Flaps in plastic surgery

1. FLAPS IN PLASTIC SURGERY PRESENTER – DR.SUMIT S. HADGAONKAR

2. Expeditious closure wounds – one of the goals of plastic surgery Closure follows a reconstructive ladder

3. LINEAR CLOSURE SKIN GRAFT SKIN FLAPS FREE FLAPS MYOCUTANEOUS /FASCIOCUTANEOUS FLAPS

4. Flaps – a partially or completely isolated segment of tissue perfused with its own blood supply. A vascularized block of tissue mobilized from its donor site and transferred to another location, adjacent or remote for reconstructive purposes. May consist of skin, subcutaneous tissue, fascia, muscle, bone or viscera (e.g.. Omentum) Reconstructive option of choice when padded and durable cover needed Vary greatly in complexity… from simple skin flap to microvascular free flap

5. History of Flaps Origin in India -2500-1500 BC Sushruta 800BC –forehead flap Charak Samhita Al- Zahrawi 10 th century scholar Branca family of Italy Sir Harold Gillies – work on facial injuries, modern plastic surgery

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

7. Classification of Flaps Can be based on (five ‘C’ s) Congruity Configuration Components Circulation Conditioning

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

9. Configuration By design and method of transfer Advancement Rotation Transposition Interpolation Pedicled

10. Components Skin flaps Containing purely another component than skin e.g. muscle ,fascia ,bone ,bowel ,omentum etc. Myocutaneous Fasciocutaneous Osteocutaneous

11. Circulation Random pattern flaps Axial pattern flaps Island axial pattern flaps Free flaps

12. Conditioning Increasing flap safety – by enhancing its axiality Used in older days Invoking delay phenomenon Classically done by cutting down on either sides of flap to be raised It opens up choke vessels Flap transferred 2-3 weeks later Particularly useful in higher risk patients e.g. Pedicled TRAM flap

13. SKIN FLAPS Use : 1.recipent bed with poor vascularity 2.coverage of vital structures ( to operate later ) 3.reconstructing full thickness structures e.g. eyelid ,cheek, nose, lip, ear etc. 4.padding bony prominences Disadvantage : it can’t sustain over contaminated (infected ) bed. Types : 1.those rotating around a pivot point a)rotation b) transposition c)interpolation 2.advancement flaps a)single pedicled advancement b) V-Y advancement c) bipedicled advancement

14. Muscle and Myocutaneous 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 )

15. According to mode of innervation (Taylor) Type I – single unbranched nerve enters muscle. Type II- Single nerve, branches prior to entering. Type III – Multiple branches from same nerve trunk. Type IV – Multiple branches from different nerve trunks. Affects suitability for functioning muscle transfer

16. Uses of muscle and myocutaneous flaps : Functional muscle flap for motor reconstruction Sensate Myocutaneous flap for sensate reconstruction Coverage of complex wounds Chronic vascular insufficiency Chronic radiation wounds Exposed or infected prosthesis

17. Local Flaps

18. Location of donor site local flap Pivotal (geometric) flaps rotation transposition interpolation Advancement flaps single pedicle bipedicle V-Y flaps both distant flap pedicled free

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

20. 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.

21. Transposition flap The rectangular flap is rotated on a pivot point. The more the flap is rotated, the shorter the flap becomes. Most commnly used in head and neck

22. Z plasty Creation of 2 triangular transposition flaps Length of both limbs must be same Angle may vary Uses : Lengthning of scar Changing direction of scar into more favorable one Interrupt scar linearity

23. Rhombic flaps Specially designed transposition flaps for rhombic shaped defects Defect must have 60 and 120 angles

24. Bilobed flaps Another variation of transposition flap 2 transposition flaps sharing common pedicle First flap used to reconstruct defect ;second used for donor site defect

25. Interpolation flaps Similar to transposition flap Difference is..pedicle rest over intervening tissue Pedicle divided and inset at second stage after revascularization E.g. median forehead flap, thenar flap

26. Advancement flaps Moved primarily in a straight line from the donor site to the recipient site. No rotational or lateral movement is applied. E.g. rectangular advancement, V-Y advancement etc.

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

28. Combined local flaps In some circumstances, such as burn contracture release, local flaps can usefully be combined to import surplus tissue from a wide area adjacent to a scar or defect that needs removal. Examples are the W-plasty and the multiple Y-to-V plasty, which is a very versatile means of releasing an isolated band scar contracture over a flexion crease

29. REGIONAL FLAPS As the distance of required flap transposition increases, the incorporation of a defined blood supply becomes critical. Classified as axial, however most flaps have random pattern at their distal ends Utilized to cover large defects which require bulk Examples : 1. PMMF 2. DPF 3. Trapezius flap

30. Distant flaps

31. 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 )

32. 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 1–2 hours.

33. Advantages Being able to select exactly the best tissue to move Only takes what is necessary Minimises donor site morbidity Disadvantages More complex surgical technique Failure involves total loss of all transferred tissue Usually takes more time unless the surgeon is experienced

34. Free-tissue donor sites

35. Seroma formation Hematoma formation Superficial skin necrosis Wound separation with eventual partial and/or complete flap loss Fat necrosis Donor site infection Complications

36. 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;

37. Thank you