1. The document discusses various types of flaps used in reconstructive surgery including local flaps, regional flaps, and free flaps. 2. Different types of local flaps are described such as rotation flaps, transposition flaps, and advancement flaps which allow redistribution of tissue near a defect. 3. Regional flaps like the pectoralis major flap provide tissue from a distance away but within the same anatomical region and rely on named vessels within a vascular pedicle.

1. Subervised by: Dr.Mohammed Khudher
Presented by : Muhanad Khames
Zahrra Abduljaleel
Faihaa Amer

2. A flap is a unit of tissue that is transferred from
one site (donor site) to another (recipient site)
while maintaining its own blood supply.
Flaps come in many different shapes and forms.
They range from simple advancements of skin
to composites of many different types of tissue.
These composites need not consist only of soft
tissue. They may include skin, muscle, bone,
fat, or fascia.

3. The term flap originated in the 16th century
from the Dutch word flappe, meaning
something that hung broad and loose,
fastened only by one side. The history of flap
surgery dates as far back as 600 BC, when
Sushruta Samita described nasal
reconstruction using a cheek flap. The origins
of forehead rhinoplasty may be traced back
to approximately 1440 AD in India. Some
reports suggest flap surgeries were being
performed before the birth of Christ.

5. The surgical procedures described during
the early years involved the use of pivotal
flaps, which transport skin to an adjacent
area while rotating the skin about its
pedicle (blood supply). The French were
the first to describe advancement flaps,
which transfer skin from an adjacent area
without rotation. Distant pedicle flaps,
which transfer tissue to a remote site,
also were reported in Italian literature
during the Renaissance period.

6. 1- Replace tissue loss due to trauma or surgical
.excision
2-Provide skin coverage through which surgery
.can be carried on latter
.3-Provide padding over bony prominences
4-Bring in better blood supply to poorly
.vascularized bed
5-Improve sensation to an area (sensate flap).
6-Bring in speialized tissue for reconstruction
such as bone or functioning muscle.

7. 1. Enable rapid reconstruction.
2.Good colour and texture.
3.Has a reliable and adequate blood
supply.
4. More adaptable to weight
bearing.

8. The microcirvculatory system of skin is composed of
:
1-Superfacial plexus in the superfacial dermal
papillae in the papillary dermis.
* Supplies the more metabolically active epiderms by
means of diffusion.
2-Deep vascular plexus at the junction of
subcutaneous fat and reticular dermis.
* Physiologic factor affecting flap survival :
1- Blood supply to the flap through its base.
2- Formation of new vascular channels between the
flap and the recipient bed.
3- Perfusion pressure of the supplying blood
vessels.

10. *Can be based on (five ‘C’ s)
1- Congruity
2- Configuration
3- Components
4- Circulation
5- Conditioning

11. Local – immediately adjacent to defect.
Regional – moved from adjacent region.
Distant – moved from remote anatomic
area.
Pedicled – moved with intact tissue bridge
for support.
Islanded – no intact skin but moved under
the skin for non contiguous defects.

12. Local flaps are flaps that are located adjacent to the defect.
They may be contiguous to the defect or a small
amount of tissue may separate the flap from the defect.
The surrounding tissue is transferred to repair the defect
and therefore the flap tends to be similar in color and tex-
ture, and the thickness can often be tailored to the needs
of the defect.
Local flaps are created by freeing a layer of tissue and then
stretching the freed layer to fill a defect.

13. :Advantages
Best local cosmetic tissue match.
Often a simple procedure.
Local or regional anaesthesia option.
Disadvantages :
Possible local tissue shortage.
Scarring may exacerbate the condition.
Surgeon may compromise local resection.

14. LOCAL FLAP
BLOOD
SUPPLY
METHOD OF
MOVEMENT
COMPOSITION

15. Local flaps can be
classified based on
their blood supply
Random flaps Axial flaps

17. Rotation flaps provide the ability to mobilize
large areas of tissue with a wide vascular base
for reconstruction. The name rotation flap
refers to the vector of motion of the flap,
which is curved or rotational, and the
procedure involving these flaps can be thought
of as the closure of a triangular defect by
rotating adjacent skin around a rotation
point(or fulcrum) into the defect.

18. Indication
1-Commonly used for coverage of sacral pressure
sores. This type of flap can cover wounds of
various sizes.
2-After excisional surgery.
*Rotation flaps are particularly useful when the
proposed donor site of the flap is the lateral
aspect of the face. These flaps are advantageous
because they have a particularly wide base and
thus an excellent blood supply. Their
disadvantage is that they require relatively
extensive cutting beyond the defect to develop
the flap.

19. A: 3*3 cm skin defect of
medial cheek.

20. Rotation flap designed for
repair

21. Flap in place. Standing cutaneous
deformity excised parallel to melolabial
crease

22. The rectangular flap is rotated on a pivot point.
The more the flap is rotated, the shorter the
flap becomes. Most commnly used in head and
neck
Transposition flaps have the following
advantages:
1: They accomplish redistribution and
redirection of tension.
2:They tend to be smaller in size than
advancement and rotation flaps.
3:Resultant scars are geometric broken lines that
may be less conspicuous and tend to be easy to
hide.

23. Reconstruction of total upper eyelid defect with lower lid
transposition. Illustration of planned reconstruction of an upper
eyelid defect with lower lid transposition.

25. Interpolation flap – the flap rotates about a
pivot point into a nearby but not adjacent
defect, with the pedicle passing above or below
a skin bridge.
E.g. median forehead flap, thenar flap

26. Advancement flaps can be used at any location
on the cheek. As with the rotation flap, the
advancement flap can be of any size. It is best
to use natural lines, even if they diverge away
from the defect, because this will still give a
.better and more natural cosmetic end result
No rotational or lateral movement is applied.
E.g. rectangular advancement, V-Y advancement
etc.


27. Create a triangular-shaped flap with the base of the
flap at the cut edge of the skin where the amputation
occurred. It should be as wide as the greatest width of
the amputation
Skin incisions are made through the full thickness of the
skin.
Advance the flap over the defected area and suture it
to the nail bed.
Place corner stitches to avoid interference with the
blood supply to the corners. Convert the V-shaped
defect into a final Y-shaped wound
The V-Y pedicle plasty technique allows most patients
to regain sensation and two-point discrimination in the
fingertip.
The cosmetic results are usually excellent, with good
contour and fingertip padding is preserved

28. A-skin defect of alar groove. V–Y island subcutaneous tissue
pedicle advancement flap designed for repair
B-Flap incised and advanced on nasalis muscle

29. (C) Flap in place.
(D) 4 months’ postoperative

30. A rhombus is classically defined as an oblique-
angled equilateral parallelogram, whereas a
rhomboid differs in that it has uneven adjacent
sides. The term rhomboid is frequently used in
facial reconstruction literature to mean either
rhombus like or to describe one of the popular
transposition flaps used to repair rhombus-
shaped defects. Specially designed transposition
flaps for rhombic shaped defects.Defect must
have 60 and 120 angles.

31. (A) Melanoma in situ right temple.
(B,C) Lesion excised. Limberg flap designed
for repair of 2*2 cm defect.
(D,E) Dufourmentel flap designed
and transferred to defect.

33. Z-plasty is one of many techniques for
scar revision and camouflage. Z-plasty
is a type of transposition flap that
incorporates qualities of advancement
and rotation flaps into its design.
USES
1-Lengthning of scar
2-Changing direction of scar into more
favorable one
3-Interrupt scar linearity

34. Regional flaps are located at a significant
distance from the donor site. Because of
this distance, the flap usually has its own
blood supply in the form of a named
vessel. Advantages of a regional flap are
that post-operative care and monitoring
are much less intense compared with a free
flap; they are usually quicker than a free
flap; large amounts of skin and/or muscle
can be obtained; and if free flap surgical
expertise is not available, regional flaps
can provide a favorable result.


35. There are several potential disadvantages of
regional flaps. The first and perhaps the most
important is the arc of rotation of the flap.
The ability to use a particular regional flap
will be dependent on the reach of the flap
based on its arc of rotation. The reliability of
regional flaps is improved when the flap can
reach the defect and the inset is performed
without tension. Other disadvantages for
regional flap are that the skin color match
and texture may be slightly different found at
the recipient site


36. Pectoralis major muscle flap (with or
without
skin).
Deltopectoral flap
Submental artery island
Supraclavicular artery island flap
Temporalis flap
Sternocleidomastoid flap
Scalping Flap
Trapezius flap
Paramedian forehead flap
Palatal Island Flap

37. Indications
*Soft tissue reconstruction of the neck and
hypopharynx
*Pharyngocutaneous fistulas
*Backup” flap
Circulation
Septocutaneously: Randomly through skin perforators
from the internal mamary artery.
Constituents
Fasciocutaneous: Skin and fascia overlying the chest
and shoulder.
Conformation:The skin island is oriented to the shape
of the defect. The flap can be tubed for pharyngeal
reconstruction.

38. Clinical Case: A young female patient aged 21
years presented with severe RTA trauma of
middle and lower vertical thirds of the face
who has admitted to maxillofacial Surgery
Department, Ramadi Teaching Hospital, Anbar
Province, Iraq.

39. The skin paddle of deltopectoral flap allowed
the reconstruction of the lower lip, submental
region, and submandibular region. The flap was
marked preoperatively and the outline of the
flap was extended laterally to simulate the
resultant defect. The incision was extended 1
cm below the clavicle parallel to the lateral
border of the pectoralis muscle. The inferior of
the flap was 2 cmabove the nipple and parallel
to the clavicle. The 2 lines of incisions were
joined laterally on right arm.

40. K-wire was inserted to maintain mandibular
bonecontinuity and prevent collapse of missed
segment of mandibularThe flap was elevated
with the deep fascia of the pectoralismuscle,
and dissection was performed inferiomedially,
the flap wasraised till the sternal border. After
preparation of recipient site, theflap was
rotated to the defect in a tension-free manner
and was sutured with 3/0 silk suture.

42. The first description of the pectoralis major
flap for head and neck reconstruction was by
Ayrian in 1978. The fol-lowing year he
published his work in the Journal of Plastic
and Reconstruction Surgery. Since the
description of this flap, its use quickly became
widespread and within a short time it held the
positionas the flap of choice in head and neck
reconstruction.
*Based upon the pectoral branch of the
thoracoacromial artery off the second portion
of axillary artery.
*Able to handle 90% of virtually all head and
neck defect.

43. ADVANTAGE:
1-The location of the donor site as it relates to
the head and neck makes this flap a great option
for reconstructing defects in this region. The
harvest of the flap can be carried out with the
patient in a supine position. i.e., in the same
position as the ablative head and neck
operation.The potential for a two-team
approach is also available. although the surgical
field would be slightly crowded.One of the
greatest advantages of the pectoralis major
myocutaneous flap is the quality and quantity of
tissue that can be harvested. The pectoralis
maior mus-cle enables the closure of a
multitudeof defects in the head and neck.

44. 2-More durable blood supply
3-Defect at the donor site can be closed
primarily.
4-Provide bulk tissue to cover large defect.
DISADVANTAGE:
1-The main disadvantage is that the pectoralis
major flapis a pedicle flap and therefore its use
in reconstruction of head and neck defects is
limited to sites within the arc of rotation of the
flap. Equally, some of the reasons that make
this flap good option for reconstruction will also
Be potential downsides in certain cases. When
the defectsite demands a thin and pliable flap,
this may not be themost ideal flap.

45. 2-In cases where the flap is used as a
myocutaneous flap with the skin island used to
reconstruct a skin defect in the head and neck,
there is often a very distinct color mismatch. In
males there may also be a significant a mount
of hair growth on the skin component of the
flap that may become bother some to patients
depending on the site of the reconstruction.

48. The trapezius flap can be used to reconstruct
numerous defects in the head and neck
regionranging from defects in the oral cavity,
resurfacing of various sites in the neck, and
coverage of mandibular and temporal defects.
ANATOMY:
The trapezius muscle is a triangular muscle that
covers the back of the neck and shoulder region
and extends inferiorly in the back. It arises from
the medial third of the superior nuchal line of
the occipital bone.
The actions of the trapezius muscle can be
divided based on the region, the upper region
elevates the shoulder,

49. the middle retracts the scapula and aids in the
abduction of the upper extremity, and the lower
portion aids in the depression of the scapula.
*blood supply from four sources: the transverse
cervical artery, the dorsal scapular artery, the
intercostal perforators lying just off the midline,
and the branches from the occipital artery.
The blood supply to the trapezius muscle and
overlying skin is primarily from the superficial and
deep descending branches of the transverse
cervical artery, as well as the occipital artery.

50. Mutter 1842, Originally described as
superior based cutaneous flap.
ADVANTAGES:
1- Flap is versatile
2- Regionality of flap
3- Strong vascular security
4- Supplies considerable bulk
5- Arc of rotation 90 - 180 degree
6- One stage procedure
7- Minimum deficit at donor area

51. DISADVANTAGES
1-Venous system difficult to preserve
2-Vascular supply in general difficult to preserve
Can present with excessive bulk
3-Cannot be easily tubed
4-Moderate shoulder drop postoperativer

52. (A) Preoperative defect in the submental
region.(B) Marking of the dorsal scapular artery
and flap planning on the back.

53. (C) Elevated flap as an island flap. (D)
Postoperative 3 months.

54. Indications
1- all soft tissue defects of the oral cavity and
neck
2- Restoration of facial contours after
parotidectomy, prevention of Frey’s
Syndrome
3- Esophageal and tracheal defects
4- Backup flap
Circulation
Axially and myocutaneously by the thyrocervical
trunk and the occipital superior thyroid,
external carotid, the superficial cervical
suprascapular, and transverse cervical artery.

57. Indications
Facial and nasal sof tissue defects.
Circulation
Axial by the supratrochlear artery
Constituents
Fasciocutaneous: Skin and fascia overlying the
forehead.
Conditioning
* Delay and subsequent two-stage
reconstruction is possible.
* Tissue expansion can be performed for large
facial defects.