flaps in surgical oncology ,one brief and easy

Overall brief on flaps in surgical oncology

1. Flaps in surgical oncology

2. FLAP A flap is a unit of tissue that maintains its own blood supply while being transferred from a donor to a recipient site.

3. Past few decades the understanding of blood supply of tissues specially skin has improved significantly and hence newer flaps have been designed. Axial pattern flaps are the flaps based on named vessels eg Radial Artery Forearm flap Random pattern flaps are supplied by unnamed vessels eg local advancement flap .

4. GOALS OF FLAP SURGERY: 1. For resurfacing of a defect 2. Reconstruction of the deformed or lost organ 3. Improving blood supply to the region 4. Reconstruction should be performed with aesthetic considerations.

5. Principles : 1. Use like to like tissue in reconstruction
2. Should be able to fill the cavity to the desired extent
3. Bring more blood supply for better healing of wound and bone
4. Should reconstruct the cavity wall in minimum two layers.
5. There should be anatomical reconstruction
6. Should be able to perform function for which it is intended to
7. Aesthetically it should be acceptable.
8. Minimal scarring and good colour match are intended.

6. CLASSIFICATION: A.Based on component tissues: The nomenclature of the flap will be based on the constituent tissues in the flap. Eg . Skin flap, fasciocutaneous flap, muscle flap, myocutaneous flap, osteomyocutaneous flap etc. B. Based on the region of its movement: Local, Regional, Distant,

7. C. Based on the blood supply: Random pattern, Axial pattern, Perforator based flap,
Free microvascular flap D. Based on the movement of the flap: Advancement, Rotation, Transposition,
Interpolation,

8. E. Based on the incision and movement of tissue: Z- plasty , V-Y, Y-V procedures.

9. Fasciocutaneous flaps Combrack and Lamberty created a classification for fasciocutaneous flaps based on their vascular patterns: Type A – Flaps supplied by multiple fasciocutaneous perforators, entering at the base of the flap and extending longitudinally throughout the length. Type B – Flaps with a single fasciocutaneous perforator of moderate size which is consistently present in the same location. Type C – Flaps based on multiple small perforators which run between muscles along a fascial septum. The flap includes the supplying deep artery. Type D – Osteomusculofasciocutaneous flap, which includes portions of adjacent muscle and bone.

10. Muscle and Musculocutaneus flaps

11. Head and neck oncology locoregional flaps

12. Local: Nasolabial flap-Angular artery,facial artery proper. FAMM-Facial artery Buccinator flap-Buccal artery of maxillary artery Forehead flap-Supra troclear ,&superficial temporal Submental:submental branch of facial artery Regional: PMMC- Thoraco acromial artery Deltopectoral flap- 2 nd 3 rd 4 th intercoastal arteries

13. Local flaps General Indications for Choosing Local Flaps Small to moderate defects (usually <3–4 cm)
Superficial or mucosal defects without major bulk requirement
When free flap not feasible
For elderly or poor surgical candidates where shorter surgery is preferred
Preservation of cosmesis and function with adjacent tissue match

14. FAMM: An intraoral, axial-pattern flap based on the facial artery and part of buccinator muscle + mucosa, used mainly for intraoral reconstruction.

Anatomy & Blood Supply
Artery: Facial artery (anterograde or retrograde flow).

Vein: Facial vein (venous drainage).

Flap composition: Buccinator muscle + oral mucosa.

Arc of rotation: Good mobility within oral cavity, can reach tongue, floor of mouth, alveolus, palate, retromolar trigone .

15. FAMM:

16. Nasolabial flap Random-pattern flap (sometimes axial when designed over facial/angular artery) raised from the nasolabial crease region of the face. Used for reconstruction of defects in the oral cavity, nose, and face. Arterial supply:Facial artery (dominant).
Angular artery (for superior extension).

Flap type: Can be random or axial.

Composition: Skin, subcutaneous tissue, sometimes part of muscle.

17. Design & Orientation Skin incision along the nasolabial fold (well-hidden scar).

Length: up to 6–7 cm; Width: 2–3 cm.

Based inferiorly ( antegrade flow) → reaches oral cavity, lower lip, floor of mouth.

Based superiorly (retrograde flow) → reaches nose, upper lip, intraoral palate.

Can be transposition (rotated over intact tissue) or interpolated ( pedicled , tunnelled into oral cavity).

18. Nasolabial flap

19. Buccinator Flap type: Axial-pattern.

Arterial supply:Buccal artery (branch of maxillary artery).
Contributions from facial artery branches.

Venous drainage: Pterygoid plexus / facial vein.

Nerve: Buccal branch of mandibular nerve (sensory, not motor).

Size: Typically 5–7 cm length × 2–3 cm width.

20. Buccinator flap

21. Forehead Flap A regional flap based on the supraorbital / supratrochlear vessels, harvested from the forehead skin.
It is one of the most reliable flaps for nasal and midface reconstruction. Design: Incision along forehead, usually paramedian (based over supratrochlear artery). Can reach entire nose and midface. Usually two-stage procedure: Flap inset.
Pedicle division (2–3 weeks later).

22. Forehead flap

23. Submental Flap: An axial-pattern flap harvested from the submental region, based on the submental artery (branch of facial artery). It provides thin, pliable, hairless skin (in females) for head and neck reconstruction. Design: Elliptical incision in submental crease, from one mandibular angle to the other.
Pedicle length ~6–8 cm (good arc of rotation).
Can be tunnelled intraorally or rotated externally to cheek/mandible.
Size: Up to ~8 × 12 cm.

24. Submental flap

25. Regional flaps PMMC FLAP

26. Pectoralis Major Myocutaneous (PMMC): A pedicled myocutaneous flap using the pectoralis major muscle + overlying skin, based on the thoracoacromial artery.
workhorse flap in head and neck reconstruction ,also called ariyan flap. Artery : Pectoral branch of thoracoacromial artery (main supply). Vein : Subclavian / cephalic system. Flap type : Axial-pattern pedicled flap. Composition : Pectoralis major muscle + overlying skin island. Arc of rotation: Reaches oral cavity, oropharynx, hypopharynx, cervical esophagus , skin of face/neck.

27. Design

Skin paddle: Elliptical island over lower chest wall, usually medial to nipple, width up to 8–10 cm, length 15–18 cm.

Muscle harvested with the skin paddle.

Flap tunneled over the clavicle into neck/oral cavity.

28. Deltopectoral (DP) Flap A pedicled fasciocutaneous flap harvested from the deltopectoral region of the chest, based on the perforators of the internal mammary artery.
It was once a workhorse flap for head & neck reconstruction before the PMMC and free flaps became common. Artery: Perforators from internal mammary artery (2 nd , 3 rd , 4 th intercostal spaces).
Type: Axial-pattern flap (based medially), random extension laterally.
Composition: Skin + subcutaneous tissue + fascia.
Reach: Oral cavity, pharynx, neck, face.

29. Design Skin paddle designed over anterior chest wall between sternum and deltopectoral groove.

Length: up to 25 cm; Width: 8–10 cm.

Raised as medially based flap → pivot over internal mammary perforators.

Can be tunneled or rotated into neck/oral cavity.

Lateral extension is random-pattern → less reliable (needs delay procedure if too long).

30. Deltopectoral flap:

31. Locoregional flaps in treating breast carcinoma

32. LD Flap TARM

33. Latissimus Dorsi (LD) Flap A large, versatile myocutaneous flap based on the thoracodorsal vessels, harvested from the back (latissimus dorsi muscle ± overlying skin).
Used widely for head & neck, chest wall, and breast reconstruction. Artery : Thoracodorsal artery (branch of subscapular artery from axillary artery). Vein : Thoracodorsal vein → axillary vein. Nerve : Thoracodorsal nerve (supplies muscle). Type : Axial-pattern flap. Components : Muscle only, or muscle + skin paddle, or muscle + rib ( osteomyocutaneous ).

34. Design Skin paddle: Over latissimus dorsi muscle, usually longitudinal/oblique.

Pedicle length: ~8–12 cm → allows microvascular anastomosis.

Can be used as: Pedicled flap (rotated to chest wall, axilla, shoulder, neck).

Free flap (for oral cavity, scalp, extremity, breast).

35. LD FLAP:

36. TRAM Flap (Transverse Rectus Abdominis Myocutaneous flap) An abdominal myocutaneous flap based on the rectus abdominis muscle and overlying skin/fat, supplied by the deep inferior epigastric artery (DIEA).
Most commonly used for breast reconstruction after mastectomy. Artery: Deep inferior epigastric artery (primary).

Type: Axial-pattern flap.

Composition: Skin, subcutaneous fat, rectus abdominis muscle, anterior rectus sheath.

Design: Transverse lower abdominal skin paddle

37. TARM:

38. Flaps in perineal malignancy defects

39. VRAM Gracilis Anterolateral thigh flap SGAP & IGAP

40. VRAM Flap (Vertical Rectus Abdominis Myocutaneous flap): A myocutaneous flap using the rectus abdominis muscle with a vertically oriented skin paddle, based on the deep inferior epigastric artery (DIEA).
It is commonly used for pelvic, perineal, and chest wall reconstruction. Artery: Deep inferior epigastric artery (main pedicle).

Vein: Deep inferior epigastric vein.

Flap type: Axial myocutaneous flap.

Components: Rectus abdominis muscle + vertically oriented ellipse of overlying skin.

Pedicle length: 8–12 cm, reliable caliber for microsurgery if needed.

41. Design :
Vertical skin paddle (para-umbilical to suprapubic).

Can be harvested as pedicled flap (through transpelvic route into perineum) or free flap.

Donor site closed primarily or with mesh reinforcement.

42. Gracilis Flap: A myocutaneous or muscle-only flap harvested from the gracilis muscle of the medial thigh, based on the ascending branch of the medial circumflex femoral artery.
It is a small, reliable flap used in head & neck, perineal, and extremity reconstruction. Artery: Ascending branch of the medial circumflex femoral artery (dominant pedicle).

Vein: Accompanying venae comitantes → profunda femoris vein.

Nerve (optional): Obturator nerve branch (for functional muscle transfer, e.g., facial reanimation).

Type: Axial flap.

Pedicle length: ~6–8 cm; vessel diameter ~1.5–2 mm.

Components: Muscle ± skin paddle ( gracilis myocutaneous flap).

43. Gracilis

44. Anterolateral Thigh (ALT) Flap : A versatile fasciocutaneous or myocutaneous free flap harvested from the anterolateral aspect of thigh, based on the descending branch of the lateral circumflex femoral artery (LCFA). Artery: Descending branch of lateral circumflex femoral artery. Type : Axial flap.
Septocutaneous (~20–30%) → through intermuscular septum. Musculocutaneous (~70–80%) → through vastus lateralis muscle. Pedicle length : ~8–16 cm, vessel diameter ~2–3 mm → excellent for microvascular anastomosis. Components : Skin, subcutaneous fat, fascia, vastus lateralis muscle (if needed).

45. Arc of Rotation / Reach: Ipsilateral groin & inguinal region
Perineum (commonly used after pelvic oncologic resections)
Ischial / sacral region
Lower abdominal wall
Trochanteric & hip region

46. ALT:

47. Gluteal Flap: A group of fasciocutaneous or musculocutaneous flaps harvested from the buttock region, based on branches of the superior and inferior gluteal vessels.
They can be used as regional or free flaps, most classically in breast, pelvic, perineal, and pressure sore reconstruction. 1.Superior Gluteal Artery Perforator (SGAP) flap
Pedicle: Superior gluteal artery (perforators).
2.Inferior Gluteal Artery Perforator (IGAP) flap
Pedicle: Inferior gluteal artery.

48. Others

49. Tensor Fascia Lata (TFL) Flap: A fasciocutaneous / myofasciocutaneous flap harvested from the lateral thigh, incorporating tensor fascia lata muscle and its overlying skin, based on the ascending branch of the lateral circumflex femoral artery (LCFA). Artery : Ascending branch of the LCFA.
V ein: Accompanying veins → LCFA → profunda femoris .
T ype : Axial flap. Pedicle length: ~6–8 cm. Components : Fascia lata (always included), muscle, skin. Orientation : Skin paddle designed along lateral thigh, centered over TFL muscle.

50. TFL flap

51. Miscellaneous: