1. 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 10th century scholar
 Branca family of Italy
 Sir Harold Gillies – work on facial injuries, modern
plastic surgery

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

12. Classification of Flaps
 Can be based on (five ‘C’ s)
1. Congruity
2. Configuration
3. Components
4. Circulation
5. Conditioning

13. 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.

14. Configuration
 By design and method of transfer
1. Advancement
2. Rotation
3. Transposition
4. Interpolation
5. Pedicled

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

16. Circulation
 Random pattern flaps
 Axial pattern flaps
1. Island axial pattern flaps
2. Free flaps

17. 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

20. 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

22. 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)

23. 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

24.  Uses of muscle and myocutaneous flaps :
1. Functional muscle flap for motor reconstruction
2. Sensate Myocutaneous flap for sensate
reconstruction
3. Coverage of complex wounds
4. Chronic vascular insufficiency
5. Chronic radiation wounds
6. Exposed or infected prosthesis

25. Local Flaps

27. 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

28. 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.

29. 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

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

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

34. 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

35. 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

36. 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.

38. 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

40. 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

41. 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

53. Distant flaps

54. 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)

55. 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.

56. 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

57. Free-tissue donor sites

58. Principles
of flap
surgery
Principle I:
Replace Like
With Like
Principle II:
Think of
Reconstructio
n in Terms of
Units
Principle III:
Always Have a
Pattern and a
Back-up Plan
Principle IV:
Steal From
Peter to Pay
Paul
Principle V:
Never Forget
the Donor
Area

59. Monitoring of the flap
Tissue colour
warmth and turgor
assess blanching
capillary refill time.

60. Complications

61. 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;

63. Thank you