FLAPS

I. General
A. Definition and terms
1. A flap is a segment of tissue that contains a network of blood vessels that may be
transferred from a donor site to reconstruct a secondary defect.
2. The base of the flap contains the blood supply is called the pedicle
B. Flaps can be categorized according to several criteria
1. According to the blood supply
a. Ramdom pattern flaps : have no dominant blood supply
b. Axial flaps : have a dominant feeding vessel
c. Reverse flow flaps (also known as distal pedicle flaps or reverse axial
pattern flaps) : The proximal blood supply is divided, leaving the flap to survive
on the intact distally based vessels (e.g, reverse radial forearm flap, reverse
superficial sural artery flap)
2. According to the proximity to the defect
1. Local : the flap shares a side with the defect (e.g., rhomboid flap)
2. Regional : the flap is near, but not immediately adjacent to the defect (e.g,.
paramedian forehead flap)
3. Distant : the flap is not near the defect (e.g., groin flap)
4. Free flap : free tissue transfer
3. According to the method of transfer
a. Advancement
b. Transposition
c. Rotation
d. Interpolation
e. Jumping
f. Waltzing
g. Free
4. According to the tissue contained
a. Cutaneous
b. Fasciocutaneous
c. Musculocutaneous
d. Osteocutaneous
e. Osteomusculocutaneous
f. Omentum / bowel
C. Monitoring of flaps
1. Clinical evaluation is the best method of flap assessment
a. Temperature : should be body temperature
b. Color : should be pink, neither white nor blue / purple
c. Capillary refill : should be approximately 2 seconds
d. Point bleeding : upon introduction of a fine-gauge needle, bleeding should be
present. Blood should be red, not purple/blue
e. Firmness : should be soft, but with some appreciable turgor
2. Signs of insufficient arterial supply
a. Cool
b. Pallid (white)
c. Capillary refill slower than 2 seconds.
d. Slow or absent point bleeding.
e. Softer.

3. Signs of insufficient venous return (venous congestion)

a. Wanner than expected.
b. Blue to purple hue.
c. Capillary refill faster than 2 seconds (blood pooled in venous system returns
rapidly).
d. Brisk point bleeding, with dark blood.
e. Tense, swollen.
4. Factors leading to flap vascular compromise
a. Tight dressings
b. Tight sutures.
c. Pressure from positioning.
d. Hematoma, causing increased tissue pressure, impeding inflow/out flow.
e. Kinking of the flap or pedicle or both.
f.

Cool ambient room temperature.

g. Nicotine, caffeine, or other vasoconstricting agents

h. Microvascular technical issues (see Chapter 6).
5. Formal tests (rarely necessary),
a. Doppler studies.
b. Fluorescein dye.
c. Sensors for O.,, pH, temperature.
D. Crane principle
1. A pedicled flap is used to lift, transport, and deposit subcutaneous tissue from one
place to another.
2. After 10 to 21 days, angiogenesis is sufficient from the recipient bed to support the
deeper layer of the overlying flap. The top (superficial) one-half to three-fourths of
the flap is then raised and returned to the original donor site.
3. A viable subcutaneous layer is left behind, which may be covered by a split skin
graft.
4. This technique provides coverage to a local or regional area, without significant
donor site morbidity.
E. Angiosome concept
1. An angiosome is a composite unit of skin and underlying tissue supplied by a
source vessel.
2. The entire surface area of the body is composed of angiosornes.
3. An angiosome consists of an arteriosome and a venosome.

4. Ansiosomes connect either by true anastomoses or by choke vessels (reducedcaliber vessels.) that may dilate up to true anastomoses under certain
circumstances, such as flap delay (see "Delay phenomenon").
5. Explains how a flap could support more than one angiosome area under certain
conditions.
F. Delay phenomenon
1. A flap is partially eievated and reset in a separate procedure or procedures before
definitive fiap elevation and transfer.
2. This allows the harvest of a larger flap because of the survival of a random
cutaneous component distal to the boundaries defined by the original vasculature.
3. Benefits of delay are thought to be due to the following.
a. Changes in sympathetic ton.
b. Increased number of vessels in the flap (angiogenesis).
c. Dilation of previously present choke vessels.
d. Metabolic changes in the flap, increasing toleionce.
4. Time recommended between delay procedures varies, but usually 7 to 14 davs
between delavs is sufficient.

FREE
TISSUE
TRANSFER
S
DISTANT
TISSUE
TRANSFERS
LOCAL
TISSUE
TRANSFERS
SKIN GRAFT
DIRECT
TISSUE
CLOSURE
ALLOW WOUND TO
HEAL BY SECONDARY
INTENTION

Fig .4-1 The reconstructive ladder (from place M. herber S, and Hardesty R.Basic technique and principles in plastic surgery. In
Grabb and Smiths Plastic Surgery,5 th ed. Aston SJ, Beasley RW, Thorne CH (eds). Philadelphia, Lippincott-Raven, 1997. With
permission.

G. Reconstructive ladder (Fig. 4-1)

1. A systematic approach that facilitates decision making when reconstructing a
defect.
2. Progresses from simple to complex choices
a. Healing by secondary intention.
b. Direct closure.
c. Skin graft.
d. Local tissue transfer A flap raised immediately adjacent or near to the defect
(the flap and the defect share an edge).
e. Regional flap: A flap raised near the defect (the flap and the defect do not
share an edge).
f.

Distant tissue transfer. A flap raised some distance from the primary defect.

g. Free tissue transfer.

3. Reconstructive "elevator": Often the best solution to a reconstructive dilemma is
not the simplest, necessitating a jump up the "ladder."
H. Factors in flap decision making
1. Location of defect
2. Size of defect
3. Underlying or exposed structures
4. Potential donor sites
5. Donor site defects or disability
6. Viability of surrounding tissue
7. Shape and contour of the potential reconstruction
8. Surgeon's experience
9. Surgical goals
10. Patient's medical history
11. Patient s expectations v
12. Potential complications
13. Outcome evaluation
14. Cost of care
II.

Cutaneous flaps

A. Indications
1. Reconstruction of a local defect with similar, adjacent tissue.
2. Need for full-thickness tissue to cover relatively less vascular tissue such as
bone or tendon without periosteum/paratenon intact (skin graft is insufficient).
B. Blood supply to the skin
1. Direct cutaneous arteries
2. Fasciocutaneous arteries
3. Musculocucaneous arteries
C. Types of skin flaps
1. Random-pattern flaps
a. Designed on a random vascular supply.
b. Roughly dependent on a length-to-width ratio of about 2:1 in the lower
extremity and 4:1 in the head and neck. Hap ischemia is expected when
these guidelines are exceeded without flap delay.
2. Axial-pattern flaps
a. Designed along a named artery (angiosome)
b. Can be much longer and robust than random-pattern flaps.
3. Advancement flaps (Fig. 4-2)
a. Single-pedicled flap: The flap is raised as a square or rectangle, and is
undermined and advanced to fill the defect. Small triangles (Burow's
triangles) may be made at the base of the flap to facilitate advancement.
b. Bipedicled flap: An incision parallel to the defect allows the flap to be
undermined and advanced. Useful for longitudinal defects of extremities.
c. V-Y advancement flap: A flap is raised in a "V shape, and advanced to fill the
defect and closed as a Y. Useful on the face and for finger tip
reconstruction. A variation of this is the Y-V flap.
4. Rotation flaps (Fig. 4-3)
a. The basic rotation flap is raised in a semicircle. It is particularly useful for
scalp defects and sacral pressure sores.
b. Bilobed flap: Two flaps are raised 45 to 50 degrees apart, adjacent to the
defect. The first flap is rotated in to fill the primary defect The second flap fills
the donor site of the first. The donor site of the second flap is closed
primarily. Useful for defects on the nose, where superior skin laxity can be
stepwise transferred to the inferior (e.g., tip) region, where laxity is sparse.
This flap moves the ultimate donor site to a distant position, where primary
closure is possible.
5. Transposition flaps (Fig. 4-4)

a. Z-plasty: Interpolation of two adjacent triangular flaps, which has the effect of
moving lateral tissue in to increase tissue length longitudinally. It classically
consists of a central component with adjacent limbs oriented at 60 degrees.
All three lines are of equal length. Angles may be 30 degrees to 90 degrees.
Increasing the angle increases the percent gain in length (Table 4-1). Multiple
Z-plasties may be done in series. Clinical examples: Lengthen scar
contractures, change scar direction, release epicanthai folds or constricting
bands.
b. Limberg or rhomboid flap: Used to close a rhombic-shaped (equilateral
parallelogram) defect, with angles of 60 degrees and 120 degrees. To create
the flap, the short diagonal of the rhombus is extended a distance equal to its
length. Complete the flap by drawing a line parallel to the nearest limb of the
flap. Four flaps can be drawn around the various sides of the defect.
c. Dufourmentel: A variation of the Limberg flap. Used for rhomboid-like defects
that have angles other than classic 60 and 120 degrees. Draw a line from the
short diagonal of the rhomboid. Continue the line of one of the sides to
intersect the line already drawn. Bisect these lines to get the limb of the flap,
which should be equal in length to the side. Complete the flap by drawing a
line parallel to the long horizontal.
d. Interpolation : Also called an island flap. A skin paddle is elevated dis-tally on
a vascular pedicle proximally. The flap is then transposed into a nearby
defect either over or under a skin bridge.
III. Fasciocutaneous flaps
A. These are flaps that include the deep fascia, winch incorporates a rich vascular
network-the fascial plexus. Branches from this plexus reach the skin as direct or
indirect perforators.
1. The arc of rotation is determined by the distance from the pedicle base to the
maximal safe length of the elevated flap.
2. The pedicle of a fasciocutaneous flap may be lengthened by tracing the
perforators of the flap back to the source vessel
3. A cutaneous nerve may be incorporated into the flap, making it sensate.
4. Can be used as local, regional, or free tissue transfer flaps.
B. Classification of fasciocutaneous flaps (Table 4-2)
C. Workhorse pedicled fasciocutaneous flaps (Table 4-3)
Table 4-1. Theoretical gain in length for Z-Plasty with different angles

Angle of Z-Plasty (degree)

% Theoretical Gain in Length of

30

the central Limb

25

45

50

60

75

75

100

90

120

IV. Muscle and musculocutaneous flaps

A. Indications
1. Need for bulk.
2. Eradication of dead space and infection (e.g., sternal and lower extremity
reconstruction).
3. Restoration of function (e.g., gracilis transfer to the upper extrenmaty or face).
B. Advantages
1. Bulk to fill depth of defects.
2. Conform to fit an irregular wound.
3. Highly vascular.
4. May include bone in the transfer.
5. May be transferred with motor or sensory nerve.
C. Disadvantage: Sacrifice of a functional muscle
D. Classification of musculocutaneous flaps (Table 4-4 and Fig. 4-5)
E. Workhorse muscle and musculocutaneous flaps (Table 4-5)
V.

Flap modifications
A. Free flaps tsee Chapter 6, "Microsurgery")
B. Supercharging
1. The process of enhancing the blood supply of a pedicled flap by performing a
microvascular anastomosis to a secondary pedicle in the flap.
2. Example: A pedicled transverse rectus abdominis (TRAM) flap-addition of
anastomosis or anastomoses of the deep inferior epigastric vessels to vessels in
the axilla, neck, or chest.
C. Flap prefabrication
1. The transfer of a new vascular pedicle into an area of tissue that will later be
raised as a flap.
2. The flap, based on new vasculature. can be raised after approximately 6 weeks.
3. Rarely used because of the availability of numerous alternative options.

D. Prelamination
1. The introduction of additional tissue layers into the flap prior to transfer.
2. A twos tased procedure: Stage 1 modifies the donor flap with the introduction of
additional tissue. Stage 2 raises the flap.
3. Allows custom-made flaps for specialized areas such as the face. Clinical
example: Prelammate a forehead flap or forearm flap with cartilage and skin
graft for nasal reconstruction.
E. Vascularized bone flaps
1. The most commonly transferred bones
a. Radius: Based on the radial artery
b. Fibula: Based on the peroneal artery.
c. Scapula: Based on either circumflex scapular or thoracodorsal artery.
d. Iliac crest: Based on the deep circumflex iliac artery.
2. Toe (or partial toe/joint) transfer
a. Great toe : based on the first dorsal metatarsal artery
b. Second toe : also based on the first dorsal metatarsal artery
Table 4-2. Nahai Mathes classification system for fasciocutaneous flaps
Type
A

Vessel Description
Direct cutaneous perforator

Examples
Temporoparietal Fascial Flap

Septocutaneous perforator

Radial artery forearm flap

Musculocutaneous Perforator

TRAM flap

Table 4-3 Workhorse Pedicled Fasciocutaneous Flaps

Name
Groin Flap

Are of Rotation

Pattern of

Maximum Size

(standard Flap)
Abdominal wall,

Circulation

(cm)

Type A

25X10

Superficial circumflex iliac

Type A

8X12

Median superficial Sural

Type B

10X40

Radial

Type B

20X7

Circumflex scapular

perineum, hand,

Source Vessels

Sensory Nerve
Lateral cutaneous T12

forearm.
Reverse Superficial

Foot and Heel

Sural
Radial Forearm

Anterior posterior,
Forearm, elbow,

Insensate
Medial and Lateral ante
Brachial cutaneous

upper arm
Scapular/

Shoulder, axilla,

Parascapular

thoracic wall

Temporoparietal

Ear, ipsilateral face,

fascia flap

FOM

Lateral arm

Anterior, posterior
shoulder

Posterior interosseus

Elbow antecubital
fossa, proximal volar

(transverse and descending)

branches
Type A

12X9

Superficial temporal

Type B

15X8

Posterior radial collateral

Type B

18X8

Posterior interosseus

Type C

6X8

Supratrochlear, supraorbital

Cutaneous of intercostals 3,
4,and 5
Auriculotemporal
Posterior brachial
cutaneous
Medial, dorsal antebrachial
cutaneous

forearm
Paramedian forehead

Nose, midface,

flap

forehead

Supratrochlear supraorbital

F. Perforator flaps : the perforating vessel or vessels are dissected down to deeper
vessels, leaving the intervening tissue intact and not included in the flap. This allows
thinner flaps to be harvested and potentially reduces donor site morbidity. For
example, a deep inferior epigastric perforator (DIEP) flap versus a free TRAM flap,
leaving the rectus muscle intact.
G. Innervated flaps
1. Motor : possible functional free tissue transfers
a. Latissimus
b. Serratus
c. Pectoralis minor
d. Gracilis
2. Sensory flaps most commonly used
a. Lateral arm flap with posterior brachial cutaneous nerve
b. Radial forearm flap with medial and lateral antebrachial cutaneous nerves
c. Dorsalis pedis flap with deep peroneal nerve in the first web and superficial
peroneal nerve in the remainder
H. Delayed flaps (see delay phenomenon)
I.

Tissue expansion (see chapter 5 tissue expansion).