Flaps

BY :- Dr. P. Koushik GUIDE :- Dr (Brig.) B. B. Dogra

 A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply.

Flap contains a network of blood vessels, arterial, capillary and venous.

Classification of skin flaps based on blood supply

Random (no named blood vessel)

Axial (named blood vessel)

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 Skin flaps
Random pattern Three sides of a rectangle, bearing no specific relationship to where the blood supply enters; the length to breadth ratio is no more than 1.5:1.

Axial pattern Much longer flaps, based on

known blood vessels supplying the skin. Pedicled/islanded flaps The axial blood supply

of these flaps means that they can be swung round

on a stalk or even fully islanded so that the business end of the skin being transferred can have the pedicle buried

 Delayed flap
It is a type of random skin flap. The purpose of a delay is to restrict the flap to the blood vessels on which it will have to rely at the time of the transfer, without adding the strain of the actual transfer itself, in this way 'training' it to rely on these vessels.

Muscle
Fascia Bone

Skin

One type of tissue

Viseral (colon, small intestine, omentum)

Sensory/Innervated flaps (eg, dorsalis pedis flap with deep peroneal nerve)

Tissue to be transferred

Fasciocutaneous (eg, radial forearm flap)

Composite flaps
Osseocutaneous (eg, fibula flap) Tendocutaneous (eg, dorsalis pedis flap) Myocutaneous (eg, transverse rectus abdominis muscle [TRAM] flap)

 Muscle flaps Mathes and Nahai classification

One vascular pedicle (eg, tensor fascia lata) Dominant pedicle(s) and minor pedicle(s) (eg, gracilis) Two dominant pedicles (eg, gluteus maximus) Segmental vascular pedicles (eg, sartorius) One dominant pedicle and secondary segmental pedicles (eg, latissimus dorsi)

 Transposition flap The rectangular flap is rotated on a pivot point. The more the flap is rotated, the shorter the flap becomes.

 Rotation flap Movement is in the direction of an arc around a fixed point and primarily in one plane. This is a semi-circular flap.

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 Interpolated flap The donor site is separated from the recipient site, and the pedicle of the flap must pass above or beneath the tissue to reach the recipient area.

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 Advancement flaps are moved primarily in a straight line from the donor site to the recipient site. No rotational or lateral movement is applied. The use of a bi-lobed flap is indicated when the tissue adjacent to a cutaneous defect is insufficiently mobile to close the defect without causing tissue distortion.
Bilobed Flap

Single Pedicle Flap

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

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Distant flaps Pedicled flaps

Distant flaps can be moved on long pedicles that contain the blood
supply. The pedicle may be buried beneath the skin to create an island flap or left

above the skin and formed into a tube.

Moving flaps long distances while still attached are with a long muscular pedicle that contains a dominant blood supply (a myocutaneous flap) or with a long fascial layer that likewise contains a major septal blood supply (a fasciocutaneous flap)

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 Free flaps With fine instruments and materials it has become commonplace to be able to disconnect the blood supply of the flap from its donor site and reconnect it in a distant place using the operating microscope. The free tissue transfer is now the best means of reconstructing major composite loss of tissue in the face, jaws, lower limb and many other body sites, as long as resources allow it.

Free muscle transfers should be reanastomosed within 12 hours.

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To provide a wellvascularized soft tissue that is relatively resistant to infection. Helps wounds heal, and offers a vascularized surface for skin grafts.

Indications
Chronic skin ulcers such as pressure sores, trophic ulcers Reconstruction defect following of the large trauma resulting tissue defects. of the excision tumors, in large

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Principle I: Replace Like With Like

Principle V: Never Forget the Donor Area

Principles of flap surgery

Principle II: Think of Reconstruction in Terms of Units

Principle IV: Steal From Peter to Pay Paul

Principle III: Always Have a Pattern and a Back-up Plan

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Principle I: Replace Like With Like When a part of one's person is lost, it should be replaced in kind, bone for bone, muscle for muscle, hairless skin for hairless skin. If this cannot be accomplished, use the next most similar tissue substitute. For example, scalp to replace a beard, skin from the forehead to cover a nose wound. The best course of action when faced with a full-thickness defect is to use eyelid skin from lower eye lid.

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Principle II: Think of Reconstruction in Terms of Units Human beings may be divided into 7 main parts: the head, neck, body, and extremities. Each of these body parts can be further subdivided into units. The head, for example, is composed of several regional units: scalp, face, and ears. Consider that each of these units has its own unique features, and each feature has, in turn, multiple subunits with their own special shapes.

All of these different units and subunits must be considered and

reproduced during reconstruction.

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Principle III: Always Have a Pattern and a Back-up Plan The reconstructive ladder is a mental exercise that provides the surgeon with options ranging from the simplest to most complex. A sound plan must provide restoration of function and aesthetic form. Once a plan has been determined, rehearse it. Trace the defect or cut a

pattern to fit the defect. Transpose the pattern and experiment with it to
decide on the best donor area and orientation. The surgeon should ask him or herself "what do I do next if this fails?" Once in the operating room, keep an open mind and be ready to adjust the surgical plan as the situation dictates.

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Principle IV: Steal From Peter to Pay Paul

Steal from Peter to pay Paul, but only when Peter can afford it. Do not make the naive mistake of merely advancing tissue to the deficient area unless this can be accomplished completely without tension.

Tension compromises the blood supply of the advanced tissue and,

ultimately, results in flap failure.

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Principle V: Never Forget the Donor Area

Surgeons once believed in treating the primary defect without worrying

about the secondary defect. Surgeons now realize the importance of considering both defects equally.

The significance of providing coverage of a defect with minimal

deformity and disability is one of the foremost principles on which the reconstructive surgery specialty is based.

If reconstruction of the primary defect is too costly in terms of resultant

deformity or disability, re-evaluate and use another reconstructive option. Carelessness or overuse of a donor area eventually causes damage that

may be far greater than the original defect.

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Monitoring of the flap

Tissue colour
warmth and turgor

assess blanching
capillary refill time.
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Complications

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Causes of flap failure

poor anatomical knowledge when raising the flap (such that the blood supply is deficient from the start)
flap inset with too much tension

local sepsis or a septicaemic patient

the dressing applied too tightly around the pedicle;

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