Flaps and its classification

Flaps and different types, differentiations from graft
principle of flap surgery

1. FLAPS AND CLASSIFICATION Dr. Kiran Pandey MS- GS Resident, NAMS

2. Co n t e n ts Introduction History pathophysiology Graft vs flap Classifications of flaps Principles of flap surgery Post operative assessment of flap complications

3. I n t r oduction A flap is a vascularized block of tissue Mobilized from its donor site Transferred to another location, adjacent or remote, For reconstructive purposes.

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

5. Hi s t o r y Origin Indian Subcontinent : 600 BC Sushruta Samita described : Nasal reconstructio n using Cheek flap for reconstruction of nose. since amputation of the nose (an organ of "respect and reputation") was common as criminal punishment.

6. History cont.. F irst muscle flap of recorded history in 1906. Louis Ombredanne : B reast reconstruction following mastectomy.

7. History cont.. Sir Harold Delf Gillies: F ather of plastic surgery. Pioneer in facial injury repairs.

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

9. Physiologic factors affecting flap survival: B lood supply to the flap through its base. F ormation of new vascular channels between flap and recipient bed. P erfusion pressure of the supplying blood vessel.

10. P athophysiology Changes of a flap and the recipient site after elevation and transfer: After 10-24 hours – Decreased arterial supply; Congestion and edema; Dilation of arterioles and capillaries After 1-3 days – Increased number and quality of Anastomoses between flap and recipient bed; Increased number of small vessels in pedicle

11. After 3-7 days - Reorientation of vessels along the long axis of the flap; anastomoses created at 1-3 days now functionally significant After 1 week - Circulation well established between flap and recipient bed After 2 weeks - Continuous maturation of anastomoses After 3 weeks - Flap achieves 90% of its final circulation

12. Classification of flaps Classification of Flaps Can be based on: Congruity Circulation An a tomical Components

13. Based on congruity: A . L ocal flap: T issue is adjacent to the open wound in need of coverage. Eg . W ound on lip may be repaired by a flap on adjacent cheek

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

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

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

17. Classification: Based on circulation A. Axial pattern flap: C ontains atleast one direct cutaneous branch blood supply along its longitudinal axsis.

18. Classification: Based on circulation B.random pattern flap: M yocutaneous flap with a random pattern of arteries, as opposed to an axial pattern flap.

19. Classification: On the basis of anatomical content: Skin flap Muscle and myocutaneous flap Fascia and fascio cutaneous flap

20. Skin flap: Uses: 1. Recipent bed with poor vascularity 2. Coverage of vital structures 3. Reconstructing full thickness structures e.g. Eyelid ,cheek, nose, lip, ear etc. 4. Padding of bony prominences

21. Skin flaps:cont.. Types : Those rotating around a pivot point: A) Rotation flap B) Transposition flap C) Interpolation flap Advancement flaps A) single pedicled advancement flap B) V-Y advancement flap C) bipedicled advancement flap

22. Skin flaps : cont .. A.Rotation flaps : Are semicircular flaps of skin and subcutaneous tissue That revolve in an arc around a pivot point to shift tissue in a circle. Provide the ability to mobilize large areas of tissue with a wide vascular base for reconstruction

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

24. Skin flaps:cont.. C. I nterpolation flap: F rom a near by but not immediately adjacent donor site T ransposed either above or below the intervening skin to recipient defect.

25. Skin flaps:cont.. Advancement flap: Advancement flaps move directly forward and rely on skin elasticity to stretch and to fill a defect. No rotational or lateral movement is applied It is of 3 types: A . S ingle pedicle advancement flap. B. B ipedicle advancement flap. C . V - Y flap advancement flap.

26. Skin flaps:advancement flap cont.. Single pedicle advancement flap: R ectangular skin flap is moved forward by virtue of its elastic properties . Bipedicle flap: I nsicion is made parallel to the defect and the flap is undermined and advanced

27. Skin flaps:advancement flap cont.. V-Y advancement flap: A dvance skin on each side of a V-shaped incision to close the wound with a Y- shaped closure. V-Y pedicle plasty technique allows most patients to regain sensation and two-point discrimination in the fingertip

28. Skin flap: types cont.. Rhomboid flaps:( limberg flap.) R ely on the looseness of adjacent skin to transfer rhomboid-shaped flap into a defect that has been converted into a similar rhomboid shape

29. Skin flap: types cont.. Z-plasty: Z-plasty transposes two interdigitating triangular flaps without tension to use lateral skin to produce a gain in length along the direction of the common limb of the Z.

30. Skin flap: types cont.. Common indications of z plasty: L engthening of a contracted linear scar across a flexor crease. C hanging the direction of a cosmetically unfavorable scars.

31. Muscle and myocutaneous flap: Consideration of a muscle as a potential flap is possible because muscles have independent, intrinsic blood supply. Compared with skin flaps, muscle flaps are less stiff,and more malleable to conform to wounds with irregular three dimensional contours. Muscle flaps are classified according to their principal means of blood supply and the patterns of vascular anatomy and according to mode of innervation.

32. Common muscle flaps: Tensor Fascia Lata: Applications- Coverage of lower abdominal wall, perineum, ischium and sacrum Vascular Anatomy: Ascending branch lateral circumflex femoral (off Profunda femoris)

33. Common muscle flaps: Trapezius: Applications – Skull, head and neck, Oral cavity, posterior trunk and shoulder. Mandible facial reanimation B lood supply: Dominant : Transverse cervical artery. Minor : Branch of Occipital artery. Dorsal Scapular artery.

34. Common muscle flaps: Gluteus Maximus: Applications – Sacrum , Ischium, Trochanter, breast reconstruction Vascular Anatomy Dominant : Superior gluteal artery Inferior Gluteal artery Minor : First perforator of Profunda femoris , Intermuscular branches of lateral circumflex femoral artery.

35. Common muscle flaps: Pectoralis Major myocutaneous flap: Applications: Coverage , Reconstruction, Functional transfer, Free flap. Vascular Anatomy: Dominant : Pectoral branch of Thoracoacromial artery . Minor : Pectoral branch of lateral thoracic , Minor Segmental Internal mammary perforators.

36. Common muscle flaps: Transverse rectus abdominis muscle flap (TRAM flap): It is either superior pedicle based on the superior epigastric vessels or inferior pedicle based on the inferior epigastric. Superior pedicle based flap is used to cover postmastectomy area or chest wall defect. Inferior pedicle flap is used to cover the defects in groin and thigh.

37. Common muscle flaps: Serratus Anterior : Applications – head and neck, Thorax, axilla, posterior trunk, breast reconstruction and free tissue transfer. Vascular anatomy : Dominant Lateral thoracic Branches of Thoracodorsal artery .

38. Myocutaneous flap: M usculocutaneous flap A lso called a myocutaneous flap, M uscle flap designed with an attached skin paddle.

39. Fascia and Fasciocutaneous Flaps: Fasciocutaneous flaps are tissue flaps that include skin, subcutaneous tissue and the underlying fascia. If raised without skin referred to as fascial flaps. Fasciocutaneous flaps to provide coverage when a skin graft is insufficient for coverage . eg , in coverage over tendon or bones. Less bulky, fasciocutaneous flaps are indicated when thinner flaps are required Fasciocutaneous flaps are not as resistant to infection as muscle flaps. Monitoring flap failure occasionally can be difficult

40. Classification of fasciocutaneous

41. Principles of flap surgery Principle I: Replace Like With Like when a part of one's person is lost, it should be replaced in kind, bone for bone, muscle for muscle, hairless skin for hairless skin, an eye for an eye, a tooth for a tooth

42. Principles of flap surgery cont.. Principle II: Think of Reconstruction in Terms of Units Human beings may be divided into 7 main parts: the head, neck, body, and extremities. Each of these body parts can be further subdivided into units. The head, for example, is composed of several regional units: scalp, face, and ears. All of these different units and subunits must be considered and reproduced during reconstruction.

43. Principles of flap surgery cont.. Principle III: always have a pattern and a back-up plan The surgeon should ask him or herself "what do I do next if this fails?" Proceed to the operating room only after answering this question definitively Principle iv: never forget the donor area:

44. Postoperative flap monitoring: The gold standard of postoperative flap monitoring is clinical observation. 1. Flap color 2. Capillary refilling time 3. Surface temperature monitoring 4. Blanching assessment

45. Complications: 1 . Seroma formation 2. Hematoma formation 3. Flap necrosis 4. Fat necrosis 5. Donor site infection

46. 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.