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Local flaps can be classified based on their blood supply
Basic Principles Of Local Flap In Plastic Surgery
PRINCIPLES OF LOCAL
FLAPS IN PLASTIC SURGERY
PRESENTED BY : DR. DEEPAK KRISHNA
DR. SHAMENDRA ANAND SAHU
DEPARTMENT OF BURNS , PLASTIC AND MAXILLOFACIAL
VARDHAMAN MAHAVIR MEDICAL COLLEGE &
SAFDARJUNG HOSPITAL ,NEW DELHI
A flap is a unit of tissue that is transferred from
donor site to recipient site while maintaining its own blood
Term “Flap” :
Originated from the 16th century Dutch word
“FLAPPE” which means “anything that hung broad and
loose, fastened only by one side”.
Timeline of the development of flap surgery
Pedicle flaps in the face and forehead for
Nasal reconstruction by tubed pedicle flap from arm; described
“delay” of pedicle flap
Latissimus dorsi musculocutaneous flap for breast
reconstruction (post- mastectomy)
Tubed pedicle flap
Muscle flaps for osteomyelitis
Compound neck flap
Lower extremity musculocutaneous flap
McGregor and Jackson
McCraw et al
1981 Mathes and Nahai
Classification of muscle flaps based on vascular anatomy
described fasciocutaneous flap
BASED ON LOCATION OF DONOR SITE
LOCAL FLAP: Flap
transferred from an area
adjacent to the defect.
DISTANT FLAP : Flap
transferred from an
CLASSIFICATION OF FLAP
Local flaps can be
classified based on
their blood supply
• Based on the rich sub dermal vascular plexus of
• Most of the local flap are
• Maximum length : breadth
ratio of 1 : 1 in the lower
• length : breadth ratio of up
to 3 : 1 in the face.
• Derive their blood supply
from a direct cutaneous
artery or named blood
• Examples :Nasolabial flap
(angular artery) , Forehead
• The surviving length of an
axial pattern flap is entirely
related to the length of the
LOCAL FLAP BASED
ON THE METHOD OF
CLASSIFICATION OF LOCAL FLAPS ON THE BASIS OF
• Local flaps can also be categorized based on
• The composition of the defect to be
reconstructed should dictate the correct
composition of the flap used for reconstruction.
• It includes :
HISTORY : CUTANEOUS CIRCULATION
Carl Manchot (1889 )
Performed the first examination of the vascular supply of the
Defined about 40 cutaneous territories on the basis of
dissection of human integument.
His work “ Die Hautarterien des menschlichen Körpers “ [The
Cutaneous Arteries of the Human Body], was initially
published in German and later translated to English by
Published paper on the origin, course and distribution
of the cutaneous perforators in adult and neonatal
He performed arterial injections of gelatin and various
pigments. The soft tissues were fixed in alcohol and
subtracted in xylol and the resulting vascular
network was embedded in Canada Balsam.
French anatomist and surgeon charted more than 80
cutaneous territories encompassing the entire body .
Salmon dissected 15 human cadavers and took
radiographs of integument which enabled him to
demonstrate much smaller vessel than Manchot.
• The blood reaching the skin originates from deep
• DANIEL AND WILLIAMS(1973) defined that the deep
vessels supplying skin are fundamentally two type of
arteries i.e. either musculocutaneous or direct
• Originally described as Direct cutaneous arteries
, are now called as septocutaneous arteries.
• Both these type of vessels are present throughout
the body but there exists appreciable difference
between them which is tabulated as following :
Origin : Major vessel supplying muscle
Origin : segmental or muscular vessel
Travel perpendicularly through
underlying muscle bellies into the
overlying cutaneous circulation of the
Arise originally from either segmental
or musculocutaneous vessels, pass
directly within intermuscular fascial
septae to supply the overlying skin.
They are most prevalent in the supply
of skin covering the broad, flat
muscles of the torso.
This arrangement is most common
between the longer, thinner muscles of
latissimus dorsi flap, rectus abdominis Radial forearm flap, Dorsalis pedis flap
WELL DEVELOPED DEEP FASCIA
COVERING THE BROAD
MUSCLES WHICH IS ELASTIC
PERMITING EXPANSION OF
ABDOMINAL MUSCLES .
DEEP FASCIA IS MORE RIGID , NOT
ONLY COVERING THE MUSCLES
BUT ALSO FORMS
SEPTA BETWEEN MUSCLES
PROVIDING ANCHORAGE TO THE
At the above said three anatomic levels 6
recognizable vascular plexus exists as shown in
Fascial plexus : divided into
1) Subfascial plexus :
plexus lying on the under surface of the fascia .
relatively minor plexus .
incapable of sustaining a fascial flap .
2) Prefascial plexus : dominant distribution system .
• Network of vessels which divide subcutaneous fat
into deep (loose) and superficial (dense) layers.
• More developed in torso than in extremities.
• Supplied by both septocutaneous and
Sub dermal Plexus :
• Primary blood supply to the skin.
• Vessels have a continuous arterial muscular wall.
• Primarily distributor function.
• Located at junction between reticular dermis and
• Corresponds with “dermal bleeding” at the edge of
• Arterioles run upwards to the overlying dermal
plexus and others run downwards to supply adipose
tissue and various glands .
• Present at lower limits of dermal papillary ridge.
• The Vessel in the plexus are arterioles and wall
contains isolated muscular elements .
• Primarily thermoregulatory function.
Sub epidermal Plexus
• Located at dermoepidermal junction.
• Consists mostly of capillaries having no muscle in
• Therefore they serve to have primarily nutritive
Modifications and refinements in both technique and
design of flaps have been used for the optimal result
in reconstructive surgery. Important modifications
1. Flap delay.
2. Tissue expansion.
1. DELAY PHENOMENON
It can be defined as “ preliminary surgical
intervention wherein a portion of the vascular
supply to a flap is divided before definitive
elevation and transfer of the flap”.
Delay procedure has been used for several hundred years.
16th century : Tagliacozzi delayed his upper arm flaps by making
parallel incisions through the skin and subcutaneous tissue
overlying the biceps muscle.
It was not until the early 1900s that the concept was recognized.
1921 :Blair introduced the term “DELAYED TRANSFER “ .
1965 : Milton using the pig model, investigated the effectiveness of
four different methods of delaying a flap .
MECHANISM OF INCREASED BLOOD FLOW IN FLAP DELAY
1. Increased axiality of blood flow:
Removal of blood flow from periphery of a random flap
promotes development of axial flow.
2. Opening of choke vessels.
3. Tolerance to ischemia :
adaptive metabolic changes at a cellular level within the
4.Sympathectomy vasodilation theory :
leading to vasodilation.
Surgical flap delay is accomplished in two ways:
1.STANDARD DELAY :
(A) with an incision at the periphery of the cutaneous
(B) partial flap elevation.
2. STRATEGIC DELAY :
involves division of selected
pedicles to the flap to enhance perfusion
through the remaining pedicle or pedicles .
2. TISSUE EXPANSION
1957 : Neumann is credited with the first modern report of this
1976 : Radovan further described the use of this technique for
1. Reconstruction with tissue of a similar colour and texture to
that of the donor defect.
2. Reconstruction with sensate skin containing skin appendages.
3. Limited donor-site deformity.
Planning and design of local flap
• Facial defects most common
– Skin malignancies
– secondary healing
– skin graft
– local flaps
Peripheral vascular disease/Coronary artery disease
Collagen vascular disease
• Cause of defect
Planning in reverse
Rotate vs. advance vs. transpose
• First employed by Celsus
Rome, popularized by
French surgeons in the
first half of 19th century
• Was called as “sliding
• Moves directly forwards
into the defect without
any lateral movement
• Execution is facilitated by presence of excess
• More feasible in elderly or when skin elasticity
is more like in very young
• Usually rectangular, perpendicular to the lines
of minimal tension
• Uses – forehead , brow
Procedures devised to
•Excision of Burrow’s
•Counterincision at the
•Triangular design of the
•Curvilinear design of the
•Z-plasty at the base
V-Y Advancement Flap
•Advancement should be
directed over the shortest
diameter of the defect
•The size of the V base
should match the size of
the largest diameter of the
•The V must be long
enough to allow tensionfree suture of the Y
V-Y Advancement Flap
•Advancement flap involves movement in two planesvertical and horizontal
•Pivot point on vertical plane which actually acts as a
•Pivot plane is the base of the flap at which the flap is
attached to the body
V-Y Advancement Flap
• α angle is determined by
– Location of defect
– Elasticity of the surrounding tissues
– Recommended to range between 20°-40°
• For leg defects, small angle is recommended
as there is less elasticity
• Gluteal region- large angle is planned
W Plasty or Zigzag plasty
• Used to break
up a single
• For scars that
do not require
• It redistributes
the length of
• A useful technique to preserve
healthy tissue in scar revision
• lessen the chance of standing
cone (ie, dog-ear) deformity
• The M-plasty, by creating 2
separate 30° angles instead of
• Derives its name from the pivot point at the
• The arc of rotation is under maximum tension
• 2 types
– Transposition flaps
– Rotation flaps
• Usually rectangular or square flap
• Transferred in a direction at right angles to
that of the blood supply
• Additional length- Back Cut
• Donor site
– Skin graft
– Another flap
Transposition Flap- DESIGN
• Recipient defect is
– Right angle triangle
– Hypotenuse- near
border of the flap
– The right angle
assumes a position
opposite the flap
– In scalp defects, apex
should direct towards
the periphery of the
• Pivot point D- across the base of the flap, parallel and equal to
• From D, a line is drawn parallel to BC
• With point D as axis, an arc is drawn from A and it intersects the
line at E
• CB is extended to meet the arc at F
• CFED is the marked flap
• Flap transposed and donor area is grafted
• In lower extremity length : breadth should be 1:1
• Designed by a French
Dufourmental in 1962
• The defect is tailored in
the shape of a rhombus
(with all sides equal)
• The short diagonal (BD)
and one of the adjacent
side (CD) are extended
•Angle HDP is
•Line DE equals the
side of the rhombus
•EF is drawn parallel
to AC and equal to
side of the rhombus
equal, eight flaps
can be designed
Triple Rhombic flap
• Circular cutaneous defect
conceptualized as hexagon.
• Sides of hexagon are equal
to radius (r) of circle.
• First side of flap created
by direct extension equal in
length to radius at alternative
corners to prevent sharing
• of common sides.
• Second side of flap designed
parallel to adjacent side of
• Consists of two lobes of skin and subcutaneous
tissue based on a common pedicle
– Primary flap is smaller than the defect
– Secondary flap is more triangular in shape
• Optimal angle between the two flaps is 90°, can vary
between 45° and 180°; greater the angle, larger the
• Zitelli's modification (1989), the primary flap is
oriented 45° from the axis of the defect, and the
secondary flap is oriented 90° from the axis of the
defect; eliminate dog ears
• Convert the defect to a "tear drop" shape by the
excision of a triangle on the side of pedicle base
• Use a caliper as a protractor, with one tip placed at
the apex of the wound, to mark out two semicircles
• Outer semicircle defines the necessary length
of the two lobes
• Inner semicircle bisects the center of the
original wound and continues across the
donor skin, defines the limit of the common
pedicle of the two lobes
• Two lines are drawn from the apex of the wound
– First line is placed 45° from the axis of the wound
– Second line is placed 90° from the axis of the wound
– These two lines mark the central axes of the two lobes
of the flap
• Draw the flap with each lobe beginning and ending at
the inner semicircle and extending to the outer
semicircle at the point where it crosses its central axis
• Involves transposition of two interdigitating
– Gain in length along the direction of the common
limb of the Z
– Direction of the common limb is changed
– Prevention and treatment of contracted scars
– Scar revision
• In 1856, Denonvilliers first described the Z-plasty
technique as a surgical treatment for lower lid
• The first reference to this technique in American
literature was in 1913, by McCurdy, as treatment for
contracture at the oral commissure.
• Limberg, in 1929, provided a more detailed
• Numerical data showing optimal angles and length
relationships of Z-plasty limbs are credited to Davis
• Release of contracture
– The central limb is placed along the line of
contracture- contractural diagonal
– 60° angle taken on each side and limbs of Z drawn, all
equal in size
– Longer diagonal is the transverse diagonal
•The contractural diagonal is under tension and
springs up when flaps are raised
•Causes change in shape of the parallelogram
•Contractural diagonal lengthens
• Mechanism of lengthening by Z plasty
– Length of contractural diagonal less than transverse
diagonal before release
– Contractural diagonal lengthens at the expense of
– Thus need for transverse skin laxity for contracture
– Variables in construction of Z Plasty
• Angle size
• Limb length
• Angle size
– Length increases with in angle
• Angle size
– Increasing the angle beyond 60° will increase
lengthening but also cause increased amount of
– Tension produced in the surrounding tissues tend to
be so great that the flaps can not readily be brought
in to their transposed position
• Limb length
– With almost fixed angle, length provides the major
– Amount of tissue available determines the limb
– More is the amount of tissue, larger the length
and vice versa
Multiple Z Plasty
• Way of reducing the amount of transverse
shortening without significantly reducing the
amount of lengthening
• Also distributes the lateral tension over
various limbs of multiple Zs
• In place of one large Z plasty, a series of
multiple small Z-plasties are constructed
Planning of Z-plasty for contracture
• Narrow contractures with lax surrounding skin
eg. Bowstring contracture
• Draw an equilateral triangle on each side of
the contracture and select the more suitable
of the two sets of limbs
– Better blood supply; avoid a flap with scar at base
– Resultant scar falling into a cosmetically
• Flap of scarred skin should be designed a little
longer initially than its fellow of the normal
• Two angles can be of unequal sizes
also, lengthening will be equal to the average
of the two angles
Use in scar revision
• Straight line scar
– Break the continuity of a straight line scar, thus
rendering them more conspicuous
• Bridle scar- scar crossing a hollow
• Curving scar
• Scar is outlined and the final postoperative
common limb (which preferably lies in a line
of election) is drawn out
• The length of the intended common limb, which
determines the size of the Z-plasty, is measured out
on the line of the scar, proportioned approximately
evenly on each side of the selected line and drawn
out as the post-operative common limb
• From each end, a line of equal length is
marked out to meet the line drawn out
• Thus Z-plasty flaps are outlined
• This ensures that transposition of the flaps will
bring the common limb into the desired line
• Unacceptable scar- lies >30° off the RSTLS
– Z-plasty breaks the line of scar and changes its
• Trapdoor scars
• Significant subcutaneous scarring producing
contracture beneath the entire area of
• Z-plasty lengthens the marginal scar and
breaks up the subcutaneous scarring
Rotation –advancement Flap
• Semicircular flap which rotates around a pivot
• Located along tension lines
• Flap designed quite large than the defect to
ensure primary closure of the donor site
• skin graft or another flap are alternatives for
the donor site
• Tissue can move into an
adjacent defect in 2 directions.
• It can advance in a straight line
(ie, advancement flap), or the
tissue can rotate into the defect
(ie, rotation flap).
• The distinction between the two
is not always clear, and one type
of motion blends into the other .
• Furthermore, a single flap can
have both straight
(advancement) movement and
rotational (rotation) movement.
•Triangulation of the
•Apex towards flap
•Apex angle <30° to
avoid buckling of the
•PIVOT POINT D- on a
projection of line AC, atleast
•E is located midway between
•An arc is drawn from B to D
•CBD constitutes the flap
Local flap template
• ABC is the triangulated
• P is marked; AB=CP
and AB parallel to CP
• P as center and AP as
radius, arc is drawn
• Skin triangle ABD is
• CDE is the local flap
template for ABC
• Conventional rotation flapgeometrically pure rotation
design where the triangulated
defect is a sector of the
• Movement is diametrically
opposite of the defect
conflicting the fact that a skin
flap rotated about a pivot point
will become shorter in effective
length the further it is rotated
• Hence conventional rotation flap are successful only in
places where lax skin is present or a back cut is needed
• Flap template employs tissue just adjacent to the
triangulated defect thus ensures coverage of the defect
and closure of the donor site
RANDOM PATTERN FLAP
Presents clinically as : congested , cyanosed ,blanching
momentarily on pressure initially but with time
becomes less and less until there is no circulation.
This process is acute .
settled one way or the other in 1-2 day, clearly defining
area of necrosis.
AXIAL PATTERN FLAP
The sequence is different with clinical events not fully understood .
Necrosis takes several days to develop.
Generally compromised flap is only slight cyanosed with no other gross
The process is slow during which time the margin gets revascularised
from surrounding tissues, due to which the area of final necrosis
instead of being the entire distal flap , is an island in its centre.
increased width of base
would increase surviving
length but feeding vessels
have same perfusion
• Perfusion pressure
PREVENTION OF FLAP NECROSIS
Important steps to prevent necrosis :
1.Avoiding tension by prior establishing pivot point or using
planning in reverse if local flap is jumping over intact skin .
2. Planning the flap with a margin of reserve is an additional way
in which tension can be avoided.
3.Avoding kinking particularly at the base of the flap.
4.In random flap proper length: breadth ratio should be
PREVENTION OF FLAP NECROSIS
5.In axial flap , length does not extend recognized safe
6.Proper plane for flap elevation for raising flap.
7. No compression at pedicle
8.Using delay principal when it was considered inadequate .
9.Avoiding infection : prevention of hematoma and
avoidance of raw area .
PLANE FOR FLAP ELEVATION
Proper plane for flap elevation is of prime
importance for preventing necrosis :
Between deep fascia and underlying
Immediately superficial or deep to
investing layer of fascia .
At the level of fat just deep to dermis .
Between glea and pericranium.
Standard : superficial to pericranium.
For smaller flap :between skin and
frontalis muscle .
THINNING OF FLAP
Thinning of a flap is required for :
1. To match the thickness of defect.
2. To allow it to be set without tension.
The amount of thinning which flap tolerate safely varies
greatly , such as :
Smaller flap can be thinned
out considerably due to well
developed sub dermal plexus
Thinning not possible as flap is
raised at subgleal level
THINNING OF FLAP
Thinning is seldom done because :
1.Fasciocutaneous flap : investing layer of
fascia forming deep surface contains
blood vessel crucial for survival.
2.Skin flaps : subcutaneous layer of fat is
too thin to warrant thinning
Males : thinning is often not required in
chest & upper abdomen.
Female : Thinning is often required
What to Do if the Flap Becomes Swollen and Bluish
Within Hours after the Operation
• A swollen, bluish flap indicates a problem with
circulation into or out of the flap.
• Usually it is a venous (i.e., outflow) problem.
• Make sure that the patient is positioned properly
and that nothing is compressing or pulling on the
• Loosen surrounding dressings and tape.
• Sometimes it is helpful to remove a few stitches
to ensure that the flap is not under too much
• Be sure that no fluid has collected under the
• Any collection of fluid requires drainage.
• Ensure adequate pain control. Pain stimulates
the sympathetic nervous system, which
decreases blood flow through the pedicle.
What to Do If Part of the Flap Dies
If a part of the flap has become purplish
it indicates inadequate circulation
the tissue may eventually die.
If there is no evidence of infection, you may
simply leave the flap alone.
• With time, this tissue will demarcate and die and
then separate or you may have to cut off the
• While this process is occurring, the underlying
tissues will heal.