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Types of flaps

1. The document discusses different types of flaps used in surgery, including their anatomy and uses. Random flaps rely on subdermal plexuses for blood supply and have limited dimensions based on an area's vascularity. Axial flaps are based on a direct artery and can be peninsular, island, or free flaps. Perforator flaps are based on named perforating arteries. 2. The reverse sural artery flap is highlighted, which uses perforators from the peroneal artery to cover defects of the lower leg/foot. It spares the sural nerve to prevent sensory deficits while maintaining blood supply, which comes from the lesser saphenous vein and deep adipose tissue rather

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Types of flaps Presenter -dr.mrunalini Moderator – dr.sarath sir
Skin Epidermis-superficial layer Dermis-deep layer-divided with the more superficial papillary dermis and the deeper reticular dermis Subcuatenous fat Glabrous skin -on palm ; soles. It is without hair; has much thicker layer than other skin of body- Hair-bearing skin is found throughout body. 4 layers of epidermis in skin, and the glabrous has additional fifth layer
• FLAP---Bailey and Love’s short practice of surgery describes a flap as a piece of tissue that is moved maintaining its blood supply and is not reliant on the recipient site for its vascularity. • Parts of flap — 1. base is the proximal segment of a flap 2. pivot is a locus around which the flap rotates and can very well be different from base. 3. Distal segment of a flap is the part commonly inserted into the defect 4. bridge segment of a flap is the central portion of the tissue that caries blood vessels.
factors that should be considered when designing the flap. 1. Pivot point 2. Movement 3. length
Nomenlcature
• circulation to flap is key component to understand and describe type of flap. • Given by McGregor and Morgan. • A) Random-pattern flap. blood supply for flap is not derived from recognized artery but, rather, comes from many little unnamed vessels. Many local cutaneous flaps fall into this category. • (B) Axial-pattern flap- blood supply for flap comes from a recognized artery. Most muscle flaps have axial blood supplies. • (C) Free flap. defined as vascular detachment of an isolated tissue, followed by transfer to another region of body with reattachment of divided artery and vein to separate artery and vein. • (D) Perforator flap-- vessels that supply blood to flap are isolated perforators derived from deep vascular system through underlying muscle or intermuscular septa
Random Flaps • Random flaps are "random" because they are not based on any specific vessel. should maintain a length-to-width ratio of 3:1. • No specific vascular supply but instead uses subdermal plexuss • Limited to length-to-width ratios. • Actual ratios do vary based on vascularity of area. • For example, lower limbs have a 1:1 ratio and faces can have 6:1. • Examples: rhombod flap,bilobed flap,z plasty.
Journal of Hand Surgery Soft Tissue Release and Bilobed Flap for Severe Radial Longitudinal Deficiency - Journal of Hand Surgery Soft Tissue Release and Bilobed Flap for Severe Radial Longitudinal Deficiency do not require skin grafting and allow for primary closure. The bilobed flap redistributes and redirects tension from the primary defect to the donor site. Bilobed flaps typically extend beyond the defect, which allows for adequate length and primary closure.
Z pplasty for scra contrcture in finger
Axial Flaps • have single direct cutaneous artery in longitudinal axis of flap. • blood supply in long axis of flap • Named according to pathway vessel takes. • These flaps can be direct or indirect - which is in reference to their perforators • Have arteriovenous pedicle (peninsular flap, island flap, free f!ap}.
• Peninsular flaps, in which the base of the flap remains in continuity • Island flaps, in which the flap is only in continuity through the arteriovenous pedicle • Free flaps, in which all continuity of the flap is interrupted and the vascularity is reestablished at the recipient site
Direct Axial Flaps: • based on named artery in subcutaneous tissue. • perforators pierce deep fascia without traversing any deeper structures. • example:Groin flap is based on superficial circumflex iliac vessels.
Groin Flap (McGregor and Jackson 1972) • is a fasciocutaneous type A flap • supplied by superficial circumflex iliac system that has a variable anatomy. • skin is innervated from T12 segment. • flap can be used either as a rotational flap for coverage of abdominal or perineal wounds or as a free flap based on its vascular pedicle or even for soft tissue coverage of hand as a parasite flap (like a cross leg flap, defect in hand is covered with harvested flap and kept in place for 3–4 weeks). • flap is then detached to provide skin coverage.
Technique • Mark the flap (Usually made 10–20% larger than defect) and incise skin down fascia, elevate flap distal to proximal superficial to tensor fascia lata (TFL) which is distal extent of flap . • flap is dissected from ASIS, inguinal ligament, external oblique fascia. • pedicle of flap lies in femoral canal & originates from femoral artery. ADVANTAGES OF FLAP ARE : • Versatile and readily available • Can be designed into large dimensions • Texture and quality of skin are excellent • Donor site can be primarily closed • Residual defect can be easily concealed • Now status relegated to “last resort” flap. Disadvantages • Variable arterial anatomy • Short pedicle • Unsuitable in obese patient.
Indirect Axial Flaps • based on perforators that pass through deeper tissues, usually in muscle or septum, before entering fascia. Example: • Fasciocutaneous: based on fascial vessels and classified by Cormack & Lamberty. • Musculocutaneous: based on perforators traveling through muscle and classified by Mathes and Nahai. • Venous: less commonly used and classified by Thatte and Thatte. • Neurocutaneous: based on perforating arteries accompanying cutaneous nerves.
Turbo- and Supercharging • Manipulations of vascular pedicle(s) have been termed “turbocharging” or “supercharging.” • When two independent pedicles of a “conjoined flap” are joined to each other before anastomosis to recipient vessels, it is termed “turbocharging.” • The two independent pedicles may be from two adjacent angiosomes or perforasomes. • “turbocharge” creates a “neo-vasculosome” and overcomes the interruption in the “vascular axis” inherent to a “conjoined flap.” • For example, a free transverse rectus abdominis musculocutaneous (TRAM) flap may be “turbocharged” by connecting the superficial epigastric vessels to the side of the deep inferior epigastric pedicle to create a “neo-vasculosome” (by bypassing the “break” in the “vascular axis”), thereby increasing the predictability of flap survival
• the resultant flap has been termed a “mosaic connected flap. • “Supercharging” of one of the pedicles of a bipedicled flap (arterial or venous), on the other hand, creates a separate pathway of arterial augmentation or venous drainage of the flap. • For example, a pedicled TRAM flap being used for breast reconstruction may be “supercharged” (and/ or “superdrained”) by anastomosing the deep inferior epigastric artery/vein to a recipient artery/vein in the axilla or thorax to increase predictability of flap survival. • When arterial supercharging is required, the flap is better termed a conjoined flap. Manipulation of the vascular pedicle by anastomoses should not be interpreted as means of producing “new” flaps but as means of supplementing flap circulation and thereby increasing predictability of flap survival
Perforator flaps • Reverse Sural Artery Flap • Flap is supplied by perforators from peroneal artery and can be a sensate flap if the sural nerve is included with flap harvest. • perforators are usually found about 5 to 6 cm above lateral malleolus and are supplied by retrograde flow, so a design with a wide pedicle and a generous arc of rotation are needed to preserve flow • lesser saphenous vein needs to be included in flap for venous outflow, • delay procedure may improve viability in high-risk patients • Maximal flap sizes can be 20 cm by 12 cm. • Use-good for heel coverage in highrisk patients. • high complication rate • lower aesthetic appeal
Uses -Soft-tissue defects of distal lower extremity and foot present significant challenges to the reconstructive surgeon. reverse superficial sural artery flap (RSSAF) is popular option for many of these difficult wounds. It is distally based fasciocutaneous or adipofascial flap that is increasingly being used for coverage of defects that involve the distal third of the leg, ankle, and foot.
Anatomical basis of flap Popliteal artery in popliteal region gives off dominant arterial branch each to medial and lateral heads of gastrocnemius. In addition to these muscular branches it also gives sural artery which divides into median, lateral and medial branches, first one being constant and last one being quite variable median sural artery generally accompanies sural nerve and short saphenous vein in proximal calf. Branches of median sural artery supply skin and subcutaneous area of posterior part of middle 1/3 of calf
This plexus of vascular network anastomoses with perforators of peroneal artery in distal 1/3 of calf. It is this reliable anastomoses of vascular network of 2 different sources that forms basis of distally based fasciocutaneous flap from middle 1/3 of calf. Peroneal perforators are quite constant in number and most distal one is given off well within 5 cm proximal to tip of lateral malleolus. Hence pivot of this distally based flap can be as distal as 5cm from tip of lateral malleolus.
study show that inclusion of sural nerve did not enhance perfusion of sural flap So sural flap was divided into two subgroups: with or without sural nerve lesser saphenous vein and deep adipose tissue are the only two necessary and critical components for the arterial supply of the sural flap. This is due to fact that arteries run along vein and all this vascular structure is located in deep adipose tissue. lesser saphenous vein and collateral parallel vein provide venous drainage.
deep fascia serves to strengthen flap and should be used in island skin flaps and adipofascial flaps but does not contribute to vascular supply. sural nerve contributes to vascular network,but sural nerve inclusion in flap does not increase vascular territory. sural nerve can be excluded from flap,preventing sensory deficit without decreasing flap survival One possible disadvantage of sparing sural nerve is that flap pivot point is dependent on level where sural nerve crosses deep fascia
prone position (patient can also be put in lateral position with the involved side up) the recipient raw area is measured. flap with a radius of 0.5cm more than that of recipient raw area is designed, marked on the posterior or postero lateral aspect of the calf on its middle 1/3, disposed either vertically or transversely as required by the pre-operative planning
A line was drawn from the popliteal fossa to lateral malleolus to approximate the vascular axis of flap. The distal limit of the flap should not extend into the proximal third of the posterior calf. The pivot of the flap is about 5cm proximal to the tip of the lateral malleolous. The pedicle of the flap between the pivot and the proximal margin of the flap is exposed with a zig zag incision of the skin where the skin flaps are elevated with a single layer of subdermal fat
actual fascio cutaneous flap is raised with deep fascia anchored to skin in order to prevent shearing between skin and deep fascia injuring precarious supra fascial plexus of vessels. At distal end of flap median sural artery, short saphenous vein and sural nerve are ligated and cut. Pedicle of appropriate length (till the pivot point) with a minimum of 2-2.5cms width is raised along with the deep fascia. At this stage of the dissection the tourniquet may be removed and viability of the flap may be assessed carefully. Sufficient time of more than 5 minutes may be allowed for this purpose with flap in unstretched position.
Once viability is confirmed flap may be transferred to recipient defect either by tunneling or by opening skin bridge, taking care that there is no undue tension over pedicle and flap. flap is sutured loosely to margin of defect without any tension with minimum sutures. Multiple drains are left behind under flap. donor defect generally needs split skin graft coverage. Pop slab given without compression bandage with provision to inspect flap at regular intervals. limb post operatively is elevated with care to prevent any compression over pedicle or grafted donor area. Marginal discoloration may be present particularly in elderly patients which usually settle as edema subsides.
Lateral and Medial Calcaneal Artery Flaps • These are fasciocutaneous flaps good for small defects of malleolar area or plantar heel region. • They are based on terminal branches of peroneal (lateral flap) & posterior tibial (medial flap) arteries • sural nerve can be included for sensation, and abductor hallucis muscle can be included with the medial flap
Keystone Flap • trapezoidal-shaped fasciocutaneous perforator flap, • made of two V-Y flaps on either end • It fits well into body contours and can reconstruct larger defects. • The borders of the defect are extended on either side to 90° angles, width of flap is similar to widest portion of flap. • deep fascia is cut to allow advancement & superficial nerves and veins are incorporated into flap design.
Propeller Flap • perforator-based local adipocutaneous flap. • designed off of a known source vessel or in a free-style fashion over a perforator found by Doppler. • They can be rotated up to 180° to fill the defect.
Instep Flap • plantar instep flap used as a fasciocutaneous island flap or as a free flap. • It comes from non-weight- bearing aspect of plantar foot but provides similar tissue quality as weight-bearing surface. • Mc based on medial plantar artery (although laterally basing is possible as well) • Can maintain sensation through medial plantar nerve. • Use-ideal for plantar heel reconstruction.
Dorsalis Pedis Flap based on dosral 2/3 of sknf from ankle to toes. Blood supply-dosrals pedis artery +first dorsal metatarsal artery – Accompanies deep peroneal nerve – Supplies a mean of 3.8 vertical branches • Venous drainage – Superficial dorsal venous arch medially into great saphenous vein and laterally into short saphenous vein Pedicle length -6-10 cm • Sensory supply—superficial peroneal nerve • Advantage:– Thin pliable skin– Large pedicle • Disadvantage:– Donor site morbidity Use –ankle ,foot,lower leg defects.,used as free flap. ◊ Simple spilt skin grafting (SSG) required and long-term care – Chronic aching foot—obvious disadvantage for footwear
commonly used flaps are listed below: Skin Flap: includes skin and superficial fascia. Fasciocutaneous Flap: skin and investing layer of deep fascia. Fascial Flap: deep fascia only. Muscle Flap: muscle only. Myocutaneous Flap: muscle and skin. Osteomyocutaneous Flap: includes muscle, bone, and skin. Bone Flaps: include vascularized bone. Visceral Flaps: organs can be transferred based on their pedicles or arcades. Innervated Flaps: functional or sensory flaps that incorporate a motor or sensory nerve.
Skin Flaps indications - • Suturing/skin grafting not possible • Flap over a bare bone may make difference between viability and sequestration of bone. principles or creating local flaps include: • Carefully map area on donor tissue with allowance of 25% excess to compensate for shrinkage of skin after transfer .
• Circular defects may be closed by creating tangential cuts in skin making double opposing semicircular flaps or making petal shaped flaps. • Should not be from a weight-bearing area, also it should not result into an unsightly conspicuous scar
Distant Skin Flaps • Cross-leg flap (Hamilton 1854): obtained from other leg (well-leg) can be of following types: – Calf-leg flap – Thigh-leg flap indicated in: ◊ Female patients wishing to avoid a visible secondary defect ◊ Large defects that cannot be closed by opposite calf skin rarely indicated. if no local donor sites, they lack appropriate inflow for a free flap, or are otherwise not a free flap candidate, cross- leg flap is an option. flap is fashioned on opposite leg and transferred with a length-towidth ratio of 3:1. It requires prolonged immobilization not practical unless there are no other options. Rarely, a free flap version of cross-leg flap can be performed when there are no appropriate vessels for anastomosis in injured leg.
-Principles of cross-leg flap. ◊ Cover defect in every direction ◊ Design in a way that the lymphatics are oriented in a direction same as of defect ◊ Delay is indicated if length-to-width ratio exceeds 1½ to 1 ◊ Should not undergo even slightest degree of traction. - Donor site ◊ Best-medial calf and anterior aspect of lower one-third of thigh ◊ Alternate sites: Anterior thigh, posteromedial calf, cross foot flap (Mir y Mir)
– Coverage of raw surface of donor site can be achieved by: ◊ Skin grafting the donor site ◊ Hinge technique - A hinge is created at the recipient site for proper coverage of the donor site. – Postoperative: As there is propensity for movement the two limbs are fixed by either applying plaster cast or by using an external fixator. One must give deep vein thrombosis (DVT) prophylaxis to these patients
• “Tube flap”: Usually removed from anterolateral aspect of abdomen and transferred via wrist or caterpillar technique – Indication: ◊ Mainly in a female who cannot tolerate position in cross-leg flap or in whom it is not possible due to amputated or disfigured limb – Shortcomings: ◊ Although unlimited in length, but its width is dependent on looseness of tissues to form a tube ◊ Flaps are usually bulky ◊ Excess of fat may constrict circulation ◊ Minimum of fat causes shrinkage – Disadvantage: ◊ Multiple procedures required.
• The jump flap: It is typically indicated for coverage of large defects. – Flap carried from abdominal wall to forearm as an intermediary host and then to fill the defect – Success depends upon maintenance of short broad pedicle throughout all stages of transfer – Sufficient mobility of leg, shoulder, body essential – Limitations: ◊ Limited to children and young adults ◊ Excess of atleast one-thirdof size of defect needed for shrinkage compensation.
MUSCLE FLAPS 1. Adv -highly vascularized, good for filling dead space, and improve local defenses to decrease infection. 2. use of muscle flaps has evolved so that muscle function is rarely sacrificed simply to supply skin blood supply but rather, muscle flaps are used when a large volume of flap is required to fill dead space or muscle function is required, as, for example, with facial reanimation. 3. It remains important that pattern of vascularity of muscles will determine muscle flap survival.
The typical advantages of a muscle or a muscle based flap include: • A rigid-walled, deep cavity can be obliterated • The vascularity of area is increased – On arterial side promotes healing – On venous side drainage is improved • Aids in controlling infection • Adherence of skin to underlining structures is prevented • An ideal recipient site for split-thickness skin graft (STSG) • Easy access to muscle locally • Closure of cavity stops leakage of protein rich exudate, leading to improvement of patient’s general condition MATHES NAHAI CLASSFICATION OF MUSCULAR FLAPS majority of musculocutaneous perforators arise near where the dominant pedicle enters the hilum of that muscle. Ex--tensor fascia lata and vastus lateralis muscles (supplied by branches from the lateral circumflex femoral artery); abductor digiti minimi muscle (supplied by branch from the ulnar artery).
MUSCLE FLAPS • Taylor Classification • Taylor et al.-- divided muscles into four groups (Types I–IV) that differ by their mode of motor innervation. • This classification becomes important when dynamic muscle transfer is considered, to ensure capture of an appropriately functioning muscle unit. classified muscles acc to increasing complexity of their innervation, concomitant diminished suitability for use as a dynamic muscle transfer. (A) Type I: single unbranched nerve entering muscle. (B) Type II: single nerve that branches just before entering muscle. (C) Type III: multiple branches from same nerve trunk. (D) Type IV: multiple branches from different nerve trunks.
OSSEOUS FLAPS • Serafin Classification Serafin has divided osseous flaps according to whether flap has a direct (endosteal) where the blood supply directly enters the bone, usually via a nutrient foramen (left), or periosteal, which circumscribes the bone within the periosteum to eventually reach the bone indirectly (periosteal) circulation . • Vascularized joint transfers could similarly be subclassified according to the source of vascularization of their bony constituents.
Bone flaps
Rotational Myocutaneous Flaps • As with rotational skin local flaps, muscle can also be incorporated into the cutaneous flaps. General Principles • Pedicled muscle flaps are workhorse for reconstruction • Proceed by classifying wounds as acute, subacute, and chronic and by dividing leg into proximal, middle, distal third • Raised flap should be slightly larger than the defect • Need adequate pedicle length • Choose donor site as per size of flap and its arc of rotation • Donor site should out of injury site • Prefer free-tissue transfer techniques for complex wounds. Goals • Close the defect with durable tissue • Aesthetically acceptable result • Minimal donor site morbidity • Functional result. Contraindications • Wounds resulting from high energy injuries • Treatment resulting in functional deficit • Concomitant radiation injur
Fasciocutaneous flaps • Cormack and Lamberty Classification • 4 major types , differentiated by origin of circulation to their “fascial plexus.” • Type A flap had multiple “fascial feeders” or perforators that did not require specific identification, reminiscent of random skin flap. • Type B flaps contained a large, solitary septocutaneous perforator. • Type C flap relied on multiple and usually diminutive segmental septocutaneous branches, so that elevation of these flaps almost always necessitated inclusion of source vessel with flap, in order to maintain their complete integrity. • Type D is similar to Type C in that it is based on multiple small perforators; however, it is raised as an osteomyofasciocutaneous flap.
Classfcaton Type A: Multiple perforators at base (Cross-leg flap, Medial thigh flap) Type B: Single vascular pedicle (medial arm flap, antecubital forearm flap, scapular flap) Type C: Segmental vascular pedicle (radial forearm flap) Type D: Single vascular pedicle (radial forearm flap with bone, fibular osseocutaneous flap). feasibility of flap is determined by extent of periosteal damage, location of defect and available soft tissue. Usually, tissue over anteromedial tibia is unsuitable so that mostly flap is based on lateral intermuscular septum or posterior tibial artery to base flap on fascial perforators. These commonly limit their usefulness in all cases so muscular flaps are preferred over them. Fasciocutaneous flap
Mathes and Nahai’s (1997) classification of fasciocutaneous flaps • based on type of deep fascial perforator • based on 3 major types of deep fascial perforators. Type A Type B Type C Directcutaneous flap, in which the vascular pedicle travels deep to fascia for a variable distance then pierces fascia to supply skin (e.g., groin flap,temporopar ietal fascia flap). septocutaneous flap, which has vascular pedicle that courses within intermuscular septum (e.g., lateral arm flap, radial forearm flap). musculocutaneo us flap and based on vascular pedicle that is traveling within muscle substance (e.g., DIEP flap).
Nakajima Classification • fasciocutaneous flaps into six forms (Types I–VI, or A–F), each based on a distinctly different perforator of deep fascia . • Type I “direct cutaneous flaps” were identical to axial flaps of McGregor and Morgan. • Type II “direct septocutaneous flaps” were identical to Cormack and Lamberty’s type B fasciocutaneous flaps, • type V “septocutaneous perforator flaps” would be same as latter’s Type C. • Type VI “musculocutaneous perforator flaps” resembled traditional myocutaneous flaps.
Location • Local flap-flap is adjacent to defect and is typically completed in a singlestage reconstruction (e.g., V-Y advancement flap or Z-plasty- rotation;transpostion,interpolation, Advancement flaps –single pedicle ,bipedicle ,v-y flaps Or both • Regional: flap is in the same region as the defect (but is still confined within the ipsilateral limb (e.g., thenar flap, cross-finger flap, radial forearm flap) • Distant: flap is far away from the defect. almost always requires two stages for harvest and inset (e.g., groin flap-type - pedicled or free flaps.
Flap Movement Classification • The method of movement is a common way for a flap to be described or classified. • It primarily relates to local flaps. • The way the flap is transferred into the defect can be classified as Advancement, Rotation, Transposition, and Interpolation.
Advancement Flaps  Unidirectional longitudinal/straight-line movement of tissue. It moves directly forward and rely on skin elasticity to stretch and fill a defect.  May need triangle excision at the base to make it work (Burrow’s Triangle) • Examples: V-Y Advancement, Rectangular Advancement
V-Y advancement flap: Advance skin on each side of a V- shaped incision to close the wound a Y- shaped closure. Eg: Cut finger tip. Y-V advancement flap: Used to release multiple band scars over joints
Rotation Flaps • Rotational movement of tissue around a pivot point. • It leaves a donor site defect, which can be closed with the flap. • To improve the degree of rotation, a back-cut can be made.
Transposition Flap • Lateral movement of tissue around a pivot point to an adjacent defect. • It leaves a donor site defect that requires another form of closure. • Examples: Bilobed Flap, Z-Plasty, Rhomboid Flap.
Z Plasty:kind of transposition flap It involves transposition of two inter-digitating triangular flaps. There is change in direction as well as gain in length of the common limb of Z. Most important factors are angle size and length of the limb. Used in contracture release like Dupuytren’s contracture and pilonidal sinus.
translation flap • Translation flaps usually are rectangular and are used to close an adjacent defect.
Interpolation • Rotate on a pivot point into a near (but not adjacent) donor site. • The flap travels under or over an intervening bridge of tissue. • Example: paramedian forehead flap.
Distant flap • Ex-groin flap, HYPOGASTRIC(superficial epigastric) FLAP HYPOGASTRIC(superficial epigastric) FLAP
Secondary Characteristics of Flaps • In an attempt to simplify flap description, Cormack and Lamberty have described the "6 C's of Flaps". • This provides a broad overview of the different types of flaps. the secondary characteristics provide further insight into flap classification.
Free flap • Fasciocutaneous Free Flaps Lateral arm free flap Parascapular free flap. • Osteocutaneous Free Flaps Iliac crest with overlying skin. • Osteofasciocutaneous Free Flaps 1. For coverage of large osseous and skin defect 2. Based on fibula with intact lateral septum as vascular supply and variable skin island
Lower limb
•
RECONSTRUCTION OF Proximal third Middle 1/3 Distal 1/3 • Muscle flaps – Gastrocnemius • Myocutaneous flaps – Gastrocnemius • Fasciocutaneous flaps-- These are based on perforators of deep arterial system & include: – Saphenous flap--Based on posteromedial perforators of saphenous artery; Can be used to close small defects of proximal third of tibia. – Sural flap. Muscle flaps: – Soleus flap – Extensor digitorum longus (EDL) – Tibialis anterior • Fasciocutaneous flaps – Lower leg septocutaneous perforator flaps – “Ponten flap”
• Various options are available for reconstruction of soft tissue defects of the lower extremity
SURAL FLAP • based on medial superficial sural artery branch of popliteal artery. Mark course of pedicle from midpoint of tendo-Achilles and lateral malleolus and midpoint of popliteal crease. donor site is located along this line. fasciocutaneous flap is raised as a circular or oval island 15% larger than recipient defect.pedicle -3cm long;diameter-1.4mm;located between popliteal foss ;mid posterior leg between medial & lteral heads of gastrocnemius pivot is located proximally 1.5 cm distal to popliteal crease . 5cm above lateral malleolus. Dissect and ligate superficial saphenous vein ;sural nerve that dips between two heads of gastrocnemius in midline. Has been also employed as a neurosensory flap. • arterial supply of this flap is variable and needs Doppler assessment preoperatively. • Disadvantage: Leaves posterior aspect of leg anesthetic in sural nerve distribution. Use-knee;upper leg defects
Fasciocutaneous Flaps for Middle Third Reconstruction • based on medial or posterolateral septocutaneous perforators of the lower leg. • greatest limitation is the precarious blood supply and the high likelihood of venous congestion in these flaps due to limited rotation arc and tense closure. • The flaps are used only by experienced persons in soft tissue reconstruction and those with familiarity of the local blood supply. Portable Doppler does come handy in pre-operative assessment of the flap harvest. • “Ponten flap”: Based upon medial septocutaneous perforators from posterior tibial artery – Can cover small defects • Random (reticular) pattern flaps: – Pure cutaneous flaps—length to width ratio = 1.5:1 – Fasciocutaneous flaps—length to width ratio = 3:1
Extensor Digitorum Longus Flap • Useful for closure of smaller wounds (< 5 cm) • Blood supply: – Anterior tibial artery that supplies around 9–14 perforators. • Disadvantages: – If too many perforators ligated flap may not survive – Close proximity to peroneal nerve—varus deformity if damaged – Permanent loss of toe extension if muscle used in entirety.
Tibialis Anterior Muscle Flap • Excellent flap to cover long narrow defects • Blood supply: – Anterior tibial artery supplies the muscle in a circumpennate distribution that allows the muscle to be split according to the need of surgeon for coverage of different locations of the soft tissue defects on leg. Use-middle two-thirds of the leg.; Defects of 10–15 cm in length and 2–4 cm in width can be reconstructed; Alternatively, partial division of muscle can be used to cover small defects up to 5 cm in diameter limitation is lack of coverage in width of defect due to small muscle mass.
Flaps
Finger tip reconstruction
Thenar flap Cross fnger flap Flag flap
Thumb finger tip reconstruction
Moberg flap
Reverse dorsal ulnr perforator forearm.
Dorsal hand defect
Posteror interosseous artery flap Distal ulnar artery perfortor flap
Palmar Hand Defect • aims to create high resistance and durability of the reconstructed tissue, achieve optimal sensory restoration, and provide supple soft tissue for adequate range of motion. – palmar skin defects should be reconstructed with glabrous skin. • locoregional glabrous skins are usually in zone of injury. • complicated microvascular free glabrous skin transfers from contralateral hand have been described, such as thenar flaps or instep free flaps from foot. – Free thenar flaps can be raised up to 2 cm in width and 10 cm in length. – Thenar flaps can be a sensate flap by including a small cutaneous nerve originating from palmar cutaneous branch of median nerve.
• Medial plantar flaps can provide glabrous skin up to 8 cm × 6 cm in dimension with minimal donor site morbidity. • These flaps can be harvested as a sensate flap by including medial plantar nerve with flap. • in larger defects, there is no supple glabrous skin flap that can provide adequate soft tissue for reconstruction, so nonglabrous skin flaps are used instead. • Posterior interosseous artery (PIA) flaps are considered as the work-horse flap for reconstruction of defects on the dorsum and volar area of the first webspace and the radial palm. • PIA flaps provide reliable and pliable soft tissue that facilitates thumb mobility • for easier tendon gliding, fasciocutaneous flaps are preferred. • using fascial flaps and skin grafts are not suitable in palmar area because scar contracture is likely to occur.
Foot and ankle
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Types of flaps

  • 1.
    Types of flaps Presenter-dr.mrunalini Moderator – dr.sarath sir
  • 2.
    Skin Epidermis-superficial layer Dermis-deep layer-dividedwith the more superficial papillary dermis and the deeper reticular dermis Subcuatenous fat Glabrous skin -on palm ; soles. It is without hair; has much thicker layer than other skin of body- Hair-bearing skin is found throughout body. 4 layers of epidermis in skin, and the glabrous has additional fifth layer
  • 3.
    • FLAP---Bailey andLove’s short practice of surgery describes a flap as a piece of tissue that is moved maintaining its blood supply and is not reliant on the recipient site for its vascularity. • Parts of flap — 1. base is the proximal segment of a flap 2. pivot is a locus around which the flap rotates and can very well be different from base. 3. Distal segment of a flap is the part commonly inserted into the defect 4. bridge segment of a flap is the central portion of the tissue that caries blood vessels.
  • 4.
    factors that shouldbe considered when designing the flap. 1. Pivot point 2. Movement 3. length
  • 5.
  • 7.
    • circulation toflap is key component to understand and describe type of flap. • Given by McGregor and Morgan. • A) Random-pattern flap. blood supply for flap is not derived from recognized artery but, rather, comes from many little unnamed vessels. Many local cutaneous flaps fall into this category. • (B) Axial-pattern flap- blood supply for flap comes from a recognized artery. Most muscle flaps have axial blood supplies. • (C) Free flap. defined as vascular detachment of an isolated tissue, followed by transfer to another region of body with reattachment of divided artery and vein to separate artery and vein. • (D) Perforator flap-- vessels that supply blood to flap are isolated perforators derived from deep vascular system through underlying muscle or intermuscular septa
  • 8.
    Random Flaps • Randomflaps are "random" because they are not based on any specific vessel. should maintain a length-to-width ratio of 3:1. • No specific vascular supply but instead uses subdermal plexuss • Limited to length-to-width ratios. • Actual ratios do vary based on vascularity of area. • For example, lower limbs have a 1:1 ratio and faces can have 6:1. • Examples: rhombod flap,bilobed flap,z plasty.
  • 9.
    Journal of HandSurgery Soft Tissue Release and Bilobed Flap for Severe Radial Longitudinal Deficiency - Journal of Hand Surgery Soft Tissue Release and Bilobed Flap for Severe Radial Longitudinal Deficiency do not require skin grafting and allow for primary closure. The bilobed flap redistributes and redirects tension from the primary defect to the donor site. Bilobed flaps typically extend beyond the defect, which allows for adequate length and primary closure.
  • 10.
    Z pplasty forscra contrcture in finger
  • 11.
    Axial Flaps • havesingle direct cutaneous artery in longitudinal axis of flap. • blood supply in long axis of flap • Named according to pathway vessel takes. • These flaps can be direct or indirect - which is in reference to their perforators • Have arteriovenous pedicle (peninsular flap, island flap, free f!ap}.
  • 12.
    • Peninsular flaps,in which the base of the flap remains in continuity • Island flaps, in which the flap is only in continuity through the arteriovenous pedicle • Free flaps, in which all continuity of the flap is interrupted and the vascularity is reestablished at the recipient site
  • 13.
    Direct Axial Flaps: •based on named artery in subcutaneous tissue. • perforators pierce deep fascia without traversing any deeper structures. • example:Groin flap is based on superficial circumflex iliac vessels.
  • 14.
    Groin Flap (McGregorand Jackson 1972) • is a fasciocutaneous type A flap • supplied by superficial circumflex iliac system that has a variable anatomy. • skin is innervated from T12 segment. • flap can be used either as a rotational flap for coverage of abdominal or perineal wounds or as a free flap based on its vascular pedicle or even for soft tissue coverage of hand as a parasite flap (like a cross leg flap, defect in hand is covered with harvested flap and kept in place for 3–4 weeks). • flap is then detached to provide skin coverage.
  • 15.
    Technique • Mark theflap (Usually made 10–20% larger than defect) and incise skin down fascia, elevate flap distal to proximal superficial to tensor fascia lata (TFL) which is distal extent of flap . • flap is dissected from ASIS, inguinal ligament, external oblique fascia. • pedicle of flap lies in femoral canal & originates from femoral artery. ADVANTAGES OF FLAP ARE : • Versatile and readily available • Can be designed into large dimensions • Texture and quality of skin are excellent • Donor site can be primarily closed • Residual defect can be easily concealed • Now status relegated to “last resort” flap. Disadvantages • Variable arterial anatomy • Short pedicle • Unsuitable in obese patient.
  • 16.
    Indirect Axial Flaps •based on perforators that pass through deeper tissues, usually in muscle or septum, before entering fascia. Example: • Fasciocutaneous: based on fascial vessels and classified by Cormack & Lamberty. • Musculocutaneous: based on perforators traveling through muscle and classified by Mathes and Nahai. • Venous: less commonly used and classified by Thatte and Thatte. • Neurocutaneous: based on perforating arteries accompanying cutaneous nerves.
  • 17.
    Turbo- and Supercharging •Manipulations of vascular pedicle(s) have been termed “turbocharging” or “supercharging.” • When two independent pedicles of a “conjoined flap” are joined to each other before anastomosis to recipient vessels, it is termed “turbocharging.” • The two independent pedicles may be from two adjacent angiosomes or perforasomes. • “turbocharge” creates a “neo-vasculosome” and overcomes the interruption in the “vascular axis” inherent to a “conjoined flap.” • For example, a free transverse rectus abdominis musculocutaneous (TRAM) flap may be “turbocharged” by connecting the superficial epigastric vessels to the side of the deep inferior epigastric pedicle to create a “neo-vasculosome” (by bypassing the “break” in the “vascular axis”), thereby increasing the predictability of flap survival
  • 18.
    • the resultantflap has been termed a “mosaic connected flap. • “Supercharging” of one of the pedicles of a bipedicled flap (arterial or venous), on the other hand, creates a separate pathway of arterial augmentation or venous drainage of the flap. • For example, a pedicled TRAM flap being used for breast reconstruction may be “supercharged” (and/ or “superdrained”) by anastomosing the deep inferior epigastric artery/vein to a recipient artery/vein in the axilla or thorax to increase predictability of flap survival. • When arterial supercharging is required, the flap is better termed a conjoined flap. Manipulation of the vascular pedicle by anastomoses should not be interpreted as means of producing “new” flaps but as means of supplementing flap circulation and thereby increasing predictability of flap survival
  • 21.
    Perforator flaps • ReverseSural Artery Flap • Flap is supplied by perforators from peroneal artery and can be a sensate flap if the sural nerve is included with flap harvest. • perforators are usually found about 5 to 6 cm above lateral malleolus and are supplied by retrograde flow, so a design with a wide pedicle and a generous arc of rotation are needed to preserve flow • lesser saphenous vein needs to be included in flap for venous outflow, • delay procedure may improve viability in high-risk patients • Maximal flap sizes can be 20 cm by 12 cm. • Use-good for heel coverage in highrisk patients. • high complication rate • lower aesthetic appeal
  • 22.
    Uses -Soft-tissue defectsof distal lower extremity and foot present significant challenges to the reconstructive surgeon. reverse superficial sural artery flap (RSSAF) is popular option for many of these difficult wounds. It is distally based fasciocutaneous or adipofascial flap that is increasingly being used for coverage of defects that involve the distal third of the leg, ankle, and foot.
  • 23.
    Anatomical basis offlap Popliteal artery in popliteal region gives off dominant arterial branch each to medial and lateral heads of gastrocnemius. In addition to these muscular branches it also gives sural artery which divides into median, lateral and medial branches, first one being constant and last one being quite variable median sural artery generally accompanies sural nerve and short saphenous vein in proximal calf. Branches of median sural artery supply skin and subcutaneous area of posterior part of middle 1/3 of calf
  • 24.
    This plexus ofvascular network anastomoses with perforators of peroneal artery in distal 1/3 of calf. It is this reliable anastomoses of vascular network of 2 different sources that forms basis of distally based fasciocutaneous flap from middle 1/3 of calf. Peroneal perforators are quite constant in number and most distal one is given off well within 5 cm proximal to tip of lateral malleolus. Hence pivot of this distally based flap can be as distal as 5cm from tip of lateral malleolus.
  • 25.
    study show thatinclusion of sural nerve did not enhance perfusion of sural flap So sural flap was divided into two subgroups: with or without sural nerve lesser saphenous vein and deep adipose tissue are the only two necessary and critical components for the arterial supply of the sural flap. This is due to fact that arteries run along vein and all this vascular structure is located in deep adipose tissue. lesser saphenous vein and collateral parallel vein provide venous drainage.
  • 26.
    deep fascia servesto strengthen flap and should be used in island skin flaps and adipofascial flaps but does not contribute to vascular supply. sural nerve contributes to vascular network,but sural nerve inclusion in flap does not increase vascular territory. sural nerve can be excluded from flap,preventing sensory deficit without decreasing flap survival One possible disadvantage of sparing sural nerve is that flap pivot point is dependent on level where sural nerve crosses deep fascia
  • 27.
    prone position (patientcan also be put in lateral position with the involved side up) the recipient raw area is measured. flap with a radius of 0.5cm more than that of recipient raw area is designed, marked on the posterior or postero lateral aspect of the calf on its middle 1/3, disposed either vertically or transversely as required by the pre-operative planning
  • 28.
    A line wasdrawn from the popliteal fossa to lateral malleolus to approximate the vascular axis of flap. The distal limit of the flap should not extend into the proximal third of the posterior calf. The pivot of the flap is about 5cm proximal to the tip of the lateral malleolous. The pedicle of the flap between the pivot and the proximal margin of the flap is exposed with a zig zag incision of the skin where the skin flaps are elevated with a single layer of subdermal fat
  • 29.
    actual fascio cutaneousflap is raised with deep fascia anchored to skin in order to prevent shearing between skin and deep fascia injuring precarious supra fascial plexus of vessels. At distal end of flap median sural artery, short saphenous vein and sural nerve are ligated and cut. Pedicle of appropriate length (till the pivot point) with a minimum of 2-2.5cms width is raised along with the deep fascia. At this stage of the dissection the tourniquet may be removed and viability of the flap may be assessed carefully. Sufficient time of more than 5 minutes may be allowed for this purpose with flap in unstretched position.
  • 30.
    Once viability isconfirmed flap may be transferred to recipient defect either by tunneling or by opening skin bridge, taking care that there is no undue tension over pedicle and flap. flap is sutured loosely to margin of defect without any tension with minimum sutures. Multiple drains are left behind under flap. donor defect generally needs split skin graft coverage. Pop slab given without compression bandage with provision to inspect flap at regular intervals. limb post operatively is elevated with care to prevent any compression over pedicle or grafted donor area. Marginal discoloration may be present particularly in elderly patients which usually settle as edema subsides.
  • 31.
    Lateral and MedialCalcaneal Artery Flaps • These are fasciocutaneous flaps good for small defects of malleolar area or plantar heel region. • They are based on terminal branches of peroneal (lateral flap) & posterior tibial (medial flap) arteries • sural nerve can be included for sensation, and abductor hallucis muscle can be included with the medial flap
  • 32.
    Keystone Flap • trapezoidal-shaped fasciocutaneousperforator flap, • made of two V-Y flaps on either end • It fits well into body contours and can reconstruct larger defects. • The borders of the defect are extended on either side to 90° angles, width of flap is similar to widest portion of flap. • deep fascia is cut to allow advancement & superficial nerves and veins are incorporated into flap design.
  • 33.
    Propeller Flap • perforator-basedlocal adipocutaneous flap. • designed off of a known source vessel or in a free-style fashion over a perforator found by Doppler. • They can be rotated up to 180° to fill the defect.
  • 34.
    Instep Flap • plantarinstep flap used as a fasciocutaneous island flap or as a free flap. • It comes from non-weight- bearing aspect of plantar foot but provides similar tissue quality as weight-bearing surface. • Mc based on medial plantar artery (although laterally basing is possible as well) • Can maintain sensation through medial plantar nerve. • Use-ideal for plantar heel reconstruction.
  • 35.
    Dorsalis Pedis Flap basedon dosral 2/3 of sknf from ankle to toes. Blood supply-dosrals pedis artery +first dorsal metatarsal artery – Accompanies deep peroneal nerve – Supplies a mean of 3.8 vertical branches • Venous drainage – Superficial dorsal venous arch medially into great saphenous vein and laterally into short saphenous vein Pedicle length -6-10 cm • Sensory supply—superficial peroneal nerve • Advantage:– Thin pliable skin– Large pedicle • Disadvantage:– Donor site morbidity Use –ankle ,foot,lower leg defects.,used as free flap. ◊ Simple spilt skin grafting (SSG) required and long-term care – Chronic aching foot—obvious disadvantage for footwear
  • 36.
    commonly used flapsare listed below: Skin Flap: includes skin and superficial fascia. Fasciocutaneous Flap: skin and investing layer of deep fascia. Fascial Flap: deep fascia only. Muscle Flap: muscle only. Myocutaneous Flap: muscle and skin. Osteomyocutaneous Flap: includes muscle, bone, and skin. Bone Flaps: include vascularized bone. Visceral Flaps: organs can be transferred based on their pedicles or arcades. Innervated Flaps: functional or sensory flaps that incorporate a motor or sensory nerve.
  • 37.
    Skin Flaps indications - •Suturing/skin grafting not possible • Flap over a bare bone may make difference between viability and sequestration of bone. principles or creating local flaps include: • Carefully map area on donor tissue with allowance of 25% excess to compensate for shrinkage of skin after transfer .
  • 38.
    • Circular defectsmay be closed by creating tangential cuts in skin making double opposing semicircular flaps or making petal shaped flaps. • Should not be from a weight-bearing area, also it should not result into an unsightly conspicuous scar
  • 39.
    Distant Skin Flaps •Cross-leg flap (Hamilton 1854): obtained from other leg (well-leg) can be of following types: – Calf-leg flap – Thigh-leg flap indicated in: ◊ Female patients wishing to avoid a visible secondary defect ◊ Large defects that cannot be closed by opposite calf skin rarely indicated. if no local donor sites, they lack appropriate inflow for a free flap, or are otherwise not a free flap candidate, cross- leg flap is an option. flap is fashioned on opposite leg and transferred with a length-towidth ratio of 3:1. It requires prolonged immobilization not practical unless there are no other options. Rarely, a free flap version of cross-leg flap can be performed when there are no appropriate vessels for anastomosis in injured leg.
  • 40.
    -Principles of cross-legflap. ◊ Cover defect in every direction ◊ Design in a way that the lymphatics are oriented in a direction same as of defect ◊ Delay is indicated if length-to-width ratio exceeds 1½ to 1 ◊ Should not undergo even slightest degree of traction. - Donor site ◊ Best-medial calf and anterior aspect of lower one-third of thigh ◊ Alternate sites: Anterior thigh, posteromedial calf, cross foot flap (Mir y Mir)
  • 41.
    – Coverage ofraw surface of donor site can be achieved by: ◊ Skin grafting the donor site ◊ Hinge technique - A hinge is created at the recipient site for proper coverage of the donor site. – Postoperative: As there is propensity for movement the two limbs are fixed by either applying plaster cast or by using an external fixator. One must give deep vein thrombosis (DVT) prophylaxis to these patients
  • 42.
    • “Tube flap”:Usually removed from anterolateral aspect of abdomen and transferred via wrist or caterpillar technique – Indication: ◊ Mainly in a female who cannot tolerate position in cross-leg flap or in whom it is not possible due to amputated or disfigured limb – Shortcomings: ◊ Although unlimited in length, but its width is dependent on looseness of tissues to form a tube ◊ Flaps are usually bulky ◊ Excess of fat may constrict circulation ◊ Minimum of fat causes shrinkage – Disadvantage: ◊ Multiple procedures required.
  • 43.
    • The jumpflap: It is typically indicated for coverage of large defects. – Flap carried from abdominal wall to forearm as an intermediary host and then to fill the defect – Success depends upon maintenance of short broad pedicle throughout all stages of transfer – Sufficient mobility of leg, shoulder, body essential – Limitations: ◊ Limited to children and young adults ◊ Excess of atleast one-thirdof size of defect needed for shrinkage compensation.
  • 44.
    MUSCLE FLAPS 1. Adv-highly vascularized, good for filling dead space, and improve local defenses to decrease infection. 2. use of muscle flaps has evolved so that muscle function is rarely sacrificed simply to supply skin blood supply but rather, muscle flaps are used when a large volume of flap is required to fill dead space or muscle function is required, as, for example, with facial reanimation. 3. It remains important that pattern of vascularity of muscles will determine muscle flap survival.
  • 45.
    The typical advantagesof a muscle or a muscle based flap include: • A rigid-walled, deep cavity can be obliterated • The vascularity of area is increased – On arterial side promotes healing – On venous side drainage is improved • Aids in controlling infection • Adherence of skin to underlining structures is prevented • An ideal recipient site for split-thickness skin graft (STSG) • Easy access to muscle locally • Closure of cavity stops leakage of protein rich exudate, leading to improvement of patient’s general condition MATHES NAHAI CLASSFICATION OF MUSCULAR FLAPS majority of musculocutaneous perforators arise near where the dominant pedicle enters the hilum of that muscle. Ex--tensor fascia lata and vastus lateralis muscles (supplied by branches from the lateral circumflex femoral artery); abductor digiti minimi muscle (supplied by branch from the ulnar artery).
  • 46.
    MUSCLE FLAPS • TaylorClassification • Taylor et al.-- divided muscles into four groups (Types I–IV) that differ by their mode of motor innervation. • This classification becomes important when dynamic muscle transfer is considered, to ensure capture of an appropriately functioning muscle unit. classified muscles acc to increasing complexity of their innervation, concomitant diminished suitability for use as a dynamic muscle transfer. (A) Type I: single unbranched nerve entering muscle. (B) Type II: single nerve that branches just before entering muscle. (C) Type III: multiple branches from same nerve trunk. (D) Type IV: multiple branches from different nerve trunks.
  • 47.
    OSSEOUS FLAPS • SerafinClassification Serafin has divided osseous flaps according to whether flap has a direct (endosteal) where the blood supply directly enters the bone, usually via a nutrient foramen (left), or periosteal, which circumscribes the bone within the periosteum to eventually reach the bone indirectly (periosteal) circulation . • Vascularized joint transfers could similarly be subclassified according to the source of vascularization of their bony constituents.
  • 48.
  • 49.
    Rotational Myocutaneous Flaps •As with rotational skin local flaps, muscle can also be incorporated into the cutaneous flaps. General Principles • Pedicled muscle flaps are workhorse for reconstruction • Proceed by classifying wounds as acute, subacute, and chronic and by dividing leg into proximal, middle, distal third • Raised flap should be slightly larger than the defect • Need adequate pedicle length • Choose donor site as per size of flap and its arc of rotation • Donor site should out of injury site • Prefer free-tissue transfer techniques for complex wounds. Goals • Close the defect with durable tissue • Aesthetically acceptable result • Minimal donor site morbidity • Functional result. Contraindications • Wounds resulting from high energy injuries • Treatment resulting in functional deficit • Concomitant radiation injur
  • 50.
    Fasciocutaneous flaps • Cormackand Lamberty Classification • 4 major types , differentiated by origin of circulation to their “fascial plexus.” • Type A flap had multiple “fascial feeders” or perforators that did not require specific identification, reminiscent of random skin flap. • Type B flaps contained a large, solitary septocutaneous perforator. • Type C flap relied on multiple and usually diminutive segmental septocutaneous branches, so that elevation of these flaps almost always necessitated inclusion of source vessel with flap, in order to maintain their complete integrity. • Type D is similar to Type C in that it is based on multiple small perforators; however, it is raised as an osteomyofasciocutaneous flap.
  • 51.
    Classfcaton Type A: Multipleperforators at base (Cross-leg flap, Medial thigh flap) Type B: Single vascular pedicle (medial arm flap, antecubital forearm flap, scapular flap) Type C: Segmental vascular pedicle (radial forearm flap) Type D: Single vascular pedicle (radial forearm flap with bone, fibular osseocutaneous flap). feasibility of flap is determined by extent of periosteal damage, location of defect and available soft tissue. Usually, tissue over anteromedial tibia is unsuitable so that mostly flap is based on lateral intermuscular septum or posterior tibial artery to base flap on fascial perforators. These commonly limit their usefulness in all cases so muscular flaps are preferred over them. Fasciocutaneous flap
  • 52.
    Mathes and Nahai’s(1997) classification of fasciocutaneous flaps • based on type of deep fascial perforator • based on 3 major types of deep fascial perforators. Type A Type B Type C Directcutaneous flap, in which the vascular pedicle travels deep to fascia for a variable distance then pierces fascia to supply skin (e.g., groin flap,temporopar ietal fascia flap). septocutaneous flap, which has vascular pedicle that courses within intermuscular septum (e.g., lateral arm flap, radial forearm flap). musculocutaneo us flap and based on vascular pedicle that is traveling within muscle substance (e.g., DIEP flap).
  • 53.
    Nakajima Classification • fasciocutaneousflaps into six forms (Types I–VI, or A–F), each based on a distinctly different perforator of deep fascia . • Type I “direct cutaneous flaps” were identical to axial flaps of McGregor and Morgan. • Type II “direct septocutaneous flaps” were identical to Cormack and Lamberty’s type B fasciocutaneous flaps, • type V “septocutaneous perforator flaps” would be same as latter’s Type C. • Type VI “musculocutaneous perforator flaps” resembled traditional myocutaneous flaps.
  • 55.
    Location • Local flap-flapis adjacent to defect and is typically completed in a singlestage reconstruction (e.g., V-Y advancement flap or Z-plasty- rotation;transpostion,interpolation, Advancement flaps –single pedicle ,bipedicle ,v-y flaps Or both • Regional: flap is in the same region as the defect (but is still confined within the ipsilateral limb (e.g., thenar flap, cross-finger flap, radial forearm flap) • Distant: flap is far away from the defect. almost always requires two stages for harvest and inset (e.g., groin flap-type - pedicled or free flaps.
  • 56.
    Flap Movement Classification •The method of movement is a common way for a flap to be described or classified. • It primarily relates to local flaps. • The way the flap is transferred into the defect can be classified as Advancement, Rotation, Transposition, and Interpolation.
  • 57.
    Advancement Flaps  Unidirectionallongitudinal/straight-line movement of tissue. It moves directly forward and rely on skin elasticity to stretch and fill a defect.  May need triangle excision at the base to make it work (Burrow’s Triangle) • Examples: V-Y Advancement, Rectangular Advancement
  • 58.
    V-Y advancement flap: Advanceskin on each side of a V- shaped incision to close the wound a Y- shaped closure. Eg: Cut finger tip. Y-V advancement flap: Used to release multiple band scars over joints
  • 59.
    Rotation Flaps • Rotationalmovement of tissue around a pivot point. • It leaves a donor site defect, which can be closed with the flap. • To improve the degree of rotation, a back-cut can be made.
  • 60.
    Transposition Flap • Lateralmovement of tissue around a pivot point to an adjacent defect. • It leaves a donor site defect that requires another form of closure. • Examples: Bilobed Flap, Z-Plasty, Rhomboid Flap.
  • 61.
    Z Plasty:kind oftransposition flap It involves transposition of two inter-digitating triangular flaps. There is change in direction as well as gain in length of the common limb of Z. Most important factors are angle size and length of the limb. Used in contracture release like Dupuytren’s contracture and pilonidal sinus.
  • 62.
    translation flap • Translationflaps usually are rectangular and are used to close an adjacent defect.
  • 63.
    Interpolation • Rotate ona pivot point into a near (but not adjacent) donor site. • The flap travels under or over an intervening bridge of tissue. • Example: paramedian forehead flap.
  • 64.
    Distant flap • Ex-groinflap, HYPOGASTRIC(superficial epigastric) FLAP HYPOGASTRIC(superficial epigastric) FLAP
  • 65.
    Secondary Characteristics ofFlaps • In an attempt to simplify flap description, Cormack and Lamberty have described the "6 C's of Flaps". • This provides a broad overview of the different types of flaps. the secondary characteristics provide further insight into flap classification.
  • 67.
    Free flap • FasciocutaneousFree Flaps Lateral arm free flap Parascapular free flap. • Osteocutaneous Free Flaps Iliac crest with overlying skin. • Osteofasciocutaneous Free Flaps 1. For coverage of large osseous and skin defect 2. Based on fibula with intact lateral septum as vascular supply and variable skin island
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  • 71.
    RECONSTRUCTION OF Proximal thirdMiddle 1/3 Distal 1/3 • Muscle flaps – Gastrocnemius • Myocutaneous flaps – Gastrocnemius • Fasciocutaneous flaps-- These are based on perforators of deep arterial system & include: – Saphenous flap--Based on posteromedial perforators of saphenous artery; Can be used to close small defects of proximal third of tibia. – Sural flap. Muscle flaps: – Soleus flap – Extensor digitorum longus (EDL) – Tibialis anterior • Fasciocutaneous flaps – Lower leg septocutaneous perforator flaps – “Ponten flap”
  • 72.
    • Various optionsare available for reconstruction of soft tissue defects of the lower extremity
  • 74.
    SURAL FLAP • basedon medial superficial sural artery branch of popliteal artery. Mark course of pedicle from midpoint of tendo-Achilles and lateral malleolus and midpoint of popliteal crease. donor site is located along this line. fasciocutaneous flap is raised as a circular or oval island 15% larger than recipient defect.pedicle -3cm long;diameter-1.4mm;located between popliteal foss ;mid posterior leg between medial & lteral heads of gastrocnemius pivot is located proximally 1.5 cm distal to popliteal crease . 5cm above lateral malleolus. Dissect and ligate superficial saphenous vein ;sural nerve that dips between two heads of gastrocnemius in midline. Has been also employed as a neurosensory flap. • arterial supply of this flap is variable and needs Doppler assessment preoperatively. • Disadvantage: Leaves posterior aspect of leg anesthetic in sural nerve distribution. Use-knee;upper leg defects
  • 75.
    Fasciocutaneous Flaps forMiddle Third Reconstruction • based on medial or posterolateral septocutaneous perforators of the lower leg. • greatest limitation is the precarious blood supply and the high likelihood of venous congestion in these flaps due to limited rotation arc and tense closure. • The flaps are used only by experienced persons in soft tissue reconstruction and those with familiarity of the local blood supply. Portable Doppler does come handy in pre-operative assessment of the flap harvest. • “Ponten flap”: Based upon medial septocutaneous perforators from posterior tibial artery – Can cover small defects • Random (reticular) pattern flaps: – Pure cutaneous flaps—length to width ratio = 1.5:1 – Fasciocutaneous flaps—length to width ratio = 3:1
  • 76.
    Extensor Digitorum LongusFlap • Useful for closure of smaller wounds (< 5 cm) • Blood supply: – Anterior tibial artery that supplies around 9–14 perforators. • Disadvantages: – If too many perforators ligated flap may not survive – Close proximity to peroneal nerve—varus deformity if damaged – Permanent loss of toe extension if muscle used in entirety.
  • 77.
    Tibialis Anterior MuscleFlap • Excellent flap to cover long narrow defects • Blood supply: – Anterior tibial artery supplies the muscle in a circumpennate distribution that allows the muscle to be split according to the need of surgeon for coverage of different locations of the soft tissue defects on leg. Use-middle two-thirds of the leg.; Defects of 10–15 cm in length and 2–4 cm in width can be reconstructed; Alternatively, partial division of muscle can be used to cover small defects up to 5 cm in diameter limitation is lack of coverage in width of defect due to small muscle mass.
  • 78.
  • 79.
  • 80.
  • 82.
    Thumb finger tipreconstruction
  • 83.
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  • 86.
  • 87.
  • 92.
    Palmar Hand Defect •aims to create high resistance and durability of the reconstructed tissue, achieve optimal sensory restoration, and provide supple soft tissue for adequate range of motion. – palmar skin defects should be reconstructed with glabrous skin. • locoregional glabrous skins are usually in zone of injury. • complicated microvascular free glabrous skin transfers from contralateral hand have been described, such as thenar flaps or instep free flaps from foot. – Free thenar flaps can be raised up to 2 cm in width and 10 cm in length. – Thenar flaps can be a sensate flap by including a small cutaneous nerve originating from palmar cutaneous branch of median nerve.
  • 93.
    • Medial plantarflaps can provide glabrous skin up to 8 cm × 6 cm in dimension with minimal donor site morbidity. • These flaps can be harvested as a sensate flap by including medial plantar nerve with flap. • in larger defects, there is no supple glabrous skin flap that can provide adequate soft tissue for reconstruction, so nonglabrous skin flaps are used instead. • Posterior interosseous artery (PIA) flaps are considered as the work-horse flap for reconstruction of defects on the dorsum and volar area of the first webspace and the radial palm. • PIA flaps provide reliable and pliable soft tissue that facilitates thumb mobility • for easier tendon gliding, fasciocutaneous flaps are preferred. • using fascial flaps and skin grafts are not suitable in palmar area because scar contracture is likely to occur.
  • 94.
  • 95.