaptable to weight bearing Most adaptable to weight bearing
Less able to survive on a bed with
questionable nutrition
Can be used on a bed with
questionable
nutrition
Requires pressure dressing Does not requires pressure dressing
Cannot bridge defects Can bridge defects

10. Physiologic factors affecting
flap survival:
• includes-
• 1.blood supply to the flap through its base.
• 2.formation of new vascular channels between
flap and recipient bed.
• 3.perfusion pressure of the supplying blood
vessel.

11. pathophysiology
chronologic changes of a flap and the recipient site
after elevation and transfer:
• After 10-24 hours - Decreased arterial supply;
congestion and edema; dilation of arterioles
and capillaries
• After 1-3 days - Increased number and quality of
anastomoses between flap and recipient bed;
increased number of small vessels in pedicle
• After 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
flap and recipient bed
• After 2 weeks - Continuous maturation of
anastomoses

12. Classification of flaps
Classification of Flaps Can be
based on:
• 1. Congruity
• 2. Circulation
• 3. Anotomical Components

13. Classification of flapscont..
Based on congruity:
A. local flap:
• A local flap implies
that the tissue is
adjacent to the open
wound in need of
coverage.
• Eg. A wound on lip
may be repaired by a
flap on adjacent
cheek

14. Classification: Basedon
congruity:cont..
• B. Regional flap:
• Skin flap is not from the adjacent area but from
the same region
• Eg.wound on the tip of the nose might be
repaired with a flap from forehead.
• C. Distant flap:
• Tissue transferred from an non contiguous
anatomic site (ie, from a different part of the
body) is referred to as a distant flap.

15. Classification: Based on
congruity:cont..
• Distant flap Is of two types:
1.pedicled flap:is transferred while flap is
still attached to their original blood supply.
2.Free flap:Free flaps are physically detached
from their native blood supply and then
reattached to vessels at the recipient site.
This anastomosis typically is performed
using a microscope, thus is known as a
microsurgical anastomosis.

16. Classification: Based on
congruity:cont..
d.island flap a flap consisting of skin and
subcutaneo us tissue, with a pedicle made up of
only the nutrient vessels.

17. Classification: Based oncirculation
• A. Axial pattern
flap:
• An axial pattern
flap contains
atleast one direct
cutaneous branch
blood supply
along its
longitudinal axsis.

18. Classification: Based oncirculation
B.random pattern
flap:
• A myocutaneous flap
w ith a random
pattern of arteries, as
opposed to an axial
pattern flap.

19. Classification: On the basisof
anatomical content:
1.Skin flap
2.Muscle and myocutaneous
flap 3.Fascia and fascio
cutaneous flap

20. Skin flap:
• Uses:
• 1.recipent bed with poor vascularity
• 2.coverage of vital structures
• 3.reconstructing full thickness structures
e.g.eyelid
,cheek, nose, lip, ear etc.
• 4.padding of bony prominences

21. Skin flaps:cont..
Types :
1.Those rotating around a pivot
point:
• a)rotation flap
• b) transpositionflap
•c)interpolation
flap
2.advancement
flaps
• a)single pedicled advancement
flap

22. Skin flaps:cont..
A.Rotation flaps :
are semicircular flaps of skin and
subcutaneoustissue
• that revolve in an arc around a pivot point to
shift tissue in a circle.
• Rotation flaps provide the ability to mobilize
large areas of tissue with a wide vascular
base for reconstruction

24. Skin flaps:cont..
B.Transposition
flaps :
• Are rectangular or
square and turn
laterally to reach
the defect.
• Donor site can
be closed
primarily.

25. Skin flaps:cont..
• C. interpolation flap:
is from a near by
but not immediately
adjacent donor site
and transposed
either above or
below the
intervening skin to
recipient defect.

26. Skin flaps:cont..
Advancement flap:
• Advancement flaps move directly forward and
rely on skin elasticity to stretch and to fill a
defect.
• No rotational or lateral movement is applied
• It is of 3 types:
A.single pedicle advancement
flap. B.bipedicle advancement
flap.
C.v-y flap advancement flap.

27. Skin flaps:advancement flapcont..
• Single pedicle advancement flap: Here the
rectangular skinflap is moved forward by virtue
of its elastic properties.
• Bipedicle flap: here an insicion is made
parallel to the defect and the flap is
undermined and advanced

28. Skin flaps:advancement flapcont..
V-Y 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

30. Skin flap: typescont..
Rhomboid flaps:( limberg flap.)
• rely on the looseness of adjacent skin to
transfer
• a rhomboid-shaped flap into a defect that has
been converted into a similar rhomboid shape

31. Skin flap: typescont..
• Z-plasty:
• 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.

32. Skin flap: typescont..
Common indications of z plasty:
• lengthening of a contracted linear scar
across a flexor crease.
• changing the direction of a
cosmetically unfavorable scars.

33. Muscle and myocutaneousflap:
• Consideration of a muscle as a potential
flap is possible 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.
• Muscle flaps are classified according to their
principal means of blood supply and the
patterns of vascular anatomy and according to
mode of innervation.

35. 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)

36. 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.

37. 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.

38. 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

39. 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

40. 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.

41. Myocutaneous flap:
• A musculocutaneous flap, also called a
myocutaneous flap, is a muscle flap designed
with an attached skin paddle.

42. Fascia and FasciocutaneousFlaps:
• 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 a skin graft or random skin flap is
insufficient for coverage (eg, in coverage
over tendon or bones).

43. Fascia and FasciocutaneousFlaps:
cont..
• Because they are less bulky, fasciocutaneous
flaps are indicated when thinner flaps are
required
• Fasciocutaneous flaps are not as resistant
to infection as muscle flaps. Monitoring flap
failure occasionally can be difficult

44. Fascia and
Fasciocutaneous
Flaps: cont..
classification of fasciocutaneous flaps is
based on vascular anatomy:

45. Principles of flapsurgery
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

46. Principles of flap surgerycont..
• 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.

47. Principles of flap surgerycont..
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:

48. Postoperative flapmonitoring:
• 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

49. Complications:
• 1.seroma formation
• 2.hematoma
formation
• 3.flap necrosis
• 4.fat necrosis
• 5.donor site infection

50. Causes of flapfailure:
• 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.