Flap types

1. Types of flaps
Presenter -dr.mrunalini
Moderator – dr.sarath sir

2. 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

3. • 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.

4. factors that should be considered when designing the flap.
1. Pivot point
2. Movement
3. length

5. Nomenlcature

7. • 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

8. 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.

9. 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.

10. Z pplasty for scra
contrcture in
finger

11. 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}.

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 (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.

15. 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.

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 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

21. 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

22. 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.

23. 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

24. 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.

25. 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.

26. 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

27. 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

28. 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

29. 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.

30. 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.

31. 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

32. 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.

33. 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.

34. 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.

35. 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

36. 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.

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 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

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-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)

41. – 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

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 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.

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 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).

46. 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.

47. 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.

48. Bone flaps

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
• 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.

51. 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

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
• 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.

55. 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.

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
 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

58. 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

59. 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.

60. 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.

61. 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.

62. translation flap
• Translation flaps
usually are
rectangular and are
used to close an
adjacent defect.

63. 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.

64. Distant flap
• Ex-groin flap, HYPOGASTRIC(superficial epigastric) FLAP
HYPOGASTRIC(superficial epigastric) FLAP

65. 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.

67. 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

68. Lower limb

70. •

71. 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”

72. • Various options are available for reconstruction of soft
tissue defects of the lower extremity

74. 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

75. 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

76. 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.

77. 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.

78. Flaps

79. Finger tip reconstruction

80. Thenar flap
Cross fnger flap
Flag flap

82. Thumb finger tip reconstruction

83. Moberg
flap

85. Reverse dorsal ulnr
perforator forearm.

86. Dorsal hand defect

87. Posteror
interosseous
artery flap
Distal ulnar artery
perfortor flap

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 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.

94. Foot and ankle

95. Thank you