FLAPS IN PLASTIC SURGERY

FLAPS IN PLASTIC SURGERYPRESENTER DR.SUMIT S. HADGAONKAR

Expeditious closure wounds one of the goals of plastic surgery

Closure follows a reconstructive ladder

LINEAR CLOSURE

SKIN GRAFTSKIN FLAPS

FREE FLAPS

MYOCUTANEOUS /FASCIOCUTANEOUS FLAPS

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 neededVary greatly in complexity from simple skin flap to microvascular free flap

History of FlapsOrigin in India -2500-1500 BC

Sushruta 800BC forehead flap

Charak Samhita

Al-Zahrawi 10th century scholar

Branca family of Italy Sir Harold Gillies work on facial injuries, modern plastic surgery

Flaps UsesReplace tissue loss due to trauma or surgical excisionProvide skin coverage through which surgery can be carried on latterProvide padding over bony prominencesBring in better blood supply to poorly vascularized bedImprove sensation to an area (sensate flap)Bring in specialized tissue for reconstruction suchas bone or functioning muscle

Classification of FlapsCan be based on (five C s)CongruityConfigurationComponentsCirculationConditioning

CongruityLocal 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.

Configuration By design and method of transferAdvancement

Rotation

Transposition

Interpolation

Pedicled

Components Skin flaps

Containing purely another component than skin e.g. muscle ,fascia ,bone ,bowel ,omentum etc.

Myocutaneous

Fasciocutaneous

Osteocutaneous

Circulation Random pattern flaps

Axial pattern flaps Island axial pattern flaps Free flaps

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

SKIN FLAPSUse : 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 prominencesDisadvantage : it cant 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

Muscle and Myocutaneous flapsMathes 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)

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

Uses of muscle and myocutaneous flaps :Functional muscle flap for motor reconstructionSensate Myocutaneous flap for sensate reconstructionCoverage of complex woundsChronic vascular insufficiencyChronic radiation woundsExposed or infected prosthesis

Local Flaps

Location of donor sitelocal flapPivotal (geometric) flapsrotationtransposition interpolationAdvancement flapssingle pediclebipedicleV-Y flapsbothdistant flappedicled free

Local flapsAdvantages 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

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

Transposition flapThe 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

Z plastyCreation of 2 triangular transposition flapsLength of both limbs must be sameAngle may varyUses : Lengthning of scarChanging direction of scar into more favorable oneInterrupt scar linearity

Rhombic flapsSpecially designed transposition flaps for rhombic shaped defectsDefect must have 60 and 120 angles

Bilobed flapsAnother variation of transposition flap2 transposition flaps sharing common pedicleFirst flap used to reconstruct defect ;second used for donor site defect

Interpolation flapsSimilar to transposition flapDifference is..pedicle rest over intervening tissuePedicle divided and inset at second stage after revascularizationE.g. median forehead flap, thenar flap

Advancement flapsMoved 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.

V-Y advancement flapCreate 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 amputationSkin 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

Combined local flapsIn 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

REGIONAL FLAPSAs 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

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)

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.

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

Free-tissue donor sites

Seroma formationHematoma formationSuperficial skin necrosis Wound separation with eventual partial and/or complete flap lossFat necrosisDonor site infectionComplications

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 tensionlocal sepsis or a septicaemic patientthe dressing applied too tightly around the pedicle;

Thank you