Flaps A flap is a partially or completely isolated segment of tissue wl its own blood supply.

By contrast, a graft does not carry its ow blood supply but is complete!}' dependent on early diffusion an late in-growth of vessels from the recipient bed. The first flag consisted of s in and subcutaneous fat, but the design of flaps been e!panded to include fascia, muscle, bone, nerve, omemun and other tissues. The nutrient artery and accompanying veins i usually referred to as the pedicle. "laps may be classified based i the type of tissue, such as musculocutaneous, osteocutnneous,# so on, but they may also be classified by the design and methodi transfer$advancement, rotation, transposition, and others. %n th random s in flap, the blood vessels have a random distributioi& whereas in an a!ial flap, they run subcutaneously along the %on a!is of the flap. 'o-called free flaps are moved from one part of % body to another, and its blood vessels are anastomosed to recipie vessels in the area of reconstruction, usually with the use of micro-( scopic techni)ue. "igure *+-, demonstrates the blood supply on which various flaps are based. -econstructive surgery with the use of flaps re)uires carefi assessment and planning. The condition of the recipient bed shon be optimi.ed. %t is imperative that every possible measure is underta en to minimi.e microbial contamination or neoplastic presence in the defect. %t is e)ually important to use the least complicated & techni)ue that will solve the problem. The principle of the reconstructive ladder /see Table *+-0} should always be adhered to# the( flap must have a significant margin of safety. Although there are many suggested pharmacologic measures to improve flap circulation, flap success or failure hinges on design, along with dissecting, anastomosing, and closing techni)ue. "igure *+-* shows an e!ample of a flap. There are some absolute indications for flaps in reconstructive1 surgery. %f, for instance, bone, radiated vessels, brain, an open &oint or nonbiological implant materials are e!posed, a flap is usi necessary to provide ade)uate closure. The same is true for closure of pressure sores where a bony prominence is e!posed. A' linear closure is not a good alternative because it will create a wound under tension immediately above a bony prominence with

2ermal-subdermal ple!us the ris of trauma from pressure to this area. A s in graft would probably not provide complete healing of a pressure sore, and if it does, it will certainly not provide the padded, durable cover that is desired for sustained s in integrity /"ig. *+-34. The discoveries of musculocutaneous flaps and free flaps in the 0+35s have greatly advanced the field of reconstructive surgery. %t is risible to design soft and hard tissue reconstruction for almost 6 defect with an acceptable functional and aesthetic result. There are many e!cellent reviews of various flaps# see, for e!ample, 7athes and 8ahai 90 and 'mith and :riba..9* Flaps

A flap is a tongue of tissue transferred from one anatomic site to another. ;ascularity of the transferred tissue is maintained by nutrient vessels within the flap pedicle. The pedicle may either remain attached at its origin or be divided during transfer and reanastomosed to recipient vessels using microsurgical techni)ues. 7icrosurgical transfer of tissue is also nown as a free flap. "laps are useful for closing defects too large for primary closure and where s in grafting is inade)uate. <!amples include e!posed structures such as brain, blood vessels, bone and &oint surfaces, and wounds with poor vascularity, where s in grafting would li ely fail. "ull-thic ness defects in the head and nec are often unacceptable in appearance and function when reconstructed with s in grafts. %n these instances flaps may provide better form and function. The reconstructive surgeon may transfer functional units of bone, muscle, and neural tissue for reconstruction of comple! defects. "laps, especially those containing muscle, have proved useful in clearing infection at the recipient site. 7uscle flaps have proved to be very immunologically active and are a mainstay in the treatment of problem infections such as osteomyelitis, sternal wound infections, and infected prosthetic materials. "laps are classified according to their blood supply. A random flap receives blood through the dermal and subdermal ple!us /"ig. =>-054. The subdermal ple!us receives its blood supply from vessels e!tending from underlying muscles to the s in. These vessels are sometimes referred to as musculocutaneous perforators. ' in flaps that receive their blood supply from cutaneous arteries and veins longitudinally oriented within the substance of the flap are nown as axial pattern flaps /"ig. =>-004. Afasciocutaneousflap contains s in and underlying fascia and is supplied by the vascular ple!us within the fascia. A musculocutaneous flap contains s in, fascia, and muscle and is supplied by perforating vessels from the muscle to the subdermal ple!us /"ig. =>-094. Arteriali.ed flaps have a richer vascular supply and allow for reliable transfer of a greater amount of tissue, ? Random "laps# -andom flaps receive their blood supply from the subdermal ple!us via musculocutaneous perforators at the base of the flap. These flaps,are usually categori.ed by their type of movement. Trie advancement flap is moved into a defect without lateral or rotational movement. To close a rectangular

defect, three sides of an ad&oining rectangle of tissue can be incised and undermined with a layer of subcutaneous fat. Tie rectangle of s in is then advanced into the defect. 'mall rectangles of tissue at the base of the flap, nown as Burow's triangles, may be e!cised to facilitate advancement. A triangle of tissue may also be advanced as a ;-@ advancement flap /"ig. =>-0>4,
Aith this techni)ue a rectangular defect is closed by incising an ad&acent triangle of tissue, which is advanced into the defect, closing the secondary defect as a linear incision behind the flap. Advancement flaps generally allow limited movement of tissue. This movement is facilitated in anatomic areas where a relative e!cess of s in e!ists or in the elderly patient with loose, mobile s in. A rotation flap is a semicircular flap rotating about a pivot point to close a triangular defect /"ig. =>-0=4. The secondary defect may then be closed primarily or s in grafted. A small bac cut into the base of the flap can facilitate movement of a rotation flap. A transposition flap is typically a rectangular flap that rotates about its base to fill an ad&acent defect /"ig. =>-0,4. This allows closure of the defect without undue tension. Bere again, a small bac cut into the base of the flap may facilitate movement. Any bac cut into the base carries some ris of compromising the vascular supply of the flap. The Z-plasty is a particularly useful type of transposition flap /"ig. =>-0*4. The C-plasty consists of two triangular flaps, each of which is rotated into the defect left by the other flap. This is fre)uently used to transfer tissue into a scar or contracture and lengthen it or to reposition a scar within lines of minimal tension. The sides of the two triangles must be e)ual in length, and the angles may vary between >5 and +5 degrees. "or any given

angle, longer triangles will transfer more tissue and provide greater lengthening. Darger angles will also transfer more tissue# however, clinical e!perience has shown that *5 degrees provides optimal lengthening. The rhomboid flap, or Dimberg flap, is another common transposition flap design /"ig. =>-034. To close a rhomboid-shaped defect with internal angles of *5 and 095 degrees, a rhomboid-shaped flap of identical dimensions is designed on the side of the defect &udged to have the most available tissue. A bilobed flap is a series of two transposition flaps /"ig. =>-0E4. A properly designed bilobed flap is rotated into the defect as a primary flap, and a secondary flap, whose diameter is half that of the primary flap, is rotated into the defect left by the primary flap. The defect left by the secondary flap is closed primarily. "or a bilobed flap to be successful the secondary flap should come from an area of relative s in la!ity. An interpolation flap is similar to a transposition flap in that a tongue of s in and subcutaneous tissue is rotated about an a!is. An interpolation flap, however, is transposed across an intervening bridge of tissue. The deltopectoral flap, discussed below, is an e!ample of an interpolation flap. Axial Flaps. A!ial pattern flaps contain cutaneous vessels running in the longitudinal a!is of the flap. They are better vas-culari.ed and more reliable than random flaps. The possible length of an a!ial pattern flap is determined by the length of thecutaneous artery and an additional distal area of s in that is randomly supplied by the subdermal ple!us. The midline forehead flap is based on supratrochlear vessels and is commonly used for nasal' reconstruction. The deltopectoral flap receives blood supply from perforating branches of the internal mammary artery through the second, third, and fourth intercostal spaces /"ig. =#F0+4. Bistorically, this flap has been a mainstay in the reconstruction of head and nec defects. The groin flap is based on the superficial circumfle! iliac artery and has been used to resurface wounds of the hand and upper e!tremity /"ig. =>-954. An a!ial pattern flap can be designed around the radial artery to involve s in and subcutaneous tissues of s in and bone. The radial forearm flap can then be transferred to defects of the uppere!tremity or transferred with microsurgical techni)ues to distant sites. The entire greater omentum may
be ta en as an a!ial flap based on either the right or left gastroepiploic arteries. The omentum is then available for closing defects of the chest wall and mediastinum /"ig. =>-904. Because of its large surface area, the omentum is particularly useful for e!tensive wounds such as radiation in&uries and sternal wound infections. The omentum readily accepts split-thic ness grafts to complete closure. Fasciocutaneous Flaps. A fasciocutaneous flap consists of s in, subcutaneous tissues, and underlying fascia. Blood supply is derived at the base of the flap from musculocutaneous perforators or direct branches of ma&or arteries. Because this flap includes the vascular ple!us immediately superficial to the fascia, it is more reliable than random flaps. "asciocu'aneous flaps are fre)uently used in the lower e!tremity. A fasciocutaneous flap can be designed to include perforators from the medial head of the gastrocnemius muscle to close difficult wounds of the middle and pro!imal thirds of the lower leg. The posterior thigh fasciocutaneous flap is fre)uently used for closure of ischial pressure sores. This flap includes fascia lata. subcutaneous s in, and tissue of the posterior

thigh and includes the descending branch of the inferior gluteal artery. This vessel runs parallel to the posterior cutaneous nerve of the thigh and accounts for the reliability of this flap. Muscle and Musculocutaneous Flaps. 7uscles can be transferred into ad&acent defects if their native vascular supply is preserved. The utility of any given muscle flap is limited by the si.e of the muscle and the length of its vascular pedicle and hence the distance it can be transferred. The defect, both functional and cosmetic, created by the muscle transfer must also be considered. 7uscle flaps transfer richly vasculari.ed and very immunologically active tissue into wounds that are ischemic or infected. The bul of muscle flaps allows contour defects to be resurfaced. ' in can be transferred with the underlying muscle. ;essels e!tending directly from the muscle to the overlying s in, nown as musculocutaneous perforators, account for a significant portion of cutaneous circulation. These perforating vessels define independent vascular territories within the s in that can be transferred as units with muscle. This principle has been rediscovered several times in the past century. 7anchot, in 0EE+, noted that the s in received much of its blood supply from the underlying muscle. Tan.ini, in 0+5*, described the latissimus dorsi myo-cutaneous unit for breast reconstruction. The concept was again lost until 7cGraw and colleagues described a number of musculocutaneous flaps and their vascular territories in 0+3=.

Delay
:artial disruption of the vascular supply to a flap in a preliminary procedure is nown as a delay procedure. The purpose of a delay procedure is to increase the length of the random portion of the flap that will survive after transfer. %n a delay procedure s in incisions defining the flap partially disrupt the subdermal ple!us but maintain the primary pedicle. The flap is then replaced in its bed. Hne wee later the flap is lifted out of its native bed and transferred to the recipient site. Glinical e!perience suggests that delay procedures can increase the amount of tissue a given pedicle can carry. The mechanism of the delay phenomenon remains incompletely understood. There are two general schools of thought. Hne theory suggests that delay acclimati.es the flap to ischemia, permitting it to survive with less blood flow than would normally be re)uired. Another theory suggests that delay improves vascularity by increasing flow through pree!isting vessels, recogni.ing the pattern of blood flow to more ischemic areas. %n reality, probably both mechanisms contribute to the delay phenomenone

Principles and Physiology of Skin Flap Surgery

Rollin K. Daniel Carolyn L. Kerrigan
PRINCIPLES OF FLAP SURGERY Classification Method of mo ement !lood s"##ly Com#osition Soft $iss"e Co e%a&e Mac%oci%c"lation Em'%yolo&y Anatomy $y#es of Fla#s Random c"taneo"s fla#s A%te%ial c"taneo"s fla#s Fascioc"taneo"s fla#s Myoc"taneo"s fla#s M"scle fla#s S#eciali(ed fla#s Com#lications FLAP P)YSIOLOGY Mic%oci%c"lation Anatomy Physiolo&y Patho#hysiolo&ic Chan&es Anatomic chan&es )emodynamic chan&es Meta'olic chan&es Pha%macolo&y A*on 'loc+e%s Rece#to% 'loc+e%s Di%ect smooth m"scle %ela*ants Alte%in& %heolo&y of 'lood Inc%easin& tole%ance to ischemia Miscellaneo"s a&ents $ests of S+in Fla# Ci%c"lation,Monito%s

PRINCIPLES OF FLAP SURGERY

The denning characteristic of a s in flap is that its survival in the recipient bed is predicated upon a functioning intravascular circulation, in contrast to the dependent plas-matic imbibition of s in grafts. "or a ,5 year period from 0+0, to 0+*,, the actual design of s in flaps was governed by a set of length-to-width ratios, varying from ,60 for the face to 060 for the lower e!tremity. These rules evolved from empiric observations and became canons as the specialty of :lastic 'urgery developed. <)ually important was the distinction between a local flap, which could be easily advanced, pivoted, or interpolated and a distant flap, which could be either inset directly or tubed. %n 0+*,, Ba am&ian published his method of pharyngeal reconstruction employing a new flap of immense dimensions that did not re)uire a delay procedure. The deltopectoral flap not only revolutioni.ed head and nec reconstruction, but reintro-duced the concept of arterial flaps as pioneered by <sser /Baese er, 0+E>4. The death nell for the restrictive arithmetic rules governing s in flap design was 7ilton's /0+354 repudiation of the simplistic length-to-width ratio. Hn the basis of his wor with arterial flaps and 2aniel's investigation of random cutaneous flaps /2aniel, 0+3>, 0+3,a,b# 2aniel and Ailliams, 0+3>4, it was shown that increasing the width of a flap did not increase the surviving length. -ather, it was the incorporated blood supply that dictated the flap's surviving length. Thus freed from arithmetic restraints, a sudden surge occurred in the number and type of flaps available. 7cIregor and Fac son /0+394 devised the groin flap supplied by the superficial circumfle! iliac artery, and classified s in flaps as either random or a!ial. 2aniel /2aniel, 0+3>, 0+3,a,b# 2aniel and Ailliams, 0+3>4 denned the blood supply to the s in as being from two types of arteries, either musculocuta-neous or direct cutaneous arteries. As the design of s in flaps became increasingly determined by a nowledge of the cutaneous vascular anatomy, the times when the delay procedure was indicated and carried out became less fre)uent. 2espite these advances, the entire spectrum of s in coverage was to be changed during the subse)uent decade of microscopes and myocutaneous flaps. "rom 0+3, to 0+E,, the operating microscope revolutioni.ed the method of flap movement, while the resurgence of myocutaneous flaps permanently altered flap composition. Aith the first report of a successful free flap by 2aniel and Taylor /0+3>4, s in flaps were effectively liberated from their restraining pedicle. <)ually, the attendant waste of time and tissue that was a part of any tube flap migration was eliminated. Attention )uic ly focused on e!panding the composition of free flaps with nerve, bone, tendon, and &oints. Although myocutaneous flaps were originally conceived of as donor tissue for free flap transfers, their versatility, simplicity, and ubi)uitousness led to their adoption as a local flap. Hperative ease and development of new procedures, e.g., the latissimus dorsi flap for breast reconstruction, led to the rapid integration of myocutaneous flaps into all aspects of plastic surgery. The primary contributions of ;ascone., Bostwic and 7cGraw /0+3=4, 7cGraw /0+E54, 7athes and 8ahai /0+3+, 0+E94, Bostwic /0+E>4, and Fur iewic. and associates /0+E,4 were critical. This advance mandated a greater awareness of muscle anatomy and blood supply, especially the arcs of rotation /see Ghap. 004. After this initial resistance was overcome, the wor of Ier /0+39, 0+334 utili.ing muscle transfers plus s in grafts was appreciated and )uic ly adopted. 7uscle transfer plus a s in graft has evolved as a first option for coverage in the lower e!tremity, as it minimi.es donor site deformity. -ecently, new hybrid flaps have emerged, including e!panded flaps in which greater flap si.e is achieved with minimal donor site morbidity, and fasciocutaneous flaps that combine the simplicity of random flaps with the vascular-ity of arterial flaps. This chapter attempts to integrate the rapidly changing field of s in flaps into a coherent set of principles. Gurrently, three ma&or trends appear to be evolving into the fundamental principles for the ne!t decade. "irst, plastic surgeons are no longer restricted to s in flaps to provide s in replacement, but rather can utili.e a wide array of operations to provide soft tissue coverage. Dong-term follow-up by 8ahai /0+E,4 and sophisticated studies by 7ay /7ay and Balls, 0+E,# 7ay, Balls, and 'imon, 0+E,4 showed that a local muscle transfer plus a partial-thic ness s in graft provides durable long-term coverage, and it is not necessary to replace full-thic ness dermis

and subcutaneous fat. 'econd, the number, type, and application of flaps continues to e!pand rapidly and the surgeon must remain open to new techniques. "or e!ample, the latissimus dorsi replaced the groin flap as the primary free flap donor site, yet the transverse abdominis myocutaneous flap has superseded the latissimus dorsi for breast reconstruction. Basic principles have also been altered6 blood supply is now the critical design criterion for a flap, not arithmetic# the microscope has replaced the tube pedicle flap as the dominant method for distant flap transfer# and minimi.ation of donor site morbidity has become of greater interest now that consistently reliable flaps have evolved. Third, the reconstruction of comple! multitis-sue deformities, especially in the face, no longer involves the fabrication of a facsimile in numerous operations using several donor parts fused by scar tissue. -ather en bloc composite reconstruction, often employing mi-crovascular anastomoses, has become the standard. %t is this type of sophisticated composite replacement that is presaging the era of reconstructive transplantation surgery.

Classification
Any classification is merely a method of organi.ation or clarification of one's thoughts on a particular sub&ect. Although numerous systems are available, classification of s in flaps has evolved in three distinct groups6 method of movement, blood supply, and composition /Table +04.
METHOD OF MOVEMENT

' in flaps can be divided into local or distant flaps on the basis of the pro!imity of donor and recipient sites /"ig. +-04. Docal or ad&acent flaps can be subdivided into advancement, pivot, and interpolation flaps. An advancement flap moves directly forward into
Table 9-1. Classi i!a"i#$ # S%i$ Flaps
Method of Movement Local fla#s Ad ancement Pi ot Inte%#olation Pedicle S"'c"taneo"s Distant fla#s Di%ect $"'e Mic%o asc"la% Blood Supply M"sc"loc"taneo"s a%te%ies Random c"taneo"s Myoc"taneo"s Se#toc"taneo"s a%te%ies Fascioc"taneo"s A%te%ial Composition C"taneo"s Fascioc"taneo"s Myoc"taneo"s M"scle - s+in Osseoc"taneo"s Senso%y

a defect without any lateral movement, the most common e!ample being the ;-@ advancement flap. %n contrast, a pivot flap, either transposition or rotation, derives its name from the pivot point at the base of the flap as well as its arc of rotation whose radius is under the greatest tension. An interpolation flap is ta en from a nearby but not immediately ad&acent donor site, and transferred either above or below the intervening s in to the recipient defect. <ven within localflaps there is a hierarchy of comple!ity. The advancement flap offers the economy of closing both the recipient and donor sites in the same procedure, whereas a pivot flap often re)uires either a s in graft or another flap to close the donor site. <ven more comple! is the interpolation flap whose donor site may be easily closed, but whose pedicle must either be s eletoni.ed for subcutaneous passage, resulting in increased ris , or sectioned in stages when passed over the

intervening s in, thereby necessitating additional operations. "laps from a distance can be divided into direct, tube, or free. A direct flap allows appro!imation of the donor and recipient site, ranging from the easily e!ecuted thenar flap in which the inde! finger is brought down to the thenar prominence, to the more complicated cross leg flap. %f the two sites cannot be appro!imated, the alternative is either a tube flap migration or a microvascular free flap transfer. A tube flap minimi.es infection and contracture during its long migration. Alternatively, a free flap allows immediate and direct transfer of a large amount of tissue with its own permanent blood supply, albeit re)uiring greater technical e!pertise for the microvascular anastomoses. -ather than signifying a distinct type of flap, the term free or microvascular flap merely refers to a method of movement.
&LOOD SUPPLY

Although a simplistic division, the blood supply to the covering tissues may be subdivided into segmental, perforator, and cutaneous, the latter being composed of muscu-locutaneous and septocutaneous vessels /"ig. +-94 /2aniel, 0+3,a,b4. Musculocutaneous arteries are branches off the ma&or vessels that supply muscle and then continue into the overlying dermal ple!i. Septocutaneous arteries /previously referred to as direct cutaneous arteries4 arise from either segmental or muscular vessels before passing through the fas-cial septa between muscles to supply both the enveloping fascia and the overlying s in. JGonceptually, musculocutaneous arteries nourish both random cutaneous and myocu-taneous flaps. A random cutaneous flap is composed of s in and subcutaneous fat with multiple musculocutaneous arteries at its base. A myocutaneous flap is composed of s in, subcutaneous fat, and muscle with its blood supply coming from muscular arteries plus numerous terminal musculocutaneousarteries. The critical factor that provides my-ocutaneous flaps with a greater reliability than random cutaneous flaps is the distinction between -their anatomic and vascular bases. %n a random cutaneous flap, the mus-culocutaneous arteries are located at the flap's anatomic base, whereas in a myocuta-neous flap multiple musculocutaneous arteries are passing upward from the perfused muscle to the overlying s in. Thus, in a myocutaneous flap the vascular base is can-tilevered far beyond the anatomic base, allowing greater length and reliability. 'eptocutaneous arteries are a reflection of vascular embryology. 'pecifically, the cutaneous capillary ple!i and underlying segmen-tal arteries develop concurrently, but must &oin at a later date despite the intervening muscle mass. The connecting vessels are found in the dividing muscular septa and are labeled 'eptocutaneous arteries. 'urgically, one can achieve greater flap survival by incorporating fascia and aligning the fasciocu-taneous flap on a distinct 'eptocutaneous vessel. 'eptocutaneous arteries that course parallel to the s in and provide numerous side branches in a Ghristmas tree fashion can nourish large-si.ed arterial flaps. %n contrast to the ubi)uitous musculocutaneous arteries, these parallel vessels are few in number, but they are of great surgical importance. As in the groin and deltopectoral flaps, one can raise flaps of almost unlimited length with little regard for width or need for a delay procedure.
COMPOSITION

Although compound flaps have a long lineage, their application was infre)uent until the introduction of myocutaneous flaps. "or most defects, a simple s in flap usually sufficed. As defects became more comple! and ad&acent donor sites were compromised, the choice was broadened to include fasciocuta-neous, myocutaneous, or muscle plus s in graft flaps /"ig. +->4. <ach flap must be considered on the basis of viability, surgical dissection, and donor site morbidity. 7uscle flaps with s in grafts have the least donor site morbidity but re)uire greater surgical dissection, and their viability may be compromised in the severely traumati.ed limb. 7yocutaneous flaps are usually highly reliable and re)uire moderate surgical e!pertise, but they leave a significant dKnor site defor-

Tes"s # S%i$ Flap Ci'!(la"i#$)M#$i"#'s

The ability to monitor the status of flap perfusion or its viability is of paramount importance in the prevention, recognition, and treatment of complications. 8umerous tests, both sub&ective and ob&ective, are available to aid this endeavor /Table +-=4. Ahen delay procedures and tube flaps were commonly used, their goal was to help the surgeon decide if the flap was ready for division or transfer. Aith the widespread use of free tissue transfers and large arterial flaps or myocutaneous flaps, monitors are re)uired that signal e!trinsic complications such as vascular thrombosis, or intrinsic complications such as distal flap ischemia. As so many tests are available, it is important to evaluate critically their optimal applications and recogni.e their limitations. 'everal important factors must be considered. "irst, is the monitor to be used for clinical or research purposesL %n clinical practice relative flows suffice, whereas in the research laboratory )uantitative values are often re-)uire'. 'econd, is flow at one point on the flap an ade)uate reflection of total flap perfusion, or do several points or the whole flap need to be assessedL %n free flaps, one point usually suffices because an Mall or noneM phenomenon is to be detected. %n local flaps, the whole unit must be assessed differentially to detect areas of distal ischemia. Third, how long does it ta e to do the test, is it repeata-ble, and how long does it ta e to respond to changes in flowL 'ome tests ta e seconds to perform and others ta e minutes or even hours. Gertain tests cannot be repeated more than once and others may ta e hours to respond to the changes in vascular perfusion. "ourth, does the test provide intermittent or continuous monitoring of the flapL "inally, can the techni)ue be applied to buried free tissue transfersL
SU&*ECTIVE TESTS

'ub&ective tests aid the experienced surgeon to evaluate the status of a s in flap's circulation. Tests commonly used include observation of color, capillary blanching and refill, warmth, and bleeding from stab wounds. Color. ' in color may be a very deceptive inde! of flap perfusion. As it is so variable, a simple observation tells us nothing. Gomparing a free flap ta en from the bac , which has not been sun e!posed, with its site of transfer, the leg, which has been sun e!posed, one notes that the flap appears pale and underperfused. A MblueM flap is usually a late change of severe ischemia in a random flap or venous failure in a free flap. Thus, color as an indicator is of limited clinical use /Ac-land, 0+3*4. Capillary Blanching. Blanching of a s in flap by gentle pressure, with subse)uent observation of capillary refill, is a widely used test. Nnfortunately, it has been shown that even a free flap, totally isolated from the body, may demonstrate this phenomenon. %n pale s in, it may be impossible to visuali.e the blanching, and thus a negative test may be misinterpreted to indicate arterial failure when in fact the flap is well perfused. %n hyperemic s in, the response may be a useful way of confirming other sub&ective or ob&ective tests. Ta en in the appropriate conte!t and interpreted by e!perienced personnel, blanching may be a helpful inde! of perfusion. Warmth. 'ub&ective assessment of flap temperature is not a reliable way to assess flap perfusion. Bleeding from Stab Wounds. Bleeding from stab wounds in the flap is a useful test of s in flap perfusion /Oerrigan and 2aniel, 0+E>b4. The test is usually made with an 0E gauge needle or a 8o. 00 scalpel blade# the absence of bleeding from the stab wound indicates arterial failure. 2elayed bleeding of bright red blood signifies some degree of arterial spasm. Bris , bright red bleeding can be interpreted as normal arterial perfusion or perhaps some degree of hyperemia. Gy-anotic bleeding that promptly clears to bright red blood indicates some degree of venous congestion. The test can be used

routinely on flaps to assess e!trinsic complications, but it is not particularly useful in detecting intrinsic failure.
O&*ECTIVE TESTS

Hb&ective tests must be used as an ad&unct to clinical &udgment. Their ma&or benefit is that they alert the surgeon to a potential problem long before sub&ective signs become evident. The surgeon must then decide how to respond to the ob&ective changes in the conte!t of the overall clinical picture. Metabolic Tests. The two metabolic tests most fre)uently used for monitoring s in flap perfusion are for pB and transcutaneous p59. Tissue pB can be measured by implantation of an electrode and continuous monitoring of the trends /Ilin. and Glodius, 0+39# 2ic son and 'harpe, 0+E,4. Transcutaneous p59 is measured by placing a heated electrode on the s in surface and also measuring trends /'erafin and associates, 0+E0# 'mith and associates, 0+E># Achauer and Blac , 0+E=4. The ma&or disadvantage of both these techni)ues is the e!pense of the e)uipment involved. Although initially used with great enthusiasm, the transcutaneous p59 is now rarely made for flap monitoring. Tissue pB testing is still being investigated for its possible application to monitoring of buried tissue transfers. hotoelectric Tests. "or assessing blood flow, the 2oppler effect has been used in two different ways. ltrasound 2oppler uses reflected sound to pic up large subcutaneous pulsatile arteries. !aser 2oppler /D24 measures the fre)uency shift of light rather than sound reflection. The laser light has limited penetration and thus measures flow to a depth of only 0., mm. D2 has become a popular research and clinical monitor used with varied enthusiasm and success. The D2 readings measure voltage and provide a relative but not absolute measure of flow rates, although efforts to generate a true flow rate are being made. This techni)ue may provide the most useful inde! of flow in the monitoring of free flaps for e!trinsic complications. The techni)ue is noninvasive. %t can be used continuously /thus giving trends4, but it is e!pensive. 'ome e!perience is re)uired to allow accurate interpretation of changing signals. -efinements in both laser and ultrasound 2opplers have permitted fabrication of small implantable probes, which are now being investigated e!perimentally for their ability to detect microvascular thromboses in buried free tissue transfers /Fones and 7ayou, 0+E9# 'vensson and associates, 0+E,4. "hotoplethysmography has been available since the 0+=5's and the instrumentation has undergone several modifications /Barrison and associates, 0+E>4. This techni)ue measures fluid volume by detecting variations in light absorption by the s in. As with laser 2oppler, flow in the tissues to a depth of only 0 to 0., mm may be detected. %n e!trinsic complications with arterial failure, the wave form disappears, and in venous failure the wave form patterns re)uire e!perience to interpret. "or detecting intrinsic flap failure, the photoplethysmograph has been disappointing. Bowever, Bardach and associates /0+3+4 modified the signal interpretation and believed this change gives a reasonably go7 prediction of the survival-necrosis interface. Gurrent e)uipment is limited to measurement of one site at a time. Hther plethysmo-graphic techni)ues, such as impedance pleth-ysmography, have not been adapted for use in s in flaps. Temperature Tests. 'everal types of temperature tests have been made to monitor s in flaps and free tissue transfers. They include surface temperature, differential thermometry, temperature clearance, and thermography. Hnly the first two will be discussed. Temperature can be measured by a. thermistor or a thermocouple. The thermocouple is a more sensitive and precise instrument that measures a voltage differential between two wires of different metals. Thermistors are semiconductors that have a lowered resistance at higher temperature. Thermistors are less precise than thermocouples but they provide ade)uate information for most types of monitoring. Surface Temperature. ' in surface temperature is easily measured and re)uires relatively ine!pensive e)uipment. To provide an effective monitor, several guidelines must be followed6 the patient's core temperature should be recorded, e!traneous light-heat sources should be avoided, dressings should not cover the flap, and room temperature and air currents must remain constant. %f the patient is moved one

should e!pect a transient change in the temperature reading. 'urface temperature is the current standard for monitoring e!trinsic complications. Nsed as a relative inde!, it has proved a dependable and useful clinical tool. "or the evaluation of intrinsic flap failures, it is inade)uate. Differential Thermometry. There is a need for a reliable ob&ective techni)ue to monitor vascular patency in buried free tissue transfers. The only techni)ue that has any significant clinical data to support its use is that of differential thermometry /7ay and Balls, 0+E,4. Thermocouple probes are sutured both pro!imal and distal to the arterial anastomoses, and their temperature difference is recorded. These are monitored on a continuous basis, and any difference greater than >P G is &udged to be significant. Time must be invested in learning to interpret this test accurately# if not, many false alarms are called and may cause greater harassment to the surgeon than no monitor at all. !ital "ye. Ahen vital dyes are administered systemically, they stain s in that is ade)uately perfused. 'everal dyes have been used, including fluorescein, 2isulphine Blue, and vital green. "luorescein is the only one used clinically at the present time and may be employed two different ways. Ahen administered intravenously, pea serum concentrations occur at 95 minutes, which is the usual time for observation of the flap by Aood's lamp illumination. At a dosage of 0., mg per g, this test may be used to monitor both e!trinsic and intrinsic flap failure /7cGraw, 7yers, and 'han lin, 0+334. The ma&or disadvantages are that the test tends to underestimate flap survival and can be repeated only every eight hours. The reason for underestimation of flap survival can best be understood if one remembers the dynamic nature of s in flap circulation and the fact that s in blood flow tends to increase with the time after flap elevation. Thus, fluorescein given one hour after flap elevation will assess flap circulation at that time. Any subse)uent increase in flow within the ne!t 09 hours will contribute to the increase in flap survival, but it will not have been measured by the early postoperative dye test. A few reported cases of anaphylactic reactions to fluorescein are in the literature, but the most common adverse reaction seen clinically is nausea. This can be minimi.ed by slow intravenous administration. The second method of using fluorescein re)uires a smaller dose of 5.0, mg per g. Tissue fluorescence at this level is not detectable by the human eye, but an instrument has been developed, the dermofluorometer, to )uantitate these levels /'ilverman and associates, 0+E5# Iraham and associates, 0+E>4. This test has the advantage of providing an ob&ective measure of s in flap circulation, and it may be repeated as often as needed, although it ta es about >5 minutes to complete. An inde! relating fluorescein levels in the flap to control s in is then calculated. Glinically an inde! of greater than >5 per cent is considered to be safe. %n the authors' e!perimental wor , it was shown that, if the test is done early postoperatively, an inde! as low as E per cent may be acceptable /Thomson, 0+EE4. This is again a reflection of the dynamic nature of s in flap circulation. The techni)ue is e)ually applicable in dar -s inned individuals and, as mentioned previously, it can be used to detect both intrinsic and e!trinsic complications. #uantitati$e Tests. Absolute )uantitative tests are used primarily for research purposes and they provide a measure of nutrient blood flow in ml per min per gm of tissue. They' tend to be more time consuming to perform and re)uire e!pensive instrumentation or e)uipment. %t may also ta e some time for data analysis before the measured flow rate is nown. Clearance Tests. The principle of all clearance tests is the same. A substance, which can be ob&ectively measured, is introduced into the tissue of concern, and over a period of time the disappearance of this substance is measured. The speed of disappearance or clearance reflects flow rates. 'everal radioactive tracers have been employed, including Qel>> /:almer, Furell, and 8orberg, 0+394, 8a99, OrE,, and Tc++ /@oung and Bopewell, 0+E>4. Bydrogen ion is the only nonradioactive substance used in the same )uantitative way /Ilogovac, Bit., and Ahite-side, 0+E94. Aith the use of the radioactive isotopes, a small amount of substance is in&ected intradermally or placed in a small sealed chamber over the s in. -adioactivity of the isotope is measured over a period of time, thus generating a clearance curve. Bigh

local concentrations of hydrogen ion can be achieved in two ways. Traditionally, the animal or patient inhales a , per cent concentration of hydrogen gas until the tissues are saturated, as measured by stable electrical activity in the s in. 7ore recently a techni)ue has been devised to generate hydrogen ion electrochemically at the site of a s in electrode, thus obviating the need for tissue saturation by inhalation of hydrogen gas /'u.u i and associates, 0+E,4. %n both cases, after delivery of hydrogen ion has pea ed, its clearance over time is used to calculate an inde! of flow. These tests fre)uently sample only one point at a time and ta e one to two hours to perform, as stabili.ation is re)uired and clearance curves often need to be followed for >5 minutes or longer. 2ata must also be analy.ed, and unless a computer is directly connected to the monitoring e)uipment this may ta e several hours to days to accomplish. Radioacti$e Microspheres. -adioactive microspheres can be used to measure blood flow in e!perimental situations only /:ang, 8eligan, and 8a atsu a, 0+E=4. 'mall spheres, usually 0, /&,m in si.e, are available, tagged with a variety of radioactive isotopes. They are administered to the e!perimental animal via the left ventricle, and thus em-boli.e peripheral tissues in direct proportion R r their blood flow. 'amples of tissue are counted for radioactivity and compared with an organ with nown flow rates, so as to calculate flow rates of the tissue in )uestion. The study can be repeated only three times, otherwise peripheral emboli.ation begins to interfere with normal hemodynamics. "ifteen S!m spheres reflect nutrient flow, but larger spheres are available if data regarding shunt flow or total flow is needed. The radioactive microspheres are the current optimal tech,-ni)ue for )uantitative measures of blood flow in the research laboratory. %lectromagnetic Flo&metry. This techni)ue is designed for e!perimental use only and re)uires a small probe capable of setting up an electrical field across a vessel lumen /Acland and 'chwart., 0+E04. Blood flow in the vessel interferes with the electrical field and can be translated into precise flow rates. The techni)ue is demanding if it is to be reliable and reproducible data are to be generated, but it is the only method that provides immediate, continuous, and )uantitative measurements of total flow. The disadvantage of this techni)ue is that it measures total flow in the flap and can differentiate neither between nutrient and shunt flow nor between flow in the pro!imal flap and flow in the distal flap. Bowever, it does provide crucial e!perimental information about flow to free flaps. Miscellaneous Tests. 'everal other tests of interest should be mentioned, as they provide additional tools for studying the cutaneous microcirculation or buried tissue transfers. ;ital capillary microscopy employs a microscope and video camera to observe and record the dynamic changes occurring within a vascular bed. 'pecial tissue preparation is re)uired for application of this techni)ue. 7icroangiography, electroarteriography, and interstitial fluid pressure measurements have also been used to study cutaneous microcirculation. %n summary, monitors of s in circulation are used for many reasons. A thorough understanding of the benefits and limitations of all available tests is imperative for their use and interpretation. The two mosD&ddely$ needed clinical applications at present are the monitoring of free tissue transfers and the assessment of an acute s in flap for a distal .one of ischemia. "or the former, if a s in flap has been utili.ed, surface temperature is the monitor of choice# if a buried tissue is to be monitored, differential thermometry with thermocouple probes is the standard, although it is not widely used. "or the latter, the fluorescein dye test remains the best available monitor. %n the research laboratory, radioactive microspheres are the golden standard. "uture research will concentrate on improving techni)ues available to the clinician, with special emphasis on the monitoring of buried free tissue transfers.